The American Heart Association says that although aspirin can help people with previous heart attacks or strokes, its risks generally outweigh the benefits for others.
This article was first published on Tuesday, March 10, 2020 inKaiser Health News.
The large red-and-white bins at Walmart pharmacies across the country read, in bold all-caps type: "Approximately every 40 seconds an American will have a heart attack."
Inside the 3-foot-tall cartons, adorned with the American Heart Association and Bayer logos, were dozens of boxes of low-dose Bayer aspirin.
The implication was that everyone could reduce their heart attack risk by taking a "baby aspirin." But recent studies have found that's not the case.
In fact, the American Heart Association says that although aspirin can help people with previous heart attacks or strokes, its risks generally outweigh the benefits for others.
After Kaiser Health News inquired about the marketing bins, the heart association in late February said it is having Bayer, one of its major donors, pull them from Walmart — although the campaign was due to wrap up by the end of the month, anyway. But 10 days later, a reporter shopping at a Walmart in Florida found a bin still on display.
About a quarter of Walmart stores nationwide displayed the bins, the association said.
"This was a misstep," said Suzanne Grant, a spokesperson for the American Heart Association. "It was a human error on our end."
Aspirin helps keep the blood from clotting, so there is less chance that blockages will form in key heart arteries. For years, it was generally recommended as an option for healthy individuals to prevent heart attacks. But it also can lead to stomach bleeding, a serious side effect, and a number of studies have raised questions about the safety of aspirin use for people without cardiovascular disease.
Last year, after three new studies were published on the issue, the American Heart Association joined other medical groups advising against aspirin therapy unless a doctor recommends it.
The U.S. Preventive Services Task Force, an expert panel that makes recommendations on medical care, is reexamining its guidelines, which advise low-dose aspirin for people ages 50-59 who have a risk of cardiovascular disease and no history of bleeding problems. It also has noted that individuals ages 60-69 at risk of heart disease may want to consider the therapy, but it should be used selectively. Evidence for other age groups is inconclusive, the task force says.
Grant said the association approved the marketing bins without including "precise language" explaining that people need to talk to a doctor before taking aspirin regularly. That language is printed in smaller type on the Bayer baby aspirin packaging.
The bins promoted the heart association's "Life Is Why We Give," a fundraising effort. Bayer is a financial supporter of the campaign.
Dr. Eduardo Sanchez, the chief medical officer for prevention at the American Heart Association, said the bins could have given people the wrong impression and led to more liberal use of baby aspirin.
"Our position is that aspirin should be used sparingly, if at all, in people who have not had a heart attack or stroke," Sanchez said.
The heart association reviews all products and marketing that contain its logo, Sanchez said. It is unclear why or how the association allowed this display to occur.
"Any inference that Bayer's demonstration of support for the AHA's heart health initiatives could be construed as medical advice is simply preposterous," said Bayer spokesman Chris Loder. "The display contains no medical claims whatsoever and is merely intended to help the AHA raise awareness of a major public health issue."
The case highlights the ongoing challenge of communicating who should take aspirin to prevent heart attacks since the national guidelines changed a year ago.
But it also illustrates potential problems when large pharmaceutical companies team up with nonprofit health groups. Arthur Caplan, a bioethicist at New York University, said those types of connections can invite ethical questions about marketing.
Bayer gave nearly $1 million to the American Heart Association in the most recent fiscal year, according to the association's latest financial records. In all, the association received about $33 million from drug companies, medical device makers, insurers and health firms. It does not endorse any particular product.
But Caplan said the marketing displays at Walmart imply that AHA endorses the Bayer aspirin brand.
That's troublesome because, as the heart association has said, aspirin is recommended only for certain people to reduce the risk of heart attack, and the displays do not disclose that less costly, generic versions of aspirin are also available.
Doctors say they worry many patients still routinely take aspirin for protection without advice from a doctor.
"People see these displays and advertising on television and they think aspirin is like taking candy," said Dr. Jacob Shani, chair of cardiology at Maimonides Heart and Vascular Institute in New York. "The display makes it look like candy and you take this candy and you do not have a heart attack."
Still, Dr. Erin Michos, associate director of preventive cardiology at Johns Hopkins University School of Medicine in Baltimore and one of the physicianswho helped develop the heart association's new position on aspirin last year, said she has seen patients who should be taking aspirin who have stopped because they heard about the new guidelines. "There is a lot of misunderstanding," she said.
"Everyone needs to discuss with their doctor about whether aspirin is recommended for them," she said.
The situation has prompted debate in the health care community about just what standards medical facilities should use before ordering workers quarantined.
This article was first published on Monday, March 9, 2020 in Kaiser Health News.
As the U.S. battles to limit the spread of the highly contagious new coronavirus, the number of health care workers ordered to self-quarantine because of potential exposure to an infected patient is rising at an exponential pace. In Vacaville, California, alone, one case — the first documented instance of community transmission in the U.S. — left more than 200 hospital workers under quarantine and unable to work for weeks.
Across California, dozens more health care workers have been ordered home because of possible contagion in response to more than 80 confirmed cases as of Sunday afternoon. In Kirkland, Washington, more than a quarter of the city's fire department was quarantined after exposure to a handful of infected patients at the Life Care Center nursing home.
With the number of confirmed COVID-19 cases mushrooming by the day, a quarantine response of this magnitude would quickly leave the health care system short-staffed and overwhelmed. The situation has prompted debate in the health care community about just what standards medical facilities should use before ordering workers quarantined — and what safety protocols need to become commonplace in clinics and emergency rooms.
Dr. Jennifer Nuzzo, a senior scholar at the Johns Hopkins Center for Health Security, is among those arguing hospitals need to change course.
"It's just not sustainable to think that every time a health care worker is exposed they have to be quarantined for 14 days. We'd run out of health care workers," Nuzzo said. Anyone showing signs of infection should stay home, she added, but providers who may have been exposed but are not symptomatic should not necessarily be excluded from work.
The correct response, she and others said, comes down to a careful balance of the evolving science with the need to maintain a functioning health care system.
While hospitals are supposed to be prepared for just such a situation, Nuzzo said, their plans often fall short. "Absent any imminent public health crisis, it may not be one of their priorities," she said. From 2003 to 2019, federal funding for the Hospital Preparedness Program in the U.S. was cut almost in half.
In Northern California, potential exposure to the new coronavirus was exacerbated because hospitals were caught unaware by the community spread of the virus and hampered by federal protocols that initially limited diagnostic testing to patients with a history of travel to a country where the virus was known to be circulating or contact with a person with a known infection.
"At the very beginning [of an outbreak] this will happen because you don't know patients are infected and you only realize later that people were exposed," said Grzegorz Rempala, a mathematician at the College of Public Health at Ohio State University who models the spread of infectious diseases.
Now that the disease has started to spread through the community, any patient with respiratory symptoms potentially could be infected, though health officials note the likelihood remains low. As providers start routinely wearing protective gear and employing strict safety protocols, accidental exposure should decline.
The Vacaville case offers stark insight into the fallout from the narrow testing protocols initially established by the Centers for Disease Control and Prevention. When a woman was admitted to NorthBay VacaValley Hospital with respiratory symptoms on Feb. 15, dozens of hospital workers walked in and out of her room performing daily tasks. Days later, as her condition worsened, she was sent to UC Davis Medical Center, where dozens more employees were potentially exposed.
Because the woman did not meet the testing criteria in place at the time, it took days for UC Davis to get approval to have her assessed for the coronavirus. After the test came back positive, about 100 NorthBay workers were sent into self-quarantine for 14 days. At UC Davis, an additional 36 nurses and 88 other employees were quarantined, according to the unions representing those workers. (A spokesman for UC Davis said the figures were not accurate but declined to give an estimate.)
"We're not used to being concerned, before we even do the triage assessment, [about] whether the patient is infectious and could infect hospital workers," said Dr. Kristi Koenig, the EMS medical director of San Diego County. She said that thinking started to evolve during the 2014 Ebola outbreak. Hospitals should routinely mask patients who come in with respiratory symptoms, she said, given any such patient could have an infectious disease such as tuberculosis.
Yet providers don't often think in those terms. "In many ways we're spoiled because we've gone from a society 50 or 100 years ago where the major killers were infectious disease," said Dr. Michael Wilkes, a professor at UC Davis School of Medicine. "Now we've become complacent because the major killers are heart disease and diabetes."
Faced with this new infection risk, many hospitals are scrambling to retrain workers in safety precautions, such as how to correctly don and doff personal protective equipment.
Sutter Health, which has 24 hospitals in Northern California, started ramping up its emergency management system five weeks ago in preparation for COVID-19. Before coming to the emergency room, Sutter patients are asked to call a hotline to be assessed by a nurse or an automated system designed to screen for symptoms of the virus. Those with likely symptoms are guided to a telemedicine appointment unless they need to be admitted to a hospital.
Anyone arriving at a Sutter emergency room with signs of a respiratory infection is given a mask and sequestered. "A runny nose and a cough doesn't tell you much. It could be a cold, it could be a flu, and in this weather it could be allergies," said Dr. Bill Isenberg, Sutter's chief quality and safety officer. A doctor or nurse in protective equipment — including N95 mask, gown and goggles — is deployed to assess the patient's symptoms. If COVID-19 is suspected, the patient is moved into a private room.
Sutter has treated several coronavirus patients who arrived from Travis Air Force Base, which housed evacuees from the Diamond Princess cruise ship quarantined off the coast of Japan after an outbreak was detected on board. The Sutter patients were placed in negative pressure rooms so that contaminated air did not circulate to the rest of the hospital, and staff used an anteroom to take off gowns and masks.
"We do everything humanly possible to minimize the number of people who have to enter [the room]," Isenberg said. Still, he said, some workers have been quarantined; Sutter would not disclose the total.
Not all hospitals are adapting so quickly. National Nurses United, a union representing more than 150,000 nurses, recently held a news conference to call on hospitals to better protect their workers. Of the 6,500 nurses who participated in a survey the union circulated, fewer than half said they had gotten instruction in how to recognize and respond to possible cases of COVID-19. Just 30% said their employer has sufficient protective equipment on hand to protect staff if there were a surge in infected patients.
As the virus continues to spread, hospitals should be stockpiling such equipment, figuring out how to add beds and planning for staffing shortages, said Dr. Richard Waldhorn, a professor of medicine at Georgetown University and contributing scholar at Johns Hopkins who recently co-authored recommendations for hospitals on how to prepare for a COVID-19 pandemic.
Hospitals should already be training providers to take on expanded duties, Waldhorn said. If a hospital becomes overwhelmed, the Medical Reserve Corps can be mobilized, as can networks of providers who have volunteered to aid in emergency situations. Once workers have been infected and recover, it might make sense to have them treat other coronavirus patients since they will have immunity.
Eventually, as a disease becomes widespread, quarantine simply stops being a priority, said Nina Fefferman, a mathematician and epidemiologist at the University of Tennessee-Knoxville.
"There's a point where we stop trying to quarantine anyone and we just say, OK, we're going to have more deaths from the fire department not being able to fight fire than from everyone getting the disease."
The stunning 2019 defeat of a plan to implement such a policy in Connecticut shows how difficult it may be to enact even "moderate" solutions that threaten the nation's most powerful and lucrative industries.
This article was first published on Wednesday, March 4, 2020 in Kaiser Health News.
Health care costs were rising. People couldn't afford coverage. So, in Connecticut, state lawmakers took action.
Their solution was to attempt to create a public health insurance option, managed by the state, which would ostensibly serve as a low-cost alternative for people who couldn't afford private plans.
Immediately, an aggressive industry mobilized to kill the idea. Despite months of lobbying, debate and organizing, the proposal was dead on arrival.
"That bill was met with a steam train of opposition," recalled state Rep. Sean Scanlon, who chairs the legislature's insurance and real estate committee.
Through a string of presidential debates, the idea of a public option was championed by moderate Democrats ― such as former South Bend, Indiana, Mayor Pete Buttigieg, Minnesota Sen. Amy Klobuchar and former Vice President Joe Biden ― as an alternative to a single-payer "Medicare for All" model. Those center-left candidates again touted the idea during the Feb. 25 Democratic debate in South Carolina, with Buttigieg arguing such an approach would deliver universal care without the political baggage. (Buttigieg and Klobuchar have since ended their presidential bids.)
The public option has a common-sense appeal for many Americans who list health care costs as a top political concern: If the market doesn't offer patients an affordable health care insurance they like, why not give them the option to buy into a government-run health plan?
But the stunning 2019 defeat of a plan to implement such a policy in Connecticut — a solidly blue, or liberal-leaning, state — shows how difficult it may be to enact even "moderate" solutions that threaten some of America's most powerful and lucrative industries. The health insurance industry's fear: If the average American could weigh a public option — Medicare or Medicaid or some amalgam of the two — against commercial plans on the market, they might find the latter wanting.
That fear has long blocked political action, said Colleen Grogan, a professor at the University of Chicago's School of Social Service Administration, because "insurance companies are at the table" when health care reform legislation gets proposed.
To be sure, the state calculus is different from what a federal one would be. In the statehouse, a single industry can have an outsize influence and legislators are more skittish about job loss. In Connecticut, that was an especially potent force. Cigna and Aetna are among the state's top 10 employers.
"They became aware of the bill, and they moved immediately to kill it," said Frances Padilla, who heads the Universal Health Care Foundation of Connecticut and worked to generate support for the public option.
And those strategies have been replicated at the national level as a national coalition of health industry players ramps up lobbying against Democratic proposals. Beyond insurance, health care systems and hospitals have joined in mobilizing against both public option and single-payer proposals, for fear a government-backed plan would pay far less than the rates of commercial insurance.
Many states are exploring implementing a public option, and once one is successful, others may well follow, opening the door to a federal program.
"State action is always a precursor for federal action," said Trish Riley, the executive director of the National Academy for State Health Policy. "There's a long history of that."
Virginia state delegate Ibraheem Samirah introduced a new public option bill this session. In Colorado, Gov. Jared Polis is spearheading an effort. And Washington state is the furthest along — it approved a public option last year, and the state-offered plan will be available next year.
But in 2019, Connecticut's legislators were stuck between two diametrically opposed constituencies, both distinctly local.
Health costs had skyrocketed. Across the state, Scanlon said, small-business owners worried that the high price of insurance was squeezing their margins. A state-provided health plan, the logic went, would be highly regulated and offer lower premiums and stable benefits, providing a viable, affordable alternative to businesses and individuals. (It could also pressure private insurance to offer cheaper plans.)
A coalition of state legislators came together around a proposal: Let small businesses and individuals buy into the state employee health benefit plan. Insurers' response was swift.
Lobbyists from the insurance industry swarmed the Capitol, recalled Kevin Lembo, the state comptroller. "There was a lot of pressure put on the legislature and governor's office not to do this."
State ethics filings make it impossible to tease out how much of Aetna and Cigna's lobbying dollars were spent on the public option legislation specifically. In the 2019-20 period, Aetna spent almost $158,000 in total lobbying: $93,000 lobbying the Statehouse, and $65,000 on the governor's office. Cigna spent about $157,000: $84,000 went to the legislature, and $73,000 to the executive.
Anthem, another large insurance company, spent almost $147,000 lobbying during that same period — $23,545 to the governor, and $123,045 to the legislature. Padilla recalled that Anthem also made its opposition clear, though it was less vocal than the other companies. (Anthem did not respond to requests for comment.)
A coalition of insurance companies and business trade groups rolled out an online campaign, commissioning reports and promoting op-eds that argued the state proposal would devastate the local economy.
Lawmakers also received scores of similarly worded emails from Cigna and Aetna employees, voicing concern that a public option would eliminate their jobs, according to documents shared with Kaiser Health News. Cigna declined to comment on those emails, and Aetna never responded to requests for comment.
Connecticut's first public option bill — which would let people directly buy into the publicly run state employee health plan ― flamed out.
So lawmakers put forth a compromise proposal: The state would contract with private plans to administer the government health option, allowing insurance companies to participate in the system.
The night before voting, that too fell apart. Accounts of what happened vary.
Somesay Cigna threatened to pull its business out of the state if a public option were implemented. Publicly, Cigna has said it never issued such a threat but made clear that a public option would harm its bottom line. The company would not elaborate when contacted by KHN.
Now, months later, both Scanlon and Lembo said another attempt is in the works, pegged to legislation resembling last year's compromise bill. But state lawmakers work only from February through early May, which is not a lot of time for a major bill.
Meanwhile, other states are making similar pushes, fighting their own uphill battles.
"It really depends on whether there are other countervailing pressures in the state that allow politicians to be able to go for a public option," Grogan said.
And, nationally, if a public option appears to gain national traction, Blendon said, insurance companies "are clearly going to battle."
"They're going to go after every Republican, every moderate Democrat, to try to say that … it's a backdoor way to have the government take over insurance," he said.
Still, when President Barack Obama first proposed the idea of a public option as part of the Affordable Care Act, it was put aside as too radical. Less than a decade later, support for the idea ― every Democratic candidate backs either an optional public health plan or Medicare for All ― is stronger than it ever has been.
So strong, Grogan said, that it is hard for people to understand "the true extent" of the resistance that must be overcome to realize such a plan.
But in Connecticut, politicians say they're up for a new battle in 2020.
"We can't accept the status quo. … People are literally dying and going bankrupt," Scanlon said. "A public option at the state level is the leading fight we can be taking."
An outbreak of coronavirus disease in a nursing home near Seattle is prompting urgent calls for precautionary tactics at America's elder care facilities, where residents are at heightened risk of serious complications from the illness because of the dual threat of age and close living conditions.
The emergence of the novel contagious illness at the Life Care Center of Kirkland, Washington, has left one resident dead and four others hospitalized, with three in critical condition, local health officials said late Sunday. A health care worker in her 40s also remained in satisfactory condition. The resident who died was a man in his 70s with underlying health conditions, officials said.
Officials previously said that of the nursing home's 108 residents and 180 staff members, more than 50 have shown signs of possible COVID-19 infections, the name given the illness caused by a novel coronavirus that emerged from Wuhan, China, late last year. Visits from families, volunteers and vendors have been halted and new admissions placed on hold, according to a statement from Ellie Basham, the center's executive director.
"Current residents and associates are being monitored closely, and any with symptoms or who were potentially exposed are quarantined," she wrote.
The cluster of illness is the first of its type in the U.S., where 2.2 million people live in long-term care settings and may be at heightened risk because of age and underlying health conditions.
"We are very concerned about an outbreak in a setting where there are many older people," said Dr. Jeff Duchin, health officer for the Seattle and King County public health agency.
The American Health Care Association, which represents 13,500 nonprofit and for-profit facilities for seniors and disabled people, issued updated guidelines Saturday, in response to the Washington outbreak. The new virus is thought to spread primarily via droplets in the air, and the guidelines largely echo strategies recommended to stem the spread of other respiratory viruses, such as influenza. That includes frequent hand sanitation among staff and visitors, grouping people who become ill in the same room or wing, and asking family members who are sick to avoid in-person visits.
But members had been anticipating cases of the new virus, said Dr. David Gifford, AHCA's chief medical officer and senior vice president of quality and regulatory affairs.
"Clearly, it signaled that it's here and that what people knew was likely to come is closer to them than before," he said.
COVID-19 has been identified in more than 85,000 people worldwide and led to nearly 3,000 deaths, including the first U.S. death reported Saturday in another Washington state man in his 50s. That man was not associated with the Kirkland nursing center, officials said.
Studies of hospitalized patients in China suggest the median age of infection is in the 50s and that about 80% of COVID-19 cases are mild.However, a new summary in the journal JAMA reported that the virus has a case fatality rate of 1% to 2% overall — and as high as 8% to 15% in older patients in China.
That is alarming news for U.S. residents in long-term care settings, where illnesses caused by more common pathogens like norovirus and seasonal influenza often spread rapidly among residents, causing severe complications. Immune response wanes as people age, leaving them more vulnerable to infections of all types.
Dr. Karl Steinberg, a geriatrician who serves as medical director for two nursing homes and as chief medical officer for a chain of 20 others in Southern California, said the news of COVID-19 cases at the Washington state nursing center is worrisome.
"That's very scary," Steinberg said. "It worries me that once it gets going, it will be really hard to control the spread."
The situation may be akin to the spread of coronavirus on cruise ships, such as the Diamond Princess that was quarantined off the coast of Japan, with one key exception, Steinberg said. People on cruise ships can be confined to their rooms with minimal interaction with staff and fellow residents. People in nursing centers are there because they need help with activities of daily living, he noted.
In the Washington state center, Duchin said, officials are advising health workers to separate cohorts of sick patients from those who remain well and to don personal protective gear, including eye protection, to avoid infection. "It's a very challenging environment with so many vulnerable patients to manage an outbreak," he said.
Duchin urged older people and those with health conditions such as heart disease, lung disease and diabetes to pay close attention to precautions such as washing hands frequently, keeping their hands away from their faces and avoiding people who show signs of illness.
Just-released guidelines from the Society for Post-Acute and Long-Term Care Medicine call for increasing hand hygiene, isolating infected patients and making plans to ensure that health care workers stay home if they're sick. The guidelines also call for screening visitors and daily temperature checks for residents and staff.
Individual centers should remain in close contact with local health officials about appropriate actions, Gifford said. Authorities — and families — should think carefully before taking steps such as removing patients from nursing centers during an outbreak.
"Evacuating a facility is not a benign event," he said, noting that moving can be traumatic to frail and elderly people.
The nursing home cases are examples of community transmission of the virus, which has now been detected in California, Oregon and Washington. None of the hospitalized people had a known history of travel to other nations where the virus is spreading or contact with a traveler diagnosed with the illness.
However, Seattle researchers reported late Saturday that new genomic analysis suggests the virus may have been spreading in Washington state since mid-January, when a 35-year-old Snohomish County man who had visited Wuhan, China, was confirmed as the first U.S. case of the infection.
"This strongly suggests that there has been cryptic transmission in Washington state for the past 6 weeks," tweeted Trevor Bedford, a computational biologist at Seattle's Fred Hutchinson Cancer Research Center, who is tracking the virus. He estimated there could be "a few hundred" infections in the state.
At least 70 cases of coronavirus infection have been confirmed or presumed positive in the U.S., and officials with the federal Centers for Disease Control and Prevention said Americans should expect to hear more reports of illness in the coming days and weeks.
The new Washington cases and the first reported U.S. deaths were identified only after the CDC expanded the definition of who could be tested for the virus and after states and hospitals were given more leeway and supplies to conduct their own tests.
"What that says to us is that as we test more, we're more likely to find cases of the disease," Duchin said.
A team from the CDC has been sent to help local and state health officials investigate the Life Care Center outbreak. "We have a large investigation ahead of us, a complicated investigation ahead of us," Duchin said.
In the meantime, Steinberg said he and others will take precautions to prevent the possible spread of COVID-19 cases in long-term care settings and act swiftly to contain them, if necessary.
"I guess there's not much to do but hunker down and hope it's not too bad," he said.
This story was updated on March 1, 2020, at 6:40 p.m. PT to reflect news developments.
Colorado has emerged as a potential model for revamping health care in other states — and provided a glimpse of what a sweeping Democratic victory in November might mean for Americans.
This story was first published on Friday, February 28, 2020 in Kaiser Health News.
DENVER — With the nation’s capital mired in gridlock and the Affordable Care Act facing a dire legal challenge, the prospects of lowering health care costs for Americans this year seem unlikely.
Just don’t tell that to Coloradans.
Democratic majorities in the state House and Senate and a Democratic governor eager to push aggressive health care measures have turned Colorado into one of the foremost health policy laboratories in the country. State lawmakers have taken swift action on many of the same health issues being debated at the federal level, including a government-run health plan known as a public option, surprise medical billing, drug importation and high drug costs.
Colorado has emerged as a potential model for revamping health care in other states — and provided a glimpse of what a sweeping Democratic victory in November might mean for Americans.
“From a national perspective, this is known as one of the cool places for health care reform, where people are trying new ideas, where there is leadership, where there is community, where there are all the critical elements to get something done,” said Dr. Jay Want, executive director of the Peterson Center for Healthcare, a New York-based health policy think tank.
Full Speed Ahead
Colorado’s push started in earnest when Gov. Jared Polis took office in January 2019 with the promise of helping consumers cut health care costs. He literally created an Office of Saving People Money on Health Care in his first month on the job. What followed was a four-month legislative session in which lawmakers pushed through a decade’s worth of health care bills.
“You can argue it was the most consequential legislative session for health care since Colorado expanded Medicaid much earlier this decade,” said Joe Hanel, director of communications for the Colorado Health Institute, a nonpartisan nonprofit focused on health policy analysis.
Lawmakers passed a reinsurance bill that shielded insurance plans from the costs of their sickest patients, resulting in a 20% drop in 2020 premiums for Coloradans who buy their coverage on the individual market, not through their employers.
Surprise billing protections, which took effect Jan. 1, cap what out-of-network doctors or other medical providers can charge when patients receive services in hospitals that are not part of their insurance network. The new provision establishes an arbitration process for ongoing billing disputes.
Legislators capped copays for insulin at $100 per month and approved the importation of drugs from Canada, once federal authorities establish the process for doing so.
And the legislature authorized the Polis administration to develop a public option proposal that would provide competition to private insurance carriers selling plans on the individual market.
Hanel said state officials have taken an aggressive approach to reining in health care costs.
“They’ve really transformed their agencies in a short year or so,” he said.
For example, Colorado Insurance Commissioner Michael Conway has shifted the Division of Insurance from mainly an actuarial agency reviewing rate filings into more of an advocate for consumers. The division is developing a standard for insurance that would consider whether premiums are affordable when approving insurance rates.
A Public Option
This year, the legislature will decide whether to implement the public option plan developed by the Polis administration.
While many thought that plan would create a government-run alternative to private insurance similar to a Medicare plan open to anyone, the final draft retains a role for insurance companies in administering public option plans.
The plan would also benchmark hospital payment rates to a percentage above what Medicare pays, developing a formula to adjust those rates for each hospital. A small rural hospital would be paid differently from a large urban hospital, while independent hospitals would be paid differently from chain hospitals.
Insurance carriers would be limited to using no more than 15% of total premiums collected for administrative costs and profits, which is lower than the Affordable Care Act cap. They would also be required to use any rebates from drug companies to reduce patients’ premiums. The state is asking legislators for the authority to force hospitals and health plans to participate if they won’t do so voluntarily.
“What Colorado is doing is very innovative. There is really only one other state, Washington state, that is doing anything comparable to a public option,” said Billy Wynne, a Washington, D.C.-based health policy consultant who recently formed the Public Option Institute. “Other states have been looking at it and will pursue similar programs in the future, especially if [Colorado] can pull off the ‘triple lindy’ and make this successful.”
Industry Pushback
Hospital representatives have expressed skepticism about the public option plan, which they see as mainly targeting hospitals to achieve savings.
“The rate-setting as it is currently proposed is a 40% hit to some hospitals,” said Katherine Mulready, senior vice president and chief strategy officer of the Colorado Hospital Association, which represents more than 100 hospitals. Hospitals and other providers, she said, may not be able to maintain the same level of services and access now available.
But state officials point to recent studies suggesting prices at Colorado hospitals are among the most expensive in the country: A Rand Corp. study found that Colorado hospitals charge three to four times the Medicare rate, and an analysis of the Denver market showed the area’s 27 hospitals netted a combined $2 billion in pretax profits in 2018, with average profit margins exceeding 19%.
Hospitals say they must charge higher rates to privately insured patients to make up for the shortfall from Medicare, Medicaid and uninsured patients. But the state released a report in January showing that even when Medicaid rates went up and the need for charity care went down, hospitals still raised their prices.
“We’re getting close to the mark because some of the hospitals and pharmaceutical companies sent out a mailer against the public option,” Polis said in a Jan. 14 public forum on the proposal. “We must be getting something right if they’re that worried about it. But it also adds insult to injury for those of us who are consumers of medical services … to know they’re using some of that money from overcharging to lobby against reforms that are saving people money. That is rubbing salt in the wounds.”
Insurers are also wary of the plan.
“We are very concerned — and I would say opposed — that the government will tell us the product, the price and the place that we have to sell,” said Amanda Massey, executive director of the Colorado Association of Health Plans. “That is fundamentally opposed to private business and competition.”
The Colorado Medical Society, which represents physicians, issued a statement generally supporting the goals of the public option plan but didn’t go so far as to endorse it.
Blueprint For The Nation?
The public option would initially be available only to those consumers who buy policies on the individual market in 2022, estimated to be fewer than 7% of the state’s population. State officials said that they plan to later expand to the small-group market and that they expect the lower prices will put pressure on rates for large-group employer-sponsored plans as well.
The proposal, while not as disruptive as a “Medicare for All” or single-payer approach, represents a step toward government-run health care.
“What the state is doing is intervening, to some degree, in commercial negotiations between plans and hospitals,” Wynne said. “Let’s be honest: The state will be leaning on hospitals on their participation and reimbursement rate, and that is a tremendous benefit to health plans.”
Colorado’s approach could provide a blueprint for any moderate Democratic presidential candidates promoting a public option on the national level, much in the way Massachusetts provided the basic framework for the Affordable Care Act.
“Colorado is doing it and is ahead of the curve,” Wynne said. “If one of those people wins, they’re going to be looking to this state as a model for what to try to help other states do.”
Locally, Democrats also are betting that by addressing what Coloradans have identified as their highest priority — reducing the cost of health care — they’ll be well positioned to build on their state majority in the 2020 elections.
“I haven’t met a single voter,” Polis quipped recently, “who said, ‘I don’t pay enough for my health care.’”
For much of the 20th century, medical progress seemed limitless.
Antibiotics revolutionized the care of infections. Vaccines turned deadly childhood diseases into distant memories. Americans lived longer, healthier lives than their parents.
Even as the world struggles to control a mysterious new virus known as COVID-19, U.S. health officials are refighting battles they thought they had won, such ashalting measles outbreaks, reducing deaths from heart disease and protecting young people from tobacco. These hard-fought victories are at risk as parents avoid vaccinating children, obesity rates climb, and vaping spreads like wildfire among teens.
Things looked promising for American health in 2014, when life expectancy hit 78.9 years. Then, life expectancy declined for three straight years — the longest sustained drop since the Spanish flu of 1918, which killed about 675,000 Americans and 50 million people worldwide, said Dr. Steven Woolf, a professor of family medicine and population health at Virginia Commonwealth University.
Although life expectancy inched up slightly in 2018, it hasn't yet regained the lost ground, according to the Centers for Disease Control and Prevention.
"These trends show we're going backwards," said Dr. Sadiya Khan, an assistant professor of cardiology and epidemiology at Northwestern University Feinberg School of Medicine.
While the reasons for the backsliding are complex, many public health problems could have been avoided, experts say, through stronger action by federal regulators and more attention to prevention.
"We've had an overwhelming investment in doctors and medicine," said Dr. Sandro Galea, dean of the Boston University School of Public Health. "We need to invest in prevention — safe housing,good schools, living wages, clean air and water."
Superbugs — resistant to even the strongest antibiotics — threaten to turn back the clock on the treatment of infectious diseases. Resistance occurs when bacteria and fungi evolve in ways that let them survive and flourish, in spite of treatment with the best available drugs. Each year, resistant organisms cause more than 2.8 million infections and kill more than 35,000 people in the U.S.
With deadly new types of bacteria and fungi ever emerging, Dr. Robert Redfield, the CDC director, said the world has entered a "post-antibiotic era." Half of all new gonorrhea infections, for example, are resistant to at least one type of antibiotic, and the CDC warns that "little now stands between us and untreatable gonorrhea."
That news comes as the CDC also reports a record number of combined cases of gonorrhea, syphilis and chlamydia, which were once so easily treated that they seemed like minor threats compared with HIV.
The United States has seen a resurgence of congenital syphilis, a scourge of the 19th century, which increases the risk of miscarriage, permanent disabilities and infant death. Although women and babies can be protected with early prenatal care, 1,306 newborns were born with congenital syphilis in 2018 and 94 of them died, according to the CDC.
Those numbers illustrate the "failure of American public health," said Dr. Cornelius "Neil" Clancy, a spokesperson for the Infectious Diseases Society of America. "It should be a global embarrassment."
The proliferation of resistant microbes has been fueled by overuse, by doctors who write unnecessary prescriptionsas well as farmers who give the drugs to livestock, said Dr. William Schaffner, a professor of preventive medicine at Vanderbilt University Medical Center in Nashville, Tennessee.
Although new medications are urgently needed, drug companies are reluctant to develop antibiotics because of the financial risk, said Clancy, noting that two developers of antibiotics recently went out of business. The federal government needs to do more to make sure patients have access to effective treatments, he said. "The antibiotic market is on life support," Clancy said. "That shows the real perversion in how the health care system is set up."
A Slow Decline
A closer look at the data shows that American health was beginning to suffer 30 years ago. Increases in life expectancy slowed as manufacturing jobs moved overseas and factory towns deteriorated, Woolf said.
By the 1990s, life expectancy in the United States was falling behind that of other developed countries.
The obesity epidemic, which began in the 1980s, is taking a toll on Americans in midlife, leading to diabetes and other chronic illnesses that deprive them of decades of life. Although novel drugs for cancer and other serious diseases give some patients additional months or even years, Khan said, "the gains we're making at the tail end of life cannot make up for what's happening in midlife."
Progress against overall heart disease has stalled since 2010. Deaths from heart failure — which can be caused by high blood pressure and blocked arteries around the heart — are rising among middle-aged people. Deaths from high blood pressure, which can lead to kidney failure, also have increased since 1999.
"It's not that we don't have good blood pressure drugs," Khan said. "But those drugs don't do any good if people don't have access to them."
Addicting A New Generation
While the United States never declared victory over alcohol or drug addiction, the country has made enormous progress against tobacco. Just a few years ago, anti-smoking activists were optimistic enough to talk about the "tobacco endgame."
Today, vaping has largely replaced smoking among teens, said Matthew Myers, president of the Campaign for Tobacco-Free Kids. Although cigarette use among high school students fell from 36% in 1997 to 5.8% today, studies show 31% of seniors used electronic cigarettes in the previous month.
FDA officials say they've taken "vigorous enforcement actions aimed at ensuring e-cigarettes and other tobacco products aren't being marketed or sold to kids." But Myers said FDA officials were slow to recognize the threat to children.
With more than5 million teens using e-cigarettes, Myers said, "more kids are addicted to nicotine today than at any time in the past 20 years. If that trend isn't reversed rapidly and dynamically, it threatens to undermine 40 years of progress."
Ignoring Science
Where children live has long determined their risk of infectious disease. Around the world, children in the poorest countries often lack access to lifesaving vaccines.
Yet in the United States — wherea federal program provides free vaccines — some of the lowest vaccination rates are in affluent communities, where some parents disregard the medical evidence that vaccinating kids is safe.
Studies show that vaccination rates are drastically lower in some private schools and "holistic kindergartens" than in public schools.
It could be argued that vaccines have been a victim of their own success.
Before the development of a vaccine in the 1960s, measles infected an estimated 4 million Americans a year, hospitalizing 48,000, causing brain inflammation in about 1,000 and killing 500, according to the CDC.
"Now, mothers say, 'I don't see any measles. Why do we have to keep vaccinating?'" Schaffner said. "When you don't fear the disease, it becomes very hard to value the vaccine."
Last year, a measles outbreak in New York communities with low vaccination rates spread to almost 1,300 people — the most in 25 years — and nearly cost the country its measles elimination status. "Measles is still out there," Schaffner said. "It is our obligation to understand how fragile our victory is."
Health-Wealth Disparities
To be sure, some aspects of American health are getting better.
Cancer death rates have fallen 27% in the past 25 years, according to the American Cancer Society. The teen birth rate is at an all-time low; teen pregnancy rates have dropped by half since 1991, according to the Department of Health and Human Services. And HIV, which was once a death sentence, can now be controlled with a single daily pill. With treatment, people with HIV can live into old age.
Yet the health gap has grown wider in recent years. Life expectancy in some regions of the country grew by four years from 2001 to 2014, while it shrank by two years in others, according to a2016 study in JAMA.
The gap in life expectancy is strongly linked to income: The richest 1% of American men live 15 years longer than the poorest 1%; the richest women live 10 years longer than the poorest, according to the JAMA study.
"We're not going to erase that difference by telling people to eat right and exercise," said Dr. Richard Besser, CEO of the Robert Wood Johnson Foundation and former acting director of the CDC. "Personal choices are part of it. But the choices people make depend on the choices they're given. For far too many people, their choices are extremely limited."
The infant mortality rate of black babies is twice as high as that of white newborns, according to the Department of Health and Human Services. Babies born to well-educated, middle-class black mothers are more likely to die before their 1st birthday than babies born to poor white mothers with less than a high school education, according to a report from the Brookings Institution.
In trying to improve American health, policymakers in recent years have focused largely on expanding access to medical care and encouraging healthy lifestyles. Today, many advocate taking a broader approach, calling for systemic change to lift families out of the povertythat erodes mental and physical health.
Several policies have been shown to improve health.
Children who receive early childhood education, for example, have lower rates of obesity, child abuse and neglect, youth violence and emergency department visits, according to the CDC.
And earned income tax credits — which provide refunds to lower-income people — have been credited with keeping more families and children above the poverty line than any other federal, state or local program, according to the CDC. Among families who receive these tax credits, mothers have better mental health and babies have lower rates of infant mortality and weigh more at birth, a sign of health.
Improving a person's environment has the potential to help them far more than writing a prescription, said John Auerbach, president and CEO of the nonprofit Trust for America's Health.
"If we think we can treat our way out of this, we will never solve the problem," Auerbach said. "We need to look upstream at the underlying causes of poor health."
BAYONNE, N.J. — For five years, Rasha Salama has taken her two children to Dr. Inas Wassef, a pediatrician a few blocks from her home in this blue-collar town across the bay from New York City.
Salama likes the doctor because Wassef speaks her native language — Arabic — and has office hours at convenient times for children.
"She knows my kids, answers the phone, is open on Saturdays and is everything for me," she said.
But UnitedHealthcare is dropping Wassef — and hundreds of other doctors in its central and northern New Jersey Medicaid physician network. The move is forcing thousands of low-income patients such as Salama to forsake longtime physicians.
Across the nation, business and contractual disputes are separating patients from longtime doctors. This often occurs when doctors don't want to accept the rates insurers are willing to pay. It sometimes occurs when insurers' business plans require having a narrower network of doctors — doctors whose practice patterns may be easier to control.
But in this case, the cause of the exclusion goes to even deeper business connections: Wassef and other doctors say the insurer appears to be trying to shift patients to Riverside Medical Group, a 20-office physicians' practice owned by Optum, a sister company of UnitedHealthcare, both of which are subsidiaries of UnitedHealth Group. UnitedHealthcare is essentially forcing patients to transfer to doctors it controls, the doctors allege.
Indeed, several patients said the health plan directed them to Riverside when informing them their doctors were being dropped.
Lawrence Downs, CEO of the Medical Society of New Jersey, said he estimates UnitedHealthcare is trying to remove hundreds of doctors in central and northern New Jersey from its network. That is the same area where Riverside Medical operates, he noted.
"It seems like they are steering patients away from small, community-based doctors to large groups that they own," he said.
Good For Profits
That raises questions about whether this type of "vertical consolidation" — the term for a practice occurring across the country — is a strategy that is good for profits but bad for patients.
UnitedHealthcare said the changes are not part of a campaign to get as many patients as possible to the Riverside practice. It points out that it is retaining the community-based doctors, like Wassef, in its networks to treat its Medicare Advantage and commercial plan members.
But, experts say, traumatic disruptions in doctor-patient relationships are an inevitable result of ongoing shifts in the complicated business of U.S. health care.
Facing a rapid consolidation of doctors' practices and hospital systems — which have hefty negotiating power to demand high fees — insurers have limited options to control costs and maintain a positive balance sheet, said Jacob Wallace, an assistant professor of public health at Yale University. Medicaid plans are especially affected because, unlike commercial plans or even Medicare, they can't increase premiums or demand copayments.
"Plans face a challenging landscape to keep costs down," Wallace said. As a result, health plans have taken other approaches, including narrowing provider networks and buying their own physician practices, he said.
But further complicating matters, many Medicaid and Medicare managed-care programs are contracted out to private, for-profit insurers such as UnitedHealthcare. They are looking to create returns for shareholders. With surging enrollment in government programs, UnitedHealthcare has enjoyed rising profits and a stock price that has soared tenfold since 2010.
Wassef and about two dozen other physicians filed a federal lawsuit in September to get reinstated. Wassef, whose termination is scheduled in May, said the move could seriously affect her practice because 80% of her patients are insured by UnitedHealthcare.
UnitedHealthcare gained millions of new customers after the Affordable Care Act led New Jersey and 35 other states and the District of Columbia to expand Medicaid and states turned to private insurers to handle the business. Salama and some other UnitedHealthcare customers said they like their insurance plan because it offers richer benefits than other Medicaid options and covers the medications they use.
The company operates New Jersey's second-largest Medicaid health plan, with 418,000 members. (The state Department of Human Services has blocked UnitedHealthcare from enrolling any additional Medicaid members, a severe and rare penalty. That move — which is not related to the termination of doctors' contracts — stems from complaints related to care management and discharge planning, the health plan's call center and other issues.)
A company spokesperson acknowledged the health plan is dropping 2% of its Medicaid doctors, saying the move was designed to help control costs.
"As health care costs continue to rise, we are working to mitigate the impact on the customers, states and members we serve by negotiating with care providers on their behalf to keep reimbursement rates affordable," the company said in a statement. "We understand that our members have personal relationships with their doctors and that network changes can be difficult."
A Practice Destroyed
New Jersey Medicaid officials refused to comment on whether they are concerned about UnitedHealthcare's actions. But patients caught up in the standoff have reason to worry, said Linda Schwimmer, CEO of the New Jersey Health Care Quality Institute, a coalition of health plans, providers and a variety of health trade groups.
"Once you have a trusted relationship with a provider, it means a lot and it goes to the quality [of your care] because if you are seeing the same providers and you trust them, you are more likely to take your medication and adhere to whatever care plan you have," she said.
Dr. Alexander Salerno, an internist who runs a 17-doctor multispecialty practice in East Orange, New Jersey, another plaintiff in the lawsuit, is helping lead the court fight. Salerno's main office is in a three-story, 19th-century house that his father used for his medical practice in the 1960s. About 40% of his patients are on Medicaid.
Until the dispute began last year, Salerno advised his patients to sign up for UnitedHealthcare because of its broad array of benefits, including vision and dental care, and because of the ease in referring to specialists.
And UnitedHealthcare never complained about this group's skill. In fact, the group received a $130,000 bonus last year for its good care to patients. Salerno said Riverside Medical offered to buy his group practice in 2018, but he declined.
Since UnitedHealthcare announced it would drop his group from the network, more than 500 of his practices' patients have already changed doctors to stay with the UnitedHealthcare plan, Salerno said.
"It's not a bad insurance company. It just seems like they have become greedy trying to control both ends of the pendulum — wanting to be the payer and provider," Salerno said.
A federal judge ordered the case to be heard by a neutral arbitrator, which in late November granted an emergency injunction that will keep Salerno from being removed from UnitedHealthcare's network until an arbitrator makes a decision on a permanent injunction, which is expected in March.
But that leaves patients in limbo.
Glorida Rivera, 68, said UnitedHealthcare's decision to drop Salerno was upsetting because she relied on him to care for her diabetes, thyroid and heart conditions. She credits Salerno for referring her to a cardiologist, who put stents in her heart to clear a blockage.
"He knows my whole story, so why do I have to change?" wondered Rivera. Nonetheless, she is sticking with UnitedHealthcare.
Velylia McIver, 83, decided in November to search for another plan so she could stay with Salerno. But it took her more than a month to get coverage for some medications.
"I feel caught in the middle of all this, and it's the pits," McIver said.
The Trump administration's top Medicaid official has been increasingly critical of the entitlement program she has overseen for three years.
Seema Verma, administrator of the Centers for Medicare & Medicaid Services, has warned that the federal government and states need to better control spending and improve care to the 70 million people on Medicaid, the state-federal health insurance program for the low-income population. She supports changes to Medicaid that would give states the option to receive capped annual federal funding for some enrollees instead of open-ended payouts based on enrollment and health costs. This would be a departure from how the program has operated since it began in 1965.
In an early February speech to the American Medical Association, Verma noted how changes are needed because Medicaid is one of the top two biggest expenses for states, and its costs are expected to increase 500% by 2050.
"Yet, for all that spending, health outcomes today on Medicaid are mediocre and many patients have difficulty accessing care," she said.
Verma's sharp comments got us wondering if Medicaid recipients were as bad off as she said. So we asked CMS what evidence it has to back up her views.
A CMS spokesperson responded by pointing us to a CMS fact sheet comparing the health status of people on Medicaid to people with private insurance and Medicare. The fact sheet, among other things, showed 43% of Medicaid enrollees report their health as excellent or very good compared with 71% of people with private insurance, 14% on Medicare and 58% who were uninsured.
The spokesperson also pointed to a 2017 report by the Medicaid and CHIP Payment and Access Commission (MACPAC), a congressional advisory board, that noted: "Medicaid enrollees have more difficulty than low-income privately insured individuals in finding a doctor who accepts their insurance and making an appointment; Medicaid enrollees also have more difficulty finding a specialist physician who will treat them."
We opted to look at those issues separately.
What About Health Status?
Several national Medicaid experts said Verma is wrong to use health status as a proxy for whether Medicaid helps improve health for people. That's because to be eligible for Medicaid, people must fall into a low-income bracket, which can impact their health in many ways. For example, they may live in substandard housing or not get proper nutrition and exercise. In addition, lack of transportation or child care responsibilities can hamper their ability to visit doctors.
Benjamin Sommers, a health economist at Harvard University, said Verma's comparison of the health status of Medicaid recipients against people with Medicare or private insurance is invalid because the populations are so different and face varied health risks. "This wouldn't pass muster in a first-year statistics class," he said.
Death rates, for example, are higher among people in the Medicare program than those in private insurance or Medicaid, he said, but that's not a knock on Medicare. It's because Medicare primarily covers people 65 and older.
By definition, Medicaid covers the most vulnerable people in the community, from newborns to the disabled and the poor, said Rachel Nuzum, a vice president with the nonpartisan Commonwealth Fund. "The Medicaid population does not look like the privately insured population."
Joe Antos, a health economist with the conservative American Enterprise Institute, also agreed, saying he is leery of any studies or statements that evaluate Medicaid without adjusting for risk.
For a better mechanism to gauge health outcomes under Medicaid, experts point to dozens of studies that track what happened in states that chose in the past six years to pursue the Affordable Care Act's Medicaid expansion. The health law gave states the option to extend Medicaid to everyone with incomes up to 138% of the federal poverty level, or about $17,600 annually for an individual. Thirty-six states and the District of Columbia have adopted the expansion.
"Most research demonstrates that Medicaid expansion has improved access to care, utilization of services, the affordability of care, and financial security among the low-income population," concluded the Kaiser Family Foundation in summarizing findings from more than 300 studies. "Studies show improved self-reported health following expansion and an association between expansion and certain positive health outcomes." (Kaiser Health News is an editorially independent program of the foundation.)
Researchers also reported that Medicaid expansion was associated with declines in the length of stay of hospitalized patients. One study found a link between expansion and declines in mechanical ventilation rates among patients hospitalized for various conditions.
Another recent study compared the health characteristics of low-income residents of Texas, which has not expanded Medicaid, and those of Arkansas and Kentucky, which did. It found that new Medicaid enrollees in the latter two states were 41 percentage points more likely to have a usual source of care and 23 percentage points more likely to say they were in excellent health than a comparable group of Texas residents.
Medicaid's benefits, though, affect far more than the millions of nondisabled adults who gained coverage as a result of the ACA. "Medicaid coverage was associated with a range of positive health behaviors and outcomes, including increased access to care; improved self-reported health status; higher rates of preventive health screenings; lower likelihood of delaying care because of costs; decreased hospital and emergency department utilization; and decreased infant, child, and adult mortality rates," according to a report issued this month by the nonpartisan Robert Wood Johnson Foundation.
Children — who make up nearly half of Medicaid enrollees — have also benefited from the coverage, studiesfind. Some studies report that Medicaid contributes to improved health outcomes, including reductions in avoidable hospitalizations and lower child mortality.
Research shows people on Medicaid are generally happy with the coverage.
A Commonwealth Fund survey found 90% of adults with Medicaid were satisfied or very satisfied with their coverage, a slightly higher percentage than those with employer coverage.
Accessible Care?
The evidence here is less emphatic.
A 2017study published in JAMA Internal Medicine found 84% of Medicaid recipients felt they were able to get all the medical care they needed in the previous six months. Only 3% said they could not get care because of long wait times or because doctors would not accept their insurance.
Verma cites a 2017 MACPAC report that noted some people on Medicaid have issues accessing care. But that report also noted: "The body of work to date by MACPAC and others shows that Medicaid beneficiaries have much better access to care, and much higher health care utilization, than individuals without insurance, particularly when controlling for socioeconomic characteristics and health status." It also notes that "Medicaid beneficiaries also fare as well as or better than individuals with private insurance on some access measures."
The report said people with Medicaid are as likely as those with private insurance to have a usual source of care, a doctor visit each year and certain services such as a Pap test to detect cervical cancer.
"Medicaid is not great coverage, but it does open the door for health access to help people deal with medical problems before they become acute," Antos said.
On the negative side, the report said Medicaid recipients are more likely than privately insured patients to experience longer waiting times to see a doctor. They also are less likely to receive mammograms, colorectal tests and dental visits than the privately insured.
"Compared to having no insurance at all, having Medicaid improves access to care and improves health," said Rachel Garfield, a vice president at the Kaiser Family Foundation. "There is pretty strong evidence that Medicaid helps patients get the care they need."
Our Ruling
Verma said that "health outcomes today on Medicaid are mediocre and many patients have difficulty accessing care."
Numerous studies show people's health improves as a result of Medicaid coverage. This includes lower mortality rates, shorter hospital stays and more people likely to get cancer screenings.
While it's hard to specify what "many patients having difficulty accessing care" means, research does show that Medicaid enrollees generally say they have no trouble accessing care most of the time.
We rate the claim as Mostly False.
Sources:
Email response from the Centers for Medicare & Medicaid Services, Feb. 12, 2020
Telephone interview with Aviva Aron-Dine, vice president for health policy, Center on Budget and Policy Priorities, Feb. 12, 2020
Telephone interview with Sara Rosenbaum, professor of health policy and law, George Washington University, Feb. 12, 2020
Telephone interview with Rachel Nuzum, a vice president with the nonpartisan Commonwealth Fund, Feb. 13, 2020
Telephone interview with Rachel Garfield, vice president, Kaiser Family Foundation, Feb. 12, 2020
Telephone interview with Benjamin Sommers, a health economist at Harvard University, Feb. 13, 2020
Telephone interview with Jay Antos, health economist, American Enterprise Institute, Feb. 18, 2020
When Carol Pak-Teng, an emergency room doctor in New Jersey, hosted a fundraiser in December for Democratic freshman Rep. Tom Malinowski, her guests, mostly doctors, were pleased when she steered the conversation to surprise medical bills.
This was a chance to send a message to Washington that any surprise billing legislation should protect doctors' incomes in their battle over payments with insurers. Lawmakers are grappling over several approaches to curtail the practice, which can leave patients on the hook for huge medical bills, even if they have insurance.
As Congress begins its 2020 legislative session, there is evidence the doctors' message has been received: The bills with the most momentum are making more and more concessions to physicians.
As surprise medical billing has emerged as a hot-button issue for voters, doctors, hospitals and insurers have been lobbying to protect their own money flows. All that lobbying meant nothing got passed last year.
Television and internet ads are the most visible manifestation of the battle. But in taking their cause to politicians, doctors like Pak-Teng have waged an extraordinary on-the-ground stealth campaign to win over members of Congress. Their professional credentials give them a kind of gravitas compared with other lobbyists, who are merely hired guns.
Ending the practice of billing patients for the amount of their treatment not covered by insurance — sometimes triggered by unwittingly seeing a doctor out of network — is ultimately a fight between doctors and insurers over rate-setting and reimbursement. But as more patients balk at surprise bills — or suffer the enormous financial strain — lawmakers are under pressure to protect patients. In turn, powerful lobbying forces have activated to protect doctors and insurers who don't want to pay the price for a fix.
The main message physicians are using to bring lawmakers into their corner? "We just want to be paid a fair amount for the services rendered," Pak-Teng said.
Her congressman, Malinowski, has not endorsed any surprise billing legislation. In congressional testimony in July, he cited the "extra $420 million" in medical debt patients in New Jersey reckon with each year.
"There are many things that Republicans and Democrats sincerely disagree about in this body," he said. "I don't think that this is one of them. I don't see any philosophical difference amongst us about whether people should be stuck with massive surprise medical bills."
Doctors say they are taking the brunt of the criticism.
But little has been as powerful in shaping surprise billing legislation as the clout of hospitals and their doctors, many of whom are, in fact, employed by private equity-backed companies and armed with years of experience shaping surprise billing legislation at the state level.
They are throwing in a lot of money, too, funneling millions to lawmakers ahead of the 2020 elections. Four physician organizations that have heavily lobbied on surprise medical bills and have private equity ties — the American College of Emergency Physicians, Envision Healthcare, US Acute Care Solutions and U.S. Anesthesia Partners — gave roughly $1.1 million in 2019 to members of Congress, according to a Kaiser Health News analysis of Federal Election Commission records.
The biggest recipients, from all four PACs combined, were Reps. Donna Shalala and Stephanie Murphy, Florida Democrats who got $26,000 each. Sen. Thom Tillis (R-N.C.) took in $25,500, Senate Majority Leader Mitch McConnell got $25,000, and Rep. Brett Guthrie (R-Ky.) received $22,500.
That was in tandem with a ground game led by local doctors. ER doctors, anesthesiologists, radiologists and other specialists who most often charge out-of-network prices — and also are among the highest-compensated practitioners — fanned out to shape legislation in a way that maintains their pay, and to voice their concern to lawmakers that insurance companies would have too much leverage to control their compensation.
"We by necessity place a tremendous amount of trust in our physicians," said Zack Cooper, an assistant professor at Yale University who has extensively researched surprise medical bills. "Frankly, they have an easier time lobbying members [of Congress] than the folks who are affected by surprise billing."
Arguing Over The Fix
Lawmakers in both parties appear unified on the need to resolve the problem of surprise billing. But as was clear when all the air blew out of legislative proposals on the table at year's end, that is largely where the agreement ends.
Fixing the problem comes down to settling on a system for deciding how much to pay for a disputed bill. One approach is to set up an outside arbitration process, in which doctors and insurance companies would negotiate payment — this is the model preferred by doctors, who contend it puts them on better footing against insurance companies. Another option would be to resolve surprise billing disputes by having insurance companies pay doctors based on the median in-network rate for the service, an approach known as benchmarking. Large employers, labor unions and insurance companies prefer this.
The failure to get legislation through Congress set up a potentially explosive battle in an election year. Republicans and Democrats who have vowed to do something about health care costs must reckon with powerful industry groups whose influence transcends party lines.
Meanwhile, physicians and hospitals have made their case in Washington and back home through in-person meetings and phone calls with lawmakers and congressional staff. They've hosted dinners and fundraisers and organized fly-ins to swarm Capitol Hill with in-person meetings. They've even led tours of their emergency rooms.
Pak-Teng is among them, coming to Washington this month with other physicians to petition lawmakers. She is employed by Envision, a physician staffing company backed by private equity firm KKR. She's also on the board of the American Academy of Emergency Medicine, a trade organization representing ER doctors.
"There is a lot of anti-physician rhetoric out there," said Pak-Teng, who is pushing her physician colleagues to be more active in shaping public policy by sharing stories about the reality of caring for patients.
The lobbying by hospitals and physicians trying to protect their reimbursements has divided key lawmakers, compounding disagreements among senior House Democrats over the policy details of a bill and turf wars in Congress. Three House committees have now unveiled legislation to ban surprise medical bills, each with different details.
"We are not trying to stop legislation. We are trying to stop bad legislation," said Anthony Cirillo, an emergency medicine physician who describes a "bad" bill as one that favors insurance companies over doctors.
Cirillo is also a lobbyist for US Acute Care Solutions, a physician staffing company backed by private equity firm Welsh, Carson, Anderson & Stowe. WCAS, which manages $27 billion in assets and is focused on health care and technology investments, is based in New York City and co-founded US Acute Care Solutions in 2015.
In an interview, Cirillo said he met with lawmakers and their aides about "10 to 12 times" in Washington last year. Financial disclosures show he spent $340,000 between July and September lobbying on surprise billing on behalf of US Acute Care Solutions. USACS' political committee also contributed $134,500 to lawmakers in 2019, according to FEC records.
Tilt Toward Doctors
Before the private equity-fueled dark-money group Doctor Patient Unity started running ads warning of the dangers of government price controls as an argument against legislation, surprise billing legislation being drafted in one of Congress' most powerful health care committees was already tilting to be more favorable to doctors.
"People on the Hill are very sympathetic to hospitals and physicians because they're actually providing the care itself," said one Democratic aide, speaking on the condition of anonymity to candidly describe sensitive political dynamics. "Nobody wants to defend the insurers."
In May, a House Energy and Commerce Committee draft proposal included no mention of outside arbitration. The same was true for a bill the Senate Health, Education, Labor and Pensions Committee approved in June. Instead, under those proposals, surprise billing disputes would be resolved by insurance companies paying doctors based on similar rates in that area.
By mid-July, though — roughly a week before Doctor Patient Unity registered as a business in Virginia — the Energy and Commerce legislation was amended to allow doctors to appeal to an independent arbiter if their payments exceed $1,250. The revision was pushed by two physicians on the committee — Democrat Raul Ruiz of California and Republican Larry Bucshon of Indiana — and was a moment Sherif Zaafran, a Texas anesthesiologist, describes as a "turning point" in negotiations over the bill.
"It's all about fairness," said Zaafran, who works for private equity-backed U.S. Anesthesia Partners. He has been involved for a decade in surprise billing fights in Texas, which enacted a new law with an arbitration process last year. U.S. Anesthesia Partners gave $197,900 in campaign contributions to members of Congress last year.
Zaafran chaired another coalition of medical specialists, Physicians for Fair Coverage, in 2019, and pressured Congress to pursue a surprise billing approach modeled on a New York law under which insurers and providers rely on arbitration. Under that process, if there is a payment dispute between doctors and insurers, the two sides submit a proposed dollar amount to an independent mediator, who then selects one.
In New York, the mediators were told to base their decisions on the 80th percentile of the prices set by the hospital or physician. Research has suggested that the model is broadly making health care more expensive for state residents because of higher payments to doctors, according to findingsfrom the USC-Brookings Schaeffer Initiative for Health Policy.
Still, on Capitol Hill, doctors complained that many procedures would fail to cost enough to qualify for arbitration as proposed in the Energy and Commerce bill, bolstered by data ER doctors presented to lawmakers showing that prices mainly fall below $1,250.
"It's largely out of reach," said Laura Wooster, a lobbyist with the American College of Emergency Physicians, whose political action committee contributed $708,000 to lawmakers in 2019. "The problem with a threshold is, you just have one threshold. It's going to impact different specialties so differently."
By December, House Energy and Commerce Committee leaders and Sen. Lamar Alexander, a Republican who chairs the Senate HELP Committee, agreed to lower the arbitration threshold to $750 as part of a bipartisan agreement on a bill. Notably, several hospital lobbying organizations, such as the American Hospital Association and the Greater New York Hospital Association — the latter a strong financial backer of Senate Minority Leader Chuck Schumer — refused to back the deal.
Pak-Teng and other physicians also say that arbitration threshold is still too high. The House Education and Labor Committee has unveiled surprise billing legislation with a similar framework.
"I'm open to listening to all sides on this," Rep. Greg Walden of Oregon, the top Republican on the House Energy and Commerce Committee, said in an interview. "We want to make sure doctors are adequately compensated."
Walden had harsh words for private equity firms that have attacked the Energy and Commerce legislation in a series of TV and internet ads, saying they were "misleading and scaring people" and just made lawmakers dig in deeper. The ads prompted a bipartisan probe from Walden and committee Chairman Frank Pallone (D-N.J.) into how the companies have influenced surprise billing practices.
"I'm not trying to hurtle a rock at them, but they've been throwing a few my way," he said.
What's Coming
Arvind Venkat, a Pittsburgh emergency physician employed by US Acute Care Solutions, traveled to Washington multiple times last year to meet with congressional offices representing Pennsylvania. But he also made sure to bring up surprise bills on his home turf, giving his congressman, freshman Democrat Conor Lamb, a tour of the emergency room at Allegheny General Hospital last summer.
"There are two issues here," said Venkat, who leads the Pennsylvania chapter of the American College of Emergency Physicians and has practiced at Allegheny General for 12 years. "Patients need to be protected, [and] we need to avoid anything that disrupts in-network relationships between insurers and clinicians."
The call seems to have been heard: Legislation is likely to change further this year as the House Ways and Means Committee pushes an approach that is friendlier to hospitals and doctors. It builds off a one-page document committee leaders issued Dec. 11 that blunted momentum for a bipartisan deal that was to be included in a December spending bill.
The latest proposal from the committee includes an arbitration process to resolve payment disputes, with no minimum dollar amount needed to trigger it, and doesn't ban surprise billing from air ambulance companies — a win for yet another special-interest lobbying group. The patient protections would not take effect until 2022.
Richard Neal, a Massachusetts Democrat who chairs the committee, remains an ally of Massachusetts hospitals. He released the brief December surprise billing document two days after the Massachusetts Medical Society and Massachusetts Hospital Association wrote a joint op-ed in The Boston Globe arguing that benchmarking physician payments — as the Senate HELP and Energy and Commerce deal would do — would wreck the state's health care system.
"The heavy hand of government would create an unfair imbalance in the health care marketplace and insurers would have no incentive to engage physicians in building robust health care networks. The connected system of care we have all been working toward in Massachusetts would immediately become fragmented and disjointed," the two groups wrote in The Boston Globe.
"They weren't asking for favorable treatment. They were asking for fair treatment, and there's a big difference," Neal said in an interview. "I don't want to rule anything out, but I think that the momentum right now is arbitration."
"We need to get a little bit more balance," added Shalala, who endorsed the Ways and Means legislation unveiled earlier this month.
Shalala has at least two hospitals in her Miami-area district that rely on private equity-supported physician staffing companies.
"I'm worried about the hospitals," she said. "And the providers obviously include the docs."
When a human heart was left behind by mistake on aSouthwest Airlines plane in 2018, transplant officials downplayed the incident. They emphasized that the organ was used for valves and tissues, not to save the life of a waiting patient, so the delay was inconsequential.
"It got to us on time, so that was the most important thing," said Doug Wilson, an executive vice president for LifeNet Health, which runs the Seattle-area operation that processed the tissue.
That high-profile event was dismissed as an anomaly, but a new analysis of transplant data finds that a startling number of lifesaving organs are lost or delayed after being shipped on commercial flights, the delays often rendering them unusable.
In a nation where nearly 113,000 people are waiting for transplants, scores of organs — mostly kidneys — are discarded after they don't reach their destination in time.
Between 2014 and 2019, nearly 170 organs could not be transplanted and almost 370 endured "near misses," with delays of two hours or more, after transportation problems, according to an investigation by Kaiser Health News and Reveal from the Center for Investigative Reporting. The media organizations reviewed data from more than 8,800 organ and tissue shipments collected voluntarily and shared upon request by the United Network for Organ Sharing, or UNOS, the nonprofit government contractor that oversees the nation's transplant system. Twenty-two additional organs classified as transportation "failures" were ultimately able to be transplanted elsewhere.
Surgeons themselves often go to hospitals to collect and transport hearts, which survive only four to six hours out of the body. But kidneys and pancreases — which have longer shelf lives — often travel commercial, as cargo. As such, they can end up missing connecting flights or delayed like lost luggage. Worse still, they are typically tracked with a primitive system of phone calls and paper manifests, with no GPS or other electronic tracking required.
Transplant surgeons around the country, irate and distressed, told KHN they have lost the chance to transplant otherwise usable kidneys because of logistics.
"We've had organs that are left on airplanes, organs that arrive at an airport and then can't get taken off the aircraft in a timely fashion and spend an extra two or three or four hours waiting for somebody to get them," said Dr. David Axelrod, a transplant surgeon at the University of Iowa.
One contributing factor is the lack of a national system to transfer organs from one region to another because they match a distant patient in need.
Instead, the U.S. relies on a patchwork of 58 nonprofit organizations called organ procurement organizations, or OPOs, to collect the organs from hospitals and package them. Teams from the OPOs monitor surgeries to remove organs from donors and then make sure the organs are properly boxed and labeled for shipping and delivery.
From there, however, the OPOs often rely on commercial couriers and airlines, which are not formally held accountable for any ensuing problems. If an airline forgets to put a kidney on a plane or a courier misses a flight because he got lost or stuck in traffic, there is no consequence, said Ginny McBride, executive director ofOurLegacy, an OPO in Orlando, Florida.
In an era when consumers can precisely monitor a FedEx package or a DoorDash dinner delivery, there are no requirements to track shipments of organs in real time — or to assess how many may be damaged or lost in transit.
"If Amazon can figure out when your paper towels and your dog food is going to arrive within 20 to 30 minutes, it certainly should be reasonable that we ought to track lifesaving organs, which are in chronic shortage," Axelrod said.
For years, organs were distributed locally and regionally first, a system that resulted in wide disparities in organ waiting times across the country. In recent years, UNOS officials and the transplant community, with federal urging, have been working, organ by organ, to restructure how it's done.
Amid those ongoing efforts to allocate organs more fairly — and, recently, a Trump administration effort to overhaul kidney care — the waste of some of these precious resources donated by good Samaritans has been overlooked. Last year, an average of nine people a day died while waiting for a new kidney.
Donor families and waiting patients may never know what's happened to an organ provided by a loved one or why a surgery is canceled at the last minute.
"We have been unaware of how many kidneys have been waylaid," said McBride, of the Orlando procurement agency. "That's not a number that's been transparent to us."
But, she added, she's aware of the risk: "I say a prayer and hold my breath every time a kidney leaves our office."
46 Minutes To Spare
In October, a kidney en route from McBride's OPO in Florida to a patient in North Carolina missed its connection in Atlanta. The box was prominently marked as a human organ and displayed a phone number to call. Apparently unaware of the urgency, a Delta cargo worker merely set it aside for a later flight.
The waiting transplant surgeon in Greensboro, North Carolina, "was having a fit," said Kim Young, the OurLegacy organ recovery coordinator. If the kidney didn't get to the hospital by 7 a.m., he wouldn't be able to use it. Both the risk of organ failure and the chance of death increase withevery hour a kidney is out of the body.
McBride had to decide whether to charter a plane at a cost of $15,000 — or to find a courier to drive the kidney through the night. She settled on the road trip, and the organ arrived at 6:14 a.m. — with just 46 minutes to spare.
Four months later, the transplant appears to have been a success, McBride said.
Delta Air Lines officials declined repeated requests to comment on its organ transport service or the specific incident McBride described.
Several domestic airlines, including Delta, United, American, Southwest and Alaska, provide special cargo services for organs with priority boarding, handling and monitoring. They all declined to comment on organ transportation.
The traveling public may not realize it, but thousands of transplant organs — mostly kidneys, but some pancreases — fly on commercial flights each year. Roger Brown, who runs the Organ Center at UNOS, estimates that as many as 10 organs for transplant are on the move this way every day.
UNOS handles about 1,800 of these organ and tissue shipments a year, of which 1,400 are kidneys. That's a fraction of the nearly 40,000 organs transplanted in the U.S. last year, including more than 23,000 kidneys. About 1 in every 6 transplanted kidneys is shipped nationally, UNOS figures show.
Most of the time, the organs get where they're going without incident, Brown said.
"We're never going to get rid of flight delays. We're never going to get rid of human error," he said. "We're never going to get rid of the person who's [trying to be] a little too helpful and perhaps puts it someplace special, which then maybe creates issues downstream."
Troubling Reports
Reports of trouble abound. In August, transplant officials at Medical City Dallas reported in a public forum that they'd lost three kidneys just that month because of problems with commercial flights.
"One organ was delayed due to weather and the next available flight wasn't till the next day," the report said. "Another organ made it to the airport, but was never placed on the intended flight. The third organ was mistakenly taken to the wrong airport and missed the intended flight."
In Kentucky, transplant surgeon Dr. Malay Shah said a kidney traveling on Delta from Pensacola, Florida, via Atlanta, on Oct. 1 sat in the Lexington airport for three hours before he was notified it was there. No one had noticed the box with the label that said "human organ for transplant," he said.
"It's scary," Shah said. "Organs traveling by this mechanism are treated as simply 'baggage' or 'cargo.'"
Before the 9/11 terror attacks in 2001, OPO workers could take organs through airport security and see them loaded onto the plane from the passenger gate, McBride said. Because of changes in security protocol, airline employees now load organs on the tarmac, where they fly in pressurized cargo holds.
While anecdotes like Shah's are common, there's little data to show how often these transportation problems occur. No federal agency, including the Health Resources and Services Administration, or HRSA, which contracts with UNOS, requires monitoring of transportation for transplant organs.
"Matters involving the transportation methods used by organ procurement organizations (OPOs) are arranged directly between OPOs and transplant centers," HRSA spokesperson David Bowman said in an email.
Airlines log organ shipments in internal booking systems and on cargo manifests, but those documents aren't public and no summary is available, said Katherine Estep, communications director for Airlines for America, an industry trade group.
"Live human organs receive the highest priority designation," she said in a statement.
But the agency didn't begin formally tracking transportation errors until 2016, when a new computer system came online. Before that, Organ Center staff kept track of problems informally, with pencil and paper, and the information wasn't verified, Brown said.
Calls for closer tracking from within the system have been met with defensiveness — or apathy, said Brianna Doby, an organ transplant community consultant for the Johns Hopkins School of Medicine.
"If you talk out loud about organ issues, they say it will drive down donation rates," Doby said. "It's not OK for us to say, 'Well, shipping is hard.' That's not an acceptable answer."
A National Network
UNOS was established in 1984 after Congress enacted the National Organ Transplant Act to address a critical shortage of donor organs and to improve organ matching and placement. It called for a national network to ensure that organs that couldn't be used in the area where they were donated would be transplanted to save lives elsewhere. Before that, many organs were lost simply because transplant teams couldn't find compatible recipients in time.
The act established the national Organ Procurement and Transplantation Network and called for the OPTN to be operated by a private, nonprofit organization under federal contract. UNOS, which has held the contract since the inception of OPTN, is overseen by HRSA, an agency of the U.S. Department of Health and Human Services.
Today, UNOS typically handles organs with conditions that can make them hard to place. That can include organs from older donors or those with medical or other characteristics that make them difficult to match.
Overall, about 7% of shipments handled by UNOS from July 2014 to November 2019 encountered transportation problems, the data obtained by KHN and Reveal showed. UNOS wouldn't release details about individual shipments, including dates or places shipped or causes of the transportation failures or delays.
But Brown, of the UNOS Organ Center, said an internal analysis showed that more than half of the transportation problems were related to commercial airlines or airports. Of those, two-thirds were caused by weather delays, mechanical delays and flight cancellations.
About one-third of transportation problems were related to logistics providers or ground couriers, mostly delays of package pickups. The rest were related to the sender or receiver of the shipments. The most common issue was the package not being ready for pickup at the designated time.
However, Brown said, poor outcomes can't be blamed directly on transportation problems, even when they do occur.
"The delay could be the primary reason an organ wasn't transplanted," he said. "It could be a contributing factor or it could have nothing to do with the reason that the organ is not transplanted."
Other transplant experts downplay the impact of transportation problems. Kelly Ranum, president of the Association of Organ Procurement Organizations, said she's "surprised at how low" UNOS' failure numbers are, considering the volume of kidneys shipped.
Dr. Kevin O'Connor, chief executive of LifeCenter Northwest, an OPO based in Seattle, said transportation problems are "minimal" compared with the other reasons organs — including about 3,500 donated kidneys — are discarded each year. These typically include biopsy findings, the inability to find a recipient and poor organ function.
"For over 30 years and literally tens of thousands of organs being transported," he said, "I can count on the fingers of one hand the number of times that, because of a transportation glitch, an organ was ultimately not transplanted."
Still, O'Connor acknowledged that "even one kidney being thrown away because of transportation errors is unacceptable."
"We don't have an end-to-end unified transportation system," Axelrod said. "We don't have a FedEx for transplant. We have a cobbled-together system of OPOs and couriers and private aircraft and commercial aircraft."
In recent years, several courier companies have emerged to meet the market for transplant organs. Don Jones, chief executive of the Nationwide Organ Recovery Transport Alliance, or NORA, contracts with more than 15 OPOs and oversees about 400 organs a year on commercial flights.
"I would say 99.8% of our transports on commercial airlines go perfectly fine," Jones said based on his estimate. Jones noted that his firm ships organs only on direct flights and uses GPS tracking to monitor them.
However, GPS tracking isn't universal — or required by UNOS or HRSA. Some couriers and airlines use it; many don't. Many OPOs monitor organs through a combination of verbal handoffs, automation and label scans, Brown said.
In Ginny McBride's misadventure last fall, she contracted with a courier, Sterling Global Aviation Logistics, which used Delta Air Lines to ship the kidney.
Delta uses GPS trackers on its Dash Critical shipments, promising fast, guaranteed delivery of human organs. But on that night in October, the kidney was shipped from Orlando to Atlanta without a GPS tracker. In Atlanta, a cargo worker couldn't find a GPS device to put on the box containing the kidney, so the worker held the organ for a later flight. That would have pushed it far beyond the window of viability.
An internal Delta report, obtained by McBride, found that Delta didn't have enough GPS devices available in Atlanta that night. "Destination stations are not returning the devices in a timely manner," according to the report. "One way to mitigate this from reoccurring is to have a larger inventory of GPS devises (sic) at each station."
Delta declined to comment on the report.
The average wait time for a kidney varies widely nationwide, from less than three years to more than a decade. One proposal to put more organs to use called for eliminating the 58 donation service areas and 11 regions now used to allocate kidneys and replacing them with a zone of up to 500 nautical miles from the donor hospital.
In December, OPTN cut that range in half — to 250 nautical miles — in part because of an outcry about problems shipping kidneys via commercial air.
"There are certainly no technological barriers to doing GPS and to actually requiring it," Brown said.
A UNOS committee is considering whether to collect data on transportation methods and outcomes, but, so far, the question remains under review.
"If the community wants it, they should ask for it," Brown said. "We can help facilitate and get it done for them."
McBride, who discussed solutions with her colleagues, hopes the transplant organizations will come together to solve transportation problems, to make sure every eligible donated kidney gets transplanted.
"Any organ that's wasted, in my opinion, is a loss to the patient and to the community," said Paul Conway, of the American Association of Kidney Patients, an advocacy group, who is himself a kidney recipient. "With all of the advances going on with drugs, with medical procedures, how can you have a logistics error be the barrier?"
This investigation and a related podcast represent a collaboration between Kaiser Health News and Reveal, from TheCenter for Investigative Reporting (CIR), a nonprofit news organization. Reveal, from CIR and PRX, is a nationally broadcast public radio show and investigative reporting podcast. Kaiser Health News (KHN) is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.