Tagged Insurance

Centene, WellCare Turn To Insurance Regulators For Approval Following Shareholders’ Overwhelming Support Of $17B Merger

Centene and WellCare said more than 99% of their shareholders supported the merger that would cover nearly 22 million people. They are now working to obtain approvals from insurance regulators in 26 states. Other industry news is on: PatientsLikeMe, uBiome Inc., and Highmark Health.

Fuzzy Math Fuels Sanders’ Claim That Cost Barriers To Health Care Kill 30,000 A Year

“Medicare for All” — or single-payer health care — is a flagship issue for Democratic presidential candidate and Vermont Sen. Bernie Sanders. So when a conservative group launched an ad campaign claiming such a policy would drive up wait times for medical care, the 2020 candidate responded aggressively.

His point: Some people may wait a bit for care under a new system. But under the current one, many people do not have access to affordable care and the results are sometimes dire.

Still, Sanders’ precision gave us pause.

Namely, he tweeted, “30,000 Americans a year die waiting for health care because of the cost.”

Where did that 30,000 figure come from? How could Sanders — or for that matter, anyone — know how many people died “waiting for health care” specifically “because of the cost”?

We reached out to the Sanders campaign but never heard back.

But multiple experts suggested that the 30,000 figure, while not conjured out of thin air, relies on math that is shaky at best. There isn’t enough evidence, either way, to entirely validate or repudiate this claim.

The Math

Sanders’ 30,000 statistic appears to come from a figure used by Physicians for a National Health Program, a doctor-driven nonprofit group that has advocated for years for single-payer health care.

But how did it compute that number? We asked Dr. David Himmelstein, a physician and part-time lecturer at Harvard Medical School, and one of PNHP’s founders.

He said the group looked at the Oregon Health Insurance Experiment, a landmark study in which some state residents had been assigned Medicaid coverage by lottery, and others remained uninsured. One year into that study, researchers found the death rate differed by 0.13 percentage points between those who received insurance and those who did not.

But, per the researchers’ analysis, that difference was not statistically significant. (That’s important and something we’ll come back to.)

Himmelstein said the margin of 0.13 percentage points suggests that for every 769 people to lack health coverage, one will die. Looking at the current American uninsured population — about 27 million lack coverage —should put you close to 30,000.

The Problem

Generally, experts said, it’s likely that cost barriers prevent thousands of Americans from accessing lifesaving medical care.

But “the particular math here seems a bit questionable” in arriving at 30,000, said Dr. Benjamin Sommers, a physician and health economist at the Harvard T.H. Chan School of Public Health.

The problem lies in extrapolating so much from the Oregon Health Insurance Experiment. While it yielded important findings, the death rate differential in particular is not statistically significant, so it cannot be applied so broadly, he said. The study wasn’t big enough to generate sufficient evidence spelling out the link between insurance coverage and mortality.

Other research makes clear that such a link exists. Sommers’ own work, for instance, looked at the impact of Massachusetts’ 2006 health reform law — the model for the Affordable Care Act, which brought the state to near-universal coverage.

That expansion was associated with a significant drop in mortality. For every 830 adults to gain coverage, one death was prevented.

But differences nationally in both population and health care generally still mean it’s difficult to apply this statistic to the rest of the country — and, namely, to the remaining 27 million uninsured.

So is 30,000 right or wrong?

We don’t know.

“My guess is that one, [Sanders] is right that thousands of people die because they remain uninsured, despite the ACA; but two, the 30,000 number may be too high,” said Stan Dorn, a senior fellow at Families USA, a left-leaning health policy advocacy group.

Going Beyond Insurance

There’s one other issue: More often than not, people are uninsured because they can’t afford to buy coverage. In turn, that often means they can’t afford health care and suffer dire consequences.

But it isn’t a one-to-one substitution.

For instance, there are healthy people who lack insurance but may not need much medical care in that particular year, or may simply choose not to buy it.

And, on the other hand, some people have coverage that isn’t robust enough to make lifesaving treatments affordable.

So, if you want to measure how many Americans do die “waiting for health care because of the cost,” you’d have to look beyond just the question of having insurance.

Our rating

On its face, Sanders’ claim speaks to an important, undisputed policy concern — thousands of Americans die because they cannot afford their health care.

But his “30,000 people” talking point relies on weak math, and it lacks meaningful support either way. It could be true. But it also could easily not be.

“The senator’s comment looks like a reasonable attempt to use prior research,” Sommers said. But “he’s overstating the precision and confidence we can have in that number.”

Sanders’ argument speaks to something more broadly true but neglects important details of the Oregon Health Insurance Experiment’s limitations. We rate it Half True.

New Budget Boosts Health Coverage For Low-Income Californians

Ann Manganello survives entirely off her Social Security stipend: $1,391 a month.

That doesn’t amount to much in the pricey desert enclave of Palm Springs, Calif. — especially for someone who contends with a host of expensive medical problems, including a blood vessel disorder, complications from a recent stroke and frequent bouts of colitis.

“Right now, I don’t really have the money to do much. I just stay here and that’s it,” Manganello said with a sigh, sad at the thought of being stuck in her apartment.

Because she is 71 and has a low income, Manganello qualifies for Medi-Cal, the state’s Medicaid program for disadvantaged people, as well as Medicare, the public insurance program for people 65 and older.

But there’s a catch: Her monthly Social Security check puts her slightly above the income level for free care under Medi-Cal. So, she reduces the amount of income counted for Medi-Cal eligibility by buying a dental insurance policy she doesn’t really need, just so she can qualify for the free coverage and avoid a $672 monthly deductible.

Things are expected to change next year for Manganello and others in similar situations. In the state budget for 2019-20, legislators approved $62.4 million to help about 25,000 older people and those with disabilities get free Medi-Cal. Gov. Gavin Newsom must sign the budget by June 30.

That’s one of several major investments the $215 billion budget makes in Medi-Cal enrollment and services. About 13 million Californians — or about a third of the state’s population — have Medi-Cal.

The spending plan also includes money to restore medical benefits that were cut 10 years ago during the recession, such as podiatry and speech therapy. It also provides full Medi-Cal coverage to low-income young adults ages 19 through 25 who are in the country illegally. That will make California the first state in the nation to offer full Medicaid benefits to unauthorized immigrant adults.

Plus there’s $30 million for outreach and enrollment and $769.5 million to boost the amount Medi-Cal pays participating doctors and dentists.

For Manganello, who worked as a manager for a signage shop in Buffalo, N.Y., before moving west, qualifying for free Medi-Cal would make a tangible difference in her life.

“I could cancel that extra insurance and buy myself a medical alert bracelet. I would also have some money to maybe pay off some other medical bills,” she said. “It would help with groceries, things like Depends. And maybe I could go out to lunch once in a while.”

The Medi-Cal expansions in the budget represent another radical departure by California from the federal government on health care and immigration. In addition to cracking down on illegal immigration, the Trump administration is pushing policies, such as work requirements for Medicaid enrollees, that often lead to reductions in enrollment.

The budget measures also bring California a step closer to Newsom’s goal of achieving universal health care coverage. The state’s estimated 1.8 million unauthorized immigrants, for example, make up roughly 60% of the state’s remaining uninsured residents.

“It seems like what has occurred in California this year is a very conscious, systematic and well-designed effort to close gaps” in coverage, said Judy Solomon, a senior fellow at the Center on Budget and Policy Priorities.

Many other states face similar coverage gaps but few can afford to address them, Solomon said.

‘Senior Penalty’

Most adults who don’t have a disability and are under 65 are eligible for free Medi-Cal with incomes up to 138% of the federal poverty level, or about $17,200 for an individual.

But adults in Medi-Cal’s Aged and Disabled Program have to meet stricter income requirements — up to 122% of the poverty level, or just under $15,240 a year for an individual.

If, like Manganello, they make slightly more than that, they must pay a certain amount of their health costs — essentially, a deductible — before Medi-Cal coverage kicks in. That can translate into hundreds of dollars or more per month.

Linda Nguy, a policy advocate at the Western Center on Law & Poverty, said that many people are simply skipping medical care because they can’t afford the deductible.

“We call this the senior penalty, because basically you’re being penalized with a stricter eligibility limit based fully on your age or disability,” said Amber Christ, an attorney with Justice in Aging, a nonprofit advocacy group focused on senior poverty.

Many states that expanded their Medicaid programs under the Affordable Care Act also have this disparity, Christ said. The 2019-20 California budget would end it by raising the income eligibility threshold for that group to 138% of the poverty level.

Restoring Benefits

During the Great Recession, California, like many other states, cut several Medicaid benefits that aren’t required by the federal government.

Starting Jan. 1, Medi-Cal will restore five areas of coverage: audiology, optical services, podiatry, incontinence supplies and speech therapy.

“People of all ages wear glasses, so this can really benefit anyone,” Nguy said. “But things like podiatry, audiology, speech therapy are probably of most benefit to people with chronic conditions.”

The new budget includes $17.4 million for these services, which could disappear again in 2022 unless lawmakers decide to extend them.

Optional benefits are usually the first to go in bad economic times, and bringing them back can take years. Full dental benefits, also cut during the recession, were restored for adults in Medi-Cal last year.

Immigrant Coverage

Lawmakers allocated $98 million to offer free health coverage for unauthorized young immigrant adults who meet the income requirements, starting next year. Of this, $74.3 million will come from the state, while the rest will come from funds the federal government provides for labor and delivery and emergency care only.

About 90,000 young adults are expected to become eligible in the first year.

Covering young adults became the most controversial health care issue in this year’s budget. Republicans criticized the effort, arguing that Medi-Cal should be fixed before it is expanded.

“Every day, my district offices get calls from my constituents who are unable to see a doctor, even though they are technically covered by Medi-Cal, because so few doctors in my district are able to take the low reimbursement rates that Medi-Cal provides,” state Assemblyman Jay Obernolte (R-Big Bear Lake) said before the Assembly’s budget vote on June 13.

In 2016, California started offering full Medi-Cal benefits to unauthorized immigrant children. The state’s current-year budget allocates $365.2 million to fund that coverage. In February 2019, 127,845 kids were enrolled in the program.


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

KHN’s ‘What The Health’: Politics Heading Into 2020: Live From Aspen!


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


The cost of health care looms as a major issue going into the 2020 campaign. But even as Democratic presidential candidates debate ways to bring down prices and expand insurance to more Americans, Democrats and Republicans in Congress are trying to pass legislation to address the price of prescription drugs and put an end to “surprise” out-of-network medical bills.

Chris Jennings and Lanhee Chen know about both. Jennings, president of Jennings Policy Strategies, has been a health adviser to Presidents Bill Clinton and Barack Obama. Lanhee Chen is a research fellow at the Hoover Institution and a director in the public policy program at Stanford University. He has advised Republican presidential candidates Mitt Romney, Marco Rubio and others.

This week’s panelists for KHN’s “What the Health?” — recorded at the Aspen Ideas: Health festival — are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico and Margot Sanger-Katz of The New York Times.

Among the takeaways from this week’s podcast:

  • The term “health care costs” means different things to different people. For most of the public, it refers to the amount they must pay out-of-pocket for premiums, deductibles and services. For policymakers, it often means the total amount the U.S. spends on the health care system. That often creates a disconnect.
  • Even small changes to the way drugs are priced and ending surprise medical bills might end up satisfying many members of the public, although those adjustments might have a minimal effect on overall health spending.
  • Republicans are as divided as Democrats on health care. That is the main reason Republicans did not repeal the Affordable Care Act in 2017 and why there has been no major Republican replacement proposal since then.
  • Many of the Democrats running for president, meanwhile, continue to advocate for a “Medicare for All” program run by the government, although many are hedging their bets by supporting other, less sweeping proposals to expand coverage, as well.

To hear all our podcasts, click here.

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

Small Colorado Ski Towns Banded Together To Drive Down Health Costs. But Can That Model Work Statewide … Or Even Nationwide?

Residents who were sick of paying astronomical health care costs figured out a way to come together so that they had negotiating power over the health groups in their area. But will other cities in the state be able to replicate the group’s success in areas where there’s less fat to trim? In other news on insurers and the health industry: medical prices continue to swell; AHIP focuses on social determinants; the importance of dental care gets lost in cost debate; and more.

Curing Cancer: Easy Politics, Difficult Science

President Donald Trump made a new promise if voters grant him a second term: “We will come up with the cures to many, many problems, to many, many diseases, including cancer.”

Trump’s statement was part of his 2020 campaign kickoff in Orlando, Fla., on Tuesday. It echoed remarks by former vice president and Democratic candidate Joe Biden on the stump last week in Iowa: “I promise you, if I’m elected president, you’re going to see the single most important thing that changes America: We’re going to cure cancer.”

“Let’s cure cancer” is hardly a new political ambition. Go back to 1971, when then-President Richard Nixon launched “The War on Cancer” by signing the National Cancer Act, which directed $1.6 billion to research and established the National Cancer Institute.

Or take a famous fictional White House: On “The West Wing,” a TV drama that first aired from 1999 to 2006, President Jed Bartlet pushes to include in his State of the Union a pledge to “cure cancer in 10 years.”

In 2016, President Barack Obama tapped Biden to run the White House’s “cancer moonshot” soon after Biden’s son Beau died of brain cancer.

It’s a compelling promise. After all, who could be against curing the nation’s second-leading cause of death?

If only it were that simple. Here are three reasons “let’s cure cancer” is very easy for politicians to say but very hard to accomplish.

Neither the Trump campaign nor the Biden campaign responded to requests for comment.

With Cancer, The Biology Is Especially Tricky

Cancer is multifaceted and uniquely complex — it is not so much one disease as a class of related diseases.

“‘One cure’ is not a tenable concept,” said Edward Giovannucci, an associate professor at Harvard Medical School. “An analogy I think of is ‘curing infectious disease.’ No one would ever say this.”

For one thing, individual cancers mutate differently. And those different mutations don’t always respond to the same medicines. That means the best therapy for one person’s lymphoma might not work for someone else’s. And there is consistently potential for new cancer mutations to develop — meaning that, in some ways, there is also a consistent need for new treatments.

“One cannot rightfully say, ‘In the next five years, we’re going to cure cancer,’ because cancer is so many different diseases,” said Dr. Philip Kantoff, the chairman of medicine at Memorial Sloan Kettering Cancer Center in New York.

Some suggested literalism isn’t the point. And, to be fair, statements and pledges like these can yield advances in cancer treatment in research when accompanied by substantial increases in research funding or efforts to encourage interdisciplinary scientific endeavors.

“One of the things Biden has done is generate a much larger public awareness that cancer is a set of problems that, if we direct both science and policy in the right way to it, we can actually transform,” said Paula Hammond, a chemical engineering professor at the Massachusetts Institute of Technology, who has worked with the nonprofit Biden Cancer Initiative.

We Already Have Treatments. But There’s An Affordability Problem.

Many cancers — certain types of breast or colon cancer, for instance — are already curable. But they need to be promptly diagnosed and treated. Meanwhile, 27.4 million Americans don’t have health insurance.

Universal prevention, treatment and curing of cancer means anyone with a chance of developing the disease needs health insurance, experts said. And the coverage needs to be robust enough that patients will go for preventive screenings and follow-up care, without being deterred by the cost.

“If you’re going to find it early, treat it early and completely, which would be the ‘cure it’ option, that’s something where insurance is going to be required, whether it’s ‘Medicare for All,’ or some variant of that,” said Amy Davidoff, a health economist at Yale who studies how cancer costs affect people.

Focusing on treatments without expanding meaningful access to coverage, she said, is “problematic.”

Already, that link is clear. For instance, research Davidoff worked on found that when states expanded eligibility for Medicaid coverage — optional under the Affordable Care Act — gaps between white and black adults closed when it came to timely treatment of advanced cancer.

Health insurance — and universal health care, in particular — has already emerged as an election issue.

Trump, for his part, has not rolled out a health care agenda. But his administration’s work thus far has exacerbated insurance barriers. Some 700,000 more Americans were uninsured in 2018 under Trump. The White House’s stance on a pending Obamacare lawsuit would dismantle the law, leaving millions more Americans without coverage and upending its protections for people with preexisting conditions — including, crucially, cancer.

Biden has not formally released a health care platform, and he has favored policies to expand coverage. This week, he suggested making a “Medicare-like public option” generally available, and available at no premium for uninsured people who live in states that did not expand Medicaid.

That sort of proposal could go a long way toward addressing the issues of uninsured people. But it also could leave holes.

Currently, even if people have coverage, Davidoff said, the price tag for many newer cancer treatments and immunotherapies can put them well out of reach.

That means the generosity of any public option, and indeed of any existing health plans, matters a great deal, too.

The Importance Of Healthy Habits

And when it comes to advancing cancer treatment, experts stressed the importance of disease prevention.

In practice, that means developing strategies to bring down smoking rates and obesity, or improving access to nutritious food. Those require funding, political will and a robust public health infrastructure — none of which is easy to come by. But the potential payoff is far bigger.

“If we are to make very significant inroads on cancer mortality rates over the next several decades, we need to focus on prevention and early detection,” Giovannucci said. “We know the majority of cancers are, in principle, preventable.”

1 In 6 Insured Hospital Patients Get A Surprise Bill For Out-Of-Network Care

About 1 in 6 Americans were surprised by a medical bill after treatment in a hospital in 2017 despite having insurance, according to a study published Thursday.

On average, 16% of inpatient stays and 18% of emergency visits left a patient with at least one out-of-network charge. Most of those came from doctors offering treatment at the hospital, even when the patients chose an in-network hospital, according to researchers from the Kaiser Family Foundation. Its study was based on large employer insurance claims. (Kaiser Health News is an editorially independent program of the foundation.)

The research also found that when a patient is admitted to the hospital from the emergency room, there’s a higher likelihood of an out-of-network charge. As many as 26% of admissions from the emergency room resulted in a surprise medical bill.

“Millions of emergency visits and hospital stays left people with large employer coverage at risk of a surprise bill in 2017,” the authors wrote.

The researchers got their data by analyzing large-employer claims from IBM’s MarketScan Research Databases, which include claims for almost 19 million individuals.

Surprise medical bills are top of mind for American patients, with 38% reporting they were “very worried” about unexpected medical bills.

Surprise bills don’t just come from the emergency room. Often, patients will pick an in-network facility and see a provider who works there but isn’t employed by the hospital. These doctors, from outside staffing firms, can charge out-of-network prices.

“It’s kind of a built-in problem,” said Karen Pollitz, a senior fellow at the Kaiser Family Foundation and an author of the study. She said most private health insurance plans are built on networks, where patients get the highest value for choosing a doctor in the network. But patients often don’t know whether they are being treated by an out-of-network doctor while in a hospital.

“By definition, there are these circumstances where they cannot choose their provider, whether it’s an emergency or it’s [a doctor] who gets brought in and they don’t even meet them face-to-face.”

The issue is ripe for a federal solution. Some states have surprise-bill protections in place, but those laws don’t apply to most large-employer plans because the federal government regulates them.

“New York and California have very high rates of surprise bills even though they have some of the strongest state statutes,” Pollitz said. “These data show why federal legislation would matter.”

Consumers in Texas, New York, Florida, New Jersey and Kansas were the most likely to see a surprise bill, while people in Minnesota, South Dakota, Nebraska, Maine and Mississippi saw fewer, according to the study.

Legislative solutions are being discussed in the White House and Congress. The leaders of the Senate Health, Education, Labor and Pensions Committee introduced a package Wednesday that included a provision to address it. The legislation from HELP sets a benchmark for what out-of-network physicians will be paid, which would be an amount comparable to what the plan is paying other doctors for that service.

That bill is set for a committee markup next week.

Other remedies are also being offered by different groups of lawmakers.

Sen. Alexander Details His Plan To Fix Surprise Medical Bills

Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.), who are pushing a major legislative package to lower health costs, announced their favored solution to handle disputes about surprise medical bills.

Those unexpected and often high charges patients face when they get care from a doctor or hospital that isn’t in their insurance network are a perpetual complaint from consumers.

Alexander and Murray formally introduced their wide-ranging bill Wednesday, but they had offered a broad outline before without taking a stand on how to mediate between health care providers and patients on the surprise bills.

When a patient is seen by a doctor who isn’t in their network, the Alexander-Murray bill says insurance would pay them the “median in-network rate,” meaning the rate would be similar to what the plan charges other doctors in the area for the same procedure. If there aren’t enough other doctors covered by the plan to compute a median in-network, the plan would use a database of local charges that is “free of conflicts of interest.”

Alexander said in a written statement that his decision was swayed by an assessment by the Congressional Budget Office, which “indicated that the benchmark solution is the most effective at lowering health care costs.”

According to early numbers from a CBO report, benchmarking could save $25 billion over the next 10 years. Loren Adler, associate director of USC-Brookings Schaeffer Initiative for Health Policy, said that means commercial insurance premiums would be reduced by about a half-percent.

“That’s pretty significant for federal policy,” Adler said.

The formula is similar to what a different group of bipartisan senators, led by Sen. Bill Cassidy (R-La.), proposed earlier this year. The critical difference is that in the Cassidy bill if the insurer and doctor can’t agree on a median-in-network rate, they can take their case to an independent arbitrator.

The provider community has pushed back on any attempt to set a “benchmark” for physician pay, like the one in Alexander and Murray’s bill.

At a hearing Tuesday before the Health, Education, Labor and Pensions Committee — of which Alexander and Murray are the chairman and ranking member, respectively — Tom Nickels, executive vice president of the American Hospital Association, said benchmarking would hurt efforts to set up broad insurance networks because providers and insurers would already know what they would be paid for surprise bills and it would be hard to recruit physicians to adequately staff hospitals.

“Health plans and hospitals have a long-standing history of resolving out-of-network emergency service claims, and this process should not be disrupted,” he said in written testimony.

Alexander also pointed out that Rep. Frank Pallone (D-N.J.), chairman of the House Energy and Commerce Committee, and Rep. Greg Walden (R-Ore.), the ranking member of that committee, have also recommended this proposal.

Although it isn’t the most aggressive solution the committee could have picked, according to Adler, it’s still a positive step, and he said it was promising that an influential health committee in the Senate and an influential health committee in the House are on the same page.

“There’s some logic to moving trains in the same direction,” Adler said.

The Alexander-Murray legislation says that any care the patient receives would count toward their in-network cost sharing, like their deductible, coinsurance or copay.

Once they are stable and lucid after an emergency, patients must be given written notice that they are going to be seen by an out-of-network doctor, an estimate of how much that could cost, and a list of in-network doctors or facilities where they could seek care.

The bill specifies that the notice must be short, easy to read and that consent to see an out-of-network doctor is clearly optional. If the patient doesn’t get this document, they can only be billed at an in-network rate.

In Debate Over What To Do About Surprise Medical Bills, Alexander Hints At Support For In-Network Guarantee

Although many lawmakers agree that patients need to be protected from surprise medical bills, there are different ways that could go and many stakeholders who have strong opinions on what the solution should be. At a hearing on Wednesday, Senate Health, Education, Labor and Pensions Committee Chairman Lamar Alexander said that requiring hospitals to guarantee that any doctor a patient sees is in-network is the strategy he “intrinsically liked the best.” But the future of any legislation is still unclear.

State Highlights: New York Lawmakers Expected To Ban ‘Gay Panic’ Defenses In Murder Cases; Texas, Florida Cut Back On Charging Students In School Shooting Threats

Media outlets report on news from New York, Florida, California, Iowa, New Hampshire, District of Columbia, Minnesota, New Jersey, Pennsylvania, Rhode Island, Massachusetts, North Carolina, Illinois, Ohio, Georgia, Oregon and Wyoming.

Senators Agree Surprise Medical Bills Must Go. But How?

Two years, 16 hearings and one massive bipartisan package of legislation later, a key Senate committee says it is ready to start marking up a bill next week designed to contain health care costs. But it might not be easy since lawmakers and stakeholders at a final hearing Tuesday showed they are still far apart on one simple aspect of the proposal.

That sticking point: a formula for paying for surprise medical bills, those unexpected and often high charges patients face when they get care from a doctor or hospital that isn’t in their insurance network.

“People get health insurance precisely so they won’t be surprised by health care bills,” said Sen. Maggie Hassan (D-N.H.), the co-author of a separate proposal to tamp down surprise bills. “So it is completely unacceptable that people do everything that they’re supposed to do to ensure that their care is in their insurance network and then still end up with large, unexpected bills from an out-of-network provider.”

It’s a cause that has been taken up by President Donald Trump and various bipartisan groups of lawmakers on Capitol Hill.

The wide-ranging legislative package on curbing health care costs is sponsored by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.), the chairman and ranking member of the Health, Education, Labor and Pensions (HELP) Committee. Given the committee’s influence, and because this legislation has bipartisan support in the Senate where not many bills are moving, industry observers are taking the HELP panel’s proposal very seriously.

Alexander and Murray’s bill lays out three options for paying surprise medical bills but does not specify which path the final legislation should take. Advocates for each of the choices were among the five witnesses Tuesday.

Their positions fell along familiar fault lines. Everyone acknowledged that patients who stumble into a surprise bill because their emergency care was handled at a facility not in their insurance network or because a doctor at their in-network hospital doesn’t take the patient’s plan should not have to pay more than they would for an in-patient service. But they differ on how much doctors, hospitals and other providers should be compensated and how the disputes should be resolved.

Tom Nickels, an executive vice president of the American Hospital Association, cautioned against using benchmarks to set pay levels, such as local customary averages or a price set in relation to Medicare. He said such a plan might underpay providers and hospitals could lose their leverage to negotiate with insurers.

Elizabeth Mitchell, president and CEO of the Pacific Business Group on Health — a group that represents employers, including some who are self-insured who pay their workers’ health costs— said doctors should be paid 125% of what Medicare pays. She told senators that an independent arbitration process like the one Nickels advocates would add unnecessary costs to the system.

Benedic Ippolito, a researcher with the American Enterprise Institute, said requiring all providers in a hospital to be in-network was the cleanest solution.

“On surprise billing, all three approaches are equal in that first and foremost they protect the consumer,” said Sean Cavanaugh, chief administrative officer for Aledade, a company that matches primary care physicians with accountable care organizations.

There was also broad support among the witnesses for some of the legislation’s transparency measures, especially the creation of a nongovernmental nonprofit organization to collect claims data from private health plans, Medicare and some states to create what’s called an all-payer claims database. That could help policymakers better understand the true cost of care, these experts told the committee.

Sen. Susan Collins (R-Maine) expressed trepidation about the all-payer claims database, noting that increased transparency could hurt rural hospitals, which typically charge higher prices than those in cities because their patient base is small and they need to bring in enough revenue to cover fixed costs.

The witnesses also offered support for eliminating “gag clauses” between doctors and health plans. These stipulations often prevent providers from telling patients the cost of a procedure or service.

“Patients and families absolutely have skin in the game … but they are in a completely untenable and unfair situation. They have no information,” said Mitchell, from the Pacific Business Group on Health. “We’re talking about providers not being allowed to share information. … Transparency is necessary so people can have active involvement.”

If one thing is clear, it’s that Alexander doesn’t want this summer to be a rehash of last year, when it appeared he had a bipartisan deal to address problems in the federal health law’s marketplaces before the effort fell apart.

“For the last decade, Congress had been locked in an argument about the individual health care market,” said Alexander at Tuesday’s hearing. “That is not this discussion. This is a different discussion. We’ll never lower the cost of health insurance until we lower the cost of health care.”

Texas Is Latest State To Attack Surprise Medical Bills

Texas is now among more than a dozen states that have cracked down on the practice of surprise medical billing.

Texas Gov. Greg Abbott, a Republican, signed legislation Friday shielding patients from getting a huge bill when their insurance company and medical provider can’t agree on payment.

The bipartisan legislation removes patients from the middle of price disputes between a health insurance company and a hospital or other medical provider.

“We wanted to try to take the patients — get them out of the middle of it, because really it’s not their fight,” said Republican state Sen. Kelly Hancock, the bill’s author.

Under the new law, insurance companies and medical providers can enter into arbitration to negotiate a payment — and state officials would oversee that process.

Surprise medical billing typically happens when someone with health insurance goes to a hospital during an emergency and that hospital is out-of-network. It also occurs if a patient goes to an in-network hospital and their doctors or medical providers are not in-network. Sometimes insurance companies and medical providers won’t agree on what’s a fair price for that care and patients end up with a hefty medical bill.

Consumer advocates in the state have urged lawmakers to do more to help Texans saddled with surprise medical bills.

Drew Calver is among the many Texans who have dealt with a surprise bill in the past few years. Calver, a high school history teacher in Austin, had a heart attack in 2017. He was rushed to the closest hospital by a friend that day, and doctors implanted stents to save his life.

Even though he had health insurance that paid the hospital more than $55,000 for his care, Calver ended up with a $109,000 bill. Calver and his wife, Erin, fought with the hospital and the insurance company for months with little success.

The Calvers eventually turned to the press. Last summer, he told his story to the “Bill of the Month” investigation from NPR and Kaiser Health News. “CBS This Morning” also covered the story. Shortly afterward, his bill was slashed to just $332. Erin Calver said she has seen her family’s story strike a chord.

“For whatever reason, people could relate to us — and be scared that maybe it could happen to them,” she said.

Drew Calver said he encounters many people who worry about the issue.

“The doctor that put my stents in — he either just had a baby or is about to have a baby — and he was saying that, ‘Yeah that could happen to me, too!’” Calver said.

In fact, getting a steep hospital bill is something many Americans call their biggest financial fear.

“Polling shows us that the top household pocketbook concern for consumers is a surprise medical bill,” said Stacey Pogue with the Center for Public Policy Priorities, a think tank that analyzes health and economic issues in Texas. “And that’s actually pretty shocking that consumers will say they are more worried about their ability to afford a surprise medical bill than their health insurance premiums [and] their really high deductibles.”

Last year, a Kaiser Family Foundation poll found that 67% of people worry about unexpected medical bills — a larger share than those who say they worry about prescription drug costs or basic necessities such as rent, food and gas. (KHN is an editorially independent program of the foundation.)

Pogue said that’s a big reason why lawmakers in the state took the issue seriously and passed legislation that she said is now one of the strongest state protections she has seen.

“It is as strong or stronger than any of the protections in the country,” Pogue said.

In addition to Texas, neighboring states Colorado and New Mexico also passed legislation in 2019 to address the problem of surprise out-of-network bills. The Commonwealth Fund’s most recent report on the issue found about half of states offer some legal protections from surprise bills, but only six states had laws that provide “comprehensive” consumer protections similar to those just passed in Texas.

Texas’ new surprise bill law officially takes effect Sept. 1, 2020.

Hancock said the fight over who pays disputed bills will be back where it belongs: with insurance companies, leaving the hospitals, doctors and labs to focus on providing medical care.

“It was just time to get the patient out” of the middle of disputed bills, Hancock said.

Instead, when a hospital and insurer can’t agree on a price, the two parties will have to work it out — without ever billing the patient.

“There is still the ability to negotiate,” Hancock said. “You didn’t have government determining what the price was or determining what the settlement was.”

But not all Texans will be protected by the new law. The Texas law does not apply to people who work for large employers whose plans are regulated by the federal government. In Texas, federally regulated plans account for roughly 40% of the state’s health insurance market.

In fact, Drew Calver would have been exempt from the state’s protections because until recently he had a self-funded health plan regulated by the federal government. However, Drew is now part of wife Erin’s health plan, which will be subject to these new protections.

Pogue said people who have federally regulated health plans will be protected only if Congress acts. She predicted the state’s action will spur federal lawmakers.

“Texas passing a bill will really help on that front,” she said. “There were five states, I think, in 2019 that passed bills that fully protected consumers — and every nudge like that is going to help Congress move.”

Texas lawmakers passed separate legislation that could help Texans with federally regulated plans. Senate Bill 1037 prevents a surprise medical bill from affecting someone’s credit, regardless of what health insurance plan they have.

Congressional leaders have said they are working on coming up with a fix for people across the country with federally regulated plans. President Donald Trump also recently held an event at the White House, with Drew and Erin Calver standing by his side, announcing his administration’s support for banning surprise medical billing in the country.

During a U.S. House Ways and Means Health subcommittee meeting in May, members discussed ways to ban the practice of surprise medical billing.

The committee’s chairman, Austin Democrat Lloyd Doggett, said that “federal action is essential” to addressing the issue for many Americans with federally regulated plans. He said he plans to continue to push for legislation that will “finally offer some relief to patients.” However, no legislation has been passed, yet.

During his opening statements, Doggett said there is a bipartisan desire to shield patients from surprise bills, but “conflict remains over how to resolve insurer-provider disputes.”

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

Democratic Voters Want To Hear Candidates’ Views On Health, But Priorities Vary

With the first Democratic debates a week away, health care is the top issue the party’s voters say they want candidates to address, according to a poll released Tuesday.

But what they mean by that varies widely.

Nearly 9 out of 10 Democrats or Democratic-leaning independents said it is very important for candidates to discuss health issues. But 28% said they want candidates to focus on “lowering the amount people pay for health care,” and about 18% said Democrats should talk about “increasing access to health care,” the Kaiser Family Foundation poll reported. (Kaiser Health News is an editorially independent program of the foundation.)

That divide extends to specific health care proposals, mirroring the split on the issue among Democratic politicians. About 16% of the voters leaning Democratic said the party should discuss “protecting the [Affordable Care Act] and protections for people with pre-existing conditions,” while about 15% said they want candidates to talk about “implementing a single-payer or Medicare-for-all system.”

That figure reflected an increase in the number of Americans who name “Medicare for All” as a priority, noted Ashley Kirzinger, a KFF polling expert. Six months before the 2018 midterm elections, only 4% of Democrats or Democratic-leaning independents said they wanted candidates to talk about single-payer.

“We’re expecting to hear candidates talk about it because individuals are talking about it,” she said.

The poll also revealed that voters are unclear how extensively Medicare for All would revamp the American health care system.

For instance, while most voters — Democrats, Republicans and independents — said they figured a tax increase would be needed to finance Medicare for All, more than 50% of all respondents said people who get private health insurance through work could keep it, that people who buy their own coverage would retain it, and that both individuals and employers would keep paying health insurance premiums. There were sharp differences in these categories, with Republicans much more likely to expect major changes in the health system under a Medicare for All system.

The flagship single-payer legislation — spearheaded by Sen. Bernie Sanders (I-Vt.), who is one of the 2020 Democratic presidential candidates — would eliminate insurance premiums, as well as most employer-sponsored or privately purchased health plans. (It’s unclear how much Medicare for All would cost, though the Congressional Budget Office has noted that “government spending on health care would increase substantially.”)

The disconnect may be the result of voters not understanding or knowing the details of the health care proposals being put forth, Kirzinger said. But it also could be that voters are skeptical of how much lawmakers would actually change the American system.

“It’s telling that a majority think large portions of the current system would stay,” she said.

The poll was conducted May 30-June 4 among about 1,200 people, of whom about 1,000 are registered voters, and 524 are either Democrats or Democratic-leaning independents. It has a margin of error of +/-3 percentage points for issues pertinent to every respondent, and of +/-4 percentage points for those regarding only registered voters. For Democrats and Democratic-leaning independents only, the margin of error is +/-5 percentage points.

Although Trump Administration Has Fallen Short Of Scrapping Health Law, The Changes It Has Made Reshaped Marketplace

The cumulative effect of the Trump administration’s rules could erode a core principle of the health law: ensuring that people can rely on their health insurance if they get sick, and to spread the costs of illness widely. The most recent change gives employers more flexibility to steer tax-exempt dollars to employees for health care.

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! Have drug prices gotten so bad that patients are now turning to robbing banks to afford them? It sounds like something out of a movie script, but it’s what a Utah man told police when he was accused of just that. While it’s unverified whether he, in fact, had any prescriptions, it doesn’t seem like much of a stretch for anyone paying attention to the state of drug prices in this country.

On to what you may have missed this week (including one of the wilder health stories I can recall reading in a while).

Lawmakers were busy, busy bees this week with hearings on health care issues.

The moment that drew perhaps the biggest spotlight was almost cinematic: A furious Jon Stewart took members to task in an almost nine-minute display of pointed, nonpartisan outrage over their feet-dragging on health care funding for 9/11 first responders and victims. Why is this “so damn hard?” the comedian asked. Firefighters, police and other first responders “did their jobs with courage, grace, tenacity and humility,” Stewart said. “Eighteen years later, do yours.” A bill allocating money to the fund for 70 years passed the House panel following the hearing.

The Associated Press: Jon Stewart Lashes Out at Congress Over 9/11 Victims Fund

The New York Times: How Jon Stewart Became a Fierce Advocate for 9/11 Responders

Reuters: House Panel Approves Permanent Sept. 11 Victims’ Compensation

But it wasn’t just made-for-TV drama on Capitol Hill this week. There was a flurry of activity related to health care. Here are some of the highlights, including a hearing on universal health coverage, which was heavy on fiery political rhetoric and light on substance:

The Hill: House Democrats Vote to Overturn Trump Ban on Fetal Tissue Research

CNN: Medicare for All Hearing Turns Into a Defense of Obamacare

Modern Healthcare: Arbitration for Surprise Medical Bills Splits House Panel

The Hill: Pelosi to Change Drug-Pricing Plan After Progressive Complaints

The Hill: Democrats Scuttle Attempt to Strike Hyde Amendment From Spending Bill

The Hill: House Panel Launches Investigation Into Juul


Even if “Medicare for All” were to overcome the daunting political hurdles lying in its path, it’s likely it would face so many legal challenges it could be bled out before it’s ever implemented. “There could be a death by a thousand-lawsuits approach,” Georgetown law professor Katie Keith told Politico. Other experts note, though, that there’s a difference between forcing someone to buy a product and banning something, which makes Medicare for All less vulnerable legally than the health law.

Politico: ‘Death by a Thousand Lawsuits’: The Legal Battles That Could Dog ‘Medicare for All’

Over in Chicago at the American Medical Association’s annual meeting, a medical student-led push to get the organization to reverse its decades-long opposition to single-payer health care failed. But, there’s more to it than that! A fabulous thread on Twitter from Bob Doherty of the American College of Physicians explains how the fact that the vote percentages were so close is remarkable in and of itself. The outcome would have been “unimaginable” in years past, he says.

The Hill: Major Doctors Group Votes to Oppose Single-Payer Health Care

And read Doherty’s thread here.


When premiums shot up over the past several years, more and more people turned to health care sharing ministries — which essentially connect people of similar faiths and set up a cost-sharing arrangement among the members. Because these models are not technically insurance, they’re allowed to skirt health law regulations and aren’t regulated by state commissioners. All of that was seen as a point in their favor from supporters at the time they joined them. But now it means that when bills aren’t paid on time, or at all, consumers have little recourse and officials’ hands are tied in holding the organizations responsible for their promises.

The Wall Street Journal: As Sharing Health-Care Costs Takes Off, States Warn: It Isn’t Insurance

Meanwhile, the Trump administration continues to chip away at the health law with its latest rule on health reimbursement arrangements, which will allow small firms to use tax-free accounts to help workers pay for insurance.

The Hill: Trump Officials Issue New Rule Aimed at Expanding Health Choices for Small Businesses


If you took anything away from last week’s drama over former Vice President Joe Biden’s stance on the Hyde Amendment it was probably that it seems the parties are dead set on their positions on abortion. But a look at how the public feels about the issue reveals blurred lines and nuance that doesn’t always fit into pat sound bites and political declarations. Many Americans struggle with the moral complexities surrounding abortion and their opinions can change from one question to the next, depending on the wording.

The New York Times: Politicians Draw Clear Lines on Abortion. Their Parties Are Not So Unified.

A new poll does show, however, that despite the ever-increasing threat to Roe v. Wade a strong majority of Americans don’t want to see it overturned.

NPR: Abortion Poll: Majority Wants to Keep Abortion Legal, but With Restrictions


Actress Jessica Biel ignited a firestorm of criticism after speaking out about a controversial California bill that would give a state official the final say on medical exemptions from vaccines. Once the blaze was lit, Biel tried to clarify that her issue was not with the vaccines themselves, but rather with the legislation introducing bureaucrats into the process. California’s governor has even hinted at similar concerns. The blowback, though, highlights how inherently inflammatory the topic has become as measles cases continue to climb across the country.

The New York Times: Here Is What Jessica Biel Opposes in California’s Vaccine Bill

In New York — the state at the heart of the record-busting measles outbreak — lawmakers passed a bill banning religious exemptions to vaccines. The governor signed it minutes later.

The Associated Press: New York Set to Cut Religious Exemption to Vaccine Mandates


I have kept you on tenterhooks long enough! One of the wilder health stories I’ve read in a long time comes from gruesomely fascinating Arizona Republic reporting. It’s a look into the thriving for-profit world of whole-body donations following death. Critics deem the practice as no better than “back alley grave robbing.” “There’s a price list for everything from a head to a shoulder, like they are a side of beef. They make money, absolutely, because there’s no cost in getting the bodies,” lawyer Michael Burg told The Arizona Republic. Supporters, however, see it as an affordable way to dispose of the remains of loved ones (which can actually be very expensive for low-income families).

Either way, it garnered my favorite quote of the week, asked by one potential donor: “Will I have a head in heaven?”

The Arizona Republic: Arizona Is a Hotbed for the Cadaver Industry, and Potential Donors Have Plenty of Options

The Arizona Republic: Despite 2-Year-Old State Law, Arizona’s Body Donation Industry Still Unregulated


In a move that left Flint, Mich., residents stunned and frustrated, prosecutors dropped all criminal charges against officials over the city’s water contamination crisis. Although prosecutors said the old investigation was bungled and there will be new charges, the announcement came like a fist to the jaw to people who already have had their faith in the government shattered.

Detroit Free Press: All Flint Water Crisis Criminal Charges Dismissed by AG’s Office


In the miscellaneous file this week:

• If you ever think you’re having a bad day at work, read this story about how an employee’s small photocopier mishap triggered a series of events that undermined a pair of late-stage clinical trials and ultimately scrapped a development deal between pharma companies.

Stat: How a Mishap at a Photocopier Derailed Clinical Trials and a Development Deal

• I am fascinated by the anatomy of pandemics, and this is a great tick-tock of the start of the last one. They don’t play out as they would in Hollywood, but, to me, the reality is even more interesting (I can’t be the only one, right?!).

Stat: The Last Pandemic Was a ‘Quiet Killer.’ Ten Years After Swine Flu, No One Can Predict the Next One

• World health officials have been begging farmers to stop using antibiotics on healthy farm animals in an effort to combat the ever-looming threat of resistance (which, as you know, terrifies yours truly). The farmer,s though, also have drugmakers whispering in their ears — despite a public facade from pharma of wanting to help combat the problem.

The New York Times: Warning of ‘Pig Zero’: One Drugmaker’s Push to Sell More Antibiotics

• Are you a sufferer of “white coat hypertension”? You might think it’s just because you get stressed out when you visit the doctor (join the club!), but a study shows that those anxiety-induced numbers are linked to an increased risk of a cardiac event.

Stat: Those With ‘White Coat Hypertension’ More Likely to Die From Cardiac Events


That’s it from me! Have a great and restful weekend. (Truly, insomnia can kill!)

Air Ambulance Costs Fly Around Fixes For Surprise Medical Bills

In April 2018, 9-year-old Christian Bolling was hiking with his parents and sister in Virginia’s Blue Ridge Mountains, near their home in Roanoke. While climbing some boulders, he lost his footing and fell down a rocky 20-foot drop, fracturing both bones in his lower left leg, his wrist, both sides of his nose and his skull.

A rescue squad carried him out of the woods, and a helicopter flew him to a pediatric hospital trauma unit in Roanoke.

Most of Christian’s care was covered by his parents’ insurance. But one bill stood out. Med-Trans, the air ambulance company, was not part of the family’s health plan network and billed $36,000 for the 34-mile trip from the mountain to the hospital. It was greater than the cost of his two-day hospitalization, scans and cast combined.

“When you’re in that moment, you’re only thinking about the life of your child,” said Christian’s mother, Cynthia Bolling, an occupational therapist. “I know that I am being taken advantage of. It’s just wrong.”

The rising number of complaints about surprise medical bills is spurring efforts on Capitol Hill and at the White House to help consumers. Over and over again, the high cost associated with air ambulance service gives patients the biggest sticker shock — the subject has come up at nearly every Capitol Hill hearing and press conference on surprise medical bills.

Yet air ambulance costs are not addressed in any of the proposals introduced or circulating in Congress. Even a congressional decision last year to set up a panel that would study air ambulance billing hasn’t gotten off the ground.

“We’re doing a disservice to patients if we protect them from hospital bills but bankrupt them on the way there,” said James Gelfand, senior vice president for health policy for the ERISA Industry Committee, known as ERIC, a trade association for large employers.

The issue came up again Wednesday at a House Energy and Commerce subcommittee hearing where Rick Sherlock, president and CEO of the Association of Air Medical Services, the industry group for air ambulances, was among eight witnesses.

Rep. Ben Ray Luján (D-N.M.) sharply questioned Sherlock why costs for air ambulance services have risen by 300 percent in his state since 2006.

“I’m trying to get my hands around why this is costing so much and why so many of my constituents are being hit by surprise bills,” Luján said.

Sherlock said that reimbursements from Medicare and Medicaid do not cover the cost of providing services, so charges to private patients must make up that difference.

Air ambulances serve more than 550,000 patients a year, according to industry data, and in many rural areas air ambulances are the only speedy way to get patients to trauma centers and burn units. As more than 100 rural hospitals have closed around the country since 2010, the need has increased for air services.

More than 80 million people can get to a Level 1 or 2 trauma center within an hour only if they’re flown by helicopter, according to Sherlock.

The service, though, comes at a cost. According to a recent report from the Government Accountability Office, two-thirds of the more than 34,000 air ambulance transports examined were not in the patients’ insurance networks. That can leave patients on the hook for the charges their insurers don’t cover, a practice known as “balance billing.”

In 2017, GAO found that the median price charged nationally by air ambulance providers was around $36,400 for helicopter rides and even higher for other aircraft. The total generally includes the costs for both the transportation and the medical care aboard the aircraft.

Additionally, the ongoing “Bill of the Month” investigative series by Kaiser Health News and NPR has received more than a dozen such bills, ranging from $28,000 to $97,000.

Cynthia Bolling said her insurance company paid about a third of Christian’s air ambulance bill and the family settled this week with Med Trans by agreeing to pay $4,400 out-of-pocket.

Reid Vogel, director of marketing and communications for Med Trans, said the company cannot talk about a private patient because of privacy rules. But he added that the company works with patients to find “equitable solutions” when their bills are not covered by insurance.

Since nearly three-quarters of flights are for patients insured by low-paying Medicare, Tricare and Medicaid, he said, “providers must shift costs to insured patients.”

Private insurers usually will pay only an amount close to what Medicare reimburses, which is around $6,500. That gives air ambulance companies an incentive to remain out-of-network, according to a 2017 GAO report.

“A representative from a large independent provider noted that being out of network with insurance is advantageous to the provider because a patient receiving a balance bill will ask for a higher payment from the insurance company, which often results in higher payment to the air ambulance provider than having a pre-negotiated payment rate with the insurer,” the GAO said.

In an interview, Sherlock, of the trade association, disputed the report’s findings, saying his members are actively trying to be in-network in more places, although he couldn’t provide any specific numbers.

“I think that everywhere they can, they’re incentivized to be in-network,” he said.

States are hampered in their efforts to ease the strain for residents.

The Airline Deregulation Act of 1978, which was intended to encourage more competition, forbids states to regulate prices for any air carrier, which applies to air ambulances. What’s more, many large employers’ health insurance is not governed by states but regulated by the federal labor law, known as ERISA.

So a remedy likely has to come from Congress. And it’s proven to be a heavy lift.

For example, the committees that deal with regulation of the air industry — the Commerce Committee in the Senate and the Transportation Committee in the House — don’t make health policy or regulate health insurance.

Last year, some lawmakers sought to let states regulate air ambulances with a provision in the bill reauthorizing the Federal Aviation Administration.

But that measure was ultimately eliminated. Instead, the bill called for the creation of an advisory committee to study air ambulance prices and surprise bills.

“The air ambulance lobby did a very good job playing defense during FAA authorization,” said ERIC’s Gelfand.

The panel, which was supposed to be formed within 60 days of the law’s enactment date — Oct. 5 — still has not been created.

Representatives from the air ambulance industry don’t think congressional action is necessary, although they are calling for higher reimbursements from Medicare.

Chris Eastlee, vice president for government relations for the Association of Air Medical Services, said his group does not favor more congressional regulation of prices but would support mandatory disclosure of costs to the secretary of Health and Human Services. The organization argues that greater transparency will help companies negotiate more in-network contracts.

A fix for surprise bills supported by some researchers and advocates would require every provider within a medical facility to accept any insurance plan that contracts with that hospital. It might also help bring down air ambulance bills, said Loren Adler, associate director of USC-Brookings Schaeffer Initiative for Health Policy.

It would avoid the situation where someone picks an in-network hospital only to find out that a surgeon or anesthesiologist at that hospital doesn’t take their insurance. Air transport should also be included in the rule, he said.

“It’s the exact same situation as with the out-of-network emergency facility rates,” Adler said. “The same solutions should apply.”

Gelfand suggested also that the House Ways and Means Committee mandate that air ambulance companies seeking to participate in Medicare must charge in-network rates.

That would require only a small tweak of the legislative language, as he sees it. “Every proposal that includes something to address surprise bills for emergency care, all you have to do is add in the words ‘air ambulances,’” Gelfand said.

Right now, the closest any surprise billing proposal has come to addressing air ambulances is a draft legislative plan on medical costs from Sen. Lamar Alexander (R-Tenn.) and Sen. Patty Murray (D-Wash.). They would require bills for air ambulance trips to be itemized to show both medical charges and the transportation charges so patients and health plans can understand them better.

Readers And Tweeters: No Rush To Judge Patients Who Leave The ER Without OK

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.


At The ER, It’s Hurry Up And Wait

At least the patients mentioned in “As ER Wait Times Grow, More Patients Leave Against Medical Advice” (May 17) were allowed to leave. An emergency room may not be a safe place for people and they may wish to go. It is not always the patient who is being irresponsible; it is sometimes those who work in the hospital.

My significant other and I ended up in a situation at the University of New Mexico Hospital. We were there for an appointment with a doctor associated with the hospital, but while she was getting checked in, she fainted. She was out for a short time. They sent over a paramedic to take her to the ER. She did not wish to go to the ER but was not immediately able to get up and leave, even by wheelchair.

The paramedic and his assistant took elaborate measures to separate me from my significant other, for whom I am a caregiver, and they interrogated her. It seemed they wanted her to admit to drug usage. She was very frightened. Eventually, I was allowed to enter the ER, and when the paramedic saw me, he scattered like a roach.

Five hours is a long time to wait. That makes no sense. If people have to wait for five hours it means you really do not have enough staff to handle them all. In most cases, an ER is useless, anyway. They work for people who suffer a car accident, gunshot wound, broken leg or heart attack. For other things, they generally are not much help and often do not even have essential services manned, like ultrasound, MRI, etc. So, in most cases, it is basically a waste of time.

Look inward to figure out why people bolt.

— Sigmund Silber, Santa Fe, N.M.


— Dr. Ali Khan, Omaha, Neb.


There is a lot of discussion over the cost of health care, but people don’t realize how inefficient our system is. I have an 18-year-old son who was born with spina bifida and has had many other health issues. In mid-May, he had a pain in the left side of his back. Not common, and he does not complain about pain. The nurse at his school was concerned; my son looked pale, he came to her wanting to lie down — not typical. So I called his urologist’s office asking how to recognize kidney stones, which he has never experienced. The front desk personnel told me to take him to the ER.

We traveled almost an hour to Children’s Healthcare of Atlanta at Scottish Rite, where he has specialty docs. After running many tests, they told us he had a stomach virus, and we were sent home. On May 30, my son got his annual renal bladder ultrasound done in preparation for a mid-June spina bifida clinic appointment. Turns out, he had a kidney stone! It showed up on the ultrasound.

I am extremely frustrated since it is not the first time I have been told to take my son to ER only to be told “nothing is wrong” or “we can’t help him” even though there later proved to be a problem. What a BIG waste of time and money on our health care system. But you can’t get in to see doctors when you have a problem, so you almost always have to go to the ER. In my opinion, that is a waste of ER services, which I do not hear talked about in the news.

— Rebecca Joiner, Fayetteville, Ga.


— Michael Bertaut, Baton Rouge, La.


Give Midwives And Birth Centers A Chance

In your “Bill of the Month” piece about laughing gas, “Not Funny: Midwife Slapped With $4,836 Bill For Laughing Gas During Her Labor” (May 29), I wish your recommendations would have included seeking out birth centers as an alternative to hospital births. Given the embarrassing state of maternity care in the United States, it’s time to focus on the advantages of midwives and birth centers. They have proven statistically better outcomes at half the cost. As a former consultant to the American Association of Birth Centers, I was impressed when I learned that the AABC built a registry of data to track, measure and improve quality over 13 years ago. They recognized the need for a separate credentialing association, the Commission for Accreditation of Birth Centers, or CABC, and supported the development of its standards. Women need an alternative to our current standard options for low-risk maternity care.

— Linda Davis, Minneapolis


Editor’s note: This is a teachable moment. The following tweeter might have confused Kaiser Health News for Kaiser Permanente. KHN, the health care policy news source you’re currently reading, is not affiliated with the managed-care consortium, although both were named for innovative American industrialist Henry J. Kaiser. Any confusion shouldn’t diminish the strength of her argument, however.

— Allie Keeley, Richmond, Va.


— Dr. Tom Pink, Geneva, Switzerland


In fact, there are positive developments in prenatal care. Several readers weighed in on our article about what to expect when you go through pregnancy with a group of other expectant parents.

— Lauren Lee White, Los Angeles


At The Center Of Group Maternity Care

It was great to see your story on the centering model of maternity care (“The Unexpected Perk Of My Group Pregnancy Care: New Friends,” May 30), but how about some credit to Sharon Rising, the nurse who founded, tested and promotes this health-expanding approach? Nurses are rarely credited. She is an astonishing clinician-scientist who deserves being named in such stories. Thank you.

— Debbie Ward, Sacramento, Calif.


A tweeter in Portugal called her role in a group prenatal program a career highlight:

— Justine Strand de Oliveira, Algarve, Portugal


Missing Tool In The Toolbox For Treating PTSD

I was grateful to see the recent story by Caroline Covington about treatment for PTSD (“For Civilians, Finding A Therapist Skilled In PTSD Treatments Is A Tough Task,” May 22). Unfortunately, she missed a huge piece of the puzzle. A therapy called Eye Movement Desensitization and Reprocessing (EMDR) is an evidence-based treatment for post-traumatic stress disorder, having been validated by more than 36 randomized controlled studies. Endorsed by the American Psychological Association, the Substance Abuse and Mental Health Services Administration, and the Departments of Defense and Veterans Affairs, it is used throughout the world to heal PTSD efficiently. It was developed in 1987 by Francine Shapiro. Please check out EMDRIA.org for research documentation. As a licensed psychotherapist and certified EMDR therapist, I have witnessed the dramatic healing effect of EMDR with my clients suffering from PTSD for many years. I appeal to Ms. Covington to look into this area and complete the story.

—Stephen Weathersbee, a licensed marriage and family therapist, Tyler, Texas


— Harry Stark, Woodland Hills, Calif.


As a short-term veteran (1988-90) diagnosed in 2016 with complex post-traumatic stress disorder, I wanted to add a couple of thoughts. As much as my story was influenced by having been in the military, I constantly found myself comparing my experiences with other veterans. I was always giving deference to the fact that my story wasn’t theirs, and that theirs was usually far more of a “good excuse” to have the condition. In treatment, that logic extended to my individual circumstances. I was constantly comparing my experiences, minimizing at every turn.

I’ve been through both Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT), about two years apart; the PE was used more recently and, in my opinion, was more effective. I wanted to mention another therapy your missed, though: Eye Movement Desensitization and Reprocessing (EMDR). I am on a waiting list with Virginia’s Salem VA Medical Center to try this cutting-edge, light-based therapeutic tool. I even wrote to Samsung and Oculus corporations to suggest they work on making EMDR programs for their VR headsets, in conjunction with VA clinicians.

As you suggested in the article, the industry is catching up to both new methodologies as well as a new client base for PTSD that includes the civilian community. The influx of money and research capacity that comes with this new client base could be well used in advancing this method, and/or combining it for use with current methods.

I know your article concentrated on PTSD experienced by civilians and overcoming the stigma that this disease is somehow reserved for veterans. People need to understand that because we’re all different in our brains that this condition is never the same exact thing … even in two veterans who served side by side. Sure, someone always has it worse than you, but that doesn’t mean your symptoms don’t deserve help.

— Neil Marsh, Moneta, Va.


Spreading The Word (Correctly) About Measles

The United States did not declare measles “eradicated” (“How Measles Detectives Work To Contain An Outbreak,” June 10). It declared the disease “eliminated.” Big difference. In medical terms, “eradicated” means gone forever, as in smallpox. “Eliminated” means no sustained transmission over the period of a year.

— Linda Hultman, Louisville, Colo.

Editor’s note: Another teachable moment. We stand corrected. Thank you!


Dignity At The End Of Life

Something useful to add to Jenny Gold’s article “Will Ties To A Catholic Hospital System Tie Doctors’ Hands?” (April 29): I believe Catholic hospitals ignore patients’ end-of-life wishes. No advance medical directives. So, if I want a do-not-resuscitate (DNR) order, they can override that and insist I live my final days in agony or zoned out.

I always learn something in your newsletters. Keep up your good work!

— Gail Jackson, Waikoloa, Hawaii


Readers everywhere rejoiced over good news, for a change.

— Oral Hazell, St. Thomas, U.S. Virgin Islands


Good Work Restoring Faith In Humanity

The article “Churches Wipe Out Millions In Medical Debt For Others” (June 3) was one of the most uplifting and inspirational stories I have read in such a long time. Kudos to the author and your publication. This is a creative solution that not only stretches donation dollars but sets an example that other religious organizations could easily follow. Thank you.

Philip Heigl, New Cumberland, Pa.


— Chase McGee, Durham, N.C.


— Don Purser, Marietta, Ga.


Helping Those With Developmental Disabilities Navigate Health Care

I have a 17-year-old son with cerebral palsy, so the article “For Those With Developmental Disabilities, Dental Needs Are Great, Good Care Elusive” (May 3) hits home. I would like to see more stories that shed light on the challenges of navigating the health care system for individuals with developmental disabilities. Along with a small share of the U.S. population, my son receives long-term services and supports (LTSS) through Arizona’s Medicaid program. According to a report from Truven Health Analytics, “The Growth of Managed Care Long-Term Services and Supports Program: 2017 Update,” approximately 1.78 million individuals are enrolled in the MLTSS program. Our health care system should do a better job easing the burden in navigating the system for this vulnerable population. I hope that by bringing more attention to these issues will result in policy changes.

— Son Yong Pak, Tempe, Ariz.


In response to the article by David Tuller on dental care for the disabled: I wanted him to know that Special Olympics Virginia provides free dental care (including treatment and procedures) for hundreds of special needs athletes at their Summer Games. Dozens of dentists donate their time for this free clinic. Special Olympics Virginia is able to do this with the support from the Virginia Dental Foundation, Virginia Commonwealth University and Missions of Mercy (MOM Project).

— Donnie Knowlson, Special Olympics Virginia board member, Chesterfield, Va.


The Other Side Of The Opioid Story

Your article “Opioid Prescriptions Drop Sharply Among State Workers” (May 20) draws from biased and highly inaccurate opinion. Here’s a contradicting view.

Massive reductions in opioid prescribing are not a measure of success but instead signal failures of pain medicine under a draconian and unjustified program of persecution of doctors by Drug Enforcement Administration and state regulatory agencies. Tens of thousands of patients have been deserted by physicians afraid of losing their licenses if they treat pain with the only therapies that work for the majority of those with severe pain.

In the article, Beth McGinty is quoted as follows: “These reductions … signal a reduction in the overprescribing practices that have driven the opioid epidemic in the U.S.” This assertion is false. Overprescribing has never substantially “driven” the opioid crisis in the U.S. Statistics on opioid deaths are grossly inflated, representing deaths where a prescription-type opioid is among several factors detected in postmortem “tox screens.” No less a figure than Dr. Nora Volkow, director of the National Institute on Drug Abuse, informs us that addiction is not a predictable outcome of prescribing, and is rare even in at-risk patients.

The article states “One major factor is that many health insurers have imposed limits on prescriptions, as recommended by the CDC in 2016.” The Centers for Disease Control and Prevention recently issued a clarification that the guideline was never intended to justify mandatory tapering of legacy patients. The American Medical Association also repudiated the fundamental logic of the guidelines in Resolution 235 of the November 2018 House of Delegates meeting. Practicing physicians do not consider the equivalent of 50 morphine milligrams (MME) a high dose. Minimum effective dosages can range from ~20 MME to over 1000 MME, depending on metabolism.

Kathy Donneson, chief of CalPERS’ Health Plan Administration Division, says the surest sign of success will be when patients with chronic pain are “kept pain-free in other ways.” However, the literature for such therapies is abysmal, offering weak evidence and no direct comparisons of “alternatives” to properly titrated opioids.

CalPERS is on a course of action that is deeply damaging to patients. The agenda is cost control, not patient care. The other side of the story involves deserted patients who are committing suicide every day.

— Richard Lawhern, Fort Mill, S.C.


— Ben Miller, Denver


Not News To Me

As someone who has worked as a health actuary and executive for major insurers, I am surprised that Rand Corp. or anyone else thought a study needed to be done on what private insurers pay compared with Medicare (“Market Muscle: Study Uncovers Differences Between Medicare And Private Insurers,” May 9). This is OLD, OLD news. Hospitals and other health providers have been demanding more from private payers for the past 30 years! No study needed to be done. Just ask any actuary or health executive who works on contracting with providers. Despite the protestations of health economists who don’t work for insurers, providers demand more from private payers to make up for insufficient payments from Medicare and Medicaid. I can’t believe that this is a surprise to KHN or anyone who is knowledgeable about how medical insurance works in this country.

— Roy Goldman, Jacksonville Beach, Fla.

KHN’s ‘What The Health’: Who Will Pay To Fix Problem Of Surprise Medical Bills?


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


Congress is finally getting down to real work on legislation to end “surprise” medical bills, which patients get if they inadvertently receive care from an out-of-network health providers or use one in an emergency. But doctors, hospitals, insurers and other health care payers can’t seem to agree on who should pay more so patients can pay less.

Meanwhile, the fight over women’s reproductive rights continues in both Washington, D.C., and the states. This week, governors in three states — Vermont, Illinois and Maine — signed bills to make abortions easier to obtain. At the same time, the Democratic-led U.S. House of Representatives took up a spending bill for the Department of Health and Human Services that still includes the “Hyde Amendment,” which bans most federal abortion funding — despite the fact that most House Democrats oppose the restriction. House Democratic leaders fear that the fight to eliminate the restriction would jeopardize the rest of the spending bill in the GOP-controlled Senate and at the White House.

This week’s panelists are Julie Rovner from Kaiser Health News, Stephanie Armour of The Wall Street Journal, Alice Miranda Ollstein of Politico and Kimberly Leonard of the Washington Examiner.

Among the takeaways from this week’s podcast:

  • Republicans on Capitol Hill and at the White House are just as eager as Democrats are to settle on legislation that would keep consumers from getting surprise medical bills. It would provide a nice counterpoint during the upcoming campaign to Democrats’ charges that the GOP has been undermining health care with its opposition to the Affordable Care Act.
  • A federal judge in Texas has struck down the ACA’s provision that health plans must cover contraception. That is at odds with another judge in Pennsylvania who earlier this year blocked the Trump administration’s plans to loosen the birth control mandate.
  • State insurance regulators are raising concerns about health care sharing ministries, which offer plans that provide coverage for some medical expenses. But consumers often don’t realize that the plans may not cover many health costs, including those from preexisting conditions.

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

Julie Rovner: The Washington Post’s “In Alabama — Where Lawmakers Banned Abortion for Rape Victims — Rapists’ Parental Rights Are Protected,” by Emily Wax-Thibodeaux

Alice Miranda Ollstein: The New York Times’ “Planned Parenthood to Host Women’s Health Forum for 2020 Democrats,” by Lisa Lerer

Stephanie Armour: NPR’s “You May Be Stressing Out Your Dog,” by Rebecca Hersher

Kimberly Leonard: Politico’s “Lost in Translation: Epic Goes to Denmark,” by Arthur Allen

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