Tagged The Health Law

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! Today is the day I’m going to challenge you to stretch those creative muscles and enter our Halloween Health Care Haiku Competition. Yes, it is going to be exactly as awesome as it sounds! The entries are already pouring in, check out the rules here. To kick things off, KHN’s very own talented and brilliant haiku master-in-residence Stephanie Stapleton wrote this one: “Goblins wear white coats, and not much is spookier, than the health system.”

Now on to what you might have missed this week.

Democrats packed themselves onto a crowded stage this week for what already feels like the umpteenth debate but was only the fourth or the sixth (depending if you count the two-nighters separately).

Going by the amount of heat she took, it seems safe to say Sen. Elizabeth Warren (D-Mass.) is considered by her rivals to be one of the race’s front-runners. With that spotlight, though, comes a target on her back.

South Bend Mayor Pete Buttigieg and Sen. Amy Klobuchar (D-Minn.) – who are both vying to become the alternative for former Vice President Joe Biden’s moderate voters – were particularly sharp in their demands for Warren to reckon with the costs of “Medicare for All.” The question of how she would pay for such a plan has been one she’s been managing to dodge, but her rivals tried to hold her feet to the fire on Tuesday. “At least Bernie’s being honest,” Klobuchar said at one point in reference to Sen. Bernie Sanders’ (I-Vt.) admission that the proposal will raise taxes.

FWIW: Despite being pressed to answer the direct question: “Will you raise taxes on the middle class to pay for it? Yes or no?” Warren still didn’t let herself be pinned down. Something that, the day after the debate, Biden jumped on as well.

The New York Times: Warren Draws Fire From All Sides, Reflecting A Shift In Fortunes In Race

The New York Times: Joe Biden Ramps Up Attacks On Elizabeth Warren’s ‘Credibility’

Health care is possibly the broadest (or at least one of the broader) topics that the candidates could talk about, and yet all it seems they’ve been discussing at the debates is health care coverage. Friends, you are not alone if you’re frustrated by not seeing a more diverse range of questions. Even Sen. Kamala Harris (D-Calif.) was fed-up enough to redirect the conversation toward abortion rights and reproductive health. Considering it’s such a viscerally hot-topic at the moment, the omission seems glaring.

Los Angeles Times: Kamala Harris Slams Republicans On Abortion, Says They’re Killing Poor Women Of Color

But it’s not just reproductive health that the moderators could ask about. Axios came up with at least four great questions that I think a lot of people in the field would like to have answered. Like: Many of the things that make people sick are not the fault of bad health care — they’re social factors like poverty, low-quality housing, etc. Should it be part of the health care system’s job to address them? (Hint, hint moderators.)

Axios: Four Health Care Questions For Tonight’s Democratic Debate

Don’t get me wrong, there were a few other health-related moments beyond “Medicare for All” bickering… including one of the more heated exchanges of the night. Beto O’Rourke said Democrats need to be courageous in their policies and not be scared of polls, to which Buttigieg responded: “I don’t need lessons from you on courage.”

The Wall Street Journal: Democratic Debate: The Moments That Mattered

Meanwhile, amid all this focus on “Medicare for All,” a new study counsels that there are many paths toward universal coverage—it doesn’t have to be “Medicare for All” or bust.

The Associated Press: Study: ‘Medicare For All’ Not Only Way To Universal Coverage


A big decision on the constitutionality of the health law is expected to drop sometime in the coming weeks. Although in theory, the Trump administration wants a certain outcome, if the court decides the ACA is unconstitutional, it could be a big ole headache for the White House heading into 2020. A ruling like that could not only foster confusion right around open enrollment, but also allow the Democrats to re-frame the health narrative in a way that could appeal to independent and moderate voters more than the current back and forth about “Medicare for All.”

The New York Times: How Pending Decision On Obamacare Could Upend 2020 Campaign


Rep. Elijah Cummings (D-Md.) passed away this week at 68 from complications of longstanding health problems. House Speaker Nancy Pelosi (D-Calif.) announced that she’ll be renaming her signature drug pricing policy after Cummings as he was a long-time champion of reigning in such costs.

Some might remember that it was Cummings who took Martin Shkreli, of “pharma bro” fame” to task at a hearing.

“It’s not funny, Mr. Shkreli,” Cummings said as Shkreli smirked. “People are dying, and they’re getting sicker and sicker.”

The Baltimore Sun: U.S. Rep. Elijah Cummings, Key Figure In Trump Impeachment Inquiry And Longtime Baltimore Advocate, Dies At 68

Stat: Pelosi: Democrats Will Name Marquee Drug Pricing Bill For Late Rep. Cummings


In a high-stakes, eleventh hour gambit Judge Dan A. Polster is summoning the drug CEOs involved in the massive, nationwide opioid trial to try to agree to a massive $50 billion settlement. Although the talks center around the big players involved — like AmerisourceBergen, Cardinal Health and McKesson — plaintiffs’ lawyers say they hope such a deal would have a domino effect on the remaining defendants.

Although the reports seem hopeful, those familiar with the talks say that the cities and counties are hesitant because they’re worried they’re not going to see their fair share of the money.

(This is as of press time! It’s happening today, so there could be developments depending when your read this—ah, the excitement of live news!)

The New York Times: Judge Summons Drug C.E.O.S For Talks On Sweeping Opioid Settlement

In a sea of heartbreaking stories on the opioid epidemic, this one stands out. The Washington Post took a look at West Virginia’s crisis and how court victories against drug companies aren’t really the panacea they’re sometimes made out to be.

The Washington Post: Inside West Virginia’s Opioid Battle: ‘They Looked At Us Like An Easy Target’


These two court stories feel like they happened ages ago, but really it was just last Friday post-Breeze. If you caught them happening in real time, there’s nothing to update, but I wanted to make sure I included them for anyone who wasn’t glued to their computer on a Friday evening.

The New York Times: Judges Strike Several Blows To Trump Immigration Policies

The Associated Press: US Appeals Court Skeptical Of Trump’s Medicaid Work Rules


This binge-worthy story needs no other introduction than the one ProPublica already wrote for it, so I’m going to quote them: “Welcome to Coffeyville, Kansas, where the judge has no law degree, debt collectors get a cut of the bail, and Americans are watching their lives — and liberty — disappear in the pursuit of medical debt collection.”

ProPublica: When Medical Debt Collectors Decide Who Gets Arrested

And, on a related note, if you’ve missed my colleague Jay Hancock’s coverage of UVA’s lawsuits against their patients, make sure to check out all the developments here.


Meanwhile, in the miscellaneous story file this week:

— Melody Petersen of LAT won the holy cannoli award this week with her investigation into the practice of harvesting body parts—and the coroners that go along with it. My face when reading the entirety of the article was an exact replica of the “shocked and distressed” emoji.

Los Angeles Times: In The Rush To Harvest Body Parts, Death Investigations Have Been Upended

— Deaths, poor quality of care, and other problems have absolutely plagued the Indian Health Service for years, and Native Americans are sick of it. They want to take over running their own health care system, but the task would be daunting.

The New York Times: Fed Up With Deaths, Native Americans Want To Run Their Own Health Care

— You can’t swing a cat these days without hitting some new CBD product. It seems inevitable that that kind of lucrative, thriving marketplace would draw pharma’s attention. Here’s a look at what companies are developing new drugs to tap into those profits. (PSA: but don’t actually swing any cats, please.)

Stat: These Four Companies Are Betting Big On CBD-Based Prescription Drugs

— If you want a fentanyl drug ring story that reads like a thriller, check this article out.

The New York Times: The China Connection: How One D.E.A. Agent Cracked A Global Fentanyl Ring


That’s it from me! Have a great weekend and don’t forget to get your flu shot!

Related Topics

Courts Elections Health Care Costs Health Industry Insurance Medicare Pharmaceuticals Public Health The Health Law Uninsured

KHN’s ‘What The Health?’: Democrats Do Drugs (Prices)


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


Despite the turmoil from the ongoing impeachment inquiry, Democrats in the U.S. House of Representatives are proceeding with work on a major prescription drug price bill crafted by House Speaker Nancy Pelosi.

Meanwhile, broader health issues continue to be a point of contention among the Democratic presidential candidates.

And courts around the country are dealing setbacks to many of the Trump administration’s health agenda items, including one that would make it harder for immigrants to get green cards if they use public programs.

This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Tami Luhby of CNN, and Margot Sanger-Katz of The New York Times.

Among the takeaways from this week’s podcast:

  • Getting an ambitious drug pricing package through Congress by the end of the year seems unlikely, not only because of impeachment, but because the Senate is not on board with Speaker Pelosi’s plan.
  • Still, a Congressional Budget Office analysis released this week found the Pelosi bill would save Medicare $345 billion over 10 years, giving Democrats a major talking point. On the other hand, the CBO also suggested the measure could reduce the number of new drugs that come to market by 8 to 15 in the coming decade, providing a talking point for opponents.
  • Also of interest, the House Energy and Commerce Committee is planning to consider adding some benefits — including dental, vision and hearing — to traditional Medicare. It’s not clear if this is a response to the campaign season, or the idea that before pursuing “Medicare for All” there are changes to the traditional Medicare program that could be done.
  • Health care again was a hot topic in this week’s Democratic presidential primary debate and Massachusetts Sen. Elizabeth Warren, now viewed as the front-runner, was in the hot seat. Warren again evaded the question of how and who would pay for her preferred Medicare for All plan, and was criticized by candidates like Sen. Amy Klobuchar of Minnesota and Mayor Pete Buttigieg of South Bend, Ind., both of whom support more incremental changes to the health system.
  • Meanwhile, the courts continue to play a key role in health policy. Federal judges in several states blocked the administration’s “public charge” rule that would make it harder for legal immigrants to obtain green cards if they or their family members use any of a long list of public programs. Federal judges also heard arguments on Medicaid work requirements. Meanwhile, a federal judge in Ohio blocked an Ohio state abortion ban, while a federal court judge in Texas blocked an Obama era rule intended to enforce anti-discrimination provisions of the Affordable Care Act.

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

Julie Rovner: KHN’s “We Vape, We Vote’: How Vaping Crackdowns Are Politicizing Vapers, by Rachel Bluth and Lauren Weber

Joanne Kenen: The Los Angeles Times’s “In the rush to harvest body parts, death investigations have been upended,” by Melody Petersen

Tami Luhby: ProPublica’s “It’s Very Unethical”: Audio Shows Hospital Kept Vegetative Patient on Life Support to Boost Survival Rates,” by Caroline Chen

Margot Sanger-Katz: “Tradeoffs,” a podcast hosted by Dan Gorenstein, Sayeh Nikpay, and Anupam Jena


To hear all our podcasts, click here.

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

Related Topics

Courts Elections Health Care Costs Medicare Multimedia Pharmaceuticals States The Health Law

Federal Judge Vacates Obama-Era Rule Banning Discrimination Against Transgender Patients

Warren Trots Out Her Own Harvard Law Research

In a back-and-forth about “Medicare for All” and the cost of health care, Sen. Elizabeth Warren (D-Mass.) directed the discussion back to medical debt and bankruptcy — citing her own work from Harvard Law School.

“Back when I was studying it, two out of three families that ended up in bankruptcy after a serious medical problem had health insurance,” Warren said.

This is a new emphasis in the ongoing debate over health care costs, and the debate over what role health care plays in American finances. Instead of focusing on uninsurance, Warren stepped into whether the insurance people currently have is sufficient.

But much of the research around medical debt and bankruptcy is controversial — especially Warren’s own work.

We decided to take a deeper look.

What The Research Says

Warren’s campaign directed us to research published in 2009 in the American Journal of Medicine. Co-authored by Warren, it looks at a random sample of 2,314 bankruptcy filers from 2007.

The paper examined what debtors reported as their cause of bankruptcy. Warren is referring here to people who either cited significant direct medical debt, remortgaging a home to pay medical debt, or lost income due to illness.

In that category, more than two-thirds of families had health insurance — in fact, three-quarters did.

So from that simple standpoint, the number checks out.

The Controversy

But it isn’t necessarily that simple. This specific paper has long been the subject of controversy. In part, it’s because it focuses on people who have declared bankruptcy, rather than looking at the financial impact of medical debt at large.

Scholars are also quick to note that, in the majority of so-called “medical bankruptcies” identified in the paper, the issue wasn’t debts incurred to pay off health care bills. Rather, the bigger problem was foregone income because people couldn’t work.

That’s fueled a lengthy back-and-forth, in particular over whether this paper is actually useful in determining what role medical debt plays in fueling bankruptcies.

But its impact on this specific claim isn’t so clear. That’s because Warren narrowed her statement, and focused on something less disputable.

For one thing, the paper is clear in finding that two-thirds of families —  in fact, more than that — experienced bankruptcy after a medical problem despite having health insurance.

That finding was “the headline of the study,” said Paul Ginsburg, a health economist and professor at the University of Southern California. (Ginsburg also noted the importance of foregone income in driving bankruptcies, rather than medical bills.)

And Warren qualified it further during the debate, by limiting this statistic to what was found “back when [she] was studying it” — making it a less sweeping claim.

What’s more suspect is whether this finding — even if accurate — supports her next point: that the cost of health care is what’s driving people’s financial problems, and that a generous single-payer plan would ameliorate this issue.

For instance, “You cannot go from that result to a conclusion that we need Medicare for All,” Ginsburg said.

Health insurance is more generous today than it was when Warren studied it, thanks to the Affordable Care Act. And insuring everyone — even as generously as Medicare for All suggests — wouldn’t necessarily address the issue of foregone income when people are sick, which the research suggests is a bigger financial concern.

Our Ruling

Warren’s claim comes from a paper that is controversial, and whose methods and interpretation have been called into question. That said, this statistic is fairly specific, and her wording in the claim precise. In itself, it’s a fair reflection of what the paper says.

Where caution is more important: Warren says this finding suggests the cost of health care is what’s causing Americans financial harm. That isn’t necessarily borne out, and requires more scrutiny.

This statement is accurate but would benefit from more information. We rate it Mostly True.

Related Topics

Cost and Quality Health Care Costs The Health Law Uninsured

Trump Promised To Replace Health Law ‘Piece By Piece.’ What Does That Look Like Two Years Later?

‘Medicare For All’ Talk Likely To Be Center Stage At Dem Debate. But What About Other Health Topics?

Patients Eligible For Charity Care Instead Get Big Bills

When Ashley Pintos went to the emergency room of St. Joseph Medical Center in Tacoma, Wash., in 2016, with a sharp pain in her abdomen and no insurance, a representative demanded a $500 deposit before treating her.

“She said, ‘Do you have $200?’ I said no,” recalled Pintos, who then earned less than $30,000 at a company that made holsters for police. “She said, ‘Do you have $100?’ They were not quiet about me not having money.” But Pintos, a single mom with two kids who is now 29, told state officials St. Joseph never gave her a financial aid application form, even after she asked.

Pintos said she was examined and discharged with instructions to buy an over-the-counter pain medication. Then St. Joseph sent her a bill for $839. When she couldn’t pay, the hospital referred the bill to a collection agency, which she said damaged her credit and resulted in a higher interest rate when she applied for a mortgage.

St. Joseph denied erecting barriers to charity care. But the hospital’s owner settled a lawsuit from the state attorney general earlier this year alleging such practices and agreed to pay more than $22 million in refunds and debt forgiveness.

When Ashley Pintos sought emergency care at St. Joseph Medical Center in Tacoma, Wash., in 2016, an employee first demanded a $500 deposit, which Pintos couldn’t cover. After she was examined, Pintos was told by a doctor to buy an over-the-counter pain medication. The hospital later billed her for $839. “They were not quiet about me not having money,” she says.(Dan DeLong for KHN)

Under the Affordable Care Act, nonprofit hospitals like St. Joseph are required to provide free or discounted care to patients of meager incomes — or risk losing their tax-exempt status. These price breaks can help people avoid financial catastrophe.

And yet nearly half — 45% — of nonprofit hospital organizations are routinely sending medical bills to patients whose incomes are low enough to qualify for charity care, according to a Kaiser Health News analysis of reports the nonprofits submit annually to the Internal Revenue Service. Those 1,134 organizations operate 1,651 hospitals.

Together, they estimated they had given up collecting $2.7 billion in bills sent to patients who probably would have qualified for financial assistance under the hospitals’ own policies if they had filled out the applications.

These written-off bills, known as bad debt, represented a tenth of all nonprofit hospital bad debt reported to the IRS in either 2017 or the most recent year for which data is available. That sum may represent an undercount because it is based on self-reported estimates from hospitals and is not independently audited. And it does not include money that financially struggling patients eventually paid.

“People, including me, had the impression that these new protections under the ACA would prevent people who should be getting help from being financially devastated,” said Sayeh Nikpay, an assistant health policy professor at Vanderbilt University School of Medicine. “Clearly, this policy isn’t working, and that’s a major failing.”

About 56% of American community hospitals have nonprofit status, which frees them of paying most taxes and allows them to float tax-exempt bonds. In return, they are supposed to provide community benefits including free or discounted care for patients who can’t afford to pay.

The IRS leaves it up to each hospital to decide the qualifying criteria. A comparatively generous hospital may give free care to people earning less than twice the federal poverty level — around $25,000 for an individual and $50,000 for a family of four — and may provide discounts for people earning up to double that.

For those who do not qualify, hospitals often offer payment plans. But they can turn to aggressive tactics if bills are not resolved. Patients can be pestered by debt collectors, and some hospitals sue them or try to garnish their wages. Medical debt can damage credit ratings — one study calculated Americans had $81 billion in collections in 2016 — and forces some people into bankruptcy.

When hospitals give up on collecting a bill, they categorize it as bad debt and absorb the cost of the care, which is indirectly subsidized by the rates they charge private insurers.

It became this moneymaking system. People would be crying at registration desks, people would be upset, people would walk out.

Rachael Murphy, a former St. Joseph’s Medical Center employee

Charity Options Often Thwarted

In 2017, BJC HealthCare, a large St. Louis-based system, estimated $77 million of its $134 million in bad debt was owed by patients who probably would have qualified for free or discounted care.

Hospitals now owned by Ballad Health, in Tennessee, estimated that $60 million of bad debt in 2016, or 70%, came from patients who might have been eligible for help.

The Hospital of the University of Pennsylvania said $43 million of its bad debt, or 52%, might have involved patients who could have been excused in 2016 from being billed.

While some hospitals say they write off the debt of poor patients without ever resorting to collection measures, several hospitals whose practices were highlighted in news reports this year for aggressively suing patients admitted to the IRS they knew many unpaid bills might have been averted through their financial assistance policies.

A quarter of bad debt at Mary Washington Healthcare, which sued so many patients that a Virginia court convened special sessions to hear the cases, involved candidates for free or discounted care, according to its IRS filing.

So did half of the bad debt at Methodist Le Bonheur Healthcare in Memphis, called out by news organizations for frequently garnishing wages, its filing said.

CHI Franciscan, which owns St. Joseph, said in multiple IRS filings that none of its bad debt arose from billing indigent patients. While Franciscan admitted no wrongdoing in its settlement with the Washington attorney general, the agreement bars the practice of discouraging charity care in the ways alleged in the lawsuit.

Charity care requests at St. Joseph’s Medical Center in Tacoma, Wash., required so much documentation that half of the requests were rejected, the state attorney general argued in a lawsuit against the hospital. The hospital agreed this year to provide refunds and debt forgiveness to thousands of patients.(Dan DeLong for KHN)

“We are exceeding the requirements of state law and providing charity care compensation to patients who may be in most need, even if they never applied for charity care or did not actually qualify at the time of service,” Cary Evans, a Franciscan spokesman, said in a statement. Franciscan declined to discuss individual patients.

According to the lawsuit and interviews with former employees, St. Joseph’s workers were told never to voluntarily offer patients a charity care application. If asked for one, they were instructed to insist on a deposit at least three times. Even when submitted, applications required so much documentation that half of the requests were rejected, the lawsuit alleged.

Internal hospital training documents the attorney general submitted as part of the case showed that St. Joseph workers were advised on how to best collect money from patients before they left the hospital. Instead of saying, “Can you pay today?” employees were told to use phrases like “How would you like to pay for that today? Cash, check or credit card?” according to the documents.

“It became this moneymaking system,” Rachael Murphy, a former employee, recalled in an interview. “People would be crying at registration desks, people would be upset, people would walk out.”

Pintos, who signed a written statement for the attorney general and was listed as a potential witness in the case, said the hospital never gave her an application even though she had qualified for charity care the previous year. “They made me feel like I wasn’t good enough to be there,” she said.

St. Joseph recently erased the $839 debt from her credit, but Pintos still owes $1,611 for care from the ER doctors, who have their own practice group and do not have to follow the hospital’s charity care policies, according to Franciscan. That bill remains in collections.

‘A Gap In Trust’

Nonprofit hospitals provide roughly $14 billion worth of charity care a year, about 2% of their operating costs. But their policies can have notable exemptions, such as excluding bills from doctors who are not on the hospital payrolls.

However, information about hospital charity care, often included in the reams of admissions documents or posted on hospital walls, can easily get overlooked by patients and families focused on medical emergencies.

“The signage might be a little hard to find, applications are complicated, documentation is complicated,” said Keith Hearle, a consultant who advised the IRS on collecting hospitals’ charity care data. “You could probably come up with 15 reasons people didn’t apply.”

In their IRS filings explaining the bad debt and in interviews, hospitals said that even when they give applications to patients, some fail to submit them or do not provide complete records of their finances, which can include tax returns and bank statements.

“There is a gap in trust where our patients must not believe that if they are willing to share information, that it will be to their benefit,” said June McAllister Fowler, a spokeswoman for BJC HealthCare.

(Story continues below.)

Shana Tate, senior vice president of revenue cycle at Ballad Health, said Ballad is looking to be more proactive.

“We made the assumption that, ‘We give you the information. What more do you need?’ But we realize a lot of patients don’t read it, don’t pay attention,” Tate said. “They need someone to hold their hand through this process.”

Methodist Le Bonheur, which erased more than 6,000 unpaid bills last month, said it is “increasing access to financial assistance information upfront and throughout the patient care journey” and “enhancing the screening process.”

Penn Medicine said that, as a safety-net hospital system, it has many patients who are poor or coping with other problems. These people, Penn said, face “barriers to completing the process for aid” and their bills are typically “left unpaid.”

Mary Washington did not respond to requests for comment, but after critical news reports last June it announced that it was suspending its lawsuits over unpaid bills and reevaluating its practices.

Laurie Jinkins, a state representative from Tacoma and author of legislation to strengthen Washington’s charity care laws, said, “The drive for dollars in the health care system, and the drive for dollars to expand, causes our nonprofit health systems to lose sight of why they’re actually here.” She said St. Joseph had “really gone off the deep end” in its focus on money.

St. Joseph’s practices hark back years, according to the attorney general’s lawsuit and interviews with employees and patients.

After Alisha Colyer’s husband went to the St. Joseph emergency room with pneumonia in 2007, she said, she tried to apply for help, but the charity care application “was like a book you had to fill out.”

“I remember them asking me what make and model my car was, and I was like, ‘You want me to sell my car to pay my hospital bill?’ ” recalled Colyer, who now works at the hospital as a dietary aide.

When Alisha Colyer applied for St. Joseph Medical Center’s charity care around 2007, she remembers them asking what make and model her car was. “And I was like, ‘You want me to sell my car to pay my hospital bill?’”(Dan DeLong for KHN)

In a statement, Franciscan noted that St. Joseph and its other hospitals now use a simplified two-page application designed by the state hospital association and have agreed to make charity care easier to obtain. It also offers free care for medically necessary services to patients earning up to three times the poverty level, which is more than most hospitals do.

It is too early to assess how the policy changes translate into results. The most recent Washington state analysis, for 2017, found St. Joseph lagged behind the regional average in the amount of charity care it provided.

KHN data editor Elizabeth Lucas contributed to this report.

METHODOLOGY

Bad debt figures were derived from the IRS 990 tax returns filed electronically by nonprofit hospital organizations. That information was downloaded in data form from the IRS website on May 7, 2019, by Jacob Fenton, an independent consultant, and analyzed by Kaiser Health News. Returns that included Schedule H, which only hospital-owning nonprofits must file, were analyzed.

For each organization identification number, we selected the return with the most recent tax period end date. In case of duplicates such as amended returns, only the return with the most recent end date and the most recent signature filing date was selected. Because there were still a few duplicates, the one with the largest unique return identifier was selected. The most recent tax returns for 2,508 nonprofits were identified.

Organizations must report their bad debt — bills they have given up on collecting — and, separately, estimate the bad debt “that reasonably is attributable to patients who likely would qualify for financial assistance under the hospital’s financial assistance policy … but for whom insufficient information was obtained to determine their eligibility.” Generally, both figures are greater than the actual cost of providing the services: They are the amount the hospital expected to be paid. For our analysis, we calculated the percentage of bad debt that the organization attributed to patients who might qualify for financial assistance.

A handful of bad debt figures were reported as negative numbers. Those were converted to positives. The amounts were not significant enough to substantially affect aggregates or the analysis’s conclusions.

Related Topics

Cost and Quality Health Care Costs Health Industry States The Health Law

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! Yours truly is back from beautiful Vietnam and it seems I missed one or two … ahem … minor news events while traipsing around.

I come bearing no souvenirs but rather two health reminders (one via Sen. Bernie Sanders). Firstly, don’t forget your flu shot — Australia has had an unusually early and severe season, which rarely bodes well for our own. The second comes in the form of a hard-earned lesson from a 2020 candidate: Don’t ignore those heart attack warning signs! (This is especially directed at women, who are dying unnecessarily from cardiac events.)

Now enough mother-henning. (You missed me, didn’t you?) On to the news of the week!

The Supremes are back in action, and a look at the high court’s docket reveals a potentially doozy of a politically charged term (with rulings expected to land as the general election heats up in 2020).

In the health care sphere, a big case to watch is the Louisiana abortion suit. An essentially identical Texas law — which requires doctors performing abortions to have admitting privileges at nearby hospitals — was ruled unconstitutional by the court in 2016, but that means little with two new justices appointed by President Donald Trump weighing in.

The New York Times: As the Supreme Court Gets Back to Work, Five Big Cases to Watch

Oral arguments in two other health-related cases were held this week. The justices grappled with the moral and legal complexities of the insanity defense. The case prompted questions such as this one from Justice Stephen Breyer: One defendant kills a victim he thinks is a dog. “The second defendant knows it’s a person but thinks the dog told him to do it,” Breyer said. “They are both crazy. And why does Kansas say one is guilty, the other is not guilty?”

The New York Times: Supreme Court Opens New Term With Argument on Insanity Defense

Tuesday was all about LGBTQ rights. Although most of the justices were divided along ideological lines on whether federal civil rights legislation applies to sexual orientation and gender identification, Justice Neil Gorsuch hinted his vote might be in play. As an avowed believer in textualism, he suggested that the words of Title VII are “really close, really close” to barring employment discrimination for those workers. But don’t go placing bets on the outcome yet. He also noted that he was worried about “the massive social upheaval” that would follow such a Supreme Court ruling.

The New York Times: Supreme Court Considers Whether Civil Rights Act Protects L.G.B.T. Workers


On that note, the 2020 Democratic candidates participated in an LGBTQ forum on the eve of National Coming Out Day. There were a handful of notable moments through the night (including a zinger from Sen. Elizabeth Warren that was met with loud applause), but much of the spotlight was on protesters who demanded the candidates pay attention to violence against black transgender women. “We are hunted,” said one member of the audience.

CNN: Protesters Interrupt CNN LGBTQ Town Hall to Highlight Plight of Black Transgender Women

Elsewhere on the campaign trail this week, controversy over a pregnancy discrimination talking point from Warren’s stump speech prompted women — including Warren rival Sen. Amy Klobuchar — to speak out on social media about their own and their mothers’ experiences.

NBC News: Women Rally in Support of Elizabeth Warren by Sharing Their Own Pregnancy Discrimination Stories

Sanders’ campaign confirmed that the health scare from last week was indeed a heart attack. The 2020 candidate — who promised to return “full blast” to the race — said he hopes people learn from his “dumb” mistake of ignoring the warning signs. In true politician-running-for-office style, he also was able to use the scare as a way to emphasize the importance of his signature policy proposal, “Medicare for All.”

Reuters: Democratic Presidential Hopeful Sanders Says He Was ‘Dumb’ to Ignore Health Warnings

In a sign of what’s to come for Big Pharma, South Bend Mayor Pete Buttigieg, one of the field’s more moderate candidates, released a drug pricing plan that is decidedly not moderate. The move falls in line with a broader sense that there’s an ever-growing appetite among even middle-ground Dems for action to rein in drugmakers.

Stat: Buttigieg Unveils an Aggressive Plan for Lowering Drug Prices

And for you political wonks out there, this was an interesting read on the shifting political dynamics of doctors, who once used to be a sure thing for the GOP.

The Wall Street Journal: Doctors, Once GOP Stalwarts, Now More Likely to Be Democrats


A key ruling on the health law is expected in the next few weeks, but officials (on condition of anonymity,  mind you) said that if the ruling is against the ACA, the Trump administration will ask the court to put any changes on hold — possibly until after the election. The reports further support the idea that the law, which has been, uh, politically fraught (to say the very least) over its entire life span, is at the moment viewed as an Achilles’ heel for Republicans.

The Washington Post: Trump Administration Plans to Delay Any Changes If the ACA Loses in Court

Two other major news items out of the administration this week to pay attention to:

The Associated Press: Trump Signs Proclamation Restricting Visas for Uninsured

The Associated Press: Overhaul Is Proposed for Decades-Old Medicare Fraud Rules


The first teenager’s death in the outbreak of vaping-related lung illnesses drove home this week public health officials’ message that young people are “playing with their lives” when they partake. The number of cases jumped to 1,299 as of Oct. 8, with the number of deaths rising to 26.

The Wall Street Journal: New York City’s First Vaping-Related Death Is a Bronx Teen

Reuters: U.S. Vaping-Related Deaths Rise to 26, Illnesses to 1,299

Although Juul is facing a barrage of lawsuits, one filed this week was notable. It was believed to be the first from school districts, which claim that fighting the vaping epidemic has been a drag on their resources. While some legal experts are dubious about whether the school districts can establish their standing, others aren’t ruling it out.

The New York Times: Juul Is Sued by School Districts That Say Vaping Is a Dangerous Drain on Their Resources

And the ripple effect of the crisis is spreading to life insurance prices.

Bloomberg: Prudential Plans to Boost Life Insurance Prices for Vapers


Time for you to flex your ethical muscles for the week: Should there be boundaries to highly personalized medicine? A pricey drug designed — and named for! — just one patient sparked questions this week about how far researchers should go in the name of curing a single person. Especially when there are thousands of patients out there with rare diseases. Would only the wealthiest subset be given cures? Who would decide which patients deserve limited research hours over others?

The New York Times: Scientists Designed a Drug for Just One Patient. Her Name Is Mila.

And ProPublica shines a light on the practice of drug companies using flashy Facebook ads, cash incentives and other marketing techniques to woo Mexican residents over the border to donate plasma. It’s not as innocuous as it might seem — donating too much plasma can compromise the immune system. (Selling plasma has been banned in Mexico since 1987.)

ProPublica: Pharmaceutical Companies Are Luring Mexicans Across the U.S. Border to Donate Blood Plasma


In the miscellaneous file for the week:

  • An Ohio doctor is being charged in 25 fentanyl-related deaths. How on earth was such a lapse allowed to occur? The New York Times peels back the curtain on years of lapses and missed warnings in one Columbus intensive care unit.

The New York Times: One Doctor. 25 Deaths. How Could It Have Happened?

  • During the week of World Mental Health Day, research finds that Americans are starting to internalize all the political rhetoric (and myths) about the connection between mental health and violence. “People want simple solutions: They want to be able to neatly explain things,” said one expert.

Los Angeles Times: Americans Increasingly Fear Violence From People Who Are Mentally Ill

  • There’s more than one way to keep a community healthy, and that goes beyond doctor’s offices, clinics and hospitals. A growing number of medical professionals are embracing the notion that steady paychecks, stable housing and good food are crucial to supporting their patients before they get sick.

The New York Times: When a Steady Paycheck Is Good Medicine for Communities

  • In a sad sign of the times, a muppet on “Sesame Street” is going to have a mother struggling with addiction. The storyline is meant to help an ever-increasing number of children affected by the opioid crisis.

Stat: ‘Sesame Street’ Launches Initiative to Help Explain Parental Addiction to Kids

  • High levels of uranium were found in the blood of Navajo women and babies in a study that underscored the real costs of America’s atomic development. Lawmakers are pushing for legislation that would compensate those who have been exposed.

The Associated Press: US Official: Research Finds Uranium in Navajo Women, Babies

  • And the Nobel Prizes are given out this week: In medicine, scientists who worked with oxygen and cells were honored. Their work has the potential to be the building blocks for things like cancer treatments.

The Washington Post: Nobel Prize in Medicine Awarded for Discovery of How Cells Sense Oxygen


That’s it from me! It’s good to be back with you guys, and I hope you have a great weekend!

Related Topics

Aging Courts Health Care Costs Health Industry Insurance Pharmaceuticals Public Health The Health Law

Age-Old Health Care Debate Shifts From Insuring More People To Cutting Costs

In a new article in the BMJ journal, Julie Rovner, chief Washington correspondent for Kaiser Health News, examines the debate over the future of the U.S. health insurance system — a debate that has waxed and waned for the better part of a century. While political parties once argued over whether the government should make sure all residents have coverage, the discussion is changing. As the cost of medical services continues to grow faster than most Americans’ incomes, even people with private insurance coverage — which comes with ever-increasing expenses in the form of deductibles and copayments — are finding the cost of care becoming unaffordable. That’s true for Medicare as well. Read the article here.

Related Topics

Cost and Quality Health Care Costs Insurance Medicaid Medicare The Health Law Uninsured

KHN’s ‘What The Health?’: Trump Merges Health And Immigration


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


President Donald Trump has merged two of his favorite hot-button topics by requiring new immigrants to either purchase health insurance within 30 days of arrival or prove they can pay for medical expenses on their own.

Meanwhile, the Supreme Court has agreed to hear an abortion case out of Louisiana and could soon take another from Indiana. Either or both could be used to weaken or possibly roll back Roe v. Wade, the 1973 ruling that legalized abortion nationwide.

And on the Democratic presidential campaign trail, Vermont Sen. Bernie Sanders has a heart attack and South Bend, Ind., Mayor Pete Buttigieg has a drug plan. Also, Republicans have a unified message: They say Democrats are pushing socialism.

This week’s panelists are Julie Rovner of Kaiser Health News, Alice Miranda Ollstein of Politico, Julie Appleby of Kaiser Health News and Paige Winfield Cunningham of The Washington Post.

Among the takeaways from this week’s podcast:

  • In his surprise announcement last week setting requirements for legal immigrants to have health insurance, Trump based the new policy on concerns about the burden uninsured people put on the health system. That is an argument often used by supporters of the Affordable Care Act, which Trump strongly criticizes.
  • The Supreme Court likely has four options in the Louisiana abortion case it accepted last week. The state law in question requires that doctors performing abortions be accredited at local hospitals ― an issue at the heart of a Texas law that the justices rejected several years ago. The court could say the Louisiana law is much like Texas’ and strike it down; use the new law to overturn abortion rights; say the Texas decision was not correct and let stand the Louisiana law; or say the facts are different in Louisiana and its law can stand.
  • Somewhat overlooked in the court’s acceptance of the case is that it will also rule on another abortion issue: whether health care providers can sue to stop restrictive state laws. If the court says they can’t and instead the burden is on women seeking an abortion, it will make challenging state statutes much more difficult.
  • The executive order signed by Trump last week could result in significant changes to Medicare, allowing doctors to opt out of the program and set up private contracts with patients.
  • Sen. Bernie Sanders’ heart attack has raised questions ― again ― about how transparent presidential candidates should be about their health.
  • As both Republican critics of the ACA and its supporters await a decision by the 5th Circuit Court of Appeals on a Texas lawsuit that could strike down the federal health law, GOP officials are growing nervous about timing. The case will be appealed to the Supreme Court, but some administration officials would like that to not hit the court during the 2020 presidential campaign and are considering ways to prolong the appeal process.

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

Julie Rovner: Kaiser Health News’ “Why Hospitals Are Getting Into The Housing Business,” by Markian Hawryluk

Alice Miranda Ollstein: The New York Times’ “Sexually Transmitted Disease Cases Rise to Record High, C.D.C. Says,” by Liam Stack

Paige Winfield Cunningham: Bloomberg’s “AbbVie, Bristol-Myers Among Patient Advocacy Groups’ Big Backers,” by Alex Ruoff. Also, Kaiser Health News’ database of pharma contributions to patient advocacy groups can be found here.

Julie Appleby: Kaiser Health News’ “They Enrolled In Medical School To Practice Rural Medicine. What Happened?” by Lauren Weber


To hear all our podcasts, click here.

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

Related Topics

Courts Medicare Multimedia The Health Law

CMS Wants To Make It Easier For Consumers To Find Out If Nursing Homes Have Been Penalized For Abuse, Neglect

During 20th Century, Doctors Were The Quintessential Republican. But That’s Starting To Change.

Extent Of Health Coverage Gains From California Gig Worker Law Uncertain

A new California law that reclassifies some independent contractors as employees, requiring they be offered a range of benefits and worker protections, will likely expand health insurance coverage in the state, health policy experts say.

But it might end up harming some workers.

That’s in part because the law, which takes effect Jan. 1, could cut two ways. While inducing many employers to extend health insurance to newly reclassified employees, it might prompt others to shift some workers from full-time to part-time status to avoid offering them health coverage, or — in the case of some small firms — to drop such benefits altogether.

Some companies might trim their workforce to limit cost increases. Benefits typically account for about 30% of total employee compensation costs, and health insurance is the largest component of that.

“I think we will see more people classified as employees over time,” said Ken Jacobs, chair of the Center for Labor Research at the University of California-Berkeley. “And that is very likely to expand the number who are offered and take coverage. But the situation is definitely fluid.”

Adding to the fluidity: Some large employers are contesting the new law. Uber, the ride-sharing app company, has said the law does not apply to its drivers and indicated it is prepared to defend its position in court. The company has joined competitor Lyft in broaching the idea of a 2020 ballot initiative to challenge the law.

California Gov. Gavin Newsom has indicated a willingness to negotiate changes and exemptions with those companies and others.

Uber did not respond to requests for comment, and Lyft declined to comment.

In addition to shared-ride drivers, the law affects construction workers, custodians and truck drivers, among others.

Some independent contractors prefer the flexibility that comes with setting their own hours, but others are eagerly eyeing health coverage.

Steve Gregg, a resident of Antioch, Calif., is among them. Gregg, 51, is uninsured and makes too much to qualify for Medi-Cal, the state’s version of the Medicaid program. He hopes to be reclassified as an Uber employee in 2020, primarily to gain access to health insurance.

“The only medical care I can really afford right now is to use an online doctor for my blood pressure medicine,” said Gregg, who typically logs 50 hours or more a week driving for Uber in the Bay Area.

Under the Affordable Care Act, companies with at least 50 full-time employees must pay a penalty if they don’t offer health insurance to those who work 30 hours or more a week.

California’s new “gig economy” law requires employers to treat independent contractors as regular employees if the work they perform is central to the core mission of the company and they operate under the company’s direction.

Several kinds of workers are exempt from the law’s provisions, however, including insurance and real estate agents, investment advisers, doctors and nurses, direct sales workers and commercial fishermen.

Jacobs said other states will closely watch what happens in California, given that some tech companies hire large numbers of independent contractors.

New Jersey, Massachusetts and Connecticut have similar labor laws on the books. Lawmakers in Oregon and Washington state are eyeing legislation akin to California’s.

Independent contractors in the Golden State are nearly twice as likely to be uninsured as regular employees, according to an analysis by UC-Berkeley’s Center for Labor Research, known as the Labor Center. From 2014 to 2016, just under 70% of workers classified as employees had employer-sponsored health insurance, compared with 32% of independent contractors, the study shows.

An estimated 1.6 million of the state’s 19.4 million workers are full-time independent contractors, according to another analysis by the Labor Center. It is unclear precisely how many contractors are “misclassified,” but sponsors of the new law, led by Assemblywoman Lorena Gonzalez (D-San Diego), put the number at around 1 million.

Whatever the exact number, employers who rely on contract workers will need to make complex health insurance decisions.

A company whose contract workers average 35 to 40 hours a week, for example, could reclassify them as employees for the purpose of complying with the new law but try to limit their weekly hours to fewer than 29, thus avoiding the ACA coverage requirement, said Dylan Roby, an associate professor of health policy and management at the University of Maryland and an adjunct associate professor at UCLA.

A large proportion of small companies that are not required by the ACA to cover their employees do so anyway, and the ones that hire independent contractors will also face hard choices.

“If they have to expand that to reclassified employees, the cost could be substantial,” said Christen Linke Young, a health insurance researcher at the Brookings Institution in Washington, D.C.

A small firm with a skilled and relatively high-wage workforce might choose to absorb the cost of expanding coverage to reclassified workers, Young said, because those workers might not qualify for subsidies to buy health insurance on their own through Covered California, the state’s ACA marketplace. Offering insurance is also a retention tool.

Other small companies, however, could choose to drop coverage altogether rather than pay the tab for newly reclassified workers.

And some might be able to place the new employees in a separate category and offer them no health benefits, or less generous ones than the existing employees get. But under federal law, an employer can do that only if the new employees are doing a different kind of work than the current ones, Young said.

Companies of all sizes can wait a year before offering new employees coverage, to establish what their average weekly hours are. That buys firms with 50 or more employees time to decide whether the reclassified workers qualify for health benefits under the ACA.

The uncertainty about how the new law will play out is sowing confusion among many independent contractors.

Vanessa Bain, a resident of Menlo Park, Calif., who works full time as a contract worker for Instacart — a same-day delivery service for groceries — worries about what her employer will do.

Bain and her family are enrolled in Medi-Cal, California’s version of the Medicaid program for people with low incomes. But she would rather get insurance through Instacart.

“What will they offer us?” Bain, 33, wonders. “If the premiums are too high or the coverage crappy, we may be better off buying it on our own through Covered California. We’ll have to see.”

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

Related Topics

California Cost and Quality Health Care Costs Insurance States The Health Law