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KHN senior correspondent Angela Hart discussed California’s contract with Civica to make lower-cost insulin on KQED’s “Forum” on March 23. She also discussed California’s potential plan to use Medicaid funding to cover up to six months of rent for low-income enrollees on KCBS’ “State of California” on March 22.
KHN South Carolina correspondent Lauren Sausser discussed prior authorization on WNHN’s “The Attitude With Arnie Arnesen” on March 21.
KHN Montana legislative fellow Keely Larson discussed Montana’s vaccine exemption legislation on the Montana Free Press’ “The Session” on March 20.
KHN Midwest correspondent Bram Sable-Smith discussed insulin costs on NPR’s “Weekend Edition Saturday” on March 18.
I was back in the crowded East Room of the White House on Thursday, as I was 13 years ago, this time standing under a portrait of first first lady Martha Washington, when President Joe Biden entered for a lunchtime event focused on the Affordable Care Act.
The room looked much the same as it did on March 23, 2010, when I had rushed over to the White House to witness President Barack Obama signing his historic health bill into law. I knew from that moment — standing under a portrait of President Teddy Roosevelt, who was the first chief executive to espouse a need for national health insurance — that my life as a health journalist would never be the same.
Yet, when Biden scheduled an event to commemorate the 13th anniversary of the health law, I was unsure of the need to keep commemorating its birthday.
After all, on the 13th anniversary of President Lyndon Johnson signing Medicare and Medicaid into law — July 30, 1978 — the Democratic president in the White House did not hold an event to commemorate the date when tens of millions of older Americans and lower-income people gained coverage. Then-President Jimmy Carter spent that Sunday at Camp David.
But with the ACA in 2010, after a century of debate, the U.S. health system was getting hit with a thunderbolt that would enable millions of people to gain medical coverage. The law made many changes affecting hospitals, doctors, insurers, drugmakers, and employers in an effort to live up to its lofty name by lowering costs.
Those sweeping provisions, the years spent implementing them, and efforts by Republicans and the courts to repeal or change the law have kept the Affordable Care Act in the news for even longer than I had anticipated. After 13 years, the job is still not done. North Carolina on Thursday became the 40th state to expand Medicaid under the ACA.
Biden used the health law anniversary to tout the law’s influence. He reminded his audience that Republicans still want to strip many of its benefits. He also stressed that the country has unfinished business to lower drug costs for many and expand health coverage to people who still don’t have it. Indeed, more than 2 million people are without coverage in the 10 states — highly populous Florida and Texas among them — that have yet to expand Medicaid.
Many former Obama staffers who helped get the law passed were there — including some who work in the Biden White House. (Obama was not there.) So, too, were several Democratic lawmakers who helped pass the law, including former House speaker Nancy Pelosi and former California congressman and now Health and Human Services Secretary Xavier Becerra.
“Look, 13 years ago today, we gathered in this room as President Obama signed into law the Affordable Health Care Act,” Biden began with his remarks. “Hard to believe 13 days ag- — 13 years ago. It seems like 13 days ago.”
“And I remember the three words I used at the time,” he said as many in the audience recalled the swear word he was caught whispering to Obama via a live microphone. “I thought it was. I thought it was a big deal. And I stand by the fact it was a big deal.”
Biden said that the health law has been called by many names, but that the most appropriate is Obamacare.
The law has become ingrained into the fabric of the country, Biden said. Over 40 million Americans are covered by Medicaid or online insurance marketplace plans, the highest on record, the Biden administration said Thursday. That’s a 36% increase from 2021.
But a 13th anniversary celebration? Jessica Altman, who helped implement Obamacare in the Obama administration and is now CEO of Covered California, one of the Obamacare exchanges, said it was important to take time to remind people what the American health system used to look like as well as the many challenges remaining to improve it. (Altman is the daughter of KFF’s president and CEO. KHN is an editorially independent program of KFF.)
“We still have places to go, and we still have work to do and the people in that room are excited to keep doing it,” Altman said.
Thousands of people struggle to access mental health services in Florida. The treatment system is disjointed and complex. Some residents bounce between providers and are prescribed different medications with clinicians unaware of what happened. Jails and prisons have become de facto homes for many who need care.
These problems and more were identified in a scathing report released earlier this year by the Commission on Mental Health and Substance Abuse, a 19-person panel that Florida lawmakers created in 2021 to push for reforms of the state’s patchwork of behavioral health services for uninsured people and low-income families.
What’s most troubling about the group’s findings? They aren’t new.
More than 20 years ago, the Florida Legislature set up a commission with the same name to examine the same issues and publish recommendations on how to improve mental health care in the publicly funded system.
Last year, the national advocacy group Mental Health America said Florida ranked 46th among the 50 states and the District of Columbia for access to such care. Arizona, Kansas, Georgia, Alabama, and Texas were worse off, according to the nonprofit, which based its rankings on access to insurance, treatment, and special education, along with the cost and quality of insurance and the number of mental health providers.
“It comes down to how much investment, financially, legislators are willing to put into building a system that works,” said Caren Howard, director of policy and advocacy at Mental Health America, a nonprofit just outside Washington, D.C.
In Florida, the 1999 Commission on Mental Health and Substance Abuse was launched when Jeb Bush was governor. In a 74-page report released in 2001, the group called the state’s treatment system “complex, fragmented, uncoordinated and often ineffective.”
The commission found that jails and prisons were Florida’s “largest mental hospitals” after “deinstitutionalization” began — the 20th-century movement to shutter state psychiatric facilities and treat people instead through community services.
The report also blasted Florida agencies for not sharing patient data with one another and being unable to track whether those with severe mental illnesses like schizophrenia were truly getting needed help.
“A lot of the things that we’re finding now, they found back then,” said Charlotte County Sheriff Bill Prummell, a member of the latest commission who served as the chairperson for about 18 months.
The similarities raise questions for the group about whether its work will also end up on a shelf, collecting dust, as Florida lawmakers continue to wrestle with the same challenges again and again.
“Are they really going to take us seriously?” Prummell asked.
A copy of the 2001 report released by Florida’s 1999 Commission on Mental Health and Substance Abuse rests on a shelf in David Shern’s home office.(Ivy Ceballo / Tampa Bay Times)
Dropping the Ball
After hosting public meetings across Florida, the 1999 commission urged a slate of reforms, including expanding jail diversion programs like mental health courts.
But the group’s key recommendation was to set up a “coordinating council” in the governor’s office to lead the system and develop a strategy for care.
That never happened.
David Shern, chairperson of the 1999 group and former dean of the University of South Florida’s Louis de la Parte Florida Mental Health Institute, said he thinks Bush’s office dropped the ball.
The Republican governor, known for his spending cuts, didn’t want to add staff to his office, so the coordinating council was never created, said Shern.
That’s “where the plan really fell apart,” he said.
Instead, lawmakers established a work group in the Department of Children and Families to review how Florida could improve its behavioral health system and submit a report to Bush, among other leaders.
The work group disbanded in 2003. That same year, the legislature created a not-for-profit corporation to oversee the system, but it was dissolved in 2011, according to state business records. When the Tampa Bay Times recently asked for the work group’s report, Laura Walthall, a spokesperson for the Department of Children and Families, said it couldn’t be found. Bush didn’t respond to emailed questions.
Former state Rep. Sandra Murman, however, said that what happened is just a reality of bureaucracy.
“It’s the same with all commissions,” said Murman, a Tampa Republican who was part of the 1999 group. “The life cycle of any big report that comes out is probably about five years.”
Lawmakers leave Tallahassee because of term limits. Agency heads step down. New officials get elected. Priorities shift.
“They come in with their agenda, and you won’t see social services ever at the top,” she said of Florida legislative leaders.
David Shern holds a copy of the report his mental health commission released in 2001. A recent report by a new state commission reached similar conclusions.(Ivy Ceballo / Tampa Bay Times)
But some state lawmakers focused on mental illness in the wake of the 2018 shooting that left 17 students and staff members dead at Marjory Stoneman Douglas High School in Parkland. Amid mounting public demand for more drastic gun control measures, such as an assault weapons ban, the Republican-controlled legislature instead approved more limited restrictions, like Florida’s “red flag” law, along with steps unrelated to gun control, allocating about $400 million for mental health and school safety initiatives.
Before the massacre, Parkland shooter Nikolas Cruz received mental health services through several public and private providers, splitting the future gunman’s medical history, according to a 2019 report from the Marjory Stoneman Douglas High School Public Safety Commission.
“No single health professional or entity had the entire ‘story’ regarding Cruz’s mental health and family issues, due, in part, to an absence of communication between providers and a lack of disclosure by the Cruz family,” the report said.
In 2020, a grand jury investigating school safety issues related to the shooting called Florida’s mental health care system “a mess.”
“Deficiencies in funding, leadership and services,” the grand jury said, “tend to turn up everywhere like bad pennies.”
The panel said it didn’t have enough time to conduct a full review of the system and urged state lawmakers to set up a commission to do so.
The latest commission reported that the system remains splintered and suffers from “enormous gaps in treatment.” And there’s still no centralized database on patients.
The group, just like its predecessor over two decades ago, has suggested that Florida create more jail diversion programs and that state agencies share patient data. The commission has pitched new ideas, too, like a pilot program in which one agency manages all public behavioral health funding in a geographic area, including state money and local dollars, so providers can focus more on care and less on complicated billing processes.
Solutions to Florida’s problems are not headline grabbers, which makes it tough to generate political support, said Holly Bullard, chief strategy and development officer at the Florida Policy Institute, an Orlando nonprofit.
“Building good government, it can get technical,” she said, “and sometimes it’s hard to communicate the importance of it.”
Will Anything Change?
David Shern with a copy of the report his mental health commission released in 2001.(Ivy Ceballo / Tampa Bay Times)
There’s been some progress in Florida’s mental health care system since 2001, said Jay Reeve, the new chairperson of the latest commission and CEO of Apalachee Center, a behavioral health provider in Tallahassee.
The system is more responsive to regional issues, partly because of state contracts with seven “managing entities” — nonprofits that oversee safety-net services for the uninsured, he said.
There’s also been an increase in initiatives like mobile response teams, which help people in mental health emergencies, and crisis intervention training for police officers, in which they get trained on de-escalation techniques and psychiatric diagnoses so they know when to get residents into treatment instead of arresting them, Reeve said.
The Department of Children and Families used to spend about $500 million a year on community-based behavioral health services such as outpatient treatment, case management, and crisis stabilization units, the 1999 commission reported. Now, its budget for such care is $1.1 billion.
Pockets of innovation exist at the local level, too, as in Palm Beach County, where an initiative called BeWellPBC aims to boost the area’s mental health care workforce, among other things, said Shern, senior associate in the department of mental health at the Johns Hopkins Bloomberg School of Public Health.
But challenges remain.
Nearly 3 million Florida adults have a mental illness, according to Mental Health America. That’s about 17% of the state’s population of those 18 and up. An estimated 225,000 youths experienced at least one major depressive episode in the past year, the nonprofit reported in October.
In 2020, Florida ranked last among states for per capita mental health care funding, the Parkland grand jury said. In 2021, the Miami-Dade County jail system was the largest psychiatric institution in the state, according to the 11th Judicial Circuit.
“As long as you keep things siloed, accountability is easier to dodge,” said Ann Berner, a member of the 2021 commission and CEO of Southeast Florida Behavioral Health Network, a managing entity.
Political will is needed to enact major reforms, Shern said. So is follow-up on the commission’s work, said Murman, who works at Shumaker Advisors Florida, a lobbying firm.
“In this case, it probably is something that has to be revived every five years to really make an impact,” she said.
Rep. Christine Hunschofsky, a Parkland Democrat on the 2021 commission, said there’s bipartisan support to improve the system.
But during the current legislative session, the Tampa Bay Times on March 13 could find only one House bill and a matching Senate bill based on the commission’s 35-page interim report: a proposal to study Medicaid expansion for some young adults age 26 and under. (Republican leaders in Florida have refused to expand the federal-state health care program under the Affordable Care Act, which became law in 2010.)
Hunschofsky said she thinks the legislature will take more action once the commission releases its final report, which is due by Sept. 1.
Republican Gov. Ron DeSantis’ office referred questions to the Department of Children and Families, where officials didn’t answer them.
Senate President Kathleen Passidomo didn’t respond to a voicemail and interview requests made through a spokesperson. Nor could House Speaker Paul Renner be reached for comment.
After more than 20 years, Shern is frustrated.
“It’s time to move on these issues,” he said. “We’ve spent literally decades thinking about them, talking about them.”
David Shern in his home office.(Ivy Ceballo / Tampa Bay Times)
This article was produced in partnership with the Tampa Bay Times.
Nearly 12 years ago, a nonprofit centered on substance abuse prevention in Lyon County, Nevada, broadened its services to dental care.
Leaders with the Healthy Communities Coalition were shocked into action after two of their food pantry volunteers used pliers to pull each other’s abscessed teeth. The volunteers saw no other option to relieve their overwhelming pain in the small town where they lived, 40 miles southeast of Reno, because of a dearth of dental care providers.
That drastic act, said Wendy Madson, executive director for the coalition, prompted her organization to use mobile clinics to offer health and dental services in rural communities where there aren’t enough patients to support brick-and-mortar offices.
The coalition now sends a van outfitted with dental equipment to county schools to treat hundreds of students per stop a few times each year. They also host events for adults in the region. The response has been overwhelming.
“Dental is the hot ticket,” Madson said. “Everybody wants dental. Availability of those services is what runs out first in those large mobile events.”
The coalition’s mobile programs mirror efforts nationwide to dispatch services to patients experiencing gaps in the health care system, especially in rural areas.
Rural residents face more significant health care provider shortages, including dentists, compared with their counterparts in larger cities. Since the beginning of the pandemic, mobile clinics have increased access to a range of services in hard-to-reach places with sparse populations.
A recently passed law, which makes it easier for rural communities to pay for new mobile clinics, could expand this trend. In the past, clinics that serve low-income rural residents couldn’t spend federal grant money, called new access point grants, on mobile services in communities where they didn’t already have facilities.
Then last fall, Congress passed the MOBILE Health Care Act, sponsored by Sens. Jacky Rosen (D-Nev.) and Susan Collins (R-Maine), which gives federally qualified health centers — health clinics serving medically underserved areas — greater flexibility to use federal funding to create and operate mobile units.
Since 2019, the number of mobile clinics on the road has expanded, according to the National Association of Community Health Centers. Many had been used for covid-19 testing and vaccinations. And health and community organizations have started using mobile units to bring primary care, behavioral health, and reproductive services to out-of-the-way patients. The new funding pathway could soon put even more mobile health vans on the road.
For now, the law is dependent on congressional funding, and experts predict it could be at least a year before health centers can access the grant money.
More than 2,000 health center advocates went to Washington, D.C., in early March to ask lawmakers to support multiyear grant funding, said Amy Simmons Farber, associate vice president of media relations for the National Association of Community Health Centers.
Once funded, the regulatory shift will allow health centers to collaborate with independent organizations like Madson’s Health Communities Coalition in Nevada to expand services in underserved regions. Because the coalition is not a federally qualified health center, it has relied on a mix of other federal and state grants.
Nearly 1,400 federally qualified health centers nationwide receive federal funding for providing comprehensive health services in underserved areas. The previous requirement that health centers establish brick-and-mortar clinics before expanding mobile clinics prevented many from applying, said Steve Messinger, policy director for the Nevada Primary Care Association. It was burdensome and costly for health centers.
But in rural areas with small populations, served well by mobile clinics, it wouldn’t make sense to first establish a building with a full-time provider, he said. That could eat up the budget of a federally qualified health center.
While health center advocates lobby Congress for base funding, the Healthy Communities Coalition is forging ahead with three dental events this year funded by a grant from the Health Resources and Services Administration, part of the Department of Health and Human Services.
At the first medical outreach event the coalition organized in 2012 in Lyon County, where 61,400 residents are spread across more than 2,000 square miles, more than 200 people showed up to receive free care and 150 teeth were pulled, Madson said. Since then, the organization has hosted several events a year — except in 2020, when the pandemic paused work.
Healthy Communities Coalition executive director Wendy Madson says mobile dental clinics in Lyon County, Nevada, help reach young students whose parents might otherwise lack the means or insurance to schedule regular visits.(Wendy Madson)
Many of the dental events are school-focused and provide children with such services as screenings, X-rays, sealings, varnish, and cleanings. But an overwhelming need for care also exists among area adults, said Madson, because Medicare and Nevada’s Medicaid do not include comprehensive dental coverage for adults. It’s harder to fund those events, she said.
Of the five communities in Lyon County, at least one, Silver Springs, does not have a single dentist. There are 10 dentists total in Fernley and Dayton, communities with a combined population of 38,600 people, but only two of those practices accept Medicaid, which covers low-income people younger than 21 and limited dental services for adults.
Traci Rothman, who manages the coalition’s food pantries, said the dental outreach events made a difference for her 29-year-old son, who moved to Silver Springs last year. He went to two mobile clinics to receive free care, which Rothman said was a big relief because he’s uninsured and needed dental care badly.
“Otherwise, you’re going to somebody that you’re paying cash,” she said. “Oftentimes I cannot pay, honestly; it’s just out of reach for some people, or most people … in rural areas.”
Madson said the coalition stepped in to help a young student in desperate need of a root canal. The coalition is helping the girl’s family apply for Medicaid or Nevada Check Up, the state Children’s Health Insurance Program, and is paying $1,600 to cover the service with federal grant money. Another student had to be referred to several specialists before she had her decayed baby teeth surgically removed and received restorative treatment for adult teeth that had begun to decay.
“Her mom was so thankful, she was in tears,” Madson said. “She told me that her daughter woke up without instant pain for the first time in years.”
Madson said her organization has enough grant funding for three events through May, but she hopes the MOBILE Health Care Act will help expand services. Besides dental care, the group provides primary care mobile clinics for immigrant workers in Yerington, a small town in an agricultural region about 70 miles southeast of Reno.
Sara Rich, CEO of Choptank Community Health in Maryland, said she shares Madson’s hope.
Choptank serves five counties in Maryland, including small towns between the Chesapeake Bay and the Delmarva Peninsula. Amid the pandemic, the health organization struck an unlikely partnership with a car dealership and used federal covid relief money to buy a Ford Transit cargo van for mobile clinics.
Choptank used its new van to provide vaccines but has since started using it to provide primary care to immigrant workers and dental services to children at 36 schools. The mobile clinics have been so successful that the health center is working on purchasing more vans to expand its services.
Rich said the mobile clinics are “breaking down barriers that a lot of us have been working on for a long time.”
Among the new services Choptank seeks to provide are behavioral health, preventing and treating substance use disorders, and skin screenings for people working on the shores of Maryland.
“Flexibility has been a theme over the last few years,” Rich said. “I think this MOBILE Health Care Act will help us do that even more into the future.”
To crack down on price gouging, proposed legislation in Missouri calls for allowing felony charges against health care staffing agencies that substantially raise their prices during a declared emergency.
A New York bill includes a cap on the amount staffing agencies can charge health care facilities. And a Texas measure would allow civil penalties against such agencies.
These proposed regulations — and others in at least 11 more states, according to the American Staffing Association industry trade group — come after demand for travel nurses, who work temporary assignments at different facilities, surged to unprecedented levels during the worst of the covid-19 pandemic.
Hospitals have long used temporary workers, who are often employed by third-party agencies, to help fill their staffing needs. But by December 2021, the average weekly travel nurse pay in the country had soared to $3,782, up from $1,896 in January 2020, according to a Becker’s Hospital Review analysis of data from hiring platform Vivian Health. That platform alone listed over 645,000 active travel nurse jobs in the final three months of 2022.
Some traveling intensive care unit nurses commanded $10,000 a week during the worst of the pandemic, prompting burned-out nurses across the country to leave their hospital staff jobs for more lucrative temporary assignments. Desperate hospitals that could afford it offered signing bonuses as high as $40,000 for nurses willing to make multiyear commitments to join their staff instead.
The escalating costs led hospitals and their allies around the country to rally against what they saw as price gouging by staffing agencies. In February 2021, the American Hospital Association urged the Federal Trade Commission to investigate “anticompetitive pricing” by agencies, and, a year later, hundreds of lawmakers urged the White House to do the same.
No substantial federal action has occurred, so states are trying to take the next step. But the resulting regulatory patchwork could pose a different challenge to hospitals in states with rate caps or other restrictive measures, according to Hannah Neprash, a University of Minnesota health care economics professor. Such facilities could find it difficult to hire travel nurses or could face a lower-quality hiring pool during a national crisis than those in neighboring states without such measures, she said.
For example, Massachusetts and Minnesota already had rate caps for temporary nurses before the pandemic but raised and even waived their caps for some staffing agencies during the crisis.
And any new restrictions may meet stiff resistance, as proposed rate caps did in Missouri last year.
As the covid omicron variant wave began to subside, Missouri legislators considered a proposal that would have set the maximum rate staffing agencies could charge at 150% of the average wage rate of the prior three years plus necessary taxes.
The Missouri Hospital Association, a trade group that represents 140 hospitals across the state, supported the bill as a crackdown on underhanded staffing firms, not on nurses being able to command higher wages, spokesperson Dave Dillon said.
“During the pandemic there were staffing companies who were making a lot of promises and not necessarily delivering,” Dillon said. “It created an opportunity for both profiteering and for bad actors to be able to play in that space.”
Nurses, though, decried what they called government overreach and argued the bill could make the state’s existing nursing shortage worse.
Theresa Newbanks, a nurse practitioner, asked legislators to imagine the government attempting to dictate how much a lawyer, electrician, or plumber could make in Missouri. “This would never be allowed,” she testified to the committee considering the bill. “Yet, this is exactly what is happening, right now, to nurses.”
Another of the nearly 30 people who testified against the bill was Michelle Hall, a longtime nurse and hospital nursing leader who started her own staffing agency in 2021, in part, she said, because she was tired of seeing her peers leave the industry over concerns about unsafe staffing ratios and low pay.
“I felt like I had to defend my nurses,” Hall later told KHN. Her nurses usually receive about 80% of the amount she charges, she said.
Typically about 75% of the price charged by a staffing agency to a health care facility goes to costs such as salary, payroll taxes, workers’ compensation programs, unemployment insurance, recruiting, training, certification, and credential verification, said Toby Malara, a vice president at the American Staffing Association trade group.
He said hospital executives have, “without understanding how a staffing firm works,” wrongly assumed price gouging has been occurring. In fact, he said many of his trade group’s members reported decreased profits during the pandemic because of the high compensation nurses were able to command.
While Missouri lawmakers did not pass the rate cap, they did make changes to the regulations governing staffing agencies, including requiring them to report the average amounts charged per health care worker for each personnel category and the average amount paid to those workers. Those reports will not be public, although the state will use them to prepare its own aggregate reports that don’t identify individual agencies. The public comment period on the proposed regulations was scheduled to begin March 15.
Hall was not concerned about the reporting requirements but said another of the changes might prompt her to close shop or move her business out of state: Agencies will be barred from collecting compensation when their employees get recruited to work for the facility where they temp.
“It doesn’t matter all the money that I have put out prior, to onboard and train that person,” Hall said.
Dillon called that complaint “pretty rich,” noting that agencies routinely recruit hospital staff members by offering higher pay. “Considering the premium agencies charge for staff, I find it hard to believe that this risk isn’t built into their business model,” he said.
Of course, as the pandemic has waned, the demand for travel nursing has subsided. But pay has yet to drop back to pre-pandemic levels. Average weekly travel nurse pay was $3,077 in January, down 20% year over year but still 62% higher in January 2020, according to reporting on Vivian Health data by Becker’s.
With the acute challenges of the pandemic behind hospitals, Dillon said, health system leaders are eyeing proactive solutions to meet their ongoing workforce challenges, such as raising pay and investing in the nursing workforce pipeline.
A hospital in South Carolina, for example, is offering day care for staffers’ children to help retain them. California lawmakers are considering a $25-per-hour minimum wage for health care workers. And some hospitals have even created their own staffing agencies to reduce their reliance on third-party agencies.
But the momentum to directly address high travel nurse rates hasn’t gone away, as evidenced by the legislative push in Missouri this year.
The latest proposal would apply to certain agencies if a “gross disparity” exists between the prices they charge during an emergency and what they charged prior to it or what other agencies are currently charging for similar services and if their earnings are at least 15% higher than before the emergency.
Malara said he doesn’t have much of a problem with this year’s bill because it gives agencies the ability to defend their practices and pricing.
Kentucky last year applied its existing price gouging rules to health care staffing agencies. The rules, which set criteria for acceptable prices, allow increases driven by higher labor costs. Malara said if the Missouri bill gains momentum he will point its sponsor to that language and ask her to clarify what constitutes a “gross disparity” in prices.
The sponsor of the bill, Missouri state Sen. Karla Eslinger, a Republican, did not respond to requests for comment on the legislation.
Hall said she is opposed to any rate caps but is ambivalent about Missouri’s new proposal. She said she saw agencies raising their prices from $70 an hour to over $300 while she worked as a hospital nursing leader at the height of the pandemic.
“All these agencies that were price gouging,” Hall said, “all they were doing was putting that money in their own pockets. They weren’t doing anything different or special for their nurses.”
Gov. Gavin Newsom may have been prescient when he acknowledged free speech concerns as he signed California’s covid misinformation bill last fall. In a message to lawmakers, the governor warned of “the chilling effect other potential laws may have” on the ability of doctors to speak frankly with patients but expressed confidence that the one he was signing did not cross that line.
Yet the law — meant to discipline doctors who give patients false information about covid-19 — is now in legal limbo after two federal judges issued conflicting rulings in recent lawsuits that say it violates free speech and is too vague for doctors to know what it bars them from telling patients.
In two of the lawsuits, Senior U.S. District Judge William Shubb in Sacramento issued a temporary halt on enforcing the law, but it applies only to the plaintiffs in those cases. Shubb said the law was “unconstitutionally vague,” in part because it “fails to provide a person of ordinary intelligence fair notice of what is prohibited.” His ruling last month clashed with one handed down in Santa Ana in December; in that case, U.S. District Judge Fred Slaughter refused to halt the law and said it was “likely to promote the health and safety of California covid-19 patients.”
The legal fight in the nation’s most populous state is to some extent a perpetuation of the pandemic-era tussle pitting supporters of public health guidelines against groups and individuals who resisted masking orders, school shutdowns, and vaccine mandates.
California’s covid misinformation law, which took effect Jan. 1, is being challenged by vaccine skeptics and civil liberties groups. Among those suing to get the law declared unconstitutional is a group founded by Robert F. Kennedy Jr., who has questioned the science and safety of vaccines for years.
But doubts about the law are not confined to those who have battled the scientific mainstream.
Dr. Leana Wen, a health policy professor at George Washington University who previously served as president of Planned Parenthood and as Baltimore’s health commissioner, wrote in an op-ed a few weeks before Newsom signed the law that it would exert “a chilling effect on medical practice, with widespread repercussions that could paradoxically worsen patient care.”
The Northern California affiliate of the American Civil Liberties Union has weighed in against the law on free speech grounds, though the national organization has affirmed the constitutionality of covid vaccine mandates.
“If doctors are scared of losing their licenses for giving advice that they think is helpful and appropriate, but they don’t quite know what the law means, they will be less likely to speak openly and frankly with their patients,” said Hannah Kieschnick, an attorney with the ACLU of Northern California.
The law establishes that doctors who give false information about covid to patients are engaging in unprofessional conduct, which could subject them to discipline by the Medical Board of California or the Osteopathic Medical Board of California.
Proponents of the law sought to crack down on what they believe are the most clear-cut cases: Doctors who tout treatments such as ivermectin, an anti-parasitic agent that is unproven as a covid treatment and can be dangerous; who exaggerate the risk of getting vaccinated compared with the dangers of the disease; or who spread unfounded theories about the vaccines, including that they can cause infertility or harm DNA.
But the law lacks such specifics, defining misinformation only as “false information that is contradicted by contemporary scientific consensus contrary to the standard of care.”
Michelle Mello, a professor of law and health policy at Stanford University, said the wording is confusing.
“On a matter like covid, science is changing all the time, so what does it mean to say there is scientific consensus?” she asked. “To me, there are lots of examples of statements that clearly, with no vagueness involved, meet the definition of the kind of conduct that the legislature was going after. The problem is that there are all kinds of other hypothetical things that people can say that don’t clearly violate it.”
Dr. Christine Cassel, a professor of medicine at the University of California-San Francisco, said she expects the law to be applied only in the most flagrant cases. “I trust scientists enough to know where there’s a legitimate dispute,” she said.
Cassel’s view mirrors Newsom’s rationale for signing the legislation despite his awareness of potential free speech concerns. “I am confident,” he wrote in his message to lawmakers, “that discussing emerging ideas or treatments including the subsequent risks and benefits does not constitute misinformation or disinformation under this bill’s criteria.”
Plaintiffs in the Santa Ana case, two doctors who have sometimes diverged from public health guidelines, appealed Slaughter’s ruling allowing the law to stand. The case has been combined in the 9th U.S. Circuit Court of Appeals with another case in which a San Diego judge declined to rule on a similar request to temporarily halt the law.
Newsom spokesperson Brandon Richards said in early February that the administration would not appeal the two Sacramento cases in which Shubb issued the narrow injunction. The plaintiffs’ lawyers had expected the state to appeal the decision, thinking all four lawsuits would then be decided by the appeals court, providing greater clarity for all parties.
Richard Jaffe, lead attorney in one of the Sacramento cases — brought by a doctor, Kennedy’s Children’s Health Defense, and a group called Physicians for Informed Consent — said Newsom’s decision not to appeal is “just going to increase the level of chaos in terms of who the law applies to.”
But the Newsom administration has decided to wait for the appeals court to rule on the other two judges’ decisions that left the law intact for now.
Jenin Younes, a lawyer with the New Civil Liberties Alliance who is lead counsel in the other Sacramento case in which Shubb issued his injunction, said Newsom may be calculating that “you’re in a stronger position going up on a win than on a loss.”
A victory for Newsom in the appeals court, Jaffe and others said, could dampen the impact of the two Sacramento cases.
Opponents of California’s covid misinformation law question why it is needed at all, since the medical boards already have authority to discipline doctors for unprofessional conduct. Yet only about 3% of the nearly 90,000 complaints the Medical Board of California received over a decade resulted in doctors being disciplined, according to a 2021 investigation by the Los Angeles Times.
That could be good news for doctors who worry the new law could constrain their ability to advise patients.
“I don’t see medical boards being particularly vigorous in policing physicians’ competence in general,” said Stanford’s Mello. “You have to be really bad to get their attention.”
This week, the eyes of the nation are on Texas, where a federal judge who formerly worked for a conservative Christian advocacy group is set to decide whether the abortion pill mifepristone can stay on the market. Mifepristone is half of a two-pill regimen that now accounts for more than half of the abortions in the United States.
Meanwhile, Novo Nordisk, another of the three large drug companies that dominate the market for diabetes treatments, has announced it will cut the price of many of its insulin products. Eli Lilly announced its cuts early this month. But the push for more affordable insulin from activists and members of Congress is not the only reason for the change: Because of quirks in the way the drug market works, cutting prices could actually save the companies money in the long run.
This week’s panelists are Julie Rovner of KHN, Jessie Hellmann of CQ Roll Call, Sarah Karlin-Smith of the Pink Sheet, and Alice Miranda Ollstein of Politico.
Among the takeaways from this week’s episode:
The federal judge examining the decades-old approval of mifepristone could issue a decision at any time after a hearing largely behind closed doors, during which he appeared open to restricting access to the drug.
Democratic governors seek to counter the chill of Republican states’ warnings to pharmacies about distributing mifepristone, and a separate lawsuit in Texas seeks to set a precedent for punishing people who aren’t medical providers for assisting someone in obtaining an abortion.
In pandemic news, Congress is moving forward with legislation that would force the Biden administration to declassify intelligence related to the origins of covid-19, while the editor of Cochrane Reviews posted a clarification of its recently published masking study, noting it is “inaccurate” to say it found that masks are not effective.
Top federal health officials sent an unusual letter to Florida’s surgeon general, warning that his embrace of vaccination misinformation is harmful, even deadly, to Americans. While covid vaccines come with some risk of negative health effects, contracting covid carries a higher risk of poor outcomes.
Novo Nordisk’s announcement that it will cut insulin prices puts pressure on Sanofi, the remaining insulin maker that has yet to adjust its prices.
The Veterans Health Administration will cover Leqembi, a new Alzheimer’s drug. The decision comes as Medicare considers whether it will also cover the drug. Experts caution that new drugs shaking up the weight-loss market could prove costly for Medicare.
Washington is eyeing changes to federal rules that would affect the practice of medicine. One change would force health plans to speed up “prior authorization” decisions by health insurers and increase transparency around denials, which supporters say would help patients better access needed care. Another proposal would ban noncompete clauses in contracts, including in health care. Arguments for and against the change both cite the issue of physician burnout — though they disagree on whether the ban would make the problem better or worse.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
When Paula Chestnut needed hip replacement surgery last year, a pre-operative X-ray found irregularities in her chest.
As a smoker for 40 years, Chestnut was at high risk for lung cancer. A specialist in Los Angeles recommended the 67-year-old undergo an MRI, a high-resolution image that could help spot the disease.
But her MRI appointment kept getting canceled, Chestnut’s son, Jaron Roux, told KHN. First, it was scheduled at the wrong hospital. Next, the provider wasn’t available. The ultimate roadblock she faced, Roux said, arrived when Chestnut’s health insurer deemed the MRI medically unnecessary and would not authorize the visit.
“On at least four or five occasions, she called me up, hysterical,” Roux said.
Months later, Chestnut, struggling to breathe, was rushed to the emergency room. A tumor in her chest had become so large that it was pressing against her windpipe. Doctors started a regimen of chemotherapy, but it was too late. Despite treatment, she died in the hospital within six weeks of being admitted.
Though Roux doesn’t fully blame the health insurer for his mother’s death, “it was a contributing factor,” he said. “It limited her options.”
Few things about the American health care system infuriate patients and doctors more than prior authorization, a common tool whose use by insurers has exploded in recent years.
Prior authorization, or pre-certification, was designed decades ago to prevent doctors from ordering expensive tests or procedures that are not indicated or needed, with the aim of delivering cost-effective care.
Originally focused on the costliest types of care, such as cancer treatment, insurers now commonly require prior authorization for many mundane medical encounters, including basic imaging and prescription refills. In a 2021 survey conducted by the American Medical Association, 40% of physicians said they have staffers who work exclusively on prior authorization.
So today, instead of providing a guardrail against useless, expensive treatment, pre-authorization prevents patients from getting the vital care they need, researchers and doctors say.
“The prior authorization system should be completely done away with in physicians’ offices,” said Dr. Shikha Jain, a Chicago hematologist-oncologist. “It’s really devastating, these unnecessary delays.”
In December, the federal government proposed several changes that would force health plans, including Medicaid, Medicare Advantage, and federal Affordable Care Act marketplace plans, to speed up prior authorization decisions and provide more information about the reasons for denials. Starting in 2026, it would require plans to respond to a standard prior authorization request within seven days, typically, instead of the current 14, and within 72 hours for urgent requests. The proposed rule was scheduled to be open for public comment through March 13.
Although groups like AHIP, an industry trade group formerly called America’s Health Insurance Plans, and the American Medical Association, which represents more than 250,000 physicians in the United States, have expressed support for the proposed changes, some doctors feel they don’t go far enough.
“Seven days is still way too long,” said Dr. Julie Kanter, a hematologist in Birmingham, Alabama, whose sickle cell patients can’t delay care when they arrive at the hospital showing signs of stroke. “We need to move very quickly. We have to make decisions.”
Meanwhile, some states have passed their own laws governing the process. In Oregon, for example, health insurers must respond to nonemergency prior authorization requests within two business days. In Michigan, insurers must report annual prior authorization data, including the number of requests denied and appeals received. Other states have adopted or are considering similar legislation, while in many places insurers regularly take four to six weeks for non-urgent appeals.
Waiting for health insurers to authorize care comes with consequences for patients, various studies show. It has led to delays in cancer care in Pennsylvania, meant sick children in Colorado were more likely to be hospitalized, and blocked low-income patients across the country from getting treatment for opioid addiction.
In some cases, care has been denied and never obtained. In others, prior authorization proved a potent but indirect deterrent, as few patients have the fortitude, time, or resources to navigate what can be a labyrinthine process of denials and appeals. They simply gave up, because fighting denials often requires patients to spend hours on the phone and computer to submit multiple forms.
Erin Conlisk, a social science researcher for the University of California-Riverside, estimated she spent dozens of hours last summer trying to obtain prior authorization for a 6-mile round-trip ambulance ride to get her mother to a clinic in San Diego.
Her 81-year-old mother has rheumatoid arthritis and has had trouble sitting up, walking, or standing without help after she damaged a tendon in her pelvis last year.
Conlisk thought her mom’s case was clear-cut, especially since they had successfully scheduled an ambulance transport a few weeks earlier to the same clinic. But the ambulance didn’t show on the day Conlisk was told it would. No one notified them the ride hadn’t been pre-authorized.
The time it takes to juggle a prior authorization request can also perpetuate racial disparities and disproportionately affect those with lower-paying, hourly jobs, said Dr. Kathleen McManus, a physician-scientist at the University of Virginia.
“When people ask for an example of structural racism in medicine, this is one that I give them,” McManus said. “It’s baked into the system.”
Research that McManus and her colleagues published in 2020 found that federal Affordable Care Act marketplace insurance plans in the South were 16 times more likely to require prior authorization for HIV prevention drugs than those in the Northeast. The reason for these regional disparities is unknown. But she said that because more than half the nation’s Black population lives in the South, they’d be the patients more likely to face this barrier.
Many of the denied claims are reversed if a patient appeals, according to the federal government. New data specific to Medicare Advantage plans found 82% of appeals resulted in fully or partially overturning the initial prior authorization denial, according to KFF.
It’s not just patients who are confused and frustrated by the process. Doctors said they find the system convoluted and time-consuming, and feel as if their expertise is being challenged.
“I lose hours of time that I really don’t have to argue … with someone who doesn’t even really know what I’m talking about,” said Kanter, the hematologist in Birmingham. “The people who are making these decisions are rarely in your field of medicine.”
Occasionally, she said, it’s more efficient to send patients to the emergency room than it is to negotiate with their insurance plan to pre-authorize imaging or tests. But emergency care costs both the insurer and the patient more.
“It’s a terrible system,” she said.
A KFF analysis of 2021 claims data found that 9% of all in-network denials by Affordable Care Act plans on the federal exchange, healthcare.gov, were attributed to lack of prior authorization or referrals, but some companies are more likely to deny a claim for these reasons than others. In Texas, for example, the analysis found 22% of all denials made by Blue Cross and Blue Shield of Texas and 24% of all denials made by Celtic Insurance Co. were based on lack of prior authorization.
Facing scrutiny, some insurers are revising their prior authorization policies. UnitedHealthcare has cut the number of prior authorizations in half in recent years by eliminating the need for patients to obtain permission for some diagnostic procedures, like MRIs and CT scans, said company spokesperson Heather Soules. Health insurers have also adopted artificial intelligence technology to speed up prior authorization decisions.
Meanwhile, most patients have no means of avoiding the burdensome process that has become a defining feature of American health care. But even those who have the time and energy to fight back may not get the outcome they hoped for.
When the ambulance never showed in July, Conlisk and her mother’s caregiver decided to drive the patient to the clinic in the caregiver’s car.
“She almost fell outside the office,” said Conlisk, who needed the assistance of five bystanders to move her mother safely into the clinic.
When her mother needed an ambulance for another appointment in September, Conlisk vowed to spend only one hour a day, for two weeks leading up to the clinic visit, working to get prior authorization. Her efforts were unsuccessful. Once again, her mother’s caregiver drove her to the clinic himself.
Do you have an experience with prior authorization you’d like to share? Click here to tell your story.
Midwest KHN correspondent Bram Sable-Smith discussed the Eli Lilly news on insulin prices on “PBS NewsHour” and insulin prices on Slate’s “What Next” on March 1.
KHN contributor Andy Miller discussed Georgia’s legislative wrap-up including Medicaid work requirements on Georgia Public Broadcasting’s “Lawmakers” on Feb. 28. He also discussed health care for foster children on WUGA’s “The Georgia Health Report” on Feb. 3.
Senior KHN correspondent Julie Appleby discussed how the end of the public health emergency will affect costs for covid-19 vaccines, treatments, and masks on KMOX’s “Health Matters” on Feb. 25.
KHN correspondent Cara Anthony discussed the youngest victims of gun violence and those who dig their graves on America’s Heroes Group on Feb. 25.
KHN contributor Eric Berger discussed distracted driving laws and why Missouri still doesn’t have one on St. Louis Public Radio’s “St. Louis on the Air” on Feb 24.
It was the first day of her family’s vacation in the San Juan Islands last June when Danielle Laskey, who was 26 weeks pregnant, thought she was leaking amniotic fluid.
A registered nurse, Laskey called her OB-GYN back home in Seattle, who said to seek immediate care. Staff members at a nearby emergency department found no leakage. But her OB-GYN still wanted to see her as soon as possible.
Laskey and her husband, Jacob, made the three-hour trip to the Swedish Maternal & Fetal Specialty Center-First Hill. Laskey had sought the clinic’s specialized care for this pregnancy, her second, after a dangerous complication with her first: The placenta had become embedded in the uterine muscles.
Back in Seattle, doctors at the clinic found Laskey’s water had broken early, posing a serious risk to her and the fetus, and ordered her immediate admission to Swedish Medical Center/First Hill. She delivered her son after seven weeks in the hospital. Though she was treated for multiple postpartum complications, she was well enough to be discharged the next day. Her son, who is healthy, went home a month later.
Laskey soon developed a fever and body aches, and she was told by her OB-GYN to go to Swedish’s emergency department. She said doctors there wanted to admit her when she arrived Aug. 20 and scheduled a procedure for Aug. 26 to remove a fragment of placenta that her body had not eliminated on its own.
Laskey, who had already spent weeks away from her 3-year-old daughter, chose to go home. She returned for the procedure, which went well, and she was home the same day.
Then the bills came.
The Patient: Danielle Laskey, 31, was covered by a state-sponsored plan offered by her employer, a local school district, and administered by Regence BlueShield.
Medical Service: In-patient hospital services for 51 days, plus a one-day stay that included a second placenta removal procedure.
Service Provider: Swedish Medical Center/First Hill, part of Providence Health & Services, a large, nonprofit, Catholic health system.
Total Bill: Swedish, through Regence, billed about $120,000 in cost sharing for Laskey’s initial hospitalization and about $15,000 for her second visit and procedure.
What Gives: The specialized clinic caring for Laskey before her hospital admission was in her insurance plan’s network. The clinic’s doctors admit patients only to Swedish Medical Center, one of the Seattle area’s only specialized providers for Laskey’s condition — which, given that connection, she assumed was also in the network.
So after being urgently admitted to Swedish, Laskey believed her bills would be largely covered, with the couple expected to pay $2,000 at most for their portion of in-network care because of her plan’s out-of-pocket cost limit.
It turned out Swedish was out of network for Laskey’s plan and, at first, Regence determined that Laskey’s hospitalizations were not emergencies. In November, a Regence case manager initially told Jacob that Laskey’s lengthy hospitalization was an emergency admission and out-of-network charges would not apply. But then she called back and said the charges would apply after all, because Laskey had not come in through the emergency department.
Both Washington state and federal laws prohibit insurers and providers from billing patients for out-of-network charges in emergency situations. The couple said neither Swedish nor Regence told them before or during the two hospitalizations that Swedish was out of network, and that they never knowingly signed anything agreeing to accept out-of-network charges.
Jacob, who works as a psychiatrist at a different hospital, said he mentioned the surprise-billing laws to the case manager, but she replied that the laws did not apply to his family’s situation.
It was only after Regence was contacted by KHN that the insurer explained its reasoning to the reporter: Regence said the Swedish hospital, while out of network for Danielle, had a broader contract with the insurer as a “participating provider” and so the insurer was not in violation of surprise-billing laws by approving Swedish’s out-of-network coinsurance charges.
The broader contract allowed Swedish to bill members of any Regence plan who receive out-of-network services there 50% coinsurance — the patient’s portion of the overall cost the insurer allows the provider to charge — with no out-of-pocket maximum for the patient.
What’s the difference between a hospital that’s “in network” and one that’s a “participating provider”? In this case, by contracting with Regence as an out-of-network but also participating provider, Swedish straddled the line between being in and out of network — designations that traditionally indicate whether a provider has a contract with an insurer or not.
Setting the terms with an insurer for providing its members emergency or other care appears to allow hospitals to sidestep new surprise-billing laws that prevent out-of-network providers from charging high, unpredictable rates in emergencies, according to government and private-sector medical billing experts.
Experts said they had not heard of out-of-network providers evading surprise-billing laws by being contracted as “participating providers” until KHN asked about Laskey’s case.
Ellen Montz, director of the Center for Consumer Information and Insurance Oversight at the Centers for Medicare & Medicaid Services, said that under the federal No Surprises Act the definition of a “participating” emergency facility that’s subject to the law’s surprise billing protections depends on whether the facility has a contract with the insurer specifying the terms and conditions under which an emergency service is provided to a plan member.
Matthew Fiedler, a senior fellow at the University of Southern California-Brookings Schaeffer Initiative for Health Policy who studies out-of-network billing, said Laskey’s case seems to fall into a “weird” gray area of the state and federal laws protecting patients from out-of-network charges in emergency situations.
If there had been no contract between Regence and Swedish, the laws clearly would have prohibited those charges. But since there was a contract specifying a 50% coinsurance rate when Swedish was out of network for a particular Regence plan, those laws legally may not apply, Fiedler said.
After he declined to apply for the hospital’s financial assistance program, Jacob said Swedish also notified the couple in November that they had two months to pay or be sent to collections.
Natalie Kozimor, a spokesperson for Providence Swedish, said the hospital disagreed with “some of the details and characterizations of events” presented by the Laskeys, though she did not specify what those were. She said Swedish assisted Danielle with her appeal to Regence.
“We had no luck with Swedish taking any role or responsibility with regard to our billing or advocating on our behalf,” Jacob said. “They basically just referred us to their financial department to put us on a payment plan.”
Danielle Laskey at her home just outside Seattle, with her infant son.(Ryan Henriksen for KHN)
The Resolution: In December, the couple appealed Regence’s approval of Swedish’s out-of-network charges for the 51-day hospitalization, claiming it was an emergency and that there was no in-network hospital with the expertise to treat her condition. They also filed a complaint with the state insurance commissioner’s office.
The office told KHN that the “participating provider” contract does not override the laws barring out-of-network charges in emergency situations. “Danielle had an emergency and Regence acknowledges it was an emergency, so she cannot be balance-billed,” said Stephanie Marquis, public affairs director for the Washington state Office of the Insurance Commissioner.
On Jan. 13, Regence said it would grant the Laskeys’ appeal to cover the first hospitalization as an in-network service, erasing the biggest part of Swedish’s bill but still leaving the family on the hook for the $15,000 bill for Danielle’s second visit and procedure.
On Jan. 27, two days after KHN contacted Regence and Swedish about Danielle Laskey’s case, a Regence representative called and informed her that her second hospitalization also would be reclassified as an in-network service.
Ashley Bach, a Regence spokesperson, confirmed to KHN that both stays now will be covered as emergency, in-network services, eliminating Swedish’s coinsurance charges. But in what appears to be contrary to the insurance commissioner’s stance, he said the bills had not violated state or federal laws prohibiting out-of-network charges in emergency situations because of the contract with Swedish covering all its plans.
“Under the Washington state and federal balance-billing laws, the definitions of whether a provider is considered in network hinges on whether there is a contract with a specific provider,” Bach said.
The Takeaway: More than a year after the federal surprise-billing law took effect, patients can still get hammered by surprise bills resulting from health plans’ limited provider networks and ambiguities about what is considered emergency medical care. The loopholes are out there, and patients like Laskey are just discovering them.
Washington state Rep. Marcus Riccelli, chair of the House Health Care and Wellness Committee, said he will ask the state’s public and private insurers what steps they could take to avoid provider network gaps and out-of-network billing surprises like this. He said he will also review whether there is a loophole in state law that needs to be closed by the legislature.
Fiedler said policymakers need to consider addressing what looks like a major gap in the new laws protecting consumers from surprise bills, since it’s possible that other insurers across the country have similar contracts with hospitals. “Potentially this is a significant loophole, and it’s not what lawmakers were aiming for,” he said.
Congress might have to fix the problem, since the federal agencies that administer the No Surprises Act may not have authority to do anything about it, he added.
Bruce Alexander, a CMS spokesperson, said the Departments of Health & Human Services, Labor, and Treasury are looking into this issue. While the agencies can’t predict whether a new rule or guidance will be needed to address it, he said, “they remain committed to protecting consumers from surprise medical bills.”
In the meantime, patients, even in emergencies, should ask their doctors before a hospital admission whether the hospital is in their plan network, out of network, or (watch for these words) a “participating provider.”
As the Laskeys discovered, hospital billing departments may offer little help in resolving surprise billing. So, while it is worth contesting questionable charges to the provider, it’s also usually an option to quickly appeal to your state insurance department or commissioner.
Bill of the Month is a crowdsourced investigation by KHN 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!
