Tagged Health Care Costs

Listen: Missouri Efforts Show How Hard It Is To Treat Pain Without Opioids

KHN Midwest correspondent Lauren Weber speaks with KBIA’s Sebastián Martínez Valdivia about the challenges Missouri faces in trying to treat chronic pain without opioids. Weber had reported that only about 500 of Missouri’s roughly 330,000 adult Medicaid beneficiaries used a new, alternative pain management plan to stem opioid overprescribing in the program’s first nine months. Meanwhile, 109,610 Missouri Medicaid patients received opioid prescriptions last year.

You can listen to the conversation on the KBIA website.

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As Health Care Costs Continue To Rise, Donating To Crowdfunding Campaigns Becomes More And More Common

Scalpels Out: Democrats Make Slashing Attacks On Health Care Plans

Top contenders for the Democratic presidential nomination torched one another’s proposals to reform the health care system Wednesday, as the contest to unify behind a single candidate to defeat President Donald Trump took a bitterly divisive turn.

Minutes after Tom Perez, the chairman of the Democratic National Committee, warmed up the debate audience in Las Vegas by describing the party as a spirited but unified family, most of the candidates abruptly shifted into attack mode — and not just against Mike Bloomberg, the billionaire businessman and former New York City mayor making his first, belated appearance in the ninth debate.

Fighting to regain momentum after weak performances in the Iowa caucuses and New Hampshire primary, Sen. Elizabeth Warren of Massachusetts dispatched with her opponents’ plans in brutally rapid succession.

Pete Buttigieg, the former South Bend, Ind., mayor, has offered “not a plan” but “a PowerPoint” that she claimed would leave millions uninsured, she said. Sen. Amy Klobuchar of Minnesota has a proposal that is “like a Post-It note: Insert plan here,” she quipped. And Sen. Bernie Sanders of Vermont, whose “Medicare for All” plan she initially adopted as her own, “has a good start,” but his campaign cannot stop attacking those who question how it would work, she said.

“Health care is a crisis in this country,” Warren concluded. “My approach to this is, we need as much help for as many people as quickly as possible.”

It wasn’t the only tense moment.

Sanders Angers The Culinary Workers Union

How Sanders’ Medicare for All proposal would affect unions in particular isn’t a new question. But despite strong support for the proposal from some national unions, it emerged as a flashpoint in the run-up to Nevada’s caucus on Saturday, turning the state’s prominent Culinary Workers Union against Sanders, the current frontrunner, in the 11th hour.

The union did not endorse a candidate but warned members that Sanders’ proposal could eliminate the health care coverage they have gained through years of collective bargaining, replacing it with a system that is untested and unknown.  The union then put out a statement last week saying its members had been “viciously attacked” by Sanders’ supporters over the organization’s opposition . Sanders responded by saying that, though there were some bad actors on social media, it was “not thinkable” that his supporters would attack union workers.

“Let me be very clear for my good friends in the Culinary Workers union, a great union: I will never sign a bill that will reduce the health care benefits they have,” Sanders said. “We will only expand it for them, for every union in America and for the working class.”

Klobuchar defended the “hard-working” culinary workers “who have health care plans that have been negotiated over time, sweat, and blood,” she said. “And that is the truth for so many Americans right now.”

Last summer Sanders tweaked his proposal to try to alleviate concerns from unions. Under a Medicare for All system, he said, the National Labor Relations Board would supervise unions in renegotiating contracts with employers, so that they could acquire “wrap-around services and other coverage not duplicative of the benefits established under Medicare-for-all.”

The idea, Sanders’ aides said then, was so that any savings a switch to single-payer achieved could still be passed on to workers, as increased benefits or wages.

But members of the Culinary Workers Union — and some other groups — still worry about losing the coverage they have, in exchange for something unknown.

Would that happen? Technically, yes, the health plan Nevada’s culinary workers get through their union would no longer exist. Under Medicare for All, private health plans could not sell coverage that duplicates what the government program offers.

But it’s worth noting that, in this world, culinary workers would still have generous health insurance. Sanders’ envisioned health plan is robust – he says it would cover virtually all practicing physicians and medically necessary services, with virtually no cost-sharing.

Of course, that would also depend on whether a President Sanders could muster support for his plan among skeptical members of Congress.

$100 Billion In Profits

Sanders brought up one favorite talking point twice Wednesday — his claim that the health care industry makes $100 billion a year in profits. We previously checked this claim and rated it True. The number comes from adding the net revenues in 2018 from 10 pharmaceutical companies and 10 health insurance companies. We recalculated the numbers, and they added up. Experts said it was even likely that the figure was an underestimate. 

Big Pharma Is Giving Money To Buttigieg And Others 

In another biting moment, Sanders charged that drug companies are donating to Buttigieg and other campaigns as the pharmaceutical industry profits off the current system.

We previously checked Sanders’ claim that Buttigieg was a “favorite of the health care industry” and rated it Half True. This is in part because it is actually Sanders who has received the most donations of any Democratic candidate from the entire health care sector, which includes pharmaceutical companies, health insurance industry, hospitals/nursing homes and health professionals.

But, while checking this claim we also found that Buttigieg has received donations from employees and executives of pharmaceutical and health insurance companies such as AbbVie, Aetna, Anthem, Eli Lilly and Co., Merck & Co. and Pfizer. We did not check into donations for other candidates from pharmaceutical executives. 

Do People ‘Love’ Their Insurance?

You don’t start out by saying, I have 160 million people, I’m going to take away the insurance plan that they love,” Bloomberg said just minutes into the debate, pointing out the shortcomings of Sanders’ Medicare for All plan.

It is true that Sanders’ signature health proposal would eliminate private health insurance, replacing it with a single public plan that covers everybody. That would include the roughly 160 million Americans who get employer-sponsored insurance

But Bloomberg’s argument here — that those people “love” their plans — is complicated.

When we previously checked a similar claim — that 160 million people “like their health insurance” — we rated it Half-True. Cursory polling suggests people with that coverage are mostly satisfied. 

But most isn’t all. And, experts pointed out to us then, once Americans try to use that coverage, many find it lacking. In a Kaiser Family Foundation/ L.A. Times poll, for instance, 40% of people with employer-sponsored insurance still reported having trouble paying for medical bills, premiums or out-of-pocket costs. In that same poll, about half said they skipped or delayed health care because — even with coverage — they couldn’t afford it. (Kaiser Health News is an editorially independent program of the Kaiser Family Foundation.)

And More About Warren’s Attach On  Klobuchar’s Health Plan

“Amy, I looked online at your (health care) plan. It’s two paragraphs.” Warren said.

This is highly misleading.

Warren’s campaign told PolitiFact that she was referring specifically to Klobuchar’s plan for “universal health care.” It pointed to the two paragraphs at the end of this Klobuchar campaign web page, which come under the heading “Propose legislation to get us to universal health care.” 

But that ignores most of Klobuchar’s health care plan, which she outlines in quite a bit of detail on four different web pages — a main health care policy page, a more detailed sub-page, a sub-page on prescription drugs and a sub-page on mental health.

We did a word count on the text from those four web pages, and it exceeded 6,000 words — and a lot more than two paragraphs.

PolitiFact’s Louis Jacobson contributed. 

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

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

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

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

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

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

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

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

Here’s how they came to be:

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

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

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

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

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

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

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

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

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

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

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

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

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

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Must-Reads Of The Week From Brianna Labuskes

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

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

Now on to equally fun things, like budgets!

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Stat: Fluctuating Funding and Flagging Interest Hurt Coronavirus Research


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

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


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

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

Reuters: Surprise Surgery Bills Happen Even When Patients Plan Ahead

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


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

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


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

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


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

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

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

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


In the miscellaneous file for the week:

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

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

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

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

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

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

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

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


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

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We (Heart) Health Policy Poets

Who says health policy can’t be fun? Experts lit up Twitter in recent days with valentine messages about topics ranging from drug prices and surprise medical bills to the Affordable Care Act and Kaiser Health News. Here are some of our favorites.

Robert Longyear:

Hey, don’t break my heart. I don’t have prior authorization!

Joanne Kenen:

Roses are red
Podcast at Kaiser.
We hope ‘What the Health?’
Makes you wiser.

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

Laura Marston:

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

Joshua Israel:

The red roses are ready
The champagne is still chilling.
I love you more than private equity
Loves surprise medical billing.

Avery Stewart:

Our love is like a hospital bill: no one understands it.

Tara Straw:

Roses are red
And given with love
You don’t need a web-broker
Because we’ve got HealthCare.gov.

Sarah Gollust:

Will it be your place or mine?
We have to make choices, my Valentine.
Should we expand benefits or reduce costs?
Health policy, like love, requires tradeoffs.

Ariel Cohen:

Roses are red,
Violets are blue,
Stop panicking about coronavirus,
You’re more likely to get the flu.

Meril Pothen:

The White House is red
But some states are blue
So health policy by litigation
Is all that we do.

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Americans Are Still Paying More And More In Health Costs But Not Because Amount Of Care Is Increasing

Would ‘Medicare For All’ Cost More Than U.S. Budget? Biden Says So. Math Says No.

During the Feb. 7 Democratic presidential debate, former Vice President Joe Biden once again questioned the price tag of “Medicare for All,” the single-payer health care proposal championed by one of his key rivals, Sen. Bernie Sanders of Vermont.

Biden argued that the plan was fiscally irresponsible and would require raising middle-class taxes. Specifically, he claimed, the plan “would cost more than the entire federal budget that we spend now.”

Medicare for All’s price — and whether it’s worth it — is a subject of fierce discussion among Democratic presidential candidates. But we had never heard this figure before. It caught our attention, so we decided to dig in.

Biden’s campaign directed us to the 2018 federal budget, which totaled $4.1 trillion. It compared that amount with the estimated cost of Sanders’ single-payer proposal: between $30 trillion and $40 trillion over a decade. The math, they said, shows Medicare for All would cost more than the national budget.

But it turns out, based on the numbers and interviews with independent experts, Biden’s comparison of Medicare for All’s price to total federal spending misses the mark because the calculation is flawed.

The Numbers

Sanders has said publicly that economists estimate Medicare for All would cost somewhere between $30 trillion and $40 trillion over 10 years. Research by the nonpartisan Urban Institute, a Washington, D.C., think tank, puts the figure in the $32 trillion to $34 trillion range.

We pointed out to Biden’s campaign that comparing 10-year spending estimates to one-year budgets is like comparing apples to oranges. The campaign suggested that if you take 10 times the current federal budget, you get a figure smaller than the estimated cost of Medicare for All over that 10-year window.

That calculation would lead you to multiply $4.1 trillion by 10 to get $41.1 trillion. That result is close to the high mark Sanders set for his program’s cost but well above the $34 trillion that Urban researchers projected.

Still, that’s not the correct way to formulate a comparison, experts say. “That’s not good math,” said Marc Goldwein, the senior vice president and senior policy director at the Committee for a Responsible Federal Budget. “That’s taking a 2018 number and multiplying it by 10, whereas the $34 trillion is a 10-year number that assumes a lot of growth.”

What you would need to do is add up the Congressional Budget Office’s projected budget outlays from 2020 to 2029, and compare the sum to the Medicare for All spending figure.

So we spoke to Linda Blumberg, an institute fellow at Urban’s Health Policy Center, who arrived at the $34 trillion estimate. She ran the CBO’s numbers: The next 10 years of on-budget outlay, the government office projects, add up to $44.8 trillion.

To be clear, $34 trillion (34 followed by 12 zeros) is no small sum. It accounts for about 75% of that nearly $45 trillion budget estimate and would represent a bigger single increase to the federal budget than we’ve ever experienced, Blumberg said.

That raises one point on which Biden may have some ground. Goldwein argued that you would indeed need significant tax increases to finance the Sanders proposal.

But its price tag still would be less than the projected budget.

“If he said [Medicare for All] was as big as the current federal budget, that would be incorrect,” Blumberg said.

Goldwein looked at the numbers another way: Including interest, he found, the federal budget would consume about $55 trillion between now and 2030. Again, that’s more than what Medicare for All would cost during the same period.

Big picture: No matter how you slice Biden’s math, his numbers are off.

“If what he said was Medicare for All will cost as much as the entire rest of the budget, that would be fair,” Goldwein said. But that’s not the same thing.

Our Ruling

Biden argued that Medicare for All “would cost more than the entire federal budget that we spend now.”

This relies on faulty math. Medicare for All would certainly represent a substantial increase to the federal budget. But it would neither match nor dwarf current federal spending overall. We rate this claim False.

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


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


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

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

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

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

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


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

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

To hear all Kaiser Health News podcasts, click here.

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

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


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


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

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

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

Among the takeaways from this week’s podcast:

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

To hear all our podcasts, click here.

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

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Viewpoints: With America Facing Serious Problems Like Obesity, Why Retreat On Healthy School Lunches?; Lessons On Caring For Elderly During Climate Crisis

After Drug Is Granted Orphan Status, Hospitals Can Be Left Paying Millions For Treatment That Was Cheap, Attainable

Ways & Means Advances Surprise Medical Bills Measure That Would Rely On Hospital-Friendly Arbitration Method

Viewpoints: Where Is All The Important Information Health Care Providers Need About Coronavirus?; Suppressing News Is China’s Biggest Medical Mistake

Even When Patients Plan Ahead A Significant Number Can Be Walloped By Surprise Medical Bills

When Your Doctor Is Also A Lobbyist: Inside The War Over Surprise Medical Bills

When Carol Pak-Teng, an emergency room doctor in New Jersey, hosted a fundraiser in December for Democratic freshman Rep. Tom Malinowski, her guests, mostly doctors, were pleased when she steered the conversation to surprise medical bills.

This was a chance to send a message to Washington that any surprise billing legislation should protect doctors’ incomes in their battle over payments with insurers. Lawmakers are grappling over several approaches to curtail the practice, which can leave patients on the hook for huge medical bills, even if they have insurance.

As Congress begins its 2020 legislative session, there is evidence the doctors’ message has been received: The bills with the most momentum are making more and more concessions to physicians.

As surprise medical billing has emerged as a hot-button issue for voters, doctors, hospitals and insurers have been lobbying to protect their own money flows. All that lobbying meant nothing got passed last year.

Television and internet ads are the most visible manifestation of the battle. But in taking their cause to politicians, doctors like Pak-Teng have waged an extraordinary on-the-ground stealth campaign to win over members of Congress. Their professional credentials give them a kind of gravitas compared with other lobbyists, who are merely hired guns.

Ending the practice of billing patients for the amount of their treatment not covered by insurance — sometimes triggered by unwittingly seeing a doctor out of network — is ultimately a fight between doctors and insurers over rate-setting and reimbursement. But as more patients balk at surprise bills — or suffer the enormous financial strain — lawmakers are under pressure to protect patients. In turn, powerful lobbying forces have activated to protect doctors and insurers who don’t want to pay the price for a fix.

The main message physicians are using to bring lawmakers into their corner? “We just want to be paid a fair amount for the services rendered,” Pak-Teng said.

Her congressman, Malinowski, has not endorsed any surprise billing legislation. In congressional testimony in July, he cited the “extra $420 million” in medical debt patients in New Jersey reckon with each year.

“There are many things that Republicans and Democrats sincerely disagree about in this body,” he said. “I don’t think that this is one of them. I don’t see any philosophical difference amongst us about whether people should be stuck with massive surprise medical bills.”

Doctors say they are taking the brunt of the criticism.

But little has been as powerful in shaping surprise billing legislation as the clout of hospitals and their doctors, many of whom are, in fact, employed by private equity-backed companies and armed with years of experience shaping surprise billing legislation at the state level.

They are throwing in a lot of money, too, funneling millions to lawmakers ahead of the 2020 elections. Four physician organizations that have heavily lobbied on surprise medical bills and have private equity ties — the American College of Emergency Physicians, Envision Healthcare, US Acute Care Solutions and U.S. Anesthesia Partners — gave roughly $1.1 million in 2019 to members of Congress, according to a Kaiser Health News analysis of Federal Election Commission records.

The biggest recipients, from all four PACs combined, were Reps. Donna Shalala and Stephanie Murphy, Florida Democrats who got $26,000 each. Sen. Thom Tillis (R-N.C.) took in $25,500, Senate Majority Leader Mitch McConnell got $25,000, and Rep. Brett Guthrie (R-Ky.) received $22,500.

That was in tandem with a ground game led by local doctors. ER doctors, anesthesiologists, radiologists and other specialists who most often charge out-of-network prices — and also are among the highest-compensated practitioners — fanned out to shape legislation in a way that maintains their pay, and to voice their concern to lawmakers that insurance companies would have too much leverage to control their compensation.

“We by necessity place a tremendous amount of trust in our physicians,” said Zack Cooper, an assistant professor at Yale University who has extensively researched surprise medical bills. “Frankly, they have an easier time lobbying members [of Congress] than the folks who are affected by surprise billing.”

Arguing Over The Fix

Lawmakers in both parties appear unified on the need to resolve the problem of surprise billing. But as was clear when all the air blew out of legislative proposals on the table at year’s end, that is largely where the agreement ends.

Fixing the problem comes down to settling on a system for deciding how much to pay for a disputed bill. One approach is to set up an outside arbitration process, in which doctors and insurance companies would negotiate payment — this is the model preferred by doctors, who contend it puts them on better footing against insurance companies. Another option would be to resolve surprise billing disputes by having insurance companies pay doctors based on the median in-network rate for the service, an approach known as benchmarking. Large employers, labor unions and insurance companies prefer this.

The failure to get legislation through Congress set up a potentially explosive battle in an election year. Republicans and Democrats who have vowed to do something about health care costs must reckon with powerful industry groups whose influence transcends party lines.

Meanwhile, physicians and hospitals have made their case in Washington and back home through in-person meetings and phone calls with lawmakers and congressional staff. They’ve hosted dinners and fundraisers and organized fly-ins to swarm Capitol Hill with in-person meetings. They’ve even led tours of their emergency rooms.

Pak-Teng is among them, coming to Washington this month with other physicians to petition lawmakers. She is employed by Envision, a physician staffing company backed by private equity firm KKR. She’s also on the board of the American Academy of Emergency Medicine, a trade organization representing ER doctors.

“There is a lot of anti-physician rhetoric out there,” said Pak-Teng, who is pushing her physician colleagues to be more active in shaping public policy by sharing stories about the reality of caring for patients.

The lobbying by hospitals and physicians trying to protect their reimbursements has divided key lawmakers, compounding disagreements among senior House Democrats over the policy details of a bill and turf wars in Congress. Three House committees have now unveiled legislation to ban surprise medical bills, each with different details.

“We are not trying to stop legislation. We are trying to stop bad legislation,” said Anthony Cirillo, an emergency medicine physician who describes a “bad” bill as one that favors insurance companies over doctors.

Cirillo is also a lobbyist for US Acute Care Solutions, a physician staffing company backed by private equity firm Welsh, Carson, Anderson & Stowe. WCAS, which manages $27 billion in assets and is focused on health care and technology investments, is based in New York City and co-founded US Acute Care Solutions in 2015.

In an interview, Cirillo said he met with lawmakers and their aides about “10 to 12 times” in Washington last year. Financial disclosures show he spent $340,000 between July and September lobbying on surprise billing on behalf of US Acute Care Solutions. USACS’ political committee also contributed $134,500 to lawmakers in 2019, according to FEC records.

Tilt Toward Doctors

Before the private equity-fueled dark-money group Doctor Patient Unity started running ads warning of the dangers of government price controls as an argument against legislation, surprise billing legislation being drafted in one of Congress’ most powerful health care committees was already tilting to be more favorable to doctors.

“People on the Hill are very sympathetic to hospitals and physicians because they’re actually providing the care itself,” said one Democratic aide, speaking on the condition of anonymity to candidly describe sensitive political dynamics. “Nobody wants to defend the insurers.”

In May, a House Energy and Commerce Committee draft proposal included no mention of outside arbitration. The same was true for a bill the Senate Health, Education, Labor and Pensions Committee approved in June. Instead, under those proposals, surprise billing disputes would be resolved by insurance companies paying doctors based on similar rates in that area.

By mid-July, though — roughly a week before Doctor Patient Unity registered as a business in Virginia — the Energy and Commerce legislation was amended to allow doctors to appeal to an independent arbiter if their payments exceed $1,250. The revision was pushed by two physicians on the committee — Democrat Raul Ruiz of California and Republican Larry Bucshon of Indiana — and was a moment Sherif Zaafran, a Texas anesthesiologist, describes as a “turning point” in negotiations over the bill.

“It’s all about fairness,” said Zaafran, who works for private equity-backed U.S. Anesthesia Partners. He has been involved for a decade in surprise billing fights in Texas, which enacted a new law with an arbitration process last year. U.S. Anesthesia Partners gave $197,900 in campaign contributions to members of Congress last year.

Zaafran chaired another coalition of medical specialists, Physicians for Fair Coverage, in 2019, and pressured Congress to pursue a surprise billing approach modeled on a New York law under which insurers and providers rely on arbitration. Under that process, if there is a payment dispute between doctors and insurers, the two sides submit a proposed dollar amount to an independent mediator, who then selects one.

In New York, the mediators were told to base their decisions on the 80th percentile of the prices set by the hospital or physician. Research has suggested that the model is broadly making health care more expensive for state residents because of higher payments to doctors, according to findings from the USC-Brookings Schaeffer Initiative for Health Policy.

Still, on Capitol Hill, doctors complained that many procedures would fail to cost enough to qualify for arbitration as proposed in the Energy and Commerce bill, bolstered by data ER doctors presented to lawmakers showing that prices mainly fall below $1,250.

“It’s largely out of reach,” said Laura Wooster, a lobbyist with the American College of Emergency Physicians, whose political action committee contributed $708,000 to lawmakers in 2019. “The problem with a threshold is, you just have one threshold. It’s going to impact different specialties so differently.”

By December, House Energy and Commerce Committee leaders and Sen. Lamar Alexander, a Republican who chairs the Senate HELP Committee, agreed to lower the arbitration threshold to $750 as part of a bipartisan agreement on a bill. Notably, several hospital lobbying organizations, such as the American Hospital Association and the Greater New York Hospital Association — the latter a strong financial backer of Senate Minority Leader Chuck Schumer — refused to back the deal.

Pak-Teng and other physicians also say that arbitration threshold is still too high. The House Education and Labor Committee has unveiled surprise billing legislation with a similar framework.

“I’m open to listening to all sides on this,” Rep. Greg Walden of Oregon, the top Republican on the House Energy and Commerce Committee, said in an interview. “We want to make sure doctors are adequately compensated.”

Walden had harsh words for private equity firms that have attacked the Energy and Commerce legislation in a series of TV and internet ads, saying they were “misleading and scaring people” and just made lawmakers dig in deeper. The ads prompted a bipartisan probe from Walden and committee Chairman Frank Pallone (D-N.J.) into how the companies have influenced surprise billing practices.

“I’m not trying to hurtle a rock at them, but they’ve been throwing a few my way,” he said.

What’s Coming

Arvind Venkat, a Pittsburgh emergency physician employed by US Acute Care Solutions, traveled to Washington multiple times last year to meet with congressional offices representing Pennsylvania. But he also made sure to bring up surprise bills on his home turf, giving his congressman, freshman Democrat Conor Lamb, a tour of the emergency room at Allegheny General Hospital last summer.

“There are two issues here,” said Venkat, who leads the Pennsylvania chapter of the American College of Emergency Physicians and has practiced at Allegheny General for 12 years. “Patients need to be protected, [and] we need to avoid anything that disrupts in-network relationships between insurers and clinicians.”

The call seems to have been heard: Legislation is likely to change further this year as the House Ways and Means Committee pushes an approach that is friendlier to hospitals and doctors. It builds off a one-page document committee leaders issued Dec. 11 that blunted momentum for a bipartisan deal that was to be included in a December spending bill.

The latest proposal from the committee includes an arbitration process to resolve payment disputes, with no minimum dollar amount needed to trigger it, and doesn’t ban surprise billing from air ambulance companies — a win for yet another special-interest lobbying group. The patient protections would not take effect until 2022.

U.S. Rep. Richard Neal, a Massachusetts Democrat who chairs the House Ways and Means Committee, remains an ally of Massachusetts hospitals.(Hannah Norman/KHN Illustration; Getty Images)

Richard Neal, a Massachusetts Democrat who chairs the committee, remains an ally of Massachusetts hospitals. He released the brief December surprise billing document two days after the Massachusetts Medical Society and Massachusetts Hospital Association wrote a joint op-ed in The Boston Globe arguing that benchmarking physician payments — as the Senate HELP and Energy and Commerce deal would do — would wreck the state’s health care system.

“The heavy hand of government would create an unfair imbalance in the health care marketplace and insurers would have no incentive to engage physicians in building robust health care networks. The connected system of care we have all been working toward in Massachusetts would immediately become fragmented and disjointed,” the two groups wrote in The Boston Globe.

“They weren’t asking for favorable treatment. They were asking for fair treatment, and there’s a big difference,” Neal said in an interview. “I don’t want to rule anything out, but I think that the momentum right now is arbitration.”

“We need to get a little bit more balance,” added Shalala, who endorsed the Ways and Means legislation unveiled earlier this month.

Shalala has at least two hospitals in her Miami-area district that rely on private equity-supported physician staffing companies.

“I’m worried about the hospitals,” she said. “And the providers obviously include the docs.”

Victoria Knight contributed to this story.

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Insurers Try To Avoid Trump Administration Order By Taking Price Transparency Into Their Own Hands

One Defensive Strategy Against Surprise Medical Bills: Set Your Own Terms

When Stacey Richter’s husband recently landed in a New Jersey emergency room, fearing a heart attack, she had an additional reason for alarm: a potential big bill from the hospital if the ER wasn’t in his insurer’s network.

So she took an unusual step. Instead of simply signing the hospital’s financial and treatment consent form, Richter first crossed out sections calling for her to pay whatever amount the hospital charged. She wrote in her own payment rate of a “maximum of two times” what the federal government would pay under Medicare, which is in the ballpark, experts said, of what hospitals might consider an acceptable rate.

“And then I signed it, took a picture of it and handed it back to them,” said Richter, co-president of the consultancy Aventria Health Group.

Advocates say such consent-form alterations could provide some protection from surprise bills, though there are several major caveats to this largely untested idea.

These bills — often called “balance bills” — happen when out-of-network providers charge more than insurers pay and patients are responsible for paying the balance. Lawmakers say they are considering ways to help, but legislation stalled in Congress late last year. And though some states have balance-bill laws in place, they don’t apply to many patients with job-based insurance.

Richter and other proponents say patients should look to state contract law for protection.

What few patients realize is that admission and financial forms serve as contracts detailing that the hospital will provide certain services and patients will pay for them. Those forms often specify that patients are responsible for “total charges.”

And therein lies the problem for those who find themselves at an out-of-network facility or are seen by an out-of-network provider at an in-network hospital.

In those cases, providers often bill full “charges,” which are amounts set by the providers themselves and can be several times higher than what insurers or Medicare generally pay. Privately insured patients — generally, not Medicare patients — can be held responsible for the balance.

But, by writing in their own limits, patients might have leverage in negotiations or even in courts if out-of-network payment disputes arise, or at least proof they didn’t agree to pay the total charges, say advocates and some legal scholars.

Patients who try this could still get hit with a large balance bill. But “the difference is you can say ‘I offered this, but they refused it,’” rather than signing the original agreement to pay all charges, said proponent Al Lewis, CEO of Quizzify, an employee health care education company.

He came up with the twice-Medicare benchmark, even putting suggested wording for patients to print and carry with them on downloadable wallet cards, because he says it’s an amount that’s defensible.

If a hospital later turns down “two times Medicare and it goes to court, their lawyer is going to say, ‘We could lose this thing,’” said Lewis.

Such efforts are best applied only in emergencies — where federal law requires hospitals to stabilize patients and not toss them into the parking lot — no matter their ability to pay. However, patients who refuse to sign documents or try to alter them in nonemergencies — say, at a doctor visit or for elective surgery — could be refused service.

Even in emergencies, there is no guarantee the hospital will later agree to limits proposed by patients on what it can charge for out-of-network care.

“It’s a hard argument to make if the patient changes it unilaterally,” said Ericka Adler, a partner at law firm Roetzel & Andress in Chicago, who represents physician group practices, including those who work out-of-network in hospitals. “It won’t be a valid contract unless both parties sign it.”

She has not had this happen with her hospital-based clients. But with office-based physicians in nonemergency cases, some patients have tried writing caveats onto their forms.

“We have never had trouble enforcing the terms of our original policy,” she said.

Still, some legal scholars question the premise that hospitals’ financial consent forms are themselves valid contracts. That’s because contract law requires “mutual assent,” something law professor Barak Richman said patients can’t really give because they are seldom told the true price of care upfront, before signing.

“There’s something deeply exploitive about the process,” said Richman, who studies contract law and teaches at Duke University Law School.

Al Lewis, CEO and co-founder of employee education consulting firm Quizzify, recommends that patients always carry this wallet card. It displays suggested wording that he says might help reduce the amount they could be billed for out-of-network emergency care. He emphasizes its value in emergencies because, under federal law, patients with true emergencies must be treated until stabilized, regardless of their ability to pay.(KHN Screenshot of Quizzify’s website)

Still, he noted that judges often “are far too deferential to these contracts” when disputed balance bills end up in court, especially the vague wording that patients “promise to pay all charges.”

If patients alter the wording with their own terms — so long as they agree to pay what is considered a reasonable amount — then judges may also look to that added language, said Richman.

“This is not crazy by any means,” said Richman. “To the degree that courts rely on specific language of the admission contract, then this should be a successful strategy.”

But it isn’t easy to speak up, particularly in emergencies, which are already fraught.

“I believe it would be legally effective,” said Mark Hall, a professor of law and public health at Wake Forest University. “However, it requires patients to be much more astute and well prepared than is typical in most surprise billing situations.”

Richter said she had to endure some “toe-tapping” by an impatient administrator when she insisted on a paper copy of the consent form, rather than signing on the computer pad offered.

As it turned out, there was no additional bill for her husband, who gets his insurance through his job. The couple doesn’t know if that’s because everyone who saw him was in-network, or if it was her proactive stance on the forms.

“I am one who will not be peer-pressured,” said Richter.

A real solution needs to be broader than simply individuals trying to rewrite hospital contracts, Richman said.

“No one thinks we can solve this national epidemic of surprise bills with individual court cases,” he said. “But what this does could create an awareness of what people are signing” when they receive care.

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Better Than Other Plans Or Better Than Nothing? Trump’s Claim About ‘Affordable’ Options

In his wide-ranging State of the Union address, President Donald Trump returned to a favorite theme: the cost of health insurance.

He cited the high cost of premiums for people who buy their coverage through the Affordable Care Act marketplaces and said his administration has provided new, less costly coverage.

“I moved quickly to provide affordable alternatives. Our new plans are up to 60% less expensive and better,” Trump told the lawmakers gathered at the Capitol.

So we wondered, to which new alternatives was he referring? We reached out to the White House to ask.

Spokesperson Adam Kennedy responded that the president was talking about short-term, limited-duration plans. But that got us thinking: Are they really less expensive and better? Or simply better than nothing?

First, Are They New?

They are not. As background, short-term insurance plans have been around for decades in various iterations and are generally considered a stopgap solution for people between jobs or attending school. They provide some protections, usually paying a percentage of hospital and doctor bills after the policyholder meets a deductible.

But they’ve always been a bit controversial.

Unlike the ACA plans now available, short-term plans can bar people with health conditions from enrolling or exclude coverage for specific conditions or treatments. They also offer fewer benefits — meaning they are not required to comply with the health law’s mandated essential benefits requirement.

So, for example, they don’t have to cover prescription drugs, or mental health services or substance abuse treatment — and many don’t. In addition, they can set annual or lifetime caps on benefits. Almost all exclude maternity care.

If a person develops a health condition during the coverage term, insurers can look through their medical records and, in some cases, retroactively cancel the plans — or refuse to renew the coverage at the end of the policy’s term.

The Obama administration restricted these policies, which still cannot be sold on the ACA marketplaces and do not qualify for subsidies, to a maximum coverage period of 90 days, down from the 364 days that applied previously.

The Trump administration reversed that time-limit restriction in 2018 and built on it by allowing insurers to offer policies renewable for up to three years.

Officials, including Health and Human Services Secretary Alex Azar, said at the time that these short-term plans provide an alternative but aren’t a good fit for everyone.

For instance, the Trump rules require the policies to carry a warning that they aren’t “required to comply with federal requirements for health insurance.” They also state that consumers should “check the policy carefully to make sure you understand what the policy does and doesn’t cover.”

Are These Plans Less Expensive?

The White House pointed us toward a January 2019 report produced by the Congressional Budget Office and the Joint Committee on Taxation as the source for the president’s assertion that these plans are 60% less expensive.

It quickly becomes clear that the analysis is very wonky and complex.

After all, it’s not easy to project what benefits insurers will include in short-term plans or what they will charge individuals, which can vary based on their health. Even the analysts called the estimating process “challenging.”

When it came right down to it, they hedged: Short-term plans are likely cheaper than the lowest-cost ACA plan for some consumers, but more expensive for others. For example, people who get a federal tax credit to buy ACA-compliant insurance or those who are older or less healthy would likely pay more in premiums for a traditional short-term plan, the analysts said.

Conversely, those without subsidies, especially younger or healthier consumers, might pay as much as 60% less than they would for the lowest-cost plan through the ACA, the analysis concluded. Another study, not cited by the White House but done by the conservative Manhattan Institute, also listed caveats, but more robustly defended the plans as less expensive. Premiums for short-term plans are lower — in some cases, almost half the cost — of ACA plans, it concluded.

But critics put these price tags in context. “I don’t have a reason to suspect the 60% is wrong if they’re lining them up against ACA plans, but if you’re a health plan that doesn’t cover much, it’s easy enough to offer a cheap premium,” said Sabrina Corlette, research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.

So That Gets To The Question, Are They Better?

The consensus is that the coverage short-term plans provide is not better than that of ACA plans. But it could be better than going without insurance entirely.

“Why not throw another option out there?” said Doug Badger, senior fellow at the conservative Galen Institute. “You might say this plan isn’t as good as that plan, but we may both agree that having this one is better than nothing.”

He said that should be a decision made by consumers, who can weigh the pros and cons: “They know their circumstances and risk tolerance.”.

Still, it’s a gamble, as no one knows what health conditions might befall them. A plan that doesn’t cover prescription drugs may be fine the first month, but if a serious illness crops up, it suddenly has unexpected costs.

Others also note that short-term plans may have wider networks of doctors and hospitals than some ACA plans, giving consumers more options.

“In Texas, for example, you cannot buy an ACA plan that covers MD Anderson,” the cancer center of the University of Texas, said Brian Blase, CEO of Blase Policy Strategies. Blase has advised Trump on his health policy efforts. “The only way you can have such a plan that includes MD Anderson — unless you have employer coverage — is in a short-term plan.”

Again, nice to have a wide network. But there’s a conundrum. Someone with cancer — attracted to a network because it includes MD Anderson — would be rejected by most short-term plans.

That ability to reject applicants — or seriously limit coverage of their preexisting conditions — helps keep premiums down.

But those are also the main reasons experts say the plans are not better than those offered under the ACA, which bars such limits.

A preexisting condition is often defined as anything treated — or for which a “prudent person” should have sought treatment — during the previous 12 months to five years, depending on the insurer.

“If you have high blood pressure and, while on one of these plans, you have a heart attack, the plan could say that was a preexisting condition,” said Corlette.

State regulation of such plans varies widely, as do the coverage benefits and limits offered by various insurers. Some have limits listed in the fine print.

While short-term plans have been embraced by regulators in some states, nearly half of all states have moved to limit them to less than 12 months. Four — California, Massachusetts, New Jersey and New York — have barred them altogether.

Those states cite concerns about the effect on ACA premiums and the risk that consumers could be left hanging by the more limited nature of the short-term plans.

Our Ruling

Trump said these are new plans that are 60% cheaper and better.

But short-terms plans are not a new idea. Just how much cheaper they are depends on a lot of factors, experts told us. And it’s very hard to examine them in an apples-to-apples comparison with ACA plans, which cover far more and are required to accept all applicants.

Given the limitations of short-term plans, they’re not better than ACA plans for most people, because policyholders could face potentially significant financial risk — or find their treatment needs are not covered. They’re definitely not better for people who qualify for federal subsidies to buy ACA insurance, especially those at the lower end of that income range, where the subsidies are larger.

That said, a short-term plan may be better than going without coverage at all, particularly for a young or otherwise healthy person, whose income is above subsidy limits.

We rate this claim as Mostly False.

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