Health Care Costs – KFF Health News https://kffhealthnews.org Mon, 07 Aug 2023 23:01:25 +0000 en-US hourly 1 https://wordpress.org/?v=6.2.2 https://kffhealthnews.org/wp-content/uploads/sites/2/2023/04/kffhealthnews-icon.png?w=32 Health Care Costs – KFF Health News https://kffhealthnews.org 32 32 The Real Costs of the New Alzheimer’s Drug, Most of Which Will Fall to Taxpayers https://kffhealthnews.org/news/article/the-real-costs-of-the-new-alzheimers-drug-most-of-which-will-fall-to-taxpayers/ Wed, 02 Aug 2023 09:00:00 +0000 https://kffhealthnews.org/?post_type=article&p=1727384 The first drug purporting to slow the advance of Alzheimer’s disease is likely to cost the U.S. health care system billions annually even as it remains out of reach for many of the lower-income seniors most likely to suffer from dementia.

Medicare and Medicaid patients will make up 92% of the market for lecanemab, according to Eisai Co., which sells the drug under the brand name Leqembi. In addition to the company’s $26,500 annual price tag for the drug, treatment could cost U.S. taxpayers $82,500 per patient per year, on average, for genetic tests and frequent brain scans, safety monitoring, and other care, according to estimates from the Institute for Clinical and Economic Review, or ICER. The FDA gave the drug full approval July 6. About 1 million Alzheimer’s patients in the U.S. could qualify to use it.

Patients with early Alzheimer’s disease who took lecanemab in a major clinical trial declined an average of five months slower than other subjects over an 18-month period, but many suffered brain swelling and bleeding. Although those side effects usually resolved without obvious harm, they apparently caused three deaths. The great expense of the drug and its treatment raises questions about how it will be paid for, and who will benefit.

“In the history of science, it’s a significant achievement to slightly slow down progression of dementia,” said John Mafi, a researcher and associate professor of medicine at the David Geffen School of Medicine at UCLA. “But the actual practical benefits to patients are very marginal, and there is a real risk and a real cost.”

To qualify for Leqembi, patients must undergo a PET scan that looks for amyloid plaques, the protein clumps that clog the brains of many Alzheimer’s patients. About 1 in 5 patients who took Leqembi in the major clinical test of the drug developed brain hemorrhaging or swelling, a risk that requires those taking the drug to undergo frequent medical checkups and brain scans called MRIs.

In anticipation of additional costs from the Leqembi drug class, the Centers for Medicare & Medicaid Services in 2021 increased monthly premiums for Medicare patients by 15%, and premiums may rise again in 2024 after a slight decline this year.

Such increases can be a significant burden for many of the 62 million Medicare subscribers who live on fixed incomes. “Real people will be affected,” Mafi said. He contributed to a study that estimated lecanemab and related care would cost Medicare $2 billion to $5 billion a year, making it one of the most expensive taxpayer-funded treatments.

In its analysis, ICER suggested that Leqembi could be cost-effective at an annual price of $8,900 to $21,500. In an interview, David Rind, ICER’s chief medical officer, said $10,000 to $15,000 a year would be reasonable. “Above that range doesn’t seem like a good place,” he said.

Whatever its price, patients may be delayed getting access to Leqembi because of the relative shortage of specialists capable of managing the drug, which will require genetic and neuropsychological testing as well as the PET scan to confirm a patient’s eligibility. A similar drug, Eli Lilly’s donanemab, is likely to win FDA approval this year.

Already there are long waits for the testing needed to assess dementia, Mafi said, noting that one of his patients with mild cognitive impairment had to wait eight months for an evaluation.

Such testing is not readily at hand because of the paucity of effective treatment for Alzheimer’s, which has helped to make geriatrics a relatively unappealing specialty. The United States has about a third as many dementia specialists per capita as Germany, and about half as many as Italy.

“Time is of the essence” for the neuropsychological testing, Mafi said, because once a patient’s cognitive ability declines below a certain threshold, they become ineligible for treatment with the drug, which was tested only in patients in the earliest stages of the disease.

Mafi’s study estimates that patients without supplemental Medicare coverage will have to pay about $6,600 out-of-pocket for each year of treatment. That could put it out of reach for many of the 1 in 7 “dual eligible” Medicare beneficiaries whose income is low enough to simultaneously qualify them for state Medicaid programs. Those programs are responsible for about 20% of physician bills for drug infusions, but they don’t always cover the full amount.

Some practitioners, such as cancer centers, cover their Medicaid losses by receiving higher rates for privately insured patients. But since almost all lecanemab patients are likely to be on government insurance, that “cross-subsidization” is less of an option, said Soeren Mattke, director of the Center for Improving Chronic Illness Care at the University of Southern California.

This poses a serious health equity issue because “dual eligibles are low-income patients with limited opportunities and education, and at higher risk of chronic illnesses including dementia,” Mattke said in an interview. Yet many doctors may not be willing to treat them, he said. “The idea of denying access to this group is just appalling.”

Eisai spokesperson Libby Holman said the company was reaching out to specialists and primary care physicians to make them aware of the drug, and that reimbursement options were improving. Eisai will provide the drug at no cost to patients in financial need, she said, and its “patient navigators” can help lock down insurance coverage.

“A lot of clinicians are excited about the drug, and patients are hearing about it,” said David Moss, chief financial officer of INmune Bio, a company that has another Alzheimer’s drug in development. “It’s a money center for infusion centers and MRI operators. It provides reasons for patients to come into the office, which is a billing thing.”

Outstanding doubts about Leqembi and related drugs have given urgency to efforts to monitor patient experiences. CMS is requiring Leqembi patients to be entered into a registry that tracks their outcomes. The agency has established a registry, but the Alzheimer’s Association, the leading advocacy group for dementia patients, is funding its own database to track those being treated, offering physician practices $2,500 to join it and up to $300 per patient visit.

In a letter to CMS on July 27, a group of policy experts said CMS should ensure that any and all Leqembi registries create and share data detailed enough for researchers and FDA safety teams to obtain a clear picture of the drug’s real-world profile.

The anti-amyloid drugs like lecanemab have created a polarized environment in medicine between those who think the drugs are a dangerous waste of money and those who believe they are a brilliant first step to a cure, said ICER’s Rind, who thinks lecanemab has modest benefits.

“People are as dug in on this as almost anything I’ve ever seen in medicine,” he said. “I don’t think it’s healthy.”

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]]> Be Aware: Someone Could Steal Your Medical Records and Bill You for Their Care https://kffhealthnews.org/news/article/be-aware-someone-could-steal-your-medical-records-and-bill-you-for-their-care/ Mon, 31 Jul 2023 09:00:00 +0000 https://kffhealthnews.org/?post_type=article&p=1720870 After HCA Healthcare announced this month that the personal identification data of roughly 11 million HCA patients in 20 states had been exposed in a breach, people may be justifiably concerned that their own medical data and identities could be stolen.

Consumers should realize that such “medical identity” fraud can happen in several ways, from a large-scale breach to individual theft of someone’s data.

Just ask Evelyn Miller. The first sign something was amiss was a text Miller received from an Emory University Hospital emergency department informing her that her wait time to be seen was 30 minutes to 1 hour. That’s weird, she thought. She no longer lives in Atlanta and hadn’t used that hospital system in years. Then she got a second text, similar to the first. Must be spam, she thought.

When she got a call the next day from an Emory staffer named Michael to discuss the diagnostic results from her ER visit, she knew something was definitely wrong. “It amazed me someone could get registered with another person’s name and no ID was checked or anything,” Miller said.

And while the name and date of birth the staffer had on record for her were correct, Miller’s address was not. She now lives in Blairsville, Georgia, a few hours north of Atlanta. Michael said he’d correct the problem. The next week, she got a bill from Emory for more than $3,600.

After an unsatisfactory conversation with someone in the hospital’s billing department, Miller sent a letter to the hospital’s privacy officer. Miller recalled writing: “I think there’s something going on, that someone is using my information, and the visit and the charges appear to be fraudulent.”

When contacted, Emory Healthcare spokesperson Janet Christenbury declined to comment on Miller’s case specifically but did say, “We take these matters seriously and work with our teams to ensure our processes and procedures are followed.”

Miller, 63, a retired health care administrator, was savvier than many about what might have occurred. The average person may have no idea a problem like this can arise until long after a theft occurs.

“The majority of victims find out when they’re trying to move on with their lives, if bills have gone to collections,” said Eva Velasquez, president and CEO of the Identity Theft Resource Center, a nonprofit that provides free assistance to victims of identity theft. Someone may apply for a mortgage, for example, and learn their credit is ruined due to unpaid medical bills for care they didn’t receive.

It’s a double whammy. Unlike other forms of identity fraud, medical identity thieves may steal not only their victims’ personal data — Social Security number, date of birth, address — but also information about their medical records and care, potentially putting their health at risk.

“Sometimes people can’t get their prescriptions, if their records are mixed with someone else’s,” Velasquez said. “Maybe you won’t be able to get treatment that you need. There are serious implications.”

A theft may affect just one person whose insurance card gets stolen or “borrowed” to pay for health care, or it may result from a data breach, as HCA Healthcare experienced. Such large-scale breaches are more likely to be used in financial fraud schemes than to get medical care, experts say.

Compared with other types of identity fraud, medical identity theft is rare. In 2022, for example, the Federal Trade Commission received 27,821 reports of medical identity theft, while reports for identity theft related to new credit card accounts totaled more than 400,000.

Medical identity theft also presents itself in different ways.

One Thief, One Victim

If someone gets ahold of another person’s health insurance number and driver’s license or other ID, they may be able to use it to receive medical services in someone else’s name.

Busy hospital emergency departments may make an attractive target for fraudsters. Procedures typically require patients to present insurance and photo identification information at check-in, said Rade Vukmir, an emergency physician in Pittsburgh and a spokesperson for the American College of Emergency Physicians. But these facilities also don’t want to put people off from getting care, and people who are uninsured or disadvantaged might not have those documents.

“We want to treat that population,” he said. “We’re America’s safety net. We always provide care.”

Medical identity theft can happen if someone loses a wallet with their insurance card in it, for example, or a piece of mail from their insurer goes astray. But it doesn’t occur only among strangers. The victim often knows the thief and may even be in on the “friendly fraud,” as it’s called. According to one study, nearly half of people who failed to report medical identity theft said it was because they knew the thief.

For example, one person might have a higher copayment for emergency department visits, Vukmir said, so they let a family member, such as a cousin or a sibling, use their insurance card to get medical care.

“Usually, in those cases, it wasn’t an emergency,” said Vukmir.

Gangs of Thieves, Millions of Victims

In 2022, 707 health care data breaches affected nearly 52 million patients, according to an analysis of data from the Department of Health and Human Services’ Office for Civil Rights by the HIPAA Journal, which tracks compliance with health care data privacy law. Under federal law, health care organizations must notify individuals when their medical data has been exposed through a breach.

The largest health care data breach to date occurred in 2015, when nearly 80 million Anthem records were exposed. Though the 2022 figures for incidents among all health plans were slightly lower than the year before, there has been a clear upward trend in recent years in breaches, which are typically caused by hacking or IT incidents.

The American Hospital Association is “very concerned” about foreign-based hacking groups from countries like Russia, China, North Korea, and Iran, said John Riggi, the national adviser for cybersecurity and risk for the American Hospital Association.

Riggi said the personal information in people’s medical records may be sold in bulk to criminals who create phony providers to submit fraudulent claims on a mass scale that can result in hundreds of millions of dollars in Medicaid, Medicare, or other insurance fraud. Or they may use the information to create fake identities to apply for loans, mortgages, or credit cards.

“They flee with the money, and the individual is left to deal with it,” Riggi said.

Health plans could take lessons from the financial services industry to detect red flags, Riggi said. Financial institutions have sophisticated algorithms to identify purchasing and other patterns that are out of the ordinary, Riggi said. In health care, such mechanisms could be used to flag claims in which a provider is located more than 1,000 miles from where a patient lives, for example, or sees a patient for conditions that don’t jibe with their age or health status.

AHIP, an insurance industry trade group, didn’t respond to requests for comment.

What Consumers Can Do

Consumers should generally monitor the notices and bills they receive from insurers and providers and contact them immediately about anything suspicious.

In Miller’s case, it’s unclear whether her problem was due to an administrative snafu, such as another patient with the same name, or medical identity theft. But within a month of her initial call, the hospital removed the charges and assured her that her medical record had been disentangled from the other patient’s.

Other steps to take:

  • Go to the FTC’s identity theft site to learn about next steps and file an identity theft report, if appropriate.
  • If someone has used your name, contact every provider who may have been involved and ask for a copy of your medical records, then report any errors to your medical providers.
  • Notify your health plan’s fraud department and send a copy of the FTC identity theft report.
  • File free fraud alerts with the three major credit reporting agencies and get free credit reports from them. Consider filing a police report. If your health plan offers free credit or identity theft monitoring following a breach, take advantage of it.

“It’s best to proceed as if your data has been compromised and will be for sale,” said Velasquez, whose organization offers free assistance in recovering from identity theft. “Don’t be afraid to ask for help.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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]]> Journalists Explore Shortage of Foster Care Sites and Prevalence of Covid Misinformation https://kffhealthnews.org/news/article/journalists-explore-shortage-of-foster-care-sites-and-prevalence-of-covid-misinformation/ Sat, 29 Jul 2023 09:00:00 +0000 https://kffhealthnews.org/?p=1726089&post_type=article&preview_id=1726089 KFF Health New correspondent Jazmin Orozco Rodriguez discussed the shortage of foster care homes in rural Nevada on The Nevada Independent’s “The Indy” on July 25.

KFF Health News former senior editor Andy Miller discussed taxation rules for nonprofit hospitals on WUGA’s “The Georgia Health Report” on July 21. He also discussed vaccination funding cuts on WUGA’s “The Georgia Health Report” on July 14.

KFF Health News correspondent Darius Tahir discussed how a combination of covid-19 lawsuits and media coverage keeps misinformation churning on American Public Media’s “Marketplace Morning Report” on July 24.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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]]> His Anesthesia Provider Billed Medicare Late. He Got Sent to Collections for the $3,000 Tab. https://kffhealthnews.org/news/article/anesthesiologists-billed-medicare-late-collections-charges/ Fri, 28 Jul 2023 09:00:00 +0000 https://kffhealthnews.org/?post_type=article&p=1725332 Thomas Greene had been experiencing pain in his right leg, a complication from diabetes, when doctors recommended a procedure to increase blood flow to the limb.

Retired from a career as an electrician and HVAC technician, he had an outpatient procedure in April 2021 to alleviate his pain by dilating the clogged artery using a balloon snaked into his blood vessel.

Greene, who lives in Oxford, Pennsylvania, came through the procedure without any problems, and it reduced his discomfort, said his wife, Bluizer Greene. She spoke with KFF Health News on behalf of Greene, who is recovering from other health problems.

Greene is covered by Medicare and a supplemental policy through Humana and did not expect to pay anything for the care, Bluizer said.

Then the bills came.

The Patient: Thomas Greene, 74, who is covered by original Medicare and a Medicare supplement policy sold by Humana.

Medical Service: Peripheral artery bypass surgery on Greene’s right leg.

Service Provider: The operation was performed at Jennersville Hospital in West Grove, Pennsylvania, which closed in December 2021. Anesthesia services were provided by two providers who work for North American Partners in Anesthesia, which is private equity-owned and, with thousands of providers operating in 21 states, identifies itself as among the nation’s largest anesthesia staffing companies.

Total Bill: For the anesthesia care, North American Partners in Anesthesia billed $2,965.58: $1,334.51 for a certified nurse anesthetist and $1,631.07 for an anesthesiologist.

What Gives: North American Partners in Anesthesia, or NAPA, pursued Greene to pay for his anesthesia care instead of billing Medicare on time, sending the debt to collections before the couple discovered the problem.

Medicare eventually received the claims from NAPA, months after the couple started receiving collection letters, Bluizer said. But Medicare denied them because they were filed late — nearly 17 months after the surgery. Humana also denied the claims.

Medicare requires providers to submit claims within a year of providing their services. And Medicare supplemental policies, like Greene’s plan from Humana, generally do not pay for services if Medicare doesn’t cover them, whether because Medicare has not paid its part yet or because the program denied the claim.

A year after Greene’s surgery, in spring 2022, the couple opened a letter from a collection agency working on behalf of the anesthesia group. It demanded Greene pay about $3,000.

“Something has to be wrong, because this is the first time my husband has ever been asked to pay out-of-pocket and we’ve had the same insurance for years,” Bluizer said.

She said for several months she called NAPA and the collection agency, C.tech Collections, of Mount Sinai, New York, to determine why it was billing her husband.

Greene was also contacted by the Faloni Law Group, a second organization working on behalf of NAPA to collect the debt, and Bluizer said she followed its instructions to respond by mail, disputing the debt on the grounds that it should be billed to insurance.

But her communication attempts did not resolve the issue, and she said her husband continued to receive collection notices.

Neither debt collector responded to requests for comment.

“We were angry, and it was very upsetting because we had never had a bill put into a collection agency for any of his hospitalizations, and it was money we did not feel that we owed,” Bluizer said.

She said they may have received some letters from the anesthesia group in 2021 and 2022 that they discarded without opening because they believed her husband’s medical bills would be covered by insurance, as the rest of his surgery bills were.

Worried about the situation, including its potential impact on their credit, the couple reached out late last year to Harold Ting, a volunteer counselor for Pennsylvania’s MEDI program, which provides free assistance to Medicare beneficiaries. Medicare generally covers anesthesia services.

“This is totally unfair that a beneficiary ends up having to pay for what should be a totally covered service, when the provider is at fault,” Ting said.

Two explanation of benefits statements from Humana show the insurer received claims from NAPA in April 2021, shortly after Greene’s surgery. The statements said the claims could not be considered at that time, though, because Humana had not yet received Medicare EOBs for the services.

Kelli LeGaspi, a Humana spokesperson, declined to comment on Greene’s case. She said a Medicare EOB — a coverage statement generated when the program processes a claim — is required for the supplement carrier to consider a claim. Without it, a claim for secondary coverage cannot be considered and is denied, she said.

Supplement plans deny claims for benefits that are denied by Medicare, she said.

“If Original Medicare declines to pay the claim, then the Medicare supplement plan is required to decline the claim as well,” she said in an email.

In December 2022, a NAPA representative told Bluizer in an email that NAPA billed Medicare after the April 2021 surgery and that Medicare denied the claims in August 2021. The representative provided an account statement showing the claims were sent to collections that month.

But Bluizer said a Medicare representative told her in late 2021 that the program had received no claims from NAPA.

Greene’s Medicare account shows NAPA filed claims in September 2022, about 17 months after his surgery and about five months after he received his first collection letter. Both claims were denied.

A quarterly summary notice said while the time limit for filing the claims had expired, Greene also could not be billed.

Meena Seshamani, director of the federal Center for Medicare, said in an email to KFF Health News that if a Medicare provider sends a claim a year or more after a service is provided, it is denied except in very rare circumstances.

There is no exception for provider error, she said.

A spokesperson for NAPA declined to be interviewed on the record, despite receiving a signed release waiving federal privacy protections.

Martine G. Brousse, a billing expert and founder of the patient advocacy firm AdviMedPRO, said Greene’s Medicare notice should have reassured the couple that he did not owe anything, despite the several overdue-bill notices they received.

If the Medicare statement “shows a zero balance to the member, then the provider cannot legally go after the patient,” said Brousse, who is not involved in Greene’s case. “The patient has zero liability because it is not their fault” the provider billed Medicare a year after the surgery. “That is the end of the story.”

Another mystery about the claim is why NAPA billed separately for a nurse anesthetist and an anesthesiologist. Bluizer said her husband was not told why NAPA billed individually for the two medical professionals — a practice some insurers believe constitutes double billing.

Brousse said there could be a simple explanation, such as if the nurse anesthetist started the procedure and the anesthesiologist finished it or if the company charged for the anesthesiologist to work in a supervisory role.

But the Medicare claims document shows each provider billed for the same amount of time — a little over an hour.

“As far as I can tell, this looks like two providers billed with the same ‘I did the job’ Medicare procedure code,” she said. “Medicare cannot accept that without an explanation.”

The Resolution: Unable to get answers, Ting connected Greene to the nonprofit, Pennsylvania-based Center for Advocacy for the Rights and Interests of Elders.

In March, Ariel Rabinovic, an advocate with the center, contacted NAPA on Greene’s behalf and explained that federal law does not allow the group to bill Medicare patients for services Medicare does not cover. He said he was told the company would stop billing Greene.

Bluizer said the couple has not received any collection notices since then.

Rabinovic said he has seen other situations in which health providers who agree to accept Medicare try to bill patients for services Medicare does not cover, which is not allowed.

“Older folks have a lot of things going on, and dealing with this can be very confusing for them,” he said. “A lot of people end up paying because they don’t want to deal with it.”

Greene has faced several health issues and spent time in a rehabilitation hospital this winter. His wife said she was happy the billing issue had been resolved without their having to pay anything.

The Takeaway: When a Medicare statement says the patient may not be billed anything for a health service, that’s the bottom line. Don’t write a check, but also don’t ignore bills and collection notices, because they could ultimately hurt your credit.

Read your mail, the experts said. While Greene was not responsible for paying the anesthesia bill given that Medicare said he did not owe anything, the couple may have prevented the debt from being sent to collections if they had responded to the anesthesia group’s communications and confirmed it had Greene’s insurance information, Brousse said.

Keep copies of bills and insurance statements, especially Medicare EOB documents, or follow them on an online portal.

The couple was smart to reach out to advocates for help resolving the issue when they could not do so on their own, Rabinovic said.

“This is why people need to read their notices from Medicare even when it says ‘This is not a bill,’” he said.

Also, when an anesthesia bill includes charges for both a nurse anesthetist and an anesthesiologist, question the charges. Many insurers will not pay for both.

The Centers for Medicare & Medicaid Services recommend beneficiaries call 800-MEDICARE with questions about their care or bills or file a complaint online.

Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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]]> KFF Health News' 'What the Health?': Another Try for Mental Health ‘Parity’ https://kffhealthnews.org/news/podcast/what-the-health-307-mental-health-parity-biden-reelection-july-27-2023/ Thu, 27 Jul 2023 19:00:00 +0000 https://kffhealthnews.org/?post_type=podcast&p=1725286 The Host Julie Rovner KFF Health News @jrovner Read Julie's stories. Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

The Biden administration continued a bipartisan, decades-long effort to ensure that health insurance treats mental illnesses the same as other ailments, with a new set of regulations aimed at ensuring that services are actually available without years-long waits or excessive out-of-pocket costs.

Meanwhile, two more committees in Congress approved bills this week aimed at reining in the power of pharmacy benefit managers, who are accused of keeping prescription drug prices high to increase their bottom lines.

This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico, and Sarah Karlin-Smith of the Pink Sheet.

Panelists

Anna Edney Bloomberg @annaedney Read Anna's stories Joanne Kenen Johns Hopkins Bloomberg School of Public Health and Politico @JoanneKenen Read Joanne's stories Sarah Karlin-Smith Pink Sheet @SarahKarlin Read Sarah's stories

Among the takeaways from this week’s episode:

  • The Biden administration’s new rules to enforce federal mental health parity requirements include no threat of sanctions when health plans do not comply; noncompliance with even the most minimal federal rules has been a problem dating to the 1990s. Improving access to mental health care is not a new policy priority, nor a partisan one, yet it remains difficult to achieve.
  • With the anniversary of the 988 Suicide & Crisis Lifeline, more people are becoming aware of how to access help and get it. Challenges remain, however, such as the hotline service’s inability to connect callers with local care. But the program seizes on the power of an initial connection for someone in a moment of crisis and offers a lifeline for a nation experiencing high rates of depression, anxiety, and suicide.
  • In news about the so-called Medicaid unwinding, 12 states have paused disenrollment efforts amid concerns they are not following renewal requirements. A major consideration is that most people who are disenrolled would qualify to obtain inexpensive or even free coverage through the Affordable Care Act. But reenrollment can be challenging, particularly for those with language barriers or housing insecurity, for instance.
  • With a flurry of committee activity, Congress is revving up to pass legislation by year’s end targeting the role of pharmacy benefit managers — and, based on the advertisements blanketing Washington, PBMs are nervous. It appears legislation would increase transparency and inform policymakers as they contemplate further, more substantive changes. That could be a tough sell to a public crying out for relief from high health care costs.
  • Also on Capitol Hill, far-right lawmakers are pushing to insert abortion restrictions into annual government spending bills, threatening yet another government shutdown on Oct. 1. The issue is causing heartburn for less conservative Republicans who do not want more abortion votes ahead of their reelection campaigns.
  • And the damage to a Pfizer storage facility by a tornado is amplifying concerns about drug shortages. After troubling problems with a factory in India caused shortages of critical cancer drugs, decision-makers in Washington have been keeping an eye on the growing issues, and a response may be brewing.

Also this week, Rovner interviews KFF Health News’ Céline Gounder about the new season of her “Epidemic” podcast. This season chronicles the successful public health effort to eradicate smallpox.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: The Nation’s “The Anti-Abortion Movement Gets a Dose of Post-Roe Reality,” by Amy Littlefield.

Joanne Kenen: Food & Environment Reporting Network’s “Can Biden’s Climate-Smart Agriculture Program Live Up to the Hype?” by Gabriel Popkin.

Anna Edney: Bloomberg’s “Mineral Sunscreens Have Potential Hidden Dangers, Too,” by Anna Edney.

Sarah Karlin-Smith: CNN’s “They Took Blockbuster Drugs for Weight Loss and Diabetes. Now Their Stomachs Are Paralyzed,” by Brenda Goodman.

Also mentioned in this week’s episode:

click to open the transcript Transcript: Another Try for Mental Health ‘Parity’

KFF Health News’ ‘What the Health?’Episode Title: Another Try for Mental Health ‘Parity’Episode Number: 307Published: July 27, 2023

[Editor’s note: This transcript, generated using transcription software, has been edited for style and clarity.]

Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, July 27, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. We are joined today via video conference by Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico.

Joanne Kenen: Hi, everybody.

Rovner: Sarah Karlin-Smith, the Pink Sheet.

Sarah Karlin-Smith: Hi, Julie.

Rovner: And Anna Edney of Bloomberg News.

Edney: Hello.

Rovner: Later in this episode, we’ll have my interview with my KFF colleague Céline Gounder about the new season of her podcast “Epidemic,” which tracks one of the last great public health success stories, the eradication of smallpox. But first, this week’s news. I want to start this week with mental health, which we haven’t talked about in a while — specifically, mental health parity, which is both a law and a concept, that mental ailments should be covered and reimbursed by health insurance the same way as a broken bone or case of pneumonia or any other — air quotes — “physical ailment.” Policymakers, Republican and Democrat, and the mental health community have been fighting pretty much nonstop since the mid-1990s to require parity. And despite at least five separate acts of Congress over that time — I looked it up this week — we are still not there yet. To this day, patients with psychiatric illnesses find their care denied reimbursement, made difficult to access, or otherwise treated as lesser. This week, the Biden administration is taking another whack at the issue, putting out proposed rules it hopes will start to close the remaining parity gap, among other things by requiring health plans to analyze their networks and prior authorization rules and other potential barriers to care to ensure that members actually can get the care they need. What I didn’t see in the rules, though, was any new threat to sanction plans that don’t comply — because plans have been not complying for a couple of decades now. How much might these new rules help in the absence of a couple of multimillion-dollar fines?

Edney: I had that same question when I was considering this because I didn’t see like, OK, like, great, they’re going to do their self-policing, and then what? But I do think that there’s the possibility, and this has been used in health care before, of public shaming. If the administration gets to look over this data and in some way compile it and say, here’s the good guys, here’s the bad guys, maybe that gets us somewhere.

Rovner: You know, it strikes me, this has been going on for so very long. I mean, at first it was the employer community actually that did most of the negotiating, not the insurers. Now that it’s required, it’s the insurers who are in charge of it. But it has been just this incredible mountain to scale, and nobody has been able to do it yet.

Kenen: And it’s always been bipartisan.

Rovner: That’s right.

Kenen: And it really goes back to mostly, you know, the late Sen. [Paul] Wellstone [(D-Minn.)] and [Sen. Pete] Domenici [(R-N.M.)], both of whom had close relatives with serious mental illness. You know, Domenici was fairly conservative and traditional conservative, and Wellstone was extremely liberal. And they just said, I mean, this — the parity move began — the original parity legislation, at least the first one I’m aware of. And it was like, I think it was before I came to Washington. I think it was in the ’80s, certainly the early — by the ’90s.

Rovner: It was 1996 when when the first one actually passed. Yeah.

Kenen: I mean, they started talking about it before that because it took them seven or eight years. So this is not a new idea, and it’s not a partisan idea, and it’s still not done. It’s still not there.

Edney: I think there’s some societal shift too, possibly. I mean, we’re seeing it, and maybe we’re getting closer. I’ve seen a lot of billboards lately. I’ve done some work travel. When I’m on the road, I feel like I’m always seeing these billboards that are saying mental health care is health care. And trying to hammer that through has really taken a long time.

Rovner: So while we are on the subject of mental health, one of the good things I think the government has done in the last year is start the 988 Suicide & Crisis Lifeline, which turned 1 this month. Early data from shifting the hotline from a 10-digit number to a three-digit one that’s a lot easier to remember does suggest that more people are becoming aware of immediate help and more people are getting it. At the same time, it’s been able to keep up with the demand, even improving call answering times — I know that was a big concern — but there is still a long way to go, and this is hardly a panacea for what we know is an ongoing mental health crisis, right?

Karlin-Smith: This is a good first step to get people in crisis help without some of the risks that we’ve seen. If you go towards the 911 route, sometimes police are not well trained to handle these calls and they end in worse outcomes than necessary. But then you have to have that second part, which is what we were talking about before, which is the access to the longer-term mental health support to actually receive the treatment you need. There’s also some issues with this hotline going forward in terms of long-term funding and, you know, other tweaks they need to work out to make sure, again, that people who are not expecting to interact with law enforcement actually don’t end up indirectly getting there and things like that as well.

Kenen: Do any of you know whether there’s discussion of sort of making people who don’t remember it’s 988 and they call 911 — instead of dispatching cops, are the dispatchers being trained to just transfer it over to 988?

Rovner: That I don’t know.

Kenen: I’m not aware of that. But it just sort of seems common sense.

Rovner: One thing I know they’re working on is, right now I think there’s no geolocation. So when you call 988, you don’t necessarily get automatically referred to resources that are in your community because they don’t necessarily know where you’re calling from. And I know that’s an effort. But yeah, I’m sure there either is or is going to be some effort to interact between 988 and 911.

Kenen: It’s common sense to us. It doesn’t mean it’s actually happening. I mean, this is health care.

Rovner: As we point out, this is mental health care, too.

Kenen: Yeah, right.

Rovner: It’s a step.

Kenen: But I think that, you know, sort of the power of that initial connection is something that’s easy for people to underestimate. I mean, my son in college was doing a helpline during 2020-2021. You know, he was trained, and he was also trained, like, if you think this is beyond what a college-aged volunteer, that if you’re uncertain, you just switched immediately to a mental health professional. But sometimes it’s just, people feel really bad and just having a voice gets them through a crisis moment. And as we all know, there are a lot of people having a lot of crisis moments. I doubt any of us don’t know of a suicide in the last year, and maybe not in our immediate circle, but a friend of a friend, I mean, or, you know — I know several. You know, we are really at a moment of extreme crisis. And if a phone call can help some percentage of those people, then, you know, it needs to be publicized even more and improved so it can be more than a friendly voice, plus a connection to what, ending this repetition of crisis.

Rovner: I feel like the people who worked hard to get this implemented are pretty happy a year later at how, you know — obviously there’s further to go — but they’re happy with how far they’ve come. Well, so, probably the only thing worse than not getting care covered that should be is losing your health coverage altogether, which brings us to the Medicaid unwinding, as states redetermine who’s still eligible for Medicaid for the first time since the start of the pandemic. Our podcast colleague Tami Luhby over at CNN had a story Friday that I still haven’t seen anywhere else. Apparently 12 states have put their disenrollments on pause, says Tami. But we don’t know which 12, according to the KFF disenrollment tracker. As of Wednesday, July 26, at least 3.7 million people have been disenrolled from the 37 states that are reporting publicly, nearly three-quarters of those people for, quote, “procedural reasons,” meaning those people might still be eligible but for some reason didn’t complete the renewal process. The dozen states on pause are apparently ones that HHS [the Department of Health and Human Services] thinks are not following the renewal requirements and presumably ones whose disenrollments are out of line. The Centers for Medicare & Medicaid Services, which is overseeing this, is not naming those states, but this points up exactly what a lot of people predicted would happen when states started looking at eligibility again, that a lot of people who were quite likely still eligible were simply going to lose their insurance altogether, right?

Edney: Yeah, it seemed like there was a lot of preparation in some ways to anticipating this. And then, yeah, obviously you had the states that were just raring to go and try to get people off the rolls. And yeah, it would be very interesting to know what those 12 are. I think Tami’s reporting was stellar and she did a really good job. But that’s, like, one piece of the puzzle we’re missing. And I know CMS said that they’re not naming them because they are working well with them to try to fix it.

Rovner: The one thing we obviously do know is that there are several states that are doing this faster than is required — in fact, faster than is recommended. And what we know is that the faster they do it, the more likely they are going to have people sort of fall between the cracks. The people who are determined to be no longer eligible for Medicaid are supposed to be guided to programs for which they are eligible. And presumably most of them, unless they have, you know, gotten a really great job or hit the lottery, will still be eligible at least for subsidies under the Affordable Care Act. And they’re supposed to be guided to those programs. And it’s not clear yet whether that’s happening, although I know there are an awful lot of people who are watching this pretty closely. There were over 90 million people on Medicaid by the end of the pandemic, by the point at which states no longer had to keep people on. That’s a lot more people than Medicaid normally has. It’s usually more around 70 or even 80 million. So there’s excess people. And the question is what’s going to happen to those people and whether they’re going to have some sort of health insurance. And I guess it’s going to be more than a couple of months before we know that. Yes, Joanne.

Kenen: I think that it’s important to remember that there’s no open enrollment season for Medicaid the way there is for the ACA, so that if you’re disenrolled and you get sick and you go to a doctor or a hospital, they can requalify you and you can get it again. The problem is people who think that they’re disenrolled or are told that they’re disenrolled may not realize. They may not go to the doctor because they think they can’t afford it. They may not understand there’s a public education campaign there, too, that I haven’t seen. You know, if you get community health clinics, hospitals, they can do Medicare, Medicaid certification. But it’s dangerous, right? If you think, oh, I’m going to get a bill I can’t afford and I’m just going to see if I can tough this out, that’s not the way to take care of your health. So there’s that additional conundrum. And then, you know, I think that HHS can be flexible on special enrollment periods for those who are not Medicaid-eligible and are ACA-eligible, but most of them are still Medicaid-eligible.

Rovner: If you get kicked off of Medicaid, you get an automatic special enrollment for the ACA anyway.

Kenen: But not forever. If the issue is it’s in a language you don’t speak or at an address you don’t live in, or you just threw it out because you didn’t understand what it was — there is institutional failures in the health care system, and then there’s people have different addresses in three years, particularly poor people; they move around. There’s a communication gap. You know, I talked to a health care system a while ago in Indiana, a safety net, that was going through electronic health records and contacting people. And yet that’s Indiana and they, you know, I think it was Tami who pointed out a few weeks ago on the podcast, Indiana is not doing great, in spite of, you know, really more of a concerted effort than other states or at least other health systems, not that I talk to every single health system in the country. I was really impressed with how proactive they were being. And still people are falling, not just through the cracks. I mean, there’s just tons of cracks. It’s like, you know, this whole landscape of cracks.

Rovner: I think everybody knew this was going to be a big undertaking. And obviously the states that are trying to do it with some care are having problems because it’s a big undertaking. And the states that are doing it with a little bit less care are throwing a lot more people off of their health insurance. And we will continue to follow this. So it is the end of July. I’m still not sure how that happened.

Kenen: ’Cause after June, Julie.

Rovner: Yes. Thank you. July is often when committees in Congress rush to mark up bills that they hope to get to the floor and possibly to the president in that brief period when lawmakers return from the August recess before they go out for the year, usually around Thanksgiving. This year is obviously no exception. While Sen. Bernie Sanders [(I-Vt.)] at the Health, Education, Labor and Pensions Committee has delayed consideration of that primary care-community health center bill that we talked about last week until September, after Republicans rebelled against what was supposed to have been a bipartisan bill, committee action on pharmacy benefit managers and other Medicare issues did take place yesterday in the Senate Finance Committee and the House Ways and Means Committee. Sarah, you’re following this, right? What’s happening? And I mean, so we’ve now had basically all four of the committees that have some kind of jurisdiction over this who’ve acted. Is something going to happen on PBM regulation this year?

Karlin-Smith: Actually, five committees have acted because the House Ed[ucation] and Workforce Committee has also acted on the topic. So there’s a lot of committees with a stake in this. I think there’s certainly set up for something for the fall, end of the year, to happen in the pharmacy benefit manager space. And there’s a decent amount of bipartisanship around the issue, depending on exactly which committee you’re looking at. But even if the policies that haven’t gotten through haven’t been bipartisan, I think there’s general bipartisan interest among all the committees of tackling the issue. The question is how meaningful, I guess, the policies that we get done are. Right now it looks like what we’re going to end up with is some kind of transparency measure. It reminded me a little bit of our discussion of the mental health stuff [President Joe] Biden is doing going forward. Essentially what it’s going to end up doing is get the government a lot of detailed data about how PBMs operate, how this vertical integration of PBMs — so there’s a lot of common ownership between PBMs, health insurance plans, pharmacies and so forth — may be impacting the cost of our health care and perhaps in a negative way. And then from that point, the idea would be that later Congress could go back and actually do the sort of policy reforms that might be needed. So I know there are some people that are super excited about this transparency because it is such an opaque industry. But at the same point, you can’t kind of go to your constituents and say, “We’ve changed something,” right away or, you know, “We’re going to save you a ton of money with this kind of legislation.”

Rovner: You could tell how worried the PBMs are by how much advertising you see, if you still watch TV that has advertising, which I do, because I watch cable news. I mean, the PBMs are clearly anxious about what Congress might do. And given the fact that, as you point out and as we’ve been saying for years, drug prices are a very bipartisan issue — and it is kind of surprising, like mental health, it’s bipartisan, and they still haven’t been able to push this as far as I think both Democrats and Republicans would like for it to go. Is there anything in these bills that surprised you, that goes further than you expected or less far than expected?

Karlin-Smith: There’s been efforts to sort of delink PBM compensation from rebates. And in the past, when Congress has tried to look into doing this, it’s ended up being extremely costly to the government. And they figured out in this set of policies sort of how to do this without those costs, which is basically, they’re making sure that the PBMs don’t have this perverse incentive to make money off of higher-priced drugs. However, the health plans are still going to be able to do that. So it’s not clear how much of a benefit this will really be, because at this point, the health plans and the PBMs are essentially one and the same. They have the same ownership. But, you know, I do think there has been some kind of creativity and thoughtfulness on Congress’ part of, OK, how do we tackle this without also actually increasing how much the government spends? Because the government helps support a lot of the premiums in these health insurance programs.

Rovner: Yeah. So the government has quite a quite a financial stake in how this all turns out. All right. Well, we will definitely watch that space closely. Let us move on to abortion. In addition to it being markup season for bills like PBMs, it’s also appropriations season on Capitol Hill, with the Sept. 30 deadline looming for a completion of the 12 annual spending bills. Otherwise, large parts of the government shut down, which we have seen before in recent years. And even though Democrats and Republicans thought they had a spending detente with the approval earlier this spring of legislation to lift the nation’s debt ceiling, Republicans in the House have other ideas; they not only want to cut spending even further than the levels agreed to in the debt ceiling bill, but they want to add abortion and other social policy riders to a long list of spending bills, including not just the one for the Department of Health and Human Services but the one for the Food and Drug Administration, which is in the agriculture appropriations, for reasons I’ve never quite determined; the financial services bill, which includes funding for abortion in the federal health insurance plan for government workers; and the spending bill for Washington, D.C., which wants to use its own taxpayer money for abortion, and Congress has been making that illegal pretty much for decades. In addition to abortion bans, conservatives want riders to ban gender-affirming care and even bar the FDA from banning menthol cigarettes. So it’s not just abortion. It’s literally a long list of social issues. Now, this is nothing new. A half a dozen spending bills have carried a Hyde [Amendment] type of abortion ban language for decades, as neither Republicans nor Democrats have had the votes to either expand or take away the existing restrictions. On the other hand, these conservatives pushing all these new riders don’t seem to care if the government shuts down if these bills pass. And that’s something new, right?

Kenen: Over abortion it’s something new, but they haven’t cared. I mean, they’ve shut down the government before.

Rovner: That’s true. The last time was over Obamacare.

Kenen: Right. And, which, the great irony is the one thing they — when they shut down the government because Obamacare was mandatory, not just discretionary funding, Obamacare went ahead anyway. So, I mean, minor details, but I think this is probably going to be an annual battle from now on. It depends how hard they fight for how long. And with some of these very conservative, ultra-conservative lawmakers, we’ve seen them dig in on abortion, on other issues like the defense appointees. So I think it’s going to be a messy October.

Rovner: Yeah, I went back and pulled some of my old clips. In the early 1990s I used to literally keep a spreadsheet, and I think that’s before we had Excel, of which bill, which of the appropriations bills had abortion language and what the status was of the fights, because they were the same fights year after year after year. And as I said, they kind of reached a rapprochement at one point, or not even a rapprochement — neither side could move what was already there. At some point, they kind of stopped trying, although we have seen liberals the last few years try to make a run at the actual, the original Hyde Amendment that bans federal funding for most abortions — that’s in the HHS bill — and unsuccessfully. They have not had the votes to do that. Presumably, Republicans don’t have the votes now to get any of these — at least certainly not in the Senate — to get any of these new riders in. But as we point out, they could definitely keep the government closed for a while over it. I mean, in the Clinton administration, President [Bill] Clinton actually had to swallow a bunch of new riders because either it was that or keep the government closed. So that’s kind of how they’ve gotten in there, is that one side has sort of pushed the other to the brink. You know, everybody seems to assume at this point that we are cruising towards a shutdown on Oct. 1. Does anybody think that we’re not?

Kenen: I mean, I’m not on the Hill anymore, but I certainly expect a shutdown. I don’t know how long it lasts or how you resolve it. And I — even more certain we’ll have one next year, which, the same issues will be hot buttons five weeks before the elections. So whatever happens this year is likely to be even more intense next year, although, you know, next year’s far away and the news cycle’s about seven seconds. So, you know, I think this could be an annual fight and for some time to come, and some years will be more intense than others. And you can create a deal about something else. And, you know, the House moderates are — there are not many moderates — but they’re sort of more traditional conservatives. And there’s a split in the Republican Party in the House, and we don’t know who’s going to fold when, and we don’t — we haven’t had this kind of a showdown. So we don’t really know how long the House will hold out, because some of the more moderate lawmakers who are — they’re all up for reelection next year. I mean, some of them don’t agree. Some of are not as all or nothing on abortion as the —

Rovner: Well, there are what, a dozen and a half Republicans who are in districts that President Biden won who do not want to vote on any of these things and have made it fairly clear to their leadership that they do not want to vote on any of these things. But obviously the conservatives do.

Kenen: And they’ve been public about that. They’ve said it. I mean, we’re not guessing. Some of them spoke up and said, you know, leave it to the states. And that’s what the court decided. And they don’t want to nationalize this even further than it’s nationalized. And I think, you know, when you have the Freedom Caucus taking out Marjorie Taylor Greene, I mean, I have no idea what’s next.

Rovner: Yeah, things are odd. Well, I want to mention one more abortion story this week that I read in the newsletter “Abortion, Every Day,” by Jessica Valenti. And shoutout here: If you’re interested in this issue and you don’t subscribe, you’re missing out. I will include the link in the show notes. The story’s about Texas and the exam to become a board-certified obstetrician-gynecologist. The board that conducts the exam is based in Dallas and has been for decades, and Texas is traditionally where this test has been administered. During the pandemic, the exam was given virtually because nothing was really in person. But this year, if a doctor wants to become board-certified, he or she will have to travel to Texas this fall. And a lot of OB-GYNs don’t want to do that, for fairly obvious reasons, like they are afraid of getting arrested and sent to prison because of Texas’ extreme anti-abortion laws. And yikes, really, this does not seem to be an insignificant legal risk here for doctors who have been performing abortions in other states. This is quite the dilemma, isn’t it?

Karlin-Smith: Well, the other thing I thought was interesting about — read part of that piece — is just, she was pointing out that you might not just want to advertise in a state where a lot of people are anti-abortion that all of these people who perform abortions are all going to be at the same place at the same time. So it’s not just that they’re going to be in Texas. Like, if anybody wants to go after them, they know exactly where they are. So it can create, if nothing else, just like an opportunity for big demonstrations or interactions that might disrupt kind of the normal flow of the exam-taking.

Kenen: Or violence. Most people who are anti-abortion are obviously not violent, but we have seen political violence in this country before. And you just need one person, which, you know, we seem to have plenty of people who are willing to shoot at other people. I thought it was an excellent piece. I mean, I had not come across that before until you sent it around, and there’s a solution — you know, like, if you did it virtually before — and I wasn’t clear, or maybe I just didn’t pay attention: Was this certification or also recertification?

Rovner: No, this was just certification. Recertification’s separate. So these are these are young doctors who want to become board-certified for the first time.

Kenen: But the recertification issues will be similar. And this is a yearly — I mean, I don’t see why they just don’t give people the option of doing it virtual.

Rovner: But we’ll see if they back down. But you know, I had the same thought that Sarah did. It’s like, great, let’s advertise that everybody’s going to be in one place at one time, you know, taking this exam. Well, we’ll see how that one plays out. Well, finally this week, building on last week’s discussion on health and climate change and on drug shortages, a tornado in Rocky Mount, North Carolina, seriously damaged a giant Pfizer drug storage facility, potentially worsening several different drug shortages. Sarah, I remember when the hurricane in Puerto Rico seemed to light a fire under the FDA and the drug industry about the dangers of manufacturing being too centralized in one place. Now we have to worry about storage, too? Are we going to end up, like, burying everything underground in Fort Knox?

Karlin-Smith: I think there’s been a focus even since before [Hurricane] Maria, but that certainly brought up that there’s a lack of redundancy in U.S. medical supply chains and, really, global supply chains. It’s not so much that they need to be buried, you know, that we need bunkers. It’s just that — Pfizer had to revise the numbers, but I think the correct number was that that facility produces about 8% of the sterile kind of injectables used in the U.S. health system, 25% of all Pfizer’s — it’s more like each company or the different plants that produce these drugs, it needs to be done in more places so that if you have these severe weather events in one part of the country, there’s another facility that’s also producing these drugs or has storage. So I don’t know that these solutions need to be as extreme as you brought up. But I think the problem has been that when solutions to drug shortages have come up in Congress, they tend to focus on FDA authorities or things that kind of nibble around the edges of this issue, and no one’s ever really been able to address some of the underlying economic tensions here and the incentives that these companies have to invest in redundancy, invest in better manufacturing quality, and so forth. Because at the end of the day these are often some of the oldest and cheapest drugs we have, but they’re not necessarily actually the easiest to produce. While oftentimes we’re talking about very expensive, high-cost drugs here, this may be a case where we have to think about whether we’ve let the prices drop too low and that’s sort of keeping a market that works if everything’s going perfectly well but then leads to these shortages and other problems in health care.

Rovner: Yeah, the whole just-in-time supply chain. Well, before we leave this, Anna, since you’re our expert on this, particularly international manufacturing, I mean, has sort of what’s been happening domestically lit a fire under anybody who’s also worried about some of these, you know, overseas plants not living up to their safety requirements?

Edney: Well, I think there are these scary things happen like a tornado or hurricane and everybody is kind of suddenly paying attention. But I think that the decision-makers in the White House or on Capitol Hill have been paying attention a little bit longer. We’ve seen these cancer — I mean, for a long time not getting anything done, as Sarah mentioned — but recently, it’s sort of I think the initial spark there was these cancer drug shortages that, you know, people not being able to get their chemo. And that was from an overseas factory; that was from a factory in India that had a lot of issues, including shredding all of their quality testing documents and throwing them in a truck, trying to get it out of there before the FDA inspectors could even see it.

Kenen: That’s always very reassuring.

Edney: It is. Yeah. It makes you feel really good. And one bag did not make it out of the plant in time, so they just threw acid on it instead of letting FDA inspectors look at it. So it’s definitely building in this tornado. And what might come out of it if there are a lot of shortages, I haven’t seen huge concern yet from the FDA on that front. But I think that it’s something that just keeps happening. It’s not letting up. And, you know, my colleagues did a really good story yesterday. There’s a shortage of a certain type of penicillin you give to pregnant people who have syphilis. If you pass syphilis on to your baby, the baby can die or be born with a lot of issues — it’s not like if an adult gets syphilis — and they’re having to ration it, and adults aren’t getting treated fully for syphilis because the babies need it more so, and so this is like a steady march that just keeps going on. And there’s so many issues with the industry, sort of how it’s set up, what Sarah was talking about, that we haven’t seen anybody really be able to touch yet.

Rovner: We will continue to stay on top of it, even if nobody else does. Well, that is this week’s news. Now we will play my interview with KFF’s Céline Gounder, and then we will come back and do our extra credit. I am pleased to welcome back to the podcast Dr. Céline Gounder, KFF senior fellow and editor-at-large for public health, as well as an infectious disease specialist and epidemiologist in New York and elsewhere. Céline is here today to tell us about the second season of her podcast, “Epidemic,” which tells the story of the successful effort to eradicate smallpox and explores whether public health can accomplish such big things ever again. Céline, thank you for joining us.

Céline Gounder: It’s great to be here, Julie.

Rovner: So how did you learn about the last steps in the journey to end smallpox, and why did you think this was a story worth telling broadly now?

Gounder: Well, this is something I actually studied back when I was in college in the ’90s, and I did my senior thesis in college on polio eradication, and this was in the late ’90s, and we have yet to eradicate polio, which goes to show you how difficult it is to eradicate an infectious disease. And in the course of doing that research, I was an intern at the World Health Organization for a summer and then continued to do research on it during my senior year. I also learned a lot about smallpox eradication. I got to meet a lot of the old leaders of that effort, folks like D.A. Henderson and Ciro de Quadros. And fast-forward to the present day: I think coming out of covid we’re unfortunately not learning what at least I think are the lessons of that pandemic. And I think sometimes it’s easier to go back in time in history, and that helps to depoliticize things, when people’s emotions are not running as high about a particular topic. And my thought was to go back and look at smallpox: What are the lessons from that effort, a successful effort, and also to make sure to get that history while we still have some of those leaders with us today.

Rovner: Yes, you’re singing my song here. I noticed the first episode is called “The Goddess of Smallpox.” Is there really a goddess of smallpox?

Gounder: There is: Shitala Mata. And the point of this episode was really twofold. One was to communicate the importance of understanding local culture and beliefs, not to dismiss these as superstitions, but really as ways of adapting to what was, in this case, a very centuries-long reality of living with smallpox. And the way people thought about it was that in some ways it was a curse, but in some ways it was also a blessing. And understanding that dichotomy is also important, whether it’s with smallpox or other infectious diseases. It’s important to understand that when you’re trying to communicate about social and public health interventions.

Rovner: Yeah, because I think people don’t understand that public health is so unique to each place. I feel like in the last 50 years, even through HIV and other infectious diseases, the industrialized world still hasn’t learned very well how to deal with developing countries in terms of cultural sensitivity and the need for local trust. Why is this a lesson that governments keep having to relearn?

Gounder: Well, I would argue we don’t even do it well in our own country. And I think it’s because we think of health in terms of health care, not public health, in the United States. And that also implies a very biomedical approach to health issues. And I think the mindset here is very much, oh, well, once you have the biomedical tools — the vaccines, the diagnostics, the drugs — problem solved. And that’s not really solving the problem in a pandemic, where much of your challenge is really social and political and economic and cultural. And so if you don’t think about it in those terms, you’re really going to have a flat-footed response.

Rovner: So what should we have learned from the smallpox eradication effort that might have helped us deal with covid or might help us in the future deal with the next pandemic?

Gounder: Well, I think one side of this is really understanding what the local culture was, spending time with people in community to build trust. I think we came around to understanding it in part, in some ways, in some populations, in some geographies, but unfortunately, I think it was very much in the crisis and not necessarily a long-term concerted effort to do this. And that I think is concerning because we will face other epidemics and pandemics in the future. So, you know, how do you lose trust? How do you build trust? I think that’s a really key piece. Another big one is dreaming big. And Dr. Bill Foege — he was one of the leaders of smallpox eradication, went on to be the director of the CDC [Centers for Disease Control and Prevention] under President [Jimmy] Carter — one of the pieces of advice he’s given to me as a mentor over the years is you’ve got to be almost foolishly optimistic about getting things done, and don’t listen to the cynics and pessimists. Of course, you want to be pragmatic and understand what will or won’t work, but to take on such huge endeavors as eradicating smallpox, you do have to be very optimistic and remind yourself every day that this is something you can do if you put your mind to it.

Rovner: I noticed, at least in the first couple of episodes that I’ve listened to, the media doesn’t come out of this looking particularly good. You’re both a journalist and a medical expert. What advice do you have for journalists trying to cover big public health stories like this, like covid, like things that are really important in how you communicate this to the public?

Gounder: Well, I think one is try to be hyperlocal in at least some of your reporting. I think one mistake during the pandemic was having this very top-down perspective of “here is what the CDC says” or “here is what the FDA says” or whomever in D.C. is saying, and that doesn’t really resonate with people. They want to see their own experiences reflected in the reporting and they want to see people from their community, people they trust. And so I think that is something that we should do better at. And unfortunately, we’re also somewhat hampered in doing so because there’s been a real collapse of local journalism in most of the country. So it really does fall to places like KFF Health News, for example, to try to do some of that important reporting.

Rovner: We will all keep at it. Céline Gounder, thank you so much for joining us. You can find Season 2 of “Epidemic,” called “Eradicating Smallpox,” wherever you get your podcasts.

Gounder: Thanks, Julie.

Rovner: OK, we’re back. It’s time for our extra credit segment. That’s when we each recommend a story we read this week we think you should read too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Sarah, why don’t you go first this week?

Karlin-Smith: Sure. I took a look at a piece from Brenda Goodman at CNN called “They Took Blockbuster Drugs for Weight Loss and Diabetes. Now Their Stomachs Are Paralyzed,” and it’s a really good deep dive into — people probably have heard of Ozempic, Wegovy — these what are called GLP-1 drugs that have been used for diabetes. And we’ve realized in higher doses even for people without diabetes, they often are very helpful at losing weight, that that’s partially because they slow the passage of food through your stomach. And there are questions about whether for some people that is leading to stomach paralysis or other extreme side effects. And I think it’s a really interesting deep dive into the complicated world of figuring out, Is this caused by the drug? Is it caused by other conditions that people have? And then how should you counsel people about whether they should receive the drugs and the benefits outweighing the risks? So I think it’s like just a good thing for people to read when you sort of hear all this hype about a product and how great they must be, that it’s always a little bit more complicated than that. And it also brought up another aspect of it, which is how these drugs may impact people who are going to get surgery and anesthesia and just the importance of communicating this to your doctor so they know how to appropriately handle the drugs. Because if you still have food content in your stomach during a surgery, that can be extremely dangerous. And I thought just that aspect alone of this story is really interesting, because they talk about people maybe not wanting to even let their doctors know they’re on these drugs because of stigma surrounding weight loss. And just again, once you get a new medicine that might end up being taken by a lot of people, the complications or, you know, there’s the dynamics of how it impacts other parts of medicine, and we need to adjust.

Rovner: Yeah. And I think the other thing is, you know, we know these drugs are safe because people with diabetes have been taking them for, what, six or seven years. But inevitably, anytime you get a drug that lots more people take, then you start to see the outlier side effects, which, if it’s a lot of people, can affect a lot of people. Joanne.

Kenen: I have a piece from FERN, which is the Food & Environment Reporting Network and in partnership with Yale Environ 360, and it’s by Gabriel Popkin. And it’s called “Can Biden’s Climate-Smart Agriculture Program Live Up to the Hype?” And I knew nothing about smart agriculture, which is why I found this so interesting. So, this is an intersection of climate change and food, which is obviously also a factor in climate change. And there’s a lot of money from the Biden administration for farmers to use new techniques that are more green-friendly because as we all know, you know, beef and dairy, things that we thought were just good for us — maybe not beef so much — but, like, they’re really not so good for the planet we live on. So can you do things like, instead of using fertilizer, plant cover crops in the offseason? I mean, there’s a whole list of things that — none of us are farmers, but there’s also questions about are they going to work? Is it greenwashing? Is it stuff that will work but not in the time frame that this program is funding? How much of it’s going to go to big agribusiness, and how much of it is going to go to small farmers? So it’s one hand, it’s another. You know, there’s a lot of low-tech practices. We’re going to have to do absolutely everything we can on climate. We’re going to have to use a variety of — you know, very large toolkit. So it was interesting to me reading about these things that you can do that make agriculture, you know, still grow our food without hurting the planet, but also a lot of questions about, you know, is this really a solution or not? But, you know, I didn’t know anything about it. So it was a very interesting read.

Rovner: And boy, you think the drug companies are influential on Capitol Hill. Try going with big agriculture. Anna.

Edney: I’m going to toot my own horn for a second here —

Rovner: Please.

Edney: — and do one of my mini-investigations that I did, “Mineral Sunscreens Have Potential Hidden Dangers, Too.” So there’s been a lot of talk: Use mineral sunscreen to save the environment or, you know, for your own health potentially. But they’re white, they’re very thick. And, you know, people don’t want to look quite that ghostly. So what’s been happening lately is they’ve been getting better. But what I found out is a lot of that is due to a chemical — that is what people are trying to move away from, is chemical sunscreens — but the sunscreen-makers are using this chemical called butyloctyl salicylate. And you can read the article for kind of the issues with it. I guess the main one I would point out is, you know, I talked to the Environmental Working Group because they do these verifications of sunscreens based on their look at how good are they for your health, and a couple of their mineral ones had this ingredient in it. So when I asked them about it, they said, Oh, whoops; like, we do actually need to revisit this because it is a chemical that is not recommended for children under 4 to be using on their bodies. So there’s other issues with it, too — just the question of whether you’re really being reef-safe if it’s in there, and other things as well.

Rovner: It is hard to be safe and be good to the planet. My story this week is by Amy Littlefield of The Nation magazine, and it’s called “The Anti-Abortion Movement Gets a Dose of Post-Roe Reality.” It’s about her visit to the annual conference of the National Right to Life Committee, which for decades was the nation’s leading anti-abortion organization, although it’s been eclipsed by some others more recently. The story includes a couple of eye-opening observations, including that the anti-abortion movement is surprised that all those bans didn’t actually reduce the number of abortions by very much. As we know, women who are looking for abortions normally will find a way to get them, either in state or out of state or underground or whatever. And we also learned in this story that some in the movement are willing to allow rape and incest exceptions in abortion bills, which they have traditionally opposed, because they want to use those as sweeteners for bills that would make it easier to enforce bans, stronger bans, things like the idea in Texas of allowing individual citizens to use civil lawsuits and forbidding local prosecutors from declining to prosecute abortion cases. We’re seeing that in some sort of blue cities in red states. It’s a really interesting read and I really recommend it. OK. That is our show for this week. As always, if you enjoyed the podcast, you can subscribe where ever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks, as always, to our producer, Francis Ying. Also as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can tweet me. I’m @jrovner, and I’m on Bluesky and Threads. Joanne.

Kenen: @joannekenen1 at Threads.

Rovner: Sarah.

Karlin-Smith: I’m @SarahKarlin or @sarah.karlinsmith, depending on which of these many social media platforms you’re looking at, though.

Rovner: Anna.

Edney: @annaedney on Twitter and @anna_edneyreports on Threads.

Rovner: You can always find us here next week where we will always be in your podcast feed. Until then, be healthy.

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]]> Covered California reducirá los costos de los pacientes cuando los demócratas obtengan fondos de Newsom https://kffhealthnews.org/news/article/covered-california-reducira-los-costos-de-los-pacientes-cuando-los-democratas-obtengan-fondos-de-newsom/ Thu, 27 Jul 2023 18:17:00 +0000 https://kffhealthnews.org/?post_type=article&p=1730177 SACRAMENTO, CA – Semanas después de que los legisladores demócratas obligaron al gobernador Gavin Newsom a cumplir una promesa de cuatro años para utilizar las multas fiscales de los no asegurados para aumentar los subsidios de salud de los californianos de bajos y medianos ingresos, los funcionarios de Covered California anunciaron que canalizarán ese dinero en la reducción de los gastos de bolsillo para muchos afiliados con problemas para pagar.

La bolsa de seguros médicos del estado eliminará los deducibles hospitalarios de algunos pacientes, hasta un máximo de $5,400; reducirá el copago de las visitas de atención primaria de $50 a $35; y reducirá el costo de los medicamentos genéricos de $19 a $15. Algunos afiliados también verán limitado su gasto de bolsillo anual a $6,100 en lugar de $7,500.

La CEO de Covered California, Jessica Altman, argumenta que se trata de reducciones tangibles —ahorros en deducibles y copagos además de subsidios para reducir las primas mensuales— que afectarán a cientos de miles de personas y les animará a utilizar la cobertura.

“Los deducibles evitan que las personas busquen atención médica, por lo que es un objetivo importante”, dijo Altman a California Healthline. “California busca lo asequible y se pregunta: ‘¿Qué significa realmente asequibilidad? Muchas personas simplemente no tienen $5,000 en su cuenta bancaria en caso de que lo necesiten para la atención médica”.

Las reducciones adicionales en los gastos de bolsillo de los pacientes —además de los subsidios federales de seguros de salud existentes para reducir las primas mensuales— entrarán en vigor en enero para las personas que renueven o adquieran cobertura durante el próximo período de inscripción de Covered California, que comienza en otoño. El estado podría ir más lejos en ayudar a reducir los costos de los pacientes en los próximos años con futuros aumentos presupuestarios, señaló Altman.

Aun así, esos ahorros pueden verse neutralizados por costos más altos en otros lugares. Covered California anunció, el 25 de julio, que la inflación y otros factores elevarán las tarifas anuales de las primas de los planes de salud participantes en un promedio de casi el 10% el próximo año, el mayor aumento desde 2018.

California comenzó a multar a aquellos sin cobertura de salud en el año fiscal 2020, estableciendo su propio “mandato individual”. En ese primer año, el estado recaudó $403 millones en ingresos por multas, según la Franchise Tax Board estatal. Ha continuado imponiendo multas, pagadas en gran parte por personas con ingresos bajos o medios, las mismas personas a las que se pretende ayudar con los nuevos subsidios.

Los líderes legislativos habían presionado a Newsom, también demócrata, para que canalizara los ingresos fiscales hacia la reducción de los costos de la atención sanitaria para las personas de ingresos bajos y medios que adquieren cobertura a través de Covered California, muchas de las cuales informaron de que habían dejado de recibir atención médica o la habían retrasado debido a los elevados gastos de bolsillo.

El gobernador se resistió durante años a las peticiones de destinar el dinero de las multas a los subsidios de Covered California, argumentando que el estado no podía permitírselo y que necesitaba el dinero ante la inminente recesión económica y la posible pérdida de los subsidios federales a las primas, que podrían verse amenazados por un cambio en el liderazgo federal.

Sin embargo, ante las continuas presiones, Newsom cedió en junio y aceptó empezar a destinar parte del dinero a aumentar las subvenciones estatales. Según el Departamento de Finanzas del estado, se espera que California destine $83 millones el próximo año y $165 millones anuales en los años siguientes para ampliar la ayuda financiera —aproximadamente la mitad de los ingresos que recauda anualmente— a reducir los costos de los pacientes de Covered California. El resto del dinero se reservará en un fondo especial de asistencia sanitaria al que se podrá recurrir más adelante.

El acuerdo presupuestario también permite a la administración Newsom a pedir prestado hasta $600 millones en ingresos por multas para el fondo general del estado, que debe devolver. Los ingresos por multas se proyecta que traerá $362 millones este año con un adicional de $366 millones previstos el próximo año, según el portavoz del Departamento de Finanzas H. D. Palmer.

Los miembros del consejo de Covered California aprobaron el nuevo diseño del plan la semana pasada. Dicen que los subsidios de costos compartidos reducirá el gasto de bolsillo de casi 700,000 personas de aproximadamente 1,6 millones de inscritos en Covered California.

El aumento de la financiación, que representa el esfuerzo más importante del Estado para reducir los costos de los pacientes en Covered California, beneficiará en gran medida a los californianos de bajos ingresos que ganan por debajo del 250% del nivel federal de pobreza, que es de $33,975 para un individuo y $69,375 para una familia de cuatro en 2023, según el intercambio.

“La reducción de los deducibles es una gran ayuda para las familias de clase media de California que luchan contra el aumento del costo de la vida”, dijo el Presidente Pro Tempore del Senado, Toni Atkins, que se unió a sus compañeros demócratas para bloquear un plan de Newsom y su administración que mantendría los ingresos en el fondo general del Estado, aunque pueden ser utilizados para cualquier propósito.

Atkins añadió: “Seguiremos trabajando para reducir aún más los costos en los próximos años”.

El portavoz de Newsom, Brandon Richards, defendió la trayectoria del gobernador en materia de salud, afirmando que Newsom se ha comprometido a garantizar que los californianos puedan acceder a la asistencia sanitaria. Además de impulsar la asistencia en Covered California, dijo Richards, el gobernador ha ampliado la cobertura del seguro de salud pública a los inmigrantes que carecen de estatus legal y está aumentando la cantidad de médicos, hospitales y otros proveedores a los que se les paga para ver a los pacientes de Medicaid.

Originalmente requerido por la Ley de Cuidado de Salud a Bajo Precio (ACA), el llamado mandato individual de tener cobertura de salud o pagar una multa fiscal fue desmantelado por los republicanos en 2017, eliminando la multa a nivel nacional. Newsom lo restableció para California cuando asumió el cargo en 2019, un componente clave de su ambiciosa plataforma de atención médica.

California es uno de al menos cinco estados, junto con Massachusetts, Nueva Jersey, Rhode Island y Vermont, así como el Distrito de Columbia, que tiene su propio mandato de cobertura de salud, aunque no todos imponen una multa fiscal por permanecer sin seguro. De todos ellos, California es el estado que más intenta reducir los costos sanitarios para lograr la cobertura universal, según Larry Levitt, vicepresidente ejecutivo de política sanitaria de KFF.

“Aunque no estén de acuerdo en todo lo que implica la reforma sanitaria y el pagador único, los demócratas de California han conseguido unirse y unificarse en torno a estos pasos incrementales para mejorar el sistema actual”, señaló Levitt. “Paso a paso, han ido colocando las piezas para acercarse lo más posible a la cobertura universal”.

Los líderes demócratas en el estado se han enfrentado a críticas políticas por no utilizar los ingresos de la multa para la atención de la salud, detalles reportados por primera vez por California Healthline, a pesar de que Newsom y otros demócratas se comprometieron a gastar el dinero para hacer más asequible la atención de la salud en Covered California.

Para los activistas, el acuerdo representa una victoria para las personas de bajos y medianos ingresos.

“Nos gusta que este dinero esté protegido para la atención de la salud, y que en última instancia se reserve para la futura asistencia”, dijo Diana Douglas, del grupo de defensa del consumidor Health Access California.

Los activistas quieren que el estado aproveche ese dinero para dar cobertura a más personas, por ejemplo, reduciendo los costos sanitarios de los inmigrantes que viven en el estado sin permiso legal.

Un proyecto de ley presentado este año por el miembro de la Asamblea Joaquín Arambula, demócrata de Fresno, exigiría a Covered California establecer un mercado de seguros de salud separado para que los inmigrantes que carecen de estatus legal y ganan demasiado para calificar a Medi-Cal, la versión californiana de Medicaid, puedan comprar una cobertura integral que sea casi idéntica a los planes vendidos en Covered California. En la actualidad, los inmigrantes sin residencia legal no pueden acceder al mercado de seguros. Otros estados, como Washington y Colorado, han creado mercados en línea similares.

“Estamos trabajando para crear un sistema que ofrezca los mismos beneficios y asistencia asequible para todos”, señaló Arámbula.

Esta historia fue producida por KFF Health News, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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]]> Covered California to Cut Patient Costs After Democratic Lawmakers Win Funding From Gov. Newsom https://kffhealthnews.org/news/article/covered-california-patient-costs-lawmakers-win-funding-newsom/ Thu, 27 Jul 2023 09:00:00 +0000 https://kffhealthnews.org/?p=1723699&post_type=article&preview_id=1723699 SACRAMENTO, Calif. — Weeks after Democratic lawmakers forced Gov. Gavin Newsom to make good on a four-year-old pledge to use tax penalty proceeds from fining the uninsured to increase health insurance subsidies for low- and middle-income Californians, Covered California officials announced they will funnel that money into reducing out-of-pocket spending for many enrollees struggling with the cost of care.

The state’s health insurance exchange will zero out some patients’ hospital deductibles, up to $5,400; lower the copay of primary care visits from $50 to $35; and reduce the cost for generic drugs from $19 to $15. Some enrollees will also see their annual out-of-pocket spending capped at $6,100, down from $7,500.

Covered California CEO Jessica Altman argues these are tangible reductions — savings on deductibles and copays on top of subsidies to lower monthly premiums — that will affect hundreds of thousands of people and entice them to use their coverage.

“Deductibles uniquely detract people from seeking care, so that’s a significant focus,” Altman told KFF Health News. “California is really grappling with affordability and thinking about, ‘What does affordability really mean?’ Many people simply do not have $5,000 sitting in their bank account in case they need it for health care.”

Additional reductions in patients’ out-of-pocket costs — on top of existing federal health insurance subsidies to reduce monthly premiums — will take effect in January for people renewing or purchasing coverage during Covered California’s next enrollment period, which begins in the fall. The state could go further in helping reduce patients’ costs in subsequent years with future budget increases, Altman said.

Still, those savings may be offset by higher costs elsewhere. Covered California announced July 25 that inflation and other factors are driving up annual premium rates on participating health plans by an average of nearly 10% next year, the largest average increase since 2018.

California started fining those without health coverage in the tax year 2020, establishing its own “individual mandate.” In that first year, the state raised $403 million in penalty revenue, according to the state Franchise Tax Board. It has continued to levy fines, paid for largely by low- or middle-income earners, the very people the new subsidies are intended to help.

Legislative leaders had pushed Newsom, a fellow Democrat, to funnel the tax revenue into lowering health care costs for low- and middle-income people purchasing coverage via Covered California — many of whom reported skipping or delaying care due to high out-of-pocket costs.

The governor for years resisted pleas to put penalty money into Covered California subsidies, arguing that the state couldn’t afford it and needed the money given looming economic downturns and the potential loss of federal premium subsidies — which could be threatened by a change in federal leadership.

But under ongoing pressure, Newsom relented in June and agreed to begin spending some of the money to boost state subsidies. According to the state Department of Finance, California is expected to plow $83 million next year and $165 million annually in subsequent years to expand financial assistance — roughly half the revenue it raises annually — into reducing Covered California patients’ costs. The remainder of the money will be set aside in a special health care fund that could be tapped later.

The budget deal also allows the Newsom administration to borrow up to $600 million in penalty revenue for the state general fund, which it must pay back. Penalty revenues are projected to bring in $362 million this year with an additional $366 million projected next year, according to Finance Department spokesperson H.D. Palmer.

Covered California board members approved the new plan design last week. They say the cost-sharing subsidies will lower out-of-pocket spending for nearly 700,000 people out of roughly 1.6 million enrolled in Covered California.

The boost in funding, which represents the state’s most significant effort to slash patients’ costs in Covered California, will largely benefit lower-income Californians who earn below 250% of the federal poverty level, which is $33,975 for an individual and $69,375 for a family of four for 2023, according to the exchange.

“Bringing down deductibles goes a long way to help middle-class California families struggling with increasing costs of living,” said Senate President Pro Tempore Toni Atkins, who rallied fellow Democrats to block a plan by Newsom and his administration to keep the revenue for the state general fund, which can be used for any purpose.

Atkins added, “We will continue our work to lower the costs even more in the years to come.”

Newsom spokesperson Brandon Richards defended the governor’s health care record, saying Newsom is committed to ensuring Californians can access health care. In addition to boosting assistance in Covered California, Richards said, the governor has expanded public health insurance coverage to immigrants lacking legal status and is increasing how much doctors, hospitals, and other providers get paid to see Medicaid patients.

Originally required by the federal Affordable Care Act, the so-called individual mandate to hold health coverage or pay a tax penalty was gutted by Republicans in 2017, eliminating the fine nationally. Newsom reinstated it for California when he took office in 2019 — a key component of his ambitious health care platform.

California is one of at least five states, along with Massachusetts, New Jersey, Rhode Island, and Vermont, as well as the District of Columbia that have their own health coverage mandate, though not all levy a tax penalty for remaining uninsured. Among them, California is most aggressively trying to lower health care costs and achieve universal coverage, said Larry Levitt, executive vice president for health policy at KFF.

“Even though they may disagree on the big picture of health care reform and single-payer, California Democrats have managed to come together and unify around these incremental steps to improve the current system,” Levitt said. “Step by step, they have put in place the pieces to get as close to universal coverage as they possibly can.”

Democratic leaders in the state have faced political blowback for not using the penalty revenue for health care, details first reported by KFF Health News, even though Newsom and other Democrats vowed to spend the money to make health care more affordable in Covered California.

Advocates say the deal represents a win for low- and middle-income people.

“We’re excited that this money is protected for health care, and ultimately is set aside for future affordability assistance,” said Diana Douglas, chief lobbyist with the consumer advocacy group Health Access California.

Advocates want the state to tap those health care dollars to get more people covered, such as lowering health care costs for immigrants living in the state without legal permission.

A bill this year by Assembly member Joaquin Arambula, a Fresno Democrat, would require Covered California to establish a separate health insurance marketplace so that immigrants who lack legal status and earn too much to qualify for Medi-Cal, California’s version of Medicaid, can purchase comprehensive coverage that is nearly identical to plans sold on Covered California. Currently, immigrants without legal residency are not allowed on the exchange. Other states, such as Washington and Colorado, have set up similar online marketplaces.

“We’re working hard to create a system that has equal benefits and affordability assistance for everyone,” Arambula said.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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]]> New Weight Loss Drugs Carry High Price Tags and Lots of Questions for Seniors https://kffhealthnews.org/news/article/weight-loss-drugs-seniors-medicare-diabetes/ Tue, 25 Jul 2023 09:00:00 +0000 https://kffhealthnews.org/?post_type=article&p=1717516 Corlee Morris has dieted throughout her adult life.

After her weight began climbing in high school, she spent years losing 50 or 100 pounds then gaining it back. Morris, 78, was at her heaviest in her mid-40s, standing 5 feet 10½ inches and weighing 310 pounds. The Pittsburgh resident has had diabetes for more than 40 years.

Managing her weight was a losing battle until Morris’ doctor prescribed a Type 2 diabetes medication, Ozempic, four months ago. It’s one in a new category of medications changing how ordinary people as well as medical experts think about obesity, a condition that affects nearly 4 in 10 people 60 and older.

The drugs include Ozempic’s sister medication, Wegovy, a weight loss drug with identical ingredients, which the FDA approved in 2021, and Mounjaro, approved as a diabetes treatment in 2022. (Ozempic was approved for diabetes in 2017.) Several other drugs are in development.

The medications reduce feelings of hunger, generate a sensation of fullness, and have been shown to help people lose an average of 15% or more of their weight.

“It takes your appetite right away. I wasn’t hungry at all and I lost weight like mad,” said Morris, who has shed 40 pounds.

But how these medications will affect older adults in the long run isn’t well understood. (Patients need to remain on the drugs permanently or risk regaining the weight they’ve lost.)

Will they help prevent cardiovascular disease and other chronic illnesses in obese older adults? Will they reduce rates of disability and improve people’s ability to move and manage daily tasks? Will they enhance people’s lives and alleviate symptoms associated with obesity-related chronic illnesses?

Unfortunately, clinical trials of the medications haven’t included significant numbers of people ages 65 and older, leaving gaps in the available data.

While the drugs appear to be safe — the most common side effects are nausea, diarrhea, vomiting, constipation, and stomach pain — “they’ve only been on the market for a few years and caution is still needed,” said Mitchell Lazar, founding director of the Institute for Diabetes, Obesity and Metabolism at the University of Pennsylvania Perelman School of Medicine.

Given these uncertainties, how are experts approaching the use of the new obesity medications in older people? As might be expected, opinions and practices vary. But several themes emerged in nearly two dozen interviews.

The first was frustration with limited access to the drugs. Because Medicare doesn’t cover weight loss medications and they can cost more than $10,000 a year, seniors’ ability to get the new drugs is restricted.

There is an exception: Medicare will cover Ozempic and Mounjaro if an older adult has diabetes, because the insurance program pays for diabetes therapies.

“We need Medicare to cover these drugs,” said Shauna Matilda Assadzandi, a geriatrician at the University of Pittsburgh who cares for Morris. Recently, she said, she tried to persuade a Medicare Advantage plan representative to authorize Wegovy for a patient with high blood pressure and cholesterol who was gaining weight rapidly.

“I’m just waiting for this patient’s blood sugar to rise to a level where diabetes can be diagnosed. Wouldn’t it make sense to intervene now?” she remembered saying. The representative’s answer: “No. We have to follow the rules.”

Seeking to change that, a bipartisan group of lawmakers has reintroduced the Treat and Reduce Obesity Act, which would require Medicare to cover weight loss drugs. But the proposal, which had been considered previously, has languished amid concerns over enormous potential costs for Medicare.

If all beneficiaries with an obesity diagnosis took brand-name semaglutide drugs (the new class of medications), annual costs would top $13.5 billion, according to a recent analysis in The New England Journal of Medicine. If all older obese adults on Medicare — a significantly larger population — took them, the cost would exceed the total spent on Medicare’s Part D drug program, which was $145 billion in 2019.

Laurie Rich, 63, of Canton, Massachusetts, was caught off guard by Medicare’s policies, which have applied to her since she qualified for Social Security Disability Insurance in December. Before that, Rich took Wegovy and another weight loss medication — both covered by private insurance — and she’d lost nearly 42 pounds. Now, Rich can’t get Wegovy and she’s regained 14 pounds.

“I haven’t changed my eating. The only thing that’s different is that some signal in my brain is telling me I’m hungry all the time,” Rich told me. “I feel horrible.” She knows that if she gains more weight, her care will cost much more.

While acknowledging difficult policy decisions that lie ahead, experts voiced considerable agreement on which older adults should take these drugs.

Generally, the medications are recommended for people with a body mass index over 30 (the World Health Organization’s definition of obesity) and those with a BMI of 27 or above and at least one obesity-related condition, such as diabetes, high blood pressure, or high cholesterol. There are no guidelines for their use in people 65 and older. (BMI is calculated based on a person’s weight and height.)

But those recommendations are problematic because BMI can under- or overestimate older adults’ body fat, the most problematic feature of obesity, noted Rodolfo Galindo, director of the Comprehensive Diabetes Center at the University of Miami Health System.

Dennis Kerrigan, director of weight management at Henry Ford Health in Michigan, a system with five hospitals, suggests physicians also examine waist circumference in older patients because abdominal fat puts them at higher risk than fat carried in the hips or buttocks. (For men, a waist over 40 inches is of concern; for women, 35 is the threshold.)

Fatima Stanford, an obesity medicine scientist at Massachusetts General Hospital, said the new drugs are “best suited for older patients who have clinical evidence of obesity,” such as elevated cholesterol or blood sugar, and people with serious obesity-related conditions such as osteoarthritis or heart disease.

Since going on Mounjaro three months ago, Muriel Branch, 73, of Perryville, Arkansas, has lost 40 pounds and stopped taking three medications as her health has improved. “I feel real good about myself,” she told me.

When adults with obesity lose weight, their risk of dying is reduced by up to 15%, according to Dinesh Edem, Branch’s doctor and the director of the medical weight management program at the University of Arkansas for Medical Sciences.

Still, weight loss alone should not be recommended to older adults, because it entails the loss of muscle mass as well as fat, experts agree. And with aging, the shrinkage of muscle mass that starts earlier in life accelerates, contributing to falls, weakness, the loss of functioning, and the onset of frailty.

Between ages 60 and 70, about 12% of muscle mass falls away, researchers estimate; after 80, it reaches 30%.

To preserve muscle mass, seniors losing weight should be prescribed physical activity — both aerobic exercise and strength training, experts agree.

Also, as older adults taking weight loss drugs eat less, “it’s critically important that their diet includes adequate protein and calcium to preserve bone and muscle mass,” said Anne Newman, director of the Center for Aging and Population Health at the University of Pittsburgh.

Ongoing monitoring of older adults having gastrointestinal side effects is needed to ensure they’re getting enough food and water, said Jamy Ard, co-director of Wake Forest Baptist Health’s Weight Management Center.

Generally, the goal for older adults should be to lose 1 to 2 pounds a week, with attention to diet and exercise accompanying medication management.

“My concern is, once we put patients on these obesity drugs, are we supporting lifestyle changes that will maintain their health? Medication alone won’t be sufficient; we will still need to address behaviors,” said Sukhpreet Singh, system medical director at Henry Ford’s weight management program.

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care, and advice you need in dealing with the health care system. Visit kffhealthnews.org/columnists to submit your requests or tips.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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]]> Everything Old Is New Again? The Latest Round of Health Policy Proposals Reprises Existing Ideas https://kffhealthnews.org/news/article/everything-old-is-new-again-the-latest-round-of-health-policy-proposals-reprises-existing-ideas/ Mon, 24 Jul 2023 09:00:00 +0000 https://kffhealthnews.org/?post_type=article&p=1720135 Forget “repeal and replace,” an oft-repeated Republican rallying cry against the Affordable Care Act.

House Republicans have advanced a package of bills that could reduce health insurance costs for certain businesses and consumers, partly by rolling back some consumer protections. Rather than outright repeal, however, the subtler effort could allow more employers to bypass the landmark health insurance overhaul’s basic benefits requirements and most state standards.

At the same time, the Biden administration seeks to undo some of the previous administration’s health insurance rules, proposing to retighten regulations for short-term plans.

Health policy experts aren’t surprised. Most of the GOP policy ideas have long drawn Republican support, have raised concern from Democrats about reduced consumer protections, and could fall under the theme: Everything old is new again.

Association Health Plans. Self-insurance. Giving workers money to buy their own individual coverage instead of offering a group plan. These are the buzzwords and, ultimately, revolve around one issue, said Joseph Antos, a senior fellow at the American Enterprise Institute, a Washington, D.C.-based think tank. “The real problem is the rising cost of health care. Always has been,” he said. And that problem, he added, is larger than the proposed solutions.

“It’s not clear that this kind of an approach would substantially help very many people,” Antos said.

The latest round of rules and legislation comes as the ACA — passed in 2010 — is now cemented in the system. More than 16 million people enrolled in their own plans this year, and millions more are getting coverage through expanded Medicaid in all but 10 states, leading to an all-time-low uninsured rate.

But even with enhanced subsidies for ACA health plans, initially approved in the American Rescue Plan and extended through 2025 by the Inflation Reduction Act, some people still struggle to afford deductibles or other costs, and employers — especially small ones — have long wrestled with rising insurance costs and the ability to offer coverage at all.

So, what is on the table in Washington? First, a caveat: Little is likely to happen in an election year.

While the Biden administration’s proposed regulations on short-term plans are likely to go into effect, either this year or early next, the GOP’s House-passed legislation — dubbed the CHOICE Arrangement Act, for Custom Health Option and Individual Care Expense — is unlikely to win favor in the Democratic-controlled Senate. If Republicans were to retake the Senate and White House, though, it illustrates the health policy direction they could take.

Here are the broad issues on the radar:

From the President’s Desk: Limits on Short-Term Policies

These types of plans have been sold for decades, often as a stopgap measure for people between jobs.

They can be far less expensive than more traditional coverage because short-term plans vary widely and “run the gamut from comprehensive policies to fairly minimal policies,” said Louise Norris, an insurance broker who regularly writes about health policy.

The plans don’t have to cover all the benefits required of ACA plans, for example, and can bar coverage for preexisting medical conditions, can set annual or lifetime limits, and often don’t include maternity care or prescription drugs. Despite notices warning of such policies’ limitations, consumers may not realize what isn’t covered until they try to use the plan.

Concerned that people would choose this option instead of more comprehensive and more expensive insurance offered through the ACA, President Barack Obama’s administration set rules limiting the policy terms to three months.

President Donald Trump’s administration loosened those rules, allowing plans to again be sold as 364-day policies, and adding the ability for insurers to renew them for up to three years. Now President Joe Biden, whose representatives have called such plans “junk insurance,” proposes reining those in again, restricting policies to four months, at most.

The Biden proposal cites estimates from the Congressional Budget Office and the Joint Committee on Taxation that about 1.5 million people are enrolled in such plans.

Michael Cannon, director of health policy studies at the Cato Institute, a Washington, D.C.-based libertarian think tank, decried the proposed rule in an opinion piece published by The Hill. He wrote that the Biden proposal removes an important lower-cost alternative and could leave some consumers facing “sky-high medical bills for up to one year” if their policies expire between open enrollment periods for ACA plans.

The real fight comes down to defining “short-term,” said John McDonough, a professor of public health practice at the Harvard T.H. Chan School of Public Health in Boston, who worked on the original ACA legislation.

Progressives and Democrats support the view that “short-term” should end after four months and “then people go into an ACA plan or Medicaid,” he said. “Republicans and conservatives would like this to be an alternative permanent coverage model for folks, some of whom legitimately know what they are getting and are willing to roll the dice.”

Association Health Plans, Self-Insurance, and Other Workplace Issues

Meanwhile, the House-passed CHOICE Arrangement Act, among other things, would allow more self-employed people and businesses to band together to buy Association Health Plans, which are essentially large group plans purchased by multiple employers.

These can be less expensive because they don’t have to meet all ACA requirements, such as covering a specified set of benefits that includes hospitalization, prescription drugs, and mental health care. Historically, some also have had solvency issues and state regulators have investigated claims of false advertising by certain association plans.

Another piece of the legislation would help more small employers self-insure, which also allows them to bypass many ACA requirements and most state insurance rules.

Both proposals represent a “chipping away at the foundation edges of the ACA structure,” said McDonough.

The package also codifies Trump-era regulations allowing employers to provide workers with tax-free contributions to shop for their own insurance, so long as it is an ACA-qualified plan, a benefit known as an individual coverage Health Reimbursement Account.

The CHOICE Arrangement Act “will go a long way toward reducing insurance costs for employers, ensuring that workers continue to have access to high-quality, affordable health care,” said Rep. Tom Cole (R-Okla.) in prepared remarks as the bill went before the House Committee on Rules in June.

Giving workers a set amount of money to buy their own coverage allows employees to choose what works best for them, supporters say. Critics warn that many workers may be unprepared to shop and that the effort by some employers might prove discriminatory.

”Firms may find strategies to shift sicker workers to HRAs, even with guardrails in the legislation meant to prevent this,” according to a blog post from the Center on Budget and Policy Priorities.

Not so, said Robin Paoli, executive director of the HRA Council, a nonprofit advocacy organization whose members include insurers, employers, and other organizations that support such individual accounts.

Employers have some discretion in choosing which groups of employees are offered such accounts, often based on geography, but cannot create a group made up solely of “people over 65, or a class of sick people,” said Paoli. “The rules absolutely prohibit discrimination based on age or health condition.”

The other two ideas — associations and the self-insured proposal — have drawn opposition from the National Association of Insurance Commissioners, which wrote to House leaders that the package “threatens the authority of states to protect consumers and markets” because it affects the ability of states to regulate such plans.

Current law allows businesses in the same industry to band together to buy coverage, essentially creating a larger pool that then can, theoretically, wield more negotiating clout and get better rates.

The House legislation would make changes to allow more self-employed people and businesses that aren’t in the same industry to do the same.

Some policy experts said expanding access to association plans and self-insurance to smaller businesses might adversely affect some workers by drawing healthier people out of the overall market for small-group insurance and potentially raising premiums for those who remain.

“The big picture of what these bills do is allow [employers and] insurance companies to get out from under the ACA standards and protections and offer cheaper insurance to younger and healthier employee groups,” said Sabrina Corlette, a researcher and the co-director of the Center on Health Insurance Reforms at Georgetown University.

But attorney Christopher Condeluci, who worked with GOP lawmakers in drafting the legislation, takes a different view. The entire GOP package, he said, represents “improvements to the status quo” that are needed because small businesses and individuals are confronting “health costs continuing to rise” and “out-of-pocket costs continuing to increase.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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]]> Journalists Discuss Abortion Lawsuits and the Pros and Cons of Health Care Sharing Plans https://kffhealthnews.org/news/article/on-the-air-this-week-07-22-2023/ Sat, 22 Jul 2023 09:00:00 +0000 https://kffhealthnews.org/?p=1718888&post_type=article&preview_id=1718888

KFF Health News senior correspondent Sarah Varney discussed the lawsuit to block the “abortion trafficking” law in Idaho on KUOW’s “Soundside” on July 13.

And on PBS NewsHour on July 20, Varney discussed a lawsuit filed by women in Texas claiming the state’s abortion restrictions put their lives in jeopardy.

KFF Health News senior Colorado correspondent Markian Hawryluk discussed health care sharing plans on “PBS News Weekend” on July 9.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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This story can be republished for free (details).

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