"How much is the ice cream?" A simple enough question, featured on a new TV and online advertisement, posed by a man who just wants something cold. A woman behind the counter responds with a smile: "Prices? No, we don't have those anymore. We have estimates."
The satirical ad pretends to be a news report highlighting a "trend" in which more retail outlets take up "the hospital pricing method": substituting estimates for actual prices for the cost of meals, merchandise on store shelves, and clothing. The scene ends with a partially deleted expletive from the ice cream-seeking man.
While the use of estimates in retail settings is imaginary and preposterous, the advertisement is part of an ongoing campaign by the advocacy group Patient Rights Advocate, which contends that some hospitals are still falling short of a law that went into effect in 2021 requiring them to publicly post their prices. Even then, said Cynthia Fisher, the group's founder and chairperson, too many post estimates rather than exact dollar-and-cent figures.
"People need price certainty," said Fisher. "Estimates are a way of gaming the people who pay for health care."
Although government data shows that hospitals' compliance with price transparency rules has improved, updating the requirements of that law is the focus of a new proposal by the Biden administration, which aims to further standardize the required data, increase its usefulness for consumers, and boost enforcement. Even with all that, however, the goal of exact price tags in every situation is likely to remain elusive.
"We're closer to that, but we're not there," said Gerard Anderson, a professor at the Johns Hopkins Bloomberg School of Public Health, who studies hospital pricing using the data that hospitals have already posted.
The proposed rule is designed to make it easier for consumers to learn in advance exactly what they might owe for nonemergency hospital care — though that was what the original price transparency rules were supposed to do.
Requiring hospitals to post their prices is part of a larger effort to make medical costs less opaque, which could help individual consumers predict their expenses and possibly slow health cost inflation, if it leads employers and insurers to contract with less expensive providers.
But the data files themselves are massive, often hard to find, and complex to decipher.
"Even for us, it's really hard to use," said Anderson.
Under current regulations, hospitals must publicly post prices for every service they offer, from drugs to stitches to time a patient spends in an operating room, as well as show all the bundled costs associated with 300 "shoppable" services, which are things people can plan for, such as a hip replacement or having a baby. Several different prices are required, including those they've negotiated with insurers and what they charge cash-paying customers.
Similar regulations, but with more prescriptive details and tougher penalties for noncompliance, went into effect for insurance companies in 2022, requiring them to post prices not only for hospital care, but also for outpatient centers and physician services.
The new hospital requirements proposed by the Centers for Medicare & Medicaid Services help "catch up to what they did with health plans," said Hal Andrews, CEO and president of Trilliant Health, a market research and analysis company.
"It's a step down the path to making the data more accessible" to data analysis firms that create online price comparison tools, said Jeff Leibach, a partner at the consulting firm Guidehouse. "And, ultimately, consumers who want to shop will then find this data more easily." Many hospitals, insurers, and third-party data firms have made such cost comparison tools available.
Even the new requirements may not resolve the demand that is central to the dystopian ad's ice cream-seeking man: getting exact prices, in dollars and cents. Such specificity may remain elusive for some consumers, if only because of the nature of medical care.
"Each patient is unique and uses a slightly different bundle of services," said Anderson of Johns Hopkins. "You might be in the operating room for 30 minutes, or it might be 45. You might need this lab test and not that one."
The proposed rule would, for one thing, further standardize the data required so that reporting is more comparable between facilities. It also mandates hospitals make their data sets easier to find on their websites, which could help data aggregators and consumers alike, and puts administrators in the hot seat to attest that their hospitals have posted all the required information accurately.
Individual hospitals that fail to post properly would face additional publicity by federal regulators: "Consider it a public naughty list," said Marcus Dorstel, vice president of operations at data analysis firm Turquoise Health, which provides an online tool consumers can use to check prices across hospitals.
In addition, the proposal adds a data category awkwardly called "consumer-friendly expected allowed charges," aimed at giving more information tied to the varied ways hospitals set prices. In plainer language, those allowed amounts are what hospitals expect to be reimbursed by insurance companies.
Some experts say that will be helpful.
For example, Dorstel said, currently a service might not be listed as a particular dollar amount, but the hospital will show the price is based on "70% of charges."
"Without the expected allowed amount, that doesn't tell you anything," Dorstel said.
Still, critics — such as Patient Rights Advocate, the group behind the new ad campaign — say that nodding to such allowed amounts will lead to even more estimates, rather than what they prefer: dollar-and-cent assessments.
"You and I would not buy a blouse at an average estimated amount," said Fisher.
Health care isn't like blouses or ice cream, responded executives from the American Hospital Association when asked about the advertisement and Fisher's concerns about exact, upfront amounts. In many situations, for example, it may be hard to know ahead of time exactly what kind of care a patient will need.
"Very few health services are so straightforward where you can expect no variation in the course of care," which could then result in a different cost than the original assessment," said Molly Smith, AHA's group vice president for public policy. "Organizations are doing the best they can to provide the closest estimate. If something changes in the course of your care, that estimate might adjust."
While hospitals' compliance with posting price information has improved, it still falls short, said Fisher, whose group in a July report said only 36% of 2,000 hospitals it reviewed complied with all aspects of the current law, marking as deficient those that had incomplete data fields or used formulas instead of dollar prices.
But the American Hospital Association says Fisher's group "misconstrues" hospital compliance, in part because hospitals are allowed to leave spaces blank, if, for example, they don't have a cash-only price. And formulas are allowed if that is how the prices are set.
The hospital group points instead to a CMS report from earlier this year that showed compliance was increasing year over year. It said 70% of hospitals were compliant with the current requirements of the law.
It took some doing to get that far. Since 2021, the federal government has sent more than 900 warning letters to hospitals about their posted data, with most resolving those concerns, according to the proposed rule. Four hospitals have been fined for failing to comply with the transparency law.
Pharmaceutical giant Novo Nordisk has turned to influential Black Americans in pursuit of what would be a lucrative victory: having Medicare cover a new class of weight loss drugs, including the company's highly sought Wegovy, which can cost patients more than $1,000 a month.
During a conference of the Congressional Black Caucus Foundation last fall — a jampacked gathering featuring prominent Black lawmakers and President Joe Biden — Novo Nordisk sponsored a panel discussion on obesity for which it selected the moderator and panelists, company spokesperson Nicole Ferreira said. The foundation is a nonprofit affiliated with the Congressional Black Caucus, a powerful group of lawmakers on Capitol Hill.
Former CNN political commentator Roland Martin moderated. Black health experts who support Medicare coverage of drugs used to treat obesity served on the panel. They included Fatima Cody Stanford, an associate professor of medicine at Harvard Medical School. Stanford is a specialist in obesity who has received consulting fees from Novo Nordisk.
During the panel discussion, Stanford told the audience that obesity "is a real disease that people struggle with," she recounted in an interview with KFF Health News. "We've denied people care for obesity when we haven't for other chronic diseases."
Novo Nordisk, the leading maker of so-called obesity drugs, followed up on the September panel by sponsoring a streaming show in March hosted by Martin, during which guests advocated for Medicare to cover drugs for weight loss. Ferreira said the company suggested experts for the segment, but she did not name them.
Those activities are part of a broader Novo Nordisk campaign to shift the public narrative about obesity. They open a new window on drugmakers' efforts to influence consumers and public policy.
Novo Nordisk is trying to reverse a 20-year-old ban on coverage of drugs used for weight loss under Medicare, the federal health insurance program primarily for people 65 and older. Congress excluded such medications when it established Medicare's Part D prescription drug benefit in 2003. The ban effectively deprives drugmakers of millions of potential customers.
Expanding the Patient Pool
Medicare coverage would put obesity drugs within reach of many people who could not otherwise afford them. It could have a multiplier effect because private insurers often follow Medicare's lead.
It would be a financial boon to Novo Nordisk and other drugmakers, including Eli Lilly, which is seeking FDA approval for a weight loss drug.
Adding to the cost, and the potential upside for the industry: To keep weight off, patients may have to take the drugs indefinitely.
Wegovy's list price is about $1,350 for roughly a month's supply. Eli Lilly's Mounjaro, a drug for people with Type 2 diabetes that doctors prescribe off-label for obesity, is priced at about $1,023 for roughly a month's supply.
Wegovy is FDA-approved for weight loss in adults who have a body mass index of 30 or greater — the definition of adult obesity, according to the Centers for Disease Control and Prevention — or a BMI of at least 27 plus at least one weight-related medical condition, such as hypertension. It's also approved for patients as young as 12 who are deemed obese.
In a statement, Novo Nordisk spokesperson Allison Schneider said, "We advocate for patients and policies that support access to all obesity treatments, including coverage for anti-obesity medications in Medicare Part D."
The company supports the Treat and Reduce Obesity Act, legislation introduced in 2013 that would overturn the Medicare coverage ban. In July, a bipartisan group of lawmakers in the House and Senate reintroduced the bill — something lawmakers have done repeatedly over the decade.
Drug companies have long used a variety of strategies to advance corporate interests, such as funding so-called patient advocacy groups focused on specific diseases and airing direct-to-consumer ads that spur patients to ask their doctors about brand-name drugs.
Novo Nordisk is the biggest corporate donor to the Obesity Action Coalition, which says its mission is "to elevate and empower those affected by obesity."
Novo Nordisk contributes more than $500,000 annually to the group, according to its website. The group's legislative objectives include reversing Medicare's coverage ban on weight loss drugs.
The Obesity Action Coalition "is not influenced in any way by our vast array of supporters," said Kendall Griffey, a spokesperson for the group.
Novo Nordisk has advertised Wegovy, which the FDA approved for weight loss in 2021, and Ozempic, which is approved for diabetes and prescribed off-label to treat obesity.
Like many large corporations, Novo Nordisk has contributed thousands of dollars annually to nonprofits tied to different groups of lawmakers while seeking support in Congress for its causes.
In 2021, Novo Nordisk gave between $100,000 and $399,999 to the Congressional Black Caucus Foundation and between $25,000 and $49,999 to the Asian Pacific American Institute for Congressional Studies, according to each nonprofit's annual report.
The latter nonprofit, known as APAICS, is affiliated with the Congressional Asian Pacific American Caucus. APAICS lists Novo Nordisk as a partner on webpages for events in March and May where panel discussions touched on the treatment of obesity.
The Congressional Hispanic Caucus Institute also lists Novo Nordisk as a donor but doesn't state how much the company contributed.
The Congressional Black Caucus, Congressional Hispanic Caucus, and Congressional Asian Pacific American Caucus back a bill on health disparities that in 2022 was revised to scrap Medicare's prohibition on covering prescriptions for weight loss.
The Congressional Black Caucus Foundation, the Congressional Hispanic Caucus Institute, and the Asian Pacific American Institute for Congressional Studies did not respond to questions for this article. Novo Nordisk declined to say how much it contributed to the Congressional Black Caucus Foundation's 2022 legislative conference and whether it sponsored the panel to influence Congressional Black Caucus members' positions; it similarly declined to specify its most recent annual contribution to the Congressional Hispanic Caucus Institute and its financial contributions for various APAICS events this year. "We support multiple organizations to help educate on and highlight issues important to their communities," company spokesperson Natalia Salomao said of Novo Nordisk's relationship with the nonprofits.
High-Profile Promoters
Martin's streaming daily news show in March featured an hourlong segment "powered by Novo Nordisk" on obesity among Black Americans. Ferreira, of Novo Nordisk, said Martin and Novo Nordisk "agreed that a segment on his show was a good opportunity to reach his audience to help further inform them about obesity as a chronic disease and the importance of good nutrition and health care."
Martin did not respond to requests for comment. During the episode, he cited Novo Nordisk's role. "I certainly want to thank them for partnering with us," he said.
Guests pushed for Medicare to cover patients' anti-obesity prescriptions, with an eye toward what coverage could mean for seniors and other adults. The federal government is "supposed to be leading the way on this," Nelson Dunlap, vice president of public policy and external affairs for Meharry Medical College, a historically Black institution, said during the segment.
"Commercial insurances tend to follow what Medicare does," Tiffani Bell Washington, a psychiatrist specializing in obesity medicine, said on the show. Obesity is "a health issue. So it really does need to be covered, and if Medicare covers it, usually other people follow."
Dunlap declined to comment for this article, and Bell Washington did not answer questions sent by email.
Novo Nordisk enlisted Black music and entertainment stars Queen Latifah and Yvette Nicole Brown to be paid spokespeople for an educational campaign that began in 2021 communicating that obesity is a chronic disease and should be treated like other ailments. Both celebrities have openly talked about living with obesity.
Stanford, one of the participants in the September panel, in 2022 received $23,188 from Novo Nordisk, nearly double what she received from the company in 2021, federal records show. The 2022 payments include consulting fees and expenses for meals and travel.
"I wouldn't want someone that has no knowledge informing them on how this actually works in real life," Stanford said, explaining her relationship with the companies. "The people they learn from are people like me, the people that actually do this work on the ground every day with patients."
Another panelist was Eric Griggs, an assistant vice president at Access Health Louisiana, a network of federally qualified health centers. In an interview, Griggs said Medicare coverage of obesity drugs "would help the solution. If you can help one group, you can help them all."
According to the Centers for Disease Control and Prevention, based on BMI, 50% of non-Hispanic Black adults in the U.S. are classified as obese, the highest rate for any race or ethnicity.
Since 2014, Novo Nordisk has spent more than $30 million lobbying members of Congress and other federal officials, according to a KFF Health News review of lobbying disclosures. A consistent subject is the Treat and Reduce Obesity Act.
"We have enormous health care challenges that flow from obesity," said Sen. Tom Carper (D-Del.), a lead sponsor of that legislation. He argued that spending money on weight loss drugs would reduce spending on chronic diseases that drive up the federal government's health care tab.
Carper is a longtime recipient of campaign cash from drug companies, including makers of weight loss drugs. However, some researchers express caution about lifting Medicare's coverage ban. For seniors, the side effects of such drugs could be more dangerous, according to a paper by scholars at Vanderbilt University and the University of Chicago.
Side effects for Wegovy and Ozempic may include kidney problems, gallbladder disease, inflammation of the pancreas, and thyroid cancer, according to the product labels. Suicidal thoughts are listed as a potentially serious side effect of Wegovy, its label says.
The Vanderbilt and Chicago researchers found that, even with modest uptake of the medications, annual Medicare Part D expenses could increase by $13.6 billion. That could leave policymakers "in the position of making broad cuts to other types of care," said Khrysta Baig, one of the paper's authors.
But people who want Medicare and other insurance programs to cover the drugs emphasize potential advantages.
Coverage would save "the lives that we're losing at early ages, especially in the Black community," Bell Washington said on Martin's show in March, before calling on viewers to take action. "You need to write to your legislators, make sure you're choosing people who are in support of health care for all," she said.
Many Americans really want to lose weight — and a new poll shows nearly half of adults would be interested in taking a prescription drug to help them do so.
At the same time, enthusiasm dims sharply if the treatment comes as an injection, if it is not covered by insurance, or if the weight is likely to return after discontinuing treatment, a new nationwide KFF poll found.
Those findings display the enthusiasm for a new generation of pricey weight loss drugs hitting the market and illustrate possible stumbling blocks, as users potentially must deal with weekly self-injections, lack of insurance coverage, and the need to continue the medications indefinitely.
For example, interest dropped to 14% when respondents were asked if they would still consider taking prescription medications if they knew they could regain weight after stopping the drugs.
One way to interpret that finding is "people want to lose a few pounds but don't want to be on a drug for the rest of their life," said Ashley Kirzinger, KFF's director of survey methodology. The monthly poll reached out to 1,327 U.S. adults.
The U.S. represents a large market for drugmakers who want to sell weight loss prescriptions: An estimated 42% of the population is classified as obese, according to a controversial metric known as BMI, or body mass index. In the KFF poll, 61% said they were currently trying to lose weight, although only 4% were taking a prescription medication to do so.
That gap between the 4% taking any kind of prescription weight loss treatment and the number of Americans deemed overweight or obese is the sweet spot drugmakers are targeting for the new drugs, which include several diabetes treatments repurposed as weight loss drugs.
The drugs have attracted much attention, both in mainstream publications and broadcasts and on social media, where they are often touted by celebrities and other influencers. Demand jumped and supplies have become limited. About 7 in 10 adults had heard at least "a little" about the new drugs, according to the survey.
The newer treatments include Wegovy, a slightly higher dose of Novo Nordisk's diabetes drug Ozempic, and Mounjaro, an Eli Lilly diabetes treatment for which the company is currently seeking FDA approval as a weight loss drug.
Weight loss with these injectable drugs surpasses those of earlier generations of weight loss medications. But they are also costlier than previous drugs. The monthly costs of the drugs set by the drugmakers can range from $900 to more than $1,300.
The drugs appear to work by mimicking a hormone that helps decrease appetite.
Still, like all drugs, they come with side effects, which can include nausea, diarrhea, vomiting, and constipation. More serious side effects include the risk of a type of thyroid cancer, inflammation of the pancreas, or low blood sugar. Health officials in Europe are investigating reports that the drugs may result in other side effects like suicidal thoughts.
The KFF survey found that 80% of adults thought insurers should cover the new weight loss drugs for those diagnosed as overweight or obese. Just over half wanted it covered for anyone who wanted to take it. Half would still support insurance coverage even if doing so could increase everyone's monthly premiums. Still, 16% of those surveyed said they would be interested in a weight loss prescription even if their insurance did not cover it.
In practice, coverage for the new treatments varies, and private insurers often peg coverage to patients' BMI, a ratio of height to weight. Medicare specifically bars coverage for drugs for "anorexia, weight loss, or weight gain," although it pays for bariatric surgery.
"Unfortunately, a lot of insurers have not caught up to the idea of recognizing obesity as a disease," said Fatima Cody Stanford, an obesity medicine specialist at Massachusetts General Hospital and Harvard Medical School.
Employers and insurers must consider the potential costs of covering the drugs for enrollees — perhaps for them to use indefinitely — against the potential savings associated with losing weight, such as a lower chance of diabetes or joint problems.
Stanford said the drugs are not a miracle cure and do not work for everyone. But for those who benefit, "it can be significantly life-altering in a positive way," she said.
It's not surprising, she added, that the drugs may need to be taken long term, as "the idea that there is a quick fix" doesn't reflect the complexity of obesity as a disease.
While the drugs currently on the market are injectables, some drugmakers are developing oral weight loss drugs, although it is unclear whether the prices will be the same or less than the injectable products.
Still, many experts predict that a lot of money will be spent on weight loss products in the coming years. In a recent report, Morgan Stanley analysts called obesity "the new hypertension" and predicted industry revenue from U.S. sales of obesity drugs could rise from a current $1.6 billion annually to $31.5 billion by 2030.
Hospital toxicologist Ryan Marino has seen up close the violent reactions of children poisoned by liquid nicotine from electronic cigarettes. One young boy who came to his emergency room experienced intense nausea, diarrhea, and vomiting, and needed intravenous fluids to treat his dehydration.
Kids can also become dizzy, lose consciousness, and suffer dangerous drops in blood pressure. In the most severe case he's seen, doctors put another boy on a ventilator in the intensive care unit because he couldn't breathe, said Marino, of Case Western Reserve University School of Medicine.
Thousands of kids a year are exposed to the liquid nicotine in e-cigarettes, also known as vapes. For a toddler, even a few drops can be fatal.
Cases of vaping-related nicotine exposure reported to poison centers hit an all-time high in 2022 — despite a 2016 law, the Child Nicotine Poisoning Prevention Act, that requires child-resistant packaging on bottles of vaping liquid. In what doctors call a major oversight, the law doesn't require protective packaging on devices themselves.
Refillable vapes are designed to hold liquid nicotine in a central reservoir, making them dangerous to kids, Marino said. Even vapes that appear more child-resistant — because their nicotine is sealed inside a removable cartridge — present a risk, because the cartridges can be pried open. And some disposable e-cigarettes, now the top-selling type on the market, allow users to take thousands of "puffs" and contain as much nicotine as multiple packs of cigarettes.
Many e-cigarettes and liquids seem designed to appeal to kids, with pastel packages, names such as "Candy King," and flavors such as bubble gum and blue raspberry. That makes vapes far more tempting — and hazardous — than traditional cigarettes, which have lower doses of nicotine and a bitter taste that often prompts children to quickly spit them out, said Diane Calello, the executive and medical director of the New Jersey Poison Information and Education System.
"Nicotine liquid is an accident waiting to happen," Calello said. "It smells good and it's highly concentrated."
Sen. Richard Blumenthal (D-Conn.), who co-sponsored the 2016 legislation, said he would push to expand the childproof packaging requirement to disposable and pod-based e-cigarettes.
"Every day that FDA allows flavored e-cigarette products to remain on the market is another day that children can be enticed by these dangerous, and sometimes deadly, products," he said.
Although the FDA declined to comment for this article, on Aug. 2 the agency included a special feature about nicotine poisoning in children in its "CTP Connect" newsletter.
The number of reports to poison control centers about e-cigarettes has more than doubled since 2018, according to an FDA analysis. Poison control centers reported more than 7,000 vaping-related exposures in people of all ages from April 1, 2022, to March 31, 2023.
According to the FDA, 43 of those exposures resulted in hospitalization and an additional 582 in other medical treatment. About half of poison center reports had no information about whether patients needed medical care.
Nearly 90% of exposures involved children under 5. Authors of the report say their numbers likely underestimate the problem, given that poison control centers aren't contacted in every case.
A 1-year-old died from vaping-related nicotine poisoning in 2014. The new FDA report also mentions the apparent suicide of an adult via e-cigarette poisoning.
A spokesperson for the vaping industry said companies take safety seriously.
"All e-liquid bottles manufactured in the United States conform to U.S. law," said April Meyers, the president of the board of directors and CEO of the Smoke-Free Alternatives Trade Association, which represents the vaping industry. "Not only are the caps child-resistant, but the flow of liquid is restricted so that only small amounts can be dispensed."
Yet many vaping products are made outside the U.S., which has recently been flooded with illegal e-cigarettes, mostly from China.
The increasing number of nicotine exposures among kids — especially curious toddlers who put virtually everything they can grab into their mouths — likely reflects the sheer volume of e-cigarette sales, said Natalie Rine, the director of the Central Ohio Poison Center at Nationwide Children's Hospital.
E-cigarette unit sales grew 47% from January 2020 to December 2022, rising from 15.5 million every four weeks to 22.7 million, according to a report published by the Centers for Disease Control and Prevention.
"This isn't something that parents see as a really big risk," Marino said. "But with the popularity of e-cigarettes, the risk isn't going away anytime soon."
One effective strategy to reduce e-cigarette sales has been to ban flavored products. California, Massachusetts, New Jersey, New York, Rhode Island, and Washington, D.C., have banned all flavored e-cigarettes, while Utah and Maryland have banned some flavors. A study showed overall e-cigarette sales dropped 25% to 31% in states after flavor bans, compared with states that didn't ban them.
Some doctors say the country needs to do more to protect children.
"If the numbers are rising, then the law ain't working," said Carl Baum, a professor of pediatrics and emergency medicine at Yale School of Medicine.
Pediatrician Gary Smith said the lack of child safety requirements for e-cigarette devices is a major problem. Refillable e-cigarettes are relatively easy for kids to open.
Although most poison control center reports don't include brand information, disposable e-cigarettes — including Elfbar, Puff Bar, and Pop Vape — were some of the most common products mentioned in the FDA analysis. Elfbar is now known as EB Design.
Expanding the federal law to include devices would be "an important step," said Smith, president of the Child Injury Prevention Alliance, an Ohio-based advocacy group that works to prevent injuries in children.
In addition, federal officials should limit the nicotine concentration in vape juices to make them less toxic, as well as ban candy-like flavors and colors on packaging, Smith said.
"The public health response should be comprehensive," Smith said.
Kids have been known to pick up a vape and begin puffing, in imitation of their parents, Calello said.
Even if children don't inhale the aerosol, sucking on a vape exposes their skin to nicotine, which can be absorbed into the bloodstream, said Robert Glatter, an assistant professor of emergency medicine at Lenox Hill Hospital in New York City. Glatter noted that e-cigarette liquids also contain numerous harmful chemicals, including arsenic and lead, which is toxic at any dose; carcinogens such as acetaldehyde and formaldehyde; and benzene, a volatile organic compound found in auto exhaust.
Fortunately, children who inhale nicotine get a much lower dose than those who ingest it, reducing the risk of serious harm, said Marc Auerbach, a professor of pediatric emergency medicine at Yale School of Medicine.
Only about 2% of exposures in the FDA study were recorded as having a moderate or major effect.
That may be because little kids who get into dangerous liquids — from vape juice to household cleaning products or gasoline — usually spill most of it, Baum said. "They often end up wearing it rather than swallowing it," Baum said.
Although Stephen Thornton has seen a lot of children with nicotine exposure, he said, the human body has ways of protecting itself from toxic substances. "Fortunately, when kids do ingest these e-cig nicotine products, they self-decontaminate. They vomit — a lot — and this keeps the mortality rate very low, but these kids still often end up in emergency departments due to all the nausea and vomiting," said Thornton, an emergency medicine physician and medical director of the Kansas Poison Control Center.
The FDA urges parents and guardians of young children to keep e-cigarettes and vaping liquid out of reach and in its original container.
For emergency assistance, call Poison Help at 800-222-1222 to speak with a poison expert, or visit poisonhelp.org for support and resources.
A new Montana law will provide sweeping legal protections to health care practitioners who refuse to prescribe marijuana or participate in procedures and treatments such as abortion, medically assisted death, gender-affirming care, or others that run afoul of their ethical, moral, or religious beliefs or principles.
The law, which goes into effect in October, will gut patients' ability to take legal action if they believe they didn't receive proper care due to a conscientious objection by a provider or an institution, such as a hospital.
So-called medical conscience objection laws have existed at the state and federal levels for years, with most protecting providers who refuse to perform an abortion or sterilization procedure. But the new Montana law, and others like it that have passed or been introduced in statehouses across the U.S., goes further, to the point of undermining patient care and threatening the right of people to receive lifesaving and essential care, according to critics.
"I tend to call them ‘medical refusal bills,'" said Liz Reiner Platt, the director of Columbia Law School's Law, Rights, and Religion Project. "Patients are being denied the standard of care, being denied adequate medical care, because objections to certain routine medical practices are being prioritized over patient health."
This year, 21 bills instituting or expanding conscience clauses have been introduced in statehouses, and two have become law, according to the nonprofit Guttmacher Institute. Florida lawmakers passed legislation that allows providers and insurers to refuse any health service that violates ethical beliefs. Montana's law goes further, prohibiting the assignment of health workers to provide, facilitate, or refer patients for abortions unless the providers have consented in writing. South Carolina, Ohio, and Arkansas previously passed bills.
Supporters of the Montana law, called the Implement Medical Ethics and Diversity Act, say it fills gaps in federal law, empowering more medical professionals to practice medicine based on their conscience in circumstances beyond abortion and sterilization.
The bill applies to a wide range of practitioners, institutions, and insurers, encompassing just about any type of health care and anyone who could be providing it. The exception is emergency rooms, where the federal Emergency Medical Treatment and Labor Act takes precedence.
"We have technology that is pushing the limits of what is maybe ethical, and that is different in everybody's minds," said Republican state Rep. Amy Regier, who sponsored the Montana bill. "Having extra protections for people to practice according to their conscience as we continue down that path of innovation is important."
Claims the bill discriminates against patients frustrate Regier, who said it's about protecting health care providers. "Because someone has a conscientious objection to a specific service, they should be able to practice that way," she said.
In 1973, federal regulations known as the Church Amendments were implemented after the Supreme Court's Roe v. Wade decision made abortion legal nationwide. Under the Church Amendments, any institution that receives funding from the federal Department of Health and Human Services may not require health care providers to perform abortion or sterilization procedures if doing so would violate their religious or moral principles. Additionally, providers who refuse to perform these services may not be discriminated against for their decision.
Since then, at least 45 states have enacted their own abortion conscience clauses, according to the Guttmacher Institute. Of those, only 17 mandate that patients be notified of the refusal or limit the clause's use in the case of miscarriage or emergency.
A March 2020 article in the American Medical Association's Journal of Ethics said, "Clinicians who object to providing care on the basis of ‘conscience' have never been more robustly protected than today." Legal remedies for patients who receive inadequate care as a result have shrunk significantly, the article said.
But the wave of medical conscience bills introduced in statehouses since that article was published go beyond abortion to include contraception, sterilization, gender-affirming care, and other services. Opponents such as the American Civil Liberties Union, Planned Parenthood, and the Human Rights Campaign have been vocal opponents of this trend, criticizing it as a backdoor way to restrict the rights of women, LGBTQ+ community members, and other individuals.
Still, lawmakers across the country insist the right of doctors, nurses, pharmacists, and other medical providers to practice medicine in alignment with their beliefs is being infringed.
Some health care practitioners would "just be done" practicing medicine if forced to perform certain procedures such as abortion, Regier said. "That, to me, is what limits patient care."
Many of the most sweeping bills are backed by organizations that have made it their business to promote this "conscience" agenda nationwide, such as the Christian Medical Association, Catholic Medical Association, and National Association of Pro-Life Nurses. Other groups launched a joint effort in 2020 with the explicit purpose of advancing state legislation that makes it easier for health care providers to refuse to perform a wide range of procedures, including abortion and types of gender-affirming care.
The organizations that started the initiative are the Religious Freedom Institute in Washington D.C., an Arizona-based nonprofit called the Alliance Defending Freedom, and the Christ Medicus Foundation in Michigan. According to its website, the coalition bolsters efforts to pass more sweeping medical conscience legislation, using methods including print and digital media campaign strategy, grassroots organizing, and advocacy. After successes in Arkansas, Ohio, and South Carolina in 2021 and 2022, it turned to Montana and Florida. Regier said there are a "number of different organizations" pushing this type of legislation, including the Alliance Defending Freedom.
Most of these conscience laws are part of an "arsenal" to further social conservatism, and they are often religiously motivated, said Lori Freedman, a researcher and associate professor at the Bixby Center for Global Reproductive Health at the University of California-San Francisco.
Although federal law is meant to ensure people receive lifesaving care in an emergency, Freedman said, there are cases in which patients don't receive the care they should simply because they don't clear the bar of what a facility considers emergent.
While experts warn of the potential patient health consequences of these medical conscience bills, academics say placing a provider's choice over their patient's rights is itself a threat.
"These bills do not protect religious liberty because they make it impossible for people to follow their own religious and moral values in making major decisions," Reiner Platt said.
About 1 in 6 patients in the U.S. are treated in Catholic health care facilities, according to Freedman. Many of those venues strictly regulate or prohibit certain procedures, such as abortion, but do not necessarily disclose that to patients. As of 2016, more than 25% of hospital beds in Montana were in such facilities, according to the ACLU. Freedman determined through her research that about one-third of people whose primary hospital was Catholic didn't know of its religious affiliation and therefore were unaware of those limitations on their care.
The problem can extend to secular medical institutions, too. According to the AMA Journal of Ethics article, there are no rules requiring a patient be informed a provider is practicing conscientious objection, which means the patient might "unknowingly receive substandard care" and "even be harmed by" the provider's refusals.
"As much as we like to think about these providers and their opinions, so much is determined at a larger, structural level," Freedman said. "Abortion has been stigmatized, marginalized, and constrained," and plenty of hospitals and physician groups have made great efforts to "make a very safe service somehow illegal to provide within their context."
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."
It has become as familiar a sight in Washington as the cherry blossoms in spring: lobbyists from the nation's hospitals descending on the Capitol to ask lawmakers to postpone billions in Medicaid funding cuts prescribed by the Affordable Care Act — cuts industry leaders agreed to years ago.
It is unlikely the reductions will occur this year, if history is any indication. Since 2013, Congress has voted 13 times to delay them, siding with hospitals over their claims that losing the money would hinder the delivery of care.
Unless Congress acts by October, the federal government will cut $8 billion from this year's budget — then make the same cut each year for the next three years — for a Medicaid program intended to help safety-net facilities that serve a large share of Medicaid and uninsured patients. The amount budgeted varies annually, though in 2021 the program's spending totaled about $19 billion.
Known as the Medicaid Disproportionate Share Hospital (DSH) payments program, it has drawn criticism amid evidence that a substantial amount of its funding goes to hospitals that do not primarily cater to low-income patients. According to industry groups, more than 2,500 hospitals — about 40% of the total in the United States — get the payments.
The cuts are part of a deal brokered with the hospital industry 14 years ago, as the fate of the ACA dangled in the balance. At the time, hospitals agreed to accept $155 billion in Medicare and Medicaid funding cuts over 10 years, assuming the legislation's promise to insure more patients would improve their bottom lines. A portion of those cuts were to Medicaid DSH payments.
Despite record-high hospital profits and record-low uninsured rates in recent years, the hospital industry again says this is not a good time for cuts, pointing to the covid-19 pandemic and the millions of people losing Medicaid coverage as a result of pandemic-era protections ending.
Current Medicaid funding covers only about 81% of hospitals' costs of caring for patients, said Jolene Calla, a vice president of The Hospital and Healthsystem Association of Pennsylvania.
Losing the Medicaid safety-net funding "would be devastating to hospitals," she said.
A bipartisan group of 231 members of the House of Representatives — a majority — have signed a letter to House leaders asking for another delay. Legislation is moving in the chamber that would delay any cuts to the Medicaid safety-net program until 2026.
The postponements show the political muscle of the hospital industry, strengthened by virtually every lawmaker's district having at least one hospital that provides care and jobs.
Hospitals have been among the biggest donors to members of Congress and have a large lobbying force.
According to the watchdog group OpenSecrets, the Greater New York Hospital Association, which represents more than 160 hospitals, gave more than $11.8 million to congressional campaigns in the 2022 cycle. The American Hospital Association spent about $27 million on lobbying to influence lawmakers in 2022, more than nearly any other organization.
Critics say the hospital industry — which often increases prices, sues patients for lack of payment, and pays big-dollar salaries to top executives — should hold up its side of the deal it made with Democrats, particularly the Obama administration, in 2009.
"Too many hospitals have for years been trying to have it both ways, benefitting from the ACA while trying to escape responsibilities they have under the law," said Daniel Skinner, an associate professor of health policy at Ohio University. "They constantly deploy their political power to wiggle out of these responsibilities while trying to maintain the generally good feeling they have within communities."
On July 8, 2009, the nation's top hospital leaders stood with then-Vice President Joe Biden at a White House press conference to announce their deal to keep national health reform legislation on track after a century of failed attempts, dating as far back as Theodore Roosevelt's push for national insurance.
At the time, ACA reform efforts teetered as interest groups feuded and Democrats struggled to settle on a plan. The agreement, which followed a similar deal with the drug industry, was part of a plan by the Obama administration to preemptively negotiate with corporate interests that had blocked previous reform efforts.
The savings from the $155 billion in hospital funding cuts would "cover health care cost reform," Biden said during the press conference. "As more people are insured, hospitals will bear less of the financial burden of caring for the uninsured and the underinsured, and we will reduce payments to cover those costs in tandem with that reduction."
President Barack Obama signed the ACA into law in March 2010. The number of uninsured, which was 48 million in 2010, fell to 28 million by 2016. By 2021, the uninsured rate fell to record lows, with about 27 million uninsured.
Hospital lobbyists argue the industry has already absorbed cuts in Medicare funding under the ACA and that the Medicaid cuts should not be implemented because uninsured rates have not dropped as low as the 5% rate predicted before the law's passage.
Though the health law has been a "godsend," it also has not met its anticipated goal of universal coverage, said Chip Kahn, the president and CEO of the Federation of American Hospitals, which represents for-profit hospitals.
Kahn, who was involved in the agreement with the Obama White House, said the ACA has fallen short of universal coverage largely because 10 states, including more populous ones like Florida and Texas, have yet to adopt Medicaid expansion.
As a result, hospitals in these states have provided more unpaid care than anticipated and need the additional Medicaid payments to cover costs, he said.
Kahn said the extra Medicaid payments also help offset shortfalls caused by Medicare and Medicaid underpaying hospitals.
The ACA called for the DSH program's cuts to be phased in, with less than $1 billion being cut in each of the first few years. But after hospitals lobbied Congress to postpone them, the revised budget deals meant future cuts would be deeper and immediate — leading to the $8 billion annual cuts currently slated for the coming years.
In fiscal year 2021, the most recent year for which data is available, DSH spending nationwide totaled $18.9 billion. While those payments represent 3% of overall Medicaid spending, they account for as much as 10% of some states' Medicaid spending.
The program, intended for safety-net hospitals, has been the subject of controversy for decades.
One reason is that the money does not always go to safety-net hospitals.
A study published in Health Affairs last year found 57% of hospitals received the DSH payments in 2015. About 94% of these payments went to hospitals with either a high percentage of uninsured patients or Medicaid enrollees or higher-than-average uncompensated care.
But 6% of recipient hospitals did not meet these criteria, the study showed.
The researchers estimated that about a third of the payments went to hospitals not focused on caring for low-income populations.
Paula Chatterjee, the lead author on the study and the director of health equity research at the Leonard Davis Institute of Health Economics at the University of Pennsylvania, said hospitals aren't transparent about how they spend the extra money and that the states that receive the most money do not always have the highest rates of uninsured residents.
While the safety-net program is intended to help hospitals treating large numbers of Medicaid and uninsured patients, the formula determining how much money states get is based on historical Medicaid spending totals before limits were put in place in 1992, she said.
As a result, states like New York and New Jersey are among the largest recipients of the supplemental funding even though they have some of the lowest uninsured rates, she said.
Beth Feldpush, the senior vice president of policy and advocacy for America's Essential Hospitals, which represents 300 safety-net hospitals, said these facilities' 3% average operating margin would disappear if not for DSH money. "Members of Congress recognize there are pockets of underserved communities in most congressional districts," she said.
Chatterjee said hospitals will likely argue there is never a good time to accept the cuts. She noted some rural and urban hospitals have closed in recent years even as other hospitals have made record profits.
"It's always hard to take money away from hospitals because they hold such symbolic meaning, and legislators know that," she said.
This article was produced by KFF Health News, formerly known as Kaiser Health News (KHN), a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.
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 healthcare. 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 healthcare. 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 healthcare," 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."
Top state health officials say they plan to plow most of the money into higher payments for doctors, hospitals, and other healthcare providers who serve Californians covered by Medi-Cal, the state's Medicaid program.
by Angela Hart and Samantha Young
California’s powerful healthcare industry just notched a historic win: The state is going to give it an $11.1 billion infusion to improve care for millions of low-income Medicaid patients.
But the intense jockeying over the money is only beginning.
Top state health officials say they plan to plow most of the money into higher payments for doctors, hospitals, and other healthcare providers who serve Californians covered by Medi-Cal, the state’s Medicaid program. But the framework, hammered out this summer as part of state budget negotiations, lacks critical details, which has set off a lobbying frenzy among health industry groups seeking a cut.
Even as they battle for their share, industry leaders are quietly plotting a November 2024 ballot initiative to lock in the Medi-Cal payment increases, which they argue are needed to sustain the safety-net program that covers nearly 16 million Californians — a staggering 40% of the state’s population.
“We are addressing decades of systemic underfunding in Medicaid that has exacerbated inequity and health care provider deserts, where patients are often forced to get their care in emergency departments,” said Dustin Corcoran, the CEO of the influential California Medical Association, which represents doctors.
Corcoran also leads the coalition negotiating with Gov. Gavin Newsom and fellow Democratic lawmakers in Sacramento over how the money — a combination of state and federal funding to be doled out over six years — will be spent.
“Even with this historic deal, there are still parts of the health care system that are going to struggle to provide the care that patients need,” Corcoran said. “The coalition is dedicated to ensuring long-term stability and predictability in reimbursement rates in California.”
California has among the lowest Medicaid reimbursement rates in the country, which is often cited as a key reason many low-income patients can’t get care and often face excruciating wait times, especially for primary care, obstetric, and mental health appointments, said Kathryn Phillips, the associate director for improving access to care at the California Health Care Foundation. (KFF Health News publishes California Healthline, which is an editorially independent service of the California Health Care Foundation.)
“That’s where the state is struggling the most,” she said. “Low rates are why a physician may not accept Medi-Cal patients, or only accept a low number of patients.”
This deal funds the largest increase in base Medi-Cal reimbursement rates in at least 25 years, said Jennifer Kent, a former director of the state Medicaid agency.
The money will come from the managed care organization tax, which has been levied since 2005 on health insurers that do business in California. Revenue from the tax, which allows the state to secure billions in federal health care dollars it wouldn’t otherwise receive, has previously been funneled into the state general fund, which can be used for anything state leaders want.
Under the deal, and for the first time, Newsom and the legislature have agreed to use the money to improve care for poor Californians. Of the $19.4 billion projected to be raised by the tax between 2023 and 2026, $11.1 billion will go directly to Medi-Cal and $8.3 billion to the general fund to offset state spending on Medi-Cal, according to state Department of Finance spokesperson H.D. Palmer.
The new funding will start flowing next year, with $820 million earmarked for initial rate increases in primary care, obstetric care, and mental health care, Palmer said.
From 2025 through 2029, the state plans to allocate nearly $2.7 billion a year, according to the department. State and industry officials said they plan to direct some of the money to expand medical residency programs for doctors serving low-income people, fund new beds for psychiatric patients, and increase the workforce of other providers such as nurses, mental health therapists, and community health workers.
But the bulk will go to rate increases for primary care and an array of providers and services, including hospitals and long-term care facilities, abortion care, and emergency services. Higher rates for specialists, such as psychiatrists and dentists, are also desperately needed.
Although Newsom and state health officials have promised to direct the money to health care providers, they haven’t specified which ones will get increases — and there’s no guarantee the money won’t be diverted to another program. Medi-Cal, a massive and ballooning program with a budget of $152 billion this fiscal year, is under tremendous pressure. The state continues to expand the program to more people and offers a growing list of expensive services, despite the threat of budget deficits.
“There has to be more guardrails,” said Assembly member Vince Fong (R-Bakersfield) during a June legislative debate. “This should not be seen as a revenue grab.”
Mark Ghaly, Newsom’s health and human services secretary, acknowledged that even though some providers and treatments may be left out initially, the payment boosts represent a critical step toward better access.
“The core providers in Medicaid will benefit,” Ghaly told KFF Health News. “There’s always going to be someone out there with a question and a concern, and I hope that as we learn about them and we hear them, we address them.”
Ghaly said the tax will bring some Medicaid rates in California from the bottom in the country to the top. While he acknowledged concerns that the money might be diverted in future years, he said Newsom is committed to spending it on Medi-Cal. “Who knows about the uncertainty of the future?” he said. “But we have basically done as much as you can to hard-wire these changes into the way we design Medicaid. The man with the pen — the governor of California — is committed to this.”
Even though the tax deal isn’t big enough to fix all the problems in Medi-Cal, it will improve patient care, said Charles Bacchi, president and CEO of the California Association of Health Plans, which represents private and public insurers.
“There’s a lot more work to do hammering out the rate increases and where they should go,” Bacchi said. “We have to make sure that the funding actually survives the budget process next year.”
Some providers worry they may be left out.
“We’ve argued hard for optometrists to be included,” said Kristine Schultz, executive director of the California Optometric Association, noting that optometrists can’t afford to treat poor patients because of low rates. For example, optometrists get about $39, on average, to conduct an eye exam on a new Medi-Cal patient, while Medicare reimburses $158, she said.
As a result, she said, patients “are not able to get in for months.”
Ann Rivello, a therapist in San Mateo County specializing in trauma, also cited low rates — and complicated medical billing demands — as the reasons she doesn’t accept Medi-Cal patients.
“I’ve been practicing over 20 years and I do not accept Medi-Cal even though it’s within my values,” she said.
Detailed rates for most health care treatments for Medi-Cal patients are not publicly available because they are negotiated privately by insurance companies and vary by geography and health insurance plan. And the state has a slew of bonus payments it uses to supplement base Medi-Cal rates, further obfuscating how much health care providers receive.
While Medi-Cal rates vary widely, on average, California reimburses 76% of Medicare rates, Phillips said. Next year, the state plans to raise that base payment rate to 87.5% of Medicare in three target areas — primary care, obstetrics, and mental health.
As health care providers battle for their slice of the tax revenue, they say they want to avoid the same lobbying fight each time the state renews the tax, which happens every few years. One option they are considering: a ballot initiative next year that would lock the Medi-Cal funding into the state constitution.
Bacchi declined to take a position on the concept but said insurers are “taking a look at it.” He argues that California “needs to make a long-term commitment to the Medi-Cal program.”
John Baackes, the CEO of L.A. Care, the largest Medi-Cal insurer, supports the idea. He argues that a permanent increase in Medi-Cal rates would help address the disparities between Medi-Cal and private insurance coverage.
“The pandemic showed us that inequality is a life-and-death matter, because if you look at the people who got sick the most and died, they were people of color,” he said. “If we continue to ignore that, we’re idiots.”
As of July 11, 195 rural hospitals have shuttered inpatient units or closed their doors altogether in the United States since 2005.
by Cecilia Nowell
About a year ago, Valory Wangler, a family medicine doctor, invited a handful of former co-workers to her backyard.
During the early months of the covid-19 outbreak, Wangler and her colleagues had worked at a hospital in this former railroad hub of about 21,000 residents just a few miles from the Navajo Nation. The pandemic had been hard on Rehoboth McKinley Christian Hospital. Emergency federal funding was drying up and nearly a third of the staff — including Wangler, the chief medical officer — left after its board of trustees hired an out-of-state, for-profit management services firm to take over operations in August 2020.
The group of former hospital employees in Wangler’s backyard that afternoon in June 2022, including two OB-GYNs and a chaplain, knew the situation was dire and wondered what they could do.
Wangler said they realized “the most important thing we could do for the community is have good access to primary care.”
The health care cliff Wangler and her former colleagues confronted is one that has challenged dozens of rural communities over the past two decades.
By late 2022, the hospital had closed its labor and delivery unit and lost most of its primary care doctors. Gallup’s McKinley County was recording the largest primary care provider deficit in rural New Mexico — and local doctors knew that could lead to an increase in untreated conditions and patients seeking emergency rather than preventive care.
As of July 11, 195 rural hospitals have shuttered inpatient units or closed their doors altogether in the United States since 2005. Hundreds of others, like the one in Gallup, have cut services. Meanwhile, from 2006 to 2018, the combined number of Federally Qualified Health Centers and Rural Health Centers — outpatient clinics that receive federal funding to operate in medically underserved areas — increased by roughly 50%, according to a 2021 study from the University of North Carolina-Chapel Hill. By 2019, 20% of rural residents accessed care at such community health centers.
In response to the challenges facing their hospital, Wangler and the colleagues who’d gathered in her yard decided to open their own physician-led, nonprofit clinic, which is on its way to becoming an FQHC Look-Alike, an organization that meets the eligibility requirements of an FQHC but does not receive grant funding. That status will qualify the clinic for multiple types of federal aid including drug pricing discounts. Since it opened its doors last August, Gallup Community Health has treated about 3,000 patients in its stucco office space just a block from the historic U.S. Route 66. Many of GCH’s doctors came to Gallup from elsewhere and could have left town for more lucrative jobs. Instead, they decided to stay and attempt to fill primary care gaps.
“I’ve not seen [an FQHC] like this,” said Tim Putnam, a faculty member of the Medical University of South Carolina, a former hospital CEO, and a past president of the National Rural Health Association. Although it’s rare, if not a first, for physicians to lead their own FQHC, he said, it’s not uncommon to see FQHCs started by community groups, and in Gallup “the physicians are so dedicated to the community” that they’re like a community group themselves.
Unlike rural hospitals, which are increasingly being purchased by private equity firms and prioritizing lucrative specialties to increase profits, these health centers must offer primary care regardless of patients’ ability to pay and be overseen by a board made up primarily of patients. But while clinics provide important primary care services, researchers note that they struggle to fill the gaps in specialty and emergency care left by hospital closures.
Marcie Richmond, one of the clinic’s family medicine doctors, came to Gallup for the same reason that drew many of her colleagues: “to work with populations that might not be receiving much care.” She envisions a day when more of the Gallup area’s providers come from the local Navajo and Zuni communities, but until then she hopes to continue offering much-needed “care for people who are victims of chronic injustice.”
The clinic’s interior reflects that care: Indigenous children’s books like “Where Did You Get Your Moccasins?” and “We Sang You Home” fill the lobby, prints by Zuni artist Mallery Quetawki are going up in exam rooms, and watercolors of nearby Red Rock Park and photographs of Canyon de Chelly hang in the hallways.
On a Thursday morning in April, Renie Lente and her sister, Elsie, waited for their appointment.
Elsie has cerebral palsy and lives in a nursing home; Lente is her caregiver. Lente had called the night before after she noticed a fungal infection on Elsie’s foot, and the clinic was able to fit her in the next morning with the provider who treats her whole family. The community clinic is a “big change” from Rehoboth McKinley, where, Lente said, there was a backlog to be seen by primary care providers that left patients turning to the emergency room. After family medicine physician Neil Jackson treated Elsie, making space in the small exam room for both sisters and nursing home staffers, Lente noted that she appreciated how Jackson “treats you like family.”
“One of the things that the staff committed to from the beginning was doing what was right for the patient and figuring out finances later,” said Wangler, the clinic’s executive director.
The clinic opened its doors in large part thanks to contributions from the community: A statewide hospital system donated equipment, Gallup residents raised $30,000, and more than half the doctors volunteered their time or asked not to be paid until the clinic was operating in the black.
The team intended to offer some reproductive health care, but not prenatal care. Their clinic wasn’t a hospital, so patients would have to give birth elsewhere. But by the time the clinic opened, Rehoboth McKinley had closed its labor and delivery unit after every OB-GYN left the hospital, forcing pregnant patients to transfer their care to the local Indian Health Service facility — a sizable hospital where many Native Americans can seek care but which not all of them prefer — or to a hospital more than an hour’s drive away.
The doctors quickly started looking into what it would take to offer prenatal care. They wanted at least to save patients from having to choose between spending hours and gas money traveling for appointments and forgoing prenatal care entirely. By November, the community had raised $24,000 to pay for prenatal malpractice insurance. And during that time the clinic’s OB-GYNs and OB-trained family medicine doctors developed a plan for providing prenatal care while maintaining relationships with the more distant hospitals where their patients could deliver.
Clinic leaders intend to keep the doors open by applying for it to become a Federally Qualified Health Center Look-Alike. That would qualify it for higher Medicare and Medicaid payments.
Clinic staffers hope providing quality outpatient care can minimize hospitalizations and the need to travel for specialty care. One of the tools helping GCH doctors provide that care is the University of New Mexico Health System’s PALS, a hotline service that connects physicians anywhere in the state with specialists who can answer questions about care outside their area of practice.
“There’s a physician shortage everywhere and a real understanding that it is challenging for people to get in from the rural setting,” said Wangler, who added that specialists have been amenable to partnering and offering guidance.
Doctors like Jackson say the tight-knit community in Gallup made them want to stay and try to fill the primary care void. “All of the folks that I’m working with here are truly rooted in the community and going to be here for better or worse.”