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Marisol Pantoja Toribio found a lump in her breast in early January. Uninsured and living in California without legal status and without her family, the usually happy-go-lucky 43-year-old quickly realized how limited her options were.
“I said, ‘What am I going to do?’” she said in Spanish, quickly getting emotional. She immediately worried she might have cancer. “I went back and forth — I have [cancer], I don’t have it, I have it, I don’t have it.” And if she was sick, she added, she wouldn’t be able to work or pay her rent. Without health insurance, Pantoja Toribio couldn’t afford to find out if she had a serious condition.
Beginning this year, Medi-Cal, California’s Medicaid program, expanded to include immigrants lacking legal residency, timing that could have worked out perfectly for Pantoja Toribio, who has lived in the Bay Area city of Brentwood for three years. But her application for Medi-Cal was quickly rejected: As a farmworker earning $16 an hour, her annual income of roughly $24,000 was too high to qualify for the program.
California is the first state to expand Medicaid to all qualifying adults regardless of immigration status, a move celebrated by health advocates and political leaders across the state. But many immigrants without permanent legal status, especially those who live in parts of California where the cost of living is highest, earn slightly too much money to qualify for Medi-Cal.
The state is footing the bill for the Medi-Cal expansion, but federal law bars those it calls “undocumented” from receiving insurance subsidies or other benefits from the Affordable Care Act, leaving many employed but without viable health insurance options.
Now, the same health advocates who fought for the Medi-Cal expansion say the next step in achieving health equity is expanding Covered California, the state’s ACA marketplace, to all immigrant adults by passing AB 4.
“There are people in this state who work and are the backbone of so many sectors of our economy and contribute their labor and even taxes … but they are locked out of our social safety net,” said Sarah Dar, policy director at the California Immigrant Policy Center, one of two organizations sponsoring the bill, dubbed #Health4All.
To qualify for Medi-Cal, an individual cannot earn more than 138% of the federal poverty level, which currently amounts to nearly $21,000 a year for a single person. A family of three would need to earn less than $35,632 a year.
For people above those thresholds, the Covered California marketplace offers various health plans, often with federal and state subsidies, yielding premiums as low as $10 a month. The hope is to create what advocates call a “mirror marketplace” on the Covered California website so that immigrants regardless of status can be offered the same health plans that would be subsidized only by the state.
Despite a Democratic supermajority in the legislature, the bill might struggle to pass, with the state facing a projected budget deficit for next year of anywhere from $38 billion to $73 billion. Gov. Gavin Newsom and legislative leaders announced a $17 billion package to start reducing the gap, but significant spending cuts appear inevitable.
It’s not clear how much it would cost to extend Covered California to all immigrants, according to Assembly member Joaquin Arambula, the Fresno Democrat who introduced the bill.
The immigrant policy center estimates that setting up the marketplace would cost at least $15 million. If the bill passes, sponsors would then need to secure funding for the subsidies, which could run into the billions of dollars annually.
“It is a tough time to be asking for new expenditures,” Dar said. “The mirror marketplace startup cost is a relatively very low number. So we’re hopeful that it’s still within the realm of possibility.”
Arambula said he’s optimistic the state will continue to lead in improving access to health care for immigrants who lack legal residency.
“I believe we will continue to stand up, as we are working to make this a California for all,” he said.
The bill passed the Assembly last July on a 64-9 vote and now awaits action by the Senate Appropriations Committee, Arambula’s office said.
An estimated 520,000 people in California would qualify for a Covered California plan if not for their lack of legal status, according to the labor research center at the University of California-Berkeley. Pantoja Toribio, who emigrated alone from Mexico after leaving an abusive relationship, said she was lucky. She learned about alternative health care options when she made her weekly visit to a food pantry at Hijas del Campo, a Contra Costa County farmworker advocacy organization, where they told her she might qualify for a plan for low-income people through Kaiser Permanente.
Pantoja Toribio applied just before open enrollment closed at the end of January. Through the plan, she learned that the lump in her breast was not cancerous.
Oregon is shipping air conditioners, air purifiers, and power banks to some of its most vulnerable residents, a first-in-the-nation experiment to use Medicaid money to prevent the potentially deadly health effects of extreme heat, wildfire smoke, and other climate-related disasters.
The equipment, which started going out in March, expands a Biden administration strategy to move Medicaid beyond traditional medical care and into the realm of social services.
At least 20 states, including California, Massachusetts, and Washington, already direct billions of Medicaid dollars into programs such as helping homeless people get housing and preparing healthy meals for people with diabetes, according to KFF. Oregon is the first to use Medicaid money explicitly for climate-related costs, part of its five-year, $1.1 billion effort to address social needs, which also includes housing and nutrition benefits.
State and federal health officials hope to show that taxpayer money and lives can be saved when investments are made before disaster strikes.
“Climate change is a health care issue,” so helping Oregon’s poorest and sickest residents prepare for potentially dangerous heat, drought, and other extreme weather makes sense, said Health and Human Services Secretary Xavier Becerra on a visit to Sacramento, California, in early April.
Becerra said the Biden administration wants states to experiment with how best to improve patient health, whether by keeping someone housed instead of homeless, or reducing their exposure to heat with an air conditioner.
But Medicaid’s expansion into social services may duplicate existing housing and nutrition programs offered by other federal agencies, while some needy Americans can’t get essential medical care, said Gary Alexander, director of the Medicaid and Health Safety Net Reform Initiative at the Paragon Health Institute.
“There are 600,000 or 700,000 intellectually disabled people in the United States waiting for Medicaid services. They’re on a waitlist,” said Alexander, who oversaw state health agencies in Pennsylvania and Rhode Island. “Meanwhile Medicaid has money for housing and food and air conditioners for recipients. Seems to me that we should serve the intellectually disabled first before we get into all of these new areas.”
Scientists and public health officials say climate change poses a growing health risk. More frequent and intense floods, droughts, wildfires, extreme temperatures, and storms cause more deaths, cardiovascular disease from poor air quality, and other problems, according to the federal government’s Fifth National Climate Assessment.
The mounting health effects disproportionately hit low-income Americans and people of color, who are often covered by Medicaid, the state-federal health insurance program for low-income people.
Most of the 102 Oregonians who died during the deadly heat dome that settled over the Pacific Northwest in 2021 “were elderly, isolated and living with low incomes,” according to a report by the Oregon Health Authority, which administers the state’s Medicaid program, with about 1.4 million enrollees. The OHA’s analysis of urgent care and emergency room use from May through September of 2021 and 2022 found that 60% of heat-related illness visits were from residents of areas with a median household income below $50,000.
“In the last 10-plus years, the amount of fires and smoke events and excessive heat events that we’ve had has shown the disproportionate impact of those events on those with lower incomes,” said Dave Baden, the OHA’s deputy director for programs and policy.
And, because dangerously high temperatures aren’t common in Oregon, many residents don’t have air conditioning in their homes.
Traditionally, states hit by natural disasters and public health emergencies have asked the federal government for permission to spend Medicaid dollars on back-up power, air filters, and other equipment to help victims recover. But those requests came after the fact, following federal emergency declarations.
Oregon wants to be proactive and pay for equipment that will help an estimated 200,000 residents manage their health at home before extreme weather or climate-related disaster hits, Baden said. In addition to air conditioning units, the program will pay for mini fridges to keep medications cold, portable power supplies to run ventilators and other medical devices during outages, space heaters for winter, and air filters to improve air quality during wildfire season.
In March, the Oregon Health Plan, the state’s Medicaid program, began asking health insurers to find patients who might need help coping with extreme weather. Recipients must meet federal guidelines that categorize them as “facing certain life transitions,” a stringent set of requirements that disqualify most enrollees. For example, a person with an underlying medical condition that could worsen during a heat wave, and who is also at risk for homelessness or has been released from prison in the past year, could receive an air conditioner. But someone with stable housing might not qualify.
“You could be in a housing complex, and your neighbor qualified for an air conditioner and you didn’t,” Baden said.
At the offices of insurer AllCare Health in Grants Pass, Oregon, air conditioners, air filters, and mini fridges were piled in three rooms in mid-April, ready to be handed over to Medicaid patients. The health plan provided equipment to 19 households in March. The idea is to get the supplies into people’s homes before the summer fire season engulfs the valley in smoke.
Health plans don’t want to find themselves “fighting the masses” at Home Depot when the skies are already smoky or the heat is unbearable, said Josh Balloch, AllCare’s vice president of health policy.
“We’re competing against everybody else, and you can’t find a fan on a hot day,” he said.
Oregon and some other states have already used Medicaid money to buy air conditioners, air purifiers, and other goods for enrollees, but not under the category of climate change. For example, California offers air purifiers to help asthma patients and New York just won federal approval to provide air conditioners to asthma patients.
Baden said Oregon health officials will evaluate whether sending air conditioners and other equipment to patients saves money by looking at their claim records in the coming years.
If Oregon can help enrollees avoid a costly trip to the doctor or the ER after extreme weather, other state Medicaid programs may ask the federal government if they can adopt the benefit. Many states haven’t yet used Medicaid money for climate change because it affects people and regions differently, said Paul Shattuck, a senior fellow at Mathematica, a research organization that has surveyed state Medicaid directors on the issue.
“The health risks of climate change are everywhere, but the nature of risk exposure is completely different in every state,” Shattuck said. “It’s been challenging for Medicaid to get momentum because each state is left to their own devices to figure out what to do.”
A California state lawmaker last year introduced legislation that would have required Medi-Cal, the state’s Medicaid program, to add a climate benefit under its existing social services expansion. The program would have been similar to Oregon’s, but AB 586, by Assembly member Lisa Calderon, died in the Assembly Appropriations Committee, which questioned in a staff analysis whether “climate change remediation supports can be defined as cost-effective.”
The cost savings are clear to Kaiser Permanente. After the 2021 heat wave, it sent air conditioners to 81 patients in Oregon and southwest Washington whose health conditions might get worse in extreme heat, said Catherine Potter, community health consultant at the health system. The following year, Kaiser Permanente estimated it had prevented $42,000 in heat-related ER visits and $400,000 in hospital admissions, she said.
“We didn’t used to have extreme heat like this, and we do now,” said Potter, who has lived in the temperate Portland area for 30 years. “If we can prevent these adverse impacts, we should be preventing them especially for people that are going to be most affected.”
Cass Smith-Collins jumped through hoops to get the surgery that would match his chest to his gender.
Living in Las Vegas and then 50, he finally felt safe enough to come out as a transgender man. He had his wife’s support and a doctor’s letter showing he had a long history of gender dysphoria, the psychological distress felt when one’s sex assigned at birth and gender identity don’t match.
“I had one shot to get the chest that I should have been born with, and I wasn’t going to chance it to someone who was not an expert at his craft,” he said.
Smith-Collins arranged to spend a week in Florida and contacted friends there who could help him recover from the outpatient procedure, he said.
Garramone’s practice required that the patient agree to its financial policies, according to documents shared by Smith-Collins. One document stated that “full payment” of Garramone’s surgical fees is required four weeks in advance of surgery and that all payments to the practice are “non-refundable.”
Smith-Collins said he and his wife dipped into their retirement savings to cover the approximately $14,000 upfront. With prior authorization from his insurer in hand saying the procedure would be “covered,” he thought his insurance would reimburse anything he paid beyond his out-of-pocket maximum for out-of-network care: $6,900.
The day before surgery, Smith-Collins signed another agreement from the surgeon’s practice, outlining how it would file an out-of-network claim with his insurance. Any insurance payment would be received by the doctor, it said.
The procedure went well. Smith-Collins went home happy and relieved.
Then the bill came. Or in this case: The reimbursement didn’t.
The Patient: Cass Smith-Collins, now 52, who has employer-based coverage through UnitedHealthcare.
Medical Services: Double-incision top surgery with nipple grafts, plus lab work.
Service Provider: Aesthetic Plastic Surgery Institute, doing business as The Garramone Center, which is owned by Garramone, according to Florida public records.
Total Bill: The surgeon’s practice billed the patient and insurance a total of $120,987 for his work. It charged the patient about $14,000 upfront — which included $300 for lab work and a $1,000 reservation fee — and then billed the patient’s insurer an additional $106,687.
The surgeon later wrote the patient that the upfront fee was for the “cosmetic” portion of the surgery, while the insurance charge was for the “reconstructive” part. Initially, the insurer paid $2,193.54 toward the surgeon’s claim, and the patient received no reimbursement.
After KFF Health News began reporting this story, the insurer reprocessed the surgeon’s claim and increased its payment to the practice to $97,738.46. Smith-Collins then received a reimbursement from Garramone of $7,245.
What Gives: Many patients write to Bill of the Month each year with their own tangled billing question. In many cases — including this one — the short answer is that the patient misunderstood their insurance coverage.
Smith-Collins was in a confusing situation. UnitedHealthcare said his out-of-network surgery would be “covered,” then it later told Smith-Collins it didn’t owe the reimbursement he had counted on. Then, after KFF Health News began reporting, he received a reimbursement.
Adding to the confusion were the practice’s financial polices, which set a pre-surgery payment deadline, gave the doctor control of any insurance payment, and left the patient vulnerable to more bills (though, fortunately, he received none).
Agreeing to an out-of-network provider’s own financial policy — which generally protects its ability to get paid and may be littered with confusing insurance and legal jargon — can create a binding contract that leaves a patient owing. In short, it can put the doctor in the driver’s seat, steering the money.
The agreement Smith-Collins signed the day before surgery says that the patient understands he is receiving out-of-network care and “may be responsible for additional costs for all services provided” by the out-of-network practice.
UnitedHealthcare said Smith-Collins’ out-of-network surgery would be “covered,” then it later told him it didn’t owe the reimbursement he had counted on. Then, after KFF Health News began reporting, he received a reimbursement.(Bridget Bennett for KFF Health News)
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Federal billing protections shield patients from big, out-of-network bills — but not in cases in which the patient knowingly chose out-of-network care. Smith-Collins could have been on the hook for the difference between what his out-of-network doctor and insurer said the procedure should cost: nearly $102,000.
Emails show Smith-Collins had a couple of weeks to review a version of the practice’s out-of-network agreement before he signed it. But he said he likely hadn’t read the entire document because he was focused on his surgery and willing to agree to just about anything to get it.
“Surgery is an emotional experience for anyone, and that’s not an ideal time for anyone to sign a complex legal agreement,” said Marianne Udow-Phillips, a health policy instructor at the University of Michigan School of Public Health.
Udow-Phillips, who reviewed the agreement, said it includes complicated terms that could confuse consumers.
Another provision in the agreement says the surgeon’s upfront charges are “a separate fee that is not related to charges made to your insurance.”
Months after his procedure, having received no reimbursement, Smith-Collins contacted his surgeon, he said. Garramone replied to him in an email, explaining that UnitedHealthcare had paid for the “reconstructive aspect of the surgery” — while the thousands of dollars Smith-Collins paid upfront was for the “cosmetic portion.”
Filing an insurance claim had initially led to a payment for Garramone, but no refund for Smith-Collins.
Garramone did not respond to questions from KFF Health News for this article or to repeated requests for an interview.
Smith-Collins had miscalculated how much his insurance would pay for an out-of-network surgeon.
Documents show that before the procedure Smith-Collins received a receipt from Garramone’s practice marked “final payment” with a zero balance due, as well as prior authorization from UnitedHealthcare stating that the surgery performed by Garramone would be “covered.”
But out-of-network providers aren’t limited in what they can charge, and insurers don’t have a minimum they must pay.
An explanation of benefits, or EOB, statement shows Garramone submitted a claim to UnitedHealthcare for more than $106,000. Of that, UnitedHealthcare determined the maximum it would pay — known as the “allowed amount” — was about $4,400. A UnitedHealthcare representative later told Smith-Collins in an email that the total was based on what Medicare would have paid for the procedure.
Smith-Collins’ upfront charges of roughly $14,000 went well beyond the price the insurer deemed fair, and UnitedHealthcare wasn’t going to pay the difference. By UnitedHealthcare’s math, Smith-Collins’ share of its allowed amount was about $2,200, which is what counted toward his out-of-pocket costs. That meant, in the insurer’s eyes, Smith-Collins still hadn’t reached his $6,900 maximum for the year, so no refund.
Neither UnitedHealthcare nor the surgeon provided KFF Health News with billing codes, making it difficult to compare the surgeon’s charges to cost estimates for the procedure.
Garramone’s website says his fee varies depending on the size and difficulty of the procedure. The site says his prices reflect his experience and adds that “cheaper” may lead to “very poor results.”
Though he spent more than he expected, Smith-Collins said he’ll never regret the procedure. He said he had lived with thoughts of suicide since youth, having realized at a young age that his body didn’t match his identity and feared others would target him for being trans.
“It was a lifesaving thing,” he said. “I jumped through whatever hoops they wanted me to go through so I could get that surgery, so that I could finally be who I was.”
UnitedHealthcare denied both of Smith-Collins’ appeals, finding its payments were correct based on the terms of his plan, and said his case was not eligible for a third, outside review.(Bridget Bennett for KFF Health News)
The Resolution: Smith-Collins submitted two appeals with his insurer, asking UnitedHealthcare to reimburse him for what he spent beyond his out-of-pocket maximum. The insurer denied both appeals, finding its payments were correct based on the terms of his plan, and said his case was not eligible for a third, outside review.
But after being contacted by KFF Health News, UnitedHealthcare reprocessed Garramone’s roughly $106,000 claim and increased its payment to the practice to $97,738.46.
Maria Gordon Shydlo, a UnitedHealthcare spokesperson, told KFF Health News the company’s initial determination was correct, but that it had reprocessed the claim so that Smith-Collins is “only” responsible for his patient share: $6,755.
“We are disappointed that this non-contracted provider elected to charge the member so much,” she said.
After that new payment, Garramone gave Smith-Collins a $7,245 refund in mid-April.
The Takeaway: Udow-Phillips, who worked in health insurance for decades and led provider services for Blue Cross Blue Shield of Michigan, said she had never seen a provider agreement like the one Smith-Collins signed.
Patients should consult a lawyer before signing any out-of-network agreements, she said, and they should make sure they understand prior authorization letters from insurers.
The prior authorization Smith-Collins received “doesn’t say covered in full, and it doesn’t say covered at what rate,” Udow-Phillips said, adding later, “I am sure [Smith-Collins] thought the prior authorization was for the cost of the procedure.”
Patients can seek in-network care to feel more secure about what insurance will cover and what their doctors might charge.
But for those who have a specific out-of-network doctor in mind, there are ways to try to avoid sticker shock, said Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University:
Patients should always ask insurers to define what “covered” means, specifically whether that means payment in full and for what expenses. And before making an upfront payment, patients should ask their insurer how much of that total it would reimburse.
Patients also can ask their provider to agree in advance to accept any insurance reimbursement as payment in full, though there’s no requirement that they do so.
And patients can try asking their insurer to provide an exact dollar estimate for their out-of-pocket costs and ask if they are refundable should insurance pick up the tab.
Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!
In the 2020 elections, then-candidate Joe Biden and many of his congressional colleagues loudly advocated for a federal “public option” health insurance plan. It was framed, at the time, as part of his incoming administration’s response to the pandemic.
“Low-income Americans will be automatically enrolled in the public option at zero cost to them, though they may choose to opt out at any time,” Democrats promised in their party platform.
But since Biden entered office, it’s been crickets. The president hasn’t uttered the phrase “public option” since December 2020, according to factba.se, which tracks his public remarks.
Why the disappearing act? In a word: politics.
“Out of the gate you’d have a huge powerful lobby against the public option — the hospitals — since providers have the most to lose: lots of money,” said Matthew Fiedler, an economist at the Brookings Institution who has studied payment disparities between insurance plans. The health-care industry is the largest lobbying sector in Washington, with more than$132 million spent annually just by hospitals and nursing homes, according to OpenSecrets.
For those who’ve forgotten, the idea was to create a government-sponsored insurance plan to compete with commercial insurers under the Affordable Care Act. The concept, previously backed by President Barack Obama, didn’t make it into the final version of the ACA due to opposition from pretty much everyone in health care.
In theory, a public option structured like Medicare, Medicaid or the military’s Tricare program could save billions in health-care spending by both the federal government and consumers because (like the existing federal plans) it would pay health providers less than commercial insurers. Fiedler said the public option could possibly save money, relative to commercial insurance, even if it paid as much as double Medicare’s rates.
And without having to earn a profit, such a plan could spend more money on patient care.
Unsurprisingly, insurers opposed the public option, but Fiedler said it’s hospital opposition that keeps it shelved.
As an example, Fiedler points to Medicare drug price negotiation, another long shot Democratic priority. Biden got that across the finish line as part of his 2022 Inflation Reduction Act.
“Congress didn’t want to pick a fight with hospitals, but they’re willing to take on drug companies,” Fiedler said.
Biden’s party hasn’t yet put together its official platform for the 2024 election, so perhaps the public option will reappear on his agenda. Spokespeople for his reelection campaign and the White House didn’t respond to emailed questions about it.
The idea still has many fans: Led by Colorado, some states have sought to create their own versions, though their plans rely on commercial insurers to administer the coverage. Insurers were able to tank public option proposals in Connecticut, and they’ve complained that they would lose money under Colorado’s proposal.
This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact NewsWeb@kff.org.
Private Medicaid health plans lost millions of members in the past year as pandemic protections that prohibited states from dropping anyone from the government program expired.
But despite Medicaid’s unwinding, as it’s known, at least two of the five largest publicly traded companies selling plans have continued to increase revenue from the program, according to their latest earnings reports.
“It’s a very interesting paradox,” said Andy Schneider, a research professor at Georgetown University’s McCourt School of Public Policy, of plans’ Medicaid revenue increasing despite enrollment drops.
Medicaid, the state-federal health program for low-income and disabled people, is administered by states. But most people enrolled in the program get their health care through insurers contracted by states, including UnitedHealthcare, Centene, and Molina.
The companies persuaded states to pay them more money per Medicaid enrollee under the assumption that younger and healthier people were dropping out — presumably for Obamacare coverage or employer-based health insurance, or because they didn’t see the need to get coverage — leaving behind an older and sicker population to cover, their executives have told investors.
Several of the companies reported that states have made midyear and retrospective changes in their payments to plans to account for the worsening health status of members.
In an earnings call with analysts on April 25, Molina Healthcare CEO Joe Zubretsky said 19 states increased their payment rates this year to adjust for sicker Medicaid enrollees. “States have been very responsive,” Zubretsky said. “We couldn’t be more pleased with the way our state customers have responded to having rates be commensurate with normal cost trends and trends that have been influenced by the acuity shift.”
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Health plans have faced much uncertainty during the Medicaid unwinding, as states began reassessing enrollees’ eligibility and dropping those deemed no longer qualified or who lost coverage because of procedural errors. Before the unwinding, plans said they expected the overall risk profile of their members to go up because those remaining in the program would be sicker.
UnitedHealthcare, Centene, and Molina had Medicaid revenue increases ranging from 3% to 18% in 2023, according to KFF. The two other large Medicaid insurers, Elevance and CVS Health, do not break out Medicaid-specific revenue.
The Medicaid enrollment of the five companies collectively declined by about 10% from the end of March 2023 through the end of December 2023, from 44.2 million people to 39.9 million, KFF data shows.
In the first quarter of 2024, UnitedHealth’s Medicaid revenue rose to $20.5 billion, up from $18.8 billion in the same quarter of 2023.
Molina on April 24 reported nearly $7.5 billion in Medicaid revenue in the first quarter of 2024, up from $6.3 billion in the same quarter a year earlier.
On April 26, Centene reported that its Medicaid enrollment fell 18.5% to 13.3 million in the first quarter of 2024 compared with the same period a year ago. The company’s Medicaid revenue dipped 3% to $22.2 billion.
Unlike UnitedHealthcare, whose Medicaid enrollment fell to 7.7 million in March 2024 from 8.4 million a year prior, Molina’s Medicaid enrollment rose in the first quarter of 2024 to 5.1 million from 4.8 million in March 2023. Molina’s enrollment jump last year was partly a result of its having bought a Medicaid plan in Wisconsin and gained a new Medicaid contract in Iowa, the company said in its earnings news release.
Molina added 1 million members because states were prohibited from terminating Medicaid coverage during the pandemic. The company has lost 550,000 of those people during the unwinding and expects to lose an additional 50,000 by June.
About 90% of Molina Medicaid members have gone through the redetermination process, Zubretsky said.
The corporate giants also offset the enrollment losses by getting more Medicaid money from states, which they use to pass on higher payments to certain facilities or providers, Schneider said. By holding the money temporarily, the companies can count these “directed payments” as revenue.
Medicaid health plans were big winners during the pandemic after the federal government prohibited states from dropping people from the program, leading to a surge in enrollment to about 93 million Americans.
States made efforts to limit health plans’ profits by clawing back some payments above certain thresholds, said Elizabeth Hinton, an associate director at KFF.
But once the prohibition on dropping Medicaid enrollees was lifted last spring, the plans faced uncertainty. It was unclear how many people would lose coverage or when it would happen. Since the unwinding began, more than 20 million people have been dropped from the rolls.
Medicaid enrollees’ health care costs were lower during the pandemic, and some states decided to exclude pandemic-era cost data as they considered how to set payment rates for 2024. That provided yet another win for the Medicaid health plans.
Most states are expected to complete their Medicaid unwinding processes this year.
The Biden administration wants to make it easier for Americans to get dental care. But don’t try booking an appointment just yet.
A new regulation out this month allows states to include adult dental care as a benefit that health insurers must cover under the Affordable Care Act. Following record ACA enrollment this year, the proposal represents an election-year aspiration for the future of Obamacare: It doesn’t require states to do anything, even as it shows off President Biden’s intention to make the ACA a more robust safety net.
“It’s huge, really significant,” said Colin Reusch, director of policy at Community Catalyst, a health coverage advocacy group. He said the new Biden administration rule represents “one of the first real changes” to coverage provisions of the law since it passed in 2010.
But like so much in health care, expanding access to dental services is a lot more complicated than it sounds.
An estimated 68.5 million U.S. adults lacked dental insurance in 2023, according to the nonprofit CareQuest Institute for Oral Health. That’s more than 2.5 times the roughly 26 million Americans of all ages who lack health insurance.
And millions of Americans lost dental coverage in the past year as part of the Medicaid “unwinding” that dropped low-income people who had been covered by the program during the pandemic.
At the same time, untreated dental disease is estimated to cost the United States more than $45 billion in lost productivity annually, according to the Centers for Disease Control and Prevention, and it’s linked to a long list of even more serious health problems, including heart disease and diabetes.
Still, efforts to expand U.S. dental coverage have long foundered on the shoals of cost. When people have dental insurance, they tend to use it. So including the coverage in a health insurance policy can raise overall premiums.
That’s one reason traditional Medicare coverage explicitly excludes most dental care. (Many private Medicare Advantage plans offer some dental coverage as an enticement for seniors to join.)
An effort to add a dental benefit to Medicarewas stripped from Biden’s “Build Back Better” legislation before it was passed in 2022 as the Inflation Reduction Act. Instead, the administrationclarified and expanded the limited circumstances in which Medicare can cover dental care. Any progress on oral health — including giving states the option to require coverage for adults — is seen by advocates as a victory. Dental coverage for children is already an essential benefit under the ACA.
But whether they actually get coverage depends on states affirmatively adding dental benefits to benchmark plans in the ACA’s insurance marketplaces. Those plans not only determine what services Affordable Care Act insurance has to cover, but also set parameters for state-employee and many private-employer health plans.
Reusch said a few states are considering the change, but it will be a while until anything is certain. States have until May 2025 to decide whether to add dental care to benchmark ACA plans; the benefit wouldn’t be effective until the 2027 plan year.
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Nearly a decade ago, Medicare launched a program to help the two-thirds of beneficiaries with chronic conditions by paying their doctors an additional monthly fee to coordinate their care.
The strategy has largely failed to live up to its potential; only about 4 percent of potentially eligible beneficiaries in the traditional Medicare program are enrolled, according to a Mathematica analysis.
But thousands of physicians have boosted their pay by participating, and auxiliary for-profit businesses have sprung up to help doctors take advantage of the program. An analysis of federal data by my KFF Health News colleague Holly K. Hacker shows that about 4,500 physicians received at least $100,000 each in chronic care management pay in 2021.
“This program had potential to have a big impact,” said Kenneth Thorpe, an Emory University health policy professor and an expert on chronic diseases. “But I knew it was never going to work from the start because it was put together wrong.”
Centers for Medicare and Medicaid Services spokespeople didn’t respond to questions about the program’s low participation rate, and it’s not clear whether the agency will address the issue.
Under the CCM program, Medicare pays physicians to develop a patient care plan, coordinate treatment with specialists and regularly check in with beneficiaries. Doctors receive an average of $62 per patient per month for at least 20 minutes of work, according to companies in the business.
Without the program, providers often have little incentive to spend time coordinating care for their patients because they can’t bill Medicare for the work.
A host of factors limit participation in the program, according to Thorpe and other experts. Chief among them is that both doctors and patients must opt into participating.
Doctors may not have the capacity to regularly monitor patients outside office visits. Some also worry about meeting strict Medicare documentation requirements for reimbursement and are reluctant to ask patients to join a program that may require a monthly co-payment, if they don’t have a supplemental policy.
“This is very time-intensive and not something physicians are used to doing or have time to do,” Thorpe said.
There’s evidence that wider uptake could generate savings ― as well as happier patients. A federally funded study by Mathematica in 2017 found the CCM program saved Medicare about $888 per patient per year ― owing mostly to decreasing hospital care.
Carrie Lester, 73, looks forward to a phone call every Thursday from her doctors’ medical assistant, who asks how she’s doing and if she needs prescription refills. The assistant counsels her on dealing with anxiety and other health issues.
Lester credits the chats for keeping her out of the hospital and reducing the need for clinic visits to manage chronic conditions including depression, fibromyalgia and hypertension.
“Just knowing someone is going to check on me is comforting,” said Lester, who lives with her dogs, Sophie and Dolly, in Independence, Kan.
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SACRAMENTO, Calif. — California state lawmakers this year are continuing their progressive tilt on health policy with dozens of proposals including a ban on a Froot Loops ingredient and free condoms for high schoolers.
As states increasingly fracture along partisan lines, California Democrats are stamping their supermajority on legislation that they will consider until they adjourn at the end of August. But the cost of these proposals will be a major factor given the enormity of the state’s deficit, currently estimated at between $38 billion and $73 billion.
Health Coverage
Lawmakers are again considering whether to create a government-run, single-payer health care system for all Californians. AB 2200 is Democratic Assembly member Ash Kalra’s second such attempt, after a similar bill failed in 2022. The price tag would be enormous, though proponents say there would also be related savings. The high potential cost left Assembly Speaker Robert Rivas and others skeptical it could become law while the state faces a deficit.
AB 4 would require Covered California, the state’s health insurance exchange, to offer health insurance policies to people who are otherwise not able to obtain coverage because of their immigration status, to the extent it can under federal law. That could eventually lead to subsidized insurance premiums similar to those offered in Colorado and Washington.
Medical Debt
Health care providers and collection agencies would be barred from sharing patients’ medical debt with credit reporting agencies under SB 1061. The bill would also prohibit credit reporting agencies from accepting, storing, or sharing any such information without consumer consent. Last year, the Biden administration announced plans to develop federal rules barring unpaid medical bills from affecting patients’ credit scores. California would be the third state to remove medical bills from consumer credit reports.
Medi-Cal
The Medi-Cal program, which provides health care for low-income people, would be required to cover medically supportive food and nutrition starting July 1, 2026, under AB 1975. The bill builds on an existing but limited pilot program. The legislation says Californians of color could benefit from adequate food and nutrition to combat largely preventable chronic health conditions, and it’s one of 14 measures sought by the California Legislative Black Caucus as part of reparations for racial injustice.
More than 1.6 million California residents, disproportionately Latinos, have been kicked off Medi-Cal since the state resumed annual eligibility checks that were halted during the covid-19 pandemic. AB 2956 would have the state seek federal approval to slow those disenrollments by taking steps such as letting people 19 and older keep their coverage automatically for 12 months.
Violence Prevention
An increase in attacks on health workers is prompting lawmakers to consider boosting criminal penalties. In California, simple assault against workers inside an ER is considered the same as simple assault against almost anyone else, and carries a maximum punishment of a $1,000 fine and six months in jail. In contrast, simple assault against emergency medical workers in the field, such as an EMT responding to a 911 call, carries maximum penalties of a $2,000 fine and a year in jail. AB 977 would set the same maximum penalties for assaulting emergency health care workers on the job, whether they are in the field or an ER.
California could toughen penalties for interfering with reproductive health care services. Posting personal information or photographs of a patient or provider would be a felony if one of them is injured as a result. AB 2099 also boosts penalties for intimidation or obstruction.
Under SB 53, gun owners would have to lock up their weapons in state-approved safes or lockboxes where they would be inaccessible to anyone but the owner or another lawfully authorized user. Democratic Sen. Anthony Portantino, the bill’s author, says that would make it tougher for anyone, including children, to use guns to harm themselves or others or use the weapons to commit crimes. Critics say it would make it harder to access the weapon when it’s needed, such as to counter a home invasion. Relatedly, AB 2621 and AB 2917 address gun violence restraining orders.
Substance Use
The spike in drug overdoses has prompted several responses: AB 3073 would require the state’s public health department to partner with local public health agencies, wastewater treatment facilities, and others to pilot wastewater testing for traces of dangerous drugs in an effort to pinpoint drug hot spots and identify new drugs. AB 1976 would require workplace first-aid kits to include naloxone nasal spray, which can reverse opioid overdoses. And senators have proposed at least nine bills aimed at curbing overdose deaths, particularly from the deadly synthetic opioid fentanyl.
Youth Welfare
Under AB 2229, backed by a “Know Your Period” campaign, school districts’ sex education curricula would have to include menstrual health. There was no registered opposition.
Public schools would have to make free condoms available to all pupils in grades nine to 12 under SB 954, which would help prevent unwanted pregnancies and sexually transmitted infections, according to the author, Democratic Sen. Caroline Menjivar. Democratic Gov. Gavin Newsom vetoeda similar bill last year.
Reality show star Paris Hilton is backing a bipartisan bill to require more reporting on the treatment of youth in state-licensed short-term residential therapeutic programs. SB 1043 would require the state Department of Social Services to post information on the use of restraints and seclusion rooms on a public dashboard.
California would expand its regulation of hemp products, which have become increasingly popular among youths as a way to bypass the state’s adults-only restrictions on legal cannabis. AB 2223 would build on a 2021 law that Assembly member Cecilia Aguiar-Curry said in hindsight didn’t go far enough.
Public schools would, under AB 2316, generally be barred from providing food containing red dye 40, titanium dioxide, and other potentially harmful substances, which are currently used in products including Froot Loops and Flamin’ Hot Cheetos. It’s Democratic Assembly member Jesse Gabriel’s follow-up to his legislation last year that attempted to ban a chemical used in Skittles.
Women’s Health
AB 2515 would ban the sale of menstrual products with intentionally added PFAS, also known as “forever chemicals.” PFAS, short for perfluoroalkyl and polyfluoroalkyl substances, have been linked to serious health problems. Newsom vetoed a previous attempt.
Public grade schools and community colleges would, under AB 2901, have to provide 14 weeks of paid leave for pregnancies, miscarriages, childbirth, termination of pregnancies, or recovery. Newsom vetoed a similar bill in 2019.
Social media companies could face substantial penalties if they don’t do enough to protect children, under AB 3172. The measure would allow financial damages of up to $1 million for each child under age 18 who proves in court they were harmed, or three times the amount of the child’s actual damages. The industry opposes the bill, calling it harmful censorship.
Cyberbullies could face civil liabilities up to $75,000 under SB 1504, and those damages could be sought by anyone. Under current law, damages are capped at $7,500 and may be pursued only by the state attorney general.
Wellness
Bosses could be fined for repeatedly contacting employees after working hours under AB 2751, a “right to disconnect” bill patterned after similar restrictions in 13 countries. The bill’s author, Democratic Assembly member Matt Haney, said despite the advent of smartphones that “have blurred the boundaries between work and home life,” employees shouldn’t be expected to work around the clock. The measure is opposed by the California Chamber of Commerce.
Finally, Democrat Anthony Rendon, a long-serving state Assembly speaker, is spending his last year in the chamber leading a first-in-the-nation Select Committee on Happiness and Public Policy Outcomes. The committee isn’t planning any legislation but intends to issue a report after lawmakers adjourn in August.
KALISPELL, Mont. — On a cold February morning at the Flathead Warming Center, Tashya Evans waited for help with her Medicaid application as others at the shelter got ready for the day in this northwestern Montana city.
Evans said she lost Medicaid coverage in September because she hadn’t received paperwork after moving from Great Falls, Montana. She has had to forgo the blood pressure medication she can no longer pay for since losing coverage. She has also had to put off needed dental work.
“The teeth broke off. My gums hurt. There’s some times where I’m not feeling good, I don’t want to eat,” she said.
Evans is one of about 130,000 Montanans who have lost Medicaid coverage as the state reevaluates everyone’s eligibility following a pause in disenrollments during the covid-19 pandemic. About two-thirds of those who were kicked off state Medicaid rolls lost coverage for technical reasons, such as incorrectly filling out paperwork. That’s one of the highest procedural disenrollment rates in the nation, according to a KFF analysis.
Even unsheltered people like Evans are losing their coverage, despite state officials saying they would automatically renew people who should still qualify by using Social Security and disability data.
As other guests filtered out of the shelter that February morning, Evans sat down in a spare office with an application counselor from Greater Valley Health Clinic, which serves much of the homeless population here, and recounted her struggle to reenroll.
She said that she had asked for help at the state public assistance office, but that the staff didn’t have time to answer her questions about which forms she needed to fill out or to walk her through the paperwork. She tried the state’s help line, but couldn’t get through.
“You just get to the point where you’re like, ‘I’m frustrated right now. I just have other things that are more important, and let’s not deal with it,’” she said.
Evans has a job and spends her free time finding a place to sleep since she doesn’t have housing. Waiting on the phone most of the day isn’t feasible.
Tashya Evans waits outside the Flathead Warming Center, a low-barrier shelter in Kalispell, Montana, on March 5. Evans had just finished work in time to join the line for a bed that evening.(Aaron Bolton/MTPR)
There’s no public data on how many unhoused people in Montana or nationwide have lost Medicaid, but homeless service providers and experts say it’s a big problem.
Those assisting unsheltered people who have lost coverage say they spend much of their time helping people contact the Montana Medicaid office. Sorting through paperwork mistakes is also a headache, said Crystal Baker, a case manager at HRDC, a homeless shelter in Bozeman.
“We’re getting mail that’s like, ‘Oh, this needs to be turned in by this date,’ and that’s already two weeks past. So, now we have to start the process all over again,” she said. “Now, they have to wait two to three months without insurance.”
Montana health officials told NPR and KFF Health News in a statement that they provided training to help homeless service agencies prepare their clients for redetermination.
Federal health officials have warned Montana and some other conservative states against disenrolling high rates of people for technicalities, also known as procedural disenrollment. They also warned states about unreasonable barriers to accessing help, such as long hold times on help lines. The Centers for Medicare & Medicaid Services said if states don’t reduce the rate of procedural disenrollments, the agency could force them to halt their redetermination process altogether. So far, CMS hasn’t taken that step.
Charlie Brereton, the director of the Montana health department, resisted calls from Democratic state lawmakers to pause the redetermination process. Redetermination ended in January, four months ahead of the federal deadline.
“I’m confident in our redetermination process,” Brereton told lawmakers in December. “I do believe that many of the Medicaid members who’ve been disenrolled were disenrolled correctly.
Health industry observers say that both liberal-leaning and conservative-leaning states are kicking homeless people off their rolls and that the redetermination process has been chaotic everywhere. Because of the barriers that unsheltered people face, it’s easy for them to fall through the cracks.
Margot Kushel, a physician and a homeless researcher at the University of California-San Francisco, said it may not seem like a big deal to fill out paperwork. But, she said, “put yourself in the position of an elder experiencing homelessness,” especially those without access to a computer, phone, or car.
If they still qualify, people can usually get their Medicaid coverage renewed — eventually — and it may reimburse patients retroactively for care received while they were unenrolled.
Kushel said being without Medicaid for any period can be particularly dangerous for people who are homeless. This population tends to have high rates of chronic health conditions.
“Being out of your asthma medicine for three days can be life-threatening. If you have high blood pressure and you suddenly stop your medicine, your blood pressure shoots up, and your risk of having a heart attack goes way up,” she said.
When people don’t understand why they’re losing coverage or how to get it back, that erodes their trust in the medical system, Kushel said.
Evans, the homeless woman, was able to get help with her application and is likely to regain coverage.
Agencies that serve unhoused people said it could take years to get everyone who lost coverage back on Medicaid. They worry that those who go without coverage will resort to using the emergency room rather than managing their health conditions proactively.
Baker, the case manager at the Bozeman shelter, set up several callbacks from the state Medicaid office for one client. The state needed to interview him to make sure he still qualified, but the state never called.
“He waited all day long. By the fifth time, it was so stressful for him, he just gave up,” she said.
That client ended up leaving the Bozeman area before Baker could convince him it was worth trying to regain Medicaid.
Baker worries his poor health will catch up with him before he decides to try again.
This article is from a partnership that includes MTPR, NPR, and KFF Health News.
Two months after a cyberattack on a UnitedHealth Group subsidiary halted payments to some doctors, medical providers say they’re still grappling with the fallout, even though UnitedHealth told shareholders on Tuesday that business is largely back to normal.
“We are still desperately struggling,” said Emily Benson, a therapist in Edina, Minnesota, who runs her own practice, Beginnings & Beyond. “This was way more devastating than covid ever was.”
Change Healthcare, a business unit of the Minnesota-based insurance giant UnitedHealth Group, controls a digital network so vast it processes nearly 1 in 3 U.S. patient records each year. The network is a critical conduit for shuttling information between most of the nation’s insurance companies and medical providers, who submit claims through it to get paid for treating patients.
For Benson, the cyberattack continues to significantly disrupt her business and her ability to pay her seven other clinicians.
Before the hack brought down the system, an insurance company would process a provider’s claim, then send a type of receipt known as an “electronic remittance,” which details the amount the provider was paid and whether the claim was denied. Without it, providers don’t know if they were paid correctly or how much to bill patients.
Now, instead of automatically handling those receipts digitally, some insurers must send forms in the mail. The forms require manual entry, which Benson said is a time-consuming process because it requires her to match up service dates and details to divvy up pay among her clinicians. And from at least one insurer, she said, she has yet to receive any remittances.
“I’m holding on to my sanity by a thread,” Benson said.
The situation is so dire, Alex Shteynshlyuger, a urologist who owns a practice in New York City, said he had to transfer money from his personal accounts to pay his office bills.
“Look, I am freaking out,” Shteynshlyuger said. “Everyone is freaking out. We are like monkeys in a cage. We can’t really do anything about it.”
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Roughly 30% of his claims were routed through Change’s platform. Except for Medicare and certain Blue Cross plans, he said, he has been unable to submit claims or receive payment from any insurers.
The company is encouraging struggling providers to reach out to the company directly via its website, said Tyler Mason, vice president of communications for UnitedHealth Group.
“I don’t think we’ve had a single provider that hasn’t been helped that’s contacted us.” As part of that help, Mason said, UnitedHealth has sent providers $7 billion so far.
Ever since the February cyberattack forced UnitedHealth to disconnect its Change platform, the company has been working “day and night to restore services” and has made “substantial progress,” UnitedHealth CEO Andrew Witty told shareholders April 16.
“We see a fairly normal claims receipts and payments flow going on at this point,” Chief Financial Officer John Rex said during the shareholder call. “But we’ll really want to be careful on that because we know there are certain care providers out there that may have been left out of it.”
Rex said the company expects full operations to resume next year.
The company reported that the hacking has already cost it $870 million and that leaders expect the final tally to total at least $1 billion this year. To put that in perspective, the company reported $99.8 billion in revenue for the first quarter of 2024, an 8.6% increase over that period last year.
Meanwhile, the House Energy and Commerce Health Subcommittee held a hearing April 16 seeking answers on the severity and damage the cyberattack caused to the nation’s health system.
Subcommittee chair Brett Guthrie (R-Ky.) said a provider in his hometown is still grappling with the fallout from the attack and losing staff because they can’t make payroll. Providers “still haven’t been made whole,” Guthrie said.
Rep. Frank Pallone Jr. (D-N.J.) voiced concern that a “single point of failure” reverberated around the country, disrupting patients’ access and providers’ financial stability.
Lawmakers expressed frustration that UnitedHealth failed to send a representative to the Capitol to answer their questions. The committee had sent Witty a list of detailed questions ahead of the hearing but was still awaiting answers.
As providers wait, too, they are trying to cover the gaps. To pay her practice’s bills, Benson said, she had to take out a nearly $40,000 loan — from a division of UnitedHealth.
