From Medicine and Health

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! This week was so busy that I am going to take the unprecedented step and highly recommend you check out our Morning Briefings for the past few days. So many compelling, interesting stories didn’t make the cut for the Breeze, but they’re worth reading.

On to what you may have missed!

Well, this one you probably didn’t miss unless you were in the middle of the woods sans cellphone service: Alabama Gov. Kay Ivey signed legislation that effectively bans all abortions and criminalizes the procedure. The uproar that followed was immediate and ferocious — especially from 2020 Democrats who all but tripped over each other to denounce it as “shameless” and “outrageous” — but is the bill actually the threat to Roe v. Wade that it so dearly wants to be?

The measure is destined for the courts, certainly, but that doesn’t mean it will make it to SCOTUS. One likely outcome: The justices can simply refuse to take it up, leaving in place the lower courts’ decision (which will probably be that the law is unconstitutional). Chief Justice John Roberts is known for favoring incrementalism over sweeping decisions that would overturn nearly 50 years of precedent on a hot-button social issue.

But you need only four votes to get a case on the docket, which has court-watchers eyeing newbie Justice Brett Kavanaugh. His appointment helped galvanize the anti-abortion movement in the first place, but in the past he’s talked seriously about needing a compelling reason to overturn precedent. So far, he has disagreed with the hard conservatives more than people expected. So, the future for Alabama’s law remains uncertain.

What seems more likely is that the high court will instead look to less extreme, but still restrictive state laws (such as bills dictating the disposal of fetal remains and an 18-hour waiting period after state-mandated ultrasound examinations) that are heading toward them even as we speak.

No matter how it plays out, you can pretty much guarantee this is going to be a Big Deal on the campaign trail.

The New York Times: Alabama Aims Squarely at Roe, but the Supreme Court May Prefer Glancing Blows

The Associated Press: Alabama Law Moves Abortion to the Center of 2020 Campaign

The Wall Street Journal: States’ Abortion Curbs Put Supreme Court to the Test

A smattering of the other (dozens and dozens) of thoughtful stories from the past few days:

• What is it like living in a liberal city in the Deep South during times like this?

The New York Times: Abortion and the Future of the New South

• Missouri wants in on the action this week.

KCUR: How Missouri’s Senate Passed a Restrictive Abortion Bill Overnight

• A vote in deep-blue (and very Catholic) Rhode Island was overshadowed by Alabama’s news, but it highlights how nuanced and complicated the issue can be.

Boston Globe: In Rhode Island, Vote on Abortion-Rights Bill Reveals a Complicated State

• A lot of Senate Republicans are trying their best to nope out of this conversation, like “no thank you, not touching that with a 10-foot pole.”

The Hill: Senate Republicans Running Away From Alabama Abortion Law

• And a really handy look at what’s going on at the state level.

The Washington Post: The Widening Gap in Abortion Laws in This Country

House Democrats took advantage of their newfound power by tying a vote on reining in high drug prices to legislation shoring up the health law. The bill is destined to die, of course, but the move forced their Republican colleagues to go on record voting against something that voters care very, very deeply about.

The New York Times: House Passes Legislation Aiming to Shore Up Health Law and Lower Drug Costs

They also foreshadowed a potential subpoena with letters to Attorney General William Barr. Five powerful committee chairmen said that they’ve been asking since April 8 for documents connected to the Justice Department’s decision to stop defending the health law but haven’t received a sufficient response. They’re giving DOJ two more weeks before they consider “alternative means of obtaining compliance.”

Politico: Dems Tee Up New Document Fight With DOJ Over Obamacare

Meanwhile, a new Sunlight Foundation report found that the Trump administration has been systematically altering and eliminating information on the health law that’s on government websites.

Wired: The Trump Admin Is Scrubbing Obamacare From Government Sites

Surprise medical billing is truly the darling of Capitol Hill recently with all the attention it’s getting. Multiple variations of bipartisan duos and groups are working on introducing legislation to combat the issue. The most recent bill unveiled would protect patients from the surprise costs, and let an outside arbitrator settle any disputes between hospitals and insurers. Other proposals have instead favored a rate-setting method to solve payment issues.

The Hill: Bipartisan Senators Unveil Measure to End Surprise Medical Bills

The Hill: Dem House Chairman, Top Republican Release Measure to End Surprise Medical Bills

Attorneys general from 44 states have filed suit against pharma companies over allegations that “the generic drug industry perpetrated a multibillion-dollar fraud on the American people.” The lawsuit implicates 20 pharma firms following an investigation into allegations that the companies sought not only to maintain their “fair share” of the generic drug market through agreements with one another but also to “significantly raise prices on as many drugs as possible.”

The Associated Press: States Bring Price Fixing Suit Against Generic Drug Makers

Washington state took a big step this week in approving the creation of a public option — which would essentially look like a state-sponsored health plan. But now comes the hard part: making it work.

And don’t call it a game changer quite yet, experts say. Even sponsors of the legislation acknowledge the state plans may save consumers only 5-10% on their premiums. Still, the rollout will likely be watched closely as the progressive universal health care push grows stronger.

Politico: 5 Key Questions About the Country’s First Public Option

NPR: Washington State to Create ‘Public Option’ Health Care Plans

(If you feel like you need a refresher on all these terms — join the crowd, amiright? this one from NYT’s Margot Sanger-Katz is great.)

Rural hospitals, which sometimes fight literally hour by hour to afford to stay open, are in a crisis in this country, as evidenced by two amazing pieces this week on what happens to a town when one dies.

“If we aren’t open, where do these people go?” asked one hospital worker in The Washington Post’s coverage.

“They’ll go to the cemetery,” another employee answered. “If we’re not here, these people don’t have time. They’ll die along with this hospital.”

The Washington Post: ‘Who’s Going to Take Care of These People?’

Kaiser Health News: Dealing With Hospital Closure, Pioneer Kansas Town Asks: What Comes Next?

But I found a flicker of hope in a lovely story about how a one-room clinic in North Carolina just marked its 100th year.

North Carolina Health News: One Hundred Years in a Rural Clinic

Think this measles outbreak is big? (It is, by the way!) How about the one in 1990, which had more than 27,000 cases? In the past few months, I’ve read and written about the record 963 cases from 1994 more times than you can count but had no idea that just four years earlier it was that much higher. If you’re as intrigued as I was about how that changed, dive into NPR’s historical look at what exactly was going on at the time, and how public officials made so much progress so quickly.

NPR: How a Measles Outbreak Was Halted in the 1990s

In the miscellaneous file for the week:

• There’s a pretty serious debate going on right now about fair distribution of donated livers. A new rule that went into effect this week and then was immediately blocked by a judge would give the organ to the sickest patient within 500 nautical miles. But advocates in the Midwest and South say that’s unfair.

The Washington Post: Liver Transplant Rules Spark Open Conflict Among Transplant Centers

• The U.S. birth rate has fallen again to the lowest in three decades. Some say that means the sky is falling; others are unconcerned.

The Associated Press: US Births Lowest in 3 Decades Despite Improving Economy

• Despite there being thousands of children in the country with a terminal diagnosis, only three hospice facilities in the U.S. are designed specifically for them.

The New York Times: Where Should a Child Die? Hospice Homes Help Families With the Unimaginable

• Can we learn about trauma from an island of monkeys that was devastated by Hurricane Maria?

The New York Times: Primal Fear: Can Monkeys Help Unlock the Secrets of Trauma?

• Many of our gun safety discussions focus on buying the weapons, but teaching about proper storage can make a bigger difference than you’d necessarily expect.

The New York Times: The Potentially Lifesaving Difference in How a Gun Is Stored

Whew! You made it both through this hefty Breeze and the week itself. Take it easy this weekend as a reward!

Pacientes sin nombre: cuando el personal del hospital tiene que ser detective

El hombre de 50 años con la cabeza rapada y los ojos marrones no reaccionó cuando los paramédicos lo llevaron a la sala de emergencias. Sus bolsillos estaban vacíos: ni billetera, ni teléfono, ni un solo trozo de papel que pudiera revelar su identidad a las enfermeras y médicos que estaban tratando de salvarle la vida. Su cuerpo no tenía cicatrices ni tatuajes distintivos.

Casi dos años después de ser atropellado por un automóvil en el ajetreado bulevar de Santa Mónica, en enero de 2017, y de que lo transportaran a Los Ángeles County + USC Medical Center con una lesión cerebral devastadora, nadie había venido a buscarlo o lo había reportado como desaparecido. El hombre murió en el hospital, todavía sin nombre.

El personal del hospital a veces debe actuar como detective cuando un paciente sin identificación llega para recibir atención. Establecer la identidad ayuda a evitar los riesgos que pueden conllevar realizar tratamientos sin conocer el historial médico del paciente. Y se esfuerzan por encontrar parientes cercanos para ayudar a tomar decisiones médicas.

“Buscamos a alguien que pueda tomar decisiones, una persona que pueda ayudarnos”, dijo Jan Crary, trabajadora social clínica supervisora ​​en L.A. County + USC: con frecuencia convocan a su equipo para identificar a pacientes sin nombre.

El hospital también necesita un nombre para cobrar el pago de un seguro privado o programas de salud del gobierno como Medicaid o Medicare.

Pero las leyes federales de privacidad pueden hacer que descubrir la identidad de un paciente sea un desafío para el personal de los hospitales de todo el país.

En L.A. County + USC, los trabajadores sociales revisan las pertenencias y la ropa del paciente, sus teléfonos celulares si no tienen contraseña, buscando nombres y números de familiares y amigos, y revisan recibos o pedazos de papel arrugados en busca de cualquier rastro de la identidad del paciente. Hacen preguntas a los paramédicos que lo trajeron o a los operadores del 911 que atendieron la llamada.

También toman nota de los tatuajes y piercings, e incluso intentan rastrear los registros dentales. Es más difícil chequear las huellas dactilares, porque eso se hace a través de la aplicación de la ley, que se involucrará solo si el caso tiene un costado criminal, dijo Crary.

A menudo, los pacientes no identificados son peatones o ciclistas que dejaron sus identificaciones en casa y fueron arrollados por vehículos, agregó Crary. También pueden ser personas con deterioro cognitivo grave, como Alzheimer, pacientes en estado psicótico o usuarios de drogas que sufrieron una sobredosis. Los pacientes más difíciles de identificar son aquellos que están socialmente aislados, incluidas las personas sin hogar, cuyas admisiones en hospitales han aumentado considerablemente en los últimos años.

Lenh Vuong, trabajadora clínica social de Los Angeles County+USC Medical Center, visita a un paciente que ingresó sin nombre y que recientemente fue identificado. ((Heidi de Marco/KHN))

En los últimos tres años, el número de pacientes que llegaron sin identificación a L.A. County + USC aumentó de 1.131 en 2016 a 1.176 en 2018, según datos proporcionados por el hospital.

Si un paciente permanece sin identificar por mucho tiempo, el personal del hospital inventará una identificación, generalmente comenzando con la letra “M” o “F” para el género, seguido de un número y un nombre al azar, dijo Crary.

Otros hospitales recurren a tácticas similares para facilitar la facturación y el tratamiento. En Nevada, los hospitales tienen un sistema electrónico que asigna a los pacientes no identificados un “alias de trauma”, dijo Christopher Lake, director ejecutivo de resiliencia comunitaria en la Asociación de Hospitales de Nevada.

El tiroteo en un concierto de Las Vegas en octubre de 2017 representó un desafío para los hospitales locales que intentaron identificar a las víctimas. La mayoría de los asistentes al concierto llevaban muñequeras con chips escaneables que contenían sus nombres y números de tarjetas de crédito para poder comprar cerveza y recuerdos. En la noche del tiroteo, el último día de un evento de tres días, muchos se sentían tan cómodos con las pulseras que no llevaban carteras ni billeteras.

Esa noche, más de 800 personas resultaron heridas y fueron trasladadas a numerosos hospitales, ninguno de los cuales estaba equipado con dispositivos para escanear las pulseras. El personal de los hospitales trabajó para identificar a los pacientes por sus tatuajes, cicatrices u otras características distintivas, y por fotografías en las redes sociales, dijo Lake. Pero fue una batalla, especialmente para los hospitales más pequeños, agregó.

Jan Crary, trabajadora social clínica supervisora ​​en L.A. County + USC, lidera un equipo que muchas veces tiene que jugar el papel de detective cuando no se puede identificar a un paciente.((Heidi de Marco/KHN))

La Ley federal de responsabilidad y portabilidad del seguro de salud (HIPAA, por sus siglas en inglés), destinada a garantizar la privacidad de los datos médicos personales, a veces puede hacer que la identificación sea más ardua porque es posible que un hospital no quiera divulgar información sobre pacientes no identificados a personas que indagan sobre personas desaparecidas.

En 2016, un hombre con Alzheimer fue ingresado en un hospital de Nueva York a través de la emergencia como paciente no identificado y se le asignó el nombre de “Trauma XXX”.

La policía y miembros de la familia preguntaron por él en el hospital varias veces, pero le decían que no estaba allí. Después de una semana, durante la cual cientos de amigos, familiares y agentes de la ley buscaron al hombre, un médico que trabajaba en el hospital vio una noticia sobre él en la televisión y se dio cuenta que era el paciente no identificado.

Más tarde, los funcionarios del hospital le dijeron al hijo de este hombre que, debido a que no había preguntado explícitamente por “Trauma XXX”, no pudieron darle información que pudiera haberlo ayudado a identificar a su padre.

A raíz de esa confusión, el Centro de Información para Personas Desaparecidas del estado de Nueva York elaboró ​​un conjunto de pautas para los administradores de hospitales que reciben solicitudes de información sobre personas desaparecidas de la policía o miembros de la familia.

Estas pautas incluyen aproximadamente dos docenas de pasos que deben seguir los hospitales, que incluyen la notificación a la recepción, la introducción de descripciones físicas detalladas en una base de datos, tomar muestras de ADN y el seguimiento de correos electrónicos y faxes sobre personas desaparecidas.

Las pautas de California estipulan que, si un paciente no está identificado y tiene incapacidades cognitivas, “el hospital puede revelar solo la información mínima necesaria que sea directamente relevante para ubicar a los familiares del paciente, si esto es por el mejor interés del paciente”.

En L.A. County + USC, la mayoría de los pacientes sin nombre se identifican rápidamente: o bien recuperan el conocimiento o, como en la mayoría de los casos, amigos o familiares llaman para preguntar por ellos, dijo Crary.

Aun así, el hospital no siempre tiene éxito. De 2016 hasta 2018, 10 personas sin nombre permanecieron sin identificar durante sus estadías en L.A. County + USC. Algunos murieron en el hospital; y otros fueron a hogares de adultos mayores con nombres inventados.

Pero Crary dijo que ella y su equipo agotan todas las vías en busca de una identidad.

Una vez, un hombre mayor, no identificado y de aspecto distinguido, con una barba recortada con pulcritud, fue llevado a la sala de urgencias delirando, con lo que luego se diagnosticó como encefalitis, y con incapacidad para hablar.

Siguiendo la corazonada de que este hombre tan distinguido debía tener a alguien que lo estaba buscando, Crary consultó con las estaciones de policía en el área. Lo que descubrió es que el hombre era buscado en varios estados por agresión sexual.

“Es un caso que nunca olvidaré”, agregó Crary. “La verdad es que estoy más feliz cuando podemos identificar a un paciente y ubicar a la familia para tener una hermosa reunificación, en vez de encontrar a un criminal”.

Listen: After Its Hospital Closes, A Pioneer Kansas Town Searches For What Comes Next

KHN senior correspondent Sarah Jane Tribble is interviewed on NPR’s “Morning Edition” about the challenges faced by rural communities when their hospitals close. She is spending a year following Fort Scott, Kan., as it copes and recovers from the loss. Listen to the conversation here:

And read the first installment of the series, “No Mercy,” here.

When A Cold Cheese Sandwich Is Humiliating: Outcry Over ‘Lunch Shaming’ In Schools Gains Traction

Federal lawmakers recently introduced legislation to shield children whose parents haven’t paid for their school lunches. Policies vary across the nation, but in Rhode Island last week there was a backlash against a school when it served some children cheese sandwiches, signaling to others their parents hadn’t paid. Other news on school lunches comes from Oregon.

Eating Chips, Other Ultra-Processed Foods Sets Off ‘Hunger Hormones,’ Rapid Weight Gain, Study Finds

More than half of the calories consumed in Americans’ diets are made up ultra-processed foods, packaged or fast foods that contain added sugars, refined carbohydrates, industrial oils and sodium. Research published Thursday in Cell Metabolism links those eating patterns to the obesity epidemic. In other public health news: measles, birthrates, mental health claims, knitting therapy, cancer apps, crowded ERs and cystic fibrosis, as well.

Gilead CEO Defends High Price Of HIV Prevention Drug As Necessary For Research, But Lawmakers Aren’t Buying It

“This treatment was developed as a result of investment made by the American taxpayers,” said House Oversight Committee Chairman Elijah E. Cummings (D-Md.). “The problem is that Gilead, the company that now sells the drug, charges astronomical prices.” Gilead charged $800 a month for the drug when it was introduced in 2004. The drug now costs nearly $2,000 a month.

Bipartisan Group Of Senators Proposes Using Outside Arbitrator To Settle Disputes Over Surprise Medical Bills

The senators unveiled the legislation among a broader national push to protect patients from sky-high surprise medical bills. Although most agree that the patient shouldn’t be stuck with the costs, there is some dispute about how to settle any conflicts between the insurers and the hospitals.

As ER Wait Times Grow, More Patients Leave Against Medical Advice

Emergency room patients increasingly leave California hospitals against medical advice, and experts say crowded ERs are likely to blame.

About 352,000 California ER visits in 2017 ended when patients left after seeing a doctor but before their medical care was complete. That’s up by 57%, or 128,000 incidents, from 2012, according to data from the Office of Statewide Health Planning and Development.

Another 322,000 would-be patients left the emergency room without seeing a doctor, up from 315,000 such episodes in 2012.

Several hospital administrators said overcrowding is a likely culprit for the trend. California emergency room trips grew by almost 20%, or 2.4 million, from 2012 to 2017.

Moreover, ER wait times also increased for many during that time period: In 2017, the median ER wait time for patients before admission as inpatients to California hospitals was 336 minutes — or more than 5½ hours. That is up 15 minutes from 2012, according to the federal Centers for Medicare & Medicaid Services. The median wait time for those discharged without admission to the hospital dropped 12 minutes over that period, but still clocked in at more than 2½ hours in 2017.

California wait times remain higher than the national average. In 2017, the median length of a stay in the ER before inpatient admission nationwide was 80 minutes shorter than the median stay in California. Four states — Maryland, New York, New Jersey and Delaware — had even longer median wait times.

The growth in patients leaving California ERs prematurely was faster than the growth in overall ER encounters. About 2.4% of ER trips in 2017 ended with patients leaving the ER against medical advice or abruptly discontinuing care after seeing a doctor, compared with 1.8% in 2012.

“Most patients are sick but not critically ill,” said Dr. Steven Polevoi, medical director of the emergency department at UCSF Helen Diller Medical Center at Parnassus Heights. “Emergency care doesn’t equal fast care all of the time.”

When a patient leaves the ER after seeing a doctor but before the doctor clears them to leave, the Office of Statewide Health Planning and Development classifies that encounter as “leaving against medical advice or discontinued care.” The definition includes encounters in which a doctor carefully explains the risks to the patient and has the patient sign a form, but also instances in which the patient simply discontinues care and bolts out the door.

Patients leaving the emergency room too soon “are deliberately putting themselves at more risk for morbidity and even mortality,” Polevoi said — a point echoed by other physicians.

Dr. Veronica Vasquez-Montez, emergency room medical director at Good Samaritan Hospital in Los Angeles, said she sometimes finds herself having “tough conversations” with sick patients intent on leaving the ER, often citing pressing responsibilities.

“If you die from this,” she tells them, “you are good to no one you are caring for.”

One of her recent patients was at high risk for a major stroke but insisted he needed to leave the ER to take care of his pet.

“Guess what he came back for? A major stroke,” said Vasquez-Montez, also a clinical assistant professor at the University of Southern California’s Keck School of Medicine.

Compared with all ER patients, those leaving against medical advice were more likely to be men; people ages 20 to 39; and uninsured or on Medi-Cal, the government insurance program for the poor, state figures show. They were also more likely to complain primarily of non-specific symptoms such as chest pain or a cough.

Fresno, Shasta, Yuba, Kern, San Bernardino and Tulare counties had the highest proportion of ER encounters in 2017 that ended with patients leaving against medical advice or abruptly discontinuing care. Each of those counties recorded more than 4% of ER patients leaving too soon, state figures show.

From 2012 to 2017, the number of emergency room encounters in Fresno County increased by almost 95,000, or 37%. At Fresno’s Community Regional Medical Center, about 9% of ER encounters ended with a patient leaving too soon, more than three times the statewide rate.

Community Regional Medical Center is one of the busiest hospitals in the state. It recently instituted a “Provider at Triage” program that puts caregivers in the lobby area with patients, said Dr. Jeffrey Thomas, the hospital’s chief medical and quality officer. The hospital’s internal data now show fewer than 2% of patients leaving against medical advice or abruptly discontinuing care.

“When patients bring themselves into the ED, they are seen in about 5 minutes by a qualified registered nurse and, on average, are seen by a provider within 30 minutes of arrival,” Thomas said in a statement.

When a sick patient is about to leave the emergency room, doctors should determine why he or she wants to go, make sure the patient is capable of making a sound decision, involve friends and family, explain the course of treatment and, if nothing works, arrange for speedy follow-up care, said Dr. Jay Brenner, emergency department medical director at Upstate University Hospital-Community Campus in New York and co-author of several studies about patients leaving against medical advice.

“When someone requests to leave,” Brenner said, “it needs to be a priority that ranks just below a cardiac arrest.”

Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento.

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

‘Sham’ Sharing Ministries Test Faith Of Patients And Insurance Regulators

Sheri Lewis, 59, of Seattle, needed a hip transplant. Bradley Fuller, 63, of nearby Kirkland, needed chemotherapy and radiation when the pain in his jaw turned out to be throat cancer. And Kim Bruzas, 55, of Waitsburg, hundreds of miles away, needed emergency care to stop sudden —and severe — rectal bleeding.

Each of these Washington state residents required medical treatment during the past few years, and each thought they had purchased health insurance through an online site.

But when it was time to pay the bills, they learned that the products they bought through Aliera Healthcare Inc. weren’t insurance at all — and that the cost of their care wasn’t covered.

Lewis and the others had enrolled in what Aliera officials claimed was a health care sharing ministry (HCSM) — faith-based co-ops in which members agree to pay one another’s medical bills.

But Washington insurance officials this week said the firm doesn’t meet the definition of a sharing ministry and described Aliera’s products as a “sham” aimed at misleading consumers. Other states, including Texas and New Hampshire, are poised to take similar action.

Insurance Commissioner Mike Kreidler on Monday ordered Aliera, which operates Trinity Healthshare Inc., both of Delaware, to halt operations in Washington, alleging the firm was selling health insurance illegally and engaging in deceptive business practices.

Aliera falsely represented itself as a sharing ministry, which would be exempt from insurance regulations, an investigation found. Though he wouldn’t name them, Kreidler said he’s investigating two additional firms over similar concerns.

“They don’t have the direct affiliation with a particular religious group, a church, a pastor,” Kreidler said. “These appear to be ones that come in with an opportunity here to make money.”

In a statement, Aliera officials disputed Kreidler’s conclusions. The company has 90 days to request a hearing.

“Aliera has never misled consumer and sales agents about its health plans,” the statement said. “For example, our website, marketing materials and other communications clearly state that Trinity’s health sharing products are not insurance. Most importantly, they have never been represented as insurance.”

The Washington order followed complaints from nearly two dozen people, including Lewis, a dance teacher who was told her planned hip surgery wouldn’t be covered.

Across the U.S., several state insurance regulators report similar concerns.

Texas insurance officials have scheduled a hearing to consider a similar order against Aliera, which has 100,000 members nationwide and reported revenue of $180 million in 2018, documents showed.

New Hampshire insurance officials on Tuesday warned consumers about Aliera, saying they were concerned about “potential fraudulent or criminal activity.” Officials in at least five other states told Kaiser Health News they are reviewing firms operating as “illegitimate” health care sharing ministries.

Aliera is operated by Shelley Steele of Marietta, Ga., and her husband, Timothy Moses, who was convicted in 2006 of federal securities fraud and perjury. He was sentenced to 6½ years in prison and ordered to repay more than $1 million to victims.

Nationwide, nearly 1 million people are enrolled in more than 100 sharing ministries in at least 29 states, according to the Alliance of Health Care Sharing Ministries. But that’s just an estimate, said James Lansberry, executive vice president of Samaritan Ministries International of Peoria, Ill. No comprehensive data is available.

“We try to track what’s going on out there,” Lansberry said. “Anyone claiming to be a health care sharing ministry could spill over onto our reputation.”

Samaritan is among what have been the three top players in the sharing ministries field. The oldest, founded in 1993, is the Medi-Share program of Melbourne, Fla., operated by Christian Care Ministry. The third is Christian Healthcare Ministries of Barberton, Ohio. All are explicitly religious and emphasize faith as the basis for members to share medical burdens.

Those groups originally were certified by the Centers for Medicare & Medicaid Services and required to meet specific criteria. Consumers who enrolled were shielded from the Affordable Care Act’s individual mandate that required they show proof of insurance or pay a fine.

But CMS no longer certifies HCSMs and, since Congress zeroed out the mandate’s penalty in 2017, a new crop of companies, including Aliera, has sprung up. That worries some of the traditional ministries.

“HCSMs must operate with integrity, transparency, full compliance with the law, and enforcement of the law,” officials with Medi-Share, which has 415,000 members nationwide, said in a statement. “Anything outside of that violates the true spirit of the HCSM community.”

Washington investigators found that Aliera’s marketing materials rarely mention religious or ethical motivations, and they don’t meet government requirements.

Many of these entities mimic the marketing, structure and language of ACA-compliant health insurance plans — but offer none of the protections, said JoAnn Volk and Justin Giovannelli, researchers at the Georgetown University Center on Health Insurance Reforms, who wrote about the issue last summer.

“The way they advertise and the services they are providing, it sounds a heck of a lot like health insurance,” Giovannelli said. “They’re letting folks believe they have a product that has a promise to pay.”

Sheri Lewis teaches a body-rolling class at Balance Physical Therapy in Issaquah, Wash. Lewis, who was enrolled in a health care sharing ministry, found out that the hip transplant she desperately needed was not covered. She got the procedure in Tijuana, Mexico, with the help of a GoFundMe account.(Dan DeLong for KHN)

That’s exactly what Lewis thought.

“It looked like Aliera was health insurance to me,” she said.

When Aliera denied her surgery, she had to resort to a GoFundMe site organized by friends to raise nearly $13,000 and then travel to Tijuana, Mexico, to get a hip transplant she could afford.

Fuller, who was diagnosed with throat cancer, said he was stuck with $81,000 in bills for his first month of treatment.

“They started checking my insurance and it didn’t cover nothing,” said the retired commercial electrician.

Fuller, his voice still raspy after radiation, said he had insurance through his union for years, but when the premiums spiked, he went online to find something else.

The person he talked to from Aliera said he could get insurance, no problem, Fuller said. The premium would be $350 a month, rather than the $1,300 fee for a gold plan on the state insurance exchange. “And that was with dental, too,” he added.

Low premiums also attracted Bruzas, who left her well-paid government job in Tacoma, and the insurance it provided, after her husband died in 2015. She moved to a small town in southeastern Washington to care for her parents and went online to find health insurance.

“I just sat down and Googled ‘Obamacare,’” she said. “I got a call back from a lady who said she could help me find coverage.” Bruzas was charged $219 for the first month.

Four days later, she was in the local emergency room with massive rectal bleeding. As she was discharged, hospital officials said they had “never heard of Aliera Healthcare,” she said.

The $10,000 bill was not covered. Bruzas, who works part time at a hardware store, filed for charity care and the debt was reduced to $6,500. She is paying it off slowly, $50 each month.

The Washington patients recalled mentions of “sharing” and vague references to spirituality. But none realized they were signing up for a religious cost-sharing ministry, they said.

“I would have hung up the phone if she would have said, ‘We’re a group, and we’ll review your records and pray for you,’” Bruzas said.

Aliera officials said they make the nature of their products clear.

“Aliera disagrees that Trinity’s inclusive and specific statement of beliefs misleads consumers or violates the applicable regulations governing healthcare sharing ministries,” the statement said.

It’s not clear how states can curb the new sharing ministries. If Aliera ignores his order, Kreidler said, he’ll seek a court injunction to force the groups to cease operations. But several states contacted by KHN said that because the ministries are not health insurance, state insurance officials don’t review or regulate them.

Some users of sharing ministries say the lower-priced products should be available for consumers who understand and accept the risks involved.

But consumers need to pay close attention to details when they sign up for any health plans, said Colorado Insurance Commissioner Michael Conway, who is investigating sharing ministries operating in his state.

“Ask if it’s actually insurance,” he advised. “Ask if there’s a guarantee of coverage. Get into the policy documents. Read the contract they’re agreeing to.”

Podcast: KHN’s ‘What The Health?’ States Race To Reverse ‘Roe’

Can’t see the audio player? Click here to listen on SoundCloud.

Alabama is the latest in a growing list of states passing bans on abortion in an attempt to get the Supreme Court to weaken or overturn Roe v. Wade, the 1973 ruling that legalized abortion nationwide. Unlike most of the other state laws that have passed this year, however, the Alabama law would completely ban abortion except when the woman’s life was in danger from the pregnancy.

On Capitol Hill, separate bipartisan groups in the House and Senate unveiled draft proposals to address “surprise” medical bills that patients get when they inadvertently receive care outside their insurance network. The bills take different approaches, however, so it’s not clear where a compromise might lie.

And in Washington state, the legislature has approved a new “public option” health insurance plan — to be run by private insurers — that will become available for consumers who purchase their own insurance.

This week’s panelists are Julie Rovner from Kaiser Health News, Margot Sanger-Katz of The New York Times, Anna Edney of Bloomberg News and Alice Miranda Ollstein of Politico.

Among the takeaways from this week’s podcast:

  • The high court’s justices can pick and choose which cases they take, and many observers think that they are more inclined to deal with abortion on an incremental basis rather than through a radical change like Alabama’s law. A law from Indiana that bans abortions for particular reasons, including gender selection and disability, has been before the court for months.
  • It’s not yet clear if the current spate of state bills will have an impact on the presidential election in 2020, but they could play a role in Senate races in Alabama, Georgia and Maine, among other states.
  • As the effort on surprise medical bills works its way forward, keep an eye on Sen. Lamar Alexander (R-Tenn.), who chairs the committee that handles these measures. He has suggested that he will have another bill to offer on the subject.
  • House Democrats have packed some popular bills to fight rising drug prices with measures to bolster the Affordable Care Act, and Republicans are crying foul. Once again, Sen. Alexander may be a critical player, because he is trying to pull together a measure that deals with drug pricing, surprise medical bills, the cost of health care and the Obamacare marketplaces.
  • Washington has become the first state to embrace a public option insurance plan for its ACA marketplace. But the plan will be run by insurance companies and it’s unclear how that would lead to lower premium prices for consumers.

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 “Why the Government Pays Billions to People Who Claim Injury by Vaccines,” by James Hamblin

Margot Sanger-Katz: Journal of the American Medical Association’s “Association of a Beverage Tax on Sugar-Sweetened and Artificially Sweetened Beverages With Changes in Beverage Prices and Sales at Chain Retailers in a Large Urban Setting,” by Christina A. Roberto, Hannah G. Lawman, Michael T. LeVasseur and others

Alice Miranda Ollstein: The New York Times’ “Why Politics Should Be Kept Out of Miscarriages,” by Aaron E. Carroll

Anna Edney: Kaiser Health News’ “No Mercy: Dealing With Hospital Closure, Pioneer Kansas Town Asks: What Comes Next?” by Sarah Jane Tribble

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California Investigation Blames PG&E Equipment For Igniting Deadliest Wildfire

The utility, which had already acknowledged its electrical transmission lines were probably the cause of last November’s blazes, could face criminal charges following the report from state fire investigators and be held responsible for billions of dollars associated with the destruction and loss of lives. PG&E filed for bankruptcy protection in January.

Pediatric Hospice Can Be A Godsend For Heartbroken Parents. But The Facilities Often Struggle To Stay Afloat.

By some estimates, around half a million children have serious medical conditions that are expected to shorten their lives. For too many of them, death will most likely happen amid the fluorescence and thrumming machinery of an intensive-care unit. For the lucky families, there’s pediatric hospice care. In other public health news: the mysterious illness in diplomats, liver transplants, snakebites, exercise for transgender people, tuberculosis, and more.

Low-Fat Diet Helps Reduce Risk Of Dying From Breast Cancer, 20-Year Study Finds

The rigorous study from the Women’s Health Initiative is the first to show postmenopausal women who modified their diets for at least eight years and who later developed breast cancer had a 21% lower risk of dying of the disease compared to others who ate as usual. “It really suggests that changing your diet, losing weight, exercising, could actually be a treatment,” said Dr. Jennifer Ligibel of the Dana-Farber Cancer Institute. Other women’s health news looks at the benefits of pelvic mesh.