Dr. Jacqui O'Kane took a job with a hospital in southern Georgia in 2020, as the lone doctor in a primary care clinic in a small town that's a medically underserved area. She soon attracted nearly 3,000 patients.
But she said the hospital pressed her to take more new patients, so she had to work nights and weekends — not ideal for the mother of two young daughters. She thought about opening her own practice in town, which would give her more control over her schedule.
The problem was that her three-year contract included a noncompete clause barring her from practicing within 50 miles of the hospital for two years after it ended.
So, she has decided to join a practice in South Carolina. That means she and her husband will sell their house, move hundreds of miles, and enroll their children in a new school.
"It sucks," she said. "I know my patients very well, and I feel like I'm being forced to abandon them. But I can't stay in this job because it's unhealthy for me to work this much."
In January, the Federal Trade Commission proposed to end predicaments like O'Kane's by prohibiting noncompete clauses in employment contracts. "The freedom to change jobs is core to economic liberty and to a competitive, thriving economy," said Lina Khan, the FTC chairperson.
The proposed rule would prohibit employment contract provisions that block employees or contractors from working for a competing employer when they move on, or from starting a competing business. Such contracts typically bar people from working within a certain geographic area for a period after the job ends.
The FTC estimates that 30 million workers are bound by noncompete clauses. It says ending those provisions would boost economic competition, reduce prices, and increase workers' earnings overall by up to $296 billion a year.
Eliminating noncompete contracts would allow doctors to practice wherever their services are needed, which would improve patients' access to care. They say it would free them to speak out about unsafe conditions for patients, since they wouldn't have to worry about getting fired and not being able to continue working in their community.
But the FTC's proposal faces resistance from employers in all industries, including hospitals and private equity-backed medical groups that employ thousands of physicians, nurse practitioners, and other medical professionals.
It's about money for them, too. They say eliminating noncompetes would drive up the cost of hospital care because hospitals would have to pay physicians more to keep them. They also say noncompete clauses are necessary to protect proprietary information and investments in employee training, and to prevent employees from taking clients and patients with them when they leave.
Business and hospital groups are likely to sue to block the rule, arguing that Congress hasn't authorized the commission to regulate noncompete clauses. While there is bipartisan support in Congress for legislation that would restrict noncompete clauses and authorize FTC action, the bill hasn't advanced; similar legislation stalled in past years.
Health care industry groups hope to block any change with the argument that the FTC lacks statutory authority to regulate nonprofit, or tax-exempt, hospitals, which account for nearly 60% of all U.S. community hospitals. In the proposed rule, the FTC acknowledged that entities not conducting business for profit may not be subject to the rule because they are exempt from coverage under the Federal Trade Commission Act, the law that gives the agency its authority.
"The rule would create an unlevel playing field because we compete with nonprofit and public hospitals that wouldn't be subject to it," said Chip Kahn, CEO of the Federation of American Hospitals, which represents for-profit hospital systems.
But other experts aren't sure the FTC lacks authority over nonprofits. While the FTC Act exempts nonprofits, the commission has acted many times under the Sherman Act and the Clayton Act, federal antitrust laws used to block anti-competitive conduct by nonprofit hospital systems. It's not clear whether the FTC will clarify this issue before it finalizes the rule.
"We fully support having the noncompete ban apply to all hospitals," said Dr. Jonathan Jones, president of the American Academy of Emergency Medicine, half of whose members are bound by noncompetes.
California, North Dakota, and Oklahoma already ban enforcement of noncompete clauses for all employees, while six other states prohibit enforcement of noncompete clauses for physicians. Even in states without bans, judges have invalidated noncompetes when they found them to be overbroad or unreasonable.
But it can cost tens of thousands of dollars in legal fees to challenge a noncompete clause, and other employers may not want to take the risk of hiring a person in the middle of a legal fight, said Luke Campbell, a Seattle attorney who represents physicians.
The FTC rule also would bar the use of nondisclosure or training repayment agreements in employment contracts if they functioned as de facto noncompetes.
Hospitals often require nurses to sign training repayment agreement provisions, called TRAPs, which nursing groups say lock nurses into jobs by demanding they pay as much as $20,000, for what's essentially job orientation, if they leave before two years. National Nurses United, a labor union, wants the FTC to explicitly prohibit TRAPs.
As of last year, nearly three-quarters of all U.S. physicians were employed by hospital systems or other companies, with many working under noncompete agreements. A 2018 survey found that nearly half of primary care physicians in California, Illinois, Georgia, Pennsylvania, and Texas were bound by noncompetes.
Private equity-owned staffing firms such as TeamHealth, Envision Healthcare, and Sound Physicians, which provide emergency physicians and other medical professionals to work in hospitals, commonly use noncompete provisions. None of those three companies agreed to talk about their employment contracts. As for-profit employers, noncompete clauses in their contracts clearly would be barred even if their employees were working in nonprofit hospitals.
Hospitals, insurers, and physician-owned medical groups also use noncompetes in employing doctors and other medical professionals.
Hospital-based doctors — emergency physicians, anesthesiologists, hospitalists, radiologists, and pathologists — refute the industry's argument that they would take patients or proprietary information with them.
"We don't have any trade secrets and we don't have the capability of stealing patients because we don't have our own patient referral base," said Dr. Robert McNamara, the chair of emergency medicine at Temple University.
Instead, he said, noncompetes are a way for the physician staffing firms to lock in their contracts with hospitals. "The private equity group can say to the hospital, ‘You might not like what we're doing, but if you get rid of us, every single one of your doctors must be replaced,'" McNamara said.
Dr. Vanessa Urbina, a general practice physician in central Florida, also worries about the impact on patients. She left a corporate-owned medical practice in Altamonte Springs last year because of what she said was an abusive environment. Hobbled by a noncompete agreement she signed forbidding her from practicing within 15 miles of the clinic, she opened her own primary care clinic in rural Mount Dora, 19 miles away.
She had to stay in the area because of a child custody agreement. Fighting the noncompete cost her $25,000 in legal fees and lost income. Even though she now must drive farther to transport her daughter to school and back, she's happier in her new practice. But she's angry she can't take care of her former patients.
"They forced me to abandon my patients," she said. "Now they have to wait three months for an appointment. Noncompetes should be illegal."
Consider three hypothetical women in their mid-70s, all living alone in identical economic circumstances with the same array of ailments: diabetes, arthritis, and high blood pressure.
Ms. Green stays home most of the time and sometimes goes a week without seeing people. But she's in frequent touch by phone with friends and relatives, and she takes a virtual class with a discussion group from a nearby college.
Ms. Smith also stays home, but rarely talks to anyone. She has lost contact with friends, stopped going to church, and spends most of her time watching TV.
Ms. Johnson has a wide circle of friends and a busy schedule. She walks with neighbors regularly, volunteers at a school twice a week, goes to church, and is in close touch with her children, who don't live nearby.
Three sets of social circumstances, three levels of risk should the women experience a fall, bout of pneumonia, or serious deterioration in health.
Of the women, Ms. Johnson would be most likely to get a ride to the doctor or a visit in the hospital, experts suggest. Several people may check on Ms. Green and arrange assistance while she recovers.
But Ms. Smith would be unlikely to get much help and more likely than the others to fare poorly if her health became challenged. She's what some experts would call "socially vulnerable" or "socially frail."
Social frailty is a corollary to physical frailty, a set of vulnerabilities (including weakness, exhaustion, unintentional weight loss, slowness, and low physical activity) shown to increase the risk of falls, disability, hospitalization, poor surgical outcomes, admission to a nursing home, and earlier death in older adults.
Essentially, people who are physically frail have less physiological strength and a reduced biological ability to bounce back from illness or injury.
Those who are socially frail similarly have fewer resources to draw upon, but for different reasons — they don't have close relationships, can't rely on others for help, aren't active in community groups or religious organizations, or live in neighborhoods that feel unsafe, among other circumstances. Also, social frailty can entail feeling a lack of control over one's life or being devalued by others.
Many of these factors have been linked to poor health outcomes in later life, along with so-called social determinants of health — low socioeconomic status, poor nutrition, insecure housing, and inaccessible transportation.
Social frailty assumes that each factor contributes to an older person's vulnerability and that they interact with and build upon each other. "It's a more complete picture of older adults' circumstances than any one factor alone," said Dr. Melissa Andrew, a professor of geriatric medicine at Dalhousie University in Halifax, Nova Scotia, who published one of the first social vulnerability indices for older adults in 2008.
This way of thinking about older adults' social lives, and how they influence health outcomes, is getting new attention from experts in the U.S. and elsewhere. In February, researchers at Massachusetts General Hospital and the University of California-San Francisco published a 10-item "social frailty index" in the Proceedings of the National Academy of Sciences journal.
Using data from 8,250 adults 65 and older who participated in the national Health and Retirement Study from 2010 to 2016, the researchers found that the index helped predict an increased risk of death during the period studied in a significant number of older adults, complementing medical tools used for this purpose.
"Our goal is to help clinicians identify older patients who are socially frail and to prompt problem-solving designed to help them cope with various challenges," said Dr. Sachin Shah, a co-author of the paper and a researcher at Massachusetts General Hospital.
"It adds dimensions of what a clinician should know about their patients beyond current screening instruments, which are focused on physical health," said Dr. Linda Fried, an internationally known frailty researcher and dean of the Mailman School of Public Health at Columbia University.
Beyond the corridors of medicine, she said, "we need society to build solutions" to issues raised in the index — the ability of seniors to work, volunteer, and engage with other people; the safety and accessibility of neighborhoods in which they live; ageism and discrimination against older adults; and more.
Meanwhile, a team of Chinese researchers recently published a comprehensive review of social frailty in adults age 60 and older, based on results from dozens of studies with about 83,900 participants in Japan, China, Korea, and Europe. They determined that 24% of these older adults, assessed both in hospitals and in the community, were socially frail — a higher portion than those deemed physically frail (12%) or cognitively frail (9%) in separate studies. Most vulnerable were people 75 and older.
What are the implications for health care? "If someone is socially vulnerable, perhaps they'll need more help at home while they're recovering from surgery. Or maybe they'll need someone outside their family circle to be an advocate for them in the hospital," said Dr. Kenneth Covinsky, a geriatrician at UCSF and co-author of the recent Proceedings of the National Academy of Sciences article.
"I can see a social frailty index being useful in identifying older adults who need extra assistance and directing them to community resources," said Jennifer Ailshire, an associate professor of gerontology and sociology at the University of Southern California Leonard Davis School of Gerontology.
Unlike other physicians, geriatricians regularly screen older adults for extra needs, albeit without using a well-vetted or consistent set of measures. "I'll ask, who do you depend on most and how do you depend on them? Do they bring you food? Drive you places? Come by and check on you? Give you their time and attention?" said Dr. William Dale, the Arthur M. Coppola Family Chair in Supportive Care Medicine at City of Hope, a comprehensive cancer center in Duarte, California.
Depending on the patients' answers, Dale will refer them to a social worker or help modify their plan of care. But, he cautioned, primary care physicians and specialists don't routinely take the time to do this.
Oak Street Health, a Chicago-based chain of 169 primary care centers for older adults in 21 states and recently purchased by CVS Health, is trying to change that in its clinics, said Dr. Ali Khan, the company's chief medical officer of value-based care strategy. At least three times a year, medical assistants, social workers, or clinicians ask patients about loneliness and social isolation, barriers to transportation, food insecurity, financial strain, housing quality and safety, access to broadband services, and utility services.
The organization combines these findings with patient-specific medical information in a "global risk assessment" that separates seniors into four tiers of risk, from very high to very low. In turn, this informs the kinds of services provided to patients, the frequency of service delivery, and individual wellness plans, which include social as well as medical priorities.
The central issue, Khan said, is "what is this patient's ability to continue down a path of resilience in the face of a very complicated health care system?" and what Oak Street Health can do to enhance that.
What's left out of an approach like this, however, is something crucial to older adults: whether their relationships with other people are positive or negative. That isn't typically measured, but it's essential in considering whether their social needs are being met, said Linda Waite, the George Herbert Mead Distinguished Service Professor of sociology at the University of Chicago and director of the National Social Life, Health, and Aging Project.
For seniors who want to think about their own social vulnerability, consider this five-item index, developed by researchers in Japan.
(1) Do you go out less frequently now than last year?
(2) Do you sometimes visit your friends?
(3) Do you feel you are helpful to friends or family?
(4) Do you live alone?
(5) Do you talk to someone every day?
Think about your answers. If you find your responses unsatisfactory, it might be time to reconsider your social circumstances and make a change.
A year after private equity-backed Noble Health shuttered two rural Missouri hospitals, patients and former employees grapple with a broken local health system or missing out on millions in unpaid wages and benefits.
Noble Health swept into two small Missouri towns promising to save their hospitals. Instead, workers and vendors say it stopped paying bills and government inspectors found it put patients at risk. Within two years — after taking millions in federal COVID relief and big administrative fees — it locked the doors.
The hospitals in Audrain and Callaway counties remain closed as a slew of lawsuits and state and federal investigations grind forward.
In March, Missouri Attorney General Andrew Bailey confirmed a civil investigation. He had previously told local talk radio that there was an "ongoing" investigation into "the hospital issue."
Bailey's comment came weeks after the U.S. Department of Labor's Employee Benefits Security Administration notified executives tied to Noble Health, a startup, that they had violated federal laws and asked them to pay $5.4 million to cover unpaid employee health insurance claims, according to a 13-page letter detailing "interim findings" that was obtained by KHN.
The January letter confirms KHN's previous reporting, which was informed by employees and patients who described missing paychecks; receiving unexpected, high-dollar medical bills; and going without care, including cancer treatment. According to the letter from federal investigators, the Noble hospitals and their corporate owners collected employee contributions for medical, dental, and vision insurance in 2021 and 2022 but then failed to fund the insurance plans.
The owners and executives were "aware of the harm to participants and, in some cases, were attempting to resolve individual participant complaints," the letter states, adding that "despite the volume and gravity of complaints and bills received," they failed to respond.
'Tomfoolery' and Doing 'Everybody Dirty'
Marissa Hagedorn, who worked as a hospital laboratory technician, has spent much of the past year starting a new job, caring for her 2-year-old son who was born with spina bifida, and haggling over unpaid medical bills. She told KHN the family owes at least $8,000 for son Ryder's specialty care in St. Louis, with $6,000 of that in collections. As a Noble employee, Hagedorn said, she was told repeatedly that her employee health insurance would cover Ryder's care. It didn't.
Noble has "done everybody dirty," she said. "We just would like for some responsibility to be taken by this company that didn't feel the need to get their act together." Hagedorn's story of unpaid bills, which was first reported by the local newspaper, the Mexico Ledger, is common among former Noble employees a year after the hospitals closed.
A former employee of the Fulton hospital has filed a class-action lawsuit intended to represent hundreds of employees from both hospitals.
The Jan. 13 letter from federal officials called for responses by Jan. 27 from Noble corporate and hospital executives as well as Platinum Neighbors, which last April bought the hospitals and assumed all liabilities. The letter instructs executives to contact the agency "to discuss how you intend to correct these violations, fund participant claims, and achieve compliance."
Former employees say their claims have not yet been paid. A Labor Department spokesperson, Grant Vaught, said the agency could not comment on an ongoing investigation.
Separately, the Kansas Department of Labor is reviewing Noble and Platinum's failure to pay wages and severance to corporate employees. Agency spokesperson Becky Shaffer confirmed that hearings took place in early February on a half-dozen cases totaling more than $1 million in claims for unpaid wages and severance.
Dave Kitchens was among those who filed claims against Noble Health. Kitchens worked briefly as a contract employee and then was hired in October 2021 as a corporate controller, an accounting role in which he was responsible for financial reporting and data analytics. Kitchens provided an audio recording of his hearing to KHN and hopes to eventually get paid more than $90,000 in lost wages, benefits, and severance pay. During the hearing, Kitchens told the administrative judge: "I would just like to be paid what I'm owed."
Kitchens, who is also named as a fiduciary on the federal investigation, said he was not on Noble's executive team. When asked by Kansas Administrative Law Judge James Ward whether he expected Noble or the secondary buyer Platinum to pay his wages, Kitchens responded he had "no idea who was in charge."
"I believe there was some tomfoolery," Kitchens said.
Despite receiving approval for nearly $20 million in federal COVID-19 relief money before it closed the hospitals — funds whose use is still not fully accounted for — Noble had stopped paying its bills, according to court records. Contractors, including nursing agencies, a lab that ran COVID tests and landscapers, have filed lawsuits seeking millions.
In Audrain County, where community members still hope to reopen the hospital or build a new one, county leaders filed suit for the repayment of a $1.8 million loan they made to Noble. Former Missouri state senator Jay Wasson also filed suit in September, asking for repayment of a $500,000 loan.
Two Noble Health real estate entities filed bankruptcy petitions this year. One Chapter 11 bankruptcy filing names the Fulton hospital property in Callaway County as an asset and lists nearly $4.9 million in liabilities. A third bankruptcy filing by FMC Clinic includes Noble Health as a codebtor.
Federal investigators listed nearly a dozen people or entities connected to Noble Health as fiduciaries who they say are personally responsible for paying back millions in unpaid medical claims. The letter also detailed Noble Health's ownership for the first time. The owners included William A. Solomon with a 16.82% share, Thomas W. Carter with a 16.82% share, The Peterson Trust with a 19.63%, and NC Holdings Inc. with 46.72%.
NC Holdings is also listed on the stock sale agreement with Platinum along with several signatures including Jeremy Tasset, chief executive of Nueterra Capital.
Tasset did not respond to a request for comment for this article. In an email to KHN in March 2022, the Nueterra Capital CEO wrote, "We are a minority investor in the real estate and have nothing to do with the operations of the hospitals." In May 2022, Tasset wrote in an email to KHN that "everything was sold (real estate included) to Platinum Neighbors, a subsidiary of Platinum Team Management."
It is unclear who owns and controls The Peterson Trust, which federal investigators identified. Peterson, who is listed on Noble's state registration papers as a director and in other roles, didn't respond to requests for comment for this article. He previously told KHN that his involvement in Noble didn't violate his exclusion, in his reading of the law.
He said he owned 3% of the company, citing guidance from the Office of Inspector General for the U.S. Department of Health and Human Services. Federal regulators may exclude companies if someone who is banned has ownership of 5% or more.
In March 2022, Peterson created Noble Health Services, which federal investigators note in their letter was "established to restructure the ownership of multiple Noble entities." Peterson dissolved that company in July 2022, according to a Missouri business filing.
In September, Peterson posted on LinkedIn that he was "sitting in the Emirates Air lounge in Dubai" to finish up due diligence on "launching a new business."
A 2013 OIG advisory states that "an excluded individual may not serve in an executive or leadership role" and "may not provide other types of administrative and management services … unless wholly unrelated to federal healthcare programs."
KHN examined the federal system meant to stop healthcare business owners and executives from repeatedly bilking government health programs and found that it failed to do so.
The OIG keeps a public list of people and businesses it has banned from all federal healthcare programs, such as Medicare and Medicaid. KHN's review found a system devoid of oversight and rife with legal gray areas.
In the wake of KHN's reporting, Oregon Sen. Ron Wyden, a Democrat who is the chair of the powerful Senate Finance Committee, said "it's imperative that federal watchdogs can ensure bad actors are kept out of Medicare." Sen. Chuck Grassley (R-Iowa) said the government needs to do more and "it's also up to private-sector entities to do a better job checking against the exclusions list."
"We can't just depend on one or the other to do everything," Grassley said.
In recent months, the Missouri hospitals appear to have been sold twice more, according to public records. Oregon-based Saint Pio of Pietrelcina notified state officials of a change of ownership in December and requested an extension of the hospital licenses, which was denied. In January, Audrain County officials, in its lawsuit, revealed another owner named Pasture Medical, which registered as a Wyoming company on Dec. 27, 2022.
"We haven't come out of the rabbit hole on this one," said Steve Bollin, director of the division of regulation and licensure for the Missouri Department of Health and Senior Services. Bollin's agency, which conducts inspections and approves hospital changes in ownership, said he would support his agency doing financial reviews.
"It's probably not a bad idea that someone takes a little bit deeper dive. We don't have that many changes of ownership, but we would need appropriate staffing to do that, including some really good CPAs [certified public accountants]."
The Biden administration's decision to end the COVID-19 public health emergency in May will institute sweeping changes across the healthcare system that go far beyond many people having to pay more for COVID tests.
In response to the pandemic, the federal government in 2020 suspended many of its rules on how care is delivered. That transformed essentially every corner of American healthcare — from hospitals and nursing homes to public health and treatment for people recovering from addiction.
Now, as the government prepares to reverse some of those steps, here's a glimpse at ways patients will be affected:
Training Rules for Nursing Home Staff Get Stricter
The end of the emergency means nursing homes will have to meet higher standards for training workers.
Advocates for nursing home residents are eager to see the old, tougher training requirements reinstated, but the industry says that move could worsen staffing shortages plaguing facilities nationwide.
In the early days of the pandemic, to help nursing homes function under the virus's onslaught, the federal government relaxed training requirements. The Centers for Medicare & Medicaid Services instituted a national policy saying nursing homes needn't follow regulations requiring nurse aides to undergo at least 75 hours of state-approved training. Normally, a nursing home couldn't employ aides for more than four months unless they met those requirements.
Last year, CMS decided the relaxed training rules would no longer apply nationwide, but states and facilities could ask for permission to be held to the lower standards. As of March, 17 states had such exemptions, according to CMS — Georgia, Indiana, Louisiana, Maryland, Massachusetts, Minnesota, Mississippi, New Jersey, New York, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Vermont, and Washington — as did 356 individual nursing homes in Arizona, California, Delaware, Florida, Illinois, Iowa, Kansas, Kentucky, Michigan, Nebraska, New Hampshire, North Carolina, Ohio, Oregon, Virginia, Wisconsin, and Washington, D.C.
Nurse aides often provide the most direct and labor-intensive care for residents, including bathing and other hygiene-related tasks, feeding, monitoring vital signs, and keeping rooms clean. Research has shown that nursing homes with staffing instability maintain a lower quality of care.
Advocates for nursing home residents are pleased the training exceptions will end but fear that the quality of care could nevertheless deteriorate. That's because CMS has signaled that, after the looser standards expire, some of the hours that nurse aides logged during the pandemic could count toward their 75 hours of required training. On-the-job experience, however, is not necessarily a sound substitute for the training workers missed, advocates argue.
Adequate training of aides is crucial so "they know what they're doing before they provide care, for their own good as well as for the residents," said Toby Edelman, a senior policy attorney for the Center for Medicare Advocacy.
The American healthcare Association, the largest nursing home lobbying group, released a December survey finding that roughly 4 in 5 facilities were dealing with moderate to high levels of staff shortages.
Treatment Threatened for People Recovering From Addiction
A looming rollback of broader access to buprenorphine, an important medication for people in recovery from opioid addiction, is alarming patients and doctors.
During the public health emergency, the Drug Enforcement Administration said providers could prescribe certain controlled substances virtually or over the phone without first conducting an in-person medical evaluation. One of those drugs, buprenorphine, is an opioid that can prevent debilitating withdrawal symptoms for people trying to recover from addiction to other opioids. Research has shown using it more than halves the risk of overdose.
Amid a national epidemic of opioid addiction, if the expanded policy for buprenorphine ends, "thousands of people are going to die," said Ryan Hampton, an activist who is in recovery.
The DEA in late February proposed regulations that would partly roll back the prescribing of controlled substances through telemedicine. A clinician could use telemedicine to order an initial 30-day supply of medications such as buprenorphine, Ambien, Valium, and Xanax, but patients would need an in-person evaluation to get a refill.
For another group of drugs, including Adderall, Ritalin, and oxycodone, the DEA proposal would institute tighter controls. Patients seeking those medications would need to see a doctor in person for an initial prescription.
David Herzberg, a historian of drugs at the University at Buffalo, said the DEA's approach reflects a fundamental challenge in developing drug policy: meeting the needs of people who rely on a drug that can be abused without making that drug too readily available to others.
The DEA, he added, is "clearly seriously wrestling with this problem."
Hospitals Return to Normal, Somewhat
During the pandemic, CMS has tried to limit problems that could arise if there weren't enough healthcare workers to treat patients — especially before there were COVID vaccines when workers were at greater risk of getting sick.
For example, CMS allowed hospitals to make broader use of nurse practitioners and physician assistants when caring for Medicare patients. And new physicians not yet credentialed to work at a particular hospital — for example, because governing bodies lacked time to conduct their reviews — could nonetheless practice there.
Other changes during the public health emergency were meant to shore up hospital capacity. Critical access hospitals, small hospitals located in rural areas, didn't have to comply with federal rules for Medicare stating they were limited to 25 inpatient beds and patients' stays could not exceed 96 hours, on average.
Once the emergency ends, those exceptions will disappear.
Hospitals are trying to persuade federal officials to maintain multiple COVID-era policies beyond the emergency or work with Congress to change the law.
Surveillance of Infectious Diseases Splinters
The way state and local public health departments monitor the spread of disease will change after the emergency ends, because the Department of Health and Human Services won't be able to require labs to report COVID testing data.
Without a uniform, federal requirement, how states and counties track the spread of the coronavirus will vary. In addition, though hospitals will still provide COVID data to the federal government, they may do so less frequently.
Public health departments are still getting their arms around the scope of the changes, said Janet Hamilton, executive director of the Council of State and Territorial Epidemiologists.
In some ways, the end of the emergency provides public health officials an opportunity to rethink COVID surveillance. Compared with the pandemic's early days, when at-home tests were unavailable and people relied heavily on labs to determine whether they were infected, testing data from labs now reveals less about how the virus is spreading.
Public health officials don't think "getting all test results from all lab tests is potentially the right strategy anymore," Hamilton said. Flu surveillance provides a potential alternative model: For influenza, public health departments seek test results from a sampling of labs.
"We're still trying to work out what's the best, consistent strategy. And I don't think we have that yet," Hamilton said.
KNOXVILLE, Iowa ― Bette Helm was glad to have someone to talk with about her insomnia.
Helm lives in a nursing home in this central Iowa town of about 7,500 people, where mental health services are sparse. On a recent morning, she had an appointment with a psychiatric nurse practitioner about 800 miles away in Austin, Texas. They spoke via video, with Helm using an iPad she held on her lap while sitting in her bed.
Video visits are an increasingly common way for residents of small-town nursing homes to receive mental healthcare. Patients don't have to travel to a clinic. They don't even have to get cleaned up and leave their bedrooms, which can be daunting for people with depression or anxiety. Online care providers face fewer appointment cancellations, and they often can work from home. While use of some other telehealth services may dwindle as the COVID-19 pandemic winds down, providers predict demand for remote mental health services will continue to increase in rural nursing homes.
"Are you anxious when you try to fall asleep? Is your mind racing?" asked the nurse practitioner, Ayesha Macon.
"Yeah, that's sort of my time to think," Helm said. Her thoughts can keep her up past 3 a.m., she said.
They discussed the anxiety Helm sometimes feels during the day and her routine of watching the TV news at 10 p.m. Macon suggested the news might wind Helm up, and she wondered if the 71-year-old patient could ease stress by skipping the news before going to bed.
"No," Helm said. "I find it interesting. I want to know what's going on in the world. I've always been a bit of a newshound."
Macon smiled and said she understood. So they talked about other approaches, including using online meditation programs and spending quiet time reading the dozens of novels Helm keeps stacked in her room. "If I couldn't read, I think I would go absolutely bananas," she told Macon, who agreed it was a good habit.
Telemedicine visits became much more common throughout the American healthcare system during the pandemic, as guidelines on "social distancing" curtailed in-person appointments and insurers eased restrictions on what they would cover. The number of telehealth visits paid for by Medicare jumped tenfold in the last nine months of 2020 compared with the same period a year before.
Supporters of online treatment say it's a good match for mental healthcare, especially in settings where in-person services have been hard to arrange. They cite small-town nursing homes as prime examples. The company that arranged Helm's recent appointment, Encounter Telehealth, serves more than 200 nursing homes and assisted living centers, mostly in the Midwest. About 95% of those facilities are in rural areas, said Jen Amis, president of the company, which is based in Omaha, Nebraska.
Encounter Telehealth uses about 20 mental health professionals, many of whom are psychiatric nurse practitioners living in cities. The practitioners read the patients' electronic medical records through a secure computer system, and they review symptoms and medications with nursing home staff members before each appointment. They complete up to 2,000 visits a month.
It's important for seniors to have expert support as they face stress and uncertainty in aging, Amis said. "We're all going to be there at some point," she said. "Don't you want that last chapter to be peaceful?"
The company saw demand for its services surge in care facilities when the pandemic hit. Nursing homes were closed to visitors for months at a time while the coronavirus caused thousands of illnesses and deaths among residents and employees. The stress could be overwhelming for everyone involved. "Oh, my gosh, the isolation and fear," Amis said.
Amis said several developments have made her company's services possible. Electronic medical records and video systems are crucial. Also, she said, many states have given more independent authority to nurse practitioners and other nonphysicians, and it has become easier to bill public and private insurance plans for mental health treatment.
The federal government could tighten rules for some kinds of telehealthcare as the pandemic wanes. But Medicare paid for many remote mental health visits to rural areas before COVID, and Amis expects the support to continue.
Jonathan Neufeld, program director of the Great Plains Telehealth Resource and Assistance Center at the University of Minnesota, said in-person mental healthcare can be hard to arrange in rural care facilities.
"You've got a double or even triple whammy going right now," said Neufeld, a psychologist whose center is supported by federal grants.
He noted the number of mental health professionals nationally has been insufficient for many years, even before the pandemic. And all kinds of rural employers, including nursing homes, face critical staffing shortages.
Neufeld said telehealth visits can be a challenge for some care-facility residents, including those with dementia, who might not understand how a video feed works. But he said it also can be difficult to treat people with dementia in person. Either way, a staff member or relative needs to accompany them during appointments and the mental health professional generally consults with facility staff about a patient's treatment.
Before telemedicine was available, more residents of rural nursing homes needed to be driven to a clinic in another town to see a mental health professional. That could eat up hours of staff time and add stress to the patients' lives.
Seleta Stewart, a certified nursing assistant at the Accura HealthCare nursing home where Helm lives, said the facility's need for the telehealth service is increasing, partly because the facility is home to several younger residents with mental illnesses. In the past, she said, many such Iowans would have been served by specialized facilities, such as two state mental hospitals that closed in 2015. But more now live in nursing homes.
"Iowa is just not a great state for mental health," Stewart said.
Neufeld said that, even with telemedicine's efficiencies, staffing can be a challenge for companies providing the service in nursing homes. Many mental health professionals already have more patients than they can handle, and they might not have time to pitch in online. He added that Medicare, which insures most seniors, pays lower rates than private insurers or patients paying on their own.
Amis, Encounter Telehealth's president, said Medicare pays about $172 for an initial appointment and about $107 for a follow-up appointment; care providers collect roughly 30% to 75% more from patients who use private insurance or pay their own bills, she said. She added that nursing homes pay a fee to Encounter for the convenience of having mental health professionals visit by video.
Several patients and care providers said the shift to video appointments is usually smooth, despite seniors' reputation for being uncomfortable with new technology.
Dr. Terry Rabinowitz, a psychiatrist and professor at the University of Vermont, has been providing telemedicine services to a rural nursing home in upstate New York since 2002. He said many patients quickly adjust to video visits, even if it's not their initial preference.
"I think most people, if they had their druthers, would rather see me in person," he said. "And if I had my druthers, I'd rather see them in person." Online visits can have special challenges, including for patients who don't hear or see well, he said. But those complications can be addressed.
Nancy Bennett, another resident of Helm's Iowa nursing home, can attest to the benefits. Bennett had a video appointment with Macon on a recent morning. She told the nurse practitioner she'd been feeling stressed. "I'm 72, I'm in a nursing home, I've got no family around, so yeah, I'm a little depressed," she said. "I do get sad sometimes."
"That's normal," Macon assured her.
Bennett said she dislikes taking a lot of pills. Macon said she could taper some of Bennett's medication.
In an interview afterward, Bennett said she'd gone to a clinic for mental healthcare in the past. That was before physical issues forced her into the nursing home, where she spends much of her time sitting in a blue recliner in her room.
If she'd had to get dressed and travel for her appointment with Macon, she said, she probably would have canceled. "There are days when I don't want to be bothered," she said.
But on this day, the mental health professional came to her on an iPad ― and helped Bennett feel a little better.
To crack down on price gouging, proposed legislation in Missouri calls for allowing felony charges against healthcare staffing agencies that substantially raise their prices during a declared emergency.
A New York bill includes a cap on the amount staffing agencies can charge healthcare facilities. And a Texas measure would allow civil penalties against such agencies.
These proposed regulations — and others in at least 11 more states, according to the American Staffing Association industry trade group — come after demand for travel nurses, who work temporary assignments at different facilities, surged to unprecedented levels during the worst of the covid-19 pandemic.
Hospitals have long used temporary workers, who are often employed by third-party agencies, to help fill their staffing needs. But by December 2021, the average weekly travel nurse pay in the country had soared to $3,782, up from $1,896 in January 2020, according to a Becker's Hospital Review analysis of data from hiring platform Vivian Health. That platform alone listed over 645,000 active travel nurse jobs in the final three months of 2022.
Some traveling intensive care unit nurses commanded $10,000 a week during the worst of the pandemic, prompting burned-out nurses across the country to leave their hospital staff jobs for more lucrative temporary assignments. Desperate hospitals that could afford it offered signing bonuses as high as $40,000 for nurses willing to make multiyear commitments to join their staff instead.
The escalating costs led hospitals and their allies around the country to rally against what they saw as price gouging by staffing agencies. In February 2021, the American Hospital Association urged the Federal Trade Commission to investigate "anticompetitive pricing" by agencies, and, a year later, hundreds of lawmakers urged the White House to do the same.
No substantial federal action has occurred, so states are trying to take the next step. But the resulting regulatory patchwork could pose a different challenge to hospitals in states with rate caps or other restrictive measures, according to Hannah Neprash, a University of Minnesota healthcare economics professor. Such facilities could find it difficult to hire travel nurses or could face a lower-quality hiring pool during a national crisis than those in neighboring states without such measures, she said.
For example, Massachusetts and Minnesota already had rate caps for temporary nurses before the pandemic but raised and even waived their caps for some staffing agencies during the crisis.
And any new restrictions may meet stiff resistance, as proposed rate caps did in Missouri last year.
As the covid omicron variant wave began to subside, Missouri legislators considered a proposal that would have set the maximum rate staffing agencies could charge at 150% of the average wage rate of the prior three years plus necessary taxes.
The Missouri Hospital Association, a trade group that represents 140 hospitals across the state, supported the bill as a crackdown on underhanded staffing firms, not on nurses being able to command higher wages, spokesperson Dave Dillon said.
"During the pandemic there were staffing companies who were making a lot of promises and not necessarily delivering," Dillon said. "It created an opportunity for both profiteering and for bad actors to be able to play in that space."
Nurses, though, decried what they called government overreach and argued the bill could make the state's existing nursing shortage worse.
Theresa Newbanks, a nurse practitioner, asked legislators to imagine the government attempting to dictate how much a lawyer, electrician, or plumber could make in Missouri. "This would never be allowed," she testified to the committee considering the bill. "Yet, this is exactly what is happening, right now, to nurses."
Another of the nearly 30 people who testified against the bill was Michelle Hall, a longtime nurse and hospital nursing leader who started her own staffing agency in 2021, in part, she said, because she was tired of seeing her peers leave the industry over concerns about unsafe staffing ratios and low pay.
"I felt like I had to defend my nurses," Hall later told KHN. Her nurses usually receive about 80% of the amount she charges, she said.
Typically about 75% of the price charged by a staffing agency to a healthcare facility goes to costs such as salary, payroll taxes, workers' compensation programs, unemployment insurance, recruiting, training, certification, and credential verification, said Toby Malara, a vice president at the American Staffing Association trade group.
He said hospital executives have, "without understanding how a staffing firm works," wrongly assumed price gouging has been occurring. In fact, he said many of his trade group's members reported decreased profits during the pandemic because of the high compensation nurses were able to command.
While Missouri lawmakers did not pass the rate cap, they did make changes to the regulations governing staffing agencies, including requiring them to report the average amounts charged per healthcare worker for each personnel category and the average amount paid to those workers. Those reports will not be public, although the state will use them to prepare its own aggregate reports that don't identify individual agencies. The public comment period on the proposed regulations was scheduled to begin March 15.
Hall was not concerned about the reporting requirements but said another of the changes might prompt her to close shop or move her business out of state: Agencies will be barred from collecting compensation when their employees get recruited to work for the facility where they temp.
"It doesn't matter all the money that I have put out prior, to onboard and train that person," Hall said.
Dillon called that complaint "pretty rich," noting that agencies routinely recruit hospital staff members by offering higher pay. "Considering the premium agencies charge for staff, I find it hard to believe that this risk isn't built into their business model," he said.
Of course, as the pandemic has waned, the demand for travel nursing has subsided. But pay has yet to drop back to pre-pandemic levels. Average weekly travel nurse pay was $3,077 in January, down 20% year over year but still 62% higher in January 2020, according to reporting on Vivian Health data by Becker's.
With the acute challenges of the pandemic behind hospitals, Dillon said, health system leaders are eyeing proactive solutions to meet their ongoing workforce challenges, such as raising pay and investing in the nursing workforce pipeline.
But the momentum to directly address high travel nurse rates hasn't gone away, as evidenced by the legislative push in Missouri this year.
The latest proposal would apply to certain agencies if a "gross disparity" exists between the prices they charge during an emergency and what they charged prior to it or what other agencies are currently charging for similar services and if their earnings are at least 15% higher than before the emergency.
Malara said he doesn't have much of a problem with this year's bill because it gives agencies the ability to defend their practices and pricing.
Kentucky last year applied its existing price gouging rules to healthcare staffing agencies. The rules, which set criteria for acceptable prices, allow increases driven by higher labor costs. Malara said if the Missouri bill gains momentum he will point its sponsor to that language and ask her to clarify what constitutes a "gross disparity" in prices.
The sponsor of the bill, Missouri state Sen. Karla Eslinger, a Republican, did not respond to requests for comment on the legislation.
Hall said she is opposed to any rate caps but is ambivalent about Missouri's new proposal. She said she saw agencies raising their prices from $70 an hour to over $300 while she worked as a hospital nursing leader at the height of the pandemic.
"All these agencies that were price gouging," Hall said, "all they were doing was putting that money in their own pockets. They weren't doing anything different or special for their nurses."
Tamara Etienne's second pregnancy was freighted with risk and worry from its earliest days — exacerbated by a first pregnancy that had ended in miscarriage.
A third-grade teacher at an overcrowded Miami-Dade County public school, she spent harried days on her feet. Financial worries weighed heavy, even with health insurance and some paid time off through her job.
"I'm experiencing it every day, not walking alone, walking with someone I have to protect," she said. "So the level of cortisol in my body when I'm pregnant? Immeasurable."
Two months into the pregnancy, the unrelenting nausea suddenly stopped. "I started to feel like my pregnancy symptoms were going away," she said. Then strange back pain started.
Etienne and her husband rushed to an emergency room, where a doctor confirmed she was at grave risk for a miscarriage. A cascade of medical interventions — progesterone injections, fetal monitoring at home, and bed rest while she took months off work — saved the child, who was born at 37 weeks.
About 1 in 10 live births in 2021 occurred before 37 weeks of gestation, according to a March of Dimes report released last year. By comparison, research in recent years has cited preterm birth rates of 7.4% in England and Wales, 6% in France, and 5.8% in Sweden.
In its 2022 report card, the March of Dimes found the preterm birth rates increased in nearly every U.S. state from 2020 to 2021. Vermont, with a rate of 8%, merited the nation's highest grade: an "A-." The grimmest outcomes were concentrated in the Southern states, which largely earned "F" ratings, with preterm birth rates of 11.5% or higher. Mississippi (15%), Louisiana (13.5%), and Alabama (13.1%) were the worst performers. The March of Dimes report found 10.9% of live births in Florida were delivered preterm in 2021, earning the state a "D" rating.
That includes Florida, where Etienne lives, and where Republican lawmakers have enacted a series of anti-abortion laws, including a ban on abortion after 15 weeks of gestation. Florida is one of the least generous states when it comes to public health insurance. About 1 in 6 women of childbearing age in Florida are uninsured, making it more difficult to begin a healthy pregnancy. Women are twice as likely to die from pregnancy and childbirth-related causes in Florida than in California.
"I lose sleep over this," said Dr. Elvire Jacques, a maternal-fetal medicine specialist at Memorial Hospital in Miramar, Florida. "It's hard to say, I expect [better birth outcomes] when I'm not investing anything from the beginning."
The causes of preterm births are varied. About 25% are medically induced, Jacques said, when the woman or fetus is in distress because of conditions like preeclampsia, a pregnancy-related hypertensive disorder. But research suggests that far more early births are thought to be rooted in a mysterious constellation of physiological conditions.
"It's very hard to identify that a patient will automatically have a preterm birth," Jacques said. "But you can definitely identify stressors for their pregnancies."
Physicians say that roughly half of all preterm births are preventable, caused by social, economic, and environmental factors, as well as inadequate access to prenatal healthcare. Risk factors include conditions such as diabetes and obesity, as well as more-hidden issues like stress or even dehydration.
At Memorial Hospital in Miramar, part of a large public healthcare system, Jacques takes on high-risk pregnancies referred from other OB-GYNs in South Florida.
When meeting a patient for the first time she asks: Who else is in your household? Where do you sleep? Do you have substance abuse issues? Where do you work? "If you don't know that your patient works in a factory [standing] on an assembly line," she said, "then how are you going to tell her to wear compression socks because that may help her prevent blood clots?"
Jacques has urged a store manager to let her pregnant patient sit while working. She persuaded an imam to grant a mom-to-be with diabetes a reprieve from religious fasting.
Because diabetes is a major risk factor, she often talks with patients about eating healthfully. For those who eat fast food, she asks them to try cooking at home. Instead of, "Can you pay for food?" she asks, "Of the foods we're discussing, which one do you think you can afford?"
Access to affordable care separates Florida from states like California and Massachusetts — which have paid family leave and low rates of uninsured residents — and separates the U.S. from other countries, health policy experts say.
In countries with socialized healthcare, "women don't have to worry about the financial cost of care," said Dr. Delisa Skeete-Henry, chair of the obstetrics and gynecology department at Broward Health in Fort Lauderdale. "A lot of places have paid leave, [and pregnant patients] don't have to worry about not being at work."
Yet, as preterm births rise in the U.S., wealth does not ensure better pregnancy outcomes.
Startling new research shows that at every U.S. income level, Black women and their infants experience far worse birth outcomes than their white counterparts. In other words, all the resources that come with wealth do not protect Black women or their babies from preterm complications, according to the study, published by the National Bureau of Economic Research.
Jamarah Amani has seen this firsthand as executive director of the Southern Birth Justice Network and an advocate for midwifery and doula care in South Florida. As she evaluates new clients, she looks for clues about birth risks in a patient's family history, lab work, and ultrasounds. She homes in quickly on stress related to work, relationships, food, family, and racism.
"I find Black women working in high-stress environments, even if they are not financially struggling, can face preterm birth," she said. She develops "wellness plans" that include breathing, meditation, stretching, and walking.
Recently, when a patient showed signs of preterm labor, Amani discovered that her electricity bill was overdue and the utility was threatening to cut service. Amani found an organization to pay off the debt.
Of Tamara Etienne's six pregnancies, two ended in miscarriage and four were threatened by preterm labor. Fed up with the onslaught of medical interventions, she found a local doula and midwife who helped guide her through the birth of her two youngest children.
"They were able to walk me through healthy, natural ways to mitigate all of those complications," she said.
Her own pregnancy experiences left a profound impact on Etienne. She has since become a fertility doula herself.
When Paula Chestnut needed hip replacement surgery last year, a pre-operative X-ray found irregularities in her chest.
As a smoker for 40 years, Chestnut was at high risk for lung cancer. A specialist in Los Angeles recommended the 67-year-old undergo an MRI, a high-resolution image that could help spot the disease.
But her MRI appointment kept getting canceled, Chestnut's son, Jaron Roux, told KHN. First, it was scheduled at the wrong hospital. Next, the provider wasn't available. The ultimate roadblock she faced, Roux said, arrived when Chestnut's health insurer deemed the MRI medically unnecessary and would not authorize the visit.
"On at least four or five occasions, she called me up, hysterical," Roux said.
Months later, Chestnut, struggling to breathe, was rushed to the emergency room. A tumor in her chest had become so large that it was pressing against her windpipe. Doctors started a regimen of chemotherapy, but it was too late. Despite treatment, she died in the hospital within six weeks of being admitted.
Though Roux doesn't fully blame the health insurer for his mother's death, "it was a contributing factor," he said. "It limited her options."
Few things about the American healthcare system infuriate patients and doctors more than prior authorization, a common tool whose use by insurers has exploded in recent years.
Prior authorization, or pre-certification, was designed decades ago to prevent doctors from ordering expensive tests or procedures that are not indicated or needed, with the aim of delivering cost-effective care.
Originally focused on the costliest types of care, such as cancer treatment, insurers now commonly require prior authorization for many mundane medical encounters, including basic imaging and prescription refills. In a 2021 survey conducted by the American Medical Association, 40% of physicians said they have staffers who work exclusively on prior authorization.
So today, instead of providing a guardrail against useless, expensive treatment, pre-authorization prevents patients from getting the vital care they need, researchers and doctors say.
"The prior authorization system should be completely done away with in physicians' offices," said Dr. Shikha Jain, a Chicago hematologist-oncologist. "It's really devastating, these unnecessary delays."
In December, the federal government proposed several changes that would force health plans, including Medicaid, Medicare Advantage, and federal Affordable Care Act marketplace plans, to speed up prior authorization decisions and provide more information about the reasons for denials. Starting in 2026, it would require plans to respond to a standard prior authorization request within seven days, typically, instead of the current 14, and within 72 hours for urgent requests. The proposed rule was scheduled to be open for public comment through March 13.
Although groups like AHIP, an industry trade group formerly called America's Health Insurance Plans, and the American Medical Association, which represents more than 250,000 physicians in the United States, have expressed support for the proposed changes, some doctors feel they don't go far enough.
"Seven days is still way too long," said Dr. Julie Kanter, a hematologist in Birmingham, Alabama, whose sickle cell patients can't delay care when they arrive at the hospital showing signs of stroke. "We need to move very quickly. We have to make decisions."
Meanwhile, some states have passed their own laws governing the process. In Oregon, for example, health insurers must respond to nonemergency prior authorization requests within two business days. In Michigan, insurers must report annual prior authorization data, including the number of requests denied and appeals received. Other states have adopted or are considering similar legislation, while in many places insurers regularly take four to six weeks for non-urgent appeals.
In some cases, care has been denied and never obtained. In others, prior authorization proved a potent but indirect deterrent, as few patients have the fortitude, time, or resources to navigate what can be a labyrinthine process of denials and appeals. They simply gave up, because fighting denials often requires patients to spend hours on the phone and computer to submit multiple forms.
Erin Conlisk, a social science researcher for the University of California-Riverside, estimated she spent dozens of hours last summer trying to obtain prior authorization for a 6-mile round-trip ambulance ride to get her mother to a clinic in San Diego.
Her 81-year-old mother has rheumatoid arthritis and has had trouble sitting up, walking, or standing without help after she damaged a tendon in her pelvis last year.
Conlisk thought her mom's case was clear-cut, especially since they had successfully scheduled an ambulance transport a few weeks earlier to the same clinic. But the ambulance didn't show on the day Conlisk was told it would. No one notified them the ride hadn't been pre-authorized.
The time it takes to juggle a prior authorization request can also perpetuate racial disparities and disproportionately affect those with lower-paying, hourly jobs, said Dr. Kathleen McManus, a physician-scientist at the University of Virginia.
"When people ask for an example of structural racism in medicine, this is one that I give them," McManus said. "It's baked into the system."
Research that McManus and her colleagues published in 2020 found that federal Affordable Care Act marketplace insurance plans in the South were 16 times more likely to require prior authorization for HIV prevention drugs than those in the Northeast. The reason for these regional disparities is unknown. But she said that because more than half the nation's Black population lives in the South, they'd be the patients more likely to face this barrier.
Many of the denied claims are reversed if a patient appeals, according to the federal government. New data specific to Medicare Advantage plans found 82% of appeals resulted in fully or partially overturning the initial prior authorization denial, according to KFF.
It's not just patients who are confused and frustrated by the process. Doctors said they find the system convoluted and time-consuming, and feel as if their expertise is being challenged.
"I lose hours of time that I really don't have to argue … with someone who doesn't even really know what I'm talking about," said Kanter, the hematologist in Birmingham. "The people who are making these decisions are rarely in your field of medicine."
Occasionally, she said, it's more efficient to send patients to the emergency room than it is to negotiate with their insurance plan to pre-authorize imaging or tests. But emergency care costs both the insurer and the patient more.
"It's a terrible system," she said.
A KFF analysis of 2021 claims data found that 9% of all in-network denials by Affordable Care Act plans on the federal exchange, healthcare.gov, were attributed to lack of prior authorization or referrals, but some companies are more likely to deny a claim for these reasons than others. In Texas, for example, the analysis found 22% of all denials made by Blue Cross and Blue Shield of Texas and 24% of all denials made by Celtic Insurance Co. were based on lack of prior authorization.
Facing scrutiny, some insurers are revising their prior authorization policies. UnitedHealthcare has cut the number of prior authorizations in half in recent years by eliminating the need for patients to obtain permission for some diagnostic procedures, like MRIs and CT scans, said company spokesperson Heather Soules. Health insurers have also adopted artificial intelligence technology to speed up prior authorization decisions.
Meanwhile, most patients have no means of avoiding the burdensome process that has become a defining feature of American healthcare. But even those who have the time and energy to fight back may not get the outcome they hoped for.
When the ambulance never showed in July, Conlisk and her mother's caregiver decided to drive the patient to the clinic in the caregiver's car.
"She almost fell outside the office," said Conlisk, who needed the assistance of five bystanders to move her mother safely into the clinic.
When her mother needed an ambulance for another appointment in September, Conlisk vowed to spend only one hour a day, for two weeks leading up to the clinic visit, working to get prior authorization. Her efforts were unsuccessful. Once again, her mother's caregiver drove her to the clinic himself.
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The federal COVID-19 pandemic protections that have largely prohibited states from dropping anyone from Medicaid since 2020 helped millions of low-income Americans retain health insurance coverage — even if they no longer qualified — and brought the U.S. uninsured rate to a record low.
It also led to a windfall for the health plans that states pay to oversee care of most Medicaid enrollees. These plans — many run by insurance titans including UnitedHealthcare, Centene, and Aetna — have seen their revenue surge by billions as their membership soared by millions.
With states poised to start disenrolling Medicaid enrollees in April who no longer qualify, the insurers hope to retain enrollees who are still eligible and capture those who lose coverage with the Affordable Care Act marketplace plans.
Except for the enrollees themselves, for whom losing coverage could restrict access to care and leave them vulnerable to large medical bills, no one has more at stake than these insurers. The plans have a strong financial incentive to keep their members enrolled because states pay them per member, per month: The more people they cover, the more money they get.
The Biden administration estimates that 15 million of the more than 91 million Medicaid enrollees will fall off the rolls, nearly half because their income exceeds program limits and the rest because they fail to complete the reenrollment paperwork.
Of the people losing eligibility, about two-thirds will enroll in a workplace health plan, health insurers predict, and the other third will be evenly divided between ACA plans and being left uninsured.
The financial ramifications of the so-called Medicaid unwinding for health plans are huge, said Gary Taylor, a securities analyst with Cowen and Co. "It's billions of dollars for these guys," he said of the five largest Medicaid health plans: Centene, UnitedHealthcare, Aetna, Elevance Health (formerly Anthem), and Molina Healthcare.
Investor-owned companies earn pretax profit margins of about 3% on average from Medicaid managed care, slightly below what they make on ACA marketplace business, he said. So moving members to an ACA plan could boost the profits of these companies.
State Medicaid officials say they need the health plans' help during the unwinding to avert a big jump in uninsured residents. The health insurers could help those who lose Medicaid coverage find other sources, such as the government-subsidized plans offered on the ACA marketplaces.
"In Nevada, our managed-care plans are motivated to keep members enrolled," Sandie Ruybalid, deputy administrator of the Nevada state health department division that oversees Medicaid, told a congressional advisory board in January. "Our managed-care plans are innovative, and we lean on them to help us through this."
Ruybalid said her state doesn't have large marketing budgets, as the giant insurers do, to educate enrollees about how to stay enrolled.
One way some companies hope to make up for their lost Medicaid revenue will be by adding customers to their ACA marketplace plans.
Centene — the nation's largest Medicaid health insurer, with 16 million members — expects to lose over 2 million enrollees during the unwinding. But it expects between 200,000 and 300,000 people who lose Medicaid coverage to sign up for a Centene ACA marketplace plan, CEO Sarah London told investment analysts in February.
In 15 of the 25 states where St. Louis-based Centene offers both Medicaid and marketplace plans, the company will reach out to members about their ACA coverage options.
Although state Medicaid programs for years have used private insurers to control their costs and improve enrollees' health, enlisting the companies for eligibility assistance is new.
Health plans are often in a better position than state Medicaid agencies to connect with enrollees because they are more likely to have their current addresses and contact information, state officials said.
"We don't have direct contact with our members all the time, and health plans have more interaction with them," said Chris Underwood, chief administrative officer for the Colorado Department of healthcare Policy and Financing, the state's Medicaid agency. Since the state contracts with health plans to help enrollees find doctors or assist with other care needs, it's not a big step to have the plans help with eligibility, he said.
Colorado health officials will do the initial outreach to Medicaid enrollees and will count on health plans to follow up with emails, calls, and texts to those who don't respond, Underwood said. Health plans will also guide enrollees no longer eligible for Medicaid to the state's ACA marketplace, which will reach out to help them sign up.
AmeriHealth Caritas, which has about 2.8 million Medicaid enrollees nationwide, will target community organizations such as churches, homeless shelters, and food banks to deliver the message about the need to reenroll. It will also email, text, and call enrollees to remind them, said Courtnay Thompson, market president for AmeriHealth Caritas' South Carolina plan, Select Health.
She said strategies to reach enrollees will vary by state. Some will try to reassess the eligibility of all members in six months, while others will take more than a year. Some states will share with the plans their enrollees' enrollment status before they lose coverage, and others won't.
UnitedHealthcare, which has about 8 million Medicaid enrollees, said its call center representatives will remind members to reenroll in Medicaid. The company will also put information about the need to reenroll at its network pharmacies and use online advertising such as on Facebook and Google. And it will work with its medical providers to make sure members understand the changes.
"We are very aware of the historical challenges that individuals face when reenrolling," said Tim Spilker, CEO of UnitedHealthcare's Community & State unit. "We are optimistic with the magnitude of the outreach that we will help increase awareness among individuals about what they need to do."
Dozens of advocates for patients and consumers, citing widespread harm caused by medical debt, are pushing the Biden administration to take more aggressive steps to protect Americans from medical bills and debt collectors.
In letters to the IRS and the Consumer Financial Protection Bureau, the groups call for new federal rules that among other things would prohibit debt for medically necessary care from appearing on consumer credit reports.
And the groups are pressing the IRS to crack down on nonprofit hospital systems that withhold financial assistance from low-income patients or make aid cumbersome to get, another common obstacle KHN documented.
"Every day people are having to make choices about housing and clothing and food because of medical debt," said Emily Stewart, executive director of Community Catalyst, a Boston nonprofit leading the effort. "It's really urgent the Biden administration take action to put protections in place."
Among the more than 50 groups supporting the initiative are national advocates such as the National Consumer Law Center, the Arthritis Foundation, and the Leukemia & Lymphoma Society.
Nationwide, 100 million people have healthcare debt, according to a KHN-NPR investigation, which has documented a crisis that is driving Americans from their homes, draining their savings, and preventing millions from accessing care they need.
While some of the debt appears on credit reports, much of it is hidden elsewhere as credit card balances, loans from relatives, or payment plans to hospitals and other medical providers.
The scale of this problem and its toll have spurred several national and state efforts.
Last spring, the White House directed federal agencies to work on relieving medical debts for veterans and to stop considering medical debt in evaluating eligibility for some federally backed mortgages.
California, Colorado, Maryland, New York, and other states have enacted new laws to expand consumer protections and require hospitals within their borders to increase financial aid. And the three largest credit agencies — Equifax, Experian, and Transunion — said they would stop including some medical debt on credit reports as of last July.
But many consumer and patient advocates say the actions, while important, still leave millions of Americans vulnerable to financial ruin if they become ill or injured. "It is critical that the CFPB take additional action," the groups wrote to the federal agency created in 2010 to bolster oversight of consumer financial products.
The major credit rating companies, for example, agreed to exclude only debts that have been paid off and unpaid debts of less than $500. Patients with larger medical bills they can't pay may still see their credit scores drop.
The groups also are asking the CFPB to eliminate deferred interest on medical credit cards. This arrangement is common for vendors such as CareCredit, whose loans carry no interest at first but can exceed 25% if patients don't pay off the loan in time.
Collection industry officials have lobbied against broader restrictions on credit reporting, saying limits would take away an important tool that hospitals, physicians' offices, and other medical providers need to collect their money and stay in business.
"We appreciate the challenges, but a broad ban on credit reporting could have some unintended consequences," said Jack Brown III, president of Florida-based Gulf Coast Collection Bureau, citing the prospect of struggling hospitals and other providers closing, which would reduce care options.
Brown, a past president of ACA International, the collection industry's leading trade association, warned that more medical providers would also start demanding upfront payment, putting additional pressure on patients.
To further protect patients from out-of-pocket costs like these, many advocates say hospitals, particularly those that are exempt from taxes because they are supposed to serve the community, must make financial aid more accessible, a key demand in the group's letters. "For too long, nonprofit hospitals have not been behaving like nonprofits," said Liz Coyle, executive director of the nonprofit Georgia Watch.
Charity care is offered at most U.S. hospitals. And nonprofit medical systems must provide aid as a condition of being tax-exempt. But at many medical centers, information about this assistance is difficult or impossible to find.
Standards also vary widely, with aid at some hospitals limited to patients with income as low as $13,590 a year. At other hospitals, people making five or six times that much can get assistance.
The result is widespread confusion that has left countless patients who should have been eligible for aid with large bills instead. A 2019 KHN analysis of hospital tax filings found that nearly half of nonprofit medical systems were billing patients with incomes low enough to qualify for charity care.
The groups are asking the IRS to issue rules that would set common standards for charity care and a uniform application across nonprofit hospitals. (Current regulations for charity care do not apply to for-profit or public hospitals.)
The advocates also want the federal agency to strengthen limits on how much nonprofit hospitals can charge and to curtail aggressive collection tactics such as foreclosing on patients' homes or denying or deferring medical care.
More than two-thirds of hospitals sue patients or take other legal action against them, such as garnishing wages or placing liens on property, according to a recent KHN investigation. A quarter sell patients' debts to debt collectors, who in turn can pursue patients for years for unpaid bills. About 1 in 5 deny nonemergency care to people with outstanding debt.
"Charitable institutions, which have other methods of collection available to them, should not be permitted to withhold needed medical care as a means to pressure patients to pay," the groups wrote.