Tagged Cost and Quality

VA Makes Major Leadership Changes In Atlanta After Reports That Nursing Home Patient Was Bitten By Ants

The VA placed the regional leader, chief medical officer and seven staff members on administrative leave while launching an investigation into the nursing home. “His room had ants, the ceiling, the walls, the beds. They were everywhere,” said Laquna Ross the patient’s daughter.

Few Things So Starkly Set America’s Health System Apart As How Much Patients Have To Pay Out Of Pocket

Nearly all of America’s global competitors — whether they have government health plans, such as Britain and Canada, or rely on private insurers, such as Germany and the Netherlands — strictly limit out-of-pocket costs. In more news on the health industry and insurance: hospital lawsuits against low-income patients; employer-based health care costs; price hikes and upcoding; America’s uninsured rate; and state marketplaces.

Do 50 Million People Really Lose Health Coverage Each Year Because Of Their Jobs?

The moderators kicked off the third Democratic debate with the topic of health care, teeing up another round of the ongoing “Medicare for All” debate.

Vermont Sen. Bernie Sanders caught our attention by claiming that 50 million people lose their private insurance every year due to employment changes.

“George, you talked about, was it 150 million people on private insurance? 50 million of those people lose their private insurance every year when they quit their jobs or they go unemployed or their employer changes their insurance policy,” Sanders said.

That sounds like a huge number even before he qualified it by attributing it to job loss and other work-related occasions for an insurance lapse.

We reached out to the Sanders’ campaign to discover the basis for this claim and were pointed to an analysis by the People’s Policy Project, a social Democratic-leaning think tank. That analysis hinges on a question asked as part of a national Centers for Disease Control and Prevention survey in 2014, plus a little basic multiplication.

The survey asked adults between ages 18 and 64, in 43 states: “In the past 12 months was there any time when you did not have any health insurance or coverage?” In response, 12.9% said they had experienced a gap in coverage, while 11.5% said they had been uninsured for more than 12 months.

The think tank analysis then combined those percentages and multiplied them by current population estimates, coming up with “just under 50 million people” who were uninsured for at least part of the year. (It went on to endorse Medicare for All.)

This claim becomes perplexing when you consider the total number of uninsured people in recent years. In 2013, overall there were more than 44 million uninsured, Americansm under age 65. With the initial implementation of the Affordable Care Act, that number steadily declined until last year when it ticked up slightly to 27.5 million.

A Sanders spokeswoman also cited another People’s Policy Project blog post analyzing the number of people who leave their jobs (66.1 million in 2018, it said) and government data on the number of jobs the average worker has had by age 50 (11.9).

The campaign specifically pointed to this sentence in the blog post: “This labor turnover data leaves little doubt that people with employer-sponsored insurance are losing that insurance constantly, as are their spouses and kids.”

The CDC data is compelling, to be sure — but Sanders did not accurately portray what it said on the debate stage, nor did he accurately portray the policy analysis his campaign claimed was his source.

Sanders appears to suggest that one-third of those with private insurance are uninsured for at least a short time every year because of a change to their employment benefits.

In actuality, the CDC data shows that about 24.4% of adults under age 65 in 2014 had experienced at least a gap in insurance coverage in the previous year. The question did not ask respondents to specify the cause.

The age of the report also poses a challenge: The Affordable Care Act’s Medicaid expansion began in 2014, and the report surveyed just 23 Medicaid expansion states at the time. Today, 37 states and the District of Columbia have expanded Medicaid, suggesting the number of people with insurance gaps on an annual basis could have dropped.

And the People’s Policy Project analysis actually refers broadly to 50 million Americans under age 65 who were uninsured, temporarily or otherwise — it doesn’t say those people were uninsured because their job situation changed.

Our Ruling

Sanders said that 50 million of those people lose their private insurance every year “when they quit their jobs or they go unemployed or their employer changes their insurance policy.”

Sanders has a point that coverage continuity is a big problem in a country where roughly 150 million get their insurance from their jobs. But his claim inflates the scope of the problem.

He took a broad finding of the number of people who had experienced an insurance gap for any reason roughly five years ago and misleadingly used it to describe a much narrower segment of the current population who lost insurance because of employment changes.

The claim has an element of truth but leaves out critical information that would give a different impression. We rate the statement Mostly False.

KHN’s ‘What The Health?’: Despite Booming Economy, Uninsured Rate Ticks Up

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

The annual report from the Census Bureau, released this week, found that 27.5 million Americans were without health insurance last year, an increase of nearly 2 million from 2017. The 0.5 percentage point increase in the uninsured rate — to 8.5% — was the first in a decade and came as unemployment and other economic indicators have been good.

Meanwhile, the Trump administration signaled that it is moving to ban flavored vaping liquid used in e-cigarettes. Companies making the products have been accused of marketing to underage users with flavors like mango and bubble gum.

And Congress is back from its summer break, with legislation to address rising prescription drug prices and surprise medical bills still on the agenda.

This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Tami Luhby of CNN and Rebecca Adams of CQ Roll Call.

Among the takeaways from this week’s podcast:

  • The Census Bureau’s report this week defied usual economic models. Normally, the more people employed, the more people insured.
  • Health advocates blame a variety of actions by the Trump administration for the lower rate of insured Americans. Those include policies intended to deter people from staying on or signing up for Medicaid; the elimination of the tax penalty for not having coverage; and the announcement that immigrants’ use of public benefits such as Medicaid could affect their ability to get a green card allowing them to live and work in the U.S.
  • The biggest surprise in the Census Bureau report was the increase in children without insurance. Coverage for kids has generally been a bipartisan goal on Capitol Hill. It’s not clear what caused that drop. It could just be a result of differences in how the survey was conducted, or it may be another sign of immigrants worried about whether using public insurance could lead to their deportation.
  • The administration’s announcement that it is moving forward on a ban of flavored vaping products comes as worries grow among parents and public health officials about an epidemic of lung problems around the country. Among those worried parents is first lady Melania Trump.
  • House Speaker Nancy Pelosi appears to be inching closer to releasing her plan to curb high drug prices. It’s not clear yet whether President Donald Trump will sign on to her effort. But Sen. Chuck Grassley (R-Iowa) is seeking support for his more modest plan instead, arguing to his Republican colleagues that if they don’t stand with him, they may be forced to accept Pelosi’s legislation if she manages to make a deal with the president.
  • Opponents of some of the legislation to curb surprise medical bills appear to have made progress over Congress’ August recess with a major advertising campaign saying the measures would hurt local hospitals and doctors. Advocates say the legislation is not dead, but the strong momentum it had is waning.

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

Julie Rovner: Vox.com’s “This life-threatening pregnancy complication is the next frontier in the abortion debate,” by Anna North

Joanne Kenen: The New York Times’ “Nursing Homes Are a Breeding Ground for a Fatal Fungus,” by Matt Richtel and Andrew Jacobs

Rebecca Adams: Kaiser Health News’ “‘UVA Has Ruined Us’: Health System Sues Thousands Of Patients, Seizing Paychecks And Claiming Homes,” by Jay Hancock and Elizabeth Lucas

Tami Luhby: The New York Times’ “Bernie Sanders Went to Canada, and a Dream of ‘Medicare for All’ Flourished,” by Sydney Ember

To hear all our podcasts, click here.

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

In Search Of Age-Friendly Health Care, Finding Room For Improvement

A month ago, during a visit to her doctor’s office in Sequim, Wash., Sue Christensen fell to her knees in the bathroom when her legs suddenly gave out.

The 74-year-old was in an accessible stall with her walker, an older model that doesn’t have brakes. On her left side was a grab bar; there was nothing to hold onto on the right.

Christensen tried to pull herself up but couldn’t. With difficulty, she rearranged her clothing and, inching forward on her knees, exited the stall. There, she tried calling the front desk on her cellphone but was placed on hold by the automated phone system.

Altogether, Christensen, who has a herniated disk in her back, was on the floor for almost half an hour before a nurse and her husband, who’d been parking the car, lifted her to her feet.

“I just wish there had been a button that I could have pushed indicating that someone in the restroom needs assistance,” she said.

For older adults, especially those who are frail, who have impaired cognition, or who have trouble seeing, hearing and moving around, health care facilities can be difficult to navigate and, occasionally, perilous.

Grab bars may not be placed where they’re needed. Doors may be too heavy to open easily. Chairs in waiting rooms may lack arms that someone can use to help them stand up.

Toilets may be too low to rise from easily. Examination tables may be too high to get onto. Lettering on signs may be too small to read. And there may not be a place to sit down while walking down a hallway if a break is needed.

“Most hospitals and clinics have been designed for 40- or 50-year-olds, not 70- or 80-year-olds,” said Dr. Lee Ann Lindquist, chief of geriatrics at Northwestern University’s Feinberg School of Medicine in Chicago. “Additional thought has to be given to seniors who have functional disabilities.”

What changes could be made to better accommodate older adults’ needs? I asked geriatric specialists and seniors to identify practical issues that should be addressed. Here are a number of suggestions that came up repeatedly.


Difficulties start in the parking lot, which may not be adjacent to the medical center.

That’s the case at Long Island Jewish Medical Center, a large teaching hospital in New Hyde Park, N.Y. Every day, Dr. Maria Torroella Carney, a geriatrician at the hospital, crosses a busy road from the parking lot to the hospital’s entrance.

“It’s challenging. There isn’t clear signage indicating where to cross safely, and if you need to stop and rest there aren’t any benches nearby,” said Carney, who is also chief of geriatrics at Hofstra/Northwell School of Medicine.

Dr. Michael Wasserman, a California geriatrician on the board of the American Geriatrics Society’s Health in Aging Foundation, observed that accessible parking spaces are often in short supply. “Even then, not all older adults who need help have a handicap sticker,” he noted.

The University of Florida’s Senior Care Clinic has a solution: valet services. “When an older patient comes by themself, if they need help, the valet will call our clinic and someone will come down and take the patient up,” said Dr. Bhanuprasad Sandesara, division chief of geriatrics.


All too often, easy-to-read signs indicating where patients should go can’t be found, either inside or outside medical centers. For older patients, this can lead to confusion and unnecessary wandering, accompanied by pain, fatigue and annoyance.

Last year, a committee examining how Long Island Jewish Medical Center should handle patients with special needs (for instance, people with cognitive impairments or hearing or speech problems) identified better signage as a priority.

Now, signs in the parking lot and outside the medical center are bigger, with larger type. Inside the medical center, large signs have been placed at bathrooms, showing clearly if they’re accessible to those with disabilities. And the staff is creating a comprehensive map of the hospital campus — a handout — to help patients find their way more easily, according to Roseanne O’Gara-Shubinsky, associate executive director for quality management at Long Island Jewish.

Appointment cards were also altered: Carney persuaded the hospital to print phone numbers in large type on cards for seven geriatricians at its senior clinic.

At Northwestern, Lindquist realized that older patients were having trouble seeing whiteboards in their hospital rooms listing scheduled procedures and the names of physicians and nurses responsible for their care. Upon Lindquist’s urging, the hospital bought whiteboards that are more than double the normal size.

Getting Around

At a recent talk in the San Francisco Bay Area to promote her new book, “Elderhood,” Dr. Louise Aronson was approached by an older woman who uses a portable oxygen tank to breathe and relies on a rollator walker (with a seat and basket attached).

The woman was new to the area and had been visiting various medical facilities. “Some of these places have ramps, but the angle is so steep I can’t push my rollator up,” she complained. “Whoever designed them wasn’t thinking of someone like me.”

At the University of Arkansas for Medical Sciences, Dr. Jeanne Wei, who heads the geriatrics department and the Donald W. Reynolds Institute on Aging, has seen many older adults injure themselves while pushing someone in a wheelchair up an incline. She has insisted that parking lots be on the same level as medical buildings and that sidewalks around facilities be kept in good shape to minimize older adults’ risk of falling.

Also, at the University of Arkansas’ Thomas and Lyon Longevity Clinic for older adults, examination tables are wider than usual and their height can be adjusted electronically. “Sometimes, it’s difficult to navigate lying in a narrow strip” and many older adults are afraid of falling, Wei said.

The staff at Long Island Jewish didn’t realize there weren’t enough walkers and wheelchairs at the hospital’s entrance until the issue came to light during deliberations by the special needs committee. Now, “we’ve made sure that we have plenty of these available,” O’Gara-Shubinsky said.

Something as simple as having a hook to hang up a cane can be a thoughtful touch. “You see this a lot: An older patient sits down, there’s nowhere to put a cane, and it falls on the floor,” said Dr. Diana Anderson, a geriatric medicine fellow at the University of California-San Francisco, who’s also a board-certified architect.


Diane Ashkenaz, 68, has fibromyalgia, chronic pain and a ruptured tendon. She also has undergone two knee replacements. Most of the time, she uses a walker when she visits doctors in the Washington metropolitan area.

Doors are often a problem. “Neither my primary care doctor nor my orthopedic surgeon have doors to their offices that open automatically,” Ashkenaz said.

Not long ago, she said, the staff at a pain clinic’s front desk handed her a pen and clipboard and asked, “Can you fill this out please?” How was Ashkenaz supposed to hold those items while finding her way to a chair? No one seemed to realize there was a problem.

At the clinic Sue Christensen visits in Washington, the front doors open wide automatically and a nursing assistant helps her into the exam room. But once her appointment is over, she’s directed to an exit door that she must open herself.

“It’s pretty heavy and hard to manage while trying to clunk my walker through,” Christensen said. “I don’t know why they don’t have a door system that would be easier for people who don’t have much strength or dexterity.”


Ashkenaz has another pet peeve: chairs in waiting rooms with seats that are too low or without arms that she can grab to push herself up into a standing position.

At her cardiologist’s office, there’s a sofa with deep seats. “It looks nice, but I’d do anything not to sit there,” Ashkenaz said. “I just can’t get up from it.”

Wei’s clinic at the University of Arkansas has brought in chairs that are 4 inches taller than usual, with arms, for older patients. “These chairs are always occupied,” she said.

Also, exam rooms at the clinic are large enough to accommodate chairs for multiple family members. “We’ll bring everyone in to talk about Mom or Dad so they can hear what the other person is saying,” Wei said.

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or suggestions for how medical facilities could become more age-friendly.

Legislation To End Surprise Medical Bills Has High Public Support — In Both Parties

Nearly 8 in 10 Americans support legislation to protect people from surprise medical bills, a new poll from the Kaiser Family Foundation shows.

That support persisted no matter which party was asked: 84% of Democrats, 78% of independents and 71% of Republicans said they support surprise billing legislation, according to the poll. (Kaiser Health News is an editorially independent program of the foundation.)

Surprise bills are the unexpected ― and often expensive — charges patients receive after getting care from a doctor or hospital not in their insurance network. The issue has attracted a lot of attention in recent years, with ongoing projects like KHN-NPR’s “Bill of the Month” series and Vox’s look at emergency room bills illuminating the scope of the problem. The White House and both parties on Capitol Hill have expressed interest in finding ways to protect consumers from the practice.

But Congress has been bombarded by relentless attack ads and deep-pocketed lobbying against legislation that would end surprise billing.

And with lawmakers returning to work this week after the summer recess, some of the supporters of legislation on Capitol Hill worry that effort may destroy their chances of passing an effective law.

Critics claim that the primary legislation under consideration — in which a patient’s insurance would pay the out-of-network provider based on the average of what other doctors nearby are paid — would result in doctors and hospitals being paid less.

But the KFF poll found 57% of respondents support passing legislation to address the problem even after hearing the critics’ argument.

And as Democratic and Republican politicians alike discuss dismantling the ACA, whether through implementing a “Medicare for All” plan or ruling the existing law unconstitutional, the poll also found the public has some reservations about making drastic changes to the health system.

Ahead of Thursday night’s Democratic presidential debate, the poll found that 55% of Democrats and Democratic-leaning independents prefer a presidential candidate who wants to build on the ACA. About 40% said they prefer one who wants to replace it with a Medicare for All plan, which some advocates such as Democratic presidential candidate Sen. Bernie Sanders suggest would provide a single health plan for the entire country and replace all private insurance.

Those numbers are nearly identical to the findings in KFF’s last tracking poll in July.

KFF’s new poll showed the polarization that could undermine Democrats’ chances of unifying behind a single presidential candidate in 2020: 14% of Democrats and Democratic-leaning independents said they would vote only for a candidate who wants to replace the ACA with Medicare for All.

It also found 69% of all Americans support a government-administered public option health plan that consumers could opt into, a policy former Vice President Joe Biden included in his health plan. About 41% of Republicans said they support a public option.

That said, the poll shows many respondents do not see the difference between the policies that Democratic candidates are pitching: About 47% said a public option and a Medicare for All plan are similar.

The new poll also shows that support for the Affordable Care Act has hit an all-time high among Democrats, with 84% saying they view it favorably. The ACA became law in 2010.

KFF’s findings confirm that the Donald Trump presidency has galvanized Democratic support for the ACA, former President Barack Obama’s signature domestic policy. The percentage of Democrats who favor the law has increased by 11 percentage points since February 2017.

Among other policy questions, 70% of those surveyed said lowering prescription drug costs should be a major health care-related priority for Congress, and 69% said maintaining the ACA’s protections for those with preexisting conditions should be a top priority.

The KFF poll was conducted Sept. 3-8, with researchers surveying 1,205 adults by landline and cellphone, in English and Spanish. The margin of error is plus or minus 3 percentage points.

One Of Trickiest Factors In Treating Vets’ PTSD Is Diagnosing It. But A Promising Blood Test Could Change That.

Oftentimes soldiers and veterans with PTSD will try to hide the symptoms. But an accurate blood test would mean all troops who return from combat would get an objective screening. The blood test couldn’t definitively diagnose PTSD, but it would alert doctors to the need for further screening. Meanwhile, some veterans are taking up beekeeping to relieve anxiety.

Hospital Giant Sutter Health Faces Legal Reckoning Over Medical Pricing

SAN FRANCISCO — Economists and researchers long have blamed the high cost of health care in Northern California on the giant medical systems that have gobbled up hospitals and physician practices — most notably Sutter Health, a nonprofit chain with 24 hospitals, 34 surgery centers and 5,000 physicians across the region.

Now, those arguments will have their day in court: A long-awaited class-action lawsuit against Sutter is set to open Sept. 23 in San Francisco Superior Court.

The hospital giant, with $13 billion in operating revenue in 2018, stands accused of violating California’s antitrust laws by leveraging its market power to drive out competition and overcharge patients. Health care costs in Northern California, where Sutter is dominant, are 20% to 30% higher than in Southern California, even after adjusting for cost of living, according to a 2018 study from the Nicholas C. Petris Center at the University of California-Berkeley cited in the complaint.

The case was initiated in 2014 by self-funded employers and union trusts that pay for worker health care. It since has been joined with a similar case brought last year by California Attorney General Xavier Becerra. The plaintiffs seek up to $900 million in damages for overpayments that they attribute to Sutter; under California’s antitrust law, the award can be tripled, leaving Sutter liable for up to $2.7 billion.

The case is being followed closely by industry leaders and academics alike.

“This case could be huge. It could be existential,” said Glenn Melnick, a health care economist at the University of Southern California. If the case is successful, he predicted, health care prices could drop significantly in Northern California. It also could have a “chilling effect” nationally for large health systems that have adopted similar negotiating tactics, he said.

The case already has proved controversial: In November 2017, San Francisco County Superior Court Judge Curtis E.A. Karnow sanctioned Sutter after finding it had intentionally destroyed 192 boxes of documents sought by plaintiffs, “knowing that the evidence was relevant to antitrust issues.” He wrote: “There is no good explanation for the specific and unusual destruction here.”

Antitrust enforcement is more commonly within the purview of the Federal Trade Commission and U.S. Department of Justice. “One of the reasons we have such a big problem [with consolidation] is that they’ve done very little. Enforcement has been very weak,” said Richard Scheffler, director of the Nicholas C. Petris Center. From 2010 to 2017, there were more than 800 hospital mergers, and the federal government has challenged just a handful.

“We feel very confident,” said Richard Grossman, lead counsel for the plaintiffs. “Sutter has been able to elevate their prices above market to the tune of many hundreds of millions of dollars.”

Or, as Attorney General Becerra put it at a news conference unveiling his 2018 lawsuit: “This is a big ‘F’ deal.”

Sutter vigorously denies the allegations, saying its large, integrated health system offers tangible benefits for patients, including more consistent high-quality care. Sutter also disputes that its prices are higher than other major health care providers in California, saying its internal analyses tell a different story.

“This lawsuit irresponsibly targets Sutter’s integrated system of hospitals, clinics, urgent care centers and affiliated doctors serving millions of patients throughout Northern California,” spokeswoman Amy Thoma Tan wrote in an emailed statement. “While insurance companies want to sell narrow networks to employers, integrated networks like Sutter’s benefit patient care and experience, which leads to greater patient choice and reduces surprise out-of-network bills to our patients.”

There’s no dispute that for years Sutter has worked aggressively to buy up hospitals and doctor practices in communities throughout Northern California. At issue in the case is how it has used that market dominance.

According to the lawsuit, Sutter has exploited its market power by using an “all-or-none” approach to contracting with insurance companies. The tactic — known as the “Sutter Model” — involves sitting down at the negotiating table with a demand: If an insurer wants to include any one of the Sutter hospitals or clinics in its network, it must include all of them. In Sutter’s case, several of its 24 hospitals are “must-haves,” meaning it would be almost impossible for an insurer to sell an insurance plan in a given community without including those facilities in the network.

“All-or-none” contracting allows hospital systems to demand higher prices from an insurer with little choice but to acquiesce, even if it might be cheaper to exclude some of the system’s hospitals that are more expensive than a competitor’s. Those higher prices trickle down to consumers in the form of higher premiums.

The California Hospital Association contends such negotiations are crucial for hospitals struggling financially. “It can be a great benefit to small hospitals and rural hospitals that don’t have a lot of bargaining power to have a larger group that can negotiate on their behalf,” said Jackie Garman, the CHA’s legal counsel.

Sutter also is accused of preventing insurers and employers from tiering benefits, a technique used to steer patients to more cost-effective options. For example, an insurer might charge $100 out-of-pocket for a procedure at a preferred surgery center, but $200 at a more expensive facility. In addition, the lawsuit alleges that for years Sutter restricted insurers from sharing information about its prices with employers and workers, making it nearly impossible to compare prices when selecting a provider.

Altogether, the plaintiffs allege, such tactics are anti-competitive and have allowed Sutter to drive up the cost of care in Northern California.

Hospitals in California and other regions across the country have watched the success of such tactics and taken note. “All the other hospitals want to emulate [Sutter] to get those rates,” said Anthony Wright, executive director of the advocacy group Health Access.

A verdict that finds such tactics illegal would “send a signal to the market that the way to compete is not to be the next Sutter,” said Wright. “You want them to compete instead by providing better quality service at a lower price, not just by who can get bigger and thus leverage a higher price.”

Along with damages, Becerra’s complaint calls for dismantling the Sutter Model. It asks that Sutter be required to negotiate prices separately for each of its hospitals — and prohibit officials at different hospitals from sharing details of their negotiations. While leaving Sutter intact, the approach would give insurers more negotiating room, particularly in communities with competing providers.

Consolidation in the health care industry is likely here to stay: Two-thirds of hospitals across the nation are part of larger medical systems. “It’s very hard to unscramble the egg,” said Melnick.

California legislators have attempted to limit the “all or nothing” contracting terms several times, but the legislation has stalled amid opposition from the hospital industry.

Now the courts will weigh in.

In Face Of Public Outrage, Novo Nordisk Follows In Competitors’ Footsteps And Offers Discounts For Insulin

Drugmakers have come under intense fire following news of more deaths of patients rationing their insulin. Novo Nordisk is the latest company to try to address the high costs of their drug. The company will start a new cash discount program that will allow many American patients to buy a month’s supply for $99 starting next year.

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! I come bearing bad news for anyone enjoying the slight decrease in D.C. traffic: Congress is back in full force next week. Although we have not had even a slight decrease in health news, I’m sure lawmakers will kick it up even further with gun control, surprise medical bills and, perennially, high drug costs on the expected docket.

For now, here’s what’s been going on during their final week of recess.

President Donald Trump has been coy about what exactly he’s put in his gun violence proposal, but one thing that seems likely: Both parties will be unhappy. (That, at least, seems a sure bet in these divided times.) What you can probably expect to see: an expedited death penalty process, changes to how troubled teens’ sealed records are shielded, and regulations — like “red flag” laws — centered on mental health.

Politico: Trump Prepares to Pitch Gun Proposals Few Really Want

Senate Majority Leader Mitch McConnell is sitting pretty on the sidelines at the moment, waiting to see what the president comes up with.

The Associated Press: McConnell Says He’s Waiting on Trump to Chart Path on Guns

Corporations, though, are taking matters into their own hands. Walgreens and CVS followed in Walmart’s footsteps this week in asking customers not to carry firearms openly in their stores. Walmart — which often tries to stay above the political fray — went further in announcing that it would stop selling ammunition for military-style assault rifles.

The New York Times: Walmart to Limit Ammunition Sales and Discourage ‘Open Carry’ of Guns in Stores

Reuters: Walgreens, CVS, Wegmans Ask Shoppers to Not Openly Carry Firearms

And in a bit of poor optics luck for Texas, a series of laws loosening gun regulations happened to take effect just a day after the state’s latest mass shooting.

Politico: Hours After Shooting Rampage, Texas Gun Laws Loosened

Also, if you want to terrify the bejesus out of yourself, dig into this piece about online forums with a toxic culture of hate that have become breeding grounds for mass shooters and where the inherent anonymity of the internet protects them from law enforcement.

The Wall Street Journal: ‘So What’s His Kill Count?’: The Toxic Online World Where Mass Shooters Thrive

In New York, health officials are eyeing vitamin E oil as a possible culprit in the mysterious vaping-related lung illness sweeping the country. The feds, however, aren’t putting their eggs in that particular basket and said that people should keep an “open mind” about the roots of the outbreak. “People need to realize that it is very probable that there are multiple causes,” said CDC Director Robert Redfield. But with a second death confirmed, officials are scrambling for answers.

Politico: Vitamin E Named as Primary Culprit in Vaping Illness, But Feds Urge Caution

An HHS internal watchdog report detailed the extent of psychological damage suffered by children affected by the “zero tolerance” separation policy. For children so young, it was hard for them to describe their emotional trauma. They were often reduced to complaints about their chest hurting, like “every heartbeat hurts” or “I can’t feel my heart.”

The Associated Press: ‘Can’t Feel My Heart:’ IG Says Separated Kids Traumatized

Crushing medical debt seems to be shaping the future of the country, and 2020 hopeful Sen. Bernie Sanders (I-Vt.) wants to change that. With a proposal that he only hinted at (i.e. did not give any solid details about how to pay for it), he said he would cancel $81 billion worth of medical debt for Americans.

The Washington Post: Sen. Bernie Sanders Teases Plan to Cancel $81 Billion in Americans’ Medical Debt

Meanwhile, despite the attention Sanders and the other progressive front-runners are giving proposals like “Medicare for All,” state lawmakers see defending the health law as the ace up their sleeves in tough elections. Virginia will be a major testing ground for that strategy as Democrats recently secured a big win on expanding Medicaid in the state. They could, however, be vulnerable to Republican messaging on high health care costs because the governor vetoed extensions for short-term plans.

Politico: Democrats Bet Big on Obamacare to Win Virginia Statehouse

So far, the implementation of Medicaid work requirements has been more crash and burn than the graceful transition many Republicans had likely hoped for. But Indiana seems on the path to becoming a model for other states as they add more restrictions to the program. I can explain it no better than Paige Winfield Cunningham at The Washington Post, who wrote: “If Arkansas and Kentucky were heavy-handed in imposing their work requirements, Indiana’s program is more like a tap on the shoulder, advocates argue.”

The Washington Post: Indiana Seeks to Impose Slower, Kinder Work Requirements on Medicaid Recipients

Meanwhile, over in Missouri, expansion advocates are hoping to follow the success of other states by getting the issue in front of voters rather than lawmakers.

The Hill: Advocates Launch Petition to Place Medicaid Expansion on 2020 Ballot in Missouri

The “Guaranteed to Make Everyone’s Blood Boil” award of the week goes to the article about how the Sacklers (the family that founded Purdue Pharma) could emerge from the opioid trials with their personal fortune intact.

The Washington Post: Sacklers Could Hold On to Most of Personal Fortune in Proposed Purdue Settlement

A cluster of HIV cases in West Virginia could be the canary in the coal mine that public health officials monitoring the opioid epidemic have been on the watch for. “This is the nightmare everyone is worried about,” said one expert about the outbreak that appears to be among the largest since one in Indiana’s Scott County four years ago.

Politico: ‘The Nightmare Everyone Is Worried About’: HIV Cases Tied to Opioids Spike in West Virginia County

In the miscellaneous file for the week:

• Reeling from persistent political attacks, Planned Parenthood has announced it will utilize telemedicine and a new app to reach young and rural patients who may have been affected by attempts to chip away at the organization.

The Wall Street Journal: Planned Parenthood to Expand App-Based Health Services to All 50 States

• We as a country are hooked on fast deliveries from Amazon, but there’s a human toll that flies under the radar that goes beyond workers’ pay. This ProPublica-New York Times story starts with the tragedy of a 9-month-old who died in an accident involving an Amazon delivery vehicle and doesn’t get any less heartbreaking as it goes on.

ProPublica/The New York Times: How Amazon Hooked America on Fast Delivery While Avoiding Responsibility for Crashes

• Be sure to check out this fantastic series about how America’s sick, poor and vulnerable will be the ones most affected by the growing climate crisis because they live in urban heat islands.

Howard Center for Investigative Journalism: Code Red: Baltimore’s Climate Divide

• On a much lighter note, scientists may have discovered a gene for left-handedness, which I just find fascinating and may make approximately 10% of my readers happy to know (mostly because it’s linked to having better verbal skills).

CNN: Scientists Identify the Genes Linked to Left-Handedness

• After millions of dollars, thousands of hours of manpower, tons of public outrage and a countless number of headlines from yours truly, the NYC measles outbreak has been declared officially over. The outbreaks in upstate New York still threaten the United States’ status as having eliminated the disease but, for now, public health officials are taking victories where they can get them.

The Washington Post: New York City Declares End to Largest Measles Outbreak in Nearly 30 Years

That’s it for me! Have a great weekend!

Groupons For Medical Treatment? Welcome To Today’s U.S. Health Care

Emory University medical fellow Dr. Nicole Herbst was shocked when she saw three patients who came in with abnormal results from chest CT scans they had bought on Groupon.

Yes, Groupon — the online coupon mecca that also sells discounted fitness classes and foosball tables.

Similar deals have shown up for various lung, heart and full-body scans across Atlanta, as well as in Oklahoma and California. Groupon also offers discount coupons for expectant parents looking for ultrasounds, sold as “fetal memories.”

While Herbst declined to comment for this story, her sentiments were shared widely by the medical community on social media. The concept of patients using Groupons to get discounted medical care elicited the typical stages of Twitter grief: anger, bargaining and acceptance that this is the medical system today in the United States.

But, ultimately, the use of Groupon and other pricing tools is symptomatic of a health care market where patients desperately want a deal — or at least tools that better nail down their costs before they get care.

“Whether or not a person may philosophically agree that medicine is a business, it is a market,” said Steven Howard, who runs Saint Louis University’s health administration program.

By offering an upfront cost on a coupon site like Groupon, Howard argued, medical companies are meeting people where they are. It helps drive prices down, he said, all while marketing the medical businesses.

For Paul Ketchel, CEO and founder of MDsave, a site that contracts with providers to offer discount-priced vouchers on bundled medical treatments and services, the use of medical Groupons and his own company’s success speak to the brokenness of the U.S. health care system.

MDsave offers deals at over 250 hospitals across the country, selling vouchers for anything from MRIs to back surgery. It has experienced rapid growth and expansion in the several years since its launch. Ketchel attributes that growth to the general lack of price transparency in the U.S. health care industry amid rising costs to consumers.

“All we are really doing is applying the e-commerce concepts and engineering concepts that have been applied to other industries to health care,” he argued. “We are like transacting with Expedia or Kayak while the rest of the health care industry is working with an old-school travel agent.”

A Closer Look At The Deal

Crown Valley Imaging in Mission Viejo, Calif., has been selling Groupon deals for services including heart scans and full-body CT scans since February 2017 — despite what Crown Valley’s president, Sami Beydoun, called Groupon’s aggressive financial practices. According to him, Groupon dictates the price for its deals based on the competition in the area — and then takes a substantial cut.

“They take about half. It’s kind of brutal. It’s a tough place to market,” he said. “But the way I look at it is you’re getting decent marketing.”

Groupon-type deals for health care aren’t new. They were more popular in 2011, 2012 and 2013, when Groupon and its then-competitor LivingSocial were at their heights. The industry has since lost some steam. Groupon stock and valuation have tumbled in recent years, even after buying LivingSocial in 2016.

Groupon did not respond to requests for comment on how many medical offerings it has featured or its pricing structure.

“Groupon is pleased any time we can save customers time and money on elective services that are important to their daily lives,” spokesman Nicholas Halliwell wrote in an emailed statement. “Our marketplace of local services brings affordable dental, chiropractic and eye care, among other procedures and treatments, to our more than 46 million customers daily and helps thousands of medical professional[s] advertise and grow their practices.”

In Atlanta, two imaging centers that each offered discount coupons from Groupon said the deals have driven in new business. Bobbi Henderson, the office manager for Virtual Imaging Inc.’s Perimeter Center, said the group had been running the deal for a heart CT scan, complete with consultation, since 2012. Currently listed at $26 — a 96% discount — more than 5,000 of the company’s coupons have been sold, according to the Groupon site.

Brittany Swanson, who works in the front office at OutPatient Imaging in the Buckhead neighborhood of Atlanta, said she has seen hundreds of customers come through after the center posted Groupons for mammograms, body scans and other screenings around six months ago.

Why did the company choose to make such discounts available?

“Honestly, we saw the other competition had it,” she said.

A lot of the deals offered are for preventive scans, Swanson said, providing patients incentives to come in.

But Dr. Andrew Bierhals, a radiology safety expert at Washington University in St. Louis’ Edward Mallinckrodt Institute of Radiology, warned that such deals may be leading patients to get unnecessary initial scans — which can lead to unnecessary tests and radiation.

“If you’re going to have any type of medical testing done, I would make sure you discuss with your primary care provider or practitioner,” he cautioned.

Appealing To Those Who Fall Into The Insurance Gap

Because mammograms are typically covered by insurance, Swanson said she believes OutPatient Imaging’s $99 Groupon deal is filling a gap for women lacking insurance. The cost of such breast screenings for those who don’t have insurance varies widely but can be up to several hundreds of dollars without a discount.

Groupon has long been used to fill insurance gaps for dental care, Howard said. He himself often bought such deals over the years to get cheaper teeth cleanings when he didn’t have dental insurance.

But advanced medical scans involve a higher level of scrutiny, as Chicagoan Anna Beck learned. In 2015, she and her husband, Miguel Centeno, were told he needed to get a chest CT after a less advanced X-ray at an urgent care center showed something suspicious. Since her husband had just been laid off and did not have insurance, they shopped online for the cheapest price. They ended up driving out to the suburbs to get a CT scan at an imaging center there.

“I knew that CT scans had such a wide range of costs in a hospital setting,” Beck said. “So going in knowing that I could price-check and have some idea of how much I’d be paying and a little more control” was preferable to going to the hospital.

On the drive back into the city, the center called and told them to go straight to the hospital — the scan had discovered a large mass that turned out to be a germ-cell tumor.

Fortunately, Centeno’s cancer is now in remission, Beck said. But their online shopping cost them more money than if they’d gone straight to the hospital initially. The hospital gave them charity care. And although Beck took along a CD of the scans Centeno had found online, the hospital ended up taking its own scans, as well.

“You’re trying to cut cost by getting a CT out of the hospital,” she said. “But they’re just going to redo it anyway.”

Watch: Five Things To Know About Hunger Among America’s Aging

One out of every 13 seniors in America struggles to get enough food to eat while the federal program intended to help hasn’t kept pace with the graying population.

Kaiser Health News Midwest editor/correspondent Laura Ungar explains what you need to know about this largely hidden problem.

Listen: India Gives Opioid Makers A Huge And Growing New Market

KHN senior correspondent Sarah Varney discussed the changing attitudes toward opioid painkillers in India with NPR’s Rachel Martin on “Morning Edition” Thursday.

Varney traveled to India to report a two-part series on the issue in partnership with The Guardian.

KHN’s ‘What The Health?’: Waiting For The Trump Health Plan

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

President Donald Trump has been promising to reveal a new health plan since early this year. That hasn’t happened yet. Now, there is a debate about whether having a plan for Democrats to criticize would help or hurt the president’s campaign.

Meanwhile, among the Democrats vying to take on Trump next November, Sen. Bernie Sanders (I-Vt.) is proposing a plan to forgive billions of dollars of medical debt owed by patients.

Other drama playing out this fall: What will happen to the federal family planning program now that Planned Parenthood has dropped out over Trump administration rules it says violate medical ethics, and what will a multimillion-dollar verdict against opioid manufacturer Johnson & Johnson mean for the funding of programs to help those with addiction?

This week’s panelists are Julie Rovner of Kaiser Health News, Stephanie Armour of The Wall Street Journal, Alice Miranda Ollstein of Politico and Kimberly Leonard of the Washington Examiner.

Among the takeaways from this week’s podcast:

  • We are still waiting to see what a Trump health care plan might look like. Conventional wisdom suggests it will likely take the form of a collection of goals and ideas — many of which have already been announced or launched, such as the administration’s efforts on health price transparency. The rollout of a legislative package is increasingly unlikely.
  • One variable that could change that: Incentives for Republicans and the administration might be different if the lower-court ruling invalidating the Affordable Care Act is upheld on appeal.
  • Democratic presidential candidate Sen. Bernie Sanders (I-Vt.) has teased out a plan to cancel an estimated $81 billion worth of medical debt. There’s no talk about how this concept would be funded. One point that could create a lot of interest among voters: Medical debt would no longer affect consumers’ credit scores.
  • Planned Parenthood has, for now, dropped out of the Title X family planning program. More states and organizations could follow suit in the weeks ahead, especially as these entities now must file plans with the administration outlining how they will comply with new requirements.
  • The first verdict in favor of a state lawsuit against an opioid manufacturer, with Oklahoma suing Johnson & Johnson, brought a verdict of more than half a billion dollars. But that was so much less than the state was seeking ($17.5 billion) that the company’s stock rose after the decision. That makes it unclear what impact this test case will have as other states sue other opioid makers to recover damages caused by their products.

Also this week, Rovner interviews KHN’s Rachel Bluth, who wrote the latest KHN-NPR “Bill of the Month” feature about a patient who did everything right to prepare financially for an elective surgical procedure — and still got billed more than he expected. If you have an outrageous medical bill you would like to share with us, you can do that here.

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

Julie Rovner: Kaiser Health News’ “Beset By Lawsuits And Criticism In U.S., Opioid Makers Eye New Market In India,” and “In India’s Slums, ‘Painkillers Are Part Of The Daily Routine,” by Sarah Varney

Alice Miranda Ollstein: The New York Times Magazine’s “Why Doesn’t the United States Have Universal Health Care? The Answer Has Everything to Do With Race,” by Jeneen Interlandi

Kimberly Leonard: Vox.com’s “She Spent More Than $110,000 on Drug Rehab. Her Son Still Died,” by German Lopez

Stephanie Armour: The Atlantic’s “L.A.’s Health-Care Reform Is a Lesson for Democrats,” by Ronald Brownstein

To hear all our podcasts, click here.

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

Insurers Face $15.5B Bill If Health Law Tax Resumes As Planned In 2020

The annual fee on insurers was suspended by Congress in 2019 out of concern for consumers’ out-of-pocket costs. Insurance premiums are likely to rise by more than 2% in 2020 if the IRS implements the tax as planned, the new report warned. Health law and state insurance news comes out of Texas, Connecticut, Minnesota, California, Ohio and Tennessee, as well.