Much like President Barack Obama, a President Biden could find his health policies initially sidelined by economic issues — in his case, caused by the pandemic.
This article was published on Thursday, October 22, 2020 in Kaiser Health News.
If Joe Biden wins the presidency in November, health is likely to play a high-profile role in his agenda. Just probably not in the way he or anyone else might have predicted.
Barring something truly unforeseen, it's fairly certain that on Jan. 20 the U.S. will still be in the grip of the coronavirus pandemic — and the economic dislocation it has caused. Coincidentally, that would put a new President Biden in much the same place as President Barack Obama at his inauguration in 2009: a Democratic administration replacing a Republican one in the midst of a national crisis.
Obama had only a financial crisis to deal with. Still, Biden would have a couple of advantages his Democratic predecessor lacked, including the fact that, as vice president, he helped guide the country through that financial meltdown. He's also had time to plan how to address the crisis, which was not the case in 2009, when the economy was in freefall just as the new administration was taking office.
But like Obama before him, Biden will face a long must-do list on taking office. He will have to tackle the pandemic and economic crisis before he can turn to some of the big health changes he's promised, such as expanding the reach of the Affordable Care Act, creating a "public option" that would allow every American to enroll in a government-sponsored plan and lowering the eligibility age for Medicare from 65 to 60.
And even if Democrats do retake the Senate majority and keep control of the House, it is unlikely the majority in either chamber will be as large as in 2009, when Obama had 60 Senate votes.
Still, no matter what the partisan makeup of Congress, "priority one is to get the COVID response going," said Len Nichols, a professor of health policy at George Mason University.
Biden's COVID plan includes taking major responsibility for the pandemic back from the states. His federal response would include more money for, and coordination of, testing and contact tracing; ensuring adequate protective equipment for health professionals; and assuring the public that new treatments and vaccines will be based on science, not politics.
In an updated version of his plan, Biden has also promised that one of his first calls if he is elected will be to Dr. Anthony Fauci, the government's top infectious disease expert, who has been deridedby President Donald Trump. "Dr. Fauci will have full access to the Oval Office and an uncensored platform to speak directly to the American people — whether delivering good news or bad," says Biden's website.
Biden's COVID plan also addresses the economy — including calls for emergency paid leave for workers dislocated by the pandemic and more financial aid for workers, families and small businesses.
"If we've learned anything, it is that the health sector and the economy are not two separate spheres. They are connected," said Nichols. "I think health care and the economy are complementary and will be for the foreseeable future."
Assuming Biden gets beyond the pandemic and recession, he could move onto some of his bigger health promises, including expanding eligibility for Medicare, creating a "public option" health plan and boosting premium subsidies for the ACA.
Biden took heat throughout the primaries for his "moderate" approach to improving health insurance access and costs, compared with the "Medicare for All" plans for a government-run system supported by his top rivals, Sens. Bernie Sanders (I-Vt.) and Elizabeth Warren (D-Mass.). But that doesn't mean his far less sweeping approach would be easy to get through Congress.
"There's a really big difference when you're running the government than when you're running for office," said Dan Mendelson, a former Clinton administration health official and founder of the health consulting firm Avalere Health.
Many of Biden's proposals, including a public option and larger subsidies to help low- and middle-income people pay for insurance, are the very things that an overwhelmingly Democratic Congress could not pass as part of the original Affordable Care Act in 2010. Conservative Democratic senators objected to the plan.
"We pushed," Obama said in a recent interview on the podcast "Pod Save America," talking about the public option. "I needed 60 votes to get it through the Senate. Joe Lieberman, Ben Nelson and a couple others said, 'I'm not voting for a public option.'"
Mendelson said another big obstacle is that for all the detail Biden has in his health plan, concepts like the public option "are not well-defined, and there are many different theories of what it should be and where it should be fielded. There's no common vision about what it really means."
The same thing is true, he added, for something that seems as simple as reducing the Medicare eligibility age. "More than half these people have commercial insurance," he said. "What will happen to them?"
Grace-Marie Turner, of the conservative Galen Institute, suggested Biden — or Trump, if he's reelected — might be better served by pursuing one of the more bipartisan health issues that already have broad support from the public, like prescription drug prices or "surprise" medical bills patients receive after getting care from a doctor outside their insurance network while being treated at an in-network facility. "It would be a big statement," she said. "Whoever wins would then have the wind at their back."
But even those issues have a way of getting complicated. Both Democrats and Republicans say they want to bring down drug prices, but Republicans are vehemently against one of the Democrats' preferred ways of doing that: by allowing Medicare to negotiate with drugmakers. And surprise medical billing has so far defied efforts to fix it, as Congress seems unable to choose between health insurers and health providers, who each want the other to bear the additional costs.
As always, even when health is at the top of the agenda, it proves difficult to address.
Facing a pandemic, record unemployment and unknown future costs for COVID-19 treatments, health insurers selling Affordable Care Act plans to individuals reacted by lowering rates in some areas and, overall, issuing only modest premium increases for 2021.
"What's been fascinating is that carriers in general are not projecting much impact from the pandemic for their 2021 premium rates," said Sabrina Corlette, a research professor at the Center on Health Insurance Reforms at Georgetown University in Washington, D.C.
Although final rates have yet to be analyzed in all states, those who study the market say the premium increases they have seen to date will be in the low single digits — and decreases are not uncommon.
That's good news for the more than 10 million Americans who purchase their own ACA health insurance through federal and state marketplaces. The federal market, which serves 36 states, opens for 2021 enrollment Nov. 1, with sign-up season ending Dec. 15. Some of the 14 states and the District of Columbia that operate their own markets have longer enrollment periods.
The flip side of flat or declining premiums is that some consumers who qualify for subsidies to help them purchase coverage may also see a reduction in that aid.
Here are a few things to know about 2021 coverage:
It might cost about the same this year — or even less.
Despite the ongoing debate about the ACA — compounded by a Supreme Court challenge brought by 20 Republican states and supported by the Trump administration — enrollment and premium prices are not forecast to shift much.
"It's the third year in a row with premiums staying pretty stable," said Louise Norris, an insurance broker in Colorado who follows rates nationwide and writes about insurance trends. "We've seen modest rate changes and influx of new insurers."
That relative stability followed ups and downs, with the last big increases coming in 2018, partly in response to the Trump administration cutting some payments to insurers.
Those increases priced out some enrollees, particularly people who don't qualify for subsidies, which are tied both to income and the cost of premiums. ACA enrollment has fallen since its peak in 2016.
Charles Gaba, a web developer who has since late 2013 tracked enrollment data in the ACA on his ACASignups.net website, follows premium changes based on filings with state regulators. Each summer, insurers must file their proposed rates for the following year with states, which have varying oversight powers.
Gaba said the average requested increase next year nationwide is 2.1%. When he looked at 18 states for which regulators have approved insurers' requested rates, the percentage is lower, at 0.4%.
Another study, by KFF, of preliminary premiums filed this summer had similar findings: Premium changes in 2021 would be modest, only a few percentage points up or down. (KHN is an editorially independent program of KFF.Bottom of Form
It's still worth it to shop around.
Actuaries and other experts say premiums vary by state or region — even by insurer — for a number of reasons, including the number and relative market power of insurers or hospitals in an area, which affects the ability of insurers to negotiate rates with providers.
Because subsidies are tied to each region's benchmark plan, and those premium costs may have gone down, subsidies also could decrease. (Benchmark plans are the second-lowest-priced silver plan in a region.)
Switching to the benchmark plan can help consumers maintain how much they spend in premiums.
Enrollees should update their financial information, particularly this year when many are affected by work reduction or job losses. "They might be eligible for a bigger" subsidy, said Myra Simon, executive director of commercial policies for America's Health Insurance Plans, the industry lobbying group.
Enrollees can update their information online, or call their federal or state marketplace for assistance. Insurance brokers, too, can aid people in signing up for ACA plans. When shopping, consumers should check whether the doctors and hospitals they want to use are included in the plan's network.
Premiums are just one part of the equation. Consumers should also look closely at annual deductibles, because the trade-off of going with a lower-cost premium may well be higher annual deductibles that must be met before much of the coverage kicks in.
"We encourage people to consider all their options," said Simon.
What's behind the variation.
Enrollees in some states next year will see premium decreases, according to Gaba's website: Maine, for example, shows a 13% drop in weighted average premium prices, while Maryland's is down almost 12%. At the same time, Indiana's average is up 10%. And Kentucky is up 5%.
Both Maine and Maryland attribute the decrease to state programs that provide reinsurance payments to health insurers to help offset high-cost medical claims.
In Florida, regulators say insurance premiums will rise about 3%, while the state exchange in California is reporting just over a half-percent increase, its lowest average increase since opening in 2014. Officials in California cite factors that include an influx of healthier enrollees and a reduction in fees that insurers pay.
Other factors affecting rates include how much state regulators step in to alter initial rate filings, along with a provision of the ACA that requires insurers to spend at least 80% of revenue on direct medical care. If insurers don't meet that standard, they must issue rebates to policyholders. Many insurers were already on the hook to return money in 2020 for previous years.
Most insurers did not cite additional COVID treatment or testing costs as factors in their requested rate increase, Gaba said. Even those that did, however, mainly found them unnecessary because of reduced expenditures resulting from patients delaying elective care during the spring and summer.
"Some of them thought, 'We're going to make more than we thought this year in profits, so let's not be aggressive with pricing next year,'" said Donna Novak, a member of the American Academy of Actuaries' Individual and Small Group Markets Committee.
A smaller factor may be the repeal of a fee paid by insurers on premiums. Part of the ACA, the fee was permanently eliminatedby the Trump administration effective for 2021.
Your choice of insurers may have widened.
More insurers, including UnitedHealth Group, either stepped back into that individual market or expanded into new counties.
"Insurers are seeing a profit or potential for it," said John Dodd, an insurance broker in Columbus and past president of the Ohio Association of Health Underwriters.
Rates are down in general across his state for ACA plans, he said, and he expects agents to be busier than ever, simply because there are more plan offerings and choices to make and people want help.
Insurers, he said, like the way the ACA is working.
"People on TV who say it's not working, they don't know what they're talking about," said Dodd. "It's working well [for insurers] and every year it gets better."
New stuff in some states, including a public option.
Residents of New Jersey and Pennsylvania will buy coverage from new state-based marketplaces for 2021, after those states pulled out of the federal healthcare.gov, which now covers 36 states.
Lawmakers in those statessaid running their own marketplaces gives them more control and may save them money over time.
In 19 Washington state counties, insurers are offering "public option plans," which have all the standard benefits, including lower deductibles, and must meet additional quality standards.
As envisioned, the public option plans aimed to be less expensive, with the legislation tying payment rates to Medicare. Insurers offering a public option must stick to an aggregate cap of paying doctors, hospitals and other medical providers an average of 160% of what Medicare would pay for the same services.
When the premium rates came in, however, the five insurers offering the plans had varying prices. Not all parts of the state have the option, but where they do, two of the public option insurers have premiums that are either lower than other plans in the area or are the lowest-cost plan the insurer offers.
But three are more expensive.
The state's marketplace staff said the higher prices may reflect a number of things, from difficulty getting the program started during COVID-19 to a lack of incentives to get providers to participate.
It could also just be normal first-year jitters.
"It's Year One. As with any market entry strategy, people are pretty conservative," said Michael Marchand, chief marketing officer of the Washington Health Benefit Exchange.
In several other competitive races for governor this year, such as those in North Carolina and Missouri, opponents clash on the role of state mandates in slowing the virus.
This article was published on Wednesday, October 21, 2020 in Kaiser Health News.
Just 15 days ahead of the election, Montana Lt. Gov. Mike Cooney laid out his ideas on how he’d handle the COVID-19 pandemic if elected governor. Details were few, but the Democrat’s plan became one of only a handful being offered by candidates in the 11 U.S. governor’s races about how they’ll approach what’s certain to be the dominant issue of their terms, should they win.
While much of the nation’s focus is on who will be president come January, voters who are deciding the next occupant of their governor’s mansion are also effectively choosing the next leader of their state’s COVID-19 response. The virus has made governors’ power highly visible to voters. As the states’ top executives, they decide whether to issue mask mandates, close businesses and order people to stay home.
All but two races for governor feature incumbents running for reelection: Montana’s Democratic Gov. Steve Bullock can’t run again because of term limits and Utah’s Republican Gov. Gary Herbert decided not to run for another term.
In several other competitive races for governor this year, such as those in North Carolina and Missouri, opponents clash on the role of state mandates in slowing the virus. Still, COVID-19 often fades into the backdrop of many long-standing platforms or primarily comes up as candidates talk about the need to revive the economy.
Cooney’s proposal, released Monday, suggested using the National Guard to transport patients in extreme weather and subsidizing heating bills to help those quarantining at home. But other parts vaguely described how he would “develop a robust plan” to come.
His opponent, Republican U.S. Rep. Greg Gianforte, has acknowledged the health crisis but has focused primarily on the economy, saying the state has to “cure the economic pandemic” the virus caused.
Bryce Ward, a health economist with the University of Montana, said Cooney’s list was one of the first times he’s seen long-term planning for COVID-19 come up in what appears to be the nation’s tightest governor’s race. But, he added, neither Montana candidate has offered a concrete plan to deal with the dual crises that risk public health when people gather and businesses’ bottom lines when they don’t. Meanwhile, the state’s number of COVID-19 cases climbs and its economy suffers.
“Whoever wins, this is going to be the bulk of their term,” Ward said. “How are the candidates going to keep people afloat as long as they can? What are we doing in terms of planning for what we think our post-COVID world is going to look like?”
An October KFF poll found 29% of registered voters said the economy was the most important issue in choosing a president, while 18% said the coronavirus outbreak was their top issue. Republican voters were more likely to pick the economy, the survey found, and Democrats were more likely to pick the coronavirus. (KHN is an editorially independent program of KFF.)
“There are voters that feel that the government needs to lead, and there are voters that feel that the government is utilizing a pandemic to become too invasive,” said Capri Cafaro, a former Democratic Ohio state senator now teaching in American University’s public administration and policy department. “People are not necessarily making their decisions on ‘Did you do contact tracing? Are you going to slow the spread?’”
Among the incumbent governors seeking reelection this year, most of their campaigns’ focus on COVID-19 has been on how well they’ve responded to the crisis. Several pledge more of what they’ve been doing. “We’ll continue to follow the science and wear masks,” Delaware Democratic Gov. John Carney said in a recent debate.
Meanwhile, their challengers generally seek to cast the incumbents as mismanaging their states’ response and promising to undo what’s been done. Those who have put out actual plans to handle the pandemic are Democratic challengers to Republican governors, and their plans are similar to what Cooney released — some specific ideas and promises to fill in the gaps later.
In Missouri, Democratic challenger Nicole Galloway, who is the state auditor, made health care the center of her campaign and released a plan to respond to the virus with a statewide mask mandate and a limit on when public school classes can meet in person based on the community’s rate of infection.
Republican Gov. Mike Parson is the apparent front-runner in that state’s race. He has pledged to lead “the greatest economic comeback that we’ve ever seen in Missouri history.” The former Polk County sheriff also has focused on supporting law enforcement amid backlash against police brutality and racial injustice.
Curbing the coronavirus has taken a back seat to boosting the economy in Parson’s campaign. And, as governor, Parson has refused to issue a statewide mask mandate, despite a White House recommendation to do so. In late September, the governor and his wife tested positive for COVID-19. Parson has returned to work, which includes traveling across the state.
One of the more heated races is in North Carolina, where Democratic Gov. Roy Cooper is defending his seat against a challenge by his lieutenant governor, Republican Dan Forest. Forest sued Cooper this year to challenge the governor’s authority to impose COVID-related restrictions by executive order.
Forest dropped the lawsuit in August after a judge made a preliminary ruling against his case, then said on Twitter, “I did my part. If y’all want your freedoms back you’ll have to make your voices heard in November.”
Cooper’s campaign called the lawsuit “a desperate tactic to garner attention” for Forest’s political campaign. Since then, the governor has slowly eased COVID restrictions, updating an executive order to allow a limited number of people in bars, sporting events, movie theaters and amusement parks. Cooper is leading the race in recent polls.
Back in Montana, the pandemic surfaced in the gubernatorial campaign after health officials announced on Oct. 16 that a Helena concert, which Gianforte attended, was linked to several COVID-19 cases. More than 100 health professionals blasted him in an open letter for flouting local health restrictions, going maskless and making light of safety precautions at campaign events. Cooney called on him to suspend his campaign events until tested. Gianforte’s campaign has said he’s taking proper precautions and accused Cooney of politicizing a public health issue.
Cooney has said he’ll keep Montana’s COVID-19 response on the track he is helping set as lieutenant governor, with science guiding that work. Gianforte, who built a tech startup in Bozeman, has touted his business experience as proof he can lead Montana’s comeback. Both have said more needs to be learned about this virus and have pitched themselves as the one to steer the state’s economy through the crisis.
Ward, the University of Montana health economist, said the details are missing, such as how the winner will support businesses through the winter without federal aid. Or what the new governor would cut from the state budget if the economic crisis hits its coffers.
The state has a public mask mandate and a plan for reopening the economy with no apparent thresholds or timelines. The option for stricter rules has been left to county governments as the state sees its largest COVID surge yet.
Jeremy Johnson, a political scientist at Carroll College in Helena, said the initial lack of detailed pandemic policy in the state’s race could be attributed to both candidates trying to win over swing voters with safe themes. President Donald Trump won Montana in 2016 by 20 points, but the state has also had a Democratic governor for 16 years. While polls show Gianforte leading Cooney slightly, election handicappers Real Clear Politics and the Cook Political Report still consider the race a toss-up.
Yet as Election Day nears, the question of how to address the pandemic only looms larger. Montana’s case count is rising, adding to its total of more than 23,000 cases in the state of roughly 1 million.
Donella Pogue has trouble finding dentists in her rural area willing to accommodate her 21-year-old son, Justin, who is 6 feet, 8 inches tall, is on the autism spectrum and has difficulty sitting still when touched.
And this summer, he had a cavity and his face swelled. Pogue, of Bristol, New York, reached out to the Eastman Institute for Oral Health in Rochester, which offers teledentistry.
Dr. Adela Planerova looked into his mouth from 28 miles away as Pogue pointed her laptop's camera into her son's mouth. Planerova determined they did not need to make an emergency one-hour drive to her clinic. Instead, the dentist prescribed antibiotics and anti-inflammatory drugs, and weeks later he had surgery.
Teledentistry allows dental professionals like Planerova to remotely review records and diagnose patients over video. Some smile about its promise, seeing it as a way to become more efficient, to reach the one-third of U.S. adults who federal figures from 2017 estimate hadn't seen a dentist in the previous year and to practice more safely during the pandemic.
But others see it as lesser-quality care that's cheaper for dental professionals to provide, allowing them to make more money. At the same time, widespread adoption is hindered by issues such as spotty internet and insurance companies unwilling to reimburse for teledentistry procedures.
Dr. Christina Carter, an orthodontistin Morristown, New Jersey, said teledentistry has its place but shouldn't replace time in the dental chair.
"It cannot be used for a full diagnosis because we need other tools, like X-rays," she said. "We have all tried to see things on our phone or even on a Zoom call, and there is still just a different feel."
Still, as the pandemic curbs in-person visits and reduces dentists' revenue, more dentists are seeking guidance from Dr. Nathan Suter, a leading teledentistry advocate who owns the consultingcompany Access Teledentistry. Since March, he said, he's done webinarsfor about 9,000 dental professionals, up from fewer than 1,000 in the three years before the pandemic.
Teledentistry providers trace the practice to 1994, when the Army launched a pilot program in which health care providers used an intra-oral camera to take photos of a patient's mouth at a fort in Georgia and then sent them over the internet to a dental clinic at a fort 120 miles away.
Over the next two decades, dentists in upstate New York and the San Francisco Bay Area led teledentistry pilot programs for underserved children, some of whom were in preschool and already had cavities. The number of children who completed the prescribed dental treatment rose significantly.
Supporters say teledentistry can help reach the 43% of rural Americans who lack access to dental care. Medicaid and the Children's Health Insurance Program will pay for many dental procedures for those enrolled in those programs, but only 38% of dentists participate in those programs, according to the American Dental Association. One reason: Medicaid typically reimburses at a significantly lower rate than those of private insurance plans.
Teledentistry could help dentists treat more patients and make more money a number of ways. If dentists remotely review data captured by hygienists, they can see more patients. Because video appointments save them time, dentists then have room for the people "who need the more expensive services" while also focusing on preventive care, said Kirill Zaydenman, vice president of innovation for DentaQuest, an administrator of dental insurance and oral health care provider.
But dentists have not widely adopted teledentistry — mainly because they've had difficulty getting insurers to pay for it, said Dr. Dorota Kopycka-Kedzierawski, a Rochester dentist. That's partly because of insurers' concerns about fraud. Dr. Paul Glassman, who started the Virtual Dental Home project to reach underserved preschool children in the Bay Area, considers those fears "completely incorrect."
"If you want to bill for something you didn't do," he said, "you can do that just as easily in an in-person environment as you can using teledentistry."
Since March, as the pandemic descended, most, if not all, private dental plans have been reimbursing for teledentistry, said Tom Meyers, vice president of public policy for America's Health Insurance Plans, a trade organization. And all state Medicaid programs now reimburse for teledentistry in some form, Glassman said, though policies differ by state and some practices may not be covered in some places.
But teledentistry isn't reimbursable under Medicare. (Most dentistry isn't.) Another obstacle to widespread adoption: Some dentists and lawmakers connect teledentistry to companies offering at-home teeth aligners with little or no in-person contact with a dentist. Glassman has promoted teledentistry throughout the United States and reviewed proposed legislation or regulations in states such as Idaho, Massachusetts and Texas. He said he hears concerns from dentists about the lack of an in-person exam during which X-rays are taken. Such concerns are reflected in some legislation.
SmileDirectClub, an at-home teeth-aligner company, has argued in statehouse testimony that in-person care is not always needed. The company opposed a 2019 bill in Texas that aimed to improve access to dentistry in rural areas because it included a number of restrictions on teledentistry, including one that would have required an in-person dentist's examination if a teledentistry provider treated that patient for more than 12 months.
SmileDirect's attorney argued at a hearing the rule "could interrupt the course of a patient's treatment."
The measure failed.
Proponents argue teledentistry isn't just about making more money. Pogue, the New York woman, said it was the best option for her son with special needs.
"He is really afraid of dentistry, so when he goes to see someone, he is really tense and really jumpy, so that's another reason the teledentistry was nice was because he was in my bedroom doing it, so he was really comfortable," said Pogue, 53, whose son is covered by Medicaid.
A few weeks later, Justin did have to have surgery, which went "perfect," his mom said.
Some dentists say teledentistry faces particular stumbling blocks in rural areas. Dr. Mack Taylor, 36, a dentist who grew up in the small town of Dexter, Missouri, now practices in a health centerjust down the road. Twenty years ago, he said, Dexter had eight dentists. Now there are only three.
Technology is a major obstacle for local residents, many of whom lack reliable internet service. Taylor recently applied for a U.S. Department of Agriculture grant that would give him $26,500 to buy equipment so that, for example, a hygienist can take photos inside the mouths of nursing home residents and send them to Taylor to review.
"It's not like medicine where you can discuss someone's ailments and have a good idea what's going on," Taylor said. "Maybe all you can tell me is 'I have a broken tooth,' but I can't physically see what's going on and prescribe the right treatment."
People of color are disproportionately affected by the coronavirus. It is not merely because they're more likely to have front-line jobs that expose them to it and the underlying conditions that make COVID-19 worse.
This article was published on Wednesday, October 21, 2020 in Kaiser Health News.
In mid-March, Karla Monterroso flew home to Alameda, California, after a hiking trip in Utah's Zion National Park. Four days later, she began to develop a bad, dry cough. Her lungs felt sticky.
The fevers that persisted for the next nine weeks grew so high — 100.4, 101.2, 101.7, 102.3 — that, on the worst night, she was in the shower on all fours, ice-cold water running down her back, willing her temperature to go down.
"That night I had written down in a journal, letters to everyone I'm close to, the things I wanted them to know in case I died," she remembered.
Then, in the second month, came a new batch of symptoms: headaches and shooting pains in her legs and abdomen that made her worry she could be at risk for the blood clots and strokes that other COVID-19 patients in their 30s had reported.
Still, she wasn't sure if she should go to the hospital.
"As women of color, you get questioned a lot about your emotions and the truth of your physical state. You get called an exaggerator a lot throughout the course of your life," said Monterroso, who is Latina. "So there was this weird, 'I don't want to go and use resources for nothing' feeling."
It took four friends to convince her she needed to call 911.
But what happened in the emergency room at Alameda Hospital only confirmed her worst fears.
At nearly every turn during her emergency room visit, Monterroso said, providers dismissed her symptoms and concerns. Her low blood pressure? That's a false reading. Her cycling oxygen levels? The machine's wrong. The shooting pains in her leg? Probably just a cyst.
"The doctor came in and said, 'I don't think that much is happening here. I think we can send you home,'" Monterroso recalled.
Her experiences, she reasons, are part of why people of color are disproportionately affected by the coronavirus. It is not merely because they're more likely to have front-line jobs that expose them to it and the underlying conditions that make COVID-19 worse.
"That is certainly part of it, but the other part is the lack of value people see in our lives," Monterroso wrote in a Twitter thread detailing her experience.
In the hospital that day in May, Monterroso was feeling woozy and having trouble communicating, so she had a friend and her friend's cousin, a cardiac nurse, on the phone to help. They started asking questions: What about Karla's accelerated heart rate? Her low oxygen levels? Why are her lips blue?
The doctor walked out of the room. He refused to care for Monterroso while her friends were on the phone, she said, and when he came back, the only thing he wanted to talk about was Monterroso's tone and her friends' tone.
"The implication was that we were insubordinate," Monterroso said.
She told the doctor she didn't want to talk about her tone. She wanted to talk about her health care. She was worried about possible blood clots in her leg and she asked for a CT scan.
"Well, you know, the CT scan is radiation right next to your breast tissue. Do you want to get breast cancer?" Monterroso recalled the doctor saying to her. "I only feel comfortable giving you that test if you say that you're fine getting breast cancer."
Monterroso thought to herself, "Swallow it up, Karla. You need to be well." And so she said to the doctor: "I'm fine getting breast cancer."
He never ordered the test.
Monterroso asked for a different doctor, for a hospital advocate. No and no, she was told. She began to worry about her safety. She wanted to get out of there. Her friends, all calling every medical professional they knew to confirm that this treatment was not right, came to pick her up and drove her to the University of California-San Francisco. The team there gave her an EKG, a chest X-ray and a CT scan.
"One of the nurses came in and she was like, 'I heard about your ordeal. I just want you to know that I believe you. And we are not going to let you go until we know that you are safe to go,'" Monterroso said. "And I started bawling. Because that's all you want is to be believed. You spend so much of the process not believing yourself, and then to not be believed when you go in? It's really hard to be questioned in that way."
Alameda Health System, which operates Alameda Hospital, declined to comment on the specifics of Monterroso's case, but said in a statement that it is "deeply committed to equity in access to health care" and "providing culturally-sensitive care for all we serve." After Monterroso filed a grievance with the hospital, management invited her to come talk to their staff and residents, but she declined.
She believes her experience is an example of why people of color are faring so badly in the pandemic.
"Because when we go and seek care, if we are advocating for ourselves, we can be treated as insubordinate," she said. "And if we are not advocating for ourselves, we can be treated as invisible."
Unconscious Bias in Health Care
Experts say this happens routinely, and regardless of a doctor's intentions or race. Monterroso's doctor was not white, for example.
Research shows that every doctor, every human being, has biases they're not aware of, said Dr. René Salazar, assistant dean for diversity at the University of Texas-Austin medical school.
"Do I question a white man in a suit who's coming in looking like he's a professional when he asks for pain meds versus a Black man?" Salazar said, noting one of his own possible biases.
Unconscious bias most often surfaces in high-stress environments, like emergency rooms — where doctors are under tremendous pressure and have to make quick, high-stakes decisions. Add in a deadly pandemic, in which the science is changing by the day, and things can spiral.
"There's just so much uncertainty," he said. "When there is this uncertainty, there always is a level of opportunity for bias to make its way in and have an impact."
Salazar used to teach at UCSF, where he helped develop unconscious-bias training for medical and pharmacy students. Although dozens of medical schools are picking up the training, he said, it's not as commonly performed in hospitals. Even when a negative patient encounter like Monterroso's is addressed, the intervention is usually weak.
"How do I tell my clinician, 'Well, the patient thinks you're racist?'" Salazar said. "It's a hard conversation: 'I gotta be careful, I don't want to say the race word because I'm going to push some buttons here.' So it just starts to become really complicated."
A Data-Based Approach
Dr. Ronald Copeland said he remembers doctors also resisting these conversations in the early days of his training. Suggestions for workshops in cultural sensitivity or unconscious bias were met with a backlash.
"It was viewed almost from a punishment standpoint. 'Doc, your patients of this persuasion don't like you and you've got to do something about it.' It's like, 'You're a bad doctor, and so your punishment is you have to go get training," said Copeland, who is chief of equity, inclusion and diversity at the Kaiser Permanente health system. (KHN is an editorially independent program of KFF, which is not affiliated with Kaiser Permanente.)
Now, KP's approach is rooted in data from patient surveys that ask if a person felt respected, if the communication was good and if they were satisfied with the experience.
KP then breaks this data down by demographics, to see if a doctor may get good scores on respect and empathy from white patients, but not Black patients.
"If you see a pattern evolving around a certain group and it's a persistent pattern, then that tells you there's something that from a cultural, from an ethnicity, from a gender, something that group has in common, that you're not addressing," Copeland said. "Then the real work starts."
When doctors are presented with the data from their patients and the science on unconscious bias, they're less likely to resist it or deny it, Copeland said. At his health system, they've reframed the goal of training around delivering better quality care and getting better patient outcomes, so doctors want to do it.
"Folks don't flinch about it," he said. "They're eager to learn more about it, particularly about how you mitigate it."
Still Unwell
It's been nearly six months since Monterroso first got sick, and she's still not feeling well.
Her heart rate continues to spike and doctors told her she may need gallbladder surgery to address the gallstones she developed as a result of COVID-related dehydration. She decided recently to leave the Bay Area and move to Los Angeles so she could be closer to her family for the long recovery.
She declined Alameda Hospital's invitation to speak to their staff about her experience, concluding it wasn't her responsibility to fix the system. But she wants the broader health care system to take responsibility for the bias perpetuated in hospitals and clinics.
She acknowledges that Alameda Hospital is public, and it doesn't have the kind of resources that KP and UCSF do. A recent audit warned that the Alameda Health System was on the brink of insolvency. But Monterroso is the CEO of Code2040, a racial equity nonprofit in the tech sector and even for her, she said, it took an army of support for her to be heard.
"Ninety percent of the people that are going to come through that hospital are not going to have what I have to fight that," she said. "And if I don't say what's happening, then people with much less resources are going to come into this experience, and they're going to die."
This story is part of a partnership that includes KQED, NPR and KHN.
This election cycle — coinciding with a looming threat to the Affordable Care Act and millions of people losing jobs and employer-sponsored health insurance during the pandemic — the high price of prescription drugs has gained new significance.
This article was published on Tuesday, October 20, 2020 in Kaiser Health News.
During the first presidential debate of 2020, President Donald Trump touted his efforts to curb skyrocketing drug prices and declared that insulin is now “so cheap, it’s like water.” The response on social media was swift, and divided, with some people sharing pharmacy bills showing thousands of dollars they’d spent on insulin, while others boasted of newfound savings.
The next day, a self-described progressive political action committee called Change Now jumped into the fray by releasing an ad that circulated on Facebook attacking Trump and Sen. Thom Tillis (R-N.C.) on this issue.
In the 30-second ad, a North Carolina woman in her 30s explains she was diagnosed with Type 1 diabetes at age 4.
“Donald Trump and Thom Tillis opposed legislation that would lower the price of insulin and other prescription drugs,” she says. “People with diabetes can’t afford to wait for Trump and Tillis to fight for us. … We need affordable insulin now.”
(Posts sharing the quote were flagged as part of Facebook’s efforts to combat false news and misinformation on its news feed. Read more about PolitiFact’s partnership with Facebook.)
In recent years, politicians on both sides of the aisle have committed to addressing the cost of insulin. This election cycle — coinciding with a looming threat to the Affordable Care Act and millions of people losing jobs and employer-sponsored health insurance during the pandemic — the high price of prescription drugs has gained new significance.
Tillis is in one of the most heated Senate races in the country and has been repeatedly criticized by his opponent for receiving more than $400,000 in campaign contributions from the pharmaceutical and health product industries. Across the country, many voters say lowering prescription drug costs should be the top health priority for elected officials.
So, did Trump and Tillis really oppose policies that would accomplish that goal? We decided to take a closer look.
It turns out they’ve both opposed certain pieces of legislation that could have lowered the price of insulin and other prescription drugs, but they’ve also offered alternatives. The question is how aggressive those alternatives are and how many Americans would benefit from them.
Opposing the Strongest Reforms
Change Now pointed to two congressional bills to support the ad’s claim: one opposed by Trump, and the other by Tillis.
The first bill, known as H.R. 3, passed the House in December 2019, largely due to Democratic votes. It contains three main elements: decreasing out-of-pocket costs for people on Medicare, penalizing pharmaceutical companies that raise the price of drugs faster than the rate of inflation and — the most aggressive and controversial feature — allowing the federal government, which administers Medicare, to negotiate the price of certain drugs, including insulin. It also requires manufacturers to offer those agreed-on prices to private insurers, extending the benefits to a wider swath of Americans.
Stacie Dusetzina, an associate professor of health policy at Vanderbilt University School of Medicine, called it “the broadest-reaching policy that has been put forward” on drug pricing.
“While a lot of reform has focused on Medicare beneficiaries, that misses many insulin users,” Dusetzina said. “H.R. 3 does the most to affect prices for young consumers, like the woman in the ad.”
At the time, Trump vowed to veto that bill, saying the price controls it imposed “would likely undermine access to lifesaving medications” by decreasing the incentive for companies to innovate. When we checked in with the Trump campaign about the ad, a spokesperson reiterated this position, adding that the president continues to seek better legislative options.
The House bill in question, though, never made it to the president’s desk because the Senate didn’t take it up. Instead, the Senate Finance Committee proposed its own bill, which brings us to the second piece of legislation cited by Change Now.
Known as the Prescription Drug Pricing Reduction Act of 2019, the Senate bill echoes two aims of the House proposal: decreasing out-of-pocket costs for people on Medicare and putting an inflation-based cap on some drug prices.
So, it’s true that Trump and Tillis have both opposed legislation that could lower the cost of insulin and other prescription drugs. But that’s not the full picture of what either politician has done on this issue.
Alternative Solutions for a Smaller Group of Americans
The Trump campaign provided a long list of actions taken by his administration to curb the high costs of medication, including a flurry of executive orders related to insulin and prescription drugs. Tillis’ campaign highlighted an alternative bill the senator co-sponsored to target drug costs. Let’s break them down one at a time.
One of Trump’s orders aims to have Federally Qualified Health Centers provide insulin and EpiPens at a discounted rate to the low-income individuals they serve. These centers, however, are already required to offer sliding-scale payments, and a full discount to patients who earn below the federal poverty line, said Rachel Sachs, an associate professor of law at Washington University in St. Louis, who tracks drug-pricing laws.
Another order deals with the importation of drugs from Canada, where they are often cheaper. Although the order specifically excludes biologic drugs, including insulin, the administration has requested proposals from private companies on how insulin could be safely brought in from other countries.
The president also issued a particularly ambitious order that seeks to tie the price Medicare pays for drugs to a lower international reference price. The Trump administration, however, hasn’t released final regulations to implement that policy, which could take years. If implemented, the policy is expected to be challenged in court by the drug industry.
Perhaps the most notable measure on insulin at the moment, experts said, is a federal demonstration project that Medicare plans can voluntarily opt into, to cap the monthly copay for insulin at $35 for some seniors. The project is slated to begin in January 2021, but its long-term future is uncertain, Sachs said, because it relies on parts of the Affordable Care Act, which could be struck down by a Supreme Court ruling later this year.
Tillis believes this is “the better option,” campaign spokesperson Andrew Romeo said, because “in addition to helping control drug prices, the legislation also seeks to preserve America’s capacity to research and develop lifesaving medications.” It includes a monthly cap on insulin copays for Medicare beneficiaries and requires manufacturers to disclose prices in consumer ads.
But experts said Tillis’ proposal is weaker than other options before the House and Senate. It doesn’t include an inflation cap, Sachs said, and the bill’s benefit would likely be limited to some seniors on Medicare, leaving out the more than 150 million Americans covered by private insurance.
Jason Roberts, an associate professor of political science at the University of North Carolina-Chapel Hill, said the bill is largely symbolic.
“Tillis is getting hit for not supporting a bill that could move,” Roberts said. “Instead, he introduces something that has no chance of going anywhere, and he knows that. But it’s a way of trying to deflect that criticism without getting a lot accomplished.”
Our Ruling
An ad sponsored by a progressive political action committee claims that Trump and Tillis have opposed legislation that would decrease the cost of insulin and other prescription drugs.
Based on the two pieces of drug-pricing legislation Change Now points to, that’s accurate. Trump and Tillis have voiced opposition to prominent bills that experts say could decrease the cost of insulin for a broad group of Americans.
However, both politicians have also proposed alternative policies to lower the price of insulin and other prescription drugs. Most of their proposals have not taken effect yet and are largely targeted at seniors.
For months, as Marilyn Walters has struggled to recover from COVID-19, she has repeated this prayer day and night.
Like other older adults who've become critically ill from the coronavirus, Walters, 65, describes what she calls "brain fog" — difficulty putting thoughts together, problems with concentration, the inability to remember what happened a short time before.
This sudden cognitive dysfunction is a common concern for seniors who've survived a serious bout of COVID-19.
"Many older patients are having trouble organizing themselves and planning what they need to do to get through the day," said Dr. Zijian Chen, medical director of the Center for Post-COVID Care at Mount Sinai Health System in New York City. "They're reporting that they've become more and more forgetful."
Other challenges abound: overcoming muscle and nerve damage, improving breathing, adapting to new impairments, regaining strength and stamina, and coping with the emotional toll of unexpected illness.
Most seniors survive COVID-19 and will encounter these concerns to varying degrees. Even among the age group at greatest risk — people 85 and older — just 28% of those with confirmed cases end up dying, according to data from the Centers for Disease Control and Prevention. (Because of gaps in testing, the actual death rate may be lower.)
Walters, who lives in Indianapolis, spent almost three weeks in March and April heavily sedated, on a ventilator, fighting for her life in intensive care. Today, she said, "I still get tired real easy and I can't breathe sometimes. If I'm walking sometimes my legs get wobbly and my arms get like jelly."
"Emotionally, it's been hard because I've always been able to do for myself, and I can't do that as I like. I've been really nervous and jittery," Walters said.
Younger adults who've survived a serious course of COVID-19 experience similar issues but older adults tend to have "more severe symptoms, and more limitations in terms of what they can do," Chen said.
"Recovery will be on the order of months and years, not days or weeks," said Dr. E. Wesley Ely, co-director of the Critical Illness, Brain Dysfunction and Survivorship Center at Vanderbilt University Medical Center. Most likely, he speculated, a year after fighting the disease at least half of the critically ill older patients will not have fully recovered.
The aftereffects of delirium — an acute, sudden change of consciousness and mental acuity — can complicate recovery from COVID-19. Seniors hospitalized for serious illness are susceptible to the often-unrecognized condition when they're immobilized for a long time, isolated from family and friends, and given sedatives to ease agitation or narcotics for pain, among other contributing factors.
In older adults, delirium is associated with a heightened risk of losing independence, developing dementia and dying. It can manifest as acute confusion and agitation or as uncharacteristic unresponsiveness and lethargy.
"What we're seeing with COVID-19 and older adults are rates of delirium in the 70% to 80% range," said Dr. Babar Khan, associate director of Indiana University's Center for Aging Research at the Regenstrief Institute, and one of Walters' physicians.
Gordon Quinn, 77, a Chicago documentary filmmaker, believes he contracted COVID-19 at a conference in Australia in early March. At Northwestern Memorial Hospital, he was put on a ventilator twice in the ICU, for a total of nearly two weeks, and remembers having "a lot of hallucinations" — a symptom of delirium.
"I remember vividly believing I was in purgatory. I was paralyzed — I couldn't move. I could hear snatches of TV — reruns of 'Law & Order: Special Victims Unit' — and I asked myself, 'Is this my life for eternity?'" Quinn said.
Given the extent of delirium and mounting evidence of neurological damage from COVID-19, Khan said he expects to see "an increased prevalence of ICU-acquired cognitive impairment in older COVID patients."
Ely agrees. "These patients will urgently need to work on recovery," he said. Family members should insist on securing rehabilitation services — physical therapy, occupational therapy, speech therapy, cognitive rehabilitation — after the patient leaves the hospital and returns home, he advised.
"Even at my age, people can get incredible benefit from rehab," said Quinn, who spent nearly two weeks at Chicago's Shirley Ryan AbilityLab, a rehabilitation hospital, before returning home and getting several weeks of home-based therapy. Today, he's able to walk nearly 2 miles and has returned to work, feeling almost back to normal.
James Talaganis, 72, of Indian Head Park, Illinois, also benefited from rehab at Shirley Ryan AbilityLab after spending nearly four months in various hospitals beginning in early May.
Talaganis had a complicated case of COVID-19: His kidneys failed and he was put on dialysis. He experienced cardiac arrest and was in a coma for almost 58 days while on a ventilator. He had intestinal bleeding, requiring multiple blood transfusions, and was found to have crystallization and fibrosis in his lungs.
When Talaganis began his rehab on Aug. 22, he said, "my whole body, my muscles were atrophied. I couldn't get out of bed or go to the toilet. I was getting fed through a tube. I couldn't eat solid foods."
In early October, after getting hours of therapy each day, Talaganis was able to walk 660 feet in six minutes and eat whatever he wanted. "My recovery — it's a miracle. Every day I feel better," he said.
Unfortunately, rehabilitation needs for most older adults are often overlooked. Notably, a recent study found that one-third of critically ill older adults who survive a stay in the ICU did not receive rehab services at home after hospital discharge.
"Seniors who live in more rural areas or outside bigger cities where major hospital systems are providing cutting-edge services are at significant risk of losing out on this potentially restorative care," said Dr. Sean Smith, an associate professor of physical medicine and rehabilitation at the University of Michigan.
Sometimes what's most needed for recovery from critical illness is human connection. That was true for Tom and Virginia Stevens of Nashville, Tennessee, in their late 80s, who were both hospitalized with COVID-19 in early August.
Ely, one of their physicians, found them in separate hospital rooms, frightened and miserable. "I'm worried about my husband," he said Virginia told him. "Where am I? What is happening? Where is my wife?" the doctor said Tom asked, before crying out, "I have to get out of here."
Ely and another physician taking care of the couple agreed. Being isolated from each other was dangerous for this couple, married for 66 years. They needed to be put in a room together.
When the doctor walked into their new room the next day, he said, "it was a night-and-day difference." The couple was sipping coffee, eating and laughing on beds that had been pushed together.
"They both got better from that point on. I know that was because of the loving touch, being together," Ely said.
That doesn't mean recovery has been easy. Virginia and Tom still struggle with confusion, fatigue, weakness and anxiety after their two-week stay in the hospital, followed by two weeks in inpatient rehabilitation. Now, they're in a new assisted living residence, which is allowing outdoor visits with their family.
"Doctors have told us it will take a long time and they may never get back to where they were before COVID," said their daughter, Karen Kreager, also of Nashville. "But that's OK. I'm just so grateful that they came through this and we get to spend more time with them."
When Terry Mutter woke up with a headache and sore muscles on a recent Wednesday, the competitive weightlifter chalked it up to a hard workout.
By that evening, though, he had a fever of 101 degrees and was clearly ill. "I felt like I had been hit by a truck," recalled Mutter, who lives near Seattle.
The next day he was diagnosed with COVID-19. By Saturday, the 58-year-old was enrolled in a clinical trial for the same antibody cocktail that President Donald Trump claimed was responsible for his coronavirus "cure."
"I had heard a little bit about it because of the news," said Mutter, who joined thestudy by drugmaker Regeneron to test whether its combination of two man-made antibodies can neutralize the deadly virus. "I think they probably treated him with everything they had."
Mutter learned about the study from his sister-in-law, who works at Seattle's Fred Hutchinson Cancer Research Center, one of dozens of trial sites nationwide. He is among hundreds of thousands of Americans — including the president — who've taken a chance on experimental therapies to treat or prevent COVID-19.
But with nearly 8 million people in the U.S. infected with the coronavirus and more than 217,000 deaths attributed to COVID, many patients are unaware of such options or unable to access them. Others remain wary of unproven treatments that can range from drugs to vaccines.
"Honestly, I don't know whether I would have gotten a call if I hadn't known somebody who said, 'Hey, here's this study,'" said Mutter, a retired executive with Boeing Co.
The website clinicaltrials.gov, which tracks such research, reports more than 3,600 studies involving COVID-19 or SARS-CoV-2, the virus that causes the disease. More than 430,000 people have volunteered for such studies through the COVID-19 Prevention Network. Thousands of others have received therapies, like the antiviral drug remdesivir, under federal emergency authorizations.
Faced with a dire COVID diagnosis, how do patients or their families know whether they can — or should — aggressively seek out such treatments? Conversely, how can they decide whether to refuse them if they're offered?
Such medical decisions are never easy — and they're even harder during a pandemic, said Annette Totten, an associate professor of medical informatics and clinical epidemiology at Oregon Health & Science University.
"The challenge is the evidence is not good because everything with COVID is new," said Totten, who specializes in medical decision-making. "I think it's hard to cut through all the noise."
Consumers have been understandably whipsawed by conflicting information about potential COVID treatments from political leaders, including Trump, and the scientific community. The antimalarial drug hydroxychloroquine, touted by the president, received emergency authorization from the federal Food and Drug Administration, only to have the decision revoked several weeks later out of concern it could cause harm.
Convalescent plasma, which uses blood products from people recovered from COVID-19 to treat those who are still ill, was given to more than 100,000 patients in an expanded-access program and made widely available through another emergency authorization — even though scientists remain uncertain of its benefits.
Regeneron and the pharmaceutical firm Eli Lilly and Co. have both requested emergency use authorization for their monoclonal antibody therapies, even as scientists say such approval could jeopardize enrollment in the randomized controlled trials that will prove whether or how well they work. So far, about 2,500 people have enrolled in the Regeneron trials, with about 2,000 of them receiving the therapy, a company spokesperson said. Others have received the treatment through so-called compassionate use programs, though the company wouldn't say how many.
"With all of the information swirling around in the media, it's hard for patients to make good decisions — and for doctors to make those decisions," said Dr. Benjamin Rome, a general internist and health policy researcher at Harvard Medical School's Portal program. "You shouldn't expect that what you've heard about on the news is the right treatment for you."
Even so, people facing COVID shouldn't be afraid to question whether treatment options are available to them, Rome said. "As a doctor, I never mind when patients ask," he said.
Patients and families should understand what the implications of those treatments might be, Totten advised. Early phase 1 clinical trials focus largely on safety, while larger phase 2 and phase 3 trials determine efficacy. Any experimental treatment raises the possibility of serious side effects.
Ideally, healthcare providers would provide such information about treatments and risks unprompted. But during a pandemic, especially in a high-stress environment, they might not, Totten noted.
"It's important to be sort of insistent," she said. "If you ask a question, you have to ask it again. Sometimes you have to be willing to be a little pushy," she said.
Patients and families should take notes or record conversations for later review. They should ask about financial compensation for participation. Many patients in COVID-19 trials are paid modest amounts for their time and travel.
And they should think about how any treatment fits into their larger system of values and goals, said Angie Fagerlin, a professor and the chair of the population health sciences department at the University of Utah.
"What are the pros and what are the cons?" Fagerlin said. "Where would your decision regret be: Not doing something and getting sicker? Or doing something and having a really negative reaction?"
One consideration may be the benefit to the wider society, not just yourself, she said. For Mutter, helping advance science was a big reason he agreed to enroll in the Regeneron trial.
"The main thing that made me interested in it was in order for therapeutics to move forward, they need people," he said. "At a time when there's so much we can't control, this would be a way to come up with some kind of a solution."
That decision led him to Fred Hutch, which is collaborating on two Regeneron trials, one for prevention of COVID-19 and one for treatment of the disease.
"It was a six-hour visit," he said. "It's two hours to get the infusion. It's a very slow IV drip."
Mutter was the second person enrolled in the treatment trial at Fred Hutch, said Dr. Shelly Karuna, a co-principal investigator. The study is testing high and low doses of the monoclonal antibody cocktail against a placebo.
"I am struck by the profound altruism of the people we are screening," she said.
Mutter isn't sure how he contracted COVID-19. He and his family have been careful about masks and social distancing — and critical of others who weren't.
"The irony now is that we're the ones who got sick," said Mutter, whose wife, Gina Mutter, 54, is also ill.
Mutter knows he has a 1-in-3 chance that he got a placebo rather than one of two active treatment dosages, but he said he was willing to take that chance. His wife didn't enroll in the trial.
"I said, there's some risks involved. We're taking one for the team here. I don't think we both need to do that," he said.
So far, Mutter has struggled with a persistent cough and lingering fatigue. He can't tell if his infusion has been helpful, never mind whether it's a cure.
"Just no way of telling if I got the antibodies or not," he said. "Did I get them and that kept me out of disaster, or did I get the placebo and my own immune system did its job?"
Stakeholders in California see Proposition 15 as a potential savior for chronically underfunded local health departments struggling to respond to the worst public health crisis in more than a century.
This article was published on Monday, October 19, 2020 in Kaiser Health News.
SACRAMENTO — A November ballot initiative to raise property taxes on big-business owners in California is drawing unconventional political support from healthcare power players and public health leaders.
They see Proposition 15 as a potential savior for chronically underfunded local health departments struggling to respond to the worst public health crisis in more than a century. The initiative would change California's property tax system to tax some commercial properties higher than residential properties, which backers say could generate billions to help local governments pay for critical public health infrastructure and staffing.
Without such additional state or federal funding, local governments could be forced to make deeper budget cuts in health and other departments next year as the COVID-19 pandemic continues to strain city and county finances.
"When you're talking about healthcare, you're talking about money," said Anthony Wright, executive director of Health Access California, a Sacramento-based consumer advocacy group. "This is the major revenue measure on the ballot this year, and it's an opportunity to fund public health at the place where the main responsibility for public health lies — at the county level."
At least that's how healthcare advocates are casting the tax hike. But there's no guarantee that if the measure passes counties would use new revenue to address COVID-19 or other healthcare needs. And some rural counties fear they would lose money if the ballot measure passes, which could undercut public health efforts.
Support within the healthcare and local government worlds is not unanimous. The powerful California Hospital Association opposes the measure because it would result in higher taxes on private and investor-owned hospitals, said spokesperson Jan Emerson-Shea. Nonprofit hospitals, including those run by Sutter Health, Kaiser Permanente and Dignity Health, are exempt from paying property taxes despite their regular high revenue. They would remain exempt under the initiative. (KHN, which produces California Healthline, is not affiliated with Kaiser Permanente.)
"This new tax will mean millions of dollars will be taken away from patient care, in perpetuity," Emerson-Shea said.
Proposition 15 would amend California's landmark 1978 property tax initiative, Proposition 13, which capped commercial and residential property tax rates at 1% of assessed value at the time of purchase, and limited annual increases thereafter to 2%. The drop in property taxes as a result of the initiative decimated a major revenue source for public schools and social welfare programs, leaving many underfunded.
Voters are now being asked to allow higher taxes for business owners with commercial holdings valued at more than $3 million. If passed, the measure could generate up to $11.5 billion a year, according to the nonpartisan state Legislative Analyst's Office. It would not apply to residential properties.
Forty percent of annual revenue would be distributed to K-12 schools and community colleges, with 60% sent to cities and counties. Nothing in the measure would require new local revenue to be spent on healthcare, but supporters say it's their best hope after losing $134 million in state public health money this year as one-time funding for specific programs expired. At the same time, slammed by a projected $54 billion deficit, Gov. Gavin Newsom and state lawmakers declinedthis year to increase funding for local health departments to combat COVID-19 and rebuild public health infrastructure.
Sponsors of Proposition 15, including the California Teachers Association and the Service Employees International Union California, argue it's an overdue change that would tax wealthier enterprises in exchange for funding vital school and healthcare programs. They point out that the initiative, supported by Newsom and Democratic presidential nominee Joe Biden, would require schools and local governments to disclose all new revenue they receive and how money is spent.
If passed, money from the measure would begin flowing to schools and counties in 2022 at the earliest.
Opponents of the measure, including the California Chamber of Commerce, the California Republican Party and the Howard Jarvis Taxpayers Association, say hiking taxes on commercial property owners would harm struggling businesses hit hard by COVID-related closures.
"This is being pushed as a panacea cure-all, but at the end of the day, there is no accountability for where these funds go," said Michael Bustamante, a spokesperson for the "No on Prop 15" campaign. "There are, without question, an infinite number of needs, but there is no specificity with what it can or can't be spent on."
Kat DeBurgh, executive director of the Health Officers Association of California, which represents the state's 61 local health officers and has not taken a position on the initiative, said ongoing, unrestricted revenue could actually benefit counties by allowing them to spearhead public health programs that address local needs.
At present, counties are limited in what they can do with their public health dollars, she said. Most additional funding in recent years has largely been earmarked for specific programs or diseases, such as hepatitis C and HIV, and counties are not allowed to spend it on their COVID-19 response or other public health activities.
"Maybe your community's highest priority is not something easily funded by one of these grants. Many rural areas in our state don't have access to clean drinking water, for example," DeBurgh said. "And our greatest demand — more public health workers — can't be funded with grants or one-time money."
Healthcare leaders also argue the initiative could help support community clinics and public hospitals that provide care for uninsured people, who have also suffered financially during the pandemic.
"What we're really trying to avoid is having to balance the budget on the backs of people who need services," said Jodi Hicks, president and CEO of Planned Parenthood Affiliates of California. "Our public health system has clear inequities that we need to address, and additional funding can help fill in the gaps at the county level."
Hicks said Planned Parenthood, which provides sex education in California public schools, is supporting the initiative not only to improve public health, but also because she worries programs like sex education will be on the chopping block as the state experiences unprecedented job and economic losses.
"Those types of programs are the first to get cut when there's not enough funding," she said.
Small, rural counties could also lose funding, county assessors said.
While the initiative would likely raise taxes on large commercial property owners who have seen their land and property appreciate in value over the years, it would eliminate property taxes for other business assets, such as machinery and equipment, for the first $500,000 in value.
Counties that haven't seen land values climb as high as those in coastal regions like the Bay Area may not collect more property taxes while also losing revenue from the tax cut on other business assets.
Chuck Leonhardt, the elected assessor for rural Plumas County, projects that his county could be one of the losers.
"This would take $90 million in assessed value from our tax roll at the beginning, and then I'd have to reassess 2,000 commercial properties," he said. "Many of us rural counties don't feel we'll benefit from doing these reappraisals and my expectation is we could lose some money."
Even among supporters in public health, some fear that any potential windfall for counties would be allocated based on the whims of local politics.
"Even though I support it, I am skeptical that this money will go to the public health programs and basic infrastructure we so desperately need because public health has no constituency," said Bruce Pomer, a public health expert and chief lobbyist for the California Association of Public Health Laboratory Directors.
He pointed to Sacramento County, where the sheriff's department received a larger share of the $181 million in federal COVID-19 relief money than the county public health department.
"I'm worried we'll see the same thing we saw with Sacramento County," Pomer said.
Doris Hutchinson wanted to use money from the sale of her late mother's house to help her grandchildren go to college.
Then she learned the University of Virginia Health System was taking $38,000 of the proceeds because a 13-year-old medical bill owed by her deceased brother had somehow turned into a lien on the property.
Over six years, the state institution filed 36,000 lawsuits against patients seeking a total of more than $106 million in unpaid bills, a KHN analysis finds.
"It was a mess," she said. "There are bills I could pay with that money. I could pay off my car, for one thing."
Property liens are the hidden icebergs of patient medical debt, legal experts say, lying unseen, often for decades, before they surface to claim hard-won family savings or inheritance proceeds.
An ongoing examination by KHN into hospital billing and collections in Virginia shows just how widespread and destructive they can be. KHNreported a year ago that UVA Health had sued patients 36,000 times over six years for more than $100 million, often for amounts far higher than what an insurer would have paid for their care. In response to the articles, the system temporarily suspended patient lawsuits and wage garnishments, increased discounts for the uninsured and broadened financial assistance, including for cases dating to 2017.
Those changes were "a first step" in reforming billing and collection practices, university officials said at the time.
However, UVA Health continues to rely on thousands of property liens to collect old bills, in contrast to VCU Health, another huge, state-owned medical system examined by KHN. VCU Healthpledged in March to stop seizing patients' wages over unpaid bills and to remove all property liens, which are created after a creditor wins a court judgment.
Working courthouse-by-courthouse, VCU Health now says it has discovered and released 45,000 property liens filed against patients just in Richmond, its home city, some dating to the 1990s. There are an estimated 35,000 more in other parts of the state. Fifteen thousand of those have been canceled and they are working on the rest, officials said. These figures have not been previously reported. The system is part of Virginia Commonwealth University.
VCU Health's total caseload is "a huge number" but perhaps not astonishing given the energy with which many hospital systems sue their patients, said Carolyn Carter, deputy director of the National Consumer Law Center.
Despite having suspended patient lawsuits, UVA Health has continued to create property liens based on older court cases, court records show. The number of new liens is "small," said UVA Health spokesperson Eric Swensen.
An advisory council of UVA Health officials and community leaders is expected to deliver new recommendations by the end of October, Swensen said. The council, whose schedule has been slowed by the coronavirus crisis, has discussed property liens, Don Gathers, an activist and council member, said in an interview this summer.
Nobody knows how many old or new UVA Health liens are scattered through scores of Virginia courthouses. The health system, which has sued patients in almost every county and city in the state, has failed to respond to repeated requests over two years to disclose the number and value of its property liens.
But in Albemarle County alone, which surrounds the university's Charlottesville home, "there are thousands" of UVA Health judgments filed in the land records, which creates a lien, said Circuit Court Clerk Jon Zug.
Not just Virginia homes are at risk. UVA Health lawyers search the nation for property or other assets owned by patients with outstanding bills and have filed liens in Maryland, West Virginia, Ohio and Florida, court records show.
The system put a lien on a Nevada vacation condo owned by Veronica Musie's family a decade ago over a $30,600 hospital bill, said Musie, who lives in northern Virginia. The family has since paid the debt.
Virginia property liens expire after 20 years. But UVA Health often renews them. Since 2017, just in Albemarle County, it has renewed more than three dozen liens. That means the medical system could seize families' home equity until 2039 for bills dating to the last century.
UVA Health and other medical systems rarely force the sale of a home to claim money. Instead, they wait for families to refinance or sell, taking their cut at the settlement table. But with 6% simple interest accumulating year after year after the court judgment, as allowed by Virginia law, the final amount owed can be much more than the original charges.
UVA Health treated Hutchinson's brother for heart disease in the early 2000s. The unpaid bill was $24,868. The system laid claim to their mother's home because he was one of her heirs. The claim is up to $38,000 now, she said, because of interest charges. Hutchinson has been disputing it for more than a year.
VCU Health and its MCV Physicians affiliate estimate that eliminating two decades of property liens in courthouses across the state, which they began to do last year after KHN published its reports, won't be finished until spring.
Richmond was especially problematic. Because releasing 40,000 Richmond liens by hand would have been impractical, VCU Health got a judge's permission to do it with computer code.
Creditors such as UVA and VCU don't need addresses to create liens. All they have to do is file a judgment in county or city land records. If debtors own any property there, title companies won't approve a sale until the debt is paid, often with home equity.
Often owners don't know debts exist until paralegals unearth them when homes are sold, property pros say. Old debts can create liens on newly acquired real estate.
"It could be your grandmother's house, and as soon as you've inherited it, and you've got judgments, those [liens] are now attached," said Richmond Court Clerk Edward Jewett.
Frequently debtors own no property, so judgments in the land records expire without hospitals or other creditors getting anything.
VCU and MCV had no idea how many liens they had placed across the state until they began investigating last year after KHN's inquiries, officials said.
"It's an incredibly manual process" to cancel the claims, partly because computer systems at many courthouses prohibit an easy tech solution, said Melinda Hancock, VCU Health's chief administrative and financial officer. But it's worth it to remove a burden on patients, she said, adding, "This is an outdated collections practice whose time has come and gone."
But many medical systems still do it, consumer debt experts say, noting that obtaining a complete picture of hospital property liens is impossible.
Land and judgment records are held by thousands of local court clerks, often using separate computer systems. Records are difficult or impossible to obtain in bulk.
"There is not a good nationwide study that I know of that looks at how widespread this is, how many consumers are affected, what's the average size of a lien," said Erin Fuse Brown, a law professor at Georgia State University who studies hospital billing.
Mike Miller and Kitt Klein are among those hoping UVA Health follows VCU Health in canceling thousands of property liens. They fear a $129,000 judgment won by UVA in 2017 against Miller will cost them the equity in their home in Quicksburg, Virginia.
They make about $25,000 a year. Miller, a house painter, was insured but received out-of-network radiation at UVA that doctors said was necessary to treat his lung cancer.
After KHN wrote about his case a year ago, benefits firm WellRithms analyzed his UVA bill and found that a commercial insurer would have paid a little more than $13,000, not $129,000, for the treatment.
"We know all [health care] providers bill a lot, but usually 'a lot' is three to six times what reasonable prices would be," said Jordan Weintraub, vice president of claims for WellRithms. Trying to collect 10 times as much, she said, "is really out there."
UVA Health does not comment on individual patient cases, Swensen said.
KHN found last year that UVA frequently sued patients for far more than what the system could have collected from insurance.
Early this year Miller and Klein emailed UVA President James Ryan, asking for help in reducing or eliminating the judgment. His office phoned in February, saying it would review the case.
"I became very emotional, filled with gratitude," Klein said. "I couldn't talk."
Months went by with no contact. Recently a lawyer from the office of Virginia Attorney General Mark Herring offered to settle the case for $120,000, Klein said, reducing the bill by only $9,000. They don't have the money. Miller's cancer has returned. Interest is mounting at 6%.
University officials do not comment on legal matters or individual cases, a Ryan spokesperson said. Herring's office did not respond to requests for comment.