Tagged Health Care Costs

How The Medicaid Battle Is Far From Over: Despite Some Red States Embracing Limited Expansion, Others Dig In Their Heels

Recent moves by red state Republicans to block voter-approved Medicaid expansion, as well as threats from some Republican governors to slash funding highlight the fact that both sides are still fighting the Medicaid expansion battle. Medicaid news comes out of Georgia and Texas, as well.

Maryland Law Designed To Curb Drug Price Gouging Dealt Fatal Blow As Supreme Court Refuses Case

The legislation had previously been ruled unconstitutional by an appeals court because it tried to regulate commerce beyond Maryland’s borders. The law, which was enacted following several high-profile drug hikes, prohibited what it termed “unconscionable” price increases for essential drugs no longer covered by patents or generic drugs that are sold in the state.

Lucrative Commissions For Insurance Brokers Seem Like Normal Business Practices–Until You Realize Who Ultimately Pays For Them

Human resource directors often rely on independent health insurance brokers to guide them through confusing benefit options offered by insurance companies. But what many don’t fully realize is how the health insurance industry steers the process through lucrative financial incentives and commissions, the cost of which are built into premiums. In other health industry and cost news: affordability, the business of specialty surgeries, health record costs, and more.

Have The Days Of Double Hospital Rooms Passed? Patients Start To Expect Private Rooms As The Norm

More and more hospitals are transitioning toward private rooms as the standard, reflecting a growing sentiment that patient comfort is an essential part of the hospital business. Hospital news comes out of California, Massachusetts, Minnesota, Illinois, and Kansas, as well.

The High Cost Of Sex: Insurers Often Don’t Pay For Drugs To Treat Problems

For some older people, the joy of sex may be tempered by financial concerns: Can they afford the medications they need to improve their experience between the sheets?

Medicare and many private insurers don’t cover drugs that are prescribed to treat problems people have engaging in sex. Recent developments, including the approval of generic versions of popular drugs Viagra and Cialis, help consumers afford the treatments. Still, for many people, paying for pricey medications may be their only option.

At 68, like many postmenopausal women, Kris Wieland, of Plano, Texas, experiences vaginal dryness that can make intercourse painful. Her symptoms are amplified by Sjogren’s syndrome, an immune system disorder that typically causes dry eyes and mouth, and can affect other tissues.

Kris Wieland, left, of Plano, Texas, pictured with daughter Anne, was denied coverage by her Medicare Part D plan for a drug that replenishes vaginal estrogen, prescribed by her doctor.(Courtesy of Kris Wieland)

Before Wieland became eligible for Medicare, her gynecologist prescribed Vagifem, a suppository that replenishes vaginal estrogen, a hormone that declines during menopause. That enabled her to have sex without pain. Her husband’s employer plan covered the medication, and her copayment was about $100 every other month.

However, after she enrolled in Medicare, her Part D plan denied coverage for the drug.

“I find it very discriminatory that they will not pay for any medication that will enable you to have sexual activity,” Wieland said. She plans to appeal.

Under the law, drugs used to treat erectile or sexual dysfunction are excluded from Part D coverage unless they are used as part of a treatment approved by the Food and Drug Administration for a different condition. Private insurers often take a similar approach, reasoning that drugs to treat sexual dysfunction are lifestyle-related rather than medically necessary, according to Brian Marcotte, CEO of the National Business Group on Health, which represents large employers.

So, for example, Medicare may pay if someone is prescribed sildenafil, the generic name for Viagra and another branded drug called Revatio, to treat pulmonary arterial hypertension, a type of high blood pressure in the lungs. But it typically won’t cover the same drug if prescribed for erectile dysfunction.

Women like Kris Wieland may encounter a similar problem. A variety of creams, suppositories and hormonal rings increase vaginal estrogen after menopause so that women can have intercourse without pain. But drugs that are prescribed to address that problem haven’t generally been covered by Medicare.

Sexual-medicine experts say such exclusions are unreasonable.

“Sexual dysfunction is not just a lifestyle issue,” said Sheryl Kingsberg, a clinical psychologist who is the chief of behavioral medicine at University Hospitals MacDonald Women’s Hospital in Cleveland. She is the immediate past president of the North American Menopause Society, an organization for professionals who treat women with these problems. “For women, this is about postmenopausal symptoms.”

Relief may be in sight for some women. Last spring, the federal Centers for Medicare & Medicaid Services sent guidance to Part D plans that they could cover drugs to treat moderate to severe “dyspareunia,” or painful intercourse, caused by menopause. Plans aren’t required to offer this coverage, but they may do so, according to CMS officials.

The North American Menopause Society applauded the change.

“Dyspareunia is a medical symptom associated with the loss of estrogen,” said Kingsberg. “They had associated it with sexual dysfunction, but it’s a menopause-related issue.”

For men who suffer from erectile dysfunction, treatment can confer both physical and emotional benefits, according to experts in sexual health.

“In my clinical work, I see a lot of older couples,” said Sandra Lindholm, a clinical psychologist and sex therapist who is also a nurse practitioner in Walnut Creek, Calif. “They are very interested in sex, and they feel like they’re able to embrace their erotic lives. But there may be medical issues that need to be addressed.”

Roughly 40 percent of men over age 40 have difficulty getting or maintaining an erection, studies show, and the problem increases with age. A similar percentage of postmenopausal women experience genitourinary syndrome of menopause, a term used to describe a host of symptoms related to declining levels of estrogen, including vaginal dryness, itching, soreness and pain during intercourse, as well as increased risk of urinary tract infections.

Low sexual desire is another common complaint among women and men. A drug called Addyi was approved in 2015 to treat low sexual desire disorder in premenopausal women. But many insurers don’t cover it.

Unfortunately, medications that treat these conditions may cost people hundreds of dollars a month if their insurance doesn’t pick up any of the tab. A 10-tablet prescription for Viagra in a typical 50-milligram dose may cost more than $600, for example, while the price of eight Vagifem tablets may exceed $200, according to GoodRx, a website that publishes current drug prices and discounts.

In recent years, much more affordable generic versions of some of these medications have gone on the market.

Generic versions of Viagra and Cialis, another popular erectile dysfunction drug, may be available for just a few dollars a pill.

“I never write a prescription for Viagra anymore,” said Dr. Elizabeth Kavaler, a urogynecologist at Lenox Hill Hospital in New York City. “These generics are inexpensive solutions for men.”

There are generic versions of some women’s products as well, including yuvafem vaginal inserts and estradiol vaginal cream.

But even those generic options are often relatively pricey. Some patients can’t afford $100 for a tube of generic estradiol vaginal cream, said Dr. Mary Jane Minkin, a clinical professor of obstetrics, gynecology and reproductive medicine at Yale University School of Medicine.

“I’ve asked, ‘Did you try any of the creams?’ And they say they used up the sample I gave them. But they didn’t buy the prescription because it was too expensive.”

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! Did you guys get as big a kick out of the #healthpolicyvalentines hashtag as I did? (I feel I’m talking to the right crowd here.) They’re quite delightful, including this timely one from KHN’s own Rachel Bluth: “Not even a PBM could get in the middle of our love.”

On to the news from the week.

Thursday was a somber day for many as the country marked the anniversary of the Parkland, Fla., mass shooting at Marjory Stoneman Douglas High School that left 17 dead.

On the eve of the anniversary, the House Judiciary Committee approved two bills that would expand federal background checks for gun purchases. Although the legislation faces certain demise in the Senate, it is the first congressional action in favor of tightening gun laws in years. In the votes you see echoes of a recent trend: Lawmakers are no longer treating gun control as “the third rail in politics.” The difference is stark if you look at just over 10 years ago when then-candidate Barack Obama was sending out mailers assuring voters he supported the Second Amendment.

Politico: House Democrats Make First Major Move to Tighten Gun Laws

The Associated Press: Parkland Anniversary Highlights Democratic Shift on Guns

There were too many heartbreaking anniversary stories to highlight just one, but a project worth checking out is one from The Trace, a nonprofit news organization that reports on gun violence. In the year since Parkland, nearly 1,200 more children have lost their lives to guns. The Trace brought together more than 200 teen reporters from across the country to remember those killed not as statistics, but as human beings with rich histories.

14 Children Died in The Parkland Shooting. Nearly 1,200 Have Died From Guns Since.

A handy reference: The good people at The Tampa Bay Times and the AP put together a useful list of all the gun laws that have been enacted in the country since the shooting.

Tampa Bay Times and Associated Press: Here Is Every New Gun Law in the U.S. Since the Parkland Shooting


There are some lawmakers on the Hill who are almost giddy to hold hearings on “Medicare-for-all” — and they’re not Democrats. Republicans have been struggling to find a winning stance on health care, ever since Dems’ midterm victories, which were attributed in part to their stance on the issue.

For the previously floundering GOP lawmakers, MFA is practically a gift-wrapped present that fell right into their laps. They’re confident they can frame the idea as reckless, radical and expensive, and pick off moderate voters who want to keep their insurance the way it is. Democratic leadership blasted the GOP’s calls for hearings as “disingenuous,” but MFA supporters were raring to duke it out — verbally, of course. “They think it’s going to be a ‘gotcha’ moment,” said Rep. Pramila Jayapal (D-Wash.) in Politico’s coverage. “But they have been wrong on this and continue to be wrong on it.”

Politico: Republicans Can’t Wait to Debate ‘Medicare For All’

Meanwhile, Democrats introduced legislation this week that would allow people over 50 to buy in to Medicare. The measure is much more politically palatable than MFA, and its sponsors are selling it is a realistic and incremental step in the direction toward universal coverage.

Politico: Push for Medicare Buy-In Picks Up With ’50 and Over’ Bill


Here’s something you don’t hear every day: Republicans and Democrats maybe (just maybe!) have found some common ground on the health law. As part of a package of bills to shore up the Affordable Care Act, Democrats are proposing slapping some consumer warnings on short-term plans. The hint of bipartisanship in the air, though, was limited to the advisories — Republicans were not fans of the rest of the changes proposed.

Modern Healthcare: Short-Term Health Insurance Plans May Get Consumer Warnings


Advocates deem Utah’s move to limit voter-approved Medicaid expansion as a “dark day for Democracy.” The governor and lawmakers who rushed through the restrictions to the expansion, however, say the work requirements and caps are necessary to make it sustainable for the state.

The Associated Press: Utah Reduces Voter-Backed Medicaid Expansion in Rare Move


As 2020 comes into focus, the abortion debate is definitely on the front burner for President Donald Trump, who has seized on recent controversies over so-called late-term abortions. This week, Trump and White House officials met with advocates, including Susan B. Anthony List President Marjorie Dannenfelser. While the discussions weren’t open to journalists, Dannenfelser confirmed that Trump was keenly interested in the issue. “The national conversation about late-term abortion … has the power to start to peel away Democrats, especially in battle grounds,” Dannenfelser said in The Hill’s coverage.

The Hill: Trump Offers Preview of Abortion Message Ahead of 2020


There was some movement in the agencies this week that should be on your radar:

— The Food and Drug Administration has announced it’s cracking down on the $40 billion supplement industry, especially targeting diseases that really should require medical care. Right now, that landscape is pretty much the Wild Wild West, where anything goes. And consumers don’t realize that.

The New York Times: F.D.A. Warns Supplement Makers to Stop Touting Cures for Diseases Like Alzheimer’s

— The Environmental Protection Agency has released its plan to address long-lasting toxins in drinking water. Activists were not impressed, saying the “action plan” was quite short on action.

Reuters: U.S. Unveils Plan to Control Some Toxins in Drinking Water, Sets No Limits

— The Centers for Medicare & Medicaid Services released two major proposed regulations that are meant to help ease patients’ access to their health care records. Right now, many health care providers and hospitals offer patient portals, but they often lack material such as doctor notes, imaging scans and genetic-testing data. Sometimes they’ll even charge for the data. The rules would address restrictions such as those.

The Wall Street Journal: New Rules Could Ease Patients’ Access to Their Own Health Records


In a sign of the growing awareness about the United States’ maternal mortality problem, the task force that sets the standards insurers are required to follow is expanding its guidance when it comes to depression during and after pregnancy. The U.S. Preventive Services Task Force already recommends that doctors screen pregnant women and new mothers, but the old guidelines focused on patients who were experiencing symptoms. The new advice is more proactive about addressing women who may be at risk.

The Wall Street Journal: New Mothers at Risk of Depression to Get Counseling Services, Covered By Insurance, Under New Guidelines


It’s a well-established fact that doctors have an unconscious bias when it comes to race and pain — one that leaves many minority patients undertreated and undermedicated. What’s interesting is to see how that disparity has shaped the opioid epidemic in the country — the ones that wreaked havoc on white communities.

Los Angeles Times: Why Opioids Hit White Areas Harder: Doctors There Prescribe More Readily, Study Finds

While all eyes are on the massive consolidated opioid lawsuit in Ohio that’s being compared to the Big Tobacco reckoning of the ’90s, this little case in Oklahoma might steal its thunder.

Stateline: Pay Attention to This Little-Noticed Opioid Lawsuit in Oklahoma


In the miscellaneous file for the week:

• A powerful investigation from The Wall Street Journal and Frontline uncovers the history behind an Indian Health Service doctor who was accused of molesting Native Americans yet allowed to continue practicing for decades. Where did it go wrong?

The Wall Street Journal: HHS to Review Indian Health Service After Revelations on Pedophile Doctor

• Rural hospitals are collapsing everywhere, leaving vulnerable residents stranded in health deserts. It can be devastating for towns to watch their hospitals die. Ducktown, Tenn., offers a snapshot of what’s playing out in states all across the country.

Nashville Tennessean: Tennessee Rural Hospitals Are Dying. Welcome to Life in Ducktown

• Employer-sponsored health care is often held up as the gold standard. But is it really that great?

CNN: Employer Health Plans Cover Less Than You Think, Study Finds

• I vividly remember the global fear surrounding the bird flu back in the aughts. People were panicking and countries were stockpiling medical supplies, as everyone braced for an epidemic reminiscent of the catastrophic 1918 Spanish flu. But then nothing happened. So … where’d it go?

Stat: What Happened to Bird Flu? How a Threat to Human Health Faded From View


Early numbers show that the flu vaccine is doing a pretty good job this year, so remember it’s not too late to get your shot! And have a great weekend!

Podcast: KHN’s ‘What The Health?’ “Medicare-For-All” For Dummies

Republicans are still in charge of the White House and the Senate, but the “Medicare-for-all” debate is in full swing. Democrats of every stripe are pledging support for a number of variations on the theme of expanding health coverage to all Americans.

This week, KHN’s “What the Health?” podcast takes a deep dive into the often-confusing Medicare-for-all debate, including its history, prospects and terminology.

This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Paige Winfield Cunningham of The Washington Post and Rebecca Adams of CQ Roll Call.

Among the takeaways from this week’s podcast:

  • Medicare-for-all is a new rallying cry for progressives, but the current Medicare program has big limitations. It does not cover most long-term care expenses, and includes no coverage of hearing, dental, vision or foot care. Medicare also includes no stop-loss or catastrophic care limit that protects beneficiaries from massive bills.
  • Though recent comments by Sen. Kamala Harris on eliminating private insurance with a move to Medicare-for-all stirred controversy, private insurance is indeed involved in many aspects of the government program. Private companies provide the Medicare Advantage plans used by more than a third of beneficiaries, the Medicare drug plans and much of the bill processing for the entire program.
  • Many consumers — and politicians — are confused by the terms being thrown around in the current debate about Medicare-for-all. The plan offered by Sen. Bernie Sanders (I-Vt.) and some of his supporters would be a “single-payer” system, in which the government would be in charge of paying for all health care — although doctors, hospitals and other health care providers would remain private. Others often use the term Medicare-for-all to mean a much less drastic change to the U.S. health care system, such as a “public option” that would offer specific groups of people — perhaps those over age 50 or consumers purchasing coverage on the insurance marketplaces — the opportunity to buy into Medicare coverage.
  • Sanders’ vision of Medicare-for-all is based on Canada’s system. But even there, hospitals and doctors are private businesses, drugs are not covered everywhere, and benefits vary among the provinces.
  • The health care industry is nearly united in opposing the talk of moving to a Medicare-for-all program because of concerns about disruption to the system and less pay. Currently, Medicare reimbursements are about 40 percent lower than private insurance.

If you want to know more about the next big health policy debate, here are some articles to get you started:

Vox’s “Private Health Insurance Exists in Europe and Canada. Here’s How It Works,” by Sarah Kliff

The Washington Post’s “How Democrats Could Lose on Health Care in 2020,” by Ronald A. Klain

The American Prospect’s “The Pleasant Illusions of the Medicare-for-All Debate,” by Paul Starr

The Week’s “Why Do Democrats Think Expanding ObamaCare Would Be Easier Than Passing Medicare-for-All?” by Jeff Spross

Vox’s “How to Build a Medicare-for-All Plan, Explained By Somebody Who’s Thought About It for 20 Years,” by Dylan Scott

The New York Times’ “The Best Health Care System in the World: Which One Would You Pick?” By Aaron E. Carroll and Austin Frakt

The Nation’s “Medicare-for-All Isn’t the Solution for Universal Health Care,” by Joshua Holland

The New York Times’ “’Don’t Get Too Excited’ About Medicare for All,” by Elisabeth Rosenthal and Shefali Luthra

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

Julie Rovner: Yahoo News’ “What Trump Got Wrong About ‘Right to Try,’” by Kadia Tubman

Joanne Kenen: STAT News’ “The Modern Tragedy of Fake Cancer Cures,” by Matthew Herper

Rebecca Adams: The Texas Tribune’s “Thousands of Texans Were Shocked By Surprise Medical Bills. Their Requests for Help Overwhelmed the State,” by Jay Root and Shannon Najmabadi

Paige Winfield Cunningham: STAT News’ “The ‘Big Pharma’ Candidate? As He Runs for President, Cory Booker Looks to Shake His Reputation for Drug Industry Coziness,” by Lev Facher

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher or Google Play.

Podcast: KHN’s ‘What The Health?’ “Medicare-For-All” For Dummies

Republicans are still in charge of the White House and the Senate, but the “Medicare-for-all” debate is in full swing. Democrats of every stripe are pledging support for a number of variations on the theme of expanding health coverage to all Americans.

This week, KHN’s “What the Health?” podcast takes a deep dive into the often-confusing Medicare-for-all debate, including its history, prospects and terminology.

This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Paige Winfield Cunningham of The Washington Post and Rebecca Adams of CQ Roll Call.

Among the takeaways from this week’s podcast:

  • Medicare-for-all is a new rallying cry for progressives, but the current Medicare program has big limitations. It does not cover most long-term care expenses, and includes no coverage of hearing, dental, vision or foot care. Medicare also includes no stop-loss or catastrophic care limit that protects beneficiaries from massive bills.
  • Though recent comments by Sen. Kamala Harris on eliminating private insurance with a move to Medicare-for-all stirred controversy, private insurance is indeed involved in many aspects of the government program. Private companies provide the Medicare Advantage plans used by more than a third of beneficiaries, the Medicare drug plans and much of the bill processing for the entire program.
  • Many consumers — and politicians — are confused by the terms being thrown around in the current debate about Medicare-for-all. The plan offered by Sen. Bernie Sanders (I-Vt.) and some of his supporters would be a “single-payer” system, in which the government would be in charge of paying for all health care — although doctors, hospitals and other health care providers would remain private. Others often use the term Medicare-for-all to mean a much less drastic change to the U.S. health care system, such as a “public option” that would offer specific groups of people — perhaps those over age 50 or consumers purchasing coverage on the insurance marketplaces — the opportunity to buy into Medicare coverage.
  • Sanders’ vision of Medicare-for-all is based on Canada’s system. But even there, hospitals and doctors are private businesses, drugs are not covered everywhere, and benefits vary among the provinces.
  • The health care industry is nearly united in opposing the talk of moving to a Medicare-for-all program because of concerns about disruption to the system and less pay. Currently, Medicare reimbursements are about 40 percent lower than private insurance.

If you want to know more about the next big health policy debate, here are some articles to get you started:

Vox’s “Private Health Insurance Exists in Europe and Canada. Here’s How It Works,” by Sarah Kliff

The Washington Post’s “How Democrats Could Lose on Health Care in 2020,” by Ronald A. Klain

The American Prospect’s “The Pleasant Illusions of the Medicare-for-All Debate,” by Paul Starr

The Week’s “Why Do Democrats Think Expanding ObamaCare Would Be Easier Than Passing Medicare-for-All?” by Jeff Spross

Vox’s “How to Build a Medicare-for-All Plan, Explained By Somebody Who’s Thought About It for 20 Years,” by Dylan Scott

The New York Times’ “The Best Health Care System in the World: Which One Would You Pick?” By Aaron E. Carroll and Austin Frakt

The Nation’s “Medicare-for-All Isn’t the Solution for Universal Health Care,” by Joshua Holland

The New York Times’ “’Don’t Get Too Excited’ About Medicare for All,” by Elisabeth Rosenthal and Shefali Luthra

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

Julie Rovner: Yahoo News’ “What Trump Got Wrong About ‘Right to Try,’” by Kadia Tubman

Joanne Kenen: STAT News’ “The Modern Tragedy of Fake Cancer Cures,” by Matthew Herper

Rebecca Adams: The Texas Tribune’s “Thousands of Texans Were Shocked By Surprise Medical Bills. Their Requests for Help Overwhelmed the State,” by Jay Root and Shannon Najmabadi

Paige Winfield Cunningham: STAT News’ “The ‘Big Pharma’ Candidate? As He Runs for President, Cory Booker Looks to Shake His Reputation for Drug Industry Coziness,” by Lev Facher

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher or Google Play.

With Purchase Of Technology Firm, J&J Continues Push Into Surgical Robotics Field

Johnson & Johnson is buying a company that created a medical device that can help physicians access nodules in patients’ lungs to diagnose and target treatments. Large medical-device makers have recently been pushing into the robotics market, partly because the equipment can command high price tags. In other health industry news: hospital sales, bankruptcy, and lawsuits.

With Purchase Of Technology Firm, J&J Continues Push Into Surgical Robotics Field

Johnson & Johnson is buying a company that created a medical device that can help physicians access nodules in patients’ lungs to diagnose and target treatments. Large medical-device makers have recently been pushing into the robotics market, partly because the equipment can command high price tags. In other health industry news: hospital sales, bankruptcy, and lawsuits.

Beyond Beltway’s ‘Medicare-For-All’ Talk, Democrats In States Push New Health Laws

As calls for “Medicare-for-all” grow louder among Democrats in Congress, Democratic governors and mayors have been pushing ahead with urgency to corral medical costs and bring health care to those who remain uninsured.

KHN senior correspondent Sarah Varney and “PBS NewsHour” producer Jason Kane filed this report on legislative initiatives pushed by California Gov. Gavin Newsom and New York City Mayor Bill de Blasio, among others around the country.

Can California Beat The Federal Government In Lowering Drug Prices?

California Gov. Gavin Newsom says he’s done waiting for the federal government to curtail the rising cost of prescription drugs.

Newsom has his own plan to ease that financial burden — one he hopes other states can join or replicate.

The Democratic governor said he intends to use California’s might as the world’s fifth-largest economy to demand lower prices directly from drug companies for millions of Medicaid enrollees, state government workers and, eventually, Californians in the private sector.

“I recognize deeply the anxiety so many of you feel around the issues related to the cost of prescription drugs,” Newsom said in a Facebook Live video when announcing his initiative. “And I hope California’s efforts here can lead the way to other states to consider the same.”

Newsom said later he’s already “talking to other state governors about how they can participate.”

Whether he can deliver on his ambitious pledge to take on big pharmaceutical companies is far from certain. The plan he introduced his first day in office is based on broad ideas, with few details and start dates that may be years away.

States have taken smaller steps to rein in drug prices and achieved limited savings. But the issue has stymied lawmakers at the federal level, including President Donald Trump, who called for lowering the cost of prescription drugs in his State of the Union address last week.

Lawmakers face an array of challenges that make reform hard, such as secretive drug pricing and the political influence of the pharmaceutical industry, one of the most powerful lobbies in the country, said Rachel Sachs, an associate professor at Washington University in St. Louis who specializes in health law.

“Drug pricing is one of the most complicated areas within a complicated health care system,” Sachs said.

In California, the amount the state government spends on prescription drugs has risen 20 percent per year since 2012, according to Newsom’s executive order.

To stem that rise, he wants the state Department of Health Care Services — which oversees Medi-Cal, the country’s largest Medicaid program, for low-income residents — to negotiate prescription drug prices for all of its roughly 13 million enrollees by 2021.

Currently, the vast majority of Medi-Cal enrollees get their prescription drugs through managed-care plans that contract with the state to provide Medi-Cal coverage — a fragmented system that doesn’t yield the best price for consumers, the Newsom administration argues.

With the state in charge of negotiations, Medi-Cal could save $150 million a year, the administration said, and Medi-Cal enrollees could go to virtually any pharmacy, as opposed to the limited options authorized by their health plans.

Although the concept of bulk purchasing might sound good, health experts say, the state faces barriers.

Federal law requires Medicaid programs to cover most drugs approved by the Food and Drug Administration. That leaves states without one of the biggest bargaining chips available to the private sector: the ability to tell drugmakers they won’t buy their products.

But California can get creative, said Jennifer Kent, the health department’s director. For example, the state can create a preferred drug list that gives drugmakers an incentive to reduce their prices. If a medication is on the list, doctors don’t need to obtain preauthorization from Medi-Cal to prescribe it, making it more accessible and thus more likely to be used by patients, Kent said.

In addition, the sheer size of California’s Medi-Cal program can help drive down prices, Kent said.

“I think of us as the third-largest public purchaser in the nation” behind Medicare and the Department of Veterans Affairs, Kent said. “We cover a very significant number of people.”

But representatives for California health plans and pharmacy benefit managers, the middlemen who negotiate with drugmakers on behalf of health plans and government entities, say their organizations already work to find the best prices for consumers. They haven’t publicly opposed Newsom’s plan but have expressed skepticism.

The Pharmaceutical Care Management Association, which represents pharmacy benefit managers, said in a written statement that its companies are set to save the California Medi-Cal program $8.59 billion in projected costs from 2016 to 2025.

Drugmakers have launched a national campaign that blames insurers for failing to pass along more than $150 billion a year in rebates and discounts to consumers.

In addition to negotiating for Medi-Cal enrollees, Newsom wants to get a better deal for state workers. He has directed his administration to study how agencies could band together in a separate drug-purchasing pool to buy prescription drugs as one entity.

Currently, more than 20 state agencies negotiate drug prices separately.

Newsom said he envisions private purchasers — including small businesses, health plans and self-insured Californians — eventually joining these state agencies at the bargaining table in a bid to “marshal public and private parties” for lower drug prices.

A report last year by the National Academy of Sciences found that spending on biopharmaceuticals accounts for nearly 17 percent of America’s annual health care bill, and that many people have difficulty paying for the drugs they need.

Among the report’s recommendations to lower costs: The federal government should consolidate its purchasing power and directly negotiate prices for all federal health care programs, including Medicare and Department of Veterans Affairs coverage. However, legislation to do that within Medicare has stalled repeatedly over the years and remains controversial.

Trump’s proposal last year to link Medicare spending for certain drugs to what other industrialized countries pay has gone nowhere. Last month, the Trump administration proposed a new prescription drug discount plan that would steer the rebates drug companies now give to insurers directly to consumers.

In the absence of federal action, states have sought to curb drug prices on their own. Among those efforts: a Connecticut law requiring drug companies to justify price increases, a California law requiring them to report price hikes, and a New York cap on drug spending in the state’s Medicaid program.

Twenty-eight states and the District of Columbia belong to multistate purchasing pools, mostly for their Medicaid programs. But data about how much money these pools have saved is scarce, said Edwin Park, a research professor at Georgetown University’s Center for Children and Families.

“I think there are real opportunities and real interest in the states about leveraging their buying power,” said Trish Riley, the executive director of the National Academy for State Health Policy. “The states can’t wait for federal action.”


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

Advocates Hope Emerging Evidence About Economic Benefits Of Medicaid Expansion Will Nudge Kansas, Missouri Into Action

The states have long-balked at the price tag associated with expansion, but economists are saying other red states are reaping the benefits of injecting the economy with millions in federal dollars. Beginning next year, however, the federal government’s contribution will phase down to 90 percent from the current 93 percent of expansion costs, which will make it a harder sell. Medicaid news comes out of Utah and North Carolina.

‘Medicare For All’ May Be A Litmus Test For Progressives, But Not All Possible 2020 Hopefuls Are Rushing To Back It

Moderate Sens. Sherrod Brown (D-Ohio) and Amy Klobuchar (D-Minn.) are bucking the trend of Democratic hopefuls voicing strong support for “Medicare for All.” “I want to see universal health care, and there are many ways to get there,” Klobuchar said when asked if she backed Medicare for All, whereas Brown has said he supports incremental changes to Medicare.

Texans Can Appeal Surprise Medical Bills, But The Process Can Be Draining

In Texas, a growing number of patients are turning to a little-known state mediation program to deal with unexpected hospital bills.

The bills in question often arrive in patients’ mailboxes with shocking balances that run into the tens or even hundreds of thousands of dollars.

When patients, through no fault of their own, are treated outside their insurers’ network of hospitals, the result can be a surprise bill. Other times, insurers won’t agree to pay what the hospital charges, and the patient is on the hook for the balance.

The Texas Department of Insurance’s mediation program can intervene when Texans complain about an unexpected bill — often after an emergency in which a patient is rushed for treatment at an out-of-network hospital.

Historically, the state program had many restrictions that left few consumers eligible for help. But the Texas Legislature expanded it in 2017.

Since then, more patients have been filing complaints. In 2014, the department was asked to mediate 686 medical bills. During the 2018 fiscal year, however, it received 4,445 bills, more than double the 2,063 bills received in 2017.

Even after the changes, the mediation program could be a lot more robust and is likely addressing only a fraction of these problematic bills, consumer advocates say.

The Road To A Surprise Medical Bill

Brad Buckingham had to deal with a surprise medical bill after a bicycle accident in 2016.

Buckingham sent his bill to Kaiser Health News and NPR’s “Bill of the Month” portal last year.

The Austin, Texas, dentist said he was on a ride with friends in December 2016 when he crossed train tracks at an angle to avoid a pileup. His wheel slipped out from under him, and he landed hard on his left hip.

“All I could do was scream,” he said. “I couldn’t even make words.”

His friends called an ambulance, and Buckingham was taken to the nearest hospital: St. David’s South Austin Medical Center.

“I specifically remember I gave them my health insurance information in the ambulance,” he said. “And they put me in the ER, and from the ER they took my insurance information again.”

Buckingham had insurance through Baylor Scott & White Health, which he bought through the Affordable Care Act marketplace. St. David’s was out of his plan’s network, but no one told him that — at first.

Buckingham had broken his hip, and doctors took him into surgery the same day.

“They held me in the hospital for three days just for recovery and never told me I was out of network until the time of my discharge,” he said.

A few weeks later, Buckingham got a bill that said he owed $71,543.

The total bill eventually came to $75,346. Baylor Scott & White, which left the ACA marketplace the following year, paid only $3,812.

Buckingham thought it was a mistake, he said. He called the hospital and the insurer to sort it out. But after weeks of inquiring about it, there was no resolution.

Both the hospital and insurer insisted payment was his responsibility.

“I’m sitting there thinking to myself that there is no way — there is no way — this is right,” he said.

Baylor Scott & White said it couldn’t discuss Buckingham’s bill “due to confidentiality requirements.”

After Buckingham gave St. David’s permission to discuss his case with the media, the hospital released a statement saying his bill was actually the amount he owed from his deductible and coinsurance — not a balance bill.

The hospital also said the bill was so large because of his “high deductible plan.”

Those plans “may be attractive to some people because they cost less, though they place more financial responsibility on the patient,” the statement from St. David’s said.

Buckingham said his policy had a deductible of $5,000 for in-network care and $10,000 for out-of-network care. He still doesn’t know how his bill got to be so high, he said.

Buckingham didn’t know about the state’s mediation program. But even if he had known, he wasn’t eligible for the program at the time. His bike accident and the billing dispute with the hospital happened months before the Texas Legislature decided to expand the pool of eligible patients. So he hired his own lawyer to help him negotiate with the hospital.

Buckingham now owes a couple of thousand dollars to St. David’s, he said, but he remains frustrated by the experience.

“You know, whenever I tell my story to anybody, they kind of agree — like, ‘Oh my gosh, this is ridiculous,’” he said. “But then when you talk to the people that have any control over it, it’s the exact opposite. It’s: ‘You owe it; we don’t.’”

‘A Total Roll Of The Dice’

A surprise bill can happen to anyone who makes an urgent trip to the nearest emergency room.

“It’s a total roll of the dice,” said Stacey Pogue, a senior policy analyst with the Center for Public Policy Priorities in Austin. She has been looking into balance billing for years. “The medical emergency that’s going to send you to the hospital where you could get a surprise bill — is that emergency room going to be in or out of network?”

Pogue said the Texas Department of Insurance’s mediation process forces an insurance company and the hospital or medical provider to negotiate a fair price for services. Ninety percent of the time those negotiations happen over the phone, she said.

There are two big reasons the number of bills sent for mediation more than doubled from 2017 to 2018, Pogue said.

“One is just increased awareness,” she said. “There is constant media attention now to surprise medical bills because the stories are so shocking, right? We see them covered more, so people are more aware that when they get one, they could do something about it.”

The second reason is that, in 2017, the Texas Legislature opened the mediation program up to more people, including teachers.

Stacey Shapiro got a $6,720 bill after being treated in the hospital for a hypoglycemic attack.(Gabriel C. Pérez/KUT)

Can’t Wish It Away

Stacey Shapiro, a first-grade teacher in Austin, also received a surprise bill from St. David’s South Austin Medical Center after she landed in the emergency room last March.

The marathon runner said she woke up one Saturday for an early run and wasn’t feeling well.

“All of a sudden the whole room started spinning. … I started sweating, sweating like buckets,” she said. “It was terrible, and then all I remember is that my ears started popping, my vision got blurred and then the next thing I knew, I had passed out.”

Shapiro’s boyfriend heard her hit the bathroom floor. He found her passed out, with her eyes open and hardly breathing. He took her to St. David’s because it was the closest hospital.

Shapiro was taken care of in a few hours, she said. Hospital staff gave her fluids and anti-nausea medication. Doctors found she had a dramatic change in her blood pressure that was likely due to a spell of hypoglycemia, or low blood sugar.

Two months later, a bill for $6,720 came in the mail.

Like many teachers in Austin, Shapiro gets her health insurance from Aetna.

In a statement, the insurer said Austin school district employees are supposed to use the Seton Accountable Care Organization network, comprising several Catholic hospitals in the area. The parent company for St. David’s, the for-profit hospital chain HCA, doesn’t participate in that network.

“Unfortunately, HCA is not currently accepting payments through Aetna’s [contracted payment] program, which provides set payment fees for non-participating providers. This has resulted in Ms. Shapiro being balance billed for her emergency room visit,” Aetna wrote in a statement.

Shapiro said she had heard of other Austin Independent School District employees dealing with high hospital bills. In fact, Shapiro reached out to radio station KUT after hearing the story of Drew Calver, an Austin high school teacher who was balance-billed for nearly $109,000 by St. David’s after a heart attack. Calver’s story was part of Kaiser Health News and NPR’s “Bill of the Month” series last year.

In her case, Shapiro said, Aetna told her not to pay what the hospital was charging her. She was told to pay only her deductible ($1,275), which she did right away, she said. But St. David’s kept sending her bills for the remaining balance, which was more than $5,000.

“I guess I just thought that it was going to go away,” Shapiro said.

But it didn’t. For a public school teacher, $5,000 would have been a huge blow to her budget, she said.

Shapiro applied for financial assistance, but St. David’s told her she didn’t qualify. She felt out of options, she said — until a friend told her about the state’s mediation program.

After she contacted the program, a state mediator set up a scheduled call with Aetna and St. David’s. But before it took place, a KUT reporter asked St. David’s for a comment on the situation. Shortly afterward, Shapiro said, St. David’s told her she no longer owed anything.

St. David’s later told KUT that Shapiro had “already satisfied her financial obligation.” It also denied that she was balance-billed to begin with.

Shapiro called the whole experience exhausting. “It’s just very frustrating because this has been very time-consuming,” she said.

More Work To Do

Pogue, of the Center for Public Policy Priorities, has been arguing that the state needs to find more ways to get involved. The current mediation process is pretty good, she said, but not enough people know it’s an option.

“Because first, the instructions for how to do it are on your medical bill and your explanation of benefits — the most indecipherable documents you are going to get,” she said.

And even if people understand they have a right to mediation, they might get scared off by the concept and think they need a lawyer, Pogue added.

When people do use the program, though, it tends to work by saving patients money.

In fiscal year 2018, the initial complaints amounted to $9.7 million worth of medical bills, according to the state insurance agency. After mediation, the final charges had been negotiated down to $1.3 million.

Mediation is helpful, Pogue said, but it still puts a big burden on the patient, who may be confused. “Why didn’t this happen in the first place?” she said. “How come I had to, while recovering from an emergency, decipher medical bills, fill out paperwork with the state department of insurance, jump through all these hoops, when all that needed to happen was a phone call?”

The ideal solution to surprise medical bills would remove consumers from this confusing web altogether, she said.

States like New York, California and Florida have systems that make things easier for consumers, Pogue said, and Texas should, too.

In 2015, New York became the first state to pass a law aimed at protecting patients from surprise medical bills from out-of-network hospitals. Its Emergency Medical Services and Surprise Bills Law holds consumers harmless if they are treated by an out-of-network doctor at a participating hospital, among other things.

In 2016, Florida lawmakers passed legislation protecting consumers from receiving surprise medical bills “from doctors and hospitals that don’t have a contract with the patient’s insurance plan,” the Miami Herald reported.

And in 2017, California passed a law shielding patients from balance billing. The law kicks in if someone visits an in-network provider, including a hospital, imaging center or lab. Under the law, patients would be responsible only for their in-network share of the cost, even if they’re seen by an out-of-network provider.

In the meantime, Pogue said, more Texans should take advantage of what’s already in place in the state.

The number of people who seek mediation is “tiny compared to the number of people who get surprise bills,” she said, “so there is a ton of work to be done.”

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

Texans Can Appeal Surprise Medical Bills, But The Process Can Be Draining

In Texas, a growing number of patients are turning to a little-known state mediation program to deal with unexpected hospital bills.

The bills in question often arrive in patients’ mailboxes with shocking balances that run into the tens or even hundreds of thousands of dollars.

When patients, through no fault of their own, are treated outside their insurers’ network of hospitals, the result can be a surprise bill. Other times, insurers won’t agree to pay what the hospital charges, and the patient is on the hook for the balance.

The Texas Department of Insurance’s mediation program can intervene when Texans complain about an unexpected bill — often after an emergency in which a patient is rushed for treatment at an out-of-network hospital.

Historically, the state program had many restrictions that left few consumers eligible for help. But the Texas Legislature expanded it in 2017.

Since then, more patients have been filing complaints. In 2014, the department was asked to mediate 686 medical bills. During the 2018 fiscal year, however, it received 4,445 bills, more than double the 2,063 bills received in 2017.

Even after the changes, the mediation program could be a lot more robust and is likely addressing only a fraction of these problematic bills, consumer advocates say.

The Road To A Surprise Medical Bill

Brad Buckingham had to deal with a surprise medical bill after a bicycle accident in 2016.

Buckingham sent his bill to Kaiser Health News and NPR’s “Bill of the Month” portal last year.

The Austin, Texas, dentist said he was on a ride with friends in December 2016 when he crossed train tracks at an angle to avoid a pileup. His wheel slipped out from under him, and he landed hard on his left hip.

“All I could do was scream,” he said. “I couldn’t even make words.”

His friends called an ambulance, and Buckingham was taken to the nearest hospital: St. David’s South Austin Medical Center.

“I specifically remember I gave them my health insurance information in the ambulance,” he said. “And they put me in the ER, and from the ER they took my insurance information again.”

Buckingham had insurance through Baylor Scott & White Health, which he bought through the Affordable Care Act marketplace. St. David’s was out of his plan’s network, but no one told him that — at first.

Buckingham had broken his hip, and doctors took him into surgery the same day.

“They held me in the hospital for three days just for recovery and never told me I was out of network until the time of my discharge,” he said.

A few weeks later, Buckingham got a bill that said he owed $71,543.

The total bill eventually came to $75,346. Baylor Scott & White, which left the ACA marketplace the following year, paid only $3,812.

Buckingham thought it was a mistake, he said. He called the hospital and the insurer to sort it out. But after weeks of inquiring about it, there was no resolution.

Both the hospital and insurer insisted payment was his responsibility.

“I’m sitting there thinking to myself that there is no way — there is no way — this is right,” he said.

Baylor Scott & White said it couldn’t discuss Buckingham’s bill “due to confidentiality requirements.”

After Buckingham gave St. David’s permission to discuss his case with the media, the hospital released a statement saying his bill was actually the amount he owed from his deductible and coinsurance — not a balance bill.

The hospital also said the bill was so large because of his “high deductible plan.”

Those plans “may be attractive to some people because they cost less, though they place more financial responsibility on the patient,” the statement from St. David’s said.

Buckingham said his policy had a deductible of $5,000 for in-network care and $10,000 for out-of-network care. He still doesn’t know how his bill got to be so high, he said.

Buckingham didn’t know about the state’s mediation program. But even if he had known, he wasn’t eligible for the program at the time. His bike accident and the billing dispute with the hospital happened months before the Texas Legislature decided to expand the pool of eligible patients. So he hired his own lawyer to help him negotiate with the hospital.

Buckingham now owes a couple of thousand dollars to St. David’s, he said, but he remains frustrated by the experience.

“You know, whenever I tell my story to anybody, they kind of agree — like, ‘Oh my gosh, this is ridiculous,’” he said. “But then when you talk to the people that have any control over it, it’s the exact opposite. It’s: ‘You owe it; we don’t.’”

‘A Total Roll Of The Dice’

A surprise bill can happen to anyone who makes an urgent trip to the nearest emergency room.

“It’s a total roll of the dice,” said Stacey Pogue, a senior policy analyst with the Center for Public Policy Priorities in Austin. She has been looking into balance billing for years. “The medical emergency that’s going to send you to the hospital where you could get a surprise bill — is that emergency room going to be in or out of network?”

Pogue said the Texas Department of Insurance’s mediation process forces an insurance company and the hospital or medical provider to negotiate a fair price for services. Ninety percent of the time those negotiations happen over the phone, she said.

There are two big reasons the number of bills sent for mediation more than doubled from 2017 to 2018, Pogue said.

“One is just increased awareness,” she said. “There is constant media attention now to surprise medical bills because the stories are so shocking, right? We see them covered more, so people are more aware that when they get one, they could do something about it.”

The second reason is that, in 2017, the Texas Legislature opened the mediation program up to more people, including teachers.

Stacey Shapiro got a $6,720 bill after being treated in the hospital for a hypoglycemic attack.(Gabriel C. Pérez/KUT)

Can’t Wish It Away

Stacey Shapiro, a first-grade teacher in Austin, also received a surprise bill from St. David’s South Austin Medical Center after she landed in the emergency room last March.

The marathon runner said she woke up one Saturday for an early run and wasn’t feeling well.

“All of a sudden the whole room started spinning. … I started sweating, sweating like buckets,” she said. “It was terrible, and then all I remember is that my ears started popping, my vision got blurred and then the next thing I knew, I had passed out.”

Shapiro’s boyfriend heard her hit the bathroom floor. He found her passed out, with her eyes open and hardly breathing. He took her to St. David’s because it was the closest hospital.

Shapiro was taken care of in a few hours, she said. Hospital staff gave her fluids and anti-nausea medication. Doctors found she had a dramatic change in her blood pressure that was likely due to a spell of hypoglycemia, or low blood sugar.

Two months later, a bill for $6,720 came in the mail.

Like many teachers in Austin, Shapiro gets her health insurance from Aetna.

In a statement, the insurer said Austin school district employees are supposed to use the Seton Accountable Care Organization network, comprising several Catholic hospitals in the area. The parent company for St. David’s, the for-profit hospital chain HCA, doesn’t participate in that network.

“Unfortunately, HCA is not currently accepting payments through Aetna’s [contracted payment] program, which provides set payment fees for non-participating providers. This has resulted in Ms. Shapiro being balance billed for her emergency room visit,” Aetna wrote in a statement.

Shapiro said she had heard of other Austin Independent School District employees dealing with high hospital bills. In fact, Shapiro reached out to radio station KUT after hearing the story of Drew Calver, an Austin high school teacher who was balance-billed for nearly $109,000 by St. David’s after a heart attack. Calver’s story was part of Kaiser Health News and NPR’s “Bill of the Month” series last year.

In her case, Shapiro said, Aetna told her not to pay what the hospital was charging her. She was told to pay only her deductible ($1,275), which she did right away, she said. But St. David’s kept sending her bills for the remaining balance, which was more than $5,000.

“I guess I just thought that it was going to go away,” Shapiro said.

But it didn’t. For a public school teacher, $5,000 would have been a huge blow to her budget, she said.

Shapiro applied for financial assistance, but St. David’s told her she didn’t qualify. She felt out of options, she said — until a friend told her about the state’s mediation program.

After she contacted the program, a state mediator set up a scheduled call with Aetna and St. David’s. But before it took place, a KUT reporter asked St. David’s for a comment on the situation. Shortly afterward, Shapiro said, St. David’s told her she no longer owed anything.

St. David’s later told KUT that Shapiro had “already satisfied her financial obligation.” It also denied that she was balance-billed to begin with.

Shapiro called the whole experience exhausting. “It’s just very frustrating because this has been very time-consuming,” she said.

More Work To Do

Pogue, of the Center for Public Policy Priorities, has been arguing that the state needs to find more ways to get involved. The current mediation process is pretty good, she said, but not enough people know it’s an option.

“Because first, the instructions for how to do it are on your medical bill and your explanation of benefits — the most indecipherable documents you are going to get,” she said.

And even if people understand they have a right to mediation, they might get scared off by the concept and think they need a lawyer, Pogue added.

When people do use the program, though, it tends to work by saving patients money.

In fiscal year 2018, the initial complaints amounted to $9.7 million worth of medical bills, according to the state insurance agency. After mediation, the final charges had been negotiated down to $1.3 million.

Mediation is helpful, Pogue said, but it still puts a big burden on the patient, who may be confused. “Why didn’t this happen in the first place?” she said. “How come I had to, while recovering from an emergency, decipher medical bills, fill out paperwork with the state department of insurance, jump through all these hoops, when all that needed to happen was a phone call?”

The ideal solution to surprise medical bills would remove consumers from this confusing web altogether, she said.

States like New York, California and Florida have systems that make things easier for consumers, Pogue said, and Texas should, too.

In 2015, New York became the first state to pass a law aimed at protecting patients from surprise medical bills from out-of-network hospitals. Its Emergency Medical Services and Surprise Bills Law holds consumers harmless if they are treated by an out-of-network doctor at a participating hospital, among other things.

In 2016, Florida lawmakers passed legislation protecting consumers from receiving surprise medical bills “from doctors and hospitals that don’t have a contract with the patient’s insurance plan,” the Miami Herald reported.

And in 2017, California passed a law shielding patients from balance billing. The law kicks in if someone visits an in-network provider, including a hospital, imaging center or lab. Under the law, patients would be responsible only for their in-network share of the cost, even if they’re seen by an out-of-network provider.

In the meantime, Pogue said, more Texans should take advantage of what’s already in place in the state.

The number of people who seek mediation is “tiny compared to the number of people who get surprise bills,” she said, “so there is a ton of work to be done.”

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