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KHN’s ‘What The Health’: Spending Bill Slowdown


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The fiscal year started a month and a half ago, but Congress has still not agreed on an annual spending bill for the Department of Health and Human Services – or any of the other annual spending bills that fund the government.

Meanwhile, Congress IS moving on efforts to further restrict tobacco and vaping products, particularly to limit their marketing to underage users. The Trump administration has been vowing to use its own authority to crack down on a youth vaping epidemic, but so far has not acted.

The administration is moving on the drug price front, however, filing a lawsuit against drugmaker Gilead for allegedly infringing a government-owned patent on a drug regimen to prevent HIV.

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

Rovner also interviews Dan Weissmann, host of the podcast “An Arm and a Leg,” about why health care costs so much and what patients can do about it. KHN is co-producing the podcast’s new season.

Among the takeaways from this week’s podcast:

  • Among the partisan arguments holding up the HHS funding bill are disagreements on spending for family planning programs and the amount of an increase for HHS as a whole.
  • A House subcommittee this week approved new regulations that would limit flavors for vaping and other tobacco products. But that comes as the administration appears likely to step back from Trump’s earlier vow to outlaw flavored products.
  • Some lawmakers and administration officials suggest that any legislation to prohibit flavored e-cigarette products should include carve-outs for some groups, including small businesses that cater to vapers and to members of the military.
  • The recent revelation that Google is working with a major health care system to analyze patient records is raising concerns about consumers’ privacy. That and other recent issues surround health care tech may signal that the federal privacy law, HIPAA, needs to be updated.
  • The Trump administration’s suit against Gilead seeking to bring down costs of its HIV pre-exposure prophylaxis drug may signal that the government is ready to take on other companies with high price tags on drugs developed with federal support.

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

Julie Rovner: The Philadelphia Inquirer’s “A Philly woman’s broken back and $36,000 bill shows how some health insurance brokers trick consumers into skimpy plans,” by Sarah Gantz.

Rebecca Adams: CQ Roll Call’s “Surprise billing fight highlights hurdles for bolder health care changes,” by Mary Ellen McIntire.

Alice Ollstein: Politico’s “Trump allies received hundreds of thousands of dollars under federal health contract,” by Dan Diamond and Adam Cancryn.


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Some Academics Quietly Take Side Jobs Helping Tobacco Companies In Court

In 1998, major tobacco companies reached a historic legal settlement with states that had sued them over the health care costs of smoking-related illnesses. But individual smokers have continued to sue, and to this day the tobacco industry remains tied up in hundreds of court fights with sickened smokers, or with family members who lost a loved one to cancer, heart disease or other smoking-related illness.

These days, tobacco companies no longer try to claim that cigarettes aren’t harmful — in fact, in an ironic reversal, a favorite legal defense in current cases is the argument that nearly everyone was aware of the dangers, even back in the 1950s. To shore up this controversial claim, known as the “common knowledge” defense, tobacco companies often enlist academics as expert witnesses. These professors are frequently historians or political scientists who tend to keep these lucrative side gigs walled off from the rest of their academic work. And their testimony can help tobacco companies limit damages.

Professor John Geer, a political scientist and dean of Arts and Science at Vanderbilt University, has consulted on behalf of tobacco companies from 2004 to at least mid-2018, according to court documents. The fees from legal firms represent as much as a quarter of his annual income.

In a 2014 deposition videotaped just off Vanderbilt’s campus, Geer was then vice provost. He stares straight ahead with an iced coffee at his side, reading glasses perched on his nose. A court reporter swears him in, and he begins to make his case:

“I have studied a lot of polls, and I’m confident of my opinion of the public being broadly aware of the dangers of smoking by the mid-1950s. The data are rock-solid clear,” Geer says in the video.

This argument is part of the “common knowledge” defense, but most of the witnesses who make it are not experts in the history of public health. Geer, for instance, specializes in political science and directs the Vanderbilt Poll. Others who have testified on behalf of tobacco companies are presidential historians or Civil War experts; they include prominent historian and author Stephen Ambrose, who died in 2002 of smoking-related lung cancer.

Stanford University history professor Robert Proctor, who wrote a book about the tobacco industry called Golden Holocaust, says most of these academics have never published any research about cigarettes because their opinions can’t stand up to peer review.

“They erase history by acting as if the things we know today have always been known,” he said.

Proctor is among a smaller group of academics who testify in opposition to tobacco companies, on behalf of smokers dealing with cancer, chronic lung disease and heart problems.

‘Under The Radar’

In his book, Proctor lists the professors known to have worked on behalf of tobacco companies. He says most expert witnesses avoid drawing attention to themselves.

“Experts often don’t even put it down on their CVs, their resumes — it’s absent,” Proctor said. “That’s one of the problems. It’s flying under the radar.”

Geer makes no mention of his consulting work — which pays more than $300 an hour — in his 17-page curriculum vitae. That document does include a detailed account of his pursuits on and off campus, down to individual guest lectures and media appearances.

“It’s not relevant,” Geer told Nashville attorney Kenneth Byrd during one deposition. “If I published something from this, I’d list it.”

Even the most active expert witnesses for the tobacco industry have not published research on tobacco. They include the University of Tennessee’s Robert Norrell, who studies race and the American South; and Elizabeth Cobbs, a historian at Texas A&M and Michael Schaller, a professor emeritus at the University of Arizona, who both focus on foreign relations. Their names are among 50 that appear in a database kept by Ramses Delafontaine, a historian who wrote a book about his peers working for the tobacco industry.

In depositions, some claim to make more than $100,000 a year for their work on tobacco litigation. None accepted requests for interviews.

Geer did issue a statement to Vanderbilt’s student newspaper, Hustler, saying he’s not a supporter of “Big Tobacco.”

“I truly understand and deeply respect those students who disagree with me having taken on this kind of work,” Geer told Hustler. “I do see their perspective and value it. Perhaps my fondest hope is that we all appreciate that disagreement itself is often an engine for change.”

Interpreting The Polls

The tobacco industry’s professors are primarily historians. Their expert reports pull newspaper clippings and excerpts from school textbooks to show judges that the smoker in question probably ran across warnings about cigarettes. And many of the industry’s witnesses lean heavily on the same Gallup poll from 1954 that indicates 90% of Americans had heard smoking could cause lung cancer.

But in 1998, Gallup told the tobacco industry to stop using this polling out of context. First, the company sent a letter to historian Lacy Ford at the University of South Carolina. (Ford had testified on behalf of R.J. Reynolds, citing the poll.) Then Gallup officials presented a paper at a conference calling Ford’s interpretation an “egregious error” that overlooked the difference between being aware of danger and actually believing smoking can cause a deadly illness.

“A review of historical Gallup surveys suggests that there was, in fact, a high degree of public doubt and confusion about the dangers of smoking in the 1950s and 60s. There may have been widespread awareness of the controversy over smoking, but public belief that smoking was linked to lung cancer trailed far behind this general awareness of the controversy,” the Gallup officials wrote in their conference paper.

Gallup points to its other surveys during the same period that found when people said smoking was “harmful,” they were thinking of less serious risks, like coughing, not cancer.

Reached for comment about the continued reliance on the 1954 poll, Gallup general counsel Steve O’Brien — who wrote the paper from 1998 — declined to wade back into the controversy.

“The fraternity that litigates these smoking cases are all aware of the history — or if they were doing their job right, they are,” O’Brien wrote in an email.

For his part, Vanderbilt’s Geer said in a 2014 deposition that he had never seen the letter to Ford or the Gallup warning, though both are publicly available as part of the Truth Tobacco Industry Documents. That’s an archival database, well known to public health researchers, of internal tobacco company documents maintained by the University of California-San Francisco.

Geer had never used it.

“I know of it broadly, but I’ve never spent any time on [the database],” Geer said.

Occasionally, the professors who work with the tobacco industry’s lawyers will be rejected as experts. In one case from late 2011, Geer was barred from testifying over questions about his methodology.

‘A Denial Of History’

Geer’s videotaped deposition in 2014 was part of Woodruff v. R.J. Reynolds Tobacco Company, et al., and he also submitted a report summarizing his research and findings. The plaintiff in that suit, a Florida widow, argued that her husband’s bladder cancer was caused by his smoking since he was a kid — as much as three packs a day. The case was ultimately settled for an undisclosed amount as part of a larger settlement.

The suit was one of thousands in Florida stemming from a former class-action verdict that was overturned but allowed many smokers to make individual claims using the same jury findings.

Tobacco companies win some and lose some. But the “common knowledge” defense has proven effective at limiting their liabilities, says Stanford’s Proctor. It’s difficult for a judge or jurors to cast their minds back to the 1950s, suspending all they know now about the dangers of smoking, thanks to 65 years of accumulated science.

But Proctor maintains that the 1950s were “another world.”

Proctor points out that most doctors used to be smokers. Some cigarettes were even branded as “doctor recommended.” Proctor calls it “a denial of history” to gloss over how broadly smoking was accepted, and how actively tobacco companies contributed to the confusion.

Proctor, along with Middle Tennessee State University historian Louis Kyriakoudes, is among a small number of professors who work on behalf of dying smokers or their surviving spouses.

Both have published extensively on smoking and list on their CVs work as an expert witness against tobacco companies.

“I’m proud of what I do,” Kyriakoudes said.

Tobacco companies deserve the chance to defend themselves, he says. But he accuses the professors they hire of donning “intellectual blinders” in order to claim everyone knew that one day smoking would kill them.

“People tell themselves that it’s the smoker’s fault for smoking, and why should somebody be suing a tobacco company anyway?” he said. “That plays into a very strong bias that blames the victim of addiction.”

Reputational Harm

Plaintiff attorneys will often question the industry’s defense experts about what they’ve disclosed to their academic employer about the outside work. And it’s clear from their answers that the academics do not widely advertise their work, even if they disclose to their employer that they consult with law firms, which write the actual checks.

But Allan Brandt, a medical historian and former dean of the Graduate School of Arts and Sciences at Harvard University, says institutions of higher education should be concerned about this vague disclosure — since the professor’s faculty appointment is often the credential used to qualify them as an expert in a lawsuit.

“I think it can harm the reputation of our own scholarship and our universities when this isn’t really put out in the open,” he said.

Many professors are called to be expert witnesses, in multiple types of cases. But Brandt says he hasn’t found any defense experts in these tobacco cases who would also be willing to defend their claims (about the awareness of smoking’s dangers) in an academic setting.

He says scholars can’t have it one way on campus and another in court.

“This is the ultimate public forum,” Brandt said. “The ideas that are presented there really ought to be subject to the kind of scrutiny and peer scrutiny that is so characteristic and a desirable value of universities.”

This story is part of a partnership that includes Nashville Public RadioNPR and Kaiser Health News.

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Bruising Labor Battles Put Kaiser Permanente’s Reputation On The Line

Kaiser Permanente, which just narrowly averted one massive strike, is facing another one Monday.

The ongoing labor battles have undermined the health giant’s once-golden reputation as a model of cost-effective care that caters to satisfied patients — which it calls “members” — and is exposing it to new scrutiny from politicians and health policy analysts.

As the labor disputes have played out loudly, ricocheting off the bargaining table and into the public realm, some critics believe that the nonprofit health system is becoming more like its for-profit counterparts and is no longer living up to its foundational ideals.

Compensation for CEO Bernard Tyson topped $16 million in 2017, making him the highest-paid nonprofit health system executive in the nation. The organization also is building a $900 million flagship headquarters in Oakland. And it bid up to $295 million to become the Golden State Warriors’ official health care provider, the San Francisco Chronicle reported. The deal gave the health system naming rights for the shopping and restaurant complex surrounding the team’s new arena in San Francisco, which it has dubbed “Thrive City.”

Kaiser Permanente reportedly bid up to $295 million to secure the naming rights for a shopping and restaurant complex surrounding the Golden State Warriors’ new arena in San Francisco, which it dubbed “Thrive City.” (Hannah Norman/KHN)

The organization reported $2.5 billion in net income in 2018 and its health plan sits on about $37.6 billion in reserves.

Against that backdrop of wealth, more than 80,000 employees were poised to strike last month over salaries, retirement benefits and concerns over outsourcing and subcontracting. Nearly 4,000 members of its mental health staff in California are threatening to walk out Monday over the long wait times their patients face for appointments.

“Kaiser’s primary mission, based on their nonprofit status, is to serve a charitable mission,” said Ge Bai, associate professor of accounting and health policy at Johns Hopkins University. “The question is, do they need such an excessive, fancy flagship space? Or should they save money to help the poor and increase employee salaries?”

Lawmakers in California, Kaiser Permanente’s home state, recently targeted it with a new financial transparency law aimed at determining why its premiums continue to increase.

There’s a growing suspicion “that these nonprofit hospitals are not here purely for charitable missions, but instead are working to expand market share,” Bai said.

Therapists, psychologists and other mental health providers rallied in Oakland in October to protest the long wait times their patients face. About 4,000 mental health providers in California who belong to the National Union of Healthcare Workers threaten a five-day strike starting Monday. (Credit: Chris Joel)

The scrutiny marks a disorienting role-reversal for Kaiser, an integrated system that acts as both health insurer and medical provider, serving 12.3 million patients and operating 39 hospitals across eight states and the District of Columbia. The bulk of its presence is in California. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

Many health systems have tried to imitate its model for delivering affordable health care, which features teams of salaried doctors and health professionals who work together closely, and charges few if any extraneous patient fees. It emphasizes caring and community with slogans like “Health isn’t an industry. It’s a cause,” and “We’re all in this together. And together, we thrive.”

Praised by President Barack Obama for its efficiency and high-quality care, the health maintenance organization has tried to set itself apart from its profit-hungry, fee-for-service counterparts.

Now, its current practices — financial and medical — are getting a more critical look.

As a nonprofit, Kaiser doesn’t have to pay local property and sales taxes, state income taxes and federal corporate taxes, in exchange for providing “charity care and community benefits” — although the federal government doesn’t specify how much.

As a percentage of its total spending, Kaiser Permanente’s charity care spending has decreased from 1.29% in 2012 to 0.8% in 2017. Other hospitals in California have exhibited a similar decrease, saying there are fewer uninsured patients who need help since the Affordable Care Act expanded insurance coverage.

CEO Tyson told California Healthline that he limits operating income to about 2% of revenue, which pays for things like capital improvements, community benefit programs and “the running of the company.”

“The idea we’re trying to maximize profit is a false premise,” he said.

The organization is different from many other health systems because of its integrated model, so comparisons are not perfect, but its operating margins were smaller and more stable than other large nonprofit hospital groups in California. AdventHealth’s operating margin was 7.15% in 2018, while Dignity Health had losses in 2016 and 2017.

Tyson said that executive compensation is a “hotspot” for any company in a labor dispute. “In no way would I try to justify it or argue against it,” he said of his salary. In addition to his generous compensation, the health plan paid 35 other executives more than $1 million each in 2017, according to its tax filings.

Even its board members are well-compensated. In 2017, 13 directors each received between $129,000 and $273,000 for what its tax filings say is five to 10 hours of work a week.

And that $37.6 billion in reserves? It’s about 17 times more than the health plan is required by the state to maintain, according to the California Department of Managed Health Care.

Kaiser Permanente said it doesn’t consider its reserves excessive because state regulations don’t account for its integrated model. These reserves represent the value of its hospitals and hundreds of medical offices in California, plus the information technology they rely on, it said.

Kaiser Permanente is spending $900 million on a new headquarters in Oakland, which the company says will save at least $60 million a year in operating costs by bringing all of its Oakland staffers together under one roof. (Credit: Kaiser Permanente)

Kaiser Permanente said its new headquarters will save at least $60 million a year in operating costs because it will bring all of its Oakland staffers under one roof. It justified the partnership with the Warriors by noting it spans 20 years, and includes a community gathering space that will provide health services for both members and the public.

Kaiser has a right to defend its spending, but “it’s hard to imagine a nearly $300 million sponsorship being justifiable,” said Michael Rozier, an assistant professor at St. Louis University who studies nonprofit hospitals.

The Service Employees International Union-United Healthcare Workers West was about to strike in October before reaching an agreement with Kaiser Permanente.

Democratic presidential candidates Kamala Harris, Bernie Sanders, Elizabeth Warren and Pete Buttigieg, as well as 132 elected California officials, supported the cause.

California legislators this year adopted a bill sponsored by SEIU California that will require the health system to report its financial data to the state by facility, as opposed to reporting aggregated data from its Northern and Southern California regions, as it currently does. This data must include expenses, revenues by payer and the reasons for premium increases.

Other hospitals already report financial data this way, but the California legislature granted Kaiser Permanente an exemption when reporting began in the 1970s because it is an integrated system. This created a financial “black hole” said state Sen. Richard Pan (D-Sacramento), the bill’s author.

“They’re the biggest game in town,” said Anthony Wright, executive director of the consumer group Health Access California. “With great power comes great responsibility, and a need for transparency.”

Patient care, too, is under scrutiny.

California’s Department of Managed Health Care fined the organization $4 million over mental health wait times in 2013, and in 2017 hammered out an agreement with it to hire an outside consultant to help improve access to care. The department said Kaiser Permanente has so far met all the requirements of the settlement.

Ann Rivello, a therapist who works at Kaiser Permanente Redwood City Medical Center, says she’s frustrated that Kaiser Permanente markets itself as a leader in mental health care. Her patients have to wait about two months between appointments for individual therapy, she says. (Credit: Chris Joel)

But according to the National Union of Healthcare Workers, which is planning Monday’s walkout, wait times have just gotten worse.

Tyson said mental health care delivery is a national issue — “not unique to Kaiser Permanente.” He said the system is actively hiring more staff, contracting with outside providers and looking into using technology to broaden access to treatment.

At a mid-October union rally in Oakland, therapists said the health system’s billions in profits should allow it to hire more than one mental health clinician for every 3,000 members, which the union says is the current ratio.

Ann Rivello, 50, who has worked periodically at Kaiser Permanente Redwood City Medical Center since 2000, said therapists are so busy they struggle to take bathroom breaks and patients wait about two months between appointments for individual therapy.

“Just take $100 million that they’re putting into the new ‘Thrive City’ over there with the Warriors,” she said. “Why can’t they just give it to mental health?”

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Listen: HHS Files Challenge Over Rights To Gilead’s HIV-Prevention Drug

KHN’s Shefali Luthra spoke with Jeremy Hobsons, host of WBUR’s Hear & Now, about the Trump administration’s lawsuit over sales of the HIV-prevention drug Truvada.

You can read the text of the lawsuit here.

Check out this earlier, related KHN story: Out-Of-Pocket Costs Put HIV Prevention Drug Out Of Reach For Many At Risk (Luthra and Gorman,7/3/2018).

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As Congress Works To Curb Surprise Medical Bills, N.Y.’s Fix Gets Examined

Lobbying campaigns and legislative battles have been underway for months as Congress tries to solve the problem of surprise billing, when patients face often exorbitant costs after they unknowingly receive care from an out-of-network doctor or hospital.

As Congress considers various plans and negotiates behind the scenes, data is trickling in from states that have been test-driving proposed solutions.

New York was among the first to tackle the issue. In 2015, it passed a surprise billing law that uses “baseball-style” arbitration as a way to settle payment disputes between insurance companies and doctors. Under this approach, which is used in Major League Baseball to negotiate salaries (hence the name), each party submits a proposed dollar amount to the arbiter, who then chooses one as the final monetary award.

According to an analysis of newly released data from New York’s Department of Financial Services, the New York model is making health care substantially more expensive in the state. In fact arbiters are typically deciding on dollar amounts above the 80th percentile of typical costs.

“This is an extremely high and extremely inflationary rule of thumb,” said Loren Adler, author of the analysis and associate director of the USC-Brookings Schaeffer Initiative for Health Policy.

New York’s financial agency reported that the law has saved consumers $400 million, but Adler challenged the claim, saying the state’s experience has shown limited relief for patients.

Arbitration, or as New York calls it “independent dispute resolution,” or IDR, works like this: A patient gets into an accident and goes to a hospital in her insurance network. While there, she sees a physician ― perhaps an emergency room doctor or anesthesiologist ― who isn’t covered by her insurance company.

The insurance company pays a small part of the bill, and the doctor sends the patient a bill for the rest (often called a balance bill). Under New York’s law, the patient is held harmless, meaning they only have to pay as much of their deductible, copay or coinsurance as they would if the doctor were in network. If the insurance company and the physician can’t agree on how much of the bill to pay, they can take the issue to IDR.

They each bring their “fair-price,” “final bid” to the arbiter, who then decides between the two.

The problem, according to Adler, comes in the guidance the New York law gives arbiters. It says they should consider the 80th percentile of “billed charges.”

“Providers’ billed charges, or list prices, are unilaterally set, largely unmoored from market forces, and generally many times higher than in-network negotiated rates or Medicare rates,” Adler wrote.

So bill charges are already much higher than what Medicare pays, and on top of that, arbiters are told to focus on the 80th percentile of those rates, an amount higher than what 80% of doctors charge for that procedure.

It wasn’t clear at first how strictly arbiters would follow this guidance, but the data suggests they’re using it most of the time. On average, arbitration decisions have been 8% higher than that 80th percentile mark.

“People think there’s something magical about arbitration, that these brilliant geniuses sit down and look at all the facts to make a decision,” Adler said. “They’re normal people who don’t have much more expertise than insurers or providers, and this strongly suggests they’re just coming up with a rule of thumb.”

According to the analysis, the number of bills undergoing arbitration went from 115 in 2015 to 1,014 in 2018. Many advocates of arbitration predict the number of claims will drop over time as insurers and providers work out claims themselves. Based on these numbers, though, this hasn’t happened yet.

Insurance plans and doctors “won” about the same number of cases, and in 2018 more cases seemed to go in the providers’ favor. Yet, Adler pointed out, consumers appeared to lose either way.

That’s because even when the insurance plan won, it was on average only 11% less than the 80th percentile, which Adler said is still around three times as much as a patient would pay if the doctor were in-network. Those extra costs, he said, get passed on in the form of higher premiums.

One of the bills in Congress seeking to address surprise medical bills also relies on arbitration as the solution. But the bill authors, Sen. Bill Cassidy (R-La.) and Sen. Maggie Hassan (D-N.H.), were both quick to draw the distinction between their arbitration bill and New York’s model at an event about surprise billing at the Bipartisan Policy Center on October 30.

“The New York system uses as its payment standard [bill] charges, which we think is wrong and misguided,” Hassan said. “Which is why our bill doesn’t.”

Hassan and Cassidy’s bill, called the STOP Surprise Medical Bills Act of 2019, avoids tying payment rates to the “bill charges” with which Adler and other experts take issue.

Instead, arbiters are supposed to consider “commercially reasonable rates” based on what other in-network doctors charge in that geographic area, as well as factors like the level of training the provider had and the complexity of the dispute.

Adler called Cassidy and Hassan’s bill “leagues better” than the New York approach, but he’s still skeptical of how vague the guidance is.

Cassidy dismissed many of the criticism in the Brookings’ analysis, including the increase in cases going to arbitration because, he said, it represents such a small portion of the overall claims in New York.

He said they were still learning a lot from New York’s experience.

“I think it’s been incredibly useful,” Cassidy said.

“We know that IDR is not abused,” he said. “And it’s been adopted by a spectrum of politically diverse states and geographically diverse states.”

As for the main Senate bill, backed by Health, Education, Labor and Pensions Committee Chairman Lamar Alexander (R-Tenn.), it would use a different method to settle payment disputes. Under this approach, known as benchmarking, out-of-network providers must accept a set payment for their services, which would be based on a median of what other providers in the area charge.

Alexander’s bill, which gained committee approval (20-3) in June, is still awaiting consideration by the full Senate.

It will have to navigate the pro-arbitration factions in the House.

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As UVA Scales Back Lawsuits, Pain For Past Patients Persists

Kitt Klein and Mike Miller lost thousands of dollars in hard-won savings more than a decade ago after UVA Health put a lien on their home for a hospital bill they couldn’t pay.

They can’t believe they’re at risk of losing a second home today.

“Can they do this twice?” said Klein, who lives with her husband, a house painter, in her late mother’s house in Virginia’s Shenandoah Valley.

The couple was hit with a $129,133 court judgment in 2017 after UVA sued them and won in a case involving unpaid bills for out-of-network treatment of Miller’s lung cancer the year before, court documents show.

Last month, UVA said it would scale back such activity after a Kaiser Health News investigation found the medical system had filed 36,000 patient lawsuits for more than $100 million over six years, sending many families into hardship and bankruptcy. Its pursuit of former patients included putting thousands of liens on homes.

The prestigious medical system, affiliated with the University of Virginia in Charlottesville, said it is suspending current lawsuits, expanding financial assistance and even reconsidering old cases and applying aid retroactively. The new policies apply to people treated in July 2017 or later, according to Doug Lischke, UVA Health’s chief financial officer.

But that means people such as Miller, who received hundreds of thousands of dollars in financial assistance from his local hospital but not from UVA, won’t benefit from the changes. Thousands of former patients owing old bills, many with court judgments against them and wages being garnished or liens on their homes, will continue to suffer under the previous rules.

“There’s so many people that I’m talking to that are so relieved, saying thank God people are finally getting some justice,” said former patient Denise Nunez, 45.

But she’s still paying off a UVA bill of about $1,500 dating to 2014, legal papers show. It never came to her house because a clerk transposed the address number, she said. The new policies don’t stand to benefit her, either.

At the same time, patients treated more recently said they are struggling to obtain information on the changed rules and uncertain whether they’ll be helped. Unlike VCU Health in Richmond, which halted all routine patient lawsuits in the wake of KHN’s inquiry, UVA says it will continue to sue patients with incomes above a certain level.

It has also said repeatedly that changes announced last month are “a first step.”

“It seems like they’re still sorting out details of exactly what their new policy looks like,” said Elaine Poon, managing attorney at the Legal Aid Justice Center in Charlottesville, which represents some lower-income UVA patients. “We want UVA to hold off — to suspend collections until they have a new policy.”

UVA has said little publicly about its new policies almost two months since it announced them, beyond posting a webpage referring to federal poverty guidelines and directing patients to a phone number with an intricate voice menu asking for a “guarantor account number.” Some patients said they didn’t understand what that means.

The website says nothing about reopening old cases for those already hit with garnished wages, court judgments or even UVA liens on their homes.

“I haven’t heard from UVA,” said Paul Baker, 41, a former yard maintenance worker who along with his wife owes the system more than $500,000 for treatment after a devastating truck accident in 2018.

Under the new rules, Baker’s stated income of about $24,000 might qualify him for relief.

UVA is updating its website and stocking clinics with cards in English and Spanish with contact information for patients having trouble with bills, said health system spokesman Eric Swensen. For patients meeting the new rules, it is halting or reversing the seizure of Virginia’s special tax refund of up to $220, being issued this fall, he said.

UVA has granted easier payment terms to hundreds of patients, stopped renewing wage garnishments for patients who qualify and suspended or dismissed more than 500 lawsuits since Sept. 12, Swensen said.

For now, however, that doesn’t help Robert Turkiewicz, who lost a case the day before, on Sept. 11, and faces a UVA judgment for $96,779 and attorney fees of $14,517, court documents show. Given his experience with the UVA billing office, he’s not sure it ever will.

A carpenter and construction worker who lives in Luray, Va., Turkiewicz, 44, accidentally shot himself in the leg a year ago while taking a pistol out of a truck to kill chickens. He and his wife make about $22,000 a year, he said. That’s well within UVA’s new income guidelines for erasing his entire bill.

Robert Turkiewicz, a carpenter and construction worker who lives in Luray, Va., and his wife make about $22,000 a year — well within UVA’s new income guidelines for erasing a bill. Yet Turkiewicz faces a UVA judgment for $96,779 and attorney fees of $14,517, court documents show.(Eze Amos for KHN)

But his stated income falls within UVA’s old guidelines for at least partial financial assistance ― and he never obtained it. A UVA billing clerk kept asking for copies of pay stubs that didn’t exist because he had been badly wounded and couldn’t work, he said.

“I knew I couldn’t afford it and I told them I couldn’t afford it,” he said. “And they said, ‘Well, you’ll get the charity care.’ And I never did get it.”

On paper, UVA’s amended policy makes it easier to qualify for financial assistance, awarding aid to families with incomes of up 400% of federal poverty guidelines, or about $100,000 for a family of four with less than $50,000 in assets, besides a home.

A family of four with income below about $50,000 would qualify for a full write-off under the new rules. UVA also has said it won’t usually sue families earning less than 400% of poverty guidelines, and will increase the discount off hospital list charges for all uninsured patients from 20% to at least 40%. It has said it will not refund money already collected.

The health system is appointing a “billing and collections advisory council” of medical and community leaders to consider further changes, leaving open the possibility it could increase discounts for the uninsured or reduce balances for people treated before the July 2017 cutoff.

The system’s collections policies have included canceling enrollment for University of Virginia students who owe medical bills. UVA has hinted it would reconsider this.

But “I’m still blocked,” said Nacy Sexton, whose UVA education was interrupted in 2014 by a hospital bill that he is still paying off. “UVA has not reached out to me.”

Even closed cases can leave families heavily indebted or stripped of savings.

“I paid every penny to them, but I still owe $25,000 to a friend of mine,” said Priti Chati, 51, who lives in Roanoke. UVA sued Chati, whose case KHN described in a previous story, for treatment of a brain tumor in 2011.

Those with old bills and legal judgments say they hope the advisory council will urge UVA to make the new policies effective further back than July 2017.

UVA is dunning money from Nunez for a five-year-old bill, taking $602 from her Virginia tax refund in April, a letter the state sent her shows.

Klein and Miller’s experience with big UVA Health bills began in the early 2000s after he hurt his wrist badly in a lawnmower accident. Multiple surgeries drove up the bills, which their daughter eventually paid with her money.

They deeded their house to her in 2012 for a few dollars to pay her back, Klein said, with UVA effectively taking their home equity. Then they moved into her mother’s house, built in the 1870s, near Quicksburg.

Since 2012, Miller has been fighting lung cancer and has tumors on his bladder and kidney. His insurance has paid more than $100,000 for treatment at Sentara RMH Medical Center in Harrisonburg, with the hospital awarding more than $400,000 in financial assistance based on his income, said Sentara spokesman Neil Mowbray.

But in 2016, doctors said he needed radiation therapy available only at UVA Health, which was out of network. The plan still paid UVA at least $64,000, insurance documents show. But UVA billed and sued the couple for $129,133. They’re paying $100 a month.

They make about $25,000 a year, said Klein, adding that UVA denied their previous financial assistance application. Their income is within the new UVA guidelines for patients to be considered for a full write-off of the bill.

But because the treatment was in 2016, before the July 2017 cutoff, she fears UVA will have a claim on her Quicksburg home, the one she grew up in, with her mother now buried nearby.

“I was furious,” she said. “Here we are going through this again, and this is our family homeplace. That’s all Mom wanted — she wanted it left with the family.”

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Missouri Governor Says He Won’t Open Investigation Into Spreadsheet Of Patients’ Periods Despite Furor

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! As tempting as it might be this weekend to catch up on your extra z’s (and as someone who wakes up at 4:30 a.m. every morning I feel you) resist! Or so experts say. I, on the other hand, say we’re all a bit tired from staying up to watch the Nats win the World Series and we deserve that extra hour when the clock falls back on Sunday.

Now here’s what you might have missed if you were busy celebrating.

Sen. Elizabeth Warren (D-Mass.) released her plan on how she would pay for “Medicare for All.” The proposal leans heavily on employers, who Warren said would “pay slightly less than what they are projected to pay today” since they’ll no longer be providing health care for their workers. She would also ramp up her signature wealth tax and cut military spending. For all of this to work, Warren is banking on substantial savings in administrative costs. And the middle class won’t see even “one penny” in tax hikes, she said.

As she only just dropped the plan this morning, I’m sure we’ll see a plethora of reactions through the weekend and into the campaign. But at first glance the main one seems to be: Good luck getting that past the major health care players (insurers, hospitals, providers) … not to mention a potentially GOP-led Senate.

The New York Times: Elizabeth Warren Releases Plan To Pay For ‘Medicare For All’

The Associated Press: Warren Health Care Plan Pledges No Middle Class Tax Increase

The politically fraught plan is unlikely to reassure vulnerable Democrats who are fretful about running down-ticket of progressives who are embracing Medicare for All. Where health care was a winning topic for the Dems in the mid-terms, candidates running for competitive seats worry the issue could become more of a headache than anything else.

The Wall Street Journal: Vulnerable House Democrats Wary Of Campaigning For Medicare For All In 2020 Race

And should we be expecting such a detailed plan from the crafter of the bill himself? Sen. Bernie Sanders (I-Vt.) essentially said, don’t hold your breath. “I don’t think I have to do that right now,” in response to questions about costs.

NPR: Bernie Sanders Won’t Yet Explain Details Of How To Pay For Medicare For All


The Affordable Care Act’s open enrollment season kicked off today with one of the most stable marketplaces we’ve seen yet. Premiums are lower on average, more insurers have come back to play, and there’s a general sense that the rough storms have been weathered. Experts still project, though, fewer people signing up this year. And a federal appeals court ruling over the health law’s constitutionality hovers like a dark cloud on the horizon.

The Hill: New ObamaCare Enrollment Period Faces Trump Headwinds

Politico: Obamacare Is Stronger Than Ever — And A Trump-Backed Lawsuit Could Destroy It.

In news that shocked no one, Senate Democrats failed to pass legislation undoing the expansion of “junk” insurance plans. It was largely symbolic move to force Republicans supporting the administration to vote on the record against the health law—which has become a handy little political tool for Dems now that Americans have become attached to provisions such as protections for people with preexisting medical conditions.

Politico: Senate Democrats Fail In Bid To Block Trump’s Obamacare Opt-Out


Indiana was the second Republican-led state in recent weeks to pump the brakes on adding work requirements to its Medicaid program. The move follows Arizona’s announcement that it would be pausing implementation and comes despite enthusiastic encouragement from the Trump administration. It’s the latest roadblock on a fairly bumpy road for work requirements—which goes to show that just because you have the political capital doesn’t mean implementation is going to be smooth sailing.

The Washington Post: Indiana Backs Away From Medicaid Work Requirements

Meanwhile, over in Tennessee, sharp negative criticism has forced leaders’ hands into reworking a controversial plan to shift the state’s Medicaid program into a block grant system. However, the changes won’t be made public until after the Centers for Medicare & Medicaid Services gets to see them.

Nashville Tennessean: TennCare’s Revised Block Grant Plan: The Feds Get It Before Public


Any other news coming out of the hearing over Missouri’s last-remaining abortion clinic was mostly overshadowed this week by the revelation that the state’s health department was tracking patients’ menstrual periods on a spreadsheet. While state officials were quick to offer assurance that the women’s privacy was not breached, many were still perturbed, to say the least. “From an ethical standpoint, it’s frankly bonkers,” said one OB-GYN.

Kansas City Star: Missouri Health Director Kept Spreadsheet Of Planned Parenthood Patients’ Periods

And, as expected, a judge blocked Alabama’s strict abortion ban, which would effectively make the procedure illegal and criminally punish doctors with harsh sentences for performing one. The bill’s supporters, however, have their eyes on Roe v. Wade and see the ruling as just a necessary step on the way to the Supreme Court.

The New York Times: Alabama Abortion Ban Is Temporarily Blocked By A Federal Judge


A lawsuit filed by a fired Juul executive claims that the company knowingly shipped 1 million nicotine pods that were contaminated. Siddharth Breja accused the former CEO Kevin Burns of shooting down concerns over the product by saying “half our customers are drunk” so they won’t notice. Both Burns and Juul denied the allegations.

BuzzFeed News: Juul Shipped At Least A Million Contaminated Nicotine Pods, New Lawsuit Says


The coverage of the wildfires in California has been so extensive and dramatic, it’s impossible to link to just one story. The Los Angeles Times, the Sacramento Bee, the San Francisco Chronicle and many other California media organizations have done a fabulous job of covering every angle of the disaster.

But for health care stories in particular, I recommend checking out our own California Healthline offerings.


In the miscellaneous file for the week:

• ProPublica offers a chilling story about a patient identification error that resulted in the wrong man being removed from life support. The realization came days too late for the patient who died minutes after the care was halted.

ProPublica: The Wrong Goodbye

• Fecal transplants were getting a lot of interest and buzz—and then came a startling death of one of the patients involved in an experimental trial. The group of doctors involved take a hard look at what went wrong in a frank and public self-examination of their missteps involved.

The New York Times: How Contaminated Stool Stored In A Freezer Left A Fecal Transplant Patient Dead

• Why doesn’t Microsoft founder Bill Gates, who is not only one of the richest men in the world but also deeply involved in health care issues, contribute more money to fighting Alzheimer’s? His science adviser says it’s because they feel “throwing money at the issue” just isn’t going to move the needle at all.

Stat: Bill Gates Spends Billions On Global Health. With Alzheimer’s, His Science Adviser Says, Money Is Not The Issue

• A new study has a stark warning for parents who don’t see the benefits of vaccines: It’s not just the measles you have to worry about. Getting infected with the virus is like a “car crash” for your immune system. Kids are far more vulnerable to other dangerous diseases up to years later. It’s flown under the radar, though, because people don’t connect a bout of pneumonia down the road to a measles infection months earlier.

Stat: How Measles Infections Can Wipe Away Immunity To Other Diseases


And that’s it from me! Have a great weekend.

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