Tagged Cost and Quality

Bad Bedside Manna: Bank Loans Signed In The Hospital Leave Patients Vulnerable

Laura Cameron, then three months pregnant, tripped and fell in a parking lot and landed in the emergency room last May — her blood pressure was low and she was scared and in pain. She was flat on her back and plugged into a saline drip when a hospital employee approached her gurney to discuss how she would pay her hospital bill.

Though both Cameron, 28, and her husband, Keith, have insurance, the bill would likely come to about $830, the representative said. If that sounded unmanageable, she offered, they could take out a loan through a bank that had a partnership with the hospital.

The hospital employee was “fairly forceful,” said Cameron, who lives in Fayetteville, Ark. “She certainly made it clear she preferred we pay then, or we take this deal with the bank.”

Hospitals are increasingly offering “patient-financing” strategies, cooperating with financial institutions to offer on-the-spot loans to make sure patients pay their bills.

Private doctors’ offices and surgery centers have long offered such no- or low-interest financing for procedures not covered by insurance, like plastic surgery, or to patients paying themselves for an expensive test or procedure with a fixed price.

But promoting bank loans at hospitals and, particularly, emergency rooms raises concerns, experts say. For one thing, the cost estimates provided — likely based on a hospital’s list price — may be far higher than the negotiated rate ultimately paid by most insurers. Sick patients, like Cameron, may feel they have no choice but to sign up for a loan since they need treatment. And the quick loan process, usually with no credit check, means they may well be signing on for expenses they can ill afford to pay.

The offers may sound like a tempting solution for scared, vulnerable patients, but they may not be such a great bargain, suggests Mark Rukavina, an expert in medical debt and billing at Community Catalyst, a Boston-based advocacy group.

His point: “If you pay zero percent interest on a seriously inflated charge, it’s not a good deal.”

How The Loans Work

Between higher deductibles and narrower networks, patients are paying larger portions of their medical bills. The federal government estimates consumers spent $352.5 billion out-of-pocket on health care in 2016.

But many patients have trouble coming up with cash to pay bills of hundreds or even thousands of dollars, meaning hospitals are having a harder time collecting what they believe they are owed.

To solve their problem, about 15 to 20 percent of hospitals are teaming up with lenders to offer loans, said Bruce Haupt, CEO of ClearBalance, a loan servicing company. He, along with many other analysts, expects that percentage to grow.

The process begins with a hospital estimate of a patient’s bill, which takes insurance coverage into account. A billing representative then lays out payment plans for the patient, often while he or she is still being treated.

A patient can then sign up for a loan, often without a credit check. Patients write smaller monthly checks to the lender, who has paid the hospital, while keeping a designated percentage of the bill as a fee.

Proponents view financing as a useful alternative to medical credit cards, which can surprise users with high interest rates. The partnerships are tempting for hospitals since they offload the need to administer monthly payment plans and collection efforts.

Federal law requires lenders be transparent about the loan terms, a protection that extends to consumers entering these health care arrangements. That means disclosure of interest rates, other fees and the payment schedule.

Even so, said Gerard Anderson, a Johns Hopkins health policy professor and an expert on health care pricing, “it’s an often gentler version of asking you to pay up.”

But an on-the-stretcher sell leaves patients little opportunity for due diligence.

“What’s the charge they’re using to determine what’s a reasonable amount to pay?” Anderson added.

Cameron was suspicious of the $830 estimate of her bill, since she had good coverage from her job at the University of Arkansas. She and her husband had extensive experience with the health care system and its costs. No one had ever asked her to pay upfront, even when her husband owed tens of thousands for cancer treatment.

“It just felt so uncomfortable to us that they would try to push us through a bank, which is designed to make a profit,” Cameron said.

A Growth Business With Risk Of Default

At Florida-based Orlando Health, which works with ClearBalance, loans typically range from $3,000 to $7,000, said Michele Napier, the health system’s chief revenue officer. The highest debt a patient has taken on — about $13,000 — was because of a high-deductible plan, she said.

“All of a sudden a catastrophic event occurs, and to have $13,000 in the bank account is a lot to ask,” she said. “They’re able to spread those payments.”

Though Laura Cameron and her husband have insurance, a hospital employee told them that an emergency room bill after a then-pregnant Laura was treated for a fall would likely total about $830. The employee said that if they couldn’t afford that, they could take out a loan through a bank that had a partnership with the hospital. The Camerons declined the offer. (Charlie Kaijo for Kaiser Health News)

Low-income patients without insurance likely will not need loans to finance large bills,because they should quality for aid from the hospital, or be treated as charity care, Napier said.

It’s a conversation that starts at registration, she added. “If a patient shares with us that they have no resources or limited resources to pay, we will provide information on our financial assistance and other programs including screening them for Medicaid.”

The idea is to foster open conversations about cost and help patients and doctors weigh their options, both financial and medical, said Rick Gundling, a senior vice president at the Healthcare Financial Management Association, a trade group.

“The patient may say, ‘Hey, do I need to do this knee surgery now? Can we wait until I save up, or do I have other options, like physical therapy?’” he said. “The doctor may say … let’s look at other options.”

But the loans can be a band-aid solution, leading vulnerable patients to sign up to pay far more than they should, said Kathleen Engel, a research professor of law at Boston-based Suffolk University and an expert in consumer credit and mortgage finance.

“The hospital potentially is charging the patient the full, what I would call ‘whack rate’ for their care,” she said. “They try to collect the debt.”

Since many of these loans come without credit checks or affordability tests, the odds are higher that a loan could be financially unwise, experts warn.

At ClearBalance, loans average about $1,700, Haupt said. In practice, that means some patients are financing $150 bills, while others have them for as large $50,000.

Default rates vary across the country, with the highest default rates — up to 1 in 5 patients — in places such as Texas and Louisiana. In other areas, closer to 6 or 7 percent of patients ultimately cannot pay off their loans.

“Some of these people are destined to default,” Engel said. “If you have to get a loan for $500 for medical care, that means you are really living at the margins.”

Cameron declined the loan — and chose not to hand over any other form of payment. She wanted to wait until she received her insurance statement.

In the end, the couple owed only $150, the copayment for an ER visit. “It felt to us like it could screw someone over who wasn’t aware about how to work that system,” she said, though she admitted to feeling intimidated as she lay on the stretcher.

She added: “It can be scary feeling like you owe someone money.”

Bad Bedside Manna: Bank Loans Signed In The Hospital Leave Patients Vulnerable

Laura Cameron, then three months pregnant, tripped and fell in a parking lot and landed in the emergency room last May — her blood pressure was low and she was scared and in pain. She was flat on her back and plugged into a saline drip when a hospital employee approached her gurney to discuss how she would pay her hospital bill.

Though both Cameron, 28, and her husband, Keith, have insurance, the bill would likely come to about $830, the representative said. If that sounded unmanageable, she offered, they could take out a loan through a bank that had a partnership with the hospital.

The hospital employee was “fairly forceful,” said Cameron, who lives in Fayetteville, Ark. “She certainly made it clear she preferred we pay then, or we take this deal with the bank.”

Hospitals are increasingly offering “patient-financing” strategies, cooperating with financial institutions to offer on-the-spot loans to make sure patients pay their bills.

Private doctors’ offices and surgery centers have long offered such no- or low-interest financing for procedures not covered by insurance, like plastic surgery, or to patients paying themselves for an expensive test or procedure with a fixed price.

But promoting bank loans at hospitals and, particularly, emergency rooms raises concerns, experts say. For one thing, the cost estimates provided — likely based on a hospital’s list price — may be far higher than the negotiated rate ultimately paid by most insurers. Sick patients, like Cameron, may feel they have no choice but to sign up for a loan since they need treatment. And the quick loan process, usually with no credit check, means they may well be signing on for expenses they can ill afford to pay.

The offers may sound like a tempting solution for scared, vulnerable patients, but they may not be such a great bargain, suggests Mark Rukavina, an expert in medical debt and billing at Community Catalyst, a Boston-based advocacy group.

His point: “If you pay zero percent interest on a seriously inflated charge, it’s not a good deal.”

How The Loans Work

Between higher deductibles and narrower networks, patients are paying larger portions of their medical bills. The federal government estimates consumers spent $352.5 billion out-of-pocket on health care in 2016.

But many patients have trouble coming up with cash to pay bills of hundreds or even thousands of dollars, meaning hospitals are having a harder time collecting what they believe they are owed.

To solve their problem, about 15 to 20 percent of hospitals are teaming up with lenders to offer loans, said Bruce Haupt, CEO of ClearBalance, a loan servicing company. He, along with many other analysts, expects that percentage to grow.

The process begins with a hospital estimate of a patient’s bill, which takes insurance coverage into account. A billing representative then lays out payment plans for the patient, often while he or she is still being treated.

A patient can then sign up for a loan, often without a credit check. Patients write smaller monthly checks to the lender, who has paid the hospital, while keeping a designated percentage of the bill as a fee.

Proponents view financing as a useful alternative to medical credit cards, which can surprise users with high interest rates. The partnerships are tempting for hospitals since they offload the need to administer monthly payment plans and collection efforts.

Federal law requires lenders be transparent about the loan terms, a protection that extends to consumers entering these health care arrangements. That means disclosure of interest rates, other fees and the payment schedule.

Even so, said Gerard Anderson, a Johns Hopkins health policy professor and an expert on health care pricing, “it’s an often gentler version of asking you to pay up.”

But an on-the-stretcher sell leaves patients little opportunity for due diligence.

“What’s the charge they’re using to determine what’s a reasonable amount to pay?” Anderson added.

Cameron was suspicious of the $830 estimate of her bill, since she had good coverage from her job at the University of Arkansas. She and her husband had extensive experience with the health care system and its costs. No one had ever asked her to pay upfront, even when her husband owed tens of thousands for cancer treatment.

“It just felt so uncomfortable to us that they would try to push us through a bank, which is designed to make a profit,” Cameron said.

A Growth Business With Risk Of Default

At Florida-based Orlando Health, which works with ClearBalance, loans typically range from $3,000 to $7,000, said Michele Napier, the health system’s chief revenue officer. The highest debt a patient has taken on — about $13,000 — was because of a high-deductible plan, she said.

“All of a sudden a catastrophic event occurs, and to have $13,000 in the bank account is a lot to ask,” she said. “They’re able to spread those payments.”

Though Laura Cameron and her husband have insurance, a hospital employee told them that an emergency room bill after a then-pregnant Laura was treated for a fall would likely total about $830. The employee said that if they couldn’t afford that, they could take out a loan through a bank that had a partnership with the hospital. The Camerons declined the offer. (Charlie Kaijo for Kaiser Health News)

Low-income patients without insurance likely will not need loans to finance large bills,because they should quality for aid from the hospital, or be treated as charity care, Napier said.

It’s a conversation that starts at registration, she added. “If a patient shares with us that they have no resources or limited resources to pay, we will provide information on our financial assistance and other programs including screening them for Medicaid.”

The idea is to foster open conversations about cost and help patients and doctors weigh their options, both financial and medical, said Rick Gundling, a senior vice president at the Healthcare Financial Management Association, a trade group.

“The patient may say, ‘Hey, do I need to do this knee surgery now? Can we wait until I save up, or do I have other options, like physical therapy?’” he said. “The doctor may say … let’s look at other options.”

But the loans can be a band-aid solution, leading vulnerable patients to sign up to pay far more than they should, said Kathleen Engel, a research professor of law at Boston-based Suffolk University and an expert in consumer credit and mortgage finance.

“The hospital potentially is charging the patient the full, what I would call ‘whack rate’ for their care,” she said. “They try to collect the debt.”

Since many of these loans come without credit checks or affordability tests, the odds are higher that a loan could be financially unwise, experts warn.

At ClearBalance, loans average about $1,700, Haupt said. In practice, that means some patients are financing $150 bills, while others have them for as large $50,000.

Default rates vary across the country, with the highest default rates — up to 1 in 5 patients — in places such as Texas and Louisiana. In other areas, closer to 6 or 7 percent of patients ultimately cannot pay off their loans.

“Some of these people are destined to default,” Engel said. “If you have to get a loan for $500 for medical care, that means you are really living at the margins.”

Cameron declined the loan — and chose not to hand over any other form of payment. She wanted to wait until she received her insurance statement.

In the end, the couple owed only $150, the copayment for an ER visit. “It felt to us like it could screw someone over who wasn’t aware about how to work that system,” she said, though she admitted to feeling intimidated as she lay on the stretcher.

She added: “It can be scary feeling like you owe someone money.”

Reducing Red Tape For Traveling Nurses

Lauren Bond, a traveling nurse, has held licenses in five states and Washington, D.C. She maintains a detailed spreadsheet to keep track of license fees, expiration dates and the different courses each state requires.

The 27-year-old got into travel nursing because she wanted to work and live in other states before settling down. She said she wished more states accepted the multistate license, which minimizes the hassles nurses face when they want to practice across state lines.

“It would make things a lot easier — one license for the country and you are good to go,” said Bond, who recently started a job in California, which does not recognize the multistate license.

The license, known as the Nurse Licensure Compact (NLC), was launched in 2000 to address nursing shortages and enable more nurses to practice telehealth. Under the agreement, registered nurses licensed in a participating state can practice in other NLC states without needing a separate license. They must still abide by the laws that govern nursing wherever their patients are located.

About half of the states joined the original compact, which was modeled on the portability of a driver’s license. Some states that declined to sign on cited a major flaw: The agreement didn’t require nurses to undergo federal fingerprint criminal background checks.

Last month, the National Council of State Boards of Nursing launched a new version of the NLC that requires those checks. Twenty-nine states have passed legislation to join the new agreement.

Jim Puente, who oversees the compact for the council, said he expects even more states to sign the agreement now that criminal background checks are required. He noted that nine states have legislation pending to join.

Among states participating in the new nurse licensing compact are Iowa, Kentucky, Tennessee, Delaware, Idaho and Arizona.

California does not plan to join the new compact, largely because of concern about maintaining state training and quality standards. The state, like many others, already requires nurses to undergo background checks. Washington, Oregon and Nevada are among the other states that do not accept the multistate license.

Proponents of the nurse licensing agreement — both the old and new versions — argue that it helps fill jobs in places where there aren’t enough nurses and enables nurses to respond quickly to natural disasters across state lines.

“The nurse shortage tends to wax and wane regionally, so being able to move nurses where the needs are is really, really important,” said Marcia Faller, chief clinical officer at AMN Healthcare, a San Diego-based medical staffing company that employs Bond. The multistate license “really helps with that mobility … to deliver care to patients across state lines.”

Similar cross-state agreements exist for physicians, psychologists, emergency medical technicians and physical therapists.

In some states, the multistate nursing license is helpful because it streamlines the process for nurses doing case management or telehealth, said Sandra Evans, executive director of the Idaho Board of Nursing. Getting nurses to work in the rural areas of Idaho is a challenge, and hospitals often rely on telemedicine in places where the closest health care facility might be in Montana, she said.

Before Idaho joined the original NLC in 2001, nurses doing telehealth or case management needed numerous licenses to work across state lines, but now they “can travel virtually — electronically or telephonically — to help their clients,” she said.

Joey Ridenour, executive director of the Arizona State Board of Nursing, said one of the biggest advantages of the compact for her state is that it allows authorities to share information and collaborate with other states to investigate and discipline problem nurses. “We are able to take action faster,” she said.

Opponents of the compact argue that states have different standards, course requirements and guidelines and that nurses licensed in one state may lack the necessary knowledge or experience to practice in another one.

“The ability to control the standards of training and quality are of some concern to us,” said Linda McDonald, president of United Nurses and Allied Professionals union in Rhode Island, which participated in the original NLC but hasn’t signed on to the new one. “We want them trained in Rhode Island. We want them licensed in Rhode Island.”

Nurses in California have similar concerns. “We really want to make sure that nurses who are entering our state and taking care of our patients are competent and qualified,” said Catherine Kennedy, a Sacramento-area nurse who is secretary of the California Nurses Association. Some traveling nurses haven’t been, she added.

Kennedy said California does not have difficulty recruiting nurses, even without the compact, because of the state’s relatively high salaries and strict nurse-to-patient ratios in hospitals.

Research has shown that California’s minimum nurse staffing requirements, which were the first in the nation, can reduce workloads and burnout, improve the quality of care and make it easier for hospitals to retain their nurses.

Lauren Bond, a traveling nurse who has a temporary position at UCLA Medical Center, Santa Monica, has held licenses in five states and the District of Columbia. She maintains a detailed spreadsheet to keep track of license fees, expiration dates and the different courses each state requires. (Courtesy of Robert Hernandez/UCLA Health)

Massachusetts, which has never participated in the nurse licensing compact, requires nurses licensed there to take courses on treating victims of domestic violence and sexual assault, said Judith Pare, director of the division of nurses for the Massachusetts Nurses Association. If the state allowed out-of-state nurses to practice in Massachusetts without getting a license there, they wouldn’t necessarily have that training, she noted.

Bond, the traveling nurse, said additional courses don’t make her more qualified to do her job. “Across the board, wherever you go to nursing school, everybody comes out with a similar experience,” said Bond, who works at UCLA Medical Center in Santa Monica. “Then most of the training you are going to do is on the job.”

Jenn Stormes works as a nurse and formally cares for her 18-year-old son, who has a severe seizure disorder and developmental disabilities. Stormes is licensed in Colorado, which participates in the multistate compact.

She has been able to use that license in some states. But she has also had to get several individual licenses so she can continue serving as her son’s nurse in other states where the family travels for medical care. Stormes estimated she has spent about $2,000 on licenses.

“It took me over a year to get all these licenses,” she said. “I had to prove to every state the same education, the same experience, the same fingerprints. I think it is a duplication of efforts and is a waste of everybody’s time and money.”

Listen: Got A Sky-High Bill? Don’t Write The Check.

Have you gotten a medical bill that sounds way too expensive or is just downright confusing? Elisabeth Rosenthal, the editor-in-chief of Kaiser Health News, says don’t be intimidated — and don’t just pay that bill. Call, discuss and negotiate, instead.

And if you are up for it, share your bill and your experience with KHN and NPR. On Friday, Rosenthal and NPR Morning Edition Host Steve Inskeep discussed the launch of “Bill Of The Month,” a crowdsourced investigation.

Listen below.

‘Bill Of The Month’: A College Student’s $17,850 Drug Test

This is the debut of a monthly feature from Kaiser Health News and NPR that will dissect and explain real medical bills in order to shed light on U.S. health care prices and to help patients learn how to be more active in managing costs. Do you have a medical bill that you’d like us to see and scrutinize? Submit it here and tell us the story behind it.

In her late 20s and attending college in Texas, Elizabeth Moreno suffered from debilitating back pain caused by a spinal abnormality. “I just could not live with the pain,” she said. “I couldn’t get dressed by myself, I couldn’t walk across my house, let alone to class, and nothing, no drug that had been prescribed to me, even dulled the pain.”

Moreno says she also tried chiropractic medicine and acupuncture, but they didn’t make the pain go away. Finally, a doctor at the student health center referred her to an orthopedic specialist who performed tests and concluded a disc was blocking nerves down her legs and needed to be removed. Moreno’s father, a retired Ohio doctor who had seen many failed back surgeries over his career, agreed it was the best course.

In late 2015, Moreno had the operation in Houston, which she described as “a complete success.” She gave it little thought when the surgical office asked her to leave a urine sample for a drug test.

Then the bill came.

Patient: Elizabeth Moreno, then 28, a student at Texas State University in San Marcos.

Total bill: $17,850 for a urine test in January 2016

Service provider: Sunset Labs LLC of Houston

Medical treatment: Moreno had a disc removed from her back in December 2015. Her surgeon prescribed an opioid painkiller, hydrocodone. At a follow-up office visit in mid-January 2016, the staff asked her to leave a urine sample, which she figured was routine. In March 2017, over a year later, the lab sent her a bill for $17,850 for testing her urine for a slew of drugs, including cocaine, methadone, anti-anxiety drugs and several other drugs she had never heard of.

(Story continues below.)

What gives: Urine drug testing has exploded over the past decade amid alarm over rising opioid overdose deaths. Many doctors who prescribe the pills rely on the urine tests to help reduce drug abuse and keep patients with chronic pain safe. Yet the tests have become a cash cow for a burgeoning testing industry, and critics charge that unneeded and often expensive ones are sometimes ordered for profit rather than patient care. Doctors can decide whether to test patients who take opioids for short periods, such as after an operation. Moreno’s surgeon would not discuss her urine test — why he ordered it and why the sample was tested for so many substances.

Related Story: Pain Hits Long After Surgery When Doctor’s Daughter Is Stunned By $17,850 Urine Test

Three experts contacted by Kaiser Health News questioned the need for such extensive testing and were shocked to hear of the lab’s prices. They said these tests rarely cost more than $200, and typically much less, depending on the complexity and the technology used. Some doctors’ offices use a simple cup test, which can detect several classes of drugs on the spot and could be purchased for about $10. Bills can climb higher when labs run tests to detect the quantity of specific drugs and bill for each one, as the lab did here.

The experts KHN interviewed said that the lab’s prices for individual tests were excessive, such as charging $1,700 to check for amphetamines or $425 to identify phencyclidine, an illegal hallucinogenic drug also known as PCP. They also criticized a charge of $850 for two tests to verify that her urine sample had not been adulterated or tampered with.

Moreno’s insurer, Blue Cross and Blue Shield of Texas, refused to pay any of the bill, arguing that the lab was out-of-network and thus not covered. Had it chipped in, it would have covered the service at $100.92, according to an explanation of benefits the insurance company sent to Moreno.

Sunset Labs says its list prices were “in line” with its competitors in the area. It also said doctors treating pain agree extensive urine testing is “the best course of action” and that a lab “is not in the position” to question tests ordered by a doctor.

Resolution: Fearing damage to his daughter’s credit rating, Moreno’s father, Dr. Paul Davis, paid the lab $5,000 in April 2017 to settle the bill. A retired doctor, he also has filed a formal complaint about the bill with the Texas attorney general’s office, accusing the lab of “price gouging of staggering proportions.” The lab’s attorney said he was not aware of the complaint. A Texas attorney general’s spokesperson confirmed to KHN that the office had received complaints about the lab, but declined further comment.

The takeaway: When a physician asks for a urine or blood sample, always ask what it’s for. Insist that it be sent to a lab in your insurance network.

Source: AG complaint; interviews

In An Effort To Curb Drug Costs, States Advance Bills To Prod Feds On Importation

Norm Thurston is a “free-market guy” — a conservative health economist in Republican-run Utah who rarely sees the government’s involvement in anything as beneficial.

But in a twist, the state lawmaker is now pushing for Utah to flex its muscle to spur federal action on ever-climbing prescription drug prices.

“This is something that a red state like Utah could do. I don’t think this is a partisan issue,” Thurston said. “Those outrageous cost increases are not the result of the free market.”

The approach: Let the state contract with wholesalers in Canada, importing cheaper prescriptions from up north and distributing them to the state’s health care system.

Other states — Vermont, West Virginia and Oklahoma, among them — are following similar paths, pushing legislation that would seek permission from the Trump administration to launch their own plans to import drugs from Canada.

For years, American consumers have tried to buy cheaper drugs from their northern neighbor, sometimes packing into buses for day trips to Canadian pharmacies, or patronizing American stores that help them order drugs from abroad. But the practice is illegal.

The states want to change that, and set up a formal process that nets broader savings. The idea is for the state health department to set up a wholesale program that buys drugs from Canada and resells them to local pharmacies and hospitals. Individual states would be responsible for ensuring that the medications are safe and that importing them does save money.

“This statute is putting pressure on the federal government to take a harder look at these questions,” said Rachel Sachs, an associate law professor at Washington University of St. Louis, who researches drug price regulations. “The state legislatures can say, ‘Look, we’re doing everything we can, but we do need the federal government to help us out on this.’”

The federal government has been slow to act on this issue, and skeptics say a 30-page Trump administration memo on drug pricing released late last week would likely have only limited impact.

But states, whose budgets for Medicaid and state employee health programs are squeezed by these costs, are moving forward.

In Vermont alone, drug spending has gone up by 35 percent from 2010 to 2015, the most recent year for which data are available.

Backers of the state plans say the strategy is a no-brainer that could save hundreds of millions of dollars. They discount concerns about drug safety, arguing that drugs from Canada are made by reputable companies, often in the same facilities and by the same firms that sell them in the U.S. — but at much higher prices.

“We would be bringing in drugs intended for the Canadian market, and therefore at Canadian pricing,” Thurston said. “One would assume if we could come up with a program that meets the recommendations of federal law, what justification would the [Health and Human Services] secretary have for saying no?”

The state measures follow model legislation developed by the National Academy for State Health Policy that uses a framework put in place by the 2003 federal law that created the Medicare Part D program. That law says the U.S. Department of Health and Human Services can approve drug importation plans if it is convinced the plans will save money and will not create any public health concerns.

Once passed, these laws task state health departments with overseeing the development of these programs. After the health department settles on the specifics, state officials must negotiate implementation with HHS. That could take years.

It is also likely to be an uphill battle.

In 15 years, HHS has never acted upon the 2003 law by approving any drug importation program.

Last spring, when members of Congress pushed a national bill, a bipartisan group of former Food and Drug Administration commissioners came out in opposition, arguing it would be impossible to verify drug safety absolutely. That bill ultimately failed to garner a majority vote.

It’s unclear where the current administration stands on this issue.

Alex Azar, the newly confirmed HHS secretary, has been coy on the subject — though in a confirmation hearing last fall, he said importing drugs from Canada could create safety concerns. Despite multiple requests, HHS did not provide comment for this story by the publication deadline.

The pharmaceutical industry echoed the cautions about safety.

“The proposals we are seeing in states across the country threaten the safety of patients and families and will not deliver the savings they promise,” said Priscilla VanderVeer, a spokeswoman for the trade group Pharmaceutical Research and Manufacturers of America (PhRMA).

In the states, though, backers say their bills address that concern.

And other analysts argued that, regardless, safety of Canadian drugs isn’t a real issue.

“A lot of the drugs used in the United States and in Canada are made in the same plants, in countries like India or Europe,” said Michael Law, a pharmaceutical policy expert and associate professor at the University of British Columbia’s Center for Health Services and Policy Research. “The U.S. FDA and other regulatory agencies rely on other agencies’ inspections — the idea that Canadian drugs are these dangerous drugs is a red herring.”

A bigger question, he said, is the amount of savings these bills would generate.

Thurston pointed to Utah state analyses that suggest the state could save $70 million in the private sector, and another $20 million to $30 million in state-funded insurance programs. If approved, he said, the state would target 15 to 20 drugs to import — insulin, for instance, because it is bought in large quantities, or expensive drugs that treat hepatitis C or HIV.

Others expressed skepticism.

For one thing, the true price of prescription drugs isn’t always clear. There’s the list price — and generally, those are much higher in the United States. But insurance plans often negotiate rebates, or discounts, from the drug company — meaning they can end up paying far less than what’s advertised. Those discounts aren’t public, making it much harder to compare prices between the two countries.

The drug industry would also likely employ strategies to counter importation.

Pharmaceutical companies, Law noted, stand to lose if American states are importing cheaper drugs. That could motivate them to tamp down how many prescriptions they sell in Canada, or find other ways to discourage Canadian wholesalers from participating.

“My guess is any Canadian distributor to engage in that would find their [medication] supply dwindle quickly, because the drug companies would stop supplying,” he said. “The supplier systems in the United States would probably find it hard to get a [Canadian drug] supply in the long term.”

That’s certainly a real concern, said Claire Ayer, a Vermont state senator and Democrat who chairs her legislature’s Health and Welfare Committee.

“We can’t tell drug companies or wholesalers what to do in Canada,” she added.

VanderVeer said PhRMA could not speculate on how individual drug companies may react to importation.

Still, these state efforts could spur the federal government to take action, Sachs suggested — even if it’s unclear how large an impact importation would have.

“Importation will not solve all the problems — and I don’t think states see it as such,” she said. “But it could be a useful way to put pressure on a federal government and White House that has thus far largely been inactive on this topic.”

Pain Hits After Surgery When A Doctor’s Daughter Is Stunned By $17,850 Urine Test

After Elizabeth Moreno had back surgery in late 2015, her surgeon prescribed an opioid painkiller and a follow-up drug test that seemed routine — until the lab slapped her with a bill for $17,850.

A Houston lab had tested her urine sample for a constellation of legal and illicit drugs, many of which, Moreno said, she had never heard of, let alone taken.

“I was totally confused. I didn’t know how I was going to pay this,” said Moreno, 30, who is finishing a degree in education at Texas State University in San Marcos and is pregnant with twins.

Related: Bill Of The Month: A College Student’s $17,850 Urine Test

Her bill shows that Sunset Labs LLC charged $4,675 to check her urine for a slew of different types of opioids: $2,975 for benzodiazepines, a class of drugs for treating anxiety, and $1,700 more for amphetamines. Tests to detect cocaine, marijuana and phencyclidine, an illegal hallucinogenic drug also known as PCP or angel dust, added $1,275 more.

The lab also billed $850 to test for buprenorphine, a drug used to treat opioid addiction, and tacked on an $850 fee for two tests to verify that nobody had tampered with her urine specimen.

Total bill: $17,850 for lab tests that her insurer, Blue Cross and Blue Shield of Texas, refused to cover, apparently because the lab was not in her insurance network. The insurer sent Moreno an “explanation of benefits” that says it would have valued the work at just $100.92.

Moreno’s father, in a complaint to the Texas attorney general’s office about the bill, identified the Houston surgeon who ordered the costly test as Dr. Stephen Esses. His office told Kaiser Health News the surgeon would have no comment.

Sunset Labs is part of a network of pain clinics and other medical businesses founded by Houston anesthesiologist Phillip C. Phan, according to Texas secretary of state filings and court records. Court records say Phan’s companies also own the facility where Moreno had her operation.

Three experts interviewed by KHN said the lab grossly overcharged; they also doubted the need for the test.

“This just blows my mind,” said Jennifer Bolen, a former federal prosecutor and lab and pain management consultant. “It’s very high and incredibly out of the norm.”

Dan Bowerman, a medical fraud expert, called the lab bill “outrageous” and “unconscionable” and said it should have prompted an investigation.

“Sounds real fishy,” added Charles Root, a veteran industry adviser. He wondered if the lab had “misplaced the decimal point,” because such a test should cost a few hundred dollars, tops.

The lab disagrees.

Sunset’s billings “are in line with the charges of competing out-of-network labs in the geographical area,” lab attorney Justo Mendez said in an emailed statement.

Mendez said pain doctors agree that extensive urine testing is “the best course of action” and that a lab “is not in the position” to question tests ordered by a doctor.

Urine testing for patients with chronic pain has grown explosively over the past decade amid a rising death toll from opioid abuse. Pain doctors say drug testing helps them make sure patients are taking the drugs as prescribed and not mixing them with illegal substances.

Yet the testing boom costs billions of dollars annually and has raised concerns that some labs and doctors run urine tests needlessly — or charge exorbitant rates — to boost profits.

Some insurers have refused to pay, which can leave patients like Moreno threatened with ruinously high bills they had no idea they had incurred.

“Surprise bills larded with unexpected expenses and little explanation inflict sticker shock on vulnerable patients,” said James Quiggle, communications director of the Coalition Against Insurance Fraud, whose members include insurers, consumer groups and government agencies. Quiggle said many “puffed-up bills straddle a fine line between abuse and outright fraud.”

Moreno said her insurance covered the disc removal surgery in December 2015. She said the operation went well and she weaned off the hydrocodone pain pills. To her surprise, on a second return about a month later, the surgeon’s office asked her to leave a urine sample.

“I didn’t think anything of it,” Moreno said of the test. “I said fine, whatever.”

More than a year later, she said, the lab phoned while she was driving and asked her to pay the $17,850 bill. The lab then sent her an invoice, dated March 10, 2017, which states: “[B]ased upon information from your health plan, you owe the amount shown.”

(Story continues below.)

Luckily, her father, Dr. Paul Davis, was visiting her in Texas at the time. Davis, 66, is a retired family practice doctor from Findlay, Ohio.

Davis doubted the need for the test, not to mention what he thought was a sky-high price. He said the University of Findlay, where he helped train physician assistants, gave applicants a basic drug test at a cost of $174, while the local juvenile courts in Ohio paid $10 for a simple drug screen.

Fearing it would ruin his daughter’s credit scores, Davis said, he called Sunset and settled the bill in April 2017 by paying $5,000, which he said he now regrets. The lab sent Moreno a receipt that said it discounted her bill because of “financial need/hardship.”

Asked for comment, Blue Cross spokesman James Campbell said he couldn’t discuss a specific case but noted:

”We are disappointed as well as concerned about transparency whenever [any] member is surprised by an excessive charge for a seemingly routine service or received services that may not have been medically necessary.”

Campbell also said the lab was out-of-network and “we do not control how much they charge for services rendered.” The insurer encourages patients to confirm that all medical care they seek comes from medical providers in the Blue Cross network, he added.

Prices for urine tests can vary widely depending upon complexity and the technology used. Some doctors’ offices use a simple cup test, which can detect several classes of drugs on the spot. These tests rarely cost more than $200, and typically much less.

Bills climb higher when labs check for levels of multiple drugs and bill for each one, a practice insurers argue is seldom medically justified. But even labs sued by insurers alleging wildly excessive testing typically have billed $9,000 or less, court records show. One insurer sued a lab for charging $1,845 for a drug test, for instance.

Davis said Sunset Labs ignored his requests for a full explanation of the charges. In May, he filed a written complaint about the bill with the Texas attorney general’s office that included a copy of the bill and accused the lab of “price gouging of staggering proportions.”

“Young people just starting out, such as my daughter, may not have the ability to pay and this could result in damaged credit ratings or even bankruptcy,” he wrote.

Davis got a letter back from Attorney General Ken Paxton, who said the office would “review the information.” A spokesperson for Paxton told KHN: “We have received complaints about that business, but we can’t comment on anything else.” Sunset attorney Mendez said the lab is “not aware” of any such complaints.

In an interview, Davis also questioned the need for his daughter’s urine test because she received opioids only for a short period and the results would have had no impact on her treatment. In his complaint to the attorney general, Davis said the surgeon told him he ordered the tests because he feared possible retribution from the state medical licensing board for not testing patients who had been prescribed an opioid. The Texas Medical Board doesn’t require urine tests for patients receiving opioids for short-term pain, said spokesman Jarrett Schneider. That’s a “question of independent medical judgment as to whether the physician believes a drug test should be required,” he said.

Bad Reviews

Sunset Labs has an “F” rating with the Houston Better Business Bureau, which on its website posts an August 2017 complaint from a patient charged $16,150 for a urine test.

“This is not covered under my health insurance so I am expected to pay this excessive bill,” the complaint reads.

A second website that publishes government billing numbers of doctors and medical businesses includes a comment section with more than a dozen negative “reviews,” mostly complaints that the lab slammed patients with thousands of dollars in fees their insurers balked at paying.

In a pair of lawsuits filed in 2015, three doctors seeking to quit working at pain clinics operated by Phan accused the facilities of improper billing practices, including unnecessary urine testing. The doctors said they feared losing their medical licenses unless they severed their ties.

In one suit, Drs. Purvi Patel and Lance LaFleur also alleged that the pain clinics “pressured” doctors to overprescribe medical gear and genetic tests to insured patients “regardless of medical necessity.” The case did not go forward because the doctors did not pursue it. Neither doctor would comment.

In the second legal case, pain specialist Dr. Baominh Vinh said he resigned in April 2015 “based on certain questionable business practices … that are inconsistent with my ethical boundaries.” Vinh also alleged urine testing was overused. In a countersuit against Vinh, the pain clinics called his allegations a “falsehood” to justify violation of his employment contract.

The parties settled in March of last year. Terms are confidential, but a lawyer for the pain clinics said Vinh paid money to the company “and not vice versa.”

FDA Head Vows To Tackle High Drug Prices And Drugmakers ‘Gaming The System’

Food and Drug Administration Commissioner Scott Gottlieb said he will do everything “within my lane” to combat high drug prices and that he sees drug companies “gaming the system to try to block competition” in a multitude of ways in the marketplace.

In a wide-ranging interview with Kaiser Health News on Thursday, Gottlieb also said that he wants to speed up the U.S. approval process for generic and “biosimilar” versions of biologic drugs, which are drugs comprised of living organisms, such as plant or animal cells.

“Where we see things that we can address, we’re going to take action,” Gottlieb said, adding that he is most bothered when brand-name companies use tactics to block makers of generics and biosimilars from developing drugs. He deflected questions about whether the FDA approves drugs of questionable value that carry exorbitant prices.

“I think we should have a free market for how products are priced,” Gottlieb said. A free market “provides proper incentives for entrepreneurs who are going to make the big investments needed to innovate. But that system is predicated on a premise that when patents have lapsed you’ll have vigorous competition from generic drugs.”

The FDA, Gottlieb said, worked with the White House on a proposal to bring generics to market faster by ensuring that a 180-day exclusivity period isn’t used by drugmakers to block competition. He said there are “situations where you see deals cut” in which a drugmaker will get the 180-day exclusivity and then be persuaded to sit on it without ever selling the drug — essentially delaying the brand drug from facing generic competition.

Currently, generics makers must buy large quantities of the brand-name product in the U.S. to run their own clinical trials. But the companies that make brand-name medicines, in some cases, are making it very difficult for makers of generics to purchase their drugs, he said.

“They are adopting all kinds of commercial restrictions with specialty pharma distributors and wholesalers” to prevent sales to generic companies, Gottlieb said, adding that not every branded company is using the tactic, but it is “going on across the board.”

To come up with a generic, a drugmaker needs 2,000 to 5,000 doses for testing, Gottlieb said. He said the companies were willing to pay sticker price but are being blocked in other ways.

The FDA is now exploring whether generics makers could buy the drugs they need in the less-expensive European market without having to do additional work to prove the biologics from Europe are the same — even though the American and European versions are often manufactured in the same plants. Gottlieb wants to get rid of such tests, known as “bridging” studies.

“I have lawyers now looking at this,” Gottlieb said. The FDA has been exploring the issue for a couple of months, he said, and he thinks it may be “hard for us to get there without legislation, but we’re not done yet looking at this; we’re still pressing on this.”

Last fall, Gottlieb said that he wanted to “end the shenanigans” that interfere with competition in the marketplace. Since then, the FDA has released a steady stream of action plans and new guidance that tinkers with the drug development system.

“All of these steps are going to have an impact, and I don’t think there’s one silver bullet,” Gottlieb said. “If anyone [thinks] there is one thing you can do with policy intervention that is going to dramatically change drug prices, that’s not true.”

Instead, he said, there are “layers of things that we can do to try to make sure the system is working.”

The agency has been approving drugs at a fast clip: The FDA’s Center for Drug Evaluation and Research approved a record 46 new drugs in 2017, including treatments for sickle cell disease and Batten disease and new cancer therapies. The list doesn’t include landmark gene and cellular therapies and vaccines that are regulated as biologics.

That rate of approvals has raised concerns about the value and quality of drugs being approved. Specifically, criticism of the FDA’s handling of cancer drugs has increased in recent years.

Although some patient advocates want the FDA to approve new drugs more quickly, others charge that the agency greenlights mediocre cancer drugs that do little to prolong survival or improve quality of life. A 2014 study found that the cancer drugs approved from 2002 to 2014 extended survival by an average of just 2.1 months. For many cancer drugs, there is no evidence showing they prolong life.

Once drugs are on the market, companies can charge whatever the market will bear; prices for cancer therapies now routinely top $100,000 a year.

But Gottlieb said it’s not his job to help insurance companies or government programs decide which drugs to cover. Health systems and insurers “have a difficult time saying no,” Gottlieb said, “so they want to put the regulator in the position of saying no.”

Gottlieb acknowledged that it can be difficult for insurance plans to decide which drugs they should include on their drug list. But insurance plans “ought to have the confidence to make [such decisions] and not say, ‘Well, it’s the job of the federal government to make those decisions for us.’”

Gottlieb defended his agency’s approval of drugs that help the average cancer patient live just two or three extra months, noting that some patients do much better than average on cancer drugs — perhaps living months or even years longer than expected. He also said it would be wrong to make cancer patients wait years to try a drug that has a chance to help them.

“We’re ultimately going to learn why some patients respond really well and some don’t,” he said. If you “try to have all that information upfront when you approve a drug, [you’ll] end up having a development process that is very long and very costly and a lot fewer products will be developed.”

Gottlieb maintains that the FDA sets a high standard for approving drugs.

“It is important that we have a rigorous bar” for approval, he said, “but a bar that doesn’t impede these products from coming to the market.”

Idaho Blue Cross Jumps Into Controversial Market For Plans That Bypass ACA Rules

That didn’t take long.

It’s barely been two weeks since Idaho regulators said they would allow the sale of health insurance that does not meet all of the Affordable Care Act’s requirements — a controversial step some experts said would likely draw legal scrutiny and, potentially, federal fines for any insurer that jumped in.

On Wednesday, Blue Cross of Idaho unveiled a menu of new health plans that break with federal health law rules in several ways, including setting premiums based on applicants’ health.

“We’re trying to offer a choice that allows the middle class to get back into insurance coverage,” said Dave Jeppesen, the insurer’s executive vice president for consumer health care.

The firm filed five plans to the state for approval and hopes to start selling them as soon as next month.

The Blue Cross decision ups the ante for Alex Azar, the Trump administration’s new Health and Human Services secretary. Will he use his authority under federal law to compel Idaho to follow the ACA and reject the Blues plans? Or will he allow state regulators to move forward, perhaps prompting other states to take more sweeping actions?

At a congressional hearing Wednesday, even as Blue Cross rolled out its plans, Azar faced such questions.

“There are rules. There is a rule of law that we need to enforce,” Azar said. Observers noted, however, he did not specifically indicate whether the federal government would step in.

Robert Laszewski, a consultant and former insurance industry executive, thinks it should.

“If Idaho is able to do this, it will mean other … states will do the same thing,” he said. “If a state can ignore federal law on this, it can ignore federal law on everything.”

Idaho’s move stirs up more issues about individual insurance market stability.

Policy experts say that allowing lower-cost plans that don’t meet the ACA’s standards to become more widespread will pull younger and healthier people out of Obamacare, raising prices for those who remain. Supporters say that is already happening, so this simply provides more choices for people who earn too much to qualify for subsidies to help them purchase ACA coverage.

The state’s move to allow such plans, announced in January, drew harsh and swift criticism.

“Crazypants illegal,” tweeted Nicholas Bagley, a law professor at the University of Michigan and former attorney with the civil division of the U.S. Department of Justice, who said that states can’t pick and choose which parts of federal law to follow. Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms, pointed out that health insurers could be liable for sharp fines if they are found to be in violation of the ACA.

But both Idaho regulators and Blue Cross officials say they are not worried.

Jeppesen said the ACA gives states regulatory authority “to make sure the market works and is stable,” and the insurer is simply “following what the state has given us guidance” to do.

Other insurers in Idaho are taking a much more cautious approach, telling The Wall Street Journal they are not stepping up immediately to offer their own plans.

Laszewski said they are likely waiting to see what legal challenges develop.

“If I were running an insurance company, there’s no way I would stick my neck out until the high court has ruled in favor of this — and they’re not going to,” he said.

Jeppesen said his company has consulted with legal experts and is moving ahead with confidence. The aim is to bring people back into the market, particularly the young, the healthy and those who don’t get a tax credit subsidy and can’t afford an ACA plan.

For some people — especially younger or healthier applicants — the new plans, which the insurer has named Freedom Blue, cost less per month than policies that meet all ACA rules.

They accomplish that by limiting coverage. If they are allowed to be sold, consumers will need to weigh the lower premiums against some of the coverage restrictions and varying premiums and deductibles, policy experts say.

The plans, for example, will include a “waiting period” of up to 12 months for any preexisting conditions if the applicant has been without coverage for more than 63 days, Jeppesen said.

Additionally, they cap total medical care coverage at $1 million annually. And premiums are based, in part, on a person’s health: The healthiest consumers get rates 50 percent below standard levels, while those deemed unhealthy would be charged 50 percent more.

All those caveats violate ACA rules, which forbid insurers from rejecting coverage of preexisting conditions or setting dollar caps on benefits or higher premiums for people with health problems.

But the rates may prove attractive to some.

Premiums for a healthy 45-year-old, for example, could be as low as $195 a month, according to a comparison issued by the insurer, while a 45-year-old with health problems could be charged $526. In that case, the 45-year old would find a lower price tag — $343 a month — for an ACA-compliant bronze plan.

While Freedom Blues plans cover many of the “essential health benefits” required under the ACA, such as hospitalization, emergency care and mental health treatment, they do not include pediatric dental or vision coverage. One of the five plans does not include maternity coverage.

When compared with one of the Blues’ ACA-compliant plans — called the Bronze 5500 — the new standard Freedom Blue plan’s annual deductibles are a mixed bag.

That’s because they have two separate deductibles — one for medical care and one for drugs. If a consumer took only generic drugs, the new plan would be less expensive, according to details provided by the plan. But with a $4,000 deductible for brand-name drugs, the Freedom Blue plan requires more upfront money before full coverage kicks in than the ACA-compliant plan it was compared with.

Jeppesen said the insurer hopes to attract many of the “110,000 uninsured state residents who cannot afford [ACA] coverage.”

That’s the total number of uninsured people who earn more than 100 percent of the federal poverty level in the state, he said.

Sarah Lueck, senior policy analyst for the Center on Budget and Policy Priorities, cautioned that some of those residents might actually be eligible for subsidies under the ACA, which are available to people earning up to four times as much.

“Many … could be getting subsidies for more comprehensive coverage through the [ACA-compliant state exchange] and would be better off,” Lueck said.

California’s Two Health Insurance Regulators To Investigate Aetna’s Medical Coverage Decisions

Both of California’s health insurance regulators said they will investigate how Aetna Inc. makes coverage decisions, as the lawsuit of a California man who is suing the nation’s third-largest insurer for improper denial of care heads for opening arguments on Wednesday.

The Department of Managed Health Care, which regulates the vast majority of health plans in California, said Monday it will investigate Hartford, Ct.-based Aetna after CNN first reported Sunday that one of the company’s medical directors had testified in a deposition related to the lawsuit that he did not examine patients’ records before deciding whether to deny or approve care. Rather, he relied on information provided by nurses who reviewed the records — and that was how he was trained by the company, he said.

Insurance Commissioner Dave Jones had already told CNN his office would investigate Aetna, which he reconfirmed in a statement Monday.

“If a health insurer is making decisions to deny coverage without a physician ever reviewing medical records, that is a significant concern and could be a violation of the law,” Jones said.

It is unclear how widespread the review of patient claims by non-physicians is in the industry or whether other insurers will feel compelled to revisit their practices.

The California Department of Insurance, which Jones heads, regulates only a small fraction of the state’s health plans, but they include several Aetna policies. He has previously criticized Aetna for “excessive” health insurance rate hikes, though neither his agency nor the managed health care department has the power to stop the increases.

Jones’ investigation of Aetna will review denials of coverage or pre-authorizations during the tenure of the medical director who testified in the California lawsuit, Jay Ken Iinuma, who has since left the company. Insurance department investigators will also look into Aetna’s procedures for managing medical coverage decisions generally.

The dual investigations come as federal regulators are examining a planned $69 billion purchase of Aetna by pharmaceutical giant CVS — a deal that many experts believe could transform the health care industry.

It’s unclear how the investigations might affect Aetna’s future coverage decisions, or those of other insurers, said Shana Alex Charles, an insurance industry expert and assistant professor at Cal State University-Fullerton. But she praised the decision to investigate as exactly what insurance regulators should be doing. “Without that strict oversight, corners get cut,” Charles said.

Scott Glovsky, the lawyer representing the California plaintiff, Gillen Washington, said he and his client were “very pleased” by the news that Aetna will be investigated. Speaking Monday, before the managed care department said it would also investigate, Glovsky said his client brought the case “to stop these illegal practices, and we’re looking forward to the insurance commissioner’s investigation so we can make things safer for Aetna patients.”

Washington, of Huntington Beach, had been receiving expensive medication for years to treat a rare immune system disorder known as Common Variable Immune Deficiency.

But in 2014, Aetna denied the college student’s monthly dose of immunoglobulin replacement therapy, saying his bloodwork was outdated. During the appeal process, Washington developed pneumonia and was hospitalized for a collapsed lung.

In recent years, as California Healthline reported last June, patients with similar diseases have faced increasing difficulty getting their insurers to approve treatments, according to clinicians and patient advocates.

In an emailed statement on Monday, Aetna did not directly address the question of case reviews by non-physicians. It said its “medical directors review all necessary available medical information for cases that they are asked to evaluate. That is how they are trained, as physicians and as Aetna employees.” It added, “adherence to those guidelines, which are based on health outcomes and not financial considerations, is an integral part of their yearly review process.”

Aetna also noted that it has paid for all of Washington’s treatments since 2014 and continues to do so.

Aetna said in previous documents filed in the lawsuit that it is standard for people with Washington’s immunodeficiency disease to get regular blood tests and that Washington had failed to do so. But Washington’s attorney said his client clearly needed the medication and that Aetna’s action violated its contract with Washington.

Charles, the professor, said she was most surprised by the fact that Iinuma had admitted not only that he hadn’t reviewed Washington’s medical records personally, but that he had no experience treating his disease. The burden should be on insurers to demonstrate why treatment should be stopped, not on doctors and patients to show why it should be continued, Charles said.

“It’s easy to see the cases as just files and not people standing in front of you,” she said.

Maryland Offers Many Insured Men Free Vasectomy Coverage

It was a well-intentioned effort to provide men with some of the same financial protection from birth control costs that women get. But a new Maryland law may jeopardize the ability of thousands of consumers — both men and women — to use health savings accounts.

The law, which took effect Jan. 1, mandates that insurers cover vasectomies without requiring patients to pay anything out-of-pocket — just as they must do for more than a dozen birth control methods for women.

But the measure may run afoul of Internal Revenue Service rules that do not include vasectomies among approved preventive services for high-deductible health plans. People with health savings accounts — which are exempt from tax liabilities — tied to those plans could no longer contribute to the savings accounts in that case.

Under the Maryland Contraceptive Equity Act, insurers generally can’t charge patients a copayment or require any other cost sharing for prescription contraceptive drugs or devices approved by the Food and Drug Administration. The 2016 law is similar to what’s required under the federal Affordable Care Act, with a twist: It adds male sterilization — vasectomies — to the list of services that are free for patients.

“While the ACA made important strides … it completely left men out of the equation,” said Karen Nelson, president and CEO of Planned Parenthood of Maryland, whose organization supported the bill.

Before the law took effect, a vasectomy at the organization’s Baltimore office would cost between $225 and $1,100, depending on someone’s ability to pay, said Nelson. Now the procedure will generally cost nothing for men in insured plans in Maryland.

The state law doesn’t apply to companies that are “self-funded,” meaning they pay their employees’ health care claims directly rather than buying state-regulated insurance policies.

Under IRS rules, consumers making tax-free contributions to health savings accounts (HSAs) that are linked to high-deductible health plans have to pay for all their medical care until they reach their deductible of at least $1,350 for individuals and $2,700 for families in 2018. The only exception is for preventive services. The hitch for the Maryland law is that vasectomies aren’t on the IRS list of approved preventive services.

The IRS hasn’t responded to a request for clarification by Maryland Insurance Commissioner Al Redmer Jr. A bill was reintroduced this year — after it failed to pass last year — that would exempt these high-deductible plans from the state mandate to cover vasectomies before the deductible is met. Such a move would preserve the tax advantages of the HSAs linked to them.

Maryland is joining a few other states, including Illinois, Vermont and, starting next year, Oregon, that have expanded contraceptive coverage without cost sharing to include male sterilization.

Vermont’s law includes language to exempt high-deductible plans with health savings accounts. While the issue has raised concerns in Maryland, in Illinois and Oregon it hasn’t appeared to generate much attention to date, legislative analysts say.

Some advocates for extending no-cost coverage to vasectomies noted that the IRS’ list of approved preventive services specifically says that it isn’t exhaustive.

But until the issue is clarified, “the safest thing to do is not make a contribution to your HSA,” said Roy Ramthun, a Maryland resident and president of HSA Consulting Services. Ramthun helped implement health savings accounts while working for the Treasury Department during the George W. Bush administration. He stressed that the uncertainty applies only to HSA contributions made after the law became effective in 2018, not to earlier contributions. The issue doesn’t affect people’s medical coverage.

Beyond the uncertainty around health savings account contributions, Maryland’s law requiring coverage of vasectomies without cost sharing addresses a gap in men’s preventive coverage.

“There are arguments to be made that male condoms and vasectomies have preventive benefits for both women and men, in terms of [sexually transmitted infection] prevention and preventing pregnancy,” said Mara Gandal-Powers, senior counsel at the National Women’s Law Center.

Seven percent of men ages 18 to 45 have had a vasectomy, according to a 2013 study by researchers at Northwestern University. The prevalence increased to 16 percent among men ages 36 to 45. Men with higher incomes, higher education and a regular source of health care were more likely to have had the procedure, the study found.

The Maryland law doesn’t apply to the method of birth control that many men use: condoms. A bill introduced this month by state Sen. John Astle, a Democrat, would expand the law to include condom coverage.

Trump’s Budget Proposal Swings At Drug Prices With A Glancing Blow

President Donald Trump’s new budget proposal flirts with combating high prescription drug prices, but industry watchers say the tweaks to Medicare and Medicaid do little more than dance around the edges of lowering the actual prices of drugs.

The White House’s proposal, which comes after Congress passed a two-year spending deal last week, though, sets the tone for the administration’s focus on prescription drugs.

“Drug costs are a populist issue for the president,” and he’s made it clear to his staff that progress needs to be made this year, said Dan Mendelson, president of Avalere Health, a health care consulting firm.

The proposal targets billions of drug spending cuts in the federal Medicare program, which provides health care for about 60 million people age 65 and older or younger patients with disabilities, and alters drug spending in Medicaid’s safety-net program for nearly 70 million Americans.

And the sheer size of the federal government’s Medicare and Medicaid programs means any drug pricing tweaks that do get made are meaningful — just not necessarily groundbreaking.

“The main question is, how far are they actually going to go in dealing with the underlying problem?” said Paul Van de Water, who spent nearly two decades in the Congressional Budget Office and is now a senior fellow at the Center on Budget and Policy Priorities. Most of the proposals for Medicare, for example, move money around rather than force decreased prices, Van de Water said.

Alex Azar, the newly appointed secretary of Health and Human Services, said the proposed budget supports the work his agency is already doing to reduce the high cost of prescriptions, “especially for America’s seniors.”

Just last month, the former Eli Lilly executive told Congress during his confirmation hearings that “all drug prices are too high in this country.”

Highlights from the proposals include:

— Passing on the discounts and rebates negotiated by pharmacy benefit managers, the financial middlemen between insurers and drugmakers, to seniors who buy drugs through Medicare Part D. The seniors would pay less out-of-pocket when buying their drugs but the proposal could potentially raise premiums because insurers wouldn’t be getting the discounts.

— Ensuring that low-income seniors in Medicare don’t pay for generics and capping out-of-pocket costs for beneficiaries who pass through the so-called doughnut hole, or coverage gap, and hit the catastrophic stage. Beneficiaries typically pay a 5 percent coinsurance in the catastrophic phase, but under the plan it would be decreased to zero.

— Moving some of the drugs paid for under Medicare Part B, which covers drugs administered in the doctor’s office such as chemotherapy and rheumatoid arthritis infusions, into the Part D part of the program to foster price negotiations. While the government pays sticker price for drugs under the Part B program, the Part D program allows insurers and pharmacy benefit managers to negotiate formularies.

— Creating a five-state pilot project to allow state Medicaid programs to negotiate prices with manufacturers and create their own drug formularies.

Trump entered office with blustering promises to bring drug prices “way down.” But critics have charged that the White House has failed to engage Congress on cost-cutting ideas, and that a leaked draft of an executive order last summer read like a wish list for the industry.

With the new budget, the administration is trying to recast that narrative at a time when Republicans in Congress may be willing to compromise.

“Americans want Washington to lower prescription drug prices, and our paper provides policy options that would make drugs more accessible to Americans, today and in the future,” wrote D.J. Nordquist, chief of staff for the president’s Council of Economic Advisers, in an email late Friday after the council released a 28-page report on reforming drug prices.

The CEA paper and the president’s budget come on the heels of Congress passing a spending pact Friday that includes a big benefit to Medicare enrollees at the expense of the pharmaceutical industry. The budget proposes closing the doughnut hole in 2019, a year earlier than expected.

Republicans “just showed a propensity to sort of take on the industry,” said Jayson Slotnik, a policy consultant and partner at Health Policy Strategies. And there is political upside for doing more since Republicans are concerned about this year’s November midterm elections approaching, Slotnik said: “They can run and [say] it’s something they have accomplished.”

Yet James Love, director of the nonprofit Knowledge Ecology International, said Trump’s proposals are not “insightful or original” and, referring to the council’s report, said it “could have been written by PhRMA,” the powerful D.C. lobbying firm for pharmaceutical manufacturers.

PhRMA released a statement late Monday applauding the provision to pass on rebates to Medicare beneficiaries but also raising concerns about other elements of the budget proposal, saying they would “limit access to innovative medicines.”

Experts from the academic and think-tank world said the district has seen several of these policies before. For example, the rebate and discount pass-through proposal has been a topic of discussion within the Centers for Medicare & Medicaid Services for more than a year and is already in the rulemaking process.

Another proposal that lowers reimbursement for Medicare Part B drugs that are new to the program is reminiscent of an Obama-era pilot that never got off the ground.

Tara O’Neill Hayes, who focuses on health policy at the conservative American Action Forum, said several Medicare proposals were also similar to those found in a June 2016 report by the Medicare Payment Advisory Commission. If all the Medicare proposals took effect — including one that calls for more flexibility in drug formularies — O’Neill Hayes said overall premiums could go up slightly for all Part D beneficiaries, but that would be offset by lowering out-of-pocket payments for the beneficiaries with the highest drug costs.

“You’re going to have winners and losers,” she said. “The real winners here are going to be the incredibly high-cost patients.”

Trump’s budget requires hospitals to provide a minimum level of charity care to get an additional payment adjustment under the 340B program, which requires pharmaceutical manufacturers to provide drugs at steep discounts to hospitals and clinics with a high ratio of low-income patients.

The administration lowered reimbursement amounts for hospitals earlier this year, and Mendelson at Avalere said he expects more changes.

In reviewing Trump’s budget and the council report, Allan Coukell, senior director of health programs at the Pew Charitable Trusts, said several of the proposals “have the potential to reduce out-of-pocket costs, several have the potential to increase competition within the programs and/or move people toward lower cost drugs. None of it changes the overall trajectory” of rising sticker prices.

Centros comunitarios de salud obtienen fondos a largo plazo

Luego de tres meses de espera, los centros comunitarios de salud obtuvieron un financiamiento clave a largo plazo, como parte de la legislación que firmó el presidente Donald Trump el viernes 9 de febrero para mantener al Gobierno en funcionamiento.

El Community Health Center Program sirve a 27 millones de personas en casi 10,000 clínicas sin fines de lucro en todo el país, la mayoría de las cuales se encuentran en áreas rurales y urbanas de bajos ingresos.

La legislación les otorga a los centros $3.8 mil millones para este año, y $4 mil millones en 2019.

En los últimos años, el Congreso ha asignado $3.6 mil millones anuales para los centros de salud. Eso representa alrededor del 20% de los presupuestos de las clínicas; gran parte del resto proviene de reembolsos por servicios. Defensores y directores de los centros aseguran que este dinero es fundamental para proporcionar servicios que no siempre están cubiertos por Medicare, Medicaid, o por seguros privados, incluidos los de salud mental y abuso de sustancias, transporte y visitas domiciliarias.

Se esperaba que el Congreso renovara el financiamiento a largo plazo para los centros el 22 de enero cuando los legisladores votaron el financiamiento por seis años del Programa de Seguro de Salud Infantil (CHIP). Uno de cada 10 niños cubiertos por CHIP recibe la mayor parte de su atención en un centro comunitario de salud.

Pero ese proyecto no se ocupó de los centros. Aunque el dinero federal se agotó el 1 de octubre, un parche presupuestario anterior les proporcionó fondos temporales hasta el 31 de marzo.

“Estamos atrapados en la disfunción política de Washington”, dijo una semana atrás Carmela Castellano-García, directora ejecutiva de la Asociación de Atención Primaria de California. “Estos centros son un salvavidas para millones de personas, especialmente en las zonas rurales, donde pueden ser el único proveedor de atención médica en millas a la redonda”.

Castellano-García dijo que el impasse presupuestario había obligado a muchos centros en el estado a congelar las contrataciones, posponer expansiones de servicios y utilizar las reservas financieras.

A nivel nacional, el 20% de los centros de salud ya habían congelado contratos, y el 4% despedido personal. Agregó que otro 53% podría haber despedido a empleados si no hubieran recibido los fondos federales, según una encuesta sobre centros de salud comunitarios realizada por la Universidad George Washington e investigadores de la Kaiser Family Foundation, publicada hace pocos días. (Kaiser Health News es un programa editorialmente independiente de la fundación).

Dan Hawkins, vicepresidente senior de la Asociación Nacional de Centros Comunitarios de Salud, con sede en Bethesda, Maryland, y expertos en políticas de salud, especularon que la razón del impasse en la asignación de fondos para los centros pudo ser por desacuerdos en el nivel de financiación y la cantidad de años. Según informes, los demócratas presionaron para que fuera de cinco o seis años, pero los republicanos pueden haber preferido un período más breve. Los senadores Debbie Stabenow (demócrata de Michigan) y Roy Blunt (republicano de Missouri), lideraron este debate.

Para los líderes de los centros comunitarios, y para los pacientes, la nueva asignación de fondos es un alivio.

California tiene la red de centros de salud más grande del país. Uno de cada 6 californianos -6,5 millones de personas- reciben atención médica en los cerca de 1,300 centros alrededor del estado. La mitad está inscrita en Medi-Cal, el programa estatal de Medicaid.

Dave Jones, director ejecutivo de Mountain Valleys Health Centers, que opera seis clínicas comunitarias cerca de la ciudad de Redding en el norte de California, dijo que podrían haber enfrentado el cierre de uno de sus seis locales de no haber recibido el dinero federal.

Anderson Valley Health Center, en Boonville, California, enfrentó la misma situación. El pequeño centro atiende a 2,800 pacientes por año, el 45% de los cuales son trabajadores agrícolas de bajos ingresos.

Chloë Guazzone-Rugebregt, directora ejecutiva del centro, dijo que la renovación de su edificio estaba esperando la señal de los fondos federales.

MMaría Soto, de 72 años, y su esposo Efrén, de 77, sus seis hijos adultos y 13 nietos, se atienden en el Anderson Valley Health Center, en Boonville, California. (Esther Soto/Cortesía de María Soto)

María Soto, de 72 años y su esposo, Efrén, de 77, junto con sus seis hijos adultos y sus 13 nietos, reciben atención en Anderson. Los abuelos Soto, ambos jubilados, tienen Medicare. El resto de la familia tiene seguro privado o está inscrito en Medi-Cal.

“La clínica juega un papel muy importante en nuestras vidas”, dijo María Soto. “Confiamos en este centro de salud para todos nuestros cuidados regulares. No tengo idea de a dónde iríamos si tuviera que cerrar”.

Charles Allbaugh y Paula Tomko, quienes dirigen Central Virginia Health Services, dijeron que también se han demorado en contratar personal y expandir los servicios en su red de 16 clínicas que atienden a 43,000 residentes de Virginia, a la espera del resultado del debate sobre los fondos.

“El Congreso juega al fútbol político con nosotros”, dijo Tomko. “No es la forma en que deberían funcionar las cosas”.

Jean Grutzius estuvo de acuerdo. Su madre de 97 años se atiende en una de las clínicas de Tomko, cerca de la pequeña ciudad de Bumpass.

“Sin la clínica, estaríamos en grandes problemas”, dijo Grutzius. Su madre, Eleanor Ciombor, está ciega y sorda, en silla de ruedas y toma múltiples medicamentos, incluso para una afección psiquiátrica. Ciombor, quien vive con su hija, está inscrita tanto en Medicare como en Medicaid. Su único ingreso es $900 por mes del Seguro Social.

“Recibe una gran atención [en la clínica] y nos cuesta poco”, dijo Grutzius, quien tiene 75 años y también vive con un ingreso fijo. “No podría pagar de otra manera. Estoy rezando para que el centro obtenga la financiación que necesita”.

Los fondos para los centros fueron apoyados sólidamente por la Ley de Cuidado de Salud Asequible (ACA). Entre 2010 y 2016, ese financiamiento impulsó un aumento del 50% en el número de locales de centros de salud en todo el país y un incremento del 33% en el número de pacientes atendidos.

Los centros de salud también participaron activamente en el registro de personas para los mercados de seguros de ACA y para Medicaid en los estados que ampliaron ese programa bajo el Obamacare.

Sin embargo, a pesar de la creciente división partidista sobre ACA, los legisladores votaron abrumadoramente -y en un acuerdo bipartidista- en 2015 para extender los fondos del centro de salud al nivel de $3.6 mil millones anuales durante dos años adicionales.

“Estos son dólares federales muy bien gastados, y $3.6 mil millones no es un gran gasto federal”, dijo Peter Shin, profesor asociado de políticas y gestión de salud en la Universidad George Washington, en Washington, DC. “De hecho, hay un fuerte argumento de por qué deberían obtener más dinero”.

Shin dijo que la investigación muestra que los centros ahorran dinero al gobierno federal a largo plazo. Lo hacen proporcionando atención primaria, preventiva y prenatal de rutina que mantiene a las personas fuera del hospital y previene las costosas visitas a las salas de emergencias.

El experto dijo que, según un estimado, los centros de salud ahorran al gobierno federal casi $25 mil millones anuales en costos para los afiliados de Medicare y Medicaid.

Centros comunitarios de salud obtienen fondos a largo plazo

Luego de tres meses de espera, los centros comunitarios de salud obtuvieron un financiamiento clave a largo plazo, como parte de la legislación que firmó el presidente Donald Trump el viernes 9 de febrero para mantener al Gobierno en funcionamiento.

El Community Health Center Program sirve a 27 millones de personas en casi 10,000 clínicas sin fines de lucro en todo el país, la mayoría de las cuales se encuentran en áreas rurales y urbanas de bajos ingresos.

La legislación les otorga a los centros $3.8 mil millones para este año, y $4 mil millones en 2019.

En los últimos años, el Congreso ha asignado $3.6 mil millones anuales para los centros de salud. Eso representa alrededor del 20% de los presupuestos de las clínicas; gran parte del resto proviene de reembolsos por servicios. Defensores y directores de los centros aseguran que este dinero es fundamental para proporcionar servicios que no siempre están cubiertos por Medicare, Medicaid, o por seguros privados, incluidos los de salud mental y abuso de sustancias, transporte y visitas domiciliarias.

Se esperaba que el Congreso renovara el financiamiento a largo plazo para los centros el 22 de enero cuando los legisladores votaron el financiamiento por seis años del Programa de Seguro de Salud Infantil (CHIP). Uno de cada 10 niños cubiertos por CHIP recibe la mayor parte de su atención en un centro comunitario de salud.

Pero ese proyecto no se ocupó de los centros. Aunque el dinero federal se agotó el 1 de octubre, un parche presupuestario anterior les proporcionó fondos temporales hasta el 31 de marzo.

“Estamos atrapados en la disfunción política de Washington”, dijo una semana atrás Carmela Castellano-García, directora ejecutiva de la Asociación de Atención Primaria de California. “Estos centros son un salvavidas para millones de personas, especialmente en las zonas rurales, donde pueden ser el único proveedor de atención médica en millas a la redonda”.

Castellano-García dijo que el impasse presupuestario había obligado a muchos centros en el estado a congelar las contrataciones, posponer expansiones de servicios y utilizar las reservas financieras.

A nivel nacional, el 20% de los centros de salud ya habían congelado contratos, y el 4% despedido personal. Agregó que otro 53% podría haber despedido a empleados si no hubieran recibido los fondos federales, según una encuesta sobre centros de salud comunitarios realizada por la Universidad George Washington e investigadores de la Kaiser Family Foundation, publicada hace pocos días. (Kaiser Health News es un programa editorialmente independiente de la fundación).

Dan Hawkins, vicepresidente senior de la Asociación Nacional de Centros Comunitarios de Salud, con sede en Bethesda, Maryland, y expertos en políticas de salud, especularon que la razón del impasse en la asignación de fondos para los centros pudo ser por desacuerdos en el nivel de financiación y la cantidad de años. Según informes, los demócratas presionaron para que fuera de cinco o seis años, pero los republicanos pueden haber preferido un período más breve. Los senadores Debbie Stabenow (demócrata de Michigan) y Roy Blunt (republicano de Missouri), lideraron este debate.

Para los líderes de los centros comunitarios, y para los pacientes, la nueva asignación de fondos es un alivio.

California tiene la red de centros de salud más grande del país. Uno de cada 6 californianos -6,5 millones de personas- reciben atención médica en los cerca de 1,300 centros alrededor del estado. La mitad está inscrita en Medi-Cal, el programa estatal de Medicaid.

Dave Jones, director ejecutivo de Mountain Valleys Health Centers, que opera seis clínicas comunitarias cerca de la ciudad de Redding en el norte de California, dijo que podrían haber enfrentado el cierre de uno de sus seis locales de no haber recibido el dinero federal.

Anderson Valley Health Center, en Boonville, California, enfrentó la misma situación. El pequeño centro atiende a 2,800 pacientes por año, el 45% de los cuales son trabajadores agrícolas de bajos ingresos.

Chloë Guazzone-Rugebregt, directora ejecutiva del centro, dijo que la renovación de su edificio estaba esperando la señal de los fondos federales.

MMaría Soto, de 72 años, y su esposo Efrén, de 77, sus seis hijos adultos y 13 nietos, se atienden en el Anderson Valley Health Center, en Boonville, California. (Esther Soto/Cortesía de María Soto)

María Soto, de 72 años y su esposo, Efrén, de 77, junto con sus seis hijos adultos y sus 13 nietos, reciben atención en Anderson. Los abuelos Soto, ambos jubilados, tienen Medicare. El resto de la familia tiene seguro privado o está inscrito en Medi-Cal.

“La clínica juega un papel muy importante en nuestras vidas”, dijo María Soto. “Confiamos en este centro de salud para todos nuestros cuidados regulares. No tengo idea de a dónde iríamos si tuviera que cerrar”.

Charles Allbaugh y Paula Tomko, quienes dirigen Central Virginia Health Services, dijeron que también se han demorado en contratar personal y expandir los servicios en su red de 16 clínicas que atienden a 43,000 residentes de Virginia, a la espera del resultado del debate sobre los fondos.

“El Congreso juega al fútbol político con nosotros”, dijo Tomko. “No es la forma en que deberían funcionar las cosas”.

Jean Grutzius estuvo de acuerdo. Su madre de 97 años se atiende en una de las clínicas de Tomko, cerca de la pequeña ciudad de Bumpass.

“Sin la clínica, estaríamos en grandes problemas”, dijo Grutzius. Su madre, Eleanor Ciombor, está ciega y sorda, en silla de ruedas y toma múltiples medicamentos, incluso para una afección psiquiátrica. Ciombor, quien vive con su hija, está inscrita tanto en Medicare como en Medicaid. Su único ingreso es $900 por mes del Seguro Social.

“Recibe una gran atención [en la clínica] y nos cuesta poco”, dijo Grutzius, quien tiene 75 años y también vive con un ingreso fijo. “No podría pagar de otra manera. Estoy rezando para que el centro obtenga la financiación que necesita”.

Los fondos para los centros fueron apoyados sólidamente por la Ley de Cuidado de Salud Asequible (ACA). Entre 2010 y 2016, ese financiamiento impulsó un aumento del 50% en el número de locales de centros de salud en todo el país y un incremento del 33% en el número de pacientes atendidos.

Los centros de salud también participaron activamente en el registro de personas para los mercados de seguros de ACA y para Medicaid en los estados que ampliaron ese programa bajo el Obamacare.

Sin embargo, a pesar de la creciente división partidista sobre ACA, los legisladores votaron abrumadoramente -y en un acuerdo bipartidista- en 2015 para extender los fondos del centro de salud al nivel de $3.6 mil millones anuales durante dos años adicionales.

“Estos son dólares federales muy bien gastados, y $3.6 mil millones no es un gran gasto federal”, dijo Peter Shin, profesor asociado de políticas y gestión de salud en la Universidad George Washington, en Washington, DC. “De hecho, hay un fuerte argumento de por qué deberían obtener más dinero”.

Shin dijo que la investigación muestra que los centros ahorran dinero al gobierno federal a largo plazo. Lo hacen proporcionando atención primaria, preventiva y prenatal de rutina que mantiene a las personas fuera del hospital y previene las costosas visitas a las salas de emergencias.

El experto dijo que, según un estimado, los centros de salud ahorran al gobierno federal casi $25 mil millones anuales en costos para los afiliados de Medicare y Medicaid.

Bipartisan Senate Budget Deal Boosts Health Programs

In a rare show of bipartisanship for the mostly polarized 115th Congress, Republican and Democratic Senate leaders announced a two-year budget deal that would increase federal spending for defense as well as key domestic priorities, including many health programs.

Not in the deal, for which the path to the president’s desk remains unclear, is any bipartisan legislation aimed at shoring up the Affordable Care Act’s individual health insurance marketplaces. Senate Majority Leader Mitch McConnell (R-Ky.) promised Sen. Susan Collins (R-Maine) a vote on health legislation in exchange for her vote for the GOP tax bill in December. So far, that vote has not materialized.

The deal does appear to include almost every other health priority Democrats have been pushing the past several months, including two years of renewed funding for community health centers and a series of other health programs Congress failed to provide for before they technically expired last year.

“I believe we have reached a budget deal that neither side loves but both sides can be proud of,” said Senate Minority Leader Chuck Schumer (D-N.Y.) on the Senate floor. “That’s compromise. That’s governing.”

Said McConnell, “This bill represents a significant bipartisan step forward.”

Senate leaders are still negotiating last details of the accord, including the size of a cut to the ACA’s Prevention and Public Health Fund, which would help offset the costs of this legislation.

According to documents circulating on Capitol Hill, the deal includes $6 billion in funding for treatment of mental health issues and opioid addiction, $2 billion in extra funding for the National Institutes of Health, and an additional four-year extension of the Children’s Health Insurance Program (CHIP), which builds on the six years approved by Congress last month.

In the Medicare program, the deal would accelerate the closing of the “doughnut hole” in Medicare drug coverage that requires seniors to pay thousands of dollars out-of-pocket before catastrophic coverage kicks in. It would also repeal the controversial Medicare Independent Payment Advisory Board (IPAB), which is charged with holding down Medicare spending for the federal government if it exceeds a certain level. Members have never been appointed to the board, however, and its use has not so far been triggered by Medicare spending. Both the closure of the doughnut hole and creation of the IPAB were part of the ACA.

The agreement would also fund a host of more limited health programs — some of which are known as “extenders” because they often ride along with other, larger health or spending bills.

Those programs include more than $7 billion in funding for the nation’s federally funded community health centers. The clinics serve 27 million low-income people and saw their funding lapse last fall — a delay advocates said had already complicated budgeting and staffing decisions for many clinics.

And in a victory for the physical therapy industry and patient advocates, the accord would permanently repeal a limit on Medicare’s coverage of physical therapy, speech-language pathology and outpatient treatment. Previously, the program capped coverage after $2,010 worth of occupational therapy and another $2,010 for speech-language therapy and physical therapy combined. But Congress had long taken action to delay those caps or provide exemptions — meaning they had never actually taken effect.

According to an analysis by the nonpartisan Congressional Budget Office, permanently repealing the caps would cost about $6.47 billion over the next decade.

Lawmakers would also forestall cuts mandated by the ACA to reduce the payments made to so-called Disproportionate Share Hospitals, which serve high rates of low-income patients. Those cuts have been delayed continuously since the law’s 2010 passage.

Limited programs are also affected. The deal would fund for five years the Maternal, Infant and Early Childhood Home Visiting Program, a program that helps guide low-income, at-risk mothers in parenting. It served about 160,000 families in fiscal year 2016.

“We are relieved that there is a deal for a 5-year reauthorization of MIECHV,” said Lori Freeman, CEO of advocacy group the Association of Maternal & Child Health Programs, in an emailed statement. “States, home visitors and families have been in limbo for the past several months, and this news will bring the stability they need to continue this successful program.”

And the budget deal funds programs that encourage doctors to practice in medically underserved areas, providing just under $500 million over the next two years for the National Health Service Corps and another $363 million over two years to the Teaching Health Center Graduate Medical Education program, which places medical residents in Community Health Centers.

Kaiser Health News correspondent Emmarie Huetteman contributed to this article.

KHN’s coverage of these topics is supported by Heising-Simons Foundation and The David and Lucile Packard Foundation

Related Topics

Cost and Quality Health Care Costs Medicaid Medicare Public Health The Health Law