Instead of dealing with disapproving insurance executives, Regenexx appeals directly to employers large enough to fund their own health plans.

This article was published by Kaiser Health News on June 20, 2019. It was also published by Time.

By Liz Szabo, Kaiser Health News

A Midwestern grocery chain, Hy-Vee, is taking an unusual—and highly controversial—approach to reducing health care costs.

Before employees in certain cities can undergo knee replacement, they first must visit a stem cell provider. Hy-Vee has contracted with one of the United States' leading stem cell companies—Regenexx, based in Des Moines, Iowa—that claims injections of concentrated bone marrow or platelets can help patients avoid expensive joint surgery.

Regenexx has persuaded over 100 employers to include its services in their health insurance plans. In a marketing booklet, Regenexx, whose injections range in price from $1,500 to $9,000, notes that its treatments cost a fraction of major surgery. A single knee replacement, for example, ranges from $19,000 to $30,000 in the U.S.

The benefits of stem cells are hotly debated in the medical community, and federal regulators have warned the public to beware of clinics that peddle unapproved injections as a cure-all. Many doctors and ethicists say they fear the public is being misled about how well stem cells work—and whether the procedures save their money or waste it.

"This definitely is not a high-quality, proven treatment," said Dr. Freddie Fu, chairman of orthopedic surgery at the University of Pittsburgh Medical Center.

Knee Pain and the Bottom Line
 

Health insurance typically doesn't cover stem cell injections, with the exception of certain accepted treatments, such as bone-marrow transplants for cancer and aplastic anemia. Aetna, the United States' third-largest health insurer, dismisses stem cells and platelet injections as experimental; Anthem, the country's second-biggest health insurance provider, classifies the injections as "not medically necessary." Without insurance coverage, patients are forced to pay out-of-pocket or forgo treatment.

So instead of dealing with disapproving insurance executives, Regenexx appeals directly to employers large enough to fund their own health plans. These businesses have the freedom to customize their plans, covering services that aren't part of a standard insurance package. Over half of U.S. workers insured through their jobs belong to such plans, according to the Employee Benefit Research Institute, a D.C.-based nonprofit.

Perhaps Regenexx's best-known corporate client is Des Moines-based Meredith Corp., which owns multiple TV and radio stations, as well as magazines such as Better Homes & Gardens. (Meredith owned Time magazine until September 2018.)

In a statement, Regenexx said its goal is to "replace more invasive surgical orthopedics" with nonsurgical options, noting that recent research has found many joint operations are ineffective. On its website, Regenexx claims its procedures "repair and regenerate damaged or degenerated bone, cartilage, muscle, tendons, and ligaments." In a bone marrow stem cell procedure, for example, a doctor withdraws bone marrow cells from a patient's hip, concentrates them, then reinjects them into a problem area, such as an arthritic knee. Doctors target the exact location in the joint using ultrasound. For a "platelet-rich plasma" treatment, doctors draw blood, concentrate the platelets, then inject them into the target area.

Regenexx, previously known as Regenerative Sciences, is one of the oldest stem cell companies in the U.S. When it opened its doors in 2005, it had only a handful of competitors. Today, there are more than 1,000 stem clinics in the U.S., said Leigh Turner, an associate professor at the University of Minnesota's Center for Bioethics, who has published a series of articles describing the stem cell market.

At times, Regenexx has clashed with the Food and Drug Administration. In 2010, for example, Regenexx sued the FDA, claiming the agency lacked the authority to regulate its procedures, which involved culturing stem cells before reinjecting them into patients. Regenexx lost its case and was countersued by the FDA, which charged that Regenexx was marketing an unapproved drug. In 2014, the U.S. Court of Appeals in Washington sided with the FDA, forcing Regenexx to stop performing the controversial procedures. Today, Regenexx performs this procedure only in the Cayman Islands, where the government allows it. The Cayman Islands, where there is less government regulation of health care, has become known as a medical tourism destination, Turner said.

Regenexx says that the treatments offered at its U.S. clinics comply with FDA regulations, which require that cells injected into patients undergo no more than "minimal manipulation."

On its website, Regenexx lists more than two dozen studies led by its doctors. For example, its chief medical officer, Dr. Chris Centeno, published a small study last year that found patients with knee arthritis who received bone marrow and platelets fared better than those randomly assigned to exercise therapy. Regenexx says it tries to be transparent about its results, noting that it posts data on patient results. In a statement, the company said most patients it treats for knee pain have good functioning five years later.

A Regenexx marketing booklet says 70% of orthopedic surgeries "can be completely avoided with a Regenexx procedure"—a claim Fu called "silly."

"There is zero evidence that you can replace 70% of surgeries with stem cells," he said.

Recent research suggests stem cells and platelets may work no better than placebos, Fu added. In a recent analysis, over 80% of patients with knee arthritis experienced a noticeable improvement in pain after receiving simple saltwater injections, writes Dr. Benjamin Rothrauff, a postdoctoral fellow who works with Fu at the University of Pittsburgh.

There's also no definitive evidence stem cells and platelets can regrow lost cartilage, Fu said. A 2018 review concluded platelets have "marginal effectiveness," and experts note that most published studies are so small or poorly designed that their results aren't reliable.

Is Regenexx Actually Saving Employers Money?
 

If Regenexx treatments worked as well as the company claims, insurance companies would rush to cover them, Turner said. But the notion that Regenexx will save employers money hasn't been proven and is "a boastful claim with no clinical merit," said Henry Garlich, director of health care value solutions and enhanced clinical programs at Blue Shield of California, who has reviewed Regenexx's publications.

"The problem is that we don't have enough data. When a company does not have this type of evidence, then they will go direct to the consumer market," Garlich said. "Some vulnerable individuals, including companies that want to reduce their health care costs, may buy what they're selling." If Regenexx procedures don't work, Garlich said, an employer could end up paying twice—once for stem cells and once for knee replacement.

Some employers are, in fact, skeptical. The Des Moines Public Schools has opted not to add Regenexx to its employee health plan, said Catherine McKay, director of employee services for the school system. She said a salesman for a local stem cell clinic, which has since merged with Regenexx, told her the treatments could save the school system lots of money. McKay wasn't sold.

"My experience with them has not been great, in terms of marketing and sales. They're very, very pushy," McKay said. "They claim they can get people back to work earlier" than surgery. "But if I still need knee surgery a year down the road, that doesn't cut my costs."

The Des Moines school system has agreed to consider covering Regenexx procedures as part of its workers' compensation program on a case-by-case basis, McKay said. The school system has not signed a contract with Regenexx, however, and hasn't included Regenexx in its health plan.

McKay said she knows of two school employees who have tried Regenexx. While one employee was satisfied with the results, McKay said, another "went through a couple procedures and ended up needing surgery anyway."

Corporate executives have become some of Regenexx's biggest boosters. Hy-Vee's former chairman and CEO, Ric Jurgens, appears in a Regenexx marketing brochure and says that he turned to Regenexx because of heel pain. The brochure, which was removed from a Regenexx website after Kaiser Health News began reporting this story, quotes Jurgens as saying, "I knew that giving our employees the chance to explore options besides surgery was in their best interest."

Hy-Vee did not make Jurgens or other employees available to interview.

Steve Lacy, Meredith's former CEO and current board chairman, said he underwent a Regenexx procedure two years after his company began covering stem cell treatments. He had been facing knee surgery and thought stem cells were worth a try. The procedure got him back to doing everything he wants to do, Lacy said, even running several days a week. He also has done daily physical therapy for over two years. "The rehab and recovery is far less onerous" with the Regenexx procedure than with surgery, Lacy said. "If the procedure doesn't work for an individual, there's no harm."

Meredith has spent about $400,000 in four years on 85 employees who have had Regenexx treatments, or about $4,700 a patient, said Meredith spokesman Art Slusark. That's a small share of the roughly $75 million a year that Meredith spends on its medical plan, he said.

At its headquarters, Meredith has promoted Regenexx procedures through email, posters and "lunch-and-learn" sessions in the office, said Jenny McCoy, Meredith's corporate communications director.

McCoy herself has become a poster child for Regenexx's benefits. She and two other Meredith employees appear with Lacy in a marketing video on the Regenexx site. Although McCoy had begun to experience knee and hip pain during exercise, she said in an interview that her pain was not severe enough to need surgery. McCoy underwent platelet injections two years ago and is pain-free today, she said.

"I thought, 'If Meredith is covering it, I might as well have it done early before [the pain] causes me too many problems,'" said McCoy, 52. Given the price tag, she said, "I would not have done it otherwise. I wouldn't have even known about it." In the Regenexx marketing video, Lacy is shown saying stem cells saved Meredith roughly $700,000 in one year. Lacy said he estimated that number by comparing what Meredith spent on Regenexx with what it would have spent on hip and knee replacements.

But Slusark said Meredith hasn't examined employee medical records to determine how many were eligible for surgery or how many needed joint surgery after trying Regenexx. "We don't spend a lot of time calculating savings," Slusark said.

Without that medical information, Meredith can't accurately estimate how much money it saved, if any, Fu said. He noted that relatively few people with joint pain undergo surgery, which doctors typically view as a last resort for patients who have exhausted all other treatment options. Although 14 million Americans have knee arthritis, the Arthritis Foundation estimates that doctors perform only about 757,000 knee replacements each year.

Before recommending joint replacement, doctors often tell patients to try exercise, physical therapy, weight loss, supportive shoe inserts or steroid injections, Garlich said. Physical therapy, in particular, helps many patients, said Fu; it's possible that PT, and not the stem cell injections, should get the credit for Lacy's recovery.

How the Patients Feel
 

Regenexx has posted video interviews of dozens of satisfied customers on its website, including a refinery worker treated for a non-healing wrist fracture, a snowboarder who had stem cell therapy in his knees and an avid weightlifter with multiple shoulder problems. All say Regenexx helped them.

Other Regenexx patients say the treatments wasted their time and money. Several patients who posted online reviews of the company agreed to be interviewed for this article.

One is Amanda Lynch, a 42-year-old Australian trapeze artist who lives in Montreal. Lynch said she spent $7,700 last year to treat an injured ligament at a Regenexx clinic in Colorado. Doctors administered a series of injections in her knee over several days, including platelets and her bone marrow, Lynch said. She shared copies of the emails she exchanged with the clinic, a bill from Regenexx and a document in which doctors evaluated her candidacy for treatment.

But within a few months, Lynch had to undergo surgery in Montreal for both knees, she said, paying an additional $16,100, according to her medical bill. Because Lynch is Australian, she was not eligible for free care in the Canadian health system and had to pay out-of-pocket.

Roland Jersevic, a 67-year-old lawyer living in Saginaw, Mich., said he needed knee replacement after his stem cell treatments failed to relieve his arthritis. Jersevic said he went to a Regenexx clinic in Toledo, Ohio, in 2015 to get help with severe arthritis in his knees, which had caused his legs to bow. "The pain was horrendous all the time," he said. Jersevic's medical bills, obtained for this article, show that he paid the clinic $7,500 out-of-pocket because his insurance wouldn't cover stem cell therapy. "They told me they were going to regrow my cartilage," he said, referring to Regenexx. "I wanted it to work."

Although the fat and bone marrow injections may have given Jersevic a "little bit" of temporary relief, his pain soon returned, he said. Regenexx offered to administer more injections, at an additional cost, Jersevic said. "At that point, I had lost all faith in what they were doing. To spend more money on a booster—what for? It wasn't working."

Jersevic had both knees replaced in summer 2016, his medical records show, and his insurance paid most of the bill. His knee pain is gone, and Jersevic said he felt well enough to return to track-and-field competitions—including hurdles and pole vaulting—in 2017.

"When your knees are that bad, it's not going to work for you," Jersevic said. "They should tell you it's not going to work for you. But they want the cash."

In response, Regenexx noted that many patients who undergo knee surgery are also unhappy with the results. Research suggests that up to one-third of those who have knees replaced continue to experience chronic pain, while one-fifth report that they are dissatisfied with the results of their surgery.

"We are disappointed to learn of any patients who didn't have a positive outcome," Regenexx said in a statement. "Our goal at Regenexx is to achieve the best possible clinical efficacy, and we are actively researching to find out why some patients respond better than others."

The study found no evidence that beneficiaries who lost coverage secured either jobs or other insurance coverage. In fact, it noted a dip in the employment rate among those eligible for Medicaid.

This article was published by Kaiser Health News on June 19, 2019.

By Phil Galewitz, Kaiser Health News

The Medicaid work requirement plan devised by Arkansas and approved by the Trump administration backfired because it caused thousands of poor adults to lose coverage without any evidence the target population gained jobs, a new study finds.

In fact, the requirement had only a limited chance for success as nearly 97% of Arkansas residents ages 30-49 who were eligible for Medicaid—those subject to the mandate—were already employed or should have been exempt from the new law, according to the study published Wednesday in the New England Journal of Medicine.

Yet the state's mandate—the first of its kind in the nation—resulted in 18,000 of the 100,000 targeted people falling off the Medicaid rolls. And despite administration officials' statements that many of them may have found jobs, the study by researchers at Harvard found no evidence they secured either jobs or other insurance coverage. In fact, it noted a dip in the employment rate among those eligible for Medicaid.

The researchers said the uninsured rate increased among 30- to 49-year-old Arkansans eligible for Medicaid from 10.5% in 2016 to 14.5% in 2018, while the employment rate fell from about 42% to just below 39%.

While the thousands of Arkansas residents losing Medicaid coverage has been documented since last year, the Harvard study is the first to provide evidence that the change left them uninsured and did not promote employment.

The results, based on a telephone survey of about 3,000 low-income adults in Arkansas, concluded that the law befuddled enrollees and that its mandatory reporting requirements led many to unnecessarily lose coverage.

"Lack of awareness and confusion about the reporting requirements were common, which may explain why thousands of individuals lost coverage," the researchers wrote.

Asked whether the findings mean the administration should pull the plug on work requirements, co-author Benjamin Sommers, a professor of health policy and economics at Harvard, replied, "It's time for them to pump the brakes at the very least."

As millions of nondisabled adults gained Medicaid coverage following the 2010 passage of the Affordable Care Act, conservatives pushed for requiring people to work or do other kinds of "community engagement" to keep their Medicaid, much as food stamps and welfare cash benefit programs do. The Trump administration embraced that ideal and has made Medicaid work requirements a central feature of its plan to restructure the federal-state entitlement program, which has more than 70 million enrollees.

Arkansas put the plan into action in spring 2018.

But in March, a federal judge struck down Arkansas' mandate and a plan to begin one in Kentucky. U.S. District Judge James Boasberg ruled the work requirement violated federal law because it failed to meet the core objective of Medicaid — getting medical coverage to the poor.

The Trump administration is appealing that ruling and, meanwhile, has approved similar plans in eight other states, including New Hampshire, which is scheduled to start cutting coverage in August for those not meeting the rules. New Hampshire's law also is being challenged in court by Medicaid advocates.

Six more states have pending applications to add work mandates.

Seema Verma, administrator of the Centers for Medicare & Medicaid Services, defends the work requirements, saying they "are not some subversive attempt to just kick people off of Medicaid. Instead, their aim is to put beneficiaries in control with the right incentives to live healthier, independent lives."

Arkansas officials disputed the thrust of the study, noting that the requirement was short-lived because the judge intervened before it was in effect even a year and researchers did not find out why people who were dismissed from Medicaid didn't reapply.

"So you cannot describe this as the robust evaluation that we want and expect of a demonstration project that truly has national significance," said Amy Webb, a spokeswoman for the state's Medicaid program. "The best way to get answers to everyone's questions about the impact of work and community engagement requirements would be to let Arkansas continue what was started and conduct a true evaluation that follows people over time."

Under the Arkansas law, targeted enrollees were notified by the state via mail and informational flyers that they were required to work 80 hours a month, participate in another qualifying activity such as job training or community service, or meet criteria for an exemption such as pregnancy, a disability or parenting a child.

If they were out of compliance for three months during a calendar year or failed to report their status to the state through online reports, they could lose coverage.

For the first several months of its new mandate, Arkansas required enrollees to use an online portal for that reporting, a problem since 20% lacked internet access and another 20% lacked fast broadband. The state online portal also was unavailable after 9 p.m. each day.

The study found one-third of individuals subject to the policy had not heard anything about it, and 44% were unsure whether the requirements applied to them.

The findings back up arguments from advocates for the poor and nonpartisan experts that many Medicaid enrollees already have jobs. They also directly contradict claims by federal and Arkansas officials that many of those who lost coverage found a job.

In a hearing before the Senate Finance Committee earlier this year, Health and Human Services Secretary Alex Azar noted that only 1,452 of the 18,000 people who lost coverage because of the work requirement rules reapplied for Medicaid. He added that likely meant most no longer needed the government assistance.

"That seems a fairly strong indication that those people got a job and insurance elsewhere and didn't need the coverage," Azar said.

Sommers said the Arkansas experiment answers many questions about how work requirements could function nationally, although he acknowledged that other states might do a better job promoting the program and making it easier for enrollees to report their status.

"There are just not that many people [enrolled in Medicaid] who aren't working but could," Sommers said.

He noted Arkansas added the work requirement feature without adding new funding for job training or child support to help people who want to work.

Federal officials who approve the waivers allowing states to use work requirements should take note of the results, he said. "It does not make sense to keep approving the same waiver without doing anything differently," Sommers said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

Aletha Maybank, MD, a pediatrician, is talks to Kaiser Health News about her challenges and priorities as the American Medical Association's Equity Chief.

This article was first published on Wednesday, June 19, 2019 in Kaiser Health News.

By Carmen Heredia Rodriguez

Part of Dr. Aletha Maybank's medical training left a sour taste in her mouth.

Her superiors told her not to worry about nonmedical issues affecting her patients' quality of life, she said, because social workers would handle it. But she didn't understand how physicians could divorce medical advice from the context of patients' lives.

"How can you offer advice as recommendations that's not even relevant to how their day-to-day plays out?" Maybank asked.

Today, Maybank is continuing to question that medical school philosophy. She was recently named the first chief health equity officer for the American Medical Association. In that job, she is responsible for implementing practices among doctors across the country to help end disparities in care. She has a full agenda, including launching the group's Center for Health Equity and helping the Chicago-based doctors association reach out to people in poor neighborhoods in the city.

A pediatrician, Maybank previously worked for the New York City government as deputy commissioner for the health department and founding director of the city's health equity center.

Carmen Heredia Rodriguez of Kaiser Health News recently spoke with Maybank about her new role and how health inequities affect Americans. This transcript has been edited for length and clarity.

Q: Can you tell me what health equity means to you, and what are some of the main drivers that are keeping health inequitable in this country?

The AMA policy around health equity is optimal health for all people.

But it's not just an outcome; there's a process to get there. How do we engage with people? How do we look at and collect our data to make sure our practices and processes are equitable? How do we hire differently to ensure diversity? All these things are processes to achieve health equity.

In order to understand what produces inequities, we have to understand what creates health. Health is created outside of the walls of the doctor's office and at the hospital. What are patients' jobs and employment like? The kind of education they have. Income. Their ability to build wealth. All of these are conditions that impact health.

Q: Is there anything along your career path that really surprised you about the state of healthcare in the U.S.?

There's the perception that all of our health is really determined by whether you have a doctor or not, or if you have insurance. What creates health is much beyond that.

So if we really want to work on health and equity, we have to partner with people who are in the education space and the economic space and the housing spaces, because that's where health inequities are produced. You could have insurance coverage. You could have a primary care doctor. But it doesn't mean that you're not going to experience health inequities.

Q: Discrimination based on racial lines is one obvious driver of health inequities. What are some of the other populations that are affected by health inequity?

I think structural racism is a system that affects us all.

It's not just the black-white issue. So, whether it's discrimination or inequities that exist among LGBT youth and transgender [or] nonconforming people, or if it's folks who are immigrants or women, a lot of that is contextualized under the umbrella of white supremacy within the country.

Q: And what are some of your priorities?

A large part of my work will be how I build the organizational capacity to better understand health equity. The reality in this country is folks aren't comfortable talking about those issues. So, we have to destigmatize talking about all of this.

Q: Are there any particular populations or relationships that you plan to focus on? 

The AMA excluded black physicians until the 1960s. So one question is, How do we work to heal relationships as well as understand the impact of our past actions? AMA definitely issued an apology in the early 2000s, and my new role is also a step in the right direction. However, there is more that we can and should do.

Another priority now is, How do we work, and who do we work with, in our own backyard of Chicago? What can we do to work directly with people experiencing the greatest burden of disease? How do we ensure that we acknowledge the power, assets and expertise of communities so that we have the process and solutions driven and led by communities? To that end, we've begun working with West Side United via a relationship at Rush Medical Center. West Side United is a community-driven, collective neighborhood planning, implementation and investment effort geared toward optimizing economic well-being and improved health outcomes.

Q: Is there anything else you feel is important to understand about health equity?

Health equity and social determinants of health have become jargon. But we are talking about people's lives. We were all born equal. We are clearly not all treated equal, but we all deserve equity. I don't live outside of it, and none of us really do. I am one of those women who were three to four times more likely to die at childbirth because I'm black. So I don't live outside of this experience. I'm talking about my own life.

Carmen Heredia Rodriguez: CarmenH@kff.org, @ByCHRodriguez

Texas Gov. Greg Abbott signed legislation shielding patients from getting a huge bill when their insurance company and medical provider can't agree on payment.

This article was first published on Tuesday, June 18, 2019 in Kaiser Health News.

By Ashley Lopez, KUT

Texas is now among more than a dozen states that have cracked down on the practice of surprise medical billing.

Texas Gov. Greg Abbott, a Republican, signed legislation Friday shielding patients from getting a huge bill when their insurance company and medical provider can't agree on payment.

The bipartisan legislation removes patients from the middle of price disputes between a health insurance company and a hospital or other medical provider.

"We wanted to try to take the patients — get them out of the middle of it, because really it's not their fight," said Republican state Sen. Kelly Hancock, the bill's author.

Under the new law, insurance companies and medical providers can enter into arbitration to negotiate a payment — and state officials would oversee that process.

Surprise medical billing typically happens when someone with health insurance goes to a hospital during an emergency and that hospital is out-of-network. It also occurs if a patient goes to an in-network hospital and their doctors or medical providers are not in-network. Sometimes insurance companies and medical providers won't agree on what's a fair price for that care and patients end up with a hefty medical bill.

Consumer advocates in the state have urged lawmakers to do more to help Texans saddled with surprise medical bills.

Drew Calver is among the many Texans who have dealt with a surprise bill in the past few years. Calver, a high school history teacher in Austin, had a heart attack in 2017. He was rushed to the closest hospital by a friend that day, and doctors implanted stents to save his life.

Even though he had health insurance that paid the hospital more than $55,000 for his care, Calver ended up with a $109,000 bill. Calver and his wife, Erin, fought with the hospital and the insurance company for months with little success.

The Calvers eventually turned to the press. Last summer, he told his story to the "Bill of the Month" investigation from NPR and Kaiser Health News. "CBS This Morning" also covered the story. Shortly afterward, his bill was slashed to just $332. Erin Calver said she has seen her family's story strike a chord.

"For whatever reason, people could relate to us — and be scared that maybe it could happen to them," she said.

Drew Calver said he encounters many people who worry about the issue.

"The doctor that put my stents in — he either just had a baby or is about to have a baby — and he was saying that, 'Yeah that could happen to me, too!'" Calver said.

In fact, getting a steep hospital bill is something many Americans call their biggest financial fear.

"Polling shows us that the top household pocketbook concern for consumers is a surprise medical bill," said Stacey Pogue with the Center for Public Policy Priorities, a think tank that analyzes health and economic issues in Texas. "And that's actually pretty shocking that consumers will say they are more worried about their ability to afford a surprise medical bill than their health insurance premiums [and] their really high deductibles."

Last year, a Kaiser Family Foundation poll found that 67% of people worry about unexpected medical bills — a larger share than those who say they worry about prescription drug costs or basic necessities such as rent, food and gas. (KHN is an editorially independent program of the foundation.)

Pogue said that's a big reason why lawmakers in the state took the issue seriously and passed legislation that she said is now one of the strongest state protections she has seen.

"It is as strong or stronger than any of the protections in the country," Pogue said.

In addition to Texas, neighboring states Colorado and New Mexico also passed legislation in 2019 to address the problem of surprise out-of-network bills. The Commonwealth Fund's most recent report on the issue found about half of states offer some legal protections from surprise bills, but only six states had laws that provide "comprehensive" consumer protections similar to those just passed in Texas.

Texas' new surprise bill law officially takes effect Sept. 1, 2020.

Hancock said the fight over who pays disputed bills will be back where it belongs: with insurance companies, leaving the hospitals, doctors and labs to focus on providing medical care.

"It was just time to get the patient out" of the middle of disputed bills, Hancock said.

Instead, when a hospital and insurer can't agree on a price, the two parties will have to work it out — without ever billing the patient.

"There is still the ability to negotiate," Hancock said. "You didn't have government determining what the price was or determining what the settlement was."

But not all Texans will be protected by the new law. The Texas law does not apply to people who work for large employers whose plans are regulated by the federal government. In Texas, federally regulated plans account for roughly 40% of the state's health insurance market.

In fact, Drew Calver would have been exempt from the state's protections because until recently he had a self-funded health plan regulated by the federal government. However, Drew is now part of wife Erin's health plan, which will be subject to these new protections.

Pogue said people who have federally regulated health plans will be protected only if Congress acts. She predicted the state's action will spur federal lawmakers.

"Texas passing a bill will really help on that front," she said. "There were five states, I think, in 2019 that passed bills that fully protected consumers — and every nudge like that is going to help Congress move."

Texas lawmakers passed separate legislation that could help Texans with federally regulated plans. Senate Bill 1037 prevents a surprise medical bill from affecting someone's credit, regardless of what health insurance plan they have.

Congressional leaders have said they are working on coming up with a fix for people across the country with federally regulated plans. President Donald Trump also recently held an event at the White House, with Drew and Erin Calver standing by his side, announcing his administration's support for banning surprise medical billing in the country.

During a U.S. House Ways and Means Health subcommittee meeting in May, members discussed ways to ban the practice of surprise medical billing.

The committee's chairman, Austin Democrat Lloyd Doggett, said that "federal action is essential" to addressing the issue for many Americans with federally regulated plans. He said he plans to continue to push for legislation that will "finally offer some relief to patients." However, no legislation has been passed, yet.

During his opening statements, Doggett said there is a bipartisan desire to shield patients from surprise bills, but "conflict remains over how to resolve insurer-provider disputes."

This story is part of a partnership that includes KUT, NPR and Kaiser Health News.

Ashley Lopez, KUT: alopez@kut.org, @‪AshLopezRa‪dio