Tag: Health Care Costs

KFF Health News’ ‘What the Health?’: Harris in the Spotlight

The Host

As Vice President Kamala Harris appears poised to become the Democratic Party’s presidential nominee, health policy in general and reproductive health issues in particular are likely to have a higher profile. Harris has long been the Biden administration’s point person on abortion rights and reproductive health and was active on other health issues while serving as California’s attorney general.

Meanwhile, Congress is back for a brief session between presidential conventions, but efforts in the GOP-led House to pass the annual spending bills, due by Oct. 1, have run into the usual roadblocks over abortion-related issues.

This week’s panelists are Julie Rovner of KFF Health News, Stephanie Armour of KFF Health News, Rachel Cohrs Zhang of Stat, and Alice Miranda Ollstein of Politico.

Among the takeaways from this week’s episode:

  • President Joe Biden’s decision to drop out of the presidential race has turned attention to his likely successor on the Democratic ticket, Vice President Kamala Harris. At this late hour in the campaign, she is expected to adopt Biden’s health policies, though many anticipate she’ll take a firmer stance on restoring Roe v. Wade. And while abortion rights supporters are enthusiastic about Harris’ candidacy, opponents are eager to frame her views as extreme.
  • As he transitions from incumbent candidate to outgoing president, Biden is working to frame his legacy, including on health policy. The president has expressed pride that his signature domestic achievement, the Inflation Reduction Act, took on the pharmaceutical industry, including by forcing the makers of the most expensive drugs into negotiations with Medicare. Yet, as with the Affordable Care Act’s delayed implementation and results, most Americans have yet to see the IRA’s potential effect on drug prices.
  • Lawmakers continue to be hung up on federal government spending, leaving appropriations work undone as they prepare to leave for summer recess. Fights over abortion are, once again, gumming up the works.
  • In abortion news, Iowa’s six-week limit is scheduled to take effect next week, causing rippling problems of abortion access throughout the region. In Louisiana, which added the two drugs used in medication abortions to its list of controlled substances, doctors are having difficulty using the pills for other indications. And doctors who oppose abortion are pushing higher-risk procedures, like cesarean sections, in lieu of pregnancy termination when the mother’s life is in danger — as states with strict bans, like Texas and Louisiana, are reporting a rise in the use of surgeries, including hysterectomies, to end pregnancies.
  • The Government Accountability Office reports that many states incorrectly removed hundreds of thousands of eligible people from the Medicaid rolls during the “unwinding” of the covid-19 public health emergency’s coverage protections. The Biden administration has been reluctant to call out those states publicly in an attempt to keep the process as apolitical as possible.

Also this week, Rovner interviews Anthony Wright, the new executive director of the consumer health advocacy group Families USA. Wright spent the past two decades in California, working with, among others, now-Vice President Kamala Harris on various health issues.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too: 

Julie Rovner: NPR’s “A Study Finds That Dogs Can Smell Your Stress — And Make Decisions Accordingly,” by Rachel Treisman.  

Alice Miranda Ollstein: Stat’s “A Pricey Gilead HIV Drug Could Be Made for Dramatically Less Than the Company Charges,” by Ed Silverman, and Politico’s “Federal HIV Program Set To Wind Down,” by Alice Miranda Ollstein and David Lim. 

Stephanie Armour: Vox’s “Free Medical School Won’t Solve the Doctor Shortage,” by Dylan Scott.  

Rachel Cohrs Zhang: Stat’s “How UnitedHealth Harnesses Its Physician Empire To Squeeze Profits out of Patients,” by Bob Herman, Tara Bannow, Casey Ross, and Lizzy Lawrence. 

Also mentioned on this week’s podcast:


To hear all our podcasts, click here.

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Qué son los medicamentos compuestos que millones de personas usan para bajar de peso

El farmacéutico Mark Mikhael ha perdido 50 libras en los últimos 12 meses. Ya no tiene diabetes y está “en un peso corporal ideal”, con su colesterol por debajo de 200 por primera vez en 20 años. “Me siento fantástico”, dijo.

Al igual que millones de personas, Mikhael atribuye su éxito a la nueva clase de medicamentos para la pérdida de peso. Pero no está usando Wegovy o Zepbound, que son medicamentos de marca. Mikhael, director ejecutivo de Olympia Pharmaceuticals, con sede en Orlando, Florida, se ha arreglado con su propio suministro: inyectándose versiones formuladas por su empresa.

No está solo. Mikhael y otros funcionarios de la industria estiman que varias grandes farmacias de compuestos como la suya están proporcionando dosis regulares de semaglutida a hasta 2 millones de estadounidenses, el nombre científico de las formulaciones Wegovy, Ozempic y Rybelsus de Novo Nordisk, o tirzepatida, el ingrediente activo en las formulaciones Zepbound y Mounjaro de Eli Lilly.

Un compuesto es un medicamento preparado de forma personalizada en farmacias especializadas. Estas farmacias también pueden producir un fármaco génerico o de marca cuando  hay escasez.

Los gigantes de la industria de medicamentos se oponen ferozmente al negocio de compuestos.

Novo Nordisk y Lilly colocan a los fabricantes de compuestos junto con “cowboys” de internet y spas médicos no regulados que venden semaglutida falsa, y tienen feroces equipos legales tratando de detenerlos.

Novo Nordisk ha presentado al menos 21 demandas en todo el país contra empresas que fabrican supuestas copias de sus medicamentos, dijo Brianna Kelley, vocera de la empresa, e insta a los médicos a evitarlas. La Administración de Drogas y Alimentos (FDA) también ha advertido sobre el peligro potencial de los compuestos, y los principales grupos de medicina de obesidad advierten enfáticamente a los pacientes contra su uso.

Pero esto no es un mercado negro ilegal, aunque tiene matices grises.

La FDA permite e incluso fomenta que las farmacias de compuestos produzcan y vendan copias cuando un medicamento está en escasez, y los populares medicamentos GLP-1 han sido escasos por un tiempo: la semaglutida desde marzo de 2022, y la tirzepatida desde diciembre de 2022.

Estos medicamentos han mostrado un éxito sin precedentes para la pérdida de peso. También revelan promesas contra enfermedades del corazón, riñón y hígado, y se están probando contra condiciones tan diversas como el Alzheimer y la adicción a drogas.

En los últimos años, el sistema de atención médica del pais ha llegado a depender de las farmacias de compuestos, muchas de las cuales son administradas como organizaciones sin fines de lucro, para tapar los agujeros de suministro de medicamentos cruciales como los medicamentos contra el cáncer cisplatino, metotrexato y 5-fluorouracilo.

La mayoría de los medicamentos compuestos son genéricos viejos y baratos. Pero la semaglutida y la tirzepatida están bajo patente y generan miles de millones de dólares al año para Novo Nordisk y Lilly. Las ventas de los medicamentos para la diabetes y la pérdida de peso este año hicieron de Novo Nordisk la empresa más valiosa de Europa, y de Lilly la mayor compañía farmacéutica del mundo.

Mientras las empresas no pueden mantenerse al día con la demanda, disputan acaloradamente el derecho de los fabricantes de compuestos a hacer y vender copias. Kristiane Silva Bello, vocera de Lilly, dijo que su empresa estaba “profundamente preocupada” por los “graves riesgos para la salud” de los medicamentos compuestos que “no deberían estar en el mercado”.

Pero están. Incluso Hims & Hers Health, que comenzó con medicamentos para la disfunción eréctil, ahora está vendiendo semaglutida compuesta. Puso anuncios de los medicamentos durante los partidos de playoffs de la NBA. (Según un informe de Hunterbrook Media, el proveedor de semaglutida de Hims & Hers ha enfrentado escrutinio legal).

Las formas compuestas son significativamente más baratas que los medicamentos de marca. Los pacientes pagan entre $100 y $450 al mes, en comparación con los precios de lista de aproximadamente $1,000 a $1,400 para los productos de Lilly y Novo Nordisk.

Cinco fabricantes de compuestos y distribuidores entrevistados para este artículo dijeron que realizan las debidas diligencias en cada lote de semaglutida o tirzepatida que compran o producen, manteniendo estándares de pureza, esterilidad y consistencia similares a los practicados en la industria comercial de medicamentos. Los fabricantes de compuestos operan bajo estrictas normas federales y estatales, enfatizaron.

Sin embargo, las materias primas utilizadas en las formas compuestas pueden diferir de las producidas para Novo Nordisk y Lilly, dijo Jens Juul Holst, co-inventor de GLP-1 de la Universidad de Copenhague, y agregó que se debe tener cuidado en la producción de medicamentos para evitar reacciones inmunes potencialmente dañinas.

Hasta la fecha, los informes de efectos secundarios por el uso de versiones compuestas no han generado grandes alarmas, según voceros de la FDA. Pero todos los que tienen conocimiento de la industria, incluidos los propios fabricantes de compuestos, temen que un solo lote de un medicamento mal hecho podría matar o mutilar a personas, y destruir la confianza en su negocio.

“Comparo la industria de compuestos con la industria aérea”, dijo Mikhael. “Cuando ocurre un accidente aéreo, perjudica a todos”.

Advertencias del pasado

La industria sufrió una catástrofe en 2012, cuando el New England Compounding Center lanzó un esteroide inyectable contaminado que mató al menos a 64 personas e hirió a cientos más.

En respuesta, el Congreso y la FDA fortalecieron la supervisión. La empresa de Mikhael es una instalación de outsourcing, o farmacia de compuestos 503B, llamada así por una sección de la ley de 2013 que estableció nuevos requisitos para los fabricantes de compuestos.

Las empresas están autorizadas a hacer versiones ligeramente diferentes de medicamentos aprobados por la FDA en respuesta a una escasez o necesidad especiales de los pacientes.

La ley creó dos clases de farmacias de compuestos: La FDA regula los mayores fabricantes de compuestos 503B con estándares similares a las compañías de medicamentos comerciales, mientras que las farmacias 503A hacen lotes más pequeños de medicamentos y están supervisadas en gran medida por juntas farmacéuticas estatales.

Las instalaciones 503A también están produciendo semaglutida y tirzepatida compuestas para cientos de miles de pacientes. Al igual que las 503B, estas operaciones toman el ingrediente activo, producido como un polvo en fábricas registradas por la FDA, principalmente en China, y luego lo reconstituyen con agua estéril y un antimicrobiano en pequeños viales de vidrio.

En conjunto, las farmacias de compuestos pueden representar hasta el 30% de la semaglutida vendida en el país, dijo Mikhael, aunque advierte que es una “cifra aproximada” ya que nadie, incluida la FDA, está rastreando las ventas en la industria.

Los fabricantes de compuestos dicen que las empresas deberían aumentar la producción si les preocupa la competencia. Al igual que las docenas de otros medicamentos que producen para hospitales y consultorios médicos, los fabricantes de compuestos dicen que los dos medicamentos dietéticos son productos esenciales.

“Si no quieres que una instalación 503B haga una copia, es bastante simple: no tengas escasez”, dijo Lee Rosebush, presidente de una asociación comercial para farmacias 503B. “La FDA creó este sistema porque estos son medicamentos necesarios”.

Novo Nordisk no ha especificado por qué no puede mantenerse al día con la demanda, pero el cuello de botella aparentemente radica en la incapacidad de la empresa para llenar y esterilizar suficientes de sus inyectores automáticos especiales, dijo Evan Seigerman, director gerente de BMO Capital Markets.

La empresa anunció el 24 de junio que estaba invirtiendo $4.1 mil millones en nuevas líneas de producción en su sitio de Clayton, Carolina del Norte. El año pasado, la FDA emitió una advertencia por violaciones de procedimiento en el sitio y advertencias separadas en una instalación en Indiana que Novo Nordisk tomó recientemente.

Composición para tontos

Al menos 28 empresas, en su mayoría en China, están registradas ante la FDA para producir o distribuir semaglutida. Al menos la mitad de las empresas han ingresado al mercado en los últimos 12 meses, reduciendo el precio de la materia prima en un 35%, según Scott Welch, quien dirige una farmacia 503A en Arlington, Virginia.

Los fabricantes de compuestos pueden comprar semaglutida en polvo de algunos distribuidores estadounidenses por menos de $4,000 el gramo, dijo Matthew Johnson, presidente y director ejecutivo del distribuidor Pharma Source Direct. Eso resulta en tan solo $10 por dosis semanal de 2.5 microgramos.

Mientras que los pacientes de Ozempic o Wegovy usan un dispositivo de Novo Nordisk para inyectar el medicamento, los pacientes que usan productos compuestos los extraen de un vial con una pequeña aguja, como el dispositivo que usan las personas que viven con diabetes para la insulina.

Algunas prácticas médicas proporcionan el medicamento compuesto a los pacientes como parte de un paquete de pérdida de peso, con recargos. El pasado julio, Tabitha Ries, madre soltera de seis hijos que trabaja como asistente de atención médica a domicilio en Garfield, Washington, encontró una clínica en línea que le cobró $1,000 por tres meses de semaglutida junto con asesoramiento. Ha perdido 35 libras.

Obtiene el medicamento de Mindful Weight Loss, una operación principalmente basada en telemedicina dirigida por el médico Vivek Gupta de Manhattan Beach, California. Gupta dijo que ha recetado los medicamentos para la pérdida de peso a 1,500 pacientes, con aproximadamente el 60% usando versiones compuestas de una farmacia 503A.

No ha visto ninguna diferencia esencial en los pacientes que usan las formas de marca y compuestas, aunque “algunas personas dicen que el compuesto es un poco menos efectivo”, dijo Gupta.

Hay algún riesgo en usar el producto no aprobado por la FDA, reconoció, y requiere que los pacientes firmen un formulario de consentimiento informado.

“Nada en la vida está exento de riesgos, pero también argumentaría que el statu quo no es seguro para las personas que necesitan el medicamento y no pueden obtenerlo”, dijo. “Están constantemente desencadenados por toda esta comida que está causando que su peso aumente y su azúcar suba, aumentando su resistencia a la insulina y afectando sus extremidades y ojos”.

Componer semaglutida es una ayuda para los farmacéuticos como él, dijo Welch, especialmente dado el aprieto en los ingresos por la venta de medicamentos que ha llevado a muchos independientes a cerrar en los últimos años. Calcula que gana el 95% de sus ingresos con medicamentos compuestos, en lugar de recetas tradicionales.

Es importante distinguir la semaglutida compuesta de los polvos no regulados vendidos como “Ozempic genérico” y similares, que pueden estar contaminados o ser falsificados, dijo Amanda Hils, vocera de la FDA. Pero dado que las formas compuestas del medicamento no están aprobadas por la FDA, quienes las fabrican, recetan o usan también deben tener “un mayor nivel de responsabilidad o conciencia”, dijo.

Batallas corporativas

En demandas que cada empresa ha presentado contra competidores, Novo Nordisk y Lilly dicen que sus propias pruebas han encontrado bacterias y otras impurezas en productos hechos por farmacias de compuestos.

Las empresas también informan de infracción de patentes, pero los fabricantes de compuestos, señalando la laguna de la FDA para medicamentos en escasez, parecen haber derrotado ese argumento por ahora.

Cuando la FDA retira los medicamentos de la lista de escasez, los fabricantes de compuestos 503B deben dejar de venderlos de inmediato. Los fabricantes de compuestos más pequeños pueden producir sus productos para un número reducido de pacientes, dijo Scott Brunner, director ejecutivo de la Alliance for Pharmacy Compounding, que representa a los fabricantes de compuestos 503A.

Que se evaporara el suministro de medicamentos compuestos podría ser un shock para los pacientes.

“Lo temo”, dijo David Wertheimer, internista en Franklin Lakes, Nueva Jersey, que receta semaglutida compuesta a algunos pacientes. “La gente no va a poder desembolsar mil dólares cada mes. Mucha gente dejará el medicamento, y eso es una lástima”.

Why Millions Are Trying FDA-Authorized Alternatives to Big Pharma’s Weight Loss Drugs

Pharmacist Mark Mikhael has lost 50 pounds over the past 12 months. He no longer has diabetes and finds himself “at my ideal body weight,” with his cholesterol below 200 for the first time in 20 years. “I feel fantastic,” he said.

Like millions of others, Mikhael credits the new class of weight loss drugs. But he isn’t using brand-name Wegovy or Zepbound. Mikhael, CEO of Orlando, Florida-based Olympia Pharmaceuticals, has been getting by with his own supply: injecting himself with copies of the drugs formulated by his company.

He’s far from alone. Mikhael and other industry officials estimate that several large compounding pharmacies like his are provisioning up to 2 million American patients with regular doses of semaglutide, the scientific name for Novo Nordisk’s Wegovy, Ozempic, and Rybelsus formulations, or tirzepatide, the active ingredient in Eli Lilly’s Zepbound and Mounjaro.

The drug-making behemoths fiercely oppose that compounding business. Novo Nordisk and Lilly lump the compounders together with internet cowboys and unregulated medical spas peddling bogus semaglutide, and have high-powered legal teams trying to stop them. Novo Nordisk has filed at least 21 lawsuits nationwide against companies making purported copies of its drugs, said Brianna Kelley, a spokesperson for the company, and urges doctors to avoid them. The FDA, too, has cautioned about the potential danger of the compounds, and leading obesity medicine groups starkly warn patients against their use.

But this isn’t an illegal black market, though it has shades of gray.

The FDA allows and even encourages compounding pharmacies to produce and sell copycats when a drug is in short supply, and the wildly popular GLP-1 drugs have enduring shortages — first reported in March 2022 for semaglutide and in December 2022 for tirzepatide. The drugs have registered unprecedented success in weight loss. They are also showing promise against heart, kidney, and liver diseases and are being tested against conditions as diverse as Alzheimer’s disease and drug addiction.

In recent years, the U.S. health care system has come to depend on compounding pharmacies, many of which are run as nonprofits, to plug supply holes of crucial drugs like cancer medicines cisplatin, methotrexate, and 5-fluorouracil.

Most compounded drugs are old, cheap generics. Semaglutide and tirzepatide, on the other hand, are under patent and earn Novo Nordisk and Lilly billions of dollars a year. Sales of the diabetes and weight loss drugs this year made Novo Nordisk Europe’s most valuable company and Lilly the world’s biggest pharmaceutical company.

While the companies can’t keep up with demand, they heatedly dispute the right of compounders to make and sell copies. Lilly spokesperson Kristiane Silva Bello said her company was “deeply concerned” about “serious health risks” from compounded drugs that “should not be on the market.”

Yet marketed they are. Even Hims & Hers Health — the telemedicine prescriber that got its start with erectile dysfunction drugs — is now peddling compounded semaglutide. It ran ads for the drugs during NBA playoff games. (According to a Hunterbrook Media report, Hims & Hers’ semaglutide supplier has faced legal scrutiny.)

The compounded forms are significantly cheaper than the branded drugs. Patients pay about $100 to $450 a month, compared with list prices of roughly $1,000 to $1,400 for Lilly and Novo Nordisk products.

Five compounders and distributors interviewed for this article said they conduct due diligence on every lot of semaglutide or tirzepatide they buy or produce, upholding standards of purity, sterility, and consistency similar to those practiced in the commercial drug industry. Compounders operate under strict federal and state standards, they noted.

However, the raw materials used in the compounded forms may differ from those produced for Novo Nordisk and Lilly, said GLP-1 co-inventor Jens Juul Holst, of the University of Copenhagen, adding that care must be taken in drug production lest it cause potentially harmful immune reactions.

To date, according to FDA spokespeople, reports of side effects from taking compounded versions haven’t raised major alarms. But everyone with knowledge of the industry, including the compounders themselves, worry that a single batch of a poorly made drug could kill or maim people and destroy confidence in their business.

“I liken the compounding industry to the airline industry,” Mikhael said. “When you have an airline crash, it hurts everybody.”

Warnings From the Past

The industry endured just such a catastrophe in 2012, when the New England Compounding Center released a contaminated injectable steroid that killed at least 64 people and harmed hundreds more.

In response, Congress and the FDA had strengthened oversight. Mikhael’s company is an outsourcing facility, or 503B compounding pharmacy — so-named for a section of the 2013 law that set new requirements for drug compounders. The companies are licensed to make slightly different versions of FDA-approved drugs in response to shortages or a patient’s special needs.

The law created two classes of compounding pharmacies: The FDA regulates the larger 503B compounders with standards like commercial drug companies, while 503A pharmacies make smaller lots of drugs and are largely overseen by state boards of pharmacy.

The 503A facilities also are producing compounded semaglutide and tirzepatide for hundreds of thousands of patients. Like the 503Bs, these operations take the active ingredient, produced as a powder in FDA-registered factories, mostly in China, then reconstitute it with sterile water and an antimicrobial in small glass vials.

Together, the compounding pharmacies may account for up to 30% of the semaglutide sold in the U.S., Mikhael said, although he cautions that is a “wild ballpark figure” since no one, including the FDA, is tracking sales in the industry.

The compounders say the companies should increase production if they’re worried about competition. Like the dozens of other drugs they produce for hospitals and medical practices, the compounders say, the two diet drugs are essential products.

“If you don’t want a 503B facility to make a copy, it’s pretty simple: Don’t go short,” said Lee Rosebush, chair of a trade association for 503B pharmacies. “FDA created this system because these are necessary drugs.”

Novo Nordisk hasn’t specified why it can’t keep up with demand, but the bottleneck apparently lies in the company’s inability to fill and sterilize enough of its special drug auto-injectors, said Evan Seigerman, a managing director at BMO Capital Markets.

The company announced June 24 that it was investing $4.1 billion in new production lines at its Clayton, North Carolina, site. The FDA last year issued a warning over procedural violations at the site and separate cautions at an Indiana facility that Novo Nordisk took over recently.

Compounding for Dummies

At least 28 companies mostly in China, are registered with the FDA to produce or distribute semaglutide. At least half the companies have entered the market in the past 12 months, driving the raw material’s price down by 35%, according to Scott Welch, who runs a 503A pharmacy in Arlington, Virginia.

Compounders can buy powdered semaglutide from some U.S. distributors for less than $4,000 a gram, said Matthew Johnson, president and CEO of distributor Pharma Source Direct. That comes out to as little as $10 per weekly 2.5-microgram dose – not including overhead and other costs.

While Ozempic or Wegovy patients use a Novo Nordisk device to inject the drug, patients using compounded products draw them from a vial with a small needle, like the device diabetics use for insulin.

Some medical practices provide the compounded drug to patients as part of a weight loss package, with markups. Last July, Tabitha Ries, a single mother of six who works as a home health care aide in Garfield, Washington, found an online clinic that charged her $1,000 for three months of semaglutide along with counseling. She has lost 35 pounds.

She gets the drug from Mindful Weight Loss, a mostly telehealth-based operation led by physician Vivek Gupta of Manhattan Beach, California. Gupta said he’s prescribed the weight loss drugs to 1,500 patients, with about 60% using compounded versions from a 503A pharmacy.

He hasn’t seen any essential difference in patients using the branded and compounded forms, although “some people say the compounding is a little less effective,” Gupta said.

There’s some risk in using the non-FDA-approved product, he acknowledged, and he requires patients to sign an informed consent waiver.

“Nothing in life is without risk, but I would also argue that the status quo is not safe for people who need the medicine and can’t get it,” he said. “They’re constantly triggered by all this food that’s causing their weight to go up and their sugar to go high, increasing their insulin resistance and affecting their limbs and eyes.”

Compounding semaglutide is a helpful sideline for pharmacists like him, Welch said, especially given the pinch on drug sale revenue that has led many independents to close in recent years. He figures he earns 95% of his revenue from compounding drugs, rather than traditional prescriptions.

It’s important to distinguish compounded semaglutide from unregulated powders sold as “generic Ozempic” and the like, which may be contaminated or counterfeit, said FDA spokesperson Amanda Hils. But since compounded forms of the drug are not FDA-approved, those who make, prescribe, or use them also should have “an increased level of responsibility or awareness,” she said.

Corporate Battles

Novo Nordisk and Lilly, in lawsuits each company has filed against competitors, say their own testing has found bacteria and other impurities in products made by compounding pharmacies. The companies also report patent infringement, but compounders, pointing to the FDA loophole for drugs in shortage, appear to have defeated that argument for now.

When the FDA removes the drugs from the shortage list, 503B compounders must immediately stop selling them. Smaller compounders may be able to produce their products for a reduced number of patients, said Scott Brunner, CEO of the Alliance for Pharmacy Compounding, which represents 503A compounders.

The evaporation of the compounded drug supply could come as a shock to patients.

“I dread it,” said David Wertheimer, an internist in Franklin Lakes, New Jersey, who prescribes compounded semaglutide to some patients. “People are not going to be able to plunk down a grand every month. A lot of people will go off the drug, and that’s a shame.”

Harris, alguna vez la voz de Biden sobre el aborto, tendría un enfoque abierto en temas de salud

A lo largo de su presidencia, Joe Biden se apoyó en Kamala Harris, la ex fiscal y senadora frontal que eligió como vicepresidenta, para ser la voz de apoyo inquebrantable de la Casa Blanca en favor de los derechos de salud reproductiva.

Ahora, mientras los demócratas reconstruyen su candidatura presidencial a pocos meses de las elecciones, se esperaría que, de ser la nueva nominada, Harris adoptase una postura agresiva en apoyo al acceso al aborto, atacando al ex presidente Donald Trump en un tema que podría socavar sus posibilidades de victoria.

Biden respaldó a Harris el domingo 21 de julio cuando anunció su decisión de retirarse de la contienda.

Aunque Biden buscaba mantener el aborto como tema central de su campaña de reelección, defensores seguían teniendo dudas de que el presidente, un católico practicante que ha dicho que no es “muy partidario del aborto”, pudiera ser un abanderado efectivo. Especialmente mientras los esfuerzos republicanos erosionan el acceso al aborto y otros servicios de salud para mujeres en todo el país.

Por otro lado, Harris se convirtió en la primera vicepresidenta en visitar una clínica operada por Planned Parenthood Federation of America. Emprendió una gira nacional centrada en los derechos reproductivos. Y cuando el senador JD Vance de Ohio fue nombrado compañero de fórmula de Trump, Harris utilizó su siguiente mitín de campaña para criticarlo por bloquear protecciones para la fertilización in vitro.

“Lo más significativo es que Harris sería el rostro del impulso para proteger el derecho al aborto”, dijo Larry Levitt, vicepresidente ejecutivo de políticas de salud en KFF, organización sin fines de lucro de información de salud de la que KFF Health News es parte, en una entrevista antes de que Biden se retirara. “El acceso al aborto probablemente sería el tema central en su campaña”.

Una postura firme sobre el aborto no es el único gran contraste con el Partido Republicano (GOP) que ofrece Harris: tiene un gran conocimiento en política de salud. De niña, a menudo acompañaba a su madre al laboratorio donde trabajaba los fines de semana, como investigadora del cáncer de mama.

Durante su campaña presidencial en 2019, apoyó el “Medicare para Todos”, una propuesta de seguro de pagador único, que estableció sus credenciales como una voz más progresista en políticas de salud. Y como fiscal general de California, luchó contra la consolidación en la industria de la salud debido a la preocupación de que esto aumentaría los precios.

En abril, defendió una norma de la administración Biden que establece niveles mínimos de personal en los hogares de adultos mayores financiados con fondos federales.

“Se merece crédito, ha hablado de estos temas en la campaña. No veo ningún cambio en las prioridades sobre lo que los demócratas quieren hacer en salud si ella se convierte en la nominada”, dijo Debbie Curtis, vicepresidenta de McDermott + Consulting.

Un enfoque intensificado en la salud de la mujer y el aborto podría ayudar a consolidar a los votantes demócratas en la recta final hacia las elecciones.

Desde que en 2022 los tres jueces de la Corte Suprema nombrados por Trump ayudaron a derogar Roe vs. Wade, la opinión pública se ha vuelto en contra de los republicanos en el tema del aborto, incluso contribuyendo a un resultado inesperadamente pobre en las elecciones intermedias de ese año.

El 32% de los votantes dijeron que solo votarían por un candidato para un cargo importante que compartiera sus opiniones sobre el aborto, según una encuesta de Gallup realizada en mayo. Ese es un récord alto desde que Gallup hizo la pregunta por primera vez en 1992. Casi el doble de votantes que apoyan el aborto, en comparación con aquellos que se oponen al aborto, tienen esa opinión.

El 63% de los adultos dijeron que el aborto debería ser legal en todos o en la mayoría de los casos, según una encuesta realizada en abril por el Pew Research Center. El 36% dijo que debería ser ilegal en todos o en la mayoría de los casos.

Mientras tanto, los republicanos han estado ansiosos por distanciarse de su propia victoria en este tema. Trump enfureció a algunos miembros de su base al decir que dejaría las decisiones sobre el aborto a los estados.

Sin embargo, defensores advierten que la nueva moderación por omisión del GOP en el tema enmascara su postura real, más extrema. Vance ha sido claro en el pasado sobre su apoyo a una prohibición nacional del aborto.

Y aunque la plataforma del GOP adoptada durante la convención del partido hace pocos días puede no pedir explícitamente una prohibición nacional del aborto, el reconocimiento de los líderes del partido de la “personalidad fetal”, la idea de que tan pronto como se fertiliza un óvulo se convierte en una persona con todos los derechos legales, crearía una prohibición automáticamente si la Corte Suprema la encontrara constitucional.

Esas opiniones contrastan con las de muchos republicanos, especialmente mujeres. Alrededor de la mitad de las votantes republicanas creen que el aborto debería ser legal en todos o en la mayoría de los casos, según una encuesta nacional reciente de KFF.

Y la mayoría de las mujeres que votan por el Partido Republicano creen que el aborto debería ser legal en casos de violación, incesto o una emergencia durante el embarazo.

Si Harris encabeza la candidatura, se esperaría que enfatice esos temas en los próximos meses.

“Ha sido uno de los temas principales, si no el principal, que ha remarcado en el último año o dos”, dijo Matthew Baum, profesor Marvin Kalb de comunicaciones globales en la Universidad de Harvard. “Claramente, los republicanos están tratando de desactivar el tema. Ha sido un desastre para ellos”.

Es probable, sin embargo, que los republicanos presenten las opiniones de Harris sobre el aborto como extremistas. Durante el debate presidencial contra Biden, Trump afirmó falsamente que los demócratas apoyan los abortos tardíos en el embarazo, “incluso después del nacimiento”.

Poco después que se diera la noticia de que Biden había respaldado a Harris, Susan B. Anthony Pro-Life America emitió un comunicado criticando el historial de Harris y ofreciendo una muestra de lo que está por venir. “Mientras Joe Biden tiene problemas para decir la palabra aborto, Kamala Harris la grita”, dijo Marjorie Dannenfelser, presidenta del grupo.

Algunos encuestadores han dicho que Harris tendrá que hacer más que simplemente hacer campaña contra los esfuerzos republicanos para revertir el acceso al aborto para realmente motivar a los votantes: temas como la inflación, la economía y la inmigración, están compitiendo por atención.

“Tiene que decir que está luchando por una ley federal que restablezca Roe vs. Wade”, dijo Robert Blendon, profesor emérito de salud pública en la Universidad de Harvard. “Necesita algo muy específico y claro”.

La elevación de Harris a la cima de la candidatura llegaría en un momento crítico en la lucha por los derechos reproductivos.

La Corte Suprema escuchó dos casos de aborto en el término que acaba de finalizar. Pero los jueces no abordaron los méritos de los temas en ninguno de los casos, fallando en su lugar sobre cuestiones técnicas. Se espera que ambos regresen a la Corte Suprema tan pronto como el próximo año.

Harris también tendría una considerable libertad para hablar sobre lo que se considera los principales logros de la política de salud de la administración Biden.

Estos incluyen mejores subsidios en la Ley de Cuidado de Salud a Bajo precio (ACA) destinados a ayudar a los consumidores a obtener seguro de salud, que se extendieron, a través de la Ley de Reducción de la Inflación, hasta 2025, el límite mensual de $35 en copagos que algunos pacientes pagan por la insulina, y la negociación de precios de medicamentos en Medicare.

“Creo que está bien posicionada. Harris es parte central de la administración y podrá atribuirse el mérito de esas cosas”, dijo Dan Mendelson, CEO de Morgan Health, una subsidiaria de J.P. Morgan Chase.

Dicho esto, puede ser difícil para cualquier candidato lograr que los votantes se enfoquen en algunos de esos logros, especialmente en los esfuerzos relacionados con los precios de los medicamentos.

Aunque la administración ha tomado algunos pasos importantes, “nuevos medicamentos costosos siguen saliendo al mercado”, dijo Mendelson. “Así que si miras la percepción de los consumidores, no creen que el costo de los medicamentos esté bajando”.

Joseph Antos, del American Enterprise Institute, dijo que es probable que Harris diga que la administración Biden-Harris “ya le está ahorrando dinero a la gente” en insulina. Pero tendrá que ir más allá de estos logros y redoblar sus esfuerzos en los precios de los medicamentos y otros temas de costo, no hablar únicamente sobre derechos reproductivos.

“Tiene que concentrarse, si quiere ganar, en temas que tengan un amplio atractivo”, dijo Antos. “El costo es uno y el acceso a tratamientos es otro gran tema”.

Samantha Young de KFF Health News contribuyó con este informe.

Harris, Once Biden’s Voice on Abortion, Would Take an Outspoken Approach to Health

Throughout Joe Biden’s presidency, he leaned on the outspoken former prosecutor and senator he selected as his vice president, Kamala Harris, to be the White House’s voice of unflinching support for reproductive health rights.

Now, as Democrats rebuild their presidential ticket just a few months before Election Day, Harris would widely be expected to take an aggressive stance in support of abortion access if she became the party’s new presumptive nominee — hitting former President Donald Trump on an issue that could undermine his chances of victory. Biden endorsed Harris on Sunday when he announced his decision to leave the race.

While Biden sought to keep abortion center stage in his reelection bid, abortion advocates had harbored doubts that the president — a practicing Catholic who has said he is not “big on abortion” — could be an effective standard-bearer as Republican efforts erode access to abortion and other women’s health care around the country.

Harris, on the other hand, became the first vice president to visit a clinic run by the Planned Parenthood Federation of America. She undertook a nationwide tour focused on reproductive rights. And when Sen. JD Vance of Ohio was named Trump’s running mate, Harris used her next campaign appearance to criticize him for blocking protections for in vitro fertilization.

“Most significantly, Harris would be the face of the drive to protect abortion rights,” Larry Levitt, executive vice president for health policy at KFF, a health information nonprofit that includes KFF Health News, said in an interview before Biden stepped aside. “Abortion access would likely be front and center in her campaign.”

A strong stance on abortion is not the only major contrast to the GOP that Harris offers: She is well versed in health policy. As a child, Harris often accompanied her mother to work on the weekends, visiting the lab where she was studying breast cancer.

While running for president in 2019, she backed “Medicare for All,” a single-payer insurance proposal that established her bona fides as a more progressive voice on health policy. And as California’s attorney general, she fought against consolidation in the health industry over concerns it would drive up prices. 

She stumped for a Biden administration rule setting minimum staffing levels at federally funded nursing homes in April.

“She deserves credit, she’s talked about them on the campaign trail. I don’t see any change there in the priorities on what Democrats want to do on health care if she becomes the nominee,” said Debbie Curtis, vice president at McDermott + Consulting. 

An intensified focus on women’s health and abortion could help galvanize Democratic voters in the final sprint to the election. Since the three Supreme Court justices named by Trump helped overturn Roe v. Wade in 2022, public opinion has turned against Republicans on abortion, even contributing to an unexpectedly poor showing in the 2022 midterm elections.

Thirty-two percent of voters said they would vote only for a candidate for a major office who shares their views on abortion, according to a Gallup Poll conducted in May. That’s a record high since Gallup first asked the question in 1992. Nearly twice as many voters who support abortion, compared with those who oppose abortion, hold that view. 

Sixty-three percent of adults said abortion should be legal in all or most cases, based on a poll conducted in April by Pew Research Center. Thirty-six percent said it should be illegal in all or most cases.

Republicans, in turn, have been eager to distance themselves from their own victory on the issue. Trump angered some members of his base by saying he would leave decisions on abortion to the states.

Regardless, advocates caution that the GOP’s new moderation-by-omission on the issue masks their actual, more extreme stance. Vance has been clear in the past about his support for a national abortion ban. And while the GOP platform adopted during the party’s convention last week may not explicitly call for a nationwide ban on abortion, party leaders’ recognition of “fetal personhood,” the idea that as soon as an egg is fertilized it becomes a person with full legal rights, would create such a ban automatically if the Supreme Court found it constitutional.

Those views stand in contrast to those of many Republicans, especially women. About half of Republican women voters think abortion should be legal in all or most cases, according to a recent national survey by KFF. And majorities of women who vote Republican believe abortion should be legal in cases of rape, incest, or a pregnancy emergency.

If Harris heads the ticket, she would be expected to hammer on those issues in the coming months. 

“It’s been one of if not the main issue she’s emphasized in the last year or two,” said Matthew Baum, Marvin Kalb professor of global communications at Harvard University. “Clearly the Republicans are trying to defang the issue. It’s been a disaster for them.”

It is likely, though, that Republicans would paint Harris’ views on abortion as extremist. During the presidential debate against Biden, Trump falsely claimed Democrats support abortions late in pregnancy, “even after birth.”

Shortly after news broke that Biden had endorsed Harris, Susan B. Anthony Pro-Life America issued a statement calling out Harris’ record and offering evidence of what is to come. “While Joe Biden has trouble saying the word abortion, Kamala Harris shouts it,” said Marjorie Dannenfelser, the group’s president.

Some pollsters have said Harris would have to do more than just campaign against Republican efforts to roll back abortion access to truly motivate voters because so many issues, such as inflation, the economy, and immigration, are competing for attention.

“She has to say she is running for a federal law that will bring back Roe v. Wade,” said Robert Blendon, an emeritus public health professor at Harvard University. “She needs something very specific and clear.”

Harris’ elevation to the top of the ticket would come at a critical juncture in the fight over reproductive rights.

The Supreme Court heard two abortion cases in the term that ended this month. But the justices did not address the merits of the issues in either case, ruling instead on technicalities. Both are expected to return to the high court as soon as next year.

In one case, challenging the FDA’s 2000 approval of the abortion pill mifepristone, the justices ruled that the group of anti-abortion medical professionals who challenged the drug lacked standing to sue because they failed to show they were personally injured by its availability. 

But the Supreme Court returned the case to the district court in Texas where it was filed, and the GOP attorneys general of three states — Idaho, Kansas, and Missouri — have joined the case as plaintiffs. Whether the courts accept the states as viable challengers remains to be seen, but if they do, the justices could soon be asked again to determine the fate of the abortion pill.  

The other abortion-related case pitted a federal law requiring hospitals to provide emergency care against Idaho’s strict ban, which allows abortions when a pregnant patient’s life is in danger — but not in cases in which it is necessary to protect her health, including future fertility.

In that case, the justices apparently failed to reach any majority agreement, declaring instead that they were premature in accepting the case and sending it back to the lower court for further consideration. That case, too, could return in relatively short order.

Harris would also have substantial leeway to talk about what are considered to be the Biden administration’s core health policy accomplishments. These include enhanced Affordable Care Act tax credits aimed at helping consumers get health insurance coverage, which were extended through the Inflation Reduction Act into 2025, the $35 monthly cap on copays some patients pay for insulin, and drug price negotiation in Medicare.

“I think she is well positioned. She is core to the administration and will be able to take credit for those things,” said Dan Mendelson, CEO of Morgan Health, a subsidiary of J.P. Morgan Chase.

That said, it may be hard for any candidate to get voters to focus on some of those accomplishments, especially drug price efforts.

While the administration has taken some important steps, “new expensive drugs keep coming out,” Mendelson said. “So if you look at the perception of consumers, they do not believe the cost of drugs is going down.”

Joseph Antos, of the American Enterprise Institute, said Harris would likely say the Biden-Harris administration “is already saving people money” on insulin. But she will have to go beyond these accomplishments and double down on drug pricing and other cost issues — not talk solely about reproductive rights.

“She’s got to concentrate, if she wants to win, on issues that have a broad appeal,” Antos said. “Cost is one and access to treatments is another big issue.”

Samantha Young of KFF Health News contributed to this report.

Trump Is Wrong in Claiming Full Credit for Lowering Insulin Prices

“Low INSULIN PRICING was gotten for millions of Americans by me, and the Trump Administration, not by Crooked Joe Biden. He had NOTHING to do with it.”

Former President Donald Trump in a Truth Social post, June 8

Former President Donald Trump has repeatedly claimed that he — and not President Joe Biden — deserves credit for lowering older Americans’ prescription drug prices, specifically for insulin.

In a June 8 post on Truth Social, the former president’s social platform, Trump wrote: “Low INSULIN PRICING was gotten for millions of Americans by me, and the Trump Administration, not by Crooked Joe Biden. He had NOTHING to do with it.”

Trump again claimed sole credit for lowering insulin prices during the June 27 presidential debate in Atlanta. After Biden touted the $35 monthly out-of-pocket cap for Medicare patients mandated by the Inflation Reduction Act, Trump responded: “I’m the one that got the insulin down for the seniors. I took care of the seniors.”

It’s not just the former president making such claims. Fox News anchor John Roberts and former Arkansas Gov. Mike Huckabee, a Republican, both have said the Biden administration is wrong to take credit for lowering insulin costs.

Because drug prices and Medicare will likely be issues in the presidential campaign, we dug into the facts surrounding those claims.

The Trump Administration’s Program

Trump is correct that his administration enacted a program to lower insulin costs for some patients on Medicare.

In July 2020, Trump signed an executive order establishing the “Part D Senior Savings Model,” a temporary, voluntary program run by the Centers for Medicare & Medicaid Services that let some Medicare Part D prescription drug plans cap monthly out-of-pocket insulin copay costs at $35 or less. It covered at least one insulin product of each dosage and type.

The program began Jan. 1, 2021, and ran through Dec. 31, 2023. In 2022, the Trump-era program included a total of 2,159 Medicare drug plans, and CMS estimated that more than 800,000 Medicare beneficiaries who use insulin could have benefited from it that year.

The Department of Health and Human Services has estimated that more than 1.5 million Medicare beneficiaries paid more than $35 a month for insulin in 2020, before Trump’s program took effect. An analysis by the Rand Corp., a nonpartisan think tank, showed the program reduced participants’ out-of-pocket insulin costs by $198 to $441 per year on average, depending on their Medicare plan.

The Inflation Reduction Act Provisions

The Inflation Reduction Act, which Congress passed and Biden signed into law in August 2022, included an insulin provision that went further than Trump’s voluntary initiative.

The act did cap out-of-pocket costs of insulin for Medicare patients at $35 per month. But whereas the Trump program applied only to certain Medicare Part D plans, the act mandated that all Medicare drug programs cap out-of-pocket insulin costs — including those in what’s known as Medicare Part B, which pays for medical equipment such as insulin pumps. The act’s insulin provisions took effect Jan. 1, 2023, for Part D plans and July 1 of that year for Part B.

The act also mandated that the out-of-pocket price cap apply to all insulin products a given Medicare plan covers, not just a subset.

Taken together, those provisions mean a far greater number of Medicare beneficiaries stand to benefit from the act’s insulin provisions — including people receiving insulin via a pump, who were left out of the Trump-era program.

CMS estimates that more than 3.3 million Medicare beneficiaries use one or more of the common forms of insulin. Although some of those people were likely already paying less than $35 per month for their medications, the Inflation Reduction Act benefited far more than the 800,000 patients affected by Trump’s program.

“It’s likely a larger population than under the Trump administration’s model,” said Juliette Cubanski, deputy director of the Program on Medicare Policy at KFF, a health information nonprofit that includes KFF Health News.

“The Trump administration did establish this voluntary model, and one perhaps could view that as some precedent for what we saw in the Inflation Reduction Act,” Cubanski added. “But I think it’s inaccurate to state that President Biden had nothing to do with enabling millions of Americans to benefit from lower insulin copayments.”

Preliminary research shows the Inflation Reduction Act’s insulin provisions had a greater average financial benefit than those in Trump’s program. Insulin-using older Americans were estimated to save an annual average of $501 per person, HHS figures show.

The Inflation Reduction Act has also had an impact beyond Medicare. After the law passed, some pharmaceutical companies — including Eli Lilly and Co., Novo Nordisk, Sanofi, and Civica Rx — self-imposed price caps for all insured insulin users, not just Medicare patients. During his 2023 State of the Union address, Biden proposed expanding this benefit to all insulin patients, and he’s made that point a staple of his campaign appearances.

“I’m determined to make that apply to every American, not just seniors, in the second term,” he said at a campaign event in May in Philadelphia.

The Stakes for the 2024 Election

Beyond insulin products, the Inflation Reduction Act caps total out-of-pocket prescription costs at $2,000 annually for people with Medicare drug plans starting in 2025, down from $3,300 this year for most Medicare beneficiaries.

But every congressional Republican opposed the Inflation Reduction Act, including its insulin savings provisions, in 2022, and the law is vulnerable to repeal should Trump take the White House. Trump has repeatedly criticized the law and called for overturning some of its provisions. He has not specified how he would address its health measures.

In an email exchange with KFF Health News, Trump campaign spokesperson Karoline Leavitt highlighted drug savings programs the former president instituted during his term in office, but repeatedly declined to extrapolate on, or defend, Trump’s claim that Biden deserves no credit for lowering insulin costs.

Asked whether Trump intended to maintain the Inflation Reduction Act’s insulin provisions should he win a second term in office, Leavitt wrote, “President Trump will do everything possible to lower drug costs for Americans when he’s back in the White House, just like he accomplished in his first term.”

Our Ruling

Trump can claim some credit for lowering insulin costs for seniors, as his administration advanced a voluntary program to do so.

But his claim that Biden had “NOTHING to do with it” is patently false. The Inflation Reduction Act, which Biden signed into law, imposed a mandatory Medicare insulin price cap that applied across the program, benefiting a significantly larger number of insulin users — including people not enrolled in Medicare. 

We rate Trump’s claim False.

Sources:

Civica Rx, “Civica to Manufacture and Distribute Affordable Insulin,” March 3, 2022

Centers for Medicare & Medicaid Services, “Part D Senior Savings Model,” accessed July 2, 2024

CMS, “President Trump Announces Lower Out of Pocket Insulin Costs for Medicare’s Seniors,” May 26, 2020

CNN, “READ: Biden-Trump Debate Transcript,” June 28, 2024

Eli Lilly and Co., “Lilly Cuts Insulin Prices by 70% and Caps Patient Insulin Out-of-Pocket Costs at $35 Per Month,” March 1, 2023

Email exchange with Karoline Leavitt, Donald J. Trump 2024 campaign national press secretary, July 1, 2024

Facebook.com, post by @MikeHuckabee, June 10, 2024

Federal Registrar, “Access to Affordable Life-Saving Medications,” July 24, 2020

Department on Health and Human Services, “Insulin Affordability and the Inflation Reduction Act: Medicare Beneficiary Savings by State and Demographics,” Jan. 24, 2023

KFF, “Changes to Medicare Part D in 2024 and 2025 Under the Inflation Reduction Act and How Enrollees Will Benefit,” April 20, 2023

Novo Nordisk, “Novo Nordisk To Lower U.S. Prices of Several Pre-Filled Insulin Pens and Vials up to 75% for People Living With Diabetes in January 2024,” March 14, 2023

Phone interview with Juliette Cubanski, deputy director of KFF’s Program on Medicare Policy, June 16, 2024

Rand Corp., “Evaluation of the Part D Senior Savings Model,” May 2023

Republican Study Committee, “Fiscal Sanity to Save America,” March 20, 2024

Sanofi, “Sanofi Capping Its Insulin to a $35 Out-of-Pocket Costs in the U.S.,” June 1, 2023

Stat, “Biden and Trump Are Fighting To Claim Credit for $35 Insulin. It Was Actually a Pharma Giant’s Idea,” June 13, 2024

The White House, “FACT SHEET: President Biden’s Cap on the Cost of Insulin Could Benefit Millions of Americans in All 50 States,” March 2, 2023

The White House, “Remarks by President Biden and Vice President Harris at a Campaign Event | Philadelphia, PA,” May 29, 2024

The White House, “Remarks of President Joe Biden — State of the Union Address as Prepared for Delivery,” Feb. 7, 2023

Truthsocial.com, post by @realDonaldTrump, June 8, 2024

X.com, post by @justinbaragona, June 3, 2024

An Arm and a Leg: The Woman Who Beat an $8,000 Hospital Fee

Hospital facility fees. They can feel like a charge just for walking in the door. Hospitals say they go toward overhead on facilities with lots of specialized equipment and staff, like emergency rooms.

But these fees have grown and become more common in recent years. And as hospitals buy up outpatient facilities, patients are starting to get charged facility fees for routine tests, procedures, and visits to the doctor’s office.

In this episode of “An Arm and a Leg,” host Dan Weissmann speaks with Georgann Boatright, a retired speech pathologist from Oxford, Mississippi, who was told by her local hospital that she needed to pay an $8,000 “operating room fee” for a routine test. She was determined not to get overcharged, even if it meant driving hours out of state to get the test someplace cheaper.

Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Dan: Hey there! A couple of months ago, we asked you to help us report on a type of fee that seems to be sneaking onto more and more medical bills. They’re often called “facility fees.” It’s like a cover charge just for walking in the door. And these kinds of fees are familiar to a lot of folks from places like emergency rooms, which do have a LOT of specialized equipment and staff in the facility behind that door. That’s basically the case for a cover charge: Once you get in the door, there’s a lot of stuff there. But in some cases, with facility fees, the door is just the entrance to a doctor’s office. Because facility fees– they’re often charged by hospitals. And hospitals own a lot of doctors’ offices these days. And once they take over, there’s no law that says they can’t just call that doctor’s office part of their facility and start charging. 

We asked what you’d been seeing. A bunch of you sent us stories, and copies of your bills, and your insurance statements. And when we called to follow up, you took our calls. You had A LOT to say. 

Teresa: Oh, it made me so mad, so mad. Anne: I mean, it’s a 10-minute appointment for a prescription. 

Amanda: I don’t understand any of it. Where did this number come from? 

Dan: We learned a bunch. Especially from those of you who are not new to this kind of thing. 

Francesca: It was a running joke with my husband and myself that like, okay, it’s time for my weekly, one-to-two hour phone call with Cigna. 

Dan: People who’ve been contending with the health care system for a while, dealing with chronic illnesses, or going to the doctor for monitoring, or having some kind of ongoing treatment. 

Anne: I see her once a year. I’ve seen her once a year for 18 years at the time. And then they started charging the facility fee. 

Dan: And I’ve always said here, we have a lot to learn from each other. And what we learned here is a lot more than is gonna fit in one episode. So we’re gonna start here with one story that really stood out. Partly because it involved the biggest dollar amount we saw: An eight-thousand dollar facility fee. And partly because the person we heard from … didn’t end up paying it. And partly because of what it took for her to avoid paying it. She had what I might call a lifetime of preparation– including lessons I think a lot of us can learn from. And she has the kind of grit that not all of us have. But I’m hoping that some of it might rub off. So let’s meet her. 

Georgann Boatright: My name is Georgann Boatright, and I am a retired speech pathologist. 

Dan: Georgann lives in Oxford, Mississippi. She works for the university there, Ole Miss, coordinating special events. 

Georgann Boatright: It’s lots of fun. Never a dull moment. Everything from weddings to conferences. 

Dan: The day we talked, she had made coffee for 500 people. Before eight am. And here’s how she describes her response to that eight-thousand dollar charge. 

Georgann Boatright: I was like, that’s insane. And of course, being the obnoxious human being that I can be at times, and a little bit pushy, you know; sometimes you got to do that. I’ve always been that advocate for everybody else, so sometimes I have to advocate for me.

Dan: Georgann pushed back– we will talk about how far she had to go. And among other things, we’re talking about actual miles she had to travel. It was not easy. But it was worth it. Let’s take a ride. 

This is An Arm and a Leg– a show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann. I’m a reporter, and I like a challenge. So the job we’ve chosen here is to take one of the most enraging, terrifying, depressing parts of American life, and bring you a show that’s entertaining, empowering, and useful. 

Georgann Boatright grew up in Oxford, went to Ole Miss– the University of Mississippi, right in town. And after a decade and change in places like Huntsville, Arkansas, and towns near Springfield, Missouri, she moved back to Oxford about 15 years ago. 

Georgann Boatright: My mom came ill. And so I moved back to Mississippi to be with her for the end. 

Dan: Georgann herself had a health scare not long after– it turned out to be a non-cancerous tumor. Her local doctors couldn’t figure out the problem, but she found good treatment at West Cancer Center in Memphis, about an hour and a half away. And then, in 2022, an actual breast cancer diagnosis. She went back to the West Cancer Center in Memphis for treatment. And while she was being treated for breast cancer, her doctors found a thyroid problem. 

Georgann Boatright: But they were kind of like, okay, we’ll put that on a back burner for right now because we got to take care of this first. 

Dan: So, they did! And you know, that took months, of course. Once she was done– and no evidence of cancer for a few months!– they picked up the thyroid thread. Her endocrinologist in town suggested what’s called a needle biopsy: no incision, just pulling a sample with basically a syringe, guided by ultrasound. And Georgann was plenty familiar with the procedure because she’d had two of them for her breast cancer.

Georgann Boatright: Well, of course, having just done all this other stuff, I was kind of like, oh, okay, just another biopsy. No big deal. 

Dan: Her endocrinologist suggested the local hospital, Baptist Memorial, North Mississippi. And started getting her scheduled there. 

Georgann Boatright: I was just sitting in my office doing my thing and, you know, answering emails, trying to get people to sign up and do a wedding. So, they called me and said, “Hey, you know, we need a thousand dollars up front.” And I’m like, why? I’ve already met my deductible. Da, da, da. You know, and they’re like, Oh, well, this is just this is just your copay.” 

Dan: None of this sounded right to Georgann, based on her experience. 

Georgann Boatright: I’d had two biopsies done in the past year, just in the process of doing the breast stuff. And I was like, that’s not normal. 

Dan: At the cancer center in Memphis, a thousand dollars was in the ballpark for the whole procedure, like before insurance paid anything. And Georgann’s share, after insurance, was like a fraction of that. 

Georgann Boatright: And I went, excuse me, because of course I was expecting, you know, under a hundred bucks, you know. And they acted very offended that I questioned. She was like, “Well, this is standard.” And I was like, “But I’m confused,” and, you know, and the more questions, she got kind of defensive. 

Dan: Georgann says she quickly developed a little sympathy for the woman on the other side of the call. 

Georgann Boatright: I was like, this person has no clue. This is their job. They’re given this information. They’re given my phone number. They’re told to collect a thousand dollars from me. You know, I mean, it’s not her fault. 

Dan: So, Georgann quickly made a new plan. First step: get a line-item version of that estimate, in writing. And next: find somebody else to talk with. 

Georgann Boatright: I was like, “Well, hey, how about you just do me a printout and I’ll come by the hospital and pick that up. If you’ll just leave it with somebody near the desk …” 

Dan: … Then Georgann figured she can actually see what these charges are for and you know, maybe talk to somebody who’ll know a little more. She went that same day. 

Georgann Boatright: I wanted to get the biopsy done. I wanted to find out what was going on. You know, once you’ve had cancer, it kind of, that C word just does not sit well with your brain. You kind of, it starts eating at you and you’re like, I really want to know. 

Dan: And she wanted to know why the hospital wanted a thousand dollars from her. She got that printout– the line item estimate. It showed thirteen thousand dollars in charges. And the single biggest charge– more than half of the whole bill– eight thousand dollars– was for an “operating room” charge. It wasn’t labeled “facility fee,” but that’s exactly what it was. Georgann sent us this line-item estimate. We showed it to a medical-bill coding expert; she confirmed– this is a facility fee. And I’ll just mention again: Of all the people who sent us bills with facility fees on them, this was the highest by a LOT. Alot a lot. And seeing this “operating room” charge really set off alarm bells for Georgann. Because Georgann had just had TWO needle biopsies. And they sure as heck had not taken place in an operating room. 

Georgann Boatright: It’s a needle aspiration. It is ultrasound-guided. So it’s done in radiology. This is not in an operating room. 

Dan: When she got to Baptist, Georgann did get to talk in person with a billing specialist. It wasn’t a satisfying heart-to-heart, but it gave Georgann the clarity she needed. 

Georgann Boatright: At a certain point in the conversation, I was just kind of like, “You do realize that there is not an operating room involved in this?” And she said, “Well, of course, there is.” I was like, “No, there really isn’t.” “Oh, well, that’s just our standard procedure.” And so she stuck with that. And so I was like, okay, well, since you’re going to just stick with this, I’m going to just let this go. Because if I can’t seem to get you to understand that I’m not going to pay you 8,000 dollars for an operating room that I’m not going to go in, we’re not going to get anywhere. 

Dan: And Georgann knew she had an alternative: She could go back to the cancer center in Memphis. It was a bit of a drive, but she trusted them to do good work and not to overbill her. So that’s what she did. Her out of pocket cost was eighty dollars. We asked Baptist all about Georgann’s experience, and what was behind this eight-thousand dollar charge. Especially since medical and surgical supplies were listed as separate line items. 

A hospital spokesperson wrote back: “The price a patient sees on the hospital bill also reflects all the people who care for them and keep the hospital operating, not just the services provided, such as nurses and caregivers at the bedside, pharmacists, lab technicians, food service staff, environmental service professionals and security personnel who, among many others, keep the hospital running 24/7. We believe we charge fair and reasonable prices for our expert care.” 

Of course, we also asked Baptist why there would be an operating room charge at all, when the patient didn’t expect to be seen in an operating room. The spokesperson wrote back: “I’m not sure why there was a discrepancy. But, in general, the pricing information we share with patients is only an estimate, and the final bill can vary. We encourage patients to contact us with any questions.” OK, then. And I just want to say: I think– well, I KNOW– that I’ve undersold what it took for Georgann to make that decision. I mean, yeah, we’ve seen, Georgann showed a lot of initiative, and savvy, and decisiveness, and a certain amount of grace in navigating a couple of conversations with her local hospital’s billing department. But we haven’t seen EXACTLY what made her so prepared for those conversations, and to make her decision so quickly. And if we’re gonna learn from Georgann’s example, we’ve gotta look at that. That’s coming right up. 

This episode of An Arm and a Leg is a co-production of Public Road Productions and KFF Health News. Public Road is the organization I founded to make this show. The name comes from Walt Whitman; I’ll tell you about it sometime. KFF Health News is a nonprofit newsroom covering healthcare in America. Their journalists do amazing work– win all kinds of awards, every year. I’m honored to work with them. So, what allowed Georgann Boatright to navigate those conversations with her hospital billing department so skillfully? And to quickly decide to drive to another city for care? Well, let’s start with her old job as a speech pathologist. You might remember, when she did that job, she was living in places like Huntsville, Arkansas. Or, as Georgann describes it … 

Georgann Boatright: … Absolutely the middle of nowhere, Arkansas. 

Dan: It’s not like a speech therapist is gonna have a ton of clients in town. Georgann worked for an agency that sent her all over the place. 

Georgann Boatright: I was driving about three- to five-hundred miles a day when I retired. 

Dan: A day! 

Georgann Boatright: Yeah, well, they’re spread a little thin in that area. 

Dan: Yeah. Yeah. Right. How fast were you driving? Like, how many hours are we talking about being on the road? 

Georgann Boatright: I was usually on the road 12 to 14 hours a day. 

Dan: Oh my god. 

Georgann Boatright: Yeah, but that’s because, you know, I was bouncing in and out everywhere from Liberty, Missouri, which is outside of Kansas City, all the way down into Arkansas. 

Dan: So, we start to get the idea that driving an hour and a half from Oxford to Memphis is, you know, not such a big deal to Georgann. But there’s this other thing. Which is what Georgann spent all those hours in her car actually doing. Because she was not listening to podcasts, I can tell you that. She was dealing with health insurance. On behalf of her colleagues and her patients. 

Georgann Boatright: I was the person in our company that would do all the appeals. I got really good at getting Medicare, Medicaid, Blue Cross Blue Shield– all the insurances to pay. 

Dan: Georgann did all this by phone, with somebody back at the home office transcribing for her. It was part of her gig– because she had all that time in the car. The agency she worked with also employed physical therapists and occupational therapists, sending them out to nursing homes. And those colleagues would have multiple appointments a day at the same spot. 

Georgann Boatright: I would only have like, maybe one or two patients during the course of the day, and then I would end up doing paperwork the rest of the day or helping someone else do paperwork. 

Dan: Because not only did Georgann have time with all those hours in the car. She had something else: language skills. 

Georgann Boatright: The crew that I worked with, they were mostly from the Philippines, and we partied very well. And I ate a lot of good food, and I gained weight. And no fault of their own, English wasn’t their first language. So that was part of my job was to make sure that the language barrier wasn’t the problem for the physical and occupational therapists getting paid. 

Dan: So for five years, she spent most of her long workday dealing with insurance. 

Georgann Boatright: That was what I did, and I was really, really good at it. You know, when you get on a first name basis with the reps in your area, you know that you’re a thorn in their side. When they would see my name, they’d be like, “We might as well just go ahead and pay this one because she’s going to find a way to get it through.” 

Dan: So when Georgann ended up talking with those folks at her local hospital’s billing office– the folks who were trying to tell her that an eight-thousand-dollar operating-room fee was just standard– she had a pretty good idea of what their jobs were: Just getting the hospital’s money. 

Georgann Boatright: I get that. And I understand that, but you know, you have to understand when you’re calling people and asking them for money that you have to know why they’re paying you money and whether or not you can justify how much they’re paying you. 

Dan: So, just to recap: When Georgann was in those conversations with the local hospital billing department, she had years and years of experience in medical billing. She was, by her account, really really good at it. It doesn’t seem like a stretch to guess that when she talked with these folks at the local hospital’s billing department, she knew a lot more about medical billing than they did. And she knew that this hospital wasn’t her only option. She had just done cancer treatment at West Cancer Center in Memphis. She trusted them, and they hadn’t overbilled her. And she wasn’t afraid of a road trip. That 300-mile, 500-mile-a-day job was a while ago, but just in the last year she’d made the trek to Memphis for cancer treatments, several times. In fact, the story of the wrap-up to that treatment gave me real appreciation for Georgann Boatright’s brand of cheerful grit and determination. For more than a year, Georgann had been planning a big family reunion for Christmas: Her kids, their kids, gathered from across the country, to a lodge near her husband’s mom. 

Georgann Boatright: I wanted his mom who has been getting on in age to get a chance to see the great grands and this kind of stuff. 

Dan: Georgann had made the reservation for the lodge months before her cancer diagnosis. And then, the last day of her radiation treatment got scheduled for December 23. The reunion was scheduled to start that very night. In Branson, Missouri– a five-hour drive from Memphis. 

Georgann Boatright: And I was like, I am not canceling this. Everybody’s like, “Mom, you don’t have to do this,” blah, blah, blah. I was like, “No, I’m going to be healthy and done with this treatment. By the time of this reservation.” I said, “I don’t care what happens!” 

Dan: The procedure that last day was to remove a device that had been delivering targeted radiation doses. And when the day came, an ice storm knocked out the power at West Cancer Center. The medical staff suggested, you know, rescheduling. 

Georgann Boatright: They’re like, “Well, do you want to come … No! I want this done. I am not coming back tomorrow. 

Dan: Wow. 

Georgann Boatright: I am going to make this reservation. I’m going to spend the night in a very nice place in Branson, Missouri and play in the snow. 

Dan: It wasn’t gonna be easy. 

Georgann Boatright: There was no power. There was no lights. There was only the little emergency generator lights that come on in a hospital. 

Dan: But they made it work. 

Georgann Boatright: I had it taken out that day. By the flashlights of the nurses 

Dan: The flashlights on the nurses phones! Georgann says she slept in the car while her husband drove them to Branson that day. Mission accomplished. 

Georgann Boatright: It was a great trip, and everybody was there, and it was wonderful to kind of celebrate at the end of that. I was done with radiation. I was like, I’m going to get well now and just keep kicking cancer’s butt. Because I was like, I am not giving up. 

Dan: I said right at the top: This story is epic, right? And I said that whatever’s powering Georgann Boatright, I hope just a little bit of it can rub off on us– on me. So, when Georgann talked with the folks in the billing department at her local hospital, she knew just what she was capable of. Also, it’s worth mentioning, she knew she had some other things that not everybody has: She knew she had excellent insurance because she’d seen it at work when she got the bills for her breast cancer treatment. And she knew she had someone to drive her to Memphis and back. Uber? That would’ve cost a LOT. Actually, Georgann says she priced it recently for her job. 

Georgann Boatright: It’s 145 dollars, and I was like, you got to be kidding me! 

Dan: I believe I could fly to Memphis from Chicago for 145 dollars one way. 

Georgann Boatright: I could get a flight to Southwest for 120. Believe me, I do it. That’s my thing. If I do it during the week, I can go from here to Midway. Yeah. 

Dan: Wait, why is flying to Chicago’s Midway airport Georgann’s thing? Well, the answer actually relates to one more thing Georgann had going for her in this whole scenario. Something– someone– I left out before. 

Melissa McChesney: My name is Melissa McShesney. I live in Chicago, Illinois. 

Dan: Melissa is Georgann’s daughter. She is the mom of two of Georgann’s grandkids. Melissa’s brother– dad to three more grandkids– he also lives in Chicago. Those kids and grandkids are, all of them, the reason Georgann has that airfare at the tip of her tongue. But it’s Melissa who plays a role in this story. Because Melissa works for CMS, the Centers for Medicare and Medicaid Services– the federal agency that oversees Medicaid and Medicare. So health insurance is her job. I mean, at least government-funded insurance. 

Melissa McChesney: I only know enough to be dangerous on the private side. But, you know, I have colleagues that know a lot more. 

Dan: Melissa and her mom– two health-insurance experts– can back each other up. 

Melissa McChesney: It’s always great to have another set of eyes. So, sometimes I call her, sometimes she calls me. 

Dan: This time– after those conversations with the hospital billing department– it was Georgann who did the dialing. 

Melissa McChesney: She called me to say, “This doesn’t make any sense. Why is this the most expensive procedure I’ve seen in a year when I just went through breast cancer treatment? At least from the out-of-pocket cost. And I quite frankly didn’t fully know either. 

Dan: So some poking around led Melissa to a story from the Bill of the Month series our pals at KFF Health News do with NPR. 

NPRHost: For our September bill of the month, we’re taking a close look at facility charges … 

Dan: And this story was a pretty exact match with Georgann’s situation: An operating room charge for a needle biopsy. NPR’s website even had a PDF of the original bill, with the billing codes.  

Melissa McChesney: Which was very helpful, actually, because I was able to see the fee that the article was focused on. And I was like, “This is the exact same thing, mom.” 

Dan: And that bit of context? It confirmed for Georgann that she could trust her initial impression: That this “operating room” fee seemed out of whack. And that she could do better. So she had that biopsy at West Cancer Center in Memphis before the week was out. And good news: She’s OK! The biopsy came back benign. Her local endocrinologist has been monitoring her bloodwork. 

Georgann Boatright: And so right at the moment, my thyroid levels are all staying normal. So they’re not concerned that it’s throwing off everything unless it becomes like a huge thing that grows in my neck. 

Dan: And she gets an occasional ultrasound at a local clinic. No needle, no hospital, no facility fees– and keeping an eye on the bills. 

Georgann Boatright: They have been very reasonable. That’s why I was like, okay, well I’ll continue doing this as long as y’all don’t screw me over anymore. 

Dan: One last thing I should tell you about Georgann and how she handled that eight thousand dollar charge the hospital had wanted: This is something she did after her daughter Melissa sent her that NPR story– you know, the one that helped her decide she was definitely going to Memphis. Melissa’s got this part of the story. 

Melissa McChesney: She sent the NPR article and her estimate to her endocrinologist and said, “Just so you know, this is what happens when you refer individuals to this hospital. And you know, it would cost them a lot of money.” I was so proud of her for doing that. it just speaks to my mom and trying to be a person who’s not just worried about her own experience, but the experience of others in her community.

 Dan: I’m telling you, we all want some of Georgann Boatright to rub off on us.An ArmandaLeg Season 12, Episode 1 July, 11, 2024 p.14 You sent us SO MANYstories about facility fees. I hope you can see why we wanted to bring you this one first, but we are not done. We talked with a bunch of you– and we talked with some experts who gave us some insights … and some lessons. 

Shelley Safian: Sometimes you talk to the physician, sometimes you talk to the facility, sometimes you got to go to the president and say, “You know what? This is not right.” 

Dan: And we talked to experts who gave us a look at what policy makers all over the country are doing– or trying to do– about these fees. Because they’re definitely paying attention. Because a lot of people are recognizing: You should not need to be Georgann Boatright to find a way around fees like this. Most of us aren’t. 

Christine Monahan: There’s bipartisan interest in this issue. We are seeing these reforms bubble up across the states. 

Dan: So over the next couple of months, we’ll be sharing a LOT more of what you’ve been helping us learn. Meanwhile, because you’ve been so incredibly helpful here, I’m going to come back to you soon asking for more help on a different story. That’s coming next time. Till then, take care of yourself. 

This episode of An Arm and a Leg was produced by Emily Pisacreta and Claire Davenport, with help from me, Dan Weissmann, and edited by Ellen Weiss. Adam Raymonda is our audio wizard. Our music is by Dave Weiner and Blue Dot Sessions. Gabrielle Healy is our managing editor for audience. Gabe Bullard is our engagement editor. Bea Bosco is our consulting director of operations. Sarah Ballama is our operations manager. 

An Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in-depth journalism about healthcare in America and a core program at KFF, an independent source of health policy research, polling, and journalism. Zach Dyer is senior audio producer at KFF Health News. He’s editorial liaison to this show. 

And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor. They allow us to accept tax-exempt donations. You can learn more about INN at INN.org. 

Finally, thank you to everybody who supports this show financially. You can join in any time at https://armandalegshow.com/support/. Thanks so much for pitching in if you can– and, thanks for listening.


“An Arm and a Leg” is a co-production of KFF Health News and Public Road Productions.

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Her Hearing Implant Was Preapproved. Nonetheless, She Got $139,000 Bills for Months.

Caitlyn Mai woke up one morning in middle school so dizzy she couldn’t stand and deaf in one ear, the result of an infection that affected one of her cranial nerves. Though her balance recovered, the hearing never came back.

Growing up, she learned to cope — but it wasn’t easy. With only one functioning ear, she couldn’t tell where sounds were coming from. She couldn’t follow along with groups of people in conversation — at social gatherings or at work — so she learned to lip-read.

For many years, insurers wouldn’t approve cochlear implants for single-sided deafness due to concerns that it would be hard to train the brain to manage signals from a biological ear and one that hears with the aid of an implant. But research on the detrimental effects of single-sided deafness and improvements in technique changed all that.

So Mai, now 27 and living near Oklahoma City, was thrilled last fall to get a prior authorization letter from her insurer saying she was covered for cochlear implant surgery.

She had successful outpatient surgery to implant the device in December and soon after was eagerly attending therapy to get her brain accustomed to its new capabilities.

“It was amazing. When I’d misplaced my phone and it rang, I could tell where the sound was coming from and find it,” she said.

Then the bill came.

The Patient: Caitlyn Mai, who is insured through her husband’s job by HealthSmart, which is owned by UnitedHealth Group.

Medical Services: Cochlear implant surgery, including the operating room, anesthesia, surgical supplies, and drugs.

Service Provider: SSM Health Bone & Joint Hospital at St. Anthony, an orthopedic hospital in Oklahoma City that is part of SSM Health, a Catholic health system in the central U.S.

Total Bill: $139,362.74 — or, with a “prompt pay discount” if she paid about two months after surgery, $125,426.47.

What Gives: Providers and insurers often have disagreements over how a bill is submitted or coded, and as they work through them (or don’t), the patient is left holding the bag, facing sometimes huge bills.

“I almost had a heart attack when I opened the bill,” Mai said of the first monthly missive, which arrived in late December. She said she was so upset she left work to investigate. Before surgery, “I’d even checked that all hospitals and doctors were in-network and that I’d met my deductible,” she said.

While she was never threatened with having her bill sent to collections, she said she worried about that possibility when the same bills arrived in January, February, and March, with ominous warnings that “your balance is now past due.”

A photo of the back of Mai's heading, showing her hearing device implant.
For many years, insurers wouldn’t approve cochlear implants for single-sided deafness — until new research and improvements in technique changed all that. Last year Mai had successful surgery to implant a hearing device.(Nick Oxford for KFF Health News)

Mai said she first called the hospital billing office but that the representative could tell her only that the claim had been denied and didn’t know why. She called her insurer, and a representative there said the hospital didn’t adequately itemize its charges or include billing codes. She then called the hospital back and relayed exactly what her insurer said must be done to rectify the bill — and the name and number of the insurance employee to fax it to.

When her insurer told her a week or two later it hadn’t received a corrected bill, Mai said, she called the hospital again … and again.

“I said, ‘I’ve done your job for you — now can you please take it from here?’” she said.

Mai said a hospital staffer promised to fax over the corrected, itemized bill in two to three weeks. “How does it take that long to send a fax,” she wondered. She said she asked to speak with a supervisor and was told the person wasn’t available but would call her back. No one did.

After receiving another $139,000 bill in late February, Mai said, she checked back in with her insurer, but a representative said it had not yet received the revised bill.

Finally, she said, she told the hospital to “just send it to me and I’ll send it over.” This time, she forwarded the bill to her insurer herself. But in late March she got another bill demanding the full amount — and offering an $11,000-a-month payment plan.

Mai said she had met her out-of-pocket deductible and, with prior authorization in hand, expected the surgery to be fully covered.

SSM Health did not respond to multiple requests for comment about why it billed Mai.

“It’s outrageous that the patients end up umpiring the decisions,” said Elisabeth Ryden Benjamin, vice president of health initiatives at the Community Service Society of New York, an advocacy organization. “And it’s outrageous that providers are allowed to bill patients while they’re haggling with the insurer.”

Indeed, more and more patients are stuck with such bills as insurers and hospitals spend more and more time arguing in the trenches, data shows. A recent report by Crowe, an accounting firm that works with a large number of hospitals, found that more than 30% of claims submitted to commercial insurers early last year weren’t paid for more than 90 days — striking compared with the lower rates of such delays in Medicare, which were 12% for inpatient claims and 11% for outpatient claims.

The Crowe report found a particular justification for denying claims was cited at 12 times the rate by commercial insurers as by Medicare: that they needed more information before they would process the submission. Such a request allows insurers to sidestep laws in most states that require claims be paid in 30 to 40 days, automatically granting health plans the right to delay payment.

In a separate analysis, the American Hospital Association complained that increases in insurance denials and delays “strain hospital resources” and “inhibit medically necessary care.”

But perhaps no one is harmed as gravely as the patient, who is barraged with bills and believes they must pay up — particularly when the missives are stamped “past due” and contain offers of prompt-payment discounts or no-interest payment plans. “The stress and anxiety was huge,” Mai said.

Caroline Landree, a spokesperson for UnitedHealth Group, said the insurer could pay Mai’s claims only “after receiving a detailed bill from her provider.”

“We encourage our members to contact the number on their insurance cards for more information on the status of payments,” she added.

The Resolution: Mai estimated she spent at least 12 hours on the phone doing tasks that typically fall to someone working in a hospital billing department: making sure the bill was coded as needed and that the insurer had what it wanted to process the payment.

More than 90 days after her surgery, after Mai had received four terrifyingly huge bills, her insurance finally paid the claim. Mai owed nothing more.

She added: “I’ve never got that call back from a supervisor to this day.”

More than 90 days after her surgery, after Mai had received four terrifyingly huge bills, her insurance finally paid the claim. She owed nothing more. “I’ve never got that call back from a supervisor to this day,” Mai said.(Nick Oxford for KFF Health News)

The Takeaway: It’s not uncommon for an insurer to delay paying a claim until it receives an itemized bill; providers sometimes get creative with billing codes to increase revenue, and studies show that more than half of hospital bills contain errors. But studies also suggest insurers are wont to drag their feet, niggling over coding and charges — and, in doing so, delaying reimbursement and holding on to the cash.

Medical billing experts say it may not seem right for patients to receive bills as this process plays out but that it’s probably legal.

“Laws say ‘hold the patient harmless,’” Benjamin said. “What we didn’t say is, ‘Don’t send them a bill.’” She said it is also unfair that patients may be forced to act as the go-between for providers and insurers who should be talking to each other.

What’s a patient to do? First step: Don’t pay the bill (aside from a copay or coinsurance) for care or services preapproved by insurance. Call the health care provider and explain they should take up their bill with the insurer.

Second, ask the provider to send an itemized bill with all billing codes used, then review it for errors. As the patient, you would know that you never had an MRI, for example. Your insurer wouldn’t.

If submissions to “Bill of the Month” are reflective of trends, many patients these days are finding themselves ping-ponging between representatives for providers and insurers to get bills resolved and paid.

“Bravo for Ms. Mai for having the energy to keep at it and get resolution,” Benjamin said.

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

California Health Care Pioneer Goes National, Girds for Partisan Skirmishes

SACRAMENTO — When then-Gov. Arnold Schwarzenegger called for nearly all Californians to buy health insurance or face a penalty, Anthony Wright slammed the 2007 proposal as “unwarranted, unworkable, and unwise” — one that would punish those who could least afford coverage. The head of Health Access California, one of the state’s most influential consumer groups, changed course only after he and his allies extracted a deal to increase subsidies for people in need.

The plan was ultimately blocked by Democrats who wanted the state to adopt a single-payer health care system instead. Yet the moment encapsulates classic Anthony Wright: independent-minded and willing to compromise if it could help Californians live healthier lives without going broke.

This summer, Wright will assume the helm of the health consumer group Families USA, taking his campaign for more affordable and accessible health care to the national level and a deeply divided Congress. In his 23 years in Sacramento, Wright has successfully lobbied to outlaw surprise medical billing, require companies to report drug price increases, and cap hospital bills for uninsured patients — policies that have spread nationwide.

“He pushed the envelope and gave people aspirational leadership,” said Jennifer Kent, who served as Schwarzenegger’s head of the Department of Health Care Services, which administers the state Medicaid program. The two were often on opposing sides on health policy issues. “There was always, like, one more thing, one more goal, one more thing to achieve.”

Recently, Wright co-led a coalition of labor and immigrant rights activists to provide comprehensive Medicaid benefits to all eligible California residents regardless of immigration status. The state funds this coverage because the federal government doesn’t allow it.

His wins have come mostly under Democratic governors and legislatures and when Republican support hasn’t been needed. That will not be the case in Washington, D.C., where Republicans currently control the House and the Senate Democratic Caucus has a razor-thin majority, which has made it extremely difficult to pass substantive legislation. November’s elections are not expected to ease the partisan impasse.

Though both Health Access and Families USA are technically nonpartisan, they tend to align with Democrats and lobby for Democratic policies, including abortion rights. But “Anthony doesn’t just talk to his own people,” said David Panush, a veteran Sacramento health policy consultant. “He has an ability to connect with people who don’t agree with you on everything.”

Wright, who interned for Vice President Al Gore and worked as a consumer advocate at the Federal Communications Commission in his 20s, acknowledges his job will be tougher in the nation’s capital, and said he is “wide-eyed about the dysfunction” there. He said he also plans to work directly with state lawmakers, including encouraging those in the 10, mostly Republican states that have not yet expanded Medicaid under the Affordable Care Act to do so.

In an interview with California Healthline senior correspondent Samantha Young, Wright, 53, discussed his accomplishments in Sacramento and the challenges he will face leading a national consumer advocacy group. His remarks have been edited for length and clarity.

Wright is leaving Sacramento to lead Families USA, a health consumer group, where his national campaign for more affordable and accessible health care will face a deeply divided Congress.(Samantha Young/KFF Health News)

Q: Is there something California has done that you’d like to see other states or the federal government adopt?

Just saying “We did this in California” is not going to get me very far in 49 other states. But stuff that has already gone national, like the additional assistance to buy health care coverage with state subsidies, that became something that was a model for what the federal government did in the American Rescue Plan [Act] and the Inflation Reduction Act. Those additional tax credits have had a huge impact. About 5 million Americans have coverage because of them. Yet, those additional tax credits expire in 2025. If those tax credits expire, the average premium will spike $400 a month.

Q: You said you will find yourself playing defense if former President Donald Trump is elected in November. What do you mean?

Our health is on the ballot. I worry about the Affordable Care Act and the protections for preexisting conditions, the help for people to afford coverage, and all the other consumer patient protections. I think reproductive health is obviously front and center, but that’s not the only thing that could be taken away. It could also be something like Medicare’s authority to negotiate prices on prescription drugs.

Q: But Trump has said he doesn’t want to repeal the ACA this time, rather “make it better.”

We just need to look at the record of what was proposed during his first term, which would have left millions more people uninsured, which would have spiked premiums, which would have gotten rid of key patient protections.

Q: What’s on your agenda if President Joe Biden wins reelection?

It partially depends on the makeup of Congress and other elected officials. Do you extend this guarantee that nobody has to spend more than 8.5% of their income on coverage? Are there benefits that we can actually improve in Medicare and Medicaid with regard to vision and dental? What are the cost drivers in our health system?

There is a lot we can do at both the state and the federal level to get people both access to health care and also financial security, so that their health emergency doesn’t become a financial emergency as well.

Q: Will it be harder to get things done in a polarized Washington?

The dysfunction of D.C. is a real thing. I don’t have delusions that I have any special powers, but we will try to do our best to make progress. There are still very stark differences, whether it’s about the Affordable Care Act or, more broadly, about the social safety net. But there’s always opportunities for advancing an agenda.

There could be a lot of common ground on areas like health care costs and having greater oversight and accountability for quality in cost and quality in value, for fixing market failures in our health system.

Q: What would happen in California if the ACA were repealed?

When there was the big threat to the ACA, a lot of people thought, “Can’t California just do its own thing?” Without the tens of billions of dollars that the Affordable Care Act provides, it would have been very hard to sustain. If you get rid of those subsidies, and 5 million Californians lose their coverage, it becomes a smaller and sicker risk pool. Then premiums spike up for everybody, and, basically, the market becomes a death spiral that will cover nobody, healthy or sick.

Q: California expanded Medicaid to qualified immigrants living in the state without authorization. Do you think that could happen at the federal level?

Not at the moment. I would probably be more focused on the states that are not providing Medicaid to American citizens [who] just happen to be low-income. They are turning away precious dollars that are available for them.

Q: What do you take away from your time at Health Access that will help you in Washington?

It’s very rare that anything of consequence is done in a year. In many cases, we’ve had to run a bill or pursue a policy for multiple years or sessions. So, the power of persistence is that if you never give up, you’re never defeated, only delayed. Prescription drug price transparency took three years, surprise medical bills took three years, the hospital fair-pricing act took five years.

Having a coalition of consumer voices is important. Patients and the public are not just another stakeholder. Patients and the public are the point of the health care system.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

Biden Budget Touches All the Bases

The Host

President Joe Biden’s fiscal 2024 budget proposal includes new policies and funding boosts for many of the Democratic Party’s important constituencies, including advocates for people with disabilities and reproductive rights. It also proposes ways to shore up Medicare’s dwindling Hospital Insurance Trust Fund without cutting benefits, basically daring Republicans to match him on the politically potent issue.

Meanwhile, five women in Texas who were denied abortions when their pregnancies threatened their lives or the viability of the fetuses they were carrying are suing the state. They charge that the language of Texas’ abortion ban makes it impossible for doctors to provide needed care without fear of enormous fines or prison sentences.

This week’s panelists are Julie Rovner of KHN, Shefali Luthra of The 19th, Victoria Knight of Axios, and Margot Sanger-Katz of The New York Times.

Among the takeaways from this week’s episode:

  • Biden’s budget manages to toe the line between preserving Medicare and keeping the Medicare trust fund solvent while advancing progressive policies. Republicans have yet to propose a budget, but it seems likely any GOP plan would lean heavily on cuts to Medicaid and subsidies provided under the Affordable Care Act. Democrats will fight both of those.
  • Even though the president’s budget includes something of a Democratic “wish list” of social policy priorities, the proposals are less sweeping than those made last year. Rather, many — such as extending to private insurance the $35 monthly Medicare cost cap for insulin — build on achievements already realized. That puts new focus on things the president has accomplished.
  • Walgreens, the nation’s second-largest pharmacy chain, is caught up in the abortion wars. In January, the chain said it would apply for certification from the FDA to sell the abortion pill mifepristone in states where abortion is legal. However, last week, under threats from Republican attorneys general in states where abortion is still legal, the chain wavered on whether it would seek to sell the pill there or not, which caused a backlash from both abortion rights proponents and opponents.
  • The five women suing Texas after being denied abortions amid dangerous pregnancy complications are not asking for the state’s ban to be lifted. Rather, they’re seeking clarification about who qualifies for exceptions to the ban, so doctors and hospitals can provide needed care without fear of prosecution.
  • Although anti-abortion groups have for decades insisted that those who have abortions should not be prosecuted, bills introduced in several state legislatures would do exactly that. In South Carolina, those who have abortions could even be subject to the death penalty. So far none of these bills have passed, but the wave of measures could herald a major policy change.

Also this week, Rovner interviews Harris Meyer, who reported and wrote the two latest KHN-NPR “Bill of the Month” features. Both were about families facing unexpected bills after childbirth. If you have an outrageous or exorbitant medical bill you want to share with us, you can do that here.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: KHN’s “Girls in Texas Could Get Birth Control at Federal Clinics, Until a Christian Father Objected,” by Sarah Varney

Shefali Luthra: The 19th’s “Language for Treating Childhood Obesity Carries Its Own Health Risks to Kids, Experts Say,” by Jennifer Gerson

Victoria Knight: KHN’s “After People on Medicaid Die, Some States Aggressively Seek Repayment From Their Estates,” by Tony Leys

Margot Sanger-Katz: ProPublica’s “How Obamacare Enabled a Multibillion-Dollar Christian Health Care Grab,” by J. David McSwane and Ryan Gabrielson

Also mentioned in this week’s podcast:


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