House Democrats are poised to pass sweeping legislation to lower drug prices using strategies President Donald Trump has endorsed. A Trump aide urged the Republican-controlled Senate to vote on a different package curbing drug prices that was drafted by a senior Republican.
But at least right now, neither measure appears likely to attract enough bipartisan support to become law.
Nearly 8 in 10 Americans say the cost of prescription drugs is unreasonable, with voters from both parties agreeing that reducing the cost of prescription drugs should be one of Congress' top priorities, according to a poll last month by the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)
With such broad and bipartisan support, why do the odds look grim for Congress to pass significant drug pricing legislation this year?
Because whether it's sharing the credit for a legislative victory with the other party or running afoul of the powerful drugmaker lobby, neither Democrats nor Republicans are sure the benefits are worth the risks, according to several of those familiar with the debate on Capitol Hill.
Complications From 'Medicare For All,' Impeachment
Senate Majority Leader Mitch McConnell, who is a Republican and controls what legislation gets to the Senate floor, has said he will not allow a vote on the House Democrats' legislation. Among other things, the bill written by House Speaker Nancy Pelosi and other Democratic leaders would enable federal health officials to negotiate the prices of as many as 250 of the most costly drugs. Although Trump has endorsed that tactic, most Republican lawmakers oppose it because they are philosophically opposed to interfering with the market.
On Friday, Trump's chief domestic policy adviser, Joe Grogan, said any drug pricing legislation would need bipartisan support, saying of Pelosi's plan: "It is not going to pass in its current form." He said the White House supports the bipartisan package drafted by Sen. Chuck Grassley (R-Iowa), who chairs the Finance Committee, and the committee's top Democrat, Sen. Ron Wyden of Oregon.
But many Senate Republicans in particular are uncomfortable with one of the bill's key provisions: a requirement that drugmakers not raise their prices on drugs covered by Medicare faster than the rate of inflation.
Asked whether the White House supports the inflation caps, Grogan said they were "not the administration's proposal, but they are the product of a bipartisan compromise, and they are the route to a bipartisan bill, in our opinion."
In a recent interview, Grassley spokesman Michael Zona dismissed the call from other Republicans to eliminate the provision. "There's no need," he said. "The bill passed with a bipartisan two-thirds majority in committee, and support's growing for the bill every week among Republicans."
While the Senate Finance Committee did vote 19-9 in July to send the Grassley-Wyden bill to the full Senate for consideration, some Republicans who voted to advance it cautioned then that they may not ultimately vote for the bill.
While considering the bill, all but two of the committee's Republican members voted to kill the provision to prevent Medicare drug prices from rising faster than inflation. Grassley, however, got Democratic support and it stayed in the bill.
But it's not clear if the bill will come to the floor. McConnell is known to be unwilling to corner Senate Republicans with votes that could be politically risky during campaign season, whether due to criticism from Democrats or pressure from the drug industry.
In addition, the push by some progressive Democratic presidential candidates for a government-controlled "Medicare for All" health system has not made it more appealing for Republicans to work with Democrats on health care issues, said Kim Monk, a health care analyst and partner at Capital Alpha Partners who used to work for Republicans in the Senate.
"Why would Republicans stick their neck out while Democrats are fighting over Medicare for All?" she asked.
And Senate Minority Leader Chuck Schumer of New York, a Democrat, has drawn a line insisting any health care legislation come with protections for those with preexisting conditions. That's a risky conversation for Republicans, because a federal appeals court is considering a lawsuit brought by Republican states seeking to throw out the entire Affordable Care Act, which guarantees those with medical conditions can get coverage.
Still, polling suggests that the issue of drug pricing has the power to motivate voters to support one party or the other, and that is likely to motivate lawmakers.
There are more Senate Republican incumbents up for reelection next year than Democrats, and several are considered vulnerable.
Meanwhile, Democrats might be able to argue that they sought to tackle the issue of prices, but Republicans backed away from it.
The decision by House Democrats last month to pursue an impeachment inquiry against Trump has no doubt poisoned the waters between the parties. But the prospects have not looked promising anyway for a comprehensive, bipartisan package of solutions to rein in escalating drug costs.
A Third Legislative Option
Acknowledging their problems with the Pelosi and Grassley-Wyden proposals, some Republicans are touting a modest measure that has failed to become law in the three years since it was introduced: the CREATES (Creating and Restoring Equal Access To Equivalent Samples) Act.
The CREATES Act does not take a direct approach to lowering prices. Nonetheless, based on political opposition to the larger packages, it could be some of the only drug-pricing legislation that passes this Congress. The bill would crack down on tactics used by brand-name drug manufacturers to dissuade generic competitors, aiming to eliminate anti-competitive behavior and allow the free market to bring down prices.
Specifically, it would empower generics manufacturers to sue brand-name drugmakers that block them from obtaining the samples needed to conduct studies and get Food and Drug Administration approval of their versions. It would also give the FDA more leeway to approve alternative safety protocols for high-risk drugs. Currently generic drugmakers are required to join with the brand-name manufacturers in a shared safety system for those drugs, but some brand-name companies refuse to negotiate with the generic companies, thus delaying their ability to get FDA approval.
It is the rare piece of legislation with support from the likes of progressive Sen. Sheldon Whitehouse (D-R.I.) and conservative Sen. Mike Lee (R-Utah).
But the bill has hit snags before. The brand-name drug industry trade group, the Pharmaceutical Research and Manufacturers of America, has opposed the CREATES Act in the past. With its heavy spending on lobbyists, advertisements and campaign contributions for lawmakers, it has been a powerful opponent.
Opposition softened earlier this year, though, when executives from seven of the world's biggest drugmakers told the Senate Finance Committee they are in favor of the bill.
"We support the overall intent of the CREATES Act," Holly Campbell, a PhRMA spokeswoman, said in an email. She added that drugmakers "should not withhold samples with the intent of delaying generic or biosimilar entry."
Facing the prospect that Congress could fail to pass bigger fixes like the Pelosi or Grassley-Wyden plans, some say CREATES could be used to offset the cost of health care programs like community health center funding that will soon expire if Congress does not extend them.
In July, the Congressional Budget Office estimatedthat the CREATES Act could save the federal government $3.7 billion over 10 years.
But even some of CREATES' supporters say it is not enough to lower drug prices.
"The idea that Congress is going to lower prescription drug prices without reforms to Medicare is nonsensical," said Zona, Grassley's spokesman. He added that the CREATES Act, which Grassley originally co-sponsored, is important. "But it's only one piece of the puzzle."
House members are home in their districts this week, and when they return, they expect to focus on passing spending bills before a Nov. 21 deadline to advert a government shutdown, before voting on Pelosi's plan.
In the meantime, some are cautious in their predictions about whether Congress can pass significant drug pricing legislation before 2020, when the election campaign may prompt lawmakers to retreat further into their respective partisan corners.
Chip Davis, the chief executive of the generic drugmakers' Association for Accessible Medicines, said that even though there is increasing agreement that the government needs to act to help curb drug price increases, the two parties are approaching it in very distinct ways.
"It remains to be seen," he added, "whether those differences of opinion can be reconciled into a package that can get enough support in both chambers."
Kaiser Permanente, which just narrowly averted one massive strike, is facing another one Monday.
The ongoing labor battles have undermined the health giant's once-golden reputation as a model of cost-effective care that caters to satisfied patients — which it calls "members" — and is exposing it to new scrutiny from politicians and health policy analysts.
As the labor disputes have played out loudly, ricocheting off the bargaining table and into the public realm, some critics believe that the nonprofit health system is becoming more like its for-profit counterparts and is no longer living up to its foundational ideals.
Compensation for CEO Bernard Tyson topped $16 million in 2017, making him the highest-paid nonprofit health system executive in the nation. The organization also is building a$900 million flagship headquarters in Oakland. And it bid up to $295 million to become the Golden State Warriors' official health care provider, the San Francisco Chronicle reported. The deal gave the health system naming rights for the shopping and restaurant complex surrounding the team's new arena in San Francisco, which it has dubbed "Thrive City."
The organization reported $2.5 billion in net income in 2018 and its health plan sits on about $37.6 billion in reserves.
Against that backdrop of wealth, more than 80,000 employees were poised to strike last month over salaries, retirement benefits and concerns over outsourcing and subcontracting. Nearly 4,000 members of its mental health staff in California are threatening to walk out Monday over the long wait times their patients face for appointments.
"Kaiser's primary mission, based on their nonprofit status, is to serve a charitable mission," said Ge Bai, associate professor of accounting and health policy at Johns Hopkins University. "The question is, do they need such an excessive, fancy flagship space? Or should they save money to help the poor and increase employee salaries?"
Lawmakers in California, Kaiser Permanente's home state, recently targeted it with a new financial transparency law aimed at determining why its premiums continue to increase.
There's a growing suspicion "that these nonprofit hospitals are not here purely for charitable missions, but instead are working to expand market share," Bai said.
The scrutiny marks a disorienting role-reversal for Kaiser, an integrated system that acts as both health insurer and medical provider, serving 12.3 million patients and operating 39 hospitals across eight states and the District of Columbia. The bulk of its presence is in California. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)
Many health systems have tried to imitate its model for delivering affordable health care, which features teams of salaried doctors and health professionals who work together closely, and charges few if any extraneous patient fees. It emphasizes caring and community with slogans like "Health isn't an industry. It's a cause," and "We're all in this together. And together, we thrive."
Praised by President Barack Obama for its efficiency and high-quality care, the health maintenance organization has tried to set itself apart from its profit-hungry, fee-for-service counterparts.
Now, its current practices — financial and medical — are getting a more critical look.
As a nonprofit, Kaiser doesn't have to pay local property and sales taxes, state income taxes and federal corporate taxes, in exchange for providing "charity care and community benefits" — although the federal government doesn't specify how much.
As a percentage of its total spending, Kaiser Permanente's charity care spending has decreased from 1.29% in 2012 to 0.8% in 2017. Other hospitals in California have exhibited a similar decrease, saying there are fewer uninsured patients who need help since the Affordable Care Act expanded insurance coverage.
CEO Tyson told California Healthline that he limits operating income to about 2% of revenue, which pays for things like capital improvements, community benefit programs and "the running of the company."
"The idea we're trying to maximize profit is a false premise," he said.
The organization is different from many other health systems because of its integrated model, so comparisons are not perfect, but its operating margins were smaller and more stable than other large nonprofit hospital groups in California. AdventHealth's operating margin was 7.15% in 2018, while Dignity Health had losses in 2016 and 2017.
Tyson said that executive compensation is a "hotspot" for any company in a labor dispute. "In no way would I try to justify it or argue against it," he said of his salary. In addition to his generous compensation, the health plan paid 35 other executives more than $1 million each in 2017, according to its tax filings.
Even its board members are well-compensated. In 2017, 13 directors each received between $129,000 and $273,000 for what its tax filings say is five to 10 hours of work a week.
And that $37.6 billion in reserves? It's about 17 times more than the health plan is required by the state to maintain, according to the California Department of Managed Health Care.
Kaiser Permanente said it doesn't consider its reserves excessive because state regulations don't account for its integrated model. These reserves represent the value of its hospitals and hundreds of medical offices in California, plus the information technology they rely on, it said.
Kaiser Permanente said its new headquarters will save at least $60 million a year in operating costs because it will bring all of its Oakland staffers under one roof. It justified the partnership with the Warriors by noting it spans 20 years, and includes a community gathering space that will provide health services for both members and the public.
Kaiser has a right to defend its spending, but "it's hard to imagine a nearly $300 million sponsorship being justifiable," said Michael Rozier, an assistant professor at St. Louis University who studies nonprofit hospitals.
The Service Employees International Union-United Healthcare Workers West was about to strike in October before reaching an agreement with Kaiser Permanente.
California legislators this year adopted a bill sponsored by SEIU California that will require the health system to report its financial data to the state by facility, as opposed to reporting aggregated data from its Northern and Southern California regions, as it currently does. This data must include expenses, revenues by payer and the reasons for premium increases.
Other hospitals already report financial data this way, but the California legislature granted Kaiser Permanente an exemption when reporting began in the 1970s because it is an integrated system. This created a financial "black hole" said state Sen. Richard Pan (D-Sacramento), the bill's author.
"They're the biggest game in town," said Anthony Wright, executive director of the consumer group Health Access California. "With great power comes great responsibility, and a need for transparency."
Patient care, too, is under scrutiny.
California's Department of Managed Health Care fined the organization $4 million over mental health wait times in 2013, and in 2017 hammered out an agreement with it to hire an outside consultant to help improve access to care. The department said Kaiser Permanente has so far met all the requirements of the settlement.
But according to the National Union of Healthcare Workers, which is planning Monday's walkout, wait times have just gotten worse.
Tyson said mental health care delivery is a national issue — "not unique to Kaiser Permanente." He said the system is actively hiring more staff, contracting with outside providers and looking into using technology to broaden access to treatment.
At a mid-October union rally in Oakland, therapists said the health system's billions in profits should allow it to hire more than one mental health clinician for every 3,000 members, which the union says is the current ratio.
Ann Rivello, 50, who has worked periodically at Kaiser Permanente Redwood City Medical Center since 2000, said therapists are so busy they struggle to take bathroom breaks and patients wait about two months between appointments for individual therapy.
"Just take $100 million that they're putting into the new 'Thrive City' over there with the Warriors," she said. "Why can't they just give it to mental health?"
Lobbying campaigns andlegislative battles have been underway for months as Congress tries to solve the problem of surprise billing, when patients face often exorbitant costs after they unknowingly receive care from an out-of-network doctor or hospital.
As Congress considers various plans and negotiates behind the scenes, data is trickling in from states that have been test-driving proposed solutions.
New York was among the first to tackle the issue. In 2015, it passed a surprise billing law that uses "baseball-style" arbitration as a way to settle payment disputes between insurance companies and doctors. Under this approach, which is used in Major League Baseball to negotiate salaries (hence the name), each party submits a proposed dollar amount to the arbiter, who then chooses one as the final monetary award.
According to an analysis of newly released datafrom New York's Department of Financial Services, the New York model is making health care substantially more expensive in the state. In fact arbiters are typically deciding on dollar amounts above the 80th percentile of typical costs.
"This is an extremely high and extremely inflationary rule of thumb," said Loren Adler, author of the analysis and associate director of the USC-Brookings Schaeffer Initiative for Health Policy.
New York's financial agency reported that the law has saved consumers $400 million, but Adler challenged the claim, saying the state's experience has shown limited relief for patients.
Arbitration, or as New York calls it "independent dispute resolution," or IDR, works like this: A patient gets into an accident and goes to a hospital in her insurance network. While there, she sees a physician ― perhaps an emergency room doctor or anesthesiologist ― who isn't covered by her insurance company.
The insurance company pays a small part of the bill, and the doctor sends the patient a bill for the rest (often called a balance bill). Under New York's law, the patient is held harmless, meaning they only have to pay as much of their deductible, copay or coinsurance as they would if the doctor were in network. If the insurance company and the physician can't agree on how much of the bill to pay, they can take the issue to IDR.
They each bring their "fair-price," "final bid" to the arbiter, who then decides between the two.
The problem, according to Adler, comes in the guidance the New York law gives arbiters. It says they should consider the 80th percentile of "billed charges."
"Providers' billed charges, or list prices, are unilaterally set, largely unmoored from market forces, and generally many times higher than in-network negotiated rates or Medicare rates," Adler wrote.
So bill charges are already much higher than what Medicare pays, and on top of that, arbiters are told to focus on the 80th percentile of those rates, an amount higher than what 80% of doctors charge for that procedure.
It wasn't clear at first how strictly arbiters would follow this guidance, but the data suggests they're using it most of the time. On average, arbitration decisions have been 8% higher than that 80th percentile mark.
"People think there's something magical about arbitration, that these brilliant geniuses sit down and look at all the facts to make a decision," Adler said. "They're normal people who don't have much more expertise than insurers or providers, and this strongly suggests they're just coming up with a rule of thumb."
According to the analysis, the number of bills undergoing arbitration went from 115 in 2015 to 1,014 in 2018. Many advocates of arbitration predict the number of claims will drop over time as insurers and providers work out claims themselves. Based on these numbers, though, this hasn't happened yet.
Insurance plans and doctors "won" about the same number of cases, and in 2018 more cases seemed to go in the providers' favor. Yet, Adler pointed out, consumers appeared to lose either way.
That's because even when the insurance plan won, it was on average only 11% less than the 80th percentile, which Adler said is still around three times as much as a patient would pay if the doctor were in-network. Those extra costs, he said, get passed on in the form of higher premiums.
One of the bills in Congress seeking to address surprise medical bills also relies on arbitration as the solution. But the bill authors, Sen. Bill Cassidy (R-La.) and Sen. Maggie Hassan (D-N.H.), were both quick to draw the distinction between their arbitration bill and New York's model at an event about surprise billing at the Bipartisan Policy Center on October 30.
"The New York system uses as its payment standard [bill] charges, which we think is wrong and misguided," Hassan said. "Which is why our bill doesn't."
Hassan and Cassidy's bill, called the STOP Surprise Medical Bills Act of 2019, avoids tying payment rates to the "bill charges" with which Adler and other experts take issue.
Instead, arbiters are supposed to consider "commercially reasonable rates" based on what other in-network doctors charge in that geographic area, as well as factors like the level of training the provider had and the complexity of the dispute.
Adler called Cassidy and Hassan's bill "leagues better" than the New York approach, but he's still skeptical of how vague the guidance is.
Cassidy dismissed many of the criticism in the Brookings' analysis, including the increase in cases going to arbitration because, he said, it represents such a small portion of the overall claims in New York.
He said they were still learning a lot from New York's experience.
"I think it's been incredibly useful," Cassidy said.
"We know that IDR is not abused," he said. "And it's been adopted by a spectrum of politically diverse states and geographically diverse states."
As for the main Senate bill, backed by Health, Education, Labor and Pensions Committee Chairman Lamar Alexander (R-Tenn.), it would use a different method to settle payment disputes. Under this approach, known as benchmarking, out-of-network providers must accept a set payment for their services, which would be based on a median of what other providers in the area charge.
Alexander's bill, which gained committee approval (20-3) in June, is still awaiting consideration by the full Senate.
It will have to navigate the pro-arbitration factions in the House.
COLORADO SPRINGS, Colo. — Forty-two boxes of returned mail lined a wall of the El Paso County Department of Human Services office on a recent fall morning. There used to be three times as many.
Every week, the U.S. Postal Service brings anywhere from four to 15 trays to the office, each containing more than 250 letters that it could not deliver to county residents enrolled in Medicaid or other public assistance programs. This plays out the same way in counties across the state. Colorado estimates about 15% of the 12 million letters from public assistance programs to 1.3 million members statewide are returned — some 1.8 million pieces of undelivered mail each year.
It falls on each county's staff, in between fielding calls, to contact the individuals to confirm their correct address and their eligibility for Medicaid, the federal-state health insurance program for people with low incomes.
But last year, state officials decided that if caseworkers can't reach recipients, they can close those cases and cut off health benefits after a single piece of returned mail.
Medicaid, food stamps and other public benefit programs have avoided the march toward digital communication and continue to operate largely in a paper-based world. That essentially ties lifesaving benefits for some of the most vulnerable populations to the vagaries of the Postal Service.
As returned mail piles up, Colorado and other states take increasingly drastic measures to work through the cumbersome backlog, lowering the bar for canceling benefits on the basis of returned mail alone. Missouri, Oklahoma and Maryland are among those that have struggled with the volume. And when Arkansas implemented Medicaid work requirements, nearly half of the people who lost benefits had failed to respond to mailings or couldn't be contacted.
At best, tightening returned mail policies could save states some money, and those cut from the benefits yet still eligible for them would experience only a temporary gap in their care. But even short delays can exacerbate some patients' chronic health conditions or lead to expensive visits to the hospital.
And at worst, the returned mail may be contributing to a major drop in Medicaid enrollment and increased numbers of uninsured. Those dropped from the rolls rarely realize it until they seek care.
"There's a lot of concern on this issue," said Ian Hill, a health policy analyst at the Urban Institute, a think tank based in Washington, D.C. "Are they getting purged from the records unfairly and too quickly?"
Taking Action
States have been walking a tightrope. While trying to aid their poorest residents, they also are grappling with budget-busting Medicaid costs and pressure from the Trump administration to ensure everyone on public assistance programs qualifies for the benefits.
Some states have sought "procedural denials because it kept their costs down," said Cindy Mann, who ran the Medicaid program under the Obama administration.
"But we certainly don't want to cut somebody off while they're still eligible," said Mann, who is now a partner with the law firm Manatt, Phelps & Phillips. "It's penny-wise and pound-foolish."
Low-income families who depend on public benefits tend to move often, leading to frequent errors in the addresses on file. But if a person moves out of state, the state-administered Medicaid benefit cannot move with them.
"States have always struggled with how to handle returned mail," said Jennifer Wagner, a senior policy analyst with the Center on Budget and Policy Priorities, a left-leaning think tank in Washington, D.C. "But we have more recently heard of states pushing a policy to be very aggressive about canceling clients when the state receives returned mail, and that has led to significant disenrollment."
In April 2018, Colorado lowered its recommended threshold for acting upon returned mail from three pieces of undeliverable mail to just one. From May 2017 to May 2019, enrollment in Medicaid and the Children's Health Insurance Program dropped 8.5% in the state — more than three times the national decline of 2.5%, according to the Medicaid and CHIP Payment and Access Commission, a congressional advisory panel.
It's unclear how much of the drop was due to returned mail. The enrollment declines could also reflect some combination of a proposed federal rule to deny green cards to immigrants who use public benefits, cuts in federal funding for outreach to sign people up for health coverage or an improved economy.
Colorado has not set up a way of tracking how many people are losing benefits because of returned mail or what happens to those who do.
"We don't have one data point that we can track," said Marivel Klueckman, who oversees Medicaid eligibility functions for Colorado. "That is something we're building into the future."
Of the more than 131,000 Colorado households that have public benefit mail returned each year, the state estimates about 1 in 4 cannot be reached, resulting in the possible closure of nearly 33,000 cases.
People cut off from benefits may never learn why and may not seek to restore their benefits, which concerns Bethany Pray, health care program director at the Colorado Center on Law and Policy, a Denver-based legal aid group.
"You're going to lose people who are truly eligible and should never have been taken off and who face barriers to re-enrollment," Pray said.
Mailing Woes
The lack of dependability of the Postal Service, particularly in rural areas of the state, adds to the concerns about relying on snail mail for important government correspondence.
Officials from the ski resort town of Snowmass Village, for example, complained last spring that they didn't have any mail delivered for an entire week.
"We have received over 6 feet of snow in the last two weeks and we still get more complaints about postal delivery than snow removal," town officials wrote in a March survey conducted by the Colorado Association of Ski Towns. "People aren't getting bills, jury summons, medications, certified mail."
In June, three members of Colorado's congressional delegation sent a letter to the postmaster general, pressing her to address a range of postal issues including lost or returned mail.
There's no question that cutting off people after one piece of paper mail is returned saves the state money in sending letters and processing undeliverable mail — though other costs may add up later. Colorado public assistance programs mail more than a million letters each month, at a cost of nearly $6 million annually. That is a small share of what is spent on the actual assistance, given that Colorado's Medicaid program alone costs $9 billion a year.
Cutting off assistance after one piece of returned mail also helps the state avoid making monthly payments to regional health organizations for case management and dental services for those who no longer qualify for benefits.
However, Colorado Medicaid's Klueckman said the state is primarily concerned with making sure eligible residents get their notifications and remain enrolled. The state moved eligibility determinations and renewals online and now offers a mobile app so residents also can receive notifications electronically.
Local Discretion
Colorado plans to open a consolidated returned mail center for the state as soon as July 2020. That could provide some economies of scale and consistency, but has the potential of increasing the number of people dropped, as local knowledge is replaced by automation.
Counties currently receive guidance from the state on how to process returned mail, but they have leeway to set their own procedures. El Paso County, for example, rarely closes cases based on a single piece of returned mail and opts not to act on addresses that are often used by those who are homeless, such as a shelter or post office.
"They're the least likely for us to be able to have a phone number to call them," said Karen Logan, economic and administrative services director for the county.
The county, Colorado's second-largest, used grant money this year to pay staff overtime to whittle down its backlog of returned mail. That has helped the county process more than 48,000 pieces of returned mail in the past year, with more than a third prompting database changes. But officials could not say how many of those resulted in people losing benefits.
"We have some other things that are a little bit higher on the priority scale, so we don't close as many cases as we probably could," Logan said. "But I can tell you this: Closing a case and having a person have to reapply two months later takes significantly more work."
ST. LOUIS — As millions of Americans start shopping Friday for individual health insurance for 2020, they will see federal ratings comparing the quality of health plans on the Affordable Care Act's insurance marketplaces.
But Christina Rinehart of Moberly, Mo., who has bought coverage on the federal insurance exchange for several years, won't be swayed by the new five-star rating system.
That's because only one insurer sells on the exchange where the 50-year-old former public school kitchen manager lives in central Missouri. Anthem Blue Cross Blue Shield in Missouri was not ranked by the Centers for Medicare & Medicaid Services.
"I'm pleased with the service I get with that and the coverage I have," she said, noting she focuses on cost and whether her medications and checkups are covered.
Rinehart's case illustrates one reason why the star ratings are unlikely to play a big role in people's decision-making for the first year of the national rollout. Nearly a third of health plans on the federal exchanges don't yet have a quality rating — including all the plans in Iowa, Kansas and Nebraska. Only one insurer is available in nearly a quarter of counties across the U.S. And consumers may not find the information behind the star ratings valuable without additional details, insurance experts say.
Across Missouri, Cigna is the only one of seven insurers to get ratings. The others have not yet been in the marketplace for the three years needed to merit a score.
Missouri is one of eight states that don't have any health plans that earned at least three stars. The others are Iowa, Kansas, Nebraska, Nevada, New Mexico, West Virginia and Wyoming. States with the most three-star or higher health plans are New York (12), Michigan (10), Pennsylvania (9), Massachusetts (8) and California (7).
The star ratings are largely new to the federal exchanges, which operate in 39 states. About 80% of plansin the federal marketplaces earned three or more stars overall, CMS said. Only 1% earned five stars.
The new federal star ratings are based on three main areas: evaluations of the plans' administration, such as customer service; clinical measures that include how often the plans provide preventive screenings; and surveys of members' perception of their plan and its doctors.
Ratings can be viewed at healthcare.gov, where consumers review plans' benefits and prices. Open enrollment runs from Friday through Dec. 15 for the federal exchange states, though enrollment lasts longer in the District of Columbia and most of the 11 states that operate their own marketplaces.
What Health Care Shoppers Need To Know
WHAT: The federal ratings for health care plans sold on the Affordable Care Act exchanges can be viewed at healthcare.gov, where consumers review plans' benefits and prices.
WHEN: Open enrollment runs from Friday, Nov. 1, through Dec. 15 for the federal exchange states, though enrollment lasts longer in most of the 12 states that run their own marketplaces.
Last year, about 11.4 million people bought coverage on all the exchanges, with more than 80% getting federal subsidies to lower their premiums.
The good news for consumers is premium prices on the federal exchanges are dropping by about 4% on average for 2020.
And consumers generally will have a wider array of choices as more companies enter the markets. Nationally, the average number of health plan choices per customer has risen from 26 to 38, according to Joshua Peck, co-founder of Get America Covered, a nonprofit that helps people enroll and find coverage. Missouri, for example, will have 28 plans from its seven insurers, he said, up from 14 this past year.
Jodi Ray, who runs Florida's largest patient navigator program as director of Florida Covering Kids & Families at the University of South Florida, is skeptical consumers will use the new ratings. Instead, she said, they will likely focus first on whether their doctor is on the plan, if their medications are covered, the size of the deductible and the monthly costs.
"The star ratings may fall out the door at that point," she said.
Many of the states that operate their own exchanges have already offered quality ratings, which were required under the ACA. California's insurance exchange has been providing quality ratings for several years, though it's unclear how much weight consumers give them.
"They have a limited effect on consumers but have a significant effect on health plans," said Peter Lee, executive director of Covered California, the state's insurance exchange. "It does tip health plans to focus on what they can do to improve care, and I think that is a positive effect."
Kaiser Permanente (which is not affiliated with Kaiser Health News) is the only insurer in the California exchange to garner the maximum five stars, Lee said. It also has the most enrollment of any plan in the state's exchange. But, he noted, the plan has a lower share of the enrollment in Southern California partly because its prices are higher compared with rival insurers, indicating low cost may trump high rankings in attracting enrollees.
"It's good news that nationally the federal marketplace is putting quality data out there for consumers," Lee said. Still, he added, customers would want to see the specific criteria that matter to them, such as how well plans care for patients with diabetes. Currently, that data is not immediately accessible for consumers at healthcare.gov.
Consumers tend to stick with their insurer even when prices and benefits change, said Katherine Hempstead, a senior policy adviser at the Robert Wood Johnson Foundation, the nation's largest public health philanthropy. "People think changing health insurance plans is a huge pain and they don't know if things will get better or worse." But, she added, "people respond to consumer ratings and reviews."
The federal government already uses star ratings to help consumers choose a Medicare Advantage plan as well as compare hospitals. It began testing the exchange ratings in a handful of states over the past two years.
Heather Korbulic, executive director of the Nevada health exchange, worries the ratings could be steered by a relatively small number of member surveys. "It's such a narrow sample," she said, noting one plan's rating was partly based on just 200 member reviews.
Even though many counties have only one insurer in 2020 ― most of them rural areas or clustered in the Southeast ― the number of enrollees with access to just one insurer is falling to 12% next year from 20% now.
"If you look at Arkansas, they've got nice competition in their marketplace, but they've also expanded Medicaid," Watson said. "We look a lot like Mississippi, which is struggling to get insurance in rural counties."
That leaves people, like Rinehart, stuck with one insurer.
Rinehart remains loyal to Anthem particularly after it helped her get care and deal with the costs of suffering four heart attacks in 24 hours nearly three years ago. She's thrilled Anthem's prices are down slightly for 2020.
"I wasn't able to afford insurance before [the Affordable Care Act]," she said, "so it was a blessing to have."
Hundreds of hospitals have joined in a handful of lawsuits in state courts, seeing the state-based suits as their best hope for winning meaningful settlement money.
"The expense of treating overdose and opioid-addicted patients has skyrocketed, straining the resources of hospitals throughout our state," said Lee Bond, CEO of Singing River Health System in Mississippi in a statement. His hospital is part of a lawsuit in Mississippi.
Hospitals may discover downsides to getting involved in litigation, said Paul Keckley, an independent health analyst.
"The drug manufacturers are a soft target," he said. But the invasive nature of litigation may generate "some unflattering attention" for hospitals, he added. They'd likely have to turn over confidential details about how they set prices, as well as their relationships with drug companies.
So, despite representing the front lines of the opioid epidemic, most hospitals have been hesitant to pile on.
Just about every emergency room has handled opioid overdoses, which cost hospitals billions of dollars a year, since so many of the patients have no insurance. But that's just the start. There are also uninsured patients, like Traci Grimes of Nashville, who end up spending weeks being treated for serious infections related to their IV drug use.
"As soon as I got to the hospital, I had to be put on an ice bath," Grimes said of her bout with endocarditis over the summer, when bacteria found its way to her heart. "I thought I was going to die, literally. And they said I wasn't very far away from death."
Grimes is in recovery from her opioid addiction but still getting her energy back after spending a month being treated through a special intravenous line to her heart at Vanderbilt University Medical Center. Most patients could be sent home with a PICC line, but not someone with a history of illicit IV drug use who could misuse it to inject other substances. Vanderbilt and other academic medical centers recognize the problem and have established special clinics to manage these complex patients.
Grimes, 37, said she's grateful for the care she received, which included multiple procedures and treatment for pneumonia, hepatitis A and hepatitis C. But like most patients in her situation, she's uninsured and strapped for cash.
"I can't pay a thing. I don't have a dime," she said. "So they do absorb all that cost."
Hospitals estimate treating complicated patients like Grimes costs an average of $107,000 per person, according to court documents. The total costs to U.S. hospitals in one year, 2012, exceeded $15 billion, according to a report cited in the suits. And most patients either couldn't pay or were covered by government insurance programs.
The expense is a leading reason cited by the hospitals who've banded together in a handful of lawsuits in Tennessee, Texas, Arizona, Florida, Kentucky, Mississippi and West Virginia. These suits are separate from the consolidated federal case in Ohio that includes cities and counties around the country. But the most prominent hospitals in those states, like Vanderbilt, have opted not to join the litigation.
West Virginia University President E. Gordon Gee, who oversees the state's largest hospital system, has been urging others to join the suits. He and former Ohio Gov. John Kasich established an organization meant to highlight the harm done to hospitals by the opioid crisis.
"I think the more hospitals we have that want to be involved in this in some way, the better off we are," he said. "You know, there's always safety in mass."
By "safety," Gee acknowledged a central concern for hospitals weighing the risk versus reward of going to court. They may have the tables turned on them by the pharmaceutical companies since, until recently, patients in the hospital were often prescribed large quantities of opioids, contributing to the epidemic.
"I suspect there are some hospitals … who are afraid that if they get into it, those who are on the defense side will point out, well, maybe hospitals were really the problem," he said.
The lead defendant in the suits, Purdue Pharma, did not respond to requests for comment.
Gee said hospitals can claim they were victims of dubious opioid marketing.
Still, many high-profile hospitals are sitting out the lawsuits, even though they're typically the ones that treat the most complicated and expensive patients.
Health analyst Keckley said if hospitals join the litigation, they may be forced to cough up actual totals for their opioid-related financial damages. That could force hospitals to reveal how much more they charge for some services, compared with the actual costs of providing the care.
"Hospitals basically have charged based on their own calculations and the underlying cost of delivering that care has been virtually nontransparent," Keckley said. "Then you open a whole new can of worms."
Big academic medical centers especially, Keckler said, have relationships with drugmakers that they may not want publicly highlighted.
Still, hospitals might benefit without having to put their names on lawsuits and exposing themselves to risk. In Oklahoma, the state won an early opioid lawsuit in August. The payout does not direct money to hospitals, per se. However, Patti Davis, president of the Oklahoma Hospital Association, said they're happy to see some of the money was earmarked for treatment.
"When we see treatment, we get very excited because it's our hospitals providing a lot of the treatment," she said.
But nationally, hospitals can't count on potential settlement money to trickle down to their bottom lines, said Don Barrett, a Mississippi litigator helping hospitals sue in state courts.
Two decades ago, when the target of litigation was Big Tobacco, Barrett was working for states. He said hospitals didn't join in, to his surprise. And when the states won those suits and started getting paid damages, hospitals missed out. Only about a third of the money was even spent on health or tobacco control, according to one watchdog's estimate.
"I guess they thought that the states were going to take care of them, that these local governments were going to take this money and give it to the hospitals where it would do some good," he said. "Of course, they didn't give them a damn penny."
Some states did set up trust funds that might help patients in the hospital stop smoking. But many are using the money to fill potholes, pay teachers and otherwise close gaps in state budgets.
Though not detailed in the lawsuits, many of the participating hospitals are in varying levels of financial distress, and not always primarily because of the opioid epidemic. Facilities owned by Community Health Systems make up a large share of the hospitals suing in Alabama, Florida, Mississippi, Tennessee and Texas. The investor-owned hospital chain, based in Franklin, Tenn., has been struggling mostly because of an outsize debt loadtaken on during a rapid period of expansion.
A CHS spokesperson declined to comment, citing a policy not to talk about pending litigation.
But Barrett said he expects more hospitals to join the cause rather than relying on states to determine how settlement money is spent.
"We're not going to allow that to happen this time," he said. "We can't afford to allow it to happen this time."
This story is part of a partnership that includes Nashville Public Radio, NPR and Kaiser Health News.
Everything old is new again. As open enrollment gets underway for next year's job-based health insurance coverage, some employees are seeing traditional plans offered alongside or instead of the plans with sky-high deductibles that may have been their only choice in the past.
Some employers say that, in a tight labor market, offering a more generous plan with a deductible that's less than four figures can be an attractive recruitment tool. Plus, a more traditional plan may appeal to workers who want more predictable out-of-pocket costs, even if the premium is a bit higher.
That's what happened at Digital River, a 650-person global e-commerce payment processing business based in Minnetonka, Minn.
Four years ago, faced with premium increases approaching double digits, Digital River ditched its traditional preferred provider organization plan in favor of three high-deductible plans. Each had different deductibles and different premiums, but all linked to health savings accounts that are exempt from taxes. This year, though, the company added back two traditional preferred provider plans to its offerings for workers.
Even with three plan options, "we still had employees who said they wanted other choices," said KT Schmidt, the company's chief administrative officer.
Digital River isn't the only company broadening its offerings. For the third year in a row, the percentage of companies that offer high-deductible plans as the sole option will decline in 2020, according to a survey of large employers by the National Business Group on Health. A quarter of the firms polled will offer these plans, sometimes called consumer-directed plans, as the only option next year, down 14 percentage points from two years ago.
That said, consumer-directed plans are hardly disappearing. Fifty-eight percent of covered employees worked at companies that offered at least one high-deductible health plan in 2019, according to an annual survey of employer health benefits released by the Kaiser Family Foundation last month. That was second only to the 76% of covered workers who were at firms that offered a PPO plan. (KHN is an editorially independent program of the foundation.)
When Digital River switched to all high-deductible plans for 2016, the firm put some of the $1 million it saved into the new health savings accounts that employees could use to cover their out-of-pocket expenses before reaching the deductible. Employees could also contribute to those accounts to save money for medical expenses. This year the deductibles on those plans are $1,850, $2,700 and $3,150 for single coverage, and $3,750, $5,300 and $6,300 for family plans.
The company put a lot of effort into educating employees about how the new plans worked, said Schmidt. Premiums are typically lower in high-deductible plans. But under federal rules, until people reach their deductible, the plans pay only for specified preventive care such as annual physicals and cancer screenings and some care for existing chronic conditions.
Enrollees are on the hook for everything else, including most doctor visits and prescription drugs. In 2020, the minimum deductible for a plan that qualifies under federal rules for a tax-exempt health savings account is $1,400 for an individual and $2,800 for a family.
As their health savings account balances grew, "more people moved into the camp that could see the benefits" of the high-deductible strategy, Schmidt said. Still, not everyone wanted to be exposed to costs upfront, even if they ended up spending less overall.
"For some people, there remained a desire to pay more to simply have that peace of mind," he said.
Digital River's PPOs have deductibles of $400 and $900 for single coverage and $800 and $1,800 for families. The premiums are significantly more expensive than those of the high-deductible plans.
In the PPO plan with the $400/$800 deductible, the employee's portion of the monthly premium ranges from $82.37 for single coverage to $356.46 for an employee plus two or more family members. The plan with the $2,700 deductible costs an employee $21.11 for single coverage and the $5,300 deductible plan costs $160.29 for the employee plus at least two others.
But costs are more predictable in the PPO plan. Instead of owing the entire cost of a doctor visit or trip to the emergency room until they reach their annual deductible, people in the PPO plans generally owe set copayments or coinsurance charges for most types of care.
When Digital River introduced the PPO plans this year, about 10% of employees moved from the high-deductible plans to the traditional plans. Open enrollment for 2020 starts later this fall, and the company is offering the same mix of traditional and high-deductible plans again for next year.
Adding PPOs to its roster of plans not only made employees happy but also made the company more competitive, Schmidt said. Two of Digital River's biggest competitors offer only high-deductible plans, and the PPOs give Digital River an edge in attracting top talent, he believes.
According to the survey by the National Business Group on Health, employers that opted to add more choices to what they offered employees typically chose a traditional PPO plan. Members in these plans generally get the most generous coverage if they use providers in the plan's network. But if they go out of network, plans often cover that as well, though they pay a smaller proportion of the costs. For the most part, deductibles are lower than the federal minimum for qualified high-deductible plans.
Traditional plans like PPOs also give employers more flexibility to try different approaches to improve employees' health, said Tracy Watts, a senior partner at benefits consultant Mercer.
"Some of the newer strategies that employers want to try just aren't [health savings account] compatible," said Watts. The firms might want to pay for care before the deductible is met, for example, or eliminate employee charges for certain services. Examples of these strategies could include direct primary care arrangements in which physicians are paid a monthly fee to provide care at no cost to the employee, or employer-subsidized telemedicine programs.
The so-called Cadillac tax, a provision of the Affordable Care Act that would impose a 40% excise on the value of health plans that exceed certain dollar thresholds, was a driving force behind the shift toward high-deductible plans. But the tax, originally supposed to take effect in 2018, has been pushed back to 2022. The House passed a bill repealing the tax in July, and there is a companion bill in the Senate.
It's unclear what will happen, but employers appear to be taking the uncertainty in stride, said Brian Marcotte, president and CEO of the National Business Group on Health.
"I think employers don't believe it's going to happen, and that's one of the reasons you're seeing [more plan choices] introduced," he said.
This article was first published on Monday, October 28, 2019 in Kaiser Health News.
Teenagersdon't get enough sleep, and California's effort to fix the problem may serve as a wake-up call to other states' lawmakers.
A law recently signed by Gov. Gavin Newsom that mandates later start times for most students — no earlier than 8 a.m. in middle school and 8:30 a.m. in high school — is the first statewide response in the United States to overwhelming evidence that chronic lack of sleep impairs teens.
But it is hardly the only attempt to address the issue.
Individual cities, regions and school districts across the U.S. have tried for years to afford their students the sleep benefits of later school starts.
Their efforts are just one aspect of a broader societal phenomenon so harmful that the Centers for Disease Control and Prevention declared it a public health epidemic five years ago. Simply put, a staggering number of Americans — or, better said, a number of staggering Americans — don't get enough sleep.
There is no simple way to alter that reality, a reminder of which will be heard early in the morning on Sunday, Nov. 3, as Daylight Saving Time ends, bringing with it the usual spate of sleep-related complications.
Last November, nearly 60% of California voters backed a ballot proposition to end twice-a-year clock changes, in part because of the havoc they wreak on sleep. State legislators followed with a billto put California on permanent Daylight Saving Time.
It passed the Assembly earlier this year but is now on hold until 2020. Assemblyman Kansen Chu (D-San Jose), who introduced the legislation, said he wanted more time to explore the option of going on permanent standard time.
Only two states — Arizona and Hawaii — do not move their clocks every spring and autumn. Both abandoned the system in the late 1960s, noting that their residents receive plenty of sunlight year round.
Other states, including Minnesota, Florida and several more, have considered legislation to remain on Daylight Saving Time year-round. Oregonalready passed a law to do so. But since legislators there wanted all the clocks on the West Coast showing the same time, their law is on hold until Washington and California do the same.
And to make the problem even more complicated, any state that jettisons biannual clock changing still needs approval from Congress.
The specifics of California's new school law reflect the complexity of any kind of change to the sleep patterns of Americans. The bill exempts some of the state's rural districts, makes allowances for optional "zero period" early classes, and is being phased in over three years.
A bill with similar provisions was rejected by lawmakers in 2017 andvetoed by then-Gov. Jerry Brown in 2018. Critics say local communities and school boards should be able to decide their own start times. And they argue that the law will disproportionately affect lower-income families, who cannot alter their morning work schedules to accommodate later rides to school — though some lucky parents may be able to get more sleep.
The momentum toward later starting times for students, who researchers say need close to nine hours of sleep a night, has been gathering for some time. And research in places that made the change has shown it is beneficial to students.
Many schools in the Minneapolis area moved back high school start times 20 years ago and found that students were generally more alert, less stressed and less likely to fall asleep in class.
In Kentucky's Jessamine County, a 2002 switch from 7:30 a.m. to 8:40 a.m. for high school students had several immediate effects, among themincreases in attendance and standardized test scores. Seattle in 2016 moved to an 8:45 a.m. start, nearly an hour later than the previous one; it has resulted in students getting more than a half-hour of extra sleep, according to research.Portsmouth, N.H., schools also moved to later start times the same year.
And there is some momentum at statewide levels, too. Days after Newsom signed the law, a legislator in Ohio introduced a bill that no school start before 8:30 a.m. — though its author was less concerned with sleep than with early-morning safety issues. Lawmakers in Indiana, South Carolina and New Jersey are also among those studying later start times.
The movement may ultimately make economic sense: Moving the first bell to 8:30 a.m. across America's middle and high schools could add $9.3 billion to the economy in the next year and $83 billion over a decade — all because of improved sleep, health and mental acuity, according to a study by the Rand Corp., the Santa Monica., Calif.-based think tank.
Well-established scientific research draws a direct line between less sleep and health — not just for developing adolescents, but for adults, too.
"The shorter your sleep, the shorter your life," University of California-Berkeley neuroscientist and sleep expert Matthew Walker wrote in his best-selling book, "Why We Sleep."
Despite this knowledge, however, "the trend is going the other way," said Aric Prather, associate professor of psychiatry at UC-San Francisco, who studies and works with patients on sleep-related problems.
The number of Americans who say they don't get even the minimum recommended seven hours of sleep per night has increased significantly since 2013, and nearly one-third of Americans now say they sleep six hours or less.
Chronic sleep disruption has been linked to a weakened immune system, low sex drive, loss of memory, increased likelihood of Type 2 diabetes, heart disease and impaired thinking, as well as higher risks of accidents, obesity, loneliness and low-grade depression.
Put it together, and those who habitually get too little sleep are going to wind up with shorter, unhappier lives.
Under pressure from the Republican-controlled Pennsylvania legislature to require Medicaid recipients to work as a condition for coverage, state health officials have devised a gentler approach to getting beneficiaries into jobs.
Starting early next year, the Pennsylvania Medicaid agency under Democratic Gov. Tom Wolf will ask people when they enroll if they want job training assistance. It will then require its private Medicaid managed-care organizations to connect those who want help to local employment specialists and follow up to make sure they got it.
Teresa Miller, the state human services secretary, predicts the strategy will get better results than strict work requirements. The Trump administration has approved requiring work in nine states, with requests from nine others pending. Arkansas is the only state to implement the requirements, and more than 18,000 enrollees there lost coverage from June 2018 to March 2019 — with little sign many found jobs.
Since then, a federal judge struck down the work requirements in Arkansas, Kentucky and New Hampshire. The Trump administration and the states are appealing the decision.
"I worry that, with its reporting rules, work requirements result in fewer people covered by Medicaid, and that is not our goal," Miller said. "Our goal is to try to get people out of poverty. If you take access to health care away for people not working, I'm not sure how that helps people get a job."
A handful of states are offering alternatives to get more enrollees into jobs to lift them out of poverty and off Medicaid, the federal-state health program for low-income residents.
In Montana, about 32,000 of the 95,000 adult enrollees who gained coverage when the state expanded Medicaid in 2016 have received employment services from the state, including 4,200 who received one-on-one employment training services.
In August, Louisiana began a pilot program to train Medicaid enrollees for jobs such as a nursing assistant, commercial driver and forklift operator. It expects 50 people to complete the training this year at a community college.
More states are expected to follow. "While currently only a small number of states are starting to more directly connect Medicaid with the workforce training systems, this is a trend that will soon expand to many more states," said Steve Bella, a Bend, Ore., health and workplace consultant.
Bobbi Stammers, 37, enrolled in Montana's Medicaid in 2017 and said the state's job training assistance helped her get a nursing degree this year. The program paid thousands of dollars for her education expenses and supplies, including for textbooks and lab fees, and even covered the cost of fixing her car.
Two months after getting her degree, Stammers has a job with full benefits as a registered nurse, which means her family no longer needs Medicaid.
"I am so thankful I did this program; it really helped me get through school," said Stammers, of Charlo, Mont.
She used student loans to pay tuition, but with her husband working as a self-employed truck driver, Stammers said, additional expenses were burdensome. "This program eased the way for sure," Stammers said.
Conservatives nationwide have pushed for work requirements since Medicaid expanded dramatically under the Affordable Care Act. That law allows states to use federal funds to provide coverage to all adults with incomes below 138% of the federal poverty level, or $17,230 for an individual. Before that, many states limited adult enrollment to pregnant women, parents and people with extremely low incomes.
Despite the focus on getting Medicaid enrollees into jobs, studies show most people on Medicaid already work, and many of the rest have some disability, go to school or are caring for a family member.
Connecting people with job training is part of a broader effort by some states to improve Medicaid enrollees' health beyond paying for doctor and hospital care, said Hannah Katch, a senior policy analyst with the Center on Budget and Policy Priorities, a left-leaning advocacy group. She said states are looking at other social determinants of health, including housing and food services.
Montana's effort has been successful, Katch said, because it surveys people about their job status and training needs and then uses caseworkers to get them into career programs. About 60% of Montana Medicaid enrollees surveyed said they are employed, and 70% expressed interest in learning about opportunities in part-time or full-time jobs. The top three barriers to employment were poor finances, a criminal conviction and lack of transportation, according to the surveys.
A study by the state found its job training program helped lead to a 6% increase in Medicaid expansion-eligible adults joining the workforce from 2016 to 2018.
Despite the success of Montana's voluntary program, conservative lawmakers earlier this year pushed through legislation requiring that the state apply to the Trump administration for a waiver to mandate that Medicaid enrollees find jobs to keep their coverage, as well as pay monthly premiums based on how long they are on the program.
Health policy experts in Montana fear the work requirement will unfairly punish people who fail to report their employment status.
"We are worried those who are working are going to be subject to some pretty strict reporting requirements in order to maintain their health coverage," said Heather O'Loughlin, co-director of research and development at the Montana Budget & Policy Center. "We know there will be a loss of coverage, leaving people in a worse position to take care of themselves."
Pennsylvania's effort to assess enrollees about their job training interest comes after the governor has twice vetoed legislation to enact work requirements. The legislature will take up the same bill this year.
Sen. David Argall, a Republican co-sponsor of the measure, said the state's effort on job training doesn't go far enough.
"What they are suggesting is a tiny step in the right direction, but we need to do so much more," Argall said.
"Everyone tells me we have tens of thousands of able-bodied Pennsylvania residents receiving Medicaid but not working, and we need to be more aggressive in encouraging them to reenter the workforce," he said. "We are not asking Great-Grandma to work in a coal mine. We are talking about guys in their 20s who need an extra push."
In response to a Kaiser Health News investigation into the University of Virginia Health System's aggressive collection practices, Senate Finance Committee Chairman Chuck Grassley (R-Iowa) sent a letter Thursday demanding answers to questions about UVA's billing practices, financial assistance policies and even its prices.
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.
The Finance Committee oversees federal tax laws, and Grassley wrote that it is "my job to make sure that entities exempt from tax are fulfilling their tax-exempt purposes."
The KHN investigation found that UVA Health System, a taxpayer-supported and state-funded entity, filed 36,000 lawsuits for more than $106 million in six years.
"Unfortunately, I have seen a variety of news reports lately discussing what appear to be relentless debt-collection efforts by tax-exempt hospitals, including UVA Health System," Grassley wrote. "I am also concerned about how patients' hospital bills get so high in the first place."
Even though the letter questions only UVA Health System, whose practices were pegged in the investigation as particularly aggressive, it sends a signal that the Senate will be paying attention to an issue that affects all state-run and nonprofit health systems. Many medical providers pursue patients for unpaid bills, sometimes forcing them into bankruptcy. Several news stories have highlighted similar collections practices at other nonprofit hospitals.
Nonprofit hospitals get big tax breaks in exchange for providing "charity care and community benefit," though there is no clear standard about what that should mean. Experts have questioned whether those breaks are deserved, given hospitals' pricing, billing and collections practices.
In the seven-page letter, Grassley asks 19 detailed questions on various topics, including the system's charity care (free or discounted care provided to low-income patients), debt collection policies, and its rationale for the litigation threshold of $1,000, enacted in 2017. Grassley asks specific questions about UVA's list of standard prices for procedures and equipment, commonly known as the "chargemaster," which is posted on its website.
The letter was addressed to CEO Pamela Sutton-Wallace, who will depart UVA Health System for NewYork-Presbyterian Hospital next month. UVA Health System has until Nov. 19 to respond.
"UVA is committed to assisting indigent and uninsured patients and making sure they receive all necessary care," UVA Health System spokesman Eric Swensen said in an email to KHN. "We will review the letter, and look forward to working with Sen. Grassley to respond to his questions and share with him the policy changes we have announced and started implementing over the past month to better serve our patients."
In response to KHN's investigation, UVA Health System swiftly vowed to change its policies to increase financial assistance, give bigger discounts to the uninsured and reduce its use of the legal system. However, KHN reported that some critics do not think the new policies go far enough.