Tagged Cost and Quality

Critics Assail J&J’s Sponsorship Of High-Profile Physician Conference Exploring Conflict Of Interests

Your School Assignment For The Day: Spelling And Specs

DELANO, Calif. — Daisy Leon struggles to sit still and read the letters on the eye chart. Her responses tumble out in a quiet, confused garble.

“You know your letters?” asks optometrist Jolly Mamauag-Camat. “Umm, ya,” says Daisy, almost inaudibly.

The 6-year-old kindergartner had her eyes examined for the first time on a recent Thursday morning. Although she hadn’t complained about headaches or blurry vision, her grandmother noticed she’d been inching closer to watch television.

After Daisy’s failed attempts at reading the eye chart, Mamauag-Camat inspects the little girl’s eyes through a phoropter and writes her a prescription for glasses.

At least 20% of school-age children in the U.S. have vision problems. But according to the Centers for Disease Control and Prevention, fewer than 15% of children get an eye exam before entering kindergarten. Because vision problems tend to worsen the longer they go undetected, many children suffer even though there are often simple, relatively inexpensive solutions such as prescription glasses.

Half of the states plus the District of Columbia require screenings or exams for preschoolers, according to the National Center for Children’s Vision & Eye Health. But California has no such requirement, said Xuejuan Jiang, an assistant professor of research ophthalmology at Keck School of Medicine of USC. California does require them for older children.

“The system in California is not as good as it can be,” Jiang said.

In much of California’s Central Valley, where roughly 1 in 5 people live in poverty, two school districts are working with two nonprofits, the Advanced Center for Eyecare and OneSight, to provide vision care to Kern County’s underserved and uninsured children.

Many of the neediest are the children of farmworkers.

“We are an agriculture-based community,” said Linda Hinojosa, coordinator of health services for the Delano Union School District. “Most of our families harvest table grapes 12 hours a day, with very limited time to take their children in for an eye exam.”

The program, funded by the nonprofits and the school districts, operates five school-based clinics in Bakersfield and Delano. Students receive comprehensive eye exams and glasses, along with free transportation. And breakfast.

Most of the children who visit the clinics have coverage through Medi-Cal, California’s Medicaid program for low-income people. There is no out-of-pocket cost for the eye exams and glasses for them, or for children who are uninsured, said Alexander Zahn, chief business development officer for the Advanced Center for Eyecare.

Almost half of the students examined need glasses.

“The need was very apparent” in the Central Valley, Zahn said. “Sixty dollars for an eye exam and $80 for glasses might be the difference between eating dinner a couple days a week.”

Daisy was among 12 students who were bused to the Delano Union School District Vision Center, adjacent to Pioneer School, an elementary school with about 1,000 students. Almost all the students at Pioneer are Hispanic and about three-quarters qualify for free lunches.

Students from throughout the Delano Union Elementary School District visit the clinic. Since it opened in 2018, the clinic has performed 961 eye exams and prescribed 517 pairs of glasses.

For Daisy, whose parents are farmworkers, the clinic has been a tremendous help.

“They prune out in the fields,” said Guadalupe Leon, Daisy’s grandmother. “They can’t afford to take days off.”

The Delano Union School District Vision Center is funded by multiple sources: OneSight, a nonprofit organization dedicated to increasing access to vision care in underserved communities around the world, donated the ophthalmic equipment and provided grant funding for the first year of operation. The Advanced Center for Eyecare provides staff and supplies. And the school district provides the facility, furnishings and transportation. (Heidi de Marco/KHN)

Twelve students from Nueva Vista Language Academy and Fremont Elementary School arrive by bus for their eye exams and follow-ups. Linda Hinojosa, a registered nurse for 20 years, says lack of transportation is a major barrier to vision care. “Parents a lot of times don’t have a car, or it can be a one-vehicle family,” she says. (Heidi de Marco/KHN)

Students are offered breakfast before their appointments with optometrist Jolly Mamauag-Camat. About three-quarters of students in the district are eligible for free/reduced-price meals. (Heidi de Marco/KHN)

Daisy Leon, a kindergartner at Nueva Vista Language Academy, takes a test to check for color blindness. Before beginning, the optical technician asks Daisy if she understands English. Because of the region’s large Spanish-speaking population, clinic staff members often act as interpreters. (Heidi de Marco/KHN)

Daisy looks into an auto refractor as part of her eye exam. (Heidi de Marco/KHN)

Daisy and Jonathon Castro watch a movie as they wait for their eyes to dilate. This is the first eye exam for both of them. (Heidi de Marco/KHN)

Daisy sits on her knees to see through a phoropter, a device to help determine eyeglass prescriptions. Mamauag-Camat says children often can’t tell if they have vision problems because they don’t know any differently. “They can fall through the cracks,” she says. “They don’t know the difference between what’s clear and not clear.” (Heidi de Marco/KHN)

About 45% of Kern County’s population is on Medi-Cal. Medi-Cal covers vision care, including an eye exam and glasses every two years, but in communities like Delano, access is a problem. “We live in an area with a big shortage of providers, particularly specialty care providers like optometrists and ophthalmologists,” says Alexander Zahn, of the Advanced Center for Eyecare. (Heidi de Marco/KHN)

Daisy picks out glasses right after her exam, a pink pair that she had been admiring all morning. “We need to go where students are,” says Hinojosa. “Vision is absolutely vital.” (Heidi de Marco/KHN)

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

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Watch: One Father’s Fight Against ‘Predatory’ Drug Price

Dr. Sudeep Taksali tells “CBS This Morning” about his efforts to get a cheaper version of a drug commonly known as a hormone blocker for his daughter, who has central precocious puberty. The report is the latest collaboration between CBS, NPR and Kaiser Health News on the “Bill of the Month” crowdsourced investigative series.

KHN Editor-in-Chief Elisabeth Rosenthal described how one active ingredient is sold by Endo Pharmaceuticals as two different drugs — the one for children has a price tag of $37,300, while one used in adults goes for $4,400.

Taksali said the discrepancy signals a type of “predation on parents who have that sense of vulnerability, who will do anything within their means to help their children.”

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Congressional Candidates Go Head-To-Head On Health Care — Again

The California Democrats who fought to flip Republican congressional seats in 2018 used health care as their crowbar. The Republicans had just voted to repeal the Affordable Care Act in the U.S. House — and Democrats didn’t let voters forget it.

Two years later, Democrats are defending the seven seats they flipped from red to blue in California. And once again, they plan to go after their Republican opponents on health care in this year’s elections.

But this time around, it’s not just about the Affordable Care Act, whose fate now rests with the federal courts. Democrats are highlighting the high costs of prescription drugs, surprise medical bills and cuts to safety-net programs.

Health care “remains the single-biggest priority for most voters in 2020,” said U.S. Rep. Josh Harder, a Democrat who represents California’s 10th congressional district, in the northern San Joaquin Valley, which includes the cities of Modesto, Turlock, Tracy and Manteca.

Harder, who defeated Republican Jeff Denham in 2018, made the case then that eliminating the federal health law and its protections for people with preexisting conditions would harm thousands of people in his district, including his younger brother, whose premature birth yielded $2 million in hospital bills.

Health care affordability — from drug costs to premiums — is still the No. 1 issue his constituents raise in conversations with him, he said.

“The problems haven’t been solved,” said Harder, who blamed the Republican-controlled U.S. Senate for stalling on health care legislation addressing prescription and other health care costs. “A lot of folks out here feel like there’s still an unbelievably long period before they can see a doctor, and they think that the costs are way too high.”

Multiple calls and emails to Republican congressional candidates and the California Republican Party requesting comment were not returned. California voters will select their party’s congressional candidates in the Super Tuesday primary March 3.

Health care is indeed a top issue for voters, confirmed Mollyann Brodie, executive director of public opinion and survey research for the Kaiser Family Foundation. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.)

“What concerns people the most is health care costs and their own affordability of health care,” Brodie said. “And when we asked people what they thought Congress should be working on, prescription drug costs came right on top.”

A national Kaiser Family Foundation tracking poll from September 2019 found that 81% of Democrats and 62% of Republicans surveyed said lowering prescription drug costs should be a top priority for Congress. Voters in both parties also want Congress to maintain protections for people with preexisting conditions and limit surprise medical bills.

Both Democratic and Republican candidates are taking note and are likely to feature health care prominently in their campaigns, but their messages will be different, said Nathan Gonzales, editor and publisher of Inside Elections, a campaign analysis site.

For example, progressive Democrats often advocate for “Medicare for All,” a national health care program that would cover everyone in the U.S.

Republicans oppose this idea fervently.

“Republicans will talk about a government takeover of health care, socialism, Democratic efforts to get rid of private health insurance and the cost of Democratic plans,” Gonzales said.

Ted Howze, one of three Republicans gunning in the primary to replace Harder, fits this description. He is running for Congress after “personally struggling with the failure of the health care system,” he said during a January debate in Modesto. His first wife died in 2013 from an undiagnosed heart condition “that could have been treated,” according to his campaign website.

Among his top three priorities, he said, is making quality health care affordable for all Americans. But he proposes to do so through the private market, not more government-run programs.

“I will support any plan that covers preexisting conditions and that increases transparency and competition to drive costs down,” he said during the debate.

In at least one California district, health care has popped up in campaign advertising.

Twelve candidates are vying for the 25th Congressional District seat, which includes portions of Los Angeles and Ventura counties. The seat was vacated by former U.S. Rep. Katie Hill, a Democrat who resigned in October.

Voters in that district will face a double election on March 3: The first is a special election for the remainder of Hill’s term, which runs through the end of this year. The second is the primary for the full 2021-23 congressional term.

Among the candidates is former U.S. Rep. Steve Knight, the Republican who lost his seat to Hill in 2018. After voting to repeal Obamacare in Congress, he introduced a bill that he argued would have protected people with preexisting conditions. His campaign did not return multiple calls and emails for comment.

State Assembly member Christy Smith, a Democrat who is running for the seat, shared a personal story about prescription drug costs in her first television ad.

Smith’s mom, a nurse, “died too young because she couldn’t afford the insulin to treat her diabetes and heart disease,” Smith says in the ad.

“My mom couldn’t afford the medicine and care she needed. I’m running for Congress to make sure you can.”

Another Democratic candidate, Cenk Uygur, co-founder of “The Young Turks,” a progressive YouTube news show, also made health care the topic of his first TV ad. Tens of thousands of people die every year because they don’t have health insurance, he says in the ad. “What if your own child was one of them?”

Democrats may find more health care fodder for their campaigns as the year progresses, said Ivy Cargile, an assistant professor of political science at California State University-Bakersfield.

For instance, she said, on Feb. 10 the Trump administration released its $4.8 trillion 2020 federal budget proposal, which includes deep cuts to Medicaid, the public health insurance program for low-income people.

Medi-Cal, California’s Medicaid program, has about 13 million enrollees. “Let’s assume this goes through,” she said. “That’s going to be fresh in the mind of voters going into the general election.”

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

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Hormone Blocker Shocker: Drug Costs 8 Times More When Used For Kids

Dr. Sudeep Taksali, an orthopedic surgeon, became worried that his 8-year-old daughter had already grown taller than his 12-year-old son. And sometimes she had an attitude more befitting a teenager. Something seemed wrong.

Taksali and his wife, Sara, realized their daughter had grown 7 inches in two years and was showing signs of puberty. They took her to the doctor, who referred her to a pediatric endocrinologist for a work-up.

Eventually, their daughter was diagnosed with central precocious puberty. It’s a rare condition that meant she would go through sexual development years earlier than her peers and would likely stop growing prematurely, too.

Adopted two years ago from India, she’s a bright, avid reader who loves to do kettlebell workouts with her dad and Zumba with her mom. Still, moving across the world and learning a new language is no easy feat.

“Having one more thing for her to deal with … where there might be maybe some negative attention drawn to her changing body,” Taksali said. “That was one of my big concerns.”

On the advice of their daughter’s doctors, the Taksalis decided to put her early puberty on hold. The recommended treatment is a product commonly known as a hormone blocker. Implanted beneath the skin in her arm, it releases a small dose of a drug each day that increases the body’s production of some hormones while decreasing others. The result is the child’s progression toward adulthood slows.

Taksali’s 8-year-old daughter recently underwent treatment for central precocious puberty, or early puberty. Her father, an orthopedist, worked with her doctor and their health insurance provider to get the less expensive of two nearly identical drugs with vastly different price tags.(Kristina Barker for KHN)

The doctors told them there were two nearly identical drug implants — each containing 50 milligrams of histrelin acetate — made by the same company, Endo Pharmaceuticals, an American drugmaker domiciled in Ireland. But one was considerably cheaper.

Taksali wanted his daughter to get the less expensive option, but his insurer said it would cover only the more expensive option. Resigned, he asked the hospital how much it would charge for the expensive drug he had been hoping to avoid.

Then the estimated bill came.

The Patient: Sudeep Taksali’s daughter, 8. She is insured through her father’s high-deductible UnitedHealthcare plan.

Total Estimated Bill: The hospital told Taksali the insurer wouldn’t cover the cheaper version of the drug, Vantas. After that, he spent hours trying to get an estimated bill ahead of the scheduled implantation. Supprelin LA would cost around $95,000 plus the cost of implantation, the hospital’s billing department told him. Under his health plan, he has a $5,000 deductible and 20% coinsurance obligation, so he was worried how much he might owe.

Service Provider: OHSU Hospital in Portland, Oregon, part of Oregon Health & Science University.

Medical Procedure: Implantation of a drug-delivery device containing 50 mg of histrelin acetate, to stave off early puberty.

What Gives: Supprelin LA was approved by the Food and Drug Administration in 2007 for central precocious puberty and has a list price of $37,300. Vantas was approved by the FDA in 2004 for late-stage prostate cancer and has a list price of $4,400.

The main difference between the two medicines is that Supprelin LA releases 65 micrograms of the drug a day, and Vantas releases 50 micrograms a day. Each implant lasts about a year.

The 15-microgram difference in daily dose with Vantas is less than the weight of an eyelash, and the doctors who recommended the treatment said it has the same effectiveness for children with central precocious puberty.

The much higher price for the children’s version of the drug grated on Taksali. “From a parent standpoint, as a physician, as a consumer, it feels abusive,” he said. “There’s sort of a predation on parents who have that sense of vulnerability, who will do anything within their means to help their children.”

Taksali questions why Endo Pharmaceuticals makes two nearly identical drug delivery implants with vastly different prices.(Kristina Barker for KHN)

Drugmakers can use the same chemical compound to create different branded drugs with different disease targets ― and apply for FDA approval for each. FDA spokesperson Brittney Manchester said by email, “Generally, it is the sponsor’s decision.” Endo makes both Supprelin LA and Vantas.

Indeed, other drugmakers have used the maneuver: Pfizer makes two versions of sildenafil citrate: Viagra for erectile dysfunction and Revatio for pulmonary arterial hypertension.

When we asked Endo Pharmaceuticals why Supprelin LA and Vantas had such different price tags, the company said the implants aren’t identical and treat very different conditions. It didn’t respond to questions about why that meant the prices should be different and whether it was somehow more expensive to manufacture one versus the other.

Resolution: Taksali spent more than a month trying to make sure his daughter could use the cheaper drug and, finally, the week his daughter was scheduled to have the procedure, it was approved. The hospital submitted the request again and UnitedHealthcare said it would cover it.

“Our coverage policies are aligned with FDA regulations and Vantas is not FDA approved to treat central precocious puberty,” UnitedHealthcare spokesperson Tracey Lempner said in an email. “In this specific case, when the provider expressed concern over the cost of Supprelin LA, we worked with them to allow for coverage of Vantas.”

Taksali’s daughter got the Vantas implant in late January.

The hormone-blocking implant was placed on the young patient’s arm to treat central precocious puberty, or early puberty.(Kristina Barker for KHN)

When he got a breakdown of charges afterward, it listed $608 for the implantation and $12,598.47 for Vantas — about three times its list price. (Hospitals add markups to the list prices.) Still, that’s far less than the $95,000 the Supprelin LA bill would have been.

According to his explanation of benefits, after insurance, Taksali will owe $4,698.45 ― most of his high deductible. Because it is early in the year, the family had not yet spent any of its 2020 deductible.

Taksali said he fought for the lower cost drug on principle.

“Even if it is the insurance company’s money, it’s still somebody’s money,” he said. “We are still contributing to those premium dollars.”

On the day the Taksali family adopted their daughter from India, she and her brother were about the same height. Now she is about 5 inches taller than him despite being more than three years younger.(Courtesy of Sudeep Taksali)

The Takeaway: If you need an expensive drug, the first thing you should do is ask your doctor if there are cheaper alternatives. Often different formulations of the same chemical compound carry vastly different prices. In this family’s case, the version to treat prostate cancer patients was far cheaper than the pediatric version for a hormone imbalance.

More commonly, the different formulations relate to different dosages ― two 250 mg tablets may be cheaper than a 500 mg pill. Likewise, a pill you have to take three times a day may be far less expensive than the once-a-day extended-release version.

When a coverage denial leads to costly care, patients can ally with their health care providers or employers to appeal, though it can be time-consuming. Self-insured employers, in particular, won’t want to waste health care dollars either. For Taksali, using social media to direct-message UnitedHealthcare garnered prompt responses and some answers.

If there aren’t other options, drug manufacturers often offer coupons to help patients with their copays. You can find some using GoodRx or by visiting the drugmaker’s website directly.

KHN senior correspondent JoNel Aleccia contributed to this report.

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

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Trump’s Medicaid Chief Labels Medicaid ‘Mediocre.’ Is It?

The Trump administration’s top Medicaid official has been increasingly critical of the entitlement program she has overseen for three years.

Seema Verma, administrator of the Centers for Medicare & Medicaid Services, has warned that the federal government and states need to better control spending and improve care to the 70 million people on Medicaid, the state-federal health insurance program for the low-income population. She supports changes to Medicaid that would give states the option to receive capped annual federal funding for some enrollees instead of open-ended payouts based on enrollment and health costs. This would be a departure from how the program has operated since it began in 1965.

In an early February speech to the American Medical Association, Verma noted how changes are needed because Medicaid is one of the top two biggest expenses for states, and its costs are expected to increase 500% by 2050.

“Yet, for all that spending, health outcomes today on Medicaid are mediocre and many patients have difficulty accessing care,” she said.

Verma’s sharp comments got us wondering if Medicaid recipients were as bad off as she said. So we asked CMS what evidence it has to back up her views.

A CMS spokesperson responded by pointing us to a CMS fact sheet comparing the health status of people on Medicaid to people with private insurance and Medicare. The fact sheet, among other things, showed 43% of Medicaid enrollees report their health as excellent or very good compared with 71% of people with private insurance, 14% on Medicare and 58% who were uninsured.

The spokesperson also pointed to a 2017 report by the Medicaid and CHIP Payment and Access Commission (MACPAC), a congressional advisory board, that noted: “Medicaid enrollees have more difficulty than low-income privately insured individuals in finding a doctor who accepts their insurance and making an appointment; Medicaid enrollees also have more difficulty finding a specialist physician who will treat them.”

We opted to look at those issues separately.

What About Health Status?

Several national Medicaid experts said Verma is wrong to use health status as a proxy for whether Medicaid helps improve health for people. That’s because to be eligible for Medicaid, people must fall into a low-income bracket, which can impact their health in many ways. For example, they may live in substandard housing or not get proper nutrition and exercise. In addition, lack of transportation or child care responsibilities can hamper their ability to visit doctors.

Benjamin Sommers, a health economist at Harvard University, said Verma’s comparison of the health status of Medicaid recipients against people with Medicare or private insurance is invalid because the populations are so different and face varied health risks. “This wouldn’t pass muster in a first-year statistics class,” he said.

Death rates, for example, are higher among people in the Medicare program than those in private insurance or Medicaid, he said, but that’s not a knock on Medicare. It’s because Medicare primarily covers people 65 and older.

By definition, Medicaid covers the most vulnerable people in the community, from newborns to the disabled and the poor, said Rachel Nuzum, a vice president with the nonpartisan Commonwealth Fund. “The Medicaid population does not look like the privately insured population.”

Joe Antos, a health economist with the conservative American Enterprise Institute, also agreed, saying he is leery of any studies or statements that evaluate Medicaid without adjusting for risk.

For a better mechanism to gauge health outcomes under Medicaid, experts point to dozens of studies that track what happened in states that chose in the past six years to pursue the Affordable Care Act’s Medicaid expansion. The health law gave states the option to extend Medicaid to everyone with incomes up to 138% of the federal poverty level, or about $17,600 annually for an individual. Thirty-six states and the District of Columbia have adopted the expansion.

“Most research demonstrates that Medicaid expansion has improved access to care, utilization of services, the affordability of care, and financial security among the low-income population,” concluded the Kaiser Family Foundation in summarizing findings from more than 300 studies. “Studies show improved self-reported health following expansion and an association between expansion and certain positive health outcomes.” (Kaiser Health News is an editorially independent program of the foundation.)

Studies found the expansion of Medicaid led to lower mortality rates for people with heart disease and among end-stage renal disease patients initiating dialysis.

Researchers also reported that Medicaid expansion was associated with declines in the length of stay of hospitalized patients. One study found a link between expansion and declines in mechanical ventilation rates among patients hospitalized for various conditions.

Another recent study compared the health characteristics of low-income residents of Texas, which has not expanded Medicaid, and those of Arkansas and Kentucky, which did. It found that new Medicaid enrollees in the latter two states were 41 percentage points more likely to have a usual source of care and 23 percentage points more likely to say they were in excellent health than a comparable group of Texas residents.

Medicaid’s benefits, though, affect far more than the millions of nondisabled adults who gained coverage as a result of the ACA. “Medicaid coverage was associated with a range of positive health behaviors and outcomes, including increased access to care; improved self-reported health status; higher rates of preventive health screenings; lower likelihood of delaying care because of costs; decreased hospital and emergency department utilization; and decreased infant, child, and adult mortality rates,” according to a report issued this month by the nonpartisan Robert Wood Johnson Foundation.

Children — who make up nearly half of Medicaid enrollees — have also benefited from the coverage, studies find. Some studies report that Medicaid contributes to improved health outcomes, including reductions in avoidable hospitalizations and lower child mortality.

Research shows people on Medicaid are generally happy with the coverage.

A Commonwealth Fund survey found 90% of adults with Medicaid were satisfied or very satisfied with their coverage, a slightly higher percentage than those with employer coverage.

Accessible Care?

The evidence here is less emphatic.

A 2017 study published in JAMA Internal Medicine found 84% of Medicaid recipients felt they were able to get all the medical care they needed in the previous six months. Only 3% said they could not get care because of long wait times or because doctors would not accept their insurance.

Verma cites a 2017 MACPAC report that noted some people on Medicaid have issues accessing care. But that report also noted: “The body of work to date by MACPAC and others shows that Medicaid beneficiaries have much better access to care, and much higher health care utilization, than individuals without insurance, particularly when controlling for socioeconomic characteristics and health status.” It also notes that “Medicaid beneficiaries also fare as well as or better than individuals with private insurance on some access measures.”

The report said people with Medicaid are as likely as those with private insurance to have a usual source of care, a doctor visit each year and certain services such as a Pap test to detect cervical cancer.

“Medicaid is not great coverage, but it does open the door for health access to help people deal with medical problems before they become acute,” Antos said.

On the negative side, the report said Medicaid recipients are more likely than privately insured patients to experience longer waiting times to see a doctor. They also are less likely to receive mammograms, colorectal tests and dental visits than the privately insured.

“Compared to having no insurance at all, having Medicaid improves access to care and improves health,” said Rachel Garfield, a vice president at the Kaiser Family Foundation. “There is pretty strong evidence that Medicaid helps patients get the care they need.”

Our Ruling

Verma said that “health outcomes today on Medicaid are mediocre and many patients have difficulty accessing care.”

Numerous studies show people’s health improves as a result of Medicaid coverage. This includes lower mortality rates, shorter hospital stays and more people likely to get cancer screenings.

While it’s hard to specify what “many patients having difficulty accessing care” means, research does show that Medicaid enrollees generally say they have no trouble accessing care most of the time.

We rate the claim as Mostly False.

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It’s Not Just Hospitals That Sue Patients Who Can’t Pay

Nashville General Hospital is a safety-net facility funded by the Tennessee capital city. For a patient without insurance, this is supposed to be the best place to go in a city with many hospitals. But for the uninsured, it may have been the worst choice in 2019.

Its emergency room was taking more patients to court for unpaid medical bills than any other hospital or practice in town. A WPLN investigation found the physician-staffing firm that runs the ER sued 700 patients in Davidson County during 2019.

They include patients such as Sonya Johnson, a 52-year-old social worker and single mother. By juggling her care between a nonprofit clinic and Nashville General, Johnson had figured out how to manage her health problems, even though she was, until recently, uninsured.

In 2018, she went to see her doctor, who charges patients on a sliding scale. Her tongue was swollen and she was feeling weak. The diagnosis? Severe anemia.

“He called me back that Halloween day and said, ‘I need you to get to the emergency [room], stat — and they’re waiting on you when you get there,’” she recalled.

Nashville General kept her overnight and gave her a blood transfusion. They wanted to keep her a second night — but she was worried about the mounting cost and asked to be sent home.

Staying the one night meant she was admitted to the hospital itself, and the bill for that part of her care wasn’t so bad, Johnson said. The institution’s financial counselors offered a 75% discount because of her strained finances and because her job didn’t offer health insurance at the time.

But emergency rooms are often run by an entirely separate entity. In Nashville General’s case, the proprietor was a company called Southeastern Emergency Physicians. And that’s the name on a bill that showed up in Johnson’s mailbox months later for $2,700.

“How in the world can I pay this company, when I couldn’t even pay for health care [insurance]?” Johnson asked.

Social worker Sonya Johnson received a civil warrant to appear in court when the company that runs Nashville General Hospital’s emergency room threatened to sue her over a $2,700 ER bill — long after she’d already negotiated a reduced payment schedule for the rest of her hospital stay.(Blake Farmer/WPLN)

Johnson didn’t recognize the name of the physician practice. A Google search didn’t help much. There’s no particular website, though a listing of webpages that do turn up in such a search suggests the company staffs a number of emergency departments in the region.

Johnson said she tried calling the number listed on her bill to see if she could get the same charity-care discount the hospital gave her, but she could only leave messages. And then came a knock at her apartment door over the summer. It was a Davidson County sheriff’s deputy with a summons requiring Johnson to appear in court.

“It’s very scary,” she said, and she recalled thinking “What have I done? And for a medical bill?”

Handoff Of Lawsuits?

Being sued over medical debt can be a big deal because it means a business can get a court-ordered judgment to garnish patients’ wages, taking money directly from their paycheck. The strategy is meant to make sure patients don’t blow off their medical debts. But this is not good for the health of people who are uninsured, said Bruce Naremore, chief financial officer at Nashville General.

“When patients owe money, and they feel like they’re being dunned all the time, they don’t come back to the hospital to get what they might need,” he said.

Under Naremore’s direction in the past few years, Nashville General had stopped suing patients for hospital fees. He said it was rarely worth the court costs.

But Southeastern Emergency Physicians — which, since 2016, has been contracted by the hospital to run and staff its emergency department — went the other way, filing more lawsuits against patients than ever in 2019.

Naremore said the decision on whether to sue over emergency care falls to the company that staffs the ER, not Nashville General Hospital.

“It’s a private entity that runs the emergency room, and it’s the cost of doing business,” he said. “If I restrict them from collecting dollars, then my cost is going to very likely go up, or I’m going to have to find another provider to do it.”

This is a common refrain, said Robert Goff, a retired hospital executive and board member of RIP Medical Debt. The nonprofit helps patients trapped under a mountain of medical bills, which are the No. 1 cause of personal bankruptcy.

“So the hospital sits there and says, ‘Not my problem.’ That’s irresponsible in every sense of the word,” Goff said.

The practice of suing patients isn’t new for Southeastern Emergency Physicians or its parent company, Knoxville, Tennessee-based TeamHealth. But such lawsuits have picked up in recent years, even as the company has stopped its practice of balance-billing patients.

TeamHealth is one of the two dominant ER staffing firms in the nation, running nearly 1 in 10 emergency departments in the United States. And its strategy of taking patients to court ramped up after it was purchased by the private equity giant Blackstone, according to an investigation by the journalism project MLK50 in Memphis, Tennessee.

Under pressure from journalists, TeamHealth ultimately pledged to stop suing patients and to offer generous discounts to uninsured patients.

Officials from TeamHealth declined WPLN’s request for an interview to answer questions about how widespread its practice of suing patients for ER doctors’ services and fees has been.

“We will work with patients on a case by case basis to reach a resolution,” TeamHealth said in an email.

According to court records obtained by WPLN, the firm filed about 700 lawsuits against patients in Nashville in 2019. That’s up from 120 in 2018 and just seven in 2017. Its only contract in the city is with Nashville General’s ER, and the patients reached by WPLN said they were uninsured when they were sued.

What’s surprising to Mandy Pellegrinwho has researched medical billing in Tennessee at the nonpartisan Sycamore Institute, is that it was all happening at Nashville General — where treating uninsured patients is part of the hospital’s mission.

“It is curious that a company that works for a hospital like that might resort to those sorts of actions,” Pellegrin said.

A Pledge To Drop Cases

As for Sonya Johnson — she eventually went to court and worked out a payment plan of $70 a month over three years.

And now TeamHealth tells WPLN that its intent is to drop pending cases.

“We will not file additional cases naming patients as defendants and will not seek further judgments,” a TeamHealth spokesperson said in an emailed statement. “Our intent is not to have these pending cases proceed. We’re working as expeditiously as possible on resolving individual outstanding cases.”

Johnson said she has been told that the lawsuit Southeastern Emergency Physicians filed against her will be dropped — but that she still owes the $2,700 bill.

This story is part of a reporting partnership that includes WPLN, NPR and Kaiser Health News. 

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Obamacare A Disgrace? Biden Highlights Bloomberg’s Negative Remarks About The Affordable Care Act.

Sparring over health care during the Nevada Democratic presidential primary debate, former Vice President Joe Biden took issue with former New York City Mayor Michael Bloomberg’s record on the Affordable Care Act.

“From the moment we passed that signature legislation, Mike called it a disgrace,” Biden said, a claim he repeated another time during the debate. 

Bloomberg sought to refute that charge, arguing that he defended the law and believed it should be expanded.

It was a heated moment. Both candidates are trying to tie themselves to former President Barack Obama, who spearheaded the 2010 legislation. So we decided to dig in.

We reached out to both campaigns for comment. We didn’t hear back from Bloomberg’s campaign. The Biden campaign sent a CNN article, which cited a speech Bloomberg gave at the Dartmouth Presidential Lecture in July 2010 — just a few months after the health care legislation was passed in March. In the speech, Bloomberg called the Affordable Care Act “a disgrace.” We found a video of the speech on YouTube. 

The remarks 

In the video, Bloomberg was unsparing. 

“We passed a health care bill that does absolutely nothing to fix the big health care problems in this country. It is just a disgrace,” he said. “The president, in all fairness, started out by pointing out what the big problems were, but then turned it over to Congress, which didn’t pay any attention to any of those big problems and just created another program that’s going to cost a lot of money.”

Those aren’t standalone remarks. As recently as 2014, Bloomberg called the law “really dysfunctional” during a talk he gave at the annual meeting of SIFMA, one of the financial industry’s trade groups. 

Both times, Bloomberg was still a registered Independent — he didn’t become a Democrat until 2018.

It’s also worth noting that Bloomberg wasn’t espousing a minority view. The ACA’s approval rating was underwater until 2017, according to polling by the Kaiser Family Foundation. (KHN is an editorially independent program of the Foundation.)

Bloomberg’s response

On the debate stage, Bloomberg sought distance from those remarks, saying he is a “fan of Obamacare.”

“I wrote something supporting it either in the New York Post or the Daily News,” he said.

The op-ed he appears to be referring to — published March 27, 2017, in the New York Post — does indeed talk about the ACA. But it comes years after Bloomberg’s mayorship ended. And while words like “disgrace” don’t appear, calling the piece a “defense” of the law isn’t entirely fair.

In it, Bloomberg noted some key shortcomings — for instance, the health law left 30 million people uninsured. He also argued in support of some ideas more popular with Republicans, such as high-risk insurance pools, as a way to bring down costs.

“It’s regrettable that none of these ideas was seriously considered in the rush to repeal ObamaCare,” Bloomberg wrote at the time.

It is worth noting that Bloomberg’s current health care plan would build on the ACA, largely by increasing subsidies for people buying private insurance on the exchanges, and by installing a Medicare-like public option. (That plan is quite similar to what’s been touted by Biden himself, as well as by candidates like former South Bend, Ind., Mayor Pete Buttigieg.)

Our ruling

Biden said that Bloomberg called the ACA “a disgrace.”

Evidence supports that. And it’s not the only time Bloomberg took issue with the law — even if it is a core component of his current proposal for health reform. 

We rate this claim True.

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Analysis: Who Profits From Steep Medical Bills? The People Tasked With Fixing Them.

Every politician condemns the phenomenon of “surprise” medical bills.

Last week, two committees in the House were marking up new surprise billing legislation. One of the few policy proposals President Donald Trump brought up in this year’s State of the Union address was his 2019 executive order targeting “balance bills.” In the Democratic debates, candidates have railed against such medical bills, and during commercial breaks, back-to-back ads from groups representing doctors and insurers proclaimed how much the health care sector also abhors this uniquely American form of patient extortion.

Patients, of course, hate surprise bills most of all. Typical scenarios: A patient having a heart attack is taken by ambulance to the nearest hospital and gets hit with a bill of over $100,000 because that hospital wasn’t in his insurance network. A patient selects an in-network provider for a minor procedure, like a colonoscopy, only to be billed thousands for the out-of-network anesthesiologist and pathologist who participated.

And yet, no one with authority in Washington has done much of anything about it.

Here’s why: Major sectors of the health industry have helped to invent this toxic phenomenon, and none of them want to solve it if it means their particular income stream takes a hit. And they have allies in the capital.

That explains why Trump’s executive order, issued last year, hasn’t resulted in real change. Why bipartisan congressional legislation supported by both the House Energy and Commerce Committee and the Senate Health Committee to shield Americans from surprise medical bills has gone nowhere. And why surprise billing provisions were left out of the end-of-year spending bill in December, which did include major tax relief for many parts of the health care industry.

Surprise bills are just the latest weapons in a decades-long war among the players in the health care industry over who gets to keep the fortunes generated each year from patient illness: $3.6 trillion in 2018.

Here’s how they came to be:

Forty years ago, when many insurers were nonprofit entities and being a doctor wasn’t seen as a particularly good entree into society’s top 1%, billed rates were far lower than they are today, and insurers mostly just paid them. Premiums were low or paid by an employer. Patients paid little or nothing in copayments or deductibles.

That’s when a more entrepreneurial streak kicked in. Think about the opportunities: If someone is paying you whatever you ask, why not ask for more?

Commercial insurers as well as Blue Cross Blue Shield plans, some of which had converted to for-profit status by 2000, began to push back on escalating fees from providers, demanding discounts.

Hospitals and doctors argued about who got to keep different streams of revenue they were paid. Doctors began to form their own companies and built their own outpatient surgery centers to capture payments for themselves.

So today your hospital and doctor and insurer — all claiming to coordinate care for your health — are often in a three-way competition for your money.

As the battle for revenue has heated up, each side has added weapons to capture more: Hospitals added facility fees and infusion charges. Insurers levied ever-rising copayments and deductibles. Most important, they limited the networks of providers to those that would accept the rates they were willing to pay.

Surprise bills are the latest tactic: When providers decided that an insurer’s contracted payment offerings were too meager, they stopped participating in the insurer’s network; either they walked away or the insurer left them out. In some cases, physicians decided not to participate in any networks at all. That way, they could charge whatever they wanted when they got involved in patient care and bill the patient directly. For their part, insurers didn’t really care if those practitioners demanding more money left.

And, for a time, all sides were basically fine with this arrangement.

But as the scope and the scale of surprise bills have grown in the past five years, more people have experienced these costly, unpleasant surprises. With accumulating bad publicity, they have become impossible to ignore. It was hard to defend a patient stuck with over $500,000 in surprise bills for 14 weeks of dialysis. Or the $10,000 bill from the out-of-network pediatrician who tends to newborns in intensive care. How about the counties where no ambulance companies participate in insurance, so every ambulance ride costs hundreds or even thousands of dollars?

These practices are an obvious outrage. But no one in the health care sector wants to unilaterally make the type of big concessions that would change them. Insurers want to pay a fixed rate. Doctors and hospitals prefer what they call “baseball-style arbitration,” where a reasonable charge is determined by mediation. Both camps have lined up sympathetic politicians for their point of view.

So, nothing has changed at the federal level, even though it’s hard to imagine another issue for which there is such widespread consensus. Two-thirds of Americans say they are worried about being able to afford an unexpected medical bill — more than any other household expense. Nearly 8 in 10 Americans say they want federal legislation to protect patients against surprise bills.

States are passing their own surprise billing laws, though they lack power since much of insurance is regulated at a national level.

Now members of Congress have yet another chance to tackle this obvious injustice. Will they listen to hospitals, doctors, insurers? Or, in this election year, will they finally heed their voter-patients?

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Must-Reads Of The Week From Brianna Labuskes

Happy Friday! And Happy Valentine’s Day, where we at KHN have compiled some of the best #HealthPolicyValentines from Twitter (this seems the right group for that level of wonkiness!). Check out some great ones, like this from Laura Marston:

“One vial a week
Keeps me alive
Used to cost $20
Now it’s $275.”

Now on to equally fun things, like budgets!

President Donald Trump released his proposed budget this week with only the vaguest of a health care plan mentioned. A mystery pot of $844 billion signaled deep cuts to Medicaid and subsidies under the health law. In particular, an obscure passage referred to “ending the financial bias that currently favors able-bodied working-age adults over the truly vulnerable.” Critics were scratching their heads how the released budget aligned with Trump’s promise to protect people’s coverage. “You can’t cut $1 trillion from these programs and protect the most vulnerable,” said Aviva Aron-Dine of the Center on Budget and Policy Priorities.

The Associated Press: Mystery $844B Pot in Trump Budget Signals Medicaid Cuts

The budget also calls for an almost 16% cut to the CDC (yes, the agency handling the coronavirus outbreak). But top officials say that’s because the administration wants the CDC to narrow its focus to its core mission of preventing and controlling infectious diseases and handling public health crises.

The Washington Post: Trump Budget Cuts Funding for Health, Science, Environment Agencies

Trump also wants to cut the budget for the National Institutes of Health by 6.5%. (Yes, that would affect the National Institute of Allergy and Infectious Diseases, which is working on a vaccine for the coronavirus.)

The Wall Street Journal: Trump Proposes $4.8 Trillion Budget, With Cuts to Safety Nets

Another odd little nugget in the budget: Trump wants to strip the FDA of its authority over tobacco products and create an agency within HHS solely for that purpose.

Stat: Trump Doesn’t Want the FDA to Regulate Tobacco

For a full breakdown of the budget’s details, check out our roundup here.


This week, the coronavirus strain got an official name, which is — drum roll, please —COVID-19. Although the announcement probably set off celebrations among scientists and researchers who have been driven up a wall because everyone has been simply calling it “coronavirus,” I am here to report that a day into its official designation 95% of headlines are stilling using only the generic term.

— It is, however, important to note that WHO officials were careful not to name the disease after a particular region or people so as to avoid further stigmatization surrounding any outbreaks.

Time: What’s in a Name? Why WHO’s Formal Name for the New Coronavirus Disease Matters

— As the death toll climbs in China, officials have expanded their “wartime” campaign to round up all the people who may be infected. But, as you can imagine, that is not going perfectly. Not only is it stoking tensions among an angry and scared nation whose residents aren’t happy with how the government is handling the crisis, but also it’s thrusting people who haven’t even tested positive for the virus into situations where they become vulnerable to infection.

The New York Times: China Expands Chaotic Dragnet in Coronavirus Crackdown

— Readers of The Friday Breeze know I’ve been harping on the fact that our national attention has been focused on COVID-19 even though we have only 15 (non-fatal) confirmed cases of it here and the common flu is far more deadly to us. Well, there’s a psychological basis for why we tend to panic over things that statistically are unlikely to affect us. Pretty much we can be terrible at accurately assessing risk.

The New York Times: Coronavirus ‘Hits All the Hot Buttons’ for How We Misjudge Risk

— It was a bit of a roller-coaster week with data coming out of China. At first, it seemed the cases were slowing down, but then the diagnostic criteria were tweaked, and all of a sudden we had nearly 15,000 cases added in one night.

The New York Times: Coronavirus Cases Seemed to Be Leveling Off. Not Anymore.

— CDC Director Robert Redfield said that the United States is essentially trying to buy time with its containment strategy, but it is quite likely there will eventually be person-to-person transmission of the virus here. (Which means people other than evacuees from Wuhan will start getting it.)

Stat: CDC Director: More Person-To-Person Coronavirus Infections in U.S. Likely

— And you can see how easily that could happen, given a U.S. evacuee was mistakenly released from the hospital even though she was infected with the coronavirus.

CNN: First US Evacuee Infected With Coronavirus Was Mistakenly Released From Hospital

— In an update from the cruise from h-e-double-hockey-sticks: Tensions continue to rise along with COVID-19 cases among the passengers and crew of a ship quarantined off the coast of Japan. As one health official said this week: Remember, quarantines are to keep those outside of its boundaries safe, not those within.

The New York Times: Quarantined Cruise Passengers Have Many Questions. Japan Has Few Answers.

— WHO has been heaping praise on China for its response to the crisis. And while other experts acknowledge the organization is in the tenuous position of not wanting to anger China enough that they break off relations, critics say the excessive compliments are setting a bad precedent about what a good pandemic response looks like.

The Wall Street Journal: The World Health Organization Draws Flak for Coronavirus Response

— Meanwhile, the coronavirus research filed is quite small. That’s because, despite the buzz these kinds of outbreaks create, eventually the world’s attention will be caught by a different shiny object and both the funding and interest in researching the virus will fade.

Stat: Fluctuating Funding and Flagging Interest Hurt Coronavirus Research


Supporters of Sen. Bernie Sanders (I-Vt.) got their wrists slapped by a powerful Nevada union this week for “viciously attacking” members and their families online. At the heart of the matter: The union had released information critical of Sanders’ “Medicare for All” plan. The clash put Sanders — who denounced any harassment as “unacceptable” — in an awkward spot just before the Nevada caucuses next week.

Politico: Nevada Culinary Union Lays Into Sanders Supporters After Health Care Backlash


A new survey found that even when patients plan ahead, many are still hit with surprise medical bills, especially if they receive anesthesia during a procedure. With health care spending rising again (driven by high costs like the out-of-pocket price tag for an emergency room visit), the report is a reminder that the issue is likely to be top of mind with voters come November.

Meanwhile, lawmakers well aware of that fact are moving forward with legislation that would favor an arbitration method for dealing with the surprise costs. This strategy is favored by hospitals and providers, and not embraced by insurers.

Reuters: Surprise Surgery Bills Happen Even When Patients Plan Ahead

Modern Healthcare: House Committee Advances Provider-Friendly Surprise Billing Fix


In a little bit of breaking news, a federal appellate court just shut down CMS’ approval of Arkansas’ Medicaid work requirement. The panel upheld a lower-court ruling that found the requirements arbitrary and capricious.

Modern Healthcare: D.C. Circuit Nixes Arkansas Medicaid Work Requirement


Juul has vowed time and again that it hasn’t marketed its products to teenagers. But new revelations from a Massachusetts lawsuit that the vaping company bought ads on Nickelodeon and the Cartoon Network are challenging those promises.

The New York Times: Juul Bought Ads Appearing on Cartoon Network and Other Youth Sites, Suit Claims


The VA is no stranger to controversy, but the latest bout comes at a bad time for the agency. The abrupt firing of the agency’s well-liked undersecretary in combination with allegations that VA Secretary Robert Wilkie sought to dig up dirt on a woman after she said she was sexually assaulted at a VA facility have shaken the agency just as it is preparing to launch an ambitious health plan.

The New York Times: Veterans Affairs, a Trump Signature Issue, Is Facing Turmoil Again

Meanwhile, Trump continued to downplay brain injuries sustained by troops from an Iran missile strike even as the number of cases jumped past 100.

The New York Times: More Than 100 Troops Have Brain Injuries From Iran Missile Strike, Pentagon Says


In the miscellaneous file for the week:

— It’s notoriously hard to get any gun measures passed … except these advocates seem to be having some success. Their strategy? Go hyper-local.

NBC News: How Moms Are Quietly Passing Gun Safety Policy Through School Boards

— What’s going on with the Equal Rights Amendment and why has it become a fight over abortion? Politico takes a deep dive into its history about how the battle around the amendment has shifted in the nearly 40 years since it was introduced.

Politico: How the Debate Over the ERA Became a Fight Over Abortion

— New parents eager to better balance family and work life in the only industrialized country in the world without a paid family leave policy have started bringing their babies to their offices.

Stateline: You Can Bring Your Baby to Work (But Wouldn’t You Rather Be at Home?)

— In another crushing disappointment, an Alzheimer’s drug that had sparked high hopes was the latest to fail to live up to expectations.

The Associated Press: Drugs Fail to Slow Decline in Inherited Alzheimer’s Disease


That’s it from me. And remember, if you ever feel like flexing your poetic muscles outside of Valentine’sDay, we accept haiku submissions year-round. Have a great weekend!

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CEO Faces Criminal Investigation Following Accusations He Has Not Operated Hospitals With Eye On Public Safety

‘An Arm And A Leg’: What We’ve Learned And What’s Ahead For The Show


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In this bonus episode of “An Arm and a Leg,” reporter and colleague Sally Herships (“Planet Money,” “Marketplace”) takes a turn in the host’s chair.

The conversation covers what we have learned so far and what’s ahead for the show.

You’ll hear stories culled from the cutting-room floor, including an early adventure from the medical-bill ninja profiled early on in Season 3.

We also dig into the stories — and lessons — listeners have shared with the show.

Looking ahead to Season 4, our question is: “How do we make this into kind of a community education project? We’ve profiled a ninja. Now, how do we build a dojo?”


Season 3 is a co-production of Kaiser Health News and Public Road Productions.

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

To hear all Kaiser Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on iTunesPocket CastsGoogle Play or Spotify.

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KHN’s ‘What The Health?’: Live from D.C. With Rep. Donna Shalala


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President Donald Trump’s proposed budget for the fiscal year that begins in October proposes big cuts to popular programs, including Medicaid and the National Institutes of Health. Although those cuts are unlikely to be enacted by Congress, both Republicans and Democrats are likely to use the budget blueprint as a campaign issue.

Meanwhile, several House committees this week relaunched work on legislation to address “surprise” medical bills — unexpected charges from out-of-network providers. And Congress is still trying to come to a bipartisan agreement on how to address drug prices.

Rep. Donna Shalala (D-Fla.) was the special guest for this week’s podcast, taped before a live audience at the Kaiser Family Foundation headquarters in Washington, D.C. Also joining host Julie Rovner of Kaiser Health News were Paige Winfield Cunningham of The Washington Post, Rebecca Adams of CQ Roll Call and Joanne Kenen of Politico.

Among the takeaways from this week’s podcast:

  • One surprise in the president’s budget is a proposal to move tobacco regulation out from under the Food and Drug Administration’s purview. That comes despite a law Congress passed several years ago that specifically named the FDA as the regulator for tobacco.
  • Last year, it seemed clear that Congress and the White House were determined to find a way to protect consumers from surprise medical bills. But heavy lobbying on the issue and deep fissures in pinpointing the best remedy have slowed that effort. Shalala said she thinks Congress will produce a bill this year that will be balanced so that insurers and medical providers have to compromise.
  • Shalala said that in the 21 town meetings she has held in South Florida, no one has asked about efforts to end surprise bills. Most of the health questions focus on high drug prices and out-of-pocket costs. High out-of-pocket costs have been driven by the large number of people shifted into high-deductible insurance plans.
  • Shalala also said she doesn’t expect a plan to import drugs from Canada, endorsed by the Trump administration and some states, to go forward. Drugmakers sell Canada enough medicine to cover the population there, and not consumers in Florida, she added.

To hear all our podcasts, click here.

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

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Coronavirus Tests Public Health Infrastructure In The Heartland

JEFFERSON CITY, Mo. — Every weekday at noon since Jan. 27, the Missouri Department of Health and Senior Services Director Randall Williams gathers his outbreak response team for a meeting on coronavirus.

Missouri has yet to have a confirmed case of what officials are now calling COVID-19, but about 20 people statewide are being monitored for the novel viral infection originating from Wuhan, China. While 15 cases have been confirmed in the U.S. so far, tens of thousands of people have been infected worldwide and more than 1,300 have died. Global — and local — fears of the spread of the respiratory virus are fueling concerns about a lack of preparation in the U.S.

Missouri health department staff have been working overtime preparing for if, and when, the cases come by ensuring they have adequate supplies of non-expired protective gear like masks and planning how to trace the movements of those who have come in contact with potentially infected people.

They’re also helping set up coronavirus testing capabilities at a regional lab based here in the state capital to evaluate potential cases from Missouri, Kansas, Nebraska and Iowa. The U.S. Centers for Disease Control and Prevention has started shipping testing kits around the country.

Coronavirus may not require a front-line battle yet in places like Missouri as it does in states with confirmed cases, such as Washington, California, Illinois and Texas. But it’s still taxing public health officials in Missouri, which has one of the lowest levels in the nation for public health spending per person. And they, like health officials in other states, are stuck in the tricky position of trying not to be over- or underprepared for a potential public health crisis that may never come.

Missouri’s legislature is considering an additional $300,000 in emergency funding for events like coronavirus. This money is vital for responding to outbreaks in the state, Williams said, including more common concerns like mumps and measles or ongoing fights against hepatitis A and tuberculosis.

However, according to Williams, the legislature denied such an appeal for $300,000 last year.

“We are essentially like a fire department, right? People want us to be available when there’s a fire,” the director said. “But when there’s not a fire, they don’t really give a lot of thought to it.”

Limited Budget

As state officials gear up for possible problems from coronavirus, local health departments in Missouri are at a disadvantage because they have lost staff amid state budget cuts, according to Lindsey Baker, research director for the Missouri Budget Project, a nonprofit focused on public policy decisions.

Similar patterns hold true across the nation. Almost a quarter of local health department jobs have been lost since 2008, according to the National Association of County and City Health Officials, and a quarter of local health departments experienced budget cuts last year.

While federal funding has supplemented public health funding in Missouri, Baker said, the federal cash comes with strict rules on how it can be used.

Williams stressed that, despite Missouri’s limited budget, his state ranked in the top tier for emergency preparedness by Trust for America’s Health, a nonprofit advocacy group promoting public health.

Money notwithstanding, viruses like COVID-19 force the staff to work longer hours, according to state epidemiologist Dr. George Turabelidze, as the health department juggles its existing workload with pressing concerns.

“Everything else is happening — it’s not like we can switch, we have to do all this at once,” Turabelidze said.

Plus, he added, since this outbreak involves world travelers arriving at all times of the day, his staff has had to work weekends to track down where travelers have come from and whether they’ve had contact with infected people. For now, salaried staffers — who do not receive overtime — are expected to shoulder the extra load.

Even as they work extra hours, some routine health department matters such as onsite sewage inspections “get put in the back seat,” said Adam Crumbliss, chief director of Missouri’s Division of Community and Public Health.

If coronavirus reaches a pandemic level — in which it spreads worldwide — Crumbliss said the National Guard could be activated.

Relying On Existing Relationships And Stockpiles

Vital to any public health emergency response are the underlying relationships, stressed Paula Nickelson, the state’s program coordinator for health care system readiness. Knowing whom to call and having an established rapport with key health care providers such as the Missouri Hospital Association is critical during a crisis.

As is experience. Nickelson said the state’s response capabilities were tested and strengthened during a successful practice transport of a hypothetical Ebola patient from St. Louis to the University of Iowa in May.

Through that exercise, they learned that the material of their ISOPODs — portable, see-through isolation units that quarantine infected patients while allowing them to still see and speak to other people — was so thick it made it hard to hear those inside. Now, they are equipping them with walkie-talkies.

Another major question in recent days is a potential onslaught of shortages of protective medical equipment — everything from masks to latex gloves ― often manufactured in China. Nickelson said the state has assessed what materials are on hand.

“They’re fairly small amounts,” she said. “What we found over the course of a decade is that a lot of that stuff sits on the shelf, doesn’t necessarily get used, and so we’re better off to have just-in-time, vendor-managed processes in place.”

Still, Nickelson noted, that could become a problem for everyone if a pandemic occurs and those vendors become swamped with orders.

“This is by no means a sprint,” Crumbliss said. “This is a long wind race.”

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