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‘An Arm And A Leg’: Why Are Drug Prices So Random? Meet Mr. PBM


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Surely, an old-time, generic drug can’t cost $720 — for a three-month supply?

After a close call with an outrageous Rx tab, host Dan Weissmann tackles the health care cost puzzle he’s been avoiding: figuring out prescription drug prices.

Here’s what he found: Your insurance company is probably in cahoots with a pharmacy benefit manager — and the negotiations that go on between them are trade secrets. No wonder it’s so hard to know what you’ll pay at the drugstore counter!

On Episode 4 of “An Arm and a Leg,” meet the behind-the-scenes negotiator that helps decide how much you pay at the pharmacy counter.


Season 2 is a co-production of Kaiser Health News and Public Road Productions.

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

To hear all Kaiser Health News podcasts, click here.

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The Values Of Health Care

Julie Rovner, the chief Washington correspondent for Kaiser Health News, joins Margot Sanger-Katz of The New York Times, Joanne Kenen of Politico and Alan Weil of Health Affairs at the Aspen IdeasHealth festival to discuss the politics surrounding the national debate on health care. The panel explores the failed effort to repeal and replace the Affordable Care Act, the strong support for coverage guarantees for people with preexisting conditions and for the expansion of Medicaid, and efforts among progressives to move to a “Medicare for All” system. The discussion is available here.

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


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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.

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Vaccine Drama On Display In California’s Capitol

SACRAMENTO, Calif. — They hoisted signs warning of corporate greed, raised their fists in solidarity against government tyranny and blasted fight songs over portable speakers.

As Queen’s “We Will Rock You” blared in the background, hundreds of parents and families from around the state gathered in front of the state Capitol Thursday morning to testify about a bill they said would — if passed — spark a revolution.

Not a bill to raise taxes. Not a bill to expand fracking. A bill to determine which kids must get their routine shots.

For this group of passionate Californians, a measure by pediatrician and state Sen. Richard Pan (D-Sacramento) poses a threat to their rights as parents. For the author, public health officials and other supporters, it’s a necessary step to keep kids safe — in school and beyond.

Vaccines have become an explosive topic around the country, even as numerous studies show they are safe and effective and complications are rare.

The bill, SB 276, would tighten the rules on which children would qualify for medical exemptions from vaccinations. It was passed by the state Senate in May, and had a key hearing before the Assembly Health Committee on Thursday.

State Sen. Richard Pan, author of SB 276, has been the object of much ire among vaccine opponents since offering a previous vaccine bill that tightened vaccine mandates. (Anna Maria Barry-Jester/KHN)

Before the hearing, bill opponents, many of them clad in yellow vests similar to those worn by protesters in France, listened as Robert F. Kennedy Jr., a high-profile vaccine opponent, hyped the crowd.

In a speech echoing others he has given around the country (and which have drawn a public rebuke from his siblings), he spoke of Jews in concentration camps and other minorities throughout history who have been “scapegoats” for diseases.

Behind him, poster-size photos of Pan, the object of vaccine opponents’ ire, were splattered in red, overlaid by the word “LIAR.”

The rancor continued inside the Capitol. As Pan presented his measure before the committee, parents in the back of the room, hands wrapped in yellow tape with “false” written on the palm, raised their hands, hissing as he spoke.

It wouldn’t be the last time lawmakers would have to ask them to be quiet and follow the rules.

The committee heard an amended version of the bill, which is intended to curb what has been described by public health experts as a dangerous increase in medical exemptions from vaccination. Since a state law enacted in 2016 ended vaccine exemptions based on religious and personal beliefs, children can be excused only on medical grounds.

Since then, the number of medical exemptions has jumped, and the exemptions are clustered in many of the same parts of the state that previously had high rates of religious or personal belief exemptions, according to new state data. Around the state, 117 schools reported that 10% or more of their kindergartners had been granted medical exemptions in the 2018-19 school year.

The measure underwent significant changes earlier this week to allay concerns from Gov. Gavin Newsom and others that it would put bureaucracy between doctors and patients. In the new version, officials with the state Department of Public Health would review medical exemptions for children at schools where more than 5% of kids aren’t vaccinated, and those written by doctors who have handed out more than five exemptions in a calendar year.

But the amendments didn’t seem to address the fears of its most ardent opponents, even as Newsom, a Democrat, told reporters Tuesday that he would sign the new version.

In testimony supporting the bill, Jenni Balck, a teacher and mother of an immunocompromised child who had a heart transplant, explained that her child’s health relies on community immunity.

“Parents want what’s best for their kids,” said Balck. “I understand that people who don’t want to vaccinate think they are doing what’s right for their kids. But they put my child in danger every day,” she said, noting cases of whooping cough in her Southern California neighborhood just two weeks earlier.

Doctors representing major medical providers around the state — including Kaiser Permanente and Sutter Health — spoke in support of the bill. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

“We’re seeing preventable disease on an almost daily basis,” said Dr. Alisa Awtry, a family physician in Sonoma County who came with her infant to testify in favor of the measure.

Another physician, Dr. Bob Sears of Orange County, a national leader in the anti-vaccine movement who was placed on probation by the Medical Board of California, testified on behalf of the opposition — speaking so long he didn’t leave time for Kennedy.

Sears, a pediatrician, said the bill would penalize physicians for doing their jobs, comparing it to “stop and frisk” public safety tactics that often target minorities and sow fear.

He was followed by hundreds of vaccine skeptics who spent the next three hours formally stating their opposition to the bill. Several warned of what would come if the bill passes. “You’re going to cause a revolution,” one woman said. Others said they would move out of state. Pan stood stoically at the front of the room, turning to acknowledge each person who testified.

Numerous opponents spoke of government overreach.

“I don’t think we should use taxpayer money to micromanage doctors,” said Heather Marie Levin Mulligan, 40, of Roseville.

After more than five hours of testimony, the bill passed the committee.

But the hearing didn’t appear to change many minds.

“We will not comply!” opponents chanted as they marched on Newsom’s office after the hearing.


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

Surgeons’ Opioid-Prescribing Habits Hard To Kick

As opioid addiction and deadly overdoses escalated into an epidemic across the U.S., thousands of surgeons continued to hand out far more pills than needed for postoperative pain relief, according to a KHN-Johns Hopkins analysis of Medicare data.

Many doctors wrote prescriptions for dozens of opioid tablets after surgeries — even for operations that cause most patients relatively little pain, according to the analysis, done in collaboration with researchers at Johns Hopkins School of Public Health. It examined almost 350,000 prescriptions written for patients operated on by nearly 20,000 surgeons from 2011 to 2016 — the latest year for which data are available.

Some surgeons wrote prescriptions for more than 100 opioid pills in the week following the surgery. The total amounts often exceeded current guidelines from several academic medical centers, which call for zero to 10 pills for many of the procedures in the analysis, and up to 30 for coronary bypass surgery.

While hundreds of state and local lawsuits have been filed against opioid manufacturers, claiming they engaged in aggressive and misleading marketing of these addictive drugs, the role of physicians in contributing to a national tragedy has received less scrutiny. Research shows that a significant portion of people who become addicted to opioids started with a prescription after surgery.

In sheer numbers, opioid prescribing in the U.S. peaked in 2010, but it remains among the highest in the world, according to studies and other data.

In 2016, opioids of all kinds were linked to 42,249 deaths, up from the 33,091 reported in 2015. The opioid-related death rate jumped nearly 28% from the year before, according to the CDC.

Yet long-ingrained and freewheeling prescribing patterns changed little over the six years analyzed. KHN and Johns Hopkins examined the prescribing habits of all U.S. surgeons who frequently perform seven common surgical procedures and found that in the first week after surgery:

  • Coronary artery bypass patients operated on by the highest-prescribing 1% of surgeons filled prescriptions in 2016 exceeding an average of 105 opioid pills.
  • Patients undergoing a far less painful procedure — a lumpectomy to remove a breast tumor — were given an average of 26 pills in 2016 the week after surgery. The highest-prescribing 5% of surgeons prescribed 40 to 70 pills on average.
  • Some knee surgery patients took home more than 100 pills in the week following their surgery.

Those amounts — each “pill” in the analysis was the equivalent of 5 milligrams of oxycodone are many times what is currently recommended by some physician groups to relieve acute pain, which occurs as a result of surgery, accident or injury. The analysis included only patients not prescribed opioids in the year before their operation.

“Prescribers should have known better” based on studies and other information available at the time, said Andrew Kolodny, co-director of opioid policy research at Brandeis University and director of the advocacy group Physicians for Responsible Opioid Prescribing.

While the dataset included only prescriptions written for patients on Medicare, the findings may well understate the depth of the problem, since doctors are more hesitant to give older patients the powerful painkillers because of their sedating side effects.

Surgeons’ prescribing habits are significant because studies show that 6% of patients who are prescribed opioids after surgery will still be taking them three to six months later, having become dependent. The likelihood of persistent use rises with the number of pills and the length of time opioids are taken during recuperation.

Also, unused pills in medicine cabinets can make their way onto the street.

Dr. Marty Makary, a surgical oncologist at Johns Hopkins, admits that he too once handed out opioids liberally. Now he is marshaling a campaign to get surgeons to use these powerful painkillers more consciously and sparingly. “I think there’s an ‘aha’ moment that many of us in medicine have had or need to have,” he said.

But old habits are hard to kick.

KHN contacted dozens of the surgeons who topped the ranks of opioid prescribers in the 2016 database. They hailed from small, community hospitals as well as major academic medical centers. The majority declined to comment, some bristling when questioned.

Some of those surgeons were critical of the analysis, saying it didn’t take into account certain essential factors. For example, it was not possible to determine whether patients had complications or needed higher amounts of pain medication for another reason. And some surgeons had only a handful of patients who filled prescriptions, making for a small sample size.

But surgeons also indicated that the way they prescribe pain pills was less than intentional. It was sometimes an outgrowth of computer programs that default to preset amounts following procedures, or practice habits developed before the opioid crisis. Additionally, they blame efforts in the late 1990s and early 2000s that encouraged doctors and hospitals to consider pain as “the fifth vital sign.” A major hospital accrediting group required providers to ask patients how well their pain was treated. Pharmaceutical companies used the fifth vital sign campaign as a way to promote their opioid treatments.

Makary, who oversaw the analysis of the Medicare dataset, said that, while opioid prescribing is slowly dropping, to date many surgeons have not paid enough attention to the problem or responded with sufficient urgency.

Dr. Audrey Garrett, an oncologic surgeon in Oregon, said she was “surprised” to hear that she was among the top tier of prescribers. She said she planned to re-evaluate her clinic’s automated prescribing program, which is set to order specific amounts of opioids.

KHN will analyze data for 2017 and subsequent years when it becomes available to follow how prescribing is changing.

Prescribing Patterns Highlight What’s At Stake 

The analysis examined prescribing habits after seven common procedures: coronary artery bypass, minimally invasive gallbladder removal, lumpectomy, meniscectomy (which removes part of a torn meniscus in the knee), minimally invasive hysterectomy, open colectomy and prostatectomy.

Across the board, the analysis showed that physicians gave a large number of narcotics when fewer pills or alternative medications, including over-the-counter pain relief tablets, could be equally effective, according to recent guidelines from Makary and other academic researchers.

On average, from 2011 to 2016, Medicare patients in the analysis took home 48 pills in the week following coronary artery bypass; 31 following laparoscopic gallbladder removal; 28 after a lumpectomy; 41 after meniscectomy; 34 after minimally invasive hysterectomy; 34 after open colon surgery; and 33 after prostatectomy.

According to post-surgical guidelines spearheaded by Makary for his hospital last year, those surgeries should require at most 30 pills for bypass; 10 pills for minimally invasive gallbladder removal, lumpectomy, minimally invasive hysterectomy and prostatectomy; and eight pills for knee surgery. It has not yet published a guideline for open colon surgery.

The Johns Hopkins’ doctors developed their own standards because of a dearth of national guidelines for post-surgical opioids. They arrived at those figures after reaching a consensus among surgeons, nurses, patients and other medical staff on how many pills were needed after particular surgeries.

Hoping to reduce overprescribing, Makary is preparing to send letters next month to surgeons around the country who are among the highest opioid prescribers under a grant he received from the Arnold Foundation, a nonprofit group whose focus includes drug price issues. (Kaiser Health News also received funding from the Arnold Foundation.)

Even if the prescription numbers have fallen since 2016, the amounts given today are likely still excessive.

“When prescribing may have been five to 20 times too high, even a reduction that is quite meaningful still likely reflects overprescribing,” said Dr. Chad Brummett, an anesthesiologist and associate professor at the University of Michigan.

Brummett is also co-director of the Michigan Opioid Prescribing Engagement Network, a collaboration of physicians that makes surgery-specific recommendations, many of them in the 10- to 20-pill range.

“Reducing unnecessary exposure is key to reducing the risk of new addiction,” said former Food and Drug Administration commissioner Scott Gottlieb. In August 2018, when Gottlieb was at the agency’s helm, it commissioned a report from the National Academy of Sciences on how best to set opioid prescribing guidelines for acute pain from specific conditions or surgical procedures. Its findings are expected later this year.

“There are still too many 30-tablet prescriptions being written,” said Gottlieb.

Healers Sowing Disease?

Naturally, surgeons rankle at the idea that they played a role in the opioid epidemic. But studies raise serious concerns.

Transplant surgeon Dr. Michael Engelsbe, director of the Michigan Surgical Quality Collaborative, points to the study showing 6% of post-op patients who get opioids for pain develop long-term dependence. That means a surgeon who does 300 operations a year paves the way for 18 newly dependent people, he said.

Many patients do not need the amounts prescribed.

Intermountain Healthcare, a not-for-profit system of hospitals, clinics, and doctors in Utah, began surveying patients two years ago to find out how much of their prescribed supply of opioids they actually took following surgery.

“Globally, we were overprescribing by 50%,” said Dr. David Hasleton, senior medical director.

But Intermountain approached individual doctors carefully. “If you go to a prescriber to say, ‘You are overprescribing,’ it never goes well. A common reaction is, ‘Your data is wrong’ or ‘My patients are different than his,’” said Hasleton.

For the analysis, KHN attempted to contact more than 50 surgeons whose 2016 numbers ranked them among the top prescribers in each surgical category.

One who did agree to speak was Dr. Daniel J. Waters, who 13 years ago had his chest cut open to remove a tumor, an operation technically similar to what he does for a living: coronary artery bypass.

“So I have both the doctor perspective and the patient perspective,” said Waters, who practices in Mason City, Iowa.

In 2016, Waters’ Medicare bypass patients who filled their prescriptions took home an average of nearly 157 pills each, according to the KHN-Johns Hopkins analysis.

“When I went home from the hospital, 30 would not have been enough,” said Waters of the number recommended by the Hopkins team for that surgery.

But he said he has recently curbed his prescribing to 84 pills.

Nationally, the average prescription filled for a coronary artery bypass was 49 pills in 2016 and had changed little since 2011, the analysis shows.

Others who spoke with KHN said they had developed the habit of prescribing copiously — sometimes giving out multiple opioid prescriptions — because they didn’t want patients to get stuck far from the office or over a weekend with pain or because they were trying to avoid calls from dissatisfied, hurting patients.

In the KHN-Johns Hopkins data, the seven patients of Dr. Antonio Santillan-Gomez who filled opioid prescriptions after minimally invasive hysterectomies in 2016 received an average of 77 pills each.

A gynecologic oncologist, Santillan-Gomez said: “I’m in San Antonio, and some of my patients come from Laredo or Corpus Christi, so they would have to drive two to three hours for a prescription.”

Still, he said, since e-prescribing of opioids became more widespread in the past few years, he and other surgeons in his group have limited prescriptions to 20 to 30 pills and encouraged patients to take Tylenol or other over-the-counter medications if they run out. E-prescribing can not only help track patients getting opioids but also reduce the problem of patients having to drive back to the office to get a written prescription.

Dr. Janet Grange, a breast surgeon in Omaha, Neb., said that in her experience, opioid dependence had not been a problem.

“I can absolutely tell you I don’t have even 1% who become long-term opioid users,” said Grange.

The analysis showed that Grange had 12 opioid-naïve Medicare patients who had a lumpectomy in 2016. Eight of them filled prescriptions for an average of 47 pills per patient.

She called Johns Hopkins’ zero-to-10-pill pain-control recommendation following that procedure “miserly.”

The Pendulum Swings

Some of the higher-prescribing surgeons in the KHN-Johns Hopkins analysis reflected on their potential contribution to a national catastrophe and are changing their practice.

“That is a shocking number,” said oncologist Garrett, speaking of the finding that 6% of patients who go home with opioids will become dependent. “If it’s true, it’s something we need to educate physicians on much earlier in their medical careers.”

Garrett, in Eugene, Ore., said she has cut back on the number of pills she gives patients since 2016. The KHN-Johns Hopkins analysis showed that seven of her 13 opioid-naïve Medicare patients undergoing minimally invasive hysterectomies filled a prescription for opioids in 2016. Those patients took home an average of 76 pills each.

Johns Hopkins guidelines call for no more than 10 opioid pills following this procedure, while Brummett’s Michigan network recommends no more than 15.

Surgeon and researcher Dr. Richard Barth, once a heavy prescriber himself, said that his own experience convinced him that physicians’ preconceptions about how much pain relief is needed are often way off.

The analysis showed his lumpectomy patients in 2013 filled an average of 33 pills in the week after surgery. By 2016, that average had dropped to seven pills. Many patients, he said, can do just fine after lumpectomy with over-the-counter medications — and often no opioids at all.

The key, he said, is to set patients’ expectations upfront.

“I tell them it’s OK to have a little discomfort, that we’re not trying to get to zero pain,” said Barth, who is chief of general surgery at Dartmouth-Hitchcock Medical Center and has published extensively on opioid prescribing.

After lumpectomy, “what I recommend is Tylenol and ibuprofen for at least a few days and to use the opioids only if the discomfort isn’t relieved by those.”

Indeed, the data analysis showed that a significant number of patients given prescriptions for opioids never filled them because they don’t need that level of pain relief.

Between 2011 and 2016, for example, only 62% of lumpectomy patients in the analysis filled prescriptions, similar to hysterectomy patients.

In 2016, patients of Dr. Kimberli Cox, a surgeon in Peoria, Ariz., were prescribed about 59 pills in the week following lumpectomy, well above the recommendations from both Johns Hopkins and others.

But the KHN-Johns Hopkins analysis of that year’s data shows that half of her patients never filled a painkiller prescription — a fact she acknowledges has changed her thinking.

“I am now starting to prescribe less because many patients say, ‘You gave me too many’ or ‘I didn’t fill it,” she said.

‘An Arm And A Leg’: Can You Shop Around For A Lower-Priced MRI?


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An MRI is one of those standard tests that doctors order routinely. But the price you’ll pay can be unpredictable.

Sometimes the price tag depends on where you live: It could reach $10,000 in San Francisco. Or be as low as $1,000 in St. Louis — if you’re willing to haggle. And the kind of imaging center you choose often makes a difference: Was it a fancy specialty hospital linked to a university or a standalone facility at the mall?

Liz Salmi — of Sacramento, Calif. — has been living with brain cancer for more than 10 years and gets an MRI every six months to make sure the cancer’s not growing. On her old insurance plan, she paid $50 for a brain scan. Then her job changed, her health insurance changed, and she was billed $1,600.

Not everyone has the time or patient know-how, but Salmi shopped around and found a deal that saves her hundreds of dollars every year.

On Episode 3 of “An Arm and a Leg,” find out how she did it.


Season 2 is a co-production of Kaiser Health News and Public Road Productions.

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

To hear all Kaiser Health News podcasts, click here.

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

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.

Federal Grants ‘A Lifesaver’ In Opioid Fight, But States Still Struggle To Curb Meth

In his 40 years of working with people struggling with addiction, David Crowe has seen various drugs fade in and out of popularity in Pennsylvania’s Crawford County.

Methamphetamine use and distribution is a major challenge for the rural area, said Crowe, the executive director of Crawford County Drug and Alcohol Executive Commission. But opioid-related overdoses have killed at least 83 people in the county since 2015, he said.

Crowe said his organization has received just over $327,300 from key federal grants designed to curb the opioid epidemic. While the money was a godsend for the county — south of Lake Erie on the Ohio state line — he said, methamphetamine is still a major problem.

But he can’t use the federal opioid grants to treat meth addiction.

“Now I’m looking for something different,” he said. “I don’t need more opiate money. I need money that will not be used exclusively for opioids.”

The federal government has doled out at least $2.4 billion in state grants since 2017 to address the opioid epidemic, which killed 47,600 people in the U.S. that year alone. But state officials noted that drug abuse problems seldom involve only one substance. And while local officials are grateful for the funding, the grants can be spent only on creating solutions to combat opioids, such as prescription OxyContin, heroin and fentanyl.

According to the most recent data from the Centers for Disease Control and Prevention, 11 states have reported that opioids were involved in fewer than half of their total drug overdose deaths in 2017, including California, Pennsylvania and Texas.

The money is also guaranteed for only a few years, which throws the sustainability of the states’ efforts into question. Drug policy experts said the money may not be adequate to improve the mental health care system. And more focus is needed on answering the underlying question of why so many Americans struggle with drug addiction, they said.

“Even just the moniker, like ‘the opioid epidemic,’ out of the gate, is problematic and incorrect,” said Leo Beletsky, an associate professor of law and health sciences at Northeastern University in Boston. “This was never just about opioids.”

(Story continues below.)

States received federal funds for opioids primarily through two grants: State Targeted Response and State Opioid Response. The first grant, authorized by the 21st Century Cures Act, totaled $1 billion. The second pot of money, $1.4 billion — approved as part of last year’s omnibus spending bill — sets aside a portion of the funding for states with the most drug poisoning deaths.

For states like Ohio and Pennsylvania, the need was great. Nearly 4,300 and 2,550 residents, respectively, died from opioid-related overdoses in 2017. State officials say the money enabled them to invest significantly in programs like training medical providers on addiction, more access points to treatment and interventions for special populations, like pregnant women. Ohio was awarded $137 million in grants; Pennsylvania, $138.1 million.

The grants also stipulate a minimum amount of money for every state, so even areas with reportedly low opioid-related overdose death rates now have considerable funds to combat the crisis. Arkansas, for example, reported 188 opioid-related deaths in 2017 and received $15.7 million from the federal government.

While 2,199 people in California died from opioid-related causes in 2017, its opioid death rate was one of the 10 lowest in the country. The Golden State received $195.8 million in funding, more than any other state.

“This funding is dedicated to opioids,” said Marlies Perez, a division chief at the California Department of Health Care Services, “but we’re not blindly just building a system dedicated just to opioids.”

Mounting evidence points to a worrisome rise in methamphetamine use nationally. The presence of cheap, purer forms of meth in the drug market coupled with a decline in opioid availability has fueled the stimulant’s popularity. The number of drug overdose deaths involving the meth tripled from 2011 to 2016, the CDC reported. Hospitalizations involving amphetamines — the class of stimulants that includes methamphetamine — are spiking. And it is harder to address. Treatment options for this addiction are narrower than the array available for opioids. In light of the increase in deaths related to other substances, are these grants the best way to fund states’ response to opioids?

Bertha Madras, a professor of psychobiology at Harvard Medical School and a former member of the federal Opioid and Drug Abuse Commission, said the federal government has responded well by tailoring the response to opioids because those drugs continue to kill tens of thousands of Americans per year. But, she said, as more people living with addiction are identified and other drugs rise in popularity, the nation’s focus will need to change.

Beletsky emphasized that the grants are insufficient to support fixes to the mental health care system, which must respond to patients living with an addiction of any kind.

People addicted to a particular substance typically use other drugs as well. Controlling addiction throughout a person’s life can be akin to “whack-a-mole,” said Dr. Paul Earley, president of the American Society of Addiction Medicine, because they may stop using one substance only to abuse another. But specific addictions may also require specific treatments that cannot be addressed with tools molded for opioids, and the appropriate treatment may not be as available.

“I think we have to really begin to self-examine why this country has so much substance use to begin with,” Madras said.

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


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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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