This story was originally published on Kaiser Health News on April 19, 2017.
Drugmaker Pfizer gave $1 million to help finance the inauguration, according to documents filed with the Federal Election Commission. Amgen, another pharmaceutical company, donated $500,000. Health insurers Anthem, Centene and Aetna all gave six-figure contributions.
Facing acute risks to their businesses from Washington policymakers, health companies spent more than $2 million to buy access to the incoming Trump administration via candlelight dinners, black-tie balls and other inauguration events, new filings show.
Drugmaker Pfizer gave $1 million to help finance the inauguration, according to documents filed with the Federal Election Commission. Amgen, another pharmaceutical company, donated $500,000. Health insurers Anthem, Centene and Aetna all gave six-figure contributions.
They joined a surge of corporate donors from multiple industries to break inauguration-finance records even as then-President-elect Donald Trump promised to “drain the swamp” of Washington influence-peddling.
But the stakes for the health industry were especially high as the new administration prepared to take power.
Two weeks before Pfizer’s donation, Trump told Time magazine: “I’m going to bring down drug prices.” At the same time, one of his top goals was repealing Obamacare — the Affordable Care Act — and its billions in subsidies for insurance companies and hospitals.
Also writing checks for the inauguration were drugmaker Abbott Laboratories, drug wholesaler Caremark, insurer MetLife and Managed Care of North America, a dental benefits manager.
Trump’s inaugural committee raised $107 million, more than twice as much as for any previous presidential investiture. President Barack Obama’s 2009 inauguration held the previous record of $53 million.
Obama banned corporate donations that year and limited individual donations to $50,000 but accepted corporate grants for his 2013 inauguration.
No health company gave more to Trump’s event than Pfizer, whose profits for Lyrica, Prevnar 13 and other high-priced medicines could come under pressure if the Medicare program for seniors is allowed to negotiate on cost, as Trump has suggested.
Lyrica alleviates nerve and muscle pain. Prevnar 13 is a vaccine against pneumococcal pneumonia.
Along with several other pharma companies, Pfizer is the subject of a Justice Departmentinvestigation over donations to charities that help Medicare patients avoid copayments for expensive drugs.
Pfizer’s $1 million donation entitled it to four tickets to a “leadership luncheon” with “select Cabinet appointees and House and Senate leadership,” according to a solicitation brochure obtained and posted online by the Center for Public Integrity.
“As it has been the case with previous presidential inaugurations, we made a financial contribution to the 58th Presidential Inaugural Committee and a group of our senior leaders participated in various official events,” said Pfizer spokesperson Sharon Castillo. She declined to identify the executives.
Amgen’s inauguration gift of $500,000 was the second-biggest from a health care donor. The company makes Enbrel for arthritis and Epogen for anemia, among other drugs.
Amgen’s contribution bought it two tickets to “an intimate dinner” with then-Vice President-elect Mike Pence and his wife, Karen Pence. Amgen CEO Robert Bradway was among seven pharma executives who met with Trump in the White House on Jan. 31, although that wasn’t part of the inauguration package.
Amgen spokesperson Kelley Davenport declined to comment beyond describing the company as joining “numerous other donors from a diverse group of industries and individuals” supporting the event.
Pfizer also got entrée to the Pence inaugural dinner. Both companies had access to balls, receptions, luncheons, concerts and other events available to lesser donors.
Neither Pfizer, Amgen nor other large, health care donors to Trump’s inauguration made contributions to Obama’s 2013 inauguration, which did accept corporate money. Pfizer gave $250,000 to President George W. Bush’s 2005 inauguration.
The biggest health care corporate donor to Obama’s 2013 investiture was drugmaker Genentech, which gave $750,000, records show. The company did not contribute to Trump’s inauguration. “Prior to the 2016 election, we made a decision not to sponsor any inaugural activities for the foreseeable future,” said Genentech spokesperson Susan Willson.
Contributors for this year’s event also included insurer Anthem, one of the largest participants in the Affordable Care Act’s online marketplaces, and Centene, which also sells insurance plans through the online exchanges. Anthem gave $100,000 while Centene gave $250,000.
Both companies’ marketplace businesses depend on generous federal subsidies that would be jeopardized by an ACA repeal or other actions by the administration. Anthem has pressed the administration to preserve the subsidies and tighten rules for marketplace enrollment.
Anthem CEO Joseph Swedish was one of a group of insurance executives who met with Trump in February. Swedish met again with Trump in the White House last month, Modern Healthcare reported.
Centene, which manages state and federal Medicaid programs for low-income people in many states, also benefited from the ACA’s Medicaid expansion. Analysts see the company as especially vulnerable to a potential repeal of Obama’s health law.
The Iowa Republican has asked CMS officials to explain why they failed to collect nearly $125 million in potential overcharges identified at five Medicare Advantage plans audited in a single year.
Sen. Chuck Grassley (R-Iowa) wants federal health officials to tighten scrutiny of private Medicare Advantage health plans amid ongoing concern that insurers overbill the government by billions of dollars every year.
Grassley, the influential chairman of the Senate Judiciary Committee, has asked Centers for Medicare and Medicaid Services (CMS) officials to explain why they failed to collect nearly $125 million in potential overcharges identified at five Medicare Advantage plans audited in a single year.
In an April 17 letter to CMS Administrator Seema Verma, Grassley cited an article on alleged overcharges published in January by Kaiser Health News. The article said that Medicare had potentially overpaid five health plans $128 million in 2007, but under pressure from the insurance industry collected just $3.4 million and settled the cases.
“The difference in the assessment and the actual recovery is striking and demands an explanation,” Grassley wrote.
Medicare Advantage is a popular alternative to traditional Medicare. The privately run health plans have enrolled more than 18 million elderly and disabled people — about a third of those eligible for Medicare — at a cost to taxpayers approaching $200 billion a year. The plans also enjoy strongsupport in Congress.
Medicare is supposed to pay the health plans higher rates for sicker patients and less for people in good health using a formula called a risk score.
Yet CMS records reveal that billions of tax dollars are wasted annually partly because some health plans exaggerate how sick their patients are by inflating risk scores and boosting their payments improperly.
Grassley asked in his letter what steps CMS is taking “to ensure that insurance companies are not fraudulently altering risk scores” and how many audits are now being conducted.
“By all accounts, risk score gaming is not going to go away. Therefore, CMS must aggressively use the tools at its disposal to ensure that it is efficiently identifying fraud and subsequently implementing timely and fair remedies,” he wrote.
Grassley also noted that CMS needs to step up oversight audits because Medicare Advantage plans are expected to grow substantially in coming years.
“The use of these tools is all the more important as Medicare Advantage adds more patients and billions of dollars of taxpayer money is at stake,” Grassley’s letter said.
The Government Accountability Office, the watchdog arm of Congress, has sharply criticized CMS for its failure to ferret out overcharges and in April 2016 called for “fundamental improvements” in audits of Medicare Advantage plans. GAO also found that CMS has spent about $117 million on Medicare Advantage audits, but recouped just under $14 million in total.
Medicare Advantage plans have been the target of at least a half-dozen whistleblower lawsuits alleging patterns of overbilling and fraud. In March, the Justice Departmentjoined one such suit against insurance giant UnitedHealth Group. The suit alleges that the health plan submitted claims for underpayments to the government, but ignored examples in which it had received too much money.
The audits disclosing the $128 million in overpayments to health plans were part of a cache of confidential CMS documents released through a Freedom of Information Act lawsuit filed by the Center for Public Integrity.
The CMS records identify the companies chosen for the initial Medicare Advantage audits as a Florida Humana plan, a Washington state subsidiary of United Healthcare called PacifiCare, an Aetna plan in New Jersey and an Independence Blue Cross plan in the Philadelphia area. The fifth one focused on a Lovelace Medicare plan in New Mexico, which has since been acquired by Blue Cross.
In the audits, CMS repeatedly found that the health plans couldn’t document their patients were as sick as the insurer had claimed.
For example, auditors couldn’t confirm that one-third of the diseases the health plans had been paid to treat actually existed, mostly because patient records lacked “sufficient documentation of a diagnosis.”
Overall, Medicare paid the wrong amount for nearly two-thirds of patients whose records were examined; all five plans were far more likely to charge too much than too little. For 1 in 5 patients, the overcharges were $5,000 or more for the year, according to the audits.
America’s Health Insurance Plans, an industry trade group, has denied that Medicare Advantage plans overcharge. The group argued in a June 2016 position paper that the auditing method used by CMS was “not yet stable and reliable.” The group also said that conducting audits “could disrupt the care being provided by plans that are working hard to meet the needs of their enrollees.”
Grassley cited reports by the Center for Public Integrity that improper payments to Medicare Advantage plans cost taxpayers as much as $70 billion from 2008 to 2013. He said that CMS’ estimate that it had overpaid the five health plans $128 million “appears low and could very well be just the tip of the iceberg.”
California lawmakers this month will consider legislation that would impose a tax on prescription opioids such as OxyContin and Norco to raise money for addiction treatment and prevention programs.
The proposal, introduced by California Assemblyman Kevin McCarty (D-Sacramento), would not levy the tax directly on consumers but rather on opioid manufacturers and wholesalers, who would pay 1 cent per milligram at the drug’s first point of sale.
Legislative analysts have not yet conducted a fiscal review of the measure, which would require a two-thirds majority vote to pass.
A similar federal opioid tax measure is being considered by Congress. It, too, is intended to create a fund to treat and prevent addiction. In addition, the Alaska State Legislature is considering a 1-cent-per-milligram opioid tax.
Nationally, the sale of prescription opioids, and overdoses from them, have nearly quadrupled since 1999, according to the U.S. Centers for Disease Control and Prevention (CDC). Almost 2 million people misused or were addicted to the painkiller medications as of 2014, the CDC reports.
California health officials say that the number of deaths from opioids has leveled off in the state, but that emergency departments are seeing a steady increase of overdoses. And some counties still have overdose-related deaths that are two to three times the national average, according to the California Department of Public Health.
Proponents of California’s opioid tax measure say the funding is necessary because the majority of people who abuse these drugs lack access to the care they need.
“We must do more to help these individuals find hope and sobriety,” said McCarty. “This plan will provide counties with critical resources needed to curb the deadly cycle of opioid and heroin addiction in California.”
In an interview with California Healthline, Rand Corp. economist David Powellsaid that while more funding would be useful to treat people addicted to opioids, it’s hard to predict whether the proposed tax would help prevent people from consuming the drugs in the first place.The Pharmaceutical Research and Manufacturers of America (PhRMA), a national trade association for drugmakers, opposes the California bill, saying that the industry is overtaxed and that the U.S. Drug Enforcement Agency already regulates opioids. Such a multifaceted social problem requires a comprehensive solution, PhRMA said, “rather than a narrow focus on one sector or aspect.”
Powell’s comments below have been edited for length and clarity.
Q: Would this proposed tax, in and of itself, reduce the prevalence of addiction to opioid painkillers?
My guess is that the taxes are going to end up being paid by health insurers in this case, including Medicaid and Medicare. … In general, people are going to be protected from the prescription drug taxes when purchasing the drugs, except that we’re all — whether we’re consumers of those drugs or not — going to have higher premiums.
Because the insurers are basically picking up the tax themselves, the price doesn’t change at all for consumers when they’re deciding whether or not to purchase more opioids. So it’s not going to reduce utilization that much.
Insurers could fight back and implement their own policies, like quantity limits or prior authorization, and it’s really hard to predict the benefits and costs of widespread implementation of policies like that.
Q: Can you say more about how people actually obtain opioids and whether you think the tax would reduce availability of them?
Most people who are using opioids for non-medical purposes report getting them from a friend or a relative — not from a doctor. The doctors are an important source as well, but there’s this medicine cabinet effect, which is pretty important.
The other big question here is, how do people get initiated into opioid use and abuse, and that’s something we really don’t know much about. How many people with opioid addiction problems started with a medical need for the drug versus how many started using them with little medical need? That determines whether this kind of policy makes sense or almost any policy makes sense. We’re a little bit blind at this point.
Q: Do you think having this pot of money for treatment and prevention of addiction would be beneficial in reducing overdoses?
That makes sense to me. There is a lot of research showing that treatment works. Having more access to substance abuse treatment centers does reduce all these harms, including overdoses. So the question is, do we want to do that regardless of whether you like the tax or not?
[In the federal bill], we’re talking about a billion dollars for substance abuse treatment centers and lots of other things. The best metric we have on the total annual economic cost of opioid abuse is $80 billion. That doesn’t include the deaths. Seems like $1 billion is a relatively small investment, with possible huge payoffs.
Q: What other policies would you recommend to prevent people from becoming addicted and to avoid overdoses?
Unfortunately, this is the part where the research is so new. We don’t really have a solid, “This is the most effective way to fight the opioid epidemic right now.” It sounds like a cop-out, but you have to take a comprehensive approach, and do a lot of things.
There’s been mixed evidence about whether prescription drug monitoring programs work, but there is some research that certain types of those programs are effective. So you want to have that, and you also want to increase drug treatment centers.
Q: Taxes on alcohol and tobacco have reduced consumption of those substances. Do you think taxing opioids is different?
In principle, they’re comparable. But the cost-sharing aspect, or the lack of cost-sharing — that the individual is not going to pay the full tax — is really the big difference.
The magnitudes are also really different. Cigarette taxes are really high. The opioid tax proposal is actually kind of small.
How an Idaho hospital that serves a region with more bears than people is helping forge the future of American medicine.
ARCO, Idaho — Just before dusk on an evening in early March, Mimi Rosenkrance set to work on her spacious cattle ranch to vaccinate a calf. But the mother cow quickly decided that just wasn’t going to happen. She charged, all 1,000 pounds of her, knocking Rosenkrance over and repeatedly stomping on her. “That cow was trying to push me to China,” Rosenkrance recalls.
Dizzy and nauseated, with bruises spreading on both her legs and around her eye, Rosenkrance, 58, nearly passed out. Her son called 911 and an ambulance staffed by volunteers drove her to Lost Rivers Medical Center, a tiny, brick hospital nestled on the snowy hills above this remote town in central Idaho.
Lost Rivers has only one full-time doctor and its emergency room has just three beds — not much bigger than a summer camp infirmary. But here’s what happened to Rosenkrance in the first 90 minutes after she showed up: She got a CT scan to check for a brain injury, X-rays to look for broken bones, an IV to replenish her fluids and her ear sewn back together. The next morning, although the hospital has no pharmacist, she got a prescription for painkillers filled through a remote prescription service. It was the kind of full-service medical treatment that might be expected of a hospital in a much larger town.
Not so long ago, providing such high-level care seemed impossible at Lost Rivers. In fact, it looked as if there wouldn’t be a Lost Rivers at all. The 14-bed hospital serves all of Butte County, whose population of 2,501 (down from 2,893 in 2000) is spread over a territory half the size of Connecticut. Arco, the county’s largest town, has seen its population drop 16 percent since 2000, from 1,026 to 857 last year. “Bears outnumber people out here,” is how hospital CEO Brad Huerta puts it.
The medical center nearly shut its doors in 2013 due in large part to the declining population of the area it serves — almost becoming another statistic, another hospital to vanish from rural America. But then the hospital got a dramatic reboot with new management, led by Huerta, who secured financing to help pay for more advanced technology, upgraded facilities and expanded services. He also brought in more rotating specialists, started using telemedicine to connect the hospital to experts elsewhere and is now planning to open a surgery center and a long-term care rehabilitation wing. If Lost Rivers had closed, the alternative would have been hospitals in Idaho Falls or Pocatello, each more than an hour away across high-altitude prairie. Instead, “I don’t have to go across the desert for hardly anything,” said Rosenkrance, resting at the hospital the morning after the cow attack.
Rural hospitals are facing one of the great slow-moving crises in American health care. Across the U.S., they’ve been closing at a rate of about one per month since 2010 — a total of 78, or about 6 percent. About 14 percent of the U.S. population lives in rural counties, a proportion that has dropped as the number of urban dwellers grows. Declining populations mean a smaller base of patients and less revenue. And the hospitals are caught in a squeeze: Because many patients in the countryside are older and sicker, they require more intensive and often expensive care
Faced with these dramatic economic and demographic pressures, however, some hospitals are surviving — even thriving — by taking advantage of some of the most cutting-edge trends in health care. They are experimenting with telemedicine, using remote monitors to track patients and purchasing high-tech equipment to perform scans and other types of exams. And because many face physician shortages, they are partnering with universities and increasingly relying on nurse practitioners, paramedics and others to deliver care. In parts of rural Oregon and Washington, veterans can get counseling through a tele-mental health program. Physicians in Iowa and North Dakota have access to virtual emergency room support.
At Lost Rivers — a dramatic rural health turnaround story — Huerta’s strategy was to use technology and innovation to offer the kind of high-quality medical care that would keep patients like Rosenkrance coming back. “Necessity is the mother of invention,” Huerta said. “Small hospitals like mine are always going to be under the gun. You have to get really creative.”
Nurse Celeste Parsons treats patient Mimi Rosenkrance, 58, as she recovers from being trampled by a mother cow protecting her calf. (M. Scott Mahaskey/Politico)
In the decades to come, America’s heartland and hinterlands will continue to be home to the people who run the country’s farms, forests and fisheries, and its wilder regions will continue to draw visitors who crave nature and recreation. And those people will need medical care. As a result, rural health researchers say hospitals like Lost Rivers are important test cases. They show that, despite daunting obstacles, rural America need not be left behind when it comes to health care. In fact, because they are being forced to innovate faster than their urban counterparts, they can provide a glimpse into the future of medicine.
“Being in a rural place does not preclude high-quality medicine,” said Tom Ricketts, senior policy fellow at the Sheps Center for Health Services Research at the University of North Carolina, Chapel Hill. “They are under a lot of pressure, but there are rural places you can point to as places you would say, ‘This is how things ought to be done.’”
Where Folks Wear ‘Multiple Hats’
It’s a Tuesday afternoon at Tara Parsons’ flower shop. She cleans up as she waits for customers — or for an emergency call. Parsons, a fourth-generation Arco resident, is not just the town florist; she is also the county coroner, a sheriff’s dispatcher and a volunteer emergency medical technician. This afternoon, she is on ambulance duty.
“We all wear multiple hats out here,” she said.
The town of Arco was founded in the 1870s as a junction for horse-drawn stagecoaches. Its quirky claim to fame is that in 1955, it became the first town in the world to be powered by nuclear energy, a credit to the Idaho National Laboratory down the road toward Idaho Falls. Every summer, to celebrate its history, the town puts on a celebration that features a rodeo and a softball tournament.
The streets are lined with shuttered and boarded-up storefronts, some with their signs still on display: the Galloping Goose, the Sawtooth Club. Residents talk nostalgically about the town’s heyday, when there were banks, a bowling alley and a movie theater, back when residents drove to Idaho Falls only twice a year, to get school supplies and do Christmas shopping.
Now, most of the businesses are gone. The town still has a lumber shop, a hardware store and a few auto garages. There’s also a bar, a gym and a dollar store. And around the corner there’s the local diner — Pickle’s Place — where people come day and night for fried pickles and biscuits and gravy.
Like so many other residents, Butte County clerk Shelly Shaffer has a personal connection to the hospital: Her mom worked there, her sister was born there, and she used to take her children there. Lost Rivers Medical Center — which also has two outpatient clinics — is one of the town’s biggest employers.
“It would be devastating if we didn’t have our hospital,” she said.
Tara Parsons, 42, prepares flowers for a customer. Parsons, who runs the Touch of Country Floral and Gifts shop in Arco, also serves as the town’s coroner and volunteer EMT. (M. Scott Mahaskey/Politico)
That was the direction they were headed. When Huerta, the CEO, arrived four years ago, he found the nearly 60-year-old hospital in disarray — dilapidated facilities, fearful employees, reluctant patients and a financial mess left behind by the former CEO. The hospital’s bank account held just $7,000 and morale was at an all-time low. “We were the poster child for everything that was wrong with rural health care,” he said. “It had been a slow, steady decline from neglect.”
Shannon Gamett, 28, a nurse at Lost Rivers, said paydays were nerve-wracking: “We would run as fast as we could to the bank to cash [a paycheck], or it might not clear.”
After borrowing money to pay his employees, Huerta campaigned to pass a $5.5 million bond for Lost Rivers. He asked locals if it was worth $5 a month — one six-pack of beer or two movie rentals — to keep the hospital running. They answered “yes” at the polls, and the hospital emerged from bankruptcy. Next, Huerta set his sights on overhauling the badly outmoded facilities. One of his top priorities was the laboratory, which he said looked like a high school science classroom from the 1950s.
He instituted a new philosophy: If it doesn’t happen at a “real” hospital, it doesn’t happen at Lost Rivers. That meant ending some local practices, nixing little things like letting staff members wear scrubs of any color they fancied, and big things, like allowing people to bring their horses in for X-rays. “I said, ‘I have no problem doing this, but you tell me what insurance the horse has,’” he recalled. “The practice stopped immediately.”
To bring in more revenue, he applied for grants and got the hospital a trauma center designation (the first level IV trauma center in Idaho) so it could get paid more for the care it was already providing. He saved money by inviting the town’s residents to help renovate clinic exam rooms and by moving the medical records to a cloud-based system that didn’t require more information technology employees.
Prognosis Unclear
Despite Huerta’s efforts, however, the long-term success of Lost Rivers is not guaranteed. “If you don’t have enough people to support a clinic or a hospital, it has no economic reason to be there,” said Ricketts, the Sheps Center fellow. “It just disappears.”
Arco and Butte County officials hope the local economy will get a boost from a planned expansion of Idaho National Laboratory, which conducts nuclear energy testing and research. Residents also are mounting a campaign to get the Craters of the Moon, a national monument in Butte County, designated as a national park.
“It would literally put us on the map,” county clerk Shaffer said.
But even if that happens, Huerta knows he can’t expect a big influx of new residents. Rural parts of the United States saw an absolute decline in population following the 2008 financial crisis, a trend that has since stabilized. But there is little or no growth. So Huerta has to concentrate on keeping the patients he has — and giving them a reason to keep coming. And it’s working: The hospital is now making a small profit and has some reserves on hand for future projects.
“If you are not offering the services, people are going to go somewhere else,” Huerta said. “And as medicine advances and reimbursement is still pegged to volume, you have to find ways to keep that existing population here.”
One big challenge for Lost Rivers and many other rural hospitals is that their patients tend to be older — and thus sicker and costlier to treat. People 65 and older account for about 18 percent of the rural population, compared with 12 percent in urban areas, according to the National Rural Health Association. An older patient base can strain hospitals because Medicare, the public insurance program for the elderly, doesn’t pay hospitals as well as private insurance does. Elderly patients also may need more intense care than small hospitals can provide.
Shane Rosenkrance fills a prescription for his wife, Mimi, after she was discharged from Lost Rivers Medical Center following a cow-related injury. (M. Scott Mahaskey/Politico)
Rural hospitals have a higher percentage of patients on Medicaid, the public insurance for poor people, which pays notoriously low rates to providers.
Some seniors move to Arco precisely because there is a hospital in town. But for others, what Lost Rivers offers simply isn’t enough.
Residents Ray Westfall, 82, and his wife, Winona, recently put their house on the market after deciding it was time to move to Utah, closer to family and more specialized health care. Westfall has neuropathy in his legs, which causes numbness most of the time. He gets around with a walker. Winona has dementia.
“We can get some care here at the local hospital, but mostly we have to travel to Idaho Falls,” he said.
Westfall is a regular at Parsons’ flower shop. On a recent Tuesday, he bought a bouquet for his wife — carnations, her favorite.
Parsons said many of the emergency calls she responds to are for older folks who’ve suffered strokes, fallen at home or are struggling to breathe. One 99-year-old woman she took to the hospital on this morning had fallen in her living room.
Parsons said she has known many of her patients for years, through her parents or grandparents. As they grow old and get sick, she picks them up in the ambulance and drives them to Lost Rivers.
“And before long, I’m doing their funeral flowers,” she said.
Telemedicine: A New Frontier
At first the Bengal Pharmacy, on the bottom floor of Lost Rivers Medical Center, looks like any other pharmacy, with racks of over-the-counter cold medications, bandages, reading glasses and medical supplies. Shelves of prescription medications sit behind the counter. But it has no pharmacist on site; instead, technicians and students from Idaho State University in Pocatello shuffle about, filling prescriptions.
Their supervisor is a pharmacist at the university, about 80 miles away, who checks their work remotely. Patients who want to talk to him go to a small private room with a phone and video link. The pharmacy is named for the university’s mascot.
For rural hospitals, telehealth can make otherwise faraway services accessible to people where they live, said Keith Mueller, director of the Center for Rural Health Policy Analysis at the University of Iowa. That can be critical, especially during the winter when snowstorms sometimes cut off access to rural towns.
“We can, in effect, bring the provider to the community without physically doing so,” Mueller said. “Even in urban areas, people want more and more convenience in how we receive our services. Here we are talking more about necessity.”
A patient uses a telephone in a private room to talk to a pharmacist at Idaho State University after receiving his medication at Lost Rivers Medical Center. The center has no on-site pharmacist and instead relies on telemedicine to fulfill the hospital's needs. (M. Scott Mahaskey/Politico)
At Lost Rivers, patients can have telemedicine appointments with a psychiatrist. And doctors can get virtual guidance from specialists in trauma, emergency care and burns. But new technologies sometimes take getting used to. “When you lose that hometown community pharmacist, that human touch, when you turn it over to computers, that’s a concept that people have difficulty with,” said Martha Danz, who sits on the hospital’s board.
Leon Coon, 83, said the concept is a bit foreign to him. “I just don’t do that stuff,” said Coon, who works loading hay. “I’m a little old-fashioned.” Sipping coffee at the truck stop early on a Wednesday morning, Coon said he doesn’t even text, so he’s a bit wary of technology that puts him in touch with a pharmacist all the way in Pocatello. But then again, he said he doesn’t rely on the medical system much at all.
“Anytime you go to the doctor, it’s just like a mechanic,” he said. “They’re going to find something wrong. I feel good most of the time, so I just don’t go.”
Shane Rosenkrance, whose wife got trampled by the cow, said he remembers when there were five community drugstores in the valley. Now, he is grateful to have the one pharmacy — even if the pharmacist isn’t actually behind the counter. “To have health care, you have to have a pharmacy,” he said. “And through technology, they are able to do it.”
Telemedicine is hardly a panacea. The projects often depend on grants or government awards, because rural hospitals’ operating margins are slim. And some of the telemedicine and remote monitoring technologies require high-speed internet, which isn’t always reliable or cost-effective in rural areas.
“You can’t do home monitoring everywhere,” said Sally Buck, CEO of the National Rural Health Resource Center. “You can’t do telehealth everywhere.”
Telemedicine also may raise more questions than it answers for some patients, and even create a need for in-person follow-ups. Orie Browne, the medical director for Lost Rivers, said he tries to keep patients from having to travel. But if someone needs more advanced medical care — or a specialist that Lost Rivers doesn’t have — he will refer them to another hospital. The hospital has a helicopter pad, and patients with emergencies that can’t be handled at Lost Rivers can either be flown out by helicopter or transferred by ambulance.
“Ego is a dangerous thing,” he said. “If there is anyone who can do a better job, I’m going to get [my patients] there.”
Nevertheless, Huerta said, he hopes to expand telemedicine, including such services as oncology. Huerta recognizes that Lost Rivers doesn’t have the staff or the expertise to do it all. He believes the hospital should try to do more when it can, and refer out the rest.
“We aren’t trying to do brain surgery,” he said. “We’re not doing Level I trauma. But colonoscopies? Tele-oncology? People in rural areas get cancer too, and it’s demanding driving hours back from a chemotherapy session.”
Rounding Up Doctors
Browne started work at Lost Rivers one recent day in March, then drove 45 minutes to one of its outpatient clinics in Mackay, 26 miles away. One of his first patients was Elizabeth Galasso, 59, who was worried because her heart rate was racing.
“I was scared,” Galasso said, speaking with a hoarse voice as she sat hunched on the exam table. “I felt my heart pounding clear down into my stomach.”
An EKG showed her heart was beating normally. Browne told her it was likely a panic attack, but suggested a stress test just to make sure. He told her that her age, her smoking history and anxiety all put her at risk for heart disease.
“But I think things are going to be just fine,” he said. Galasso reached over and hugged him.
Browne, who took over as Lost Rivers’ medical director in 2015, said he was drawn to the outdoor activities in the area — and the variety of rural health care. He used to have a private practice in Idaho Falls and rotated into Lost Rivers for a week at a time. Now, he spends his days bouncing between the emergency room, the hospital inpatient beds and the primary care clinic. “That’s good for a person who gets bored easily,” he said.
Lost Rivers Medical Center CEO Brad Huerta describes his acquisition of a CT scanner
Many doctors, however, don’t feel the same pull. Rural hospitals and clinics have long struggled to recruit doctors. In rural areas, there are roughly 13 physicians — of any kind — per 100,000 people, compared with 31 in urban areas, according to the National Rural Health Association.
Doctors and other medical providers can be enticed by programs that repay their school loans if they work in a rural area. Some medical schools have programs designed specifically for students who plan to practice in rural or underserved communities. Another way to make treatment more accessible in rural areas is to expand the responsibilities of nurse practitioners, physician assistants and even paramedics.
Lost Rivers relies on nurse practitioners and physician assistants to provide care for patients in the clinics and the hospital. In addition to Browne, the medical center has four part-time primary care physicians, some who live hours away and come in once a week. Various specialists, including a cardiologist and an orthopedist, also rotate into the medical center’s outpatient clinics about once a month. And an MRI machine gets driven to the hospital once a week.
Tim Tomlinson, a podiatrist who lives in Twin Falls and drives 100 miles to Arco once a week, spent a recent morning seeing a lineup of patients. One was a man who had to have a toe amputated after a horse stepped on his foot, another a diabetic who needed a skin graft checked on his foot.
Tomlinson said he’s gotten paid late before, and he has seen the hospital nearly shut down more than once. But he keeps coming because he has developed a practice — and he thinks its important patients have access to specialty care. Lost Rivers isn’t unique in its difficulties, he noted. “All those small towns are struggling as young people move out, leaving mostly old people,” he said. “That puts a drain on the hospitals.”
Patients are living longer with chronic diseases now, so the demand for elderly care is only going to increase. If not the rural clinics and hospitals, Tomlinson said, “who’s going to deliver it?”
Even with the decline in the nation’s rural population, many people are rooted in rural America because of family or because they like the outdoors and a slower pace of life. One of them is Gene Davies, who has lived in Arco more than 60 years, runs a mechanic shop straight out of a different era. Handwritten signs sit on a wooden chair next to the door: “Gone to Dr.” “Be back tomorrow.” “Hope to be back Monday.”
Davies said he appreciates the remoteness of the region. “I ain’t got no plans to go anywhere else,” he said. “I’ve seen enough of the other world. I don’t want it.”
Rosenkrance, the cattle farmer, said she’s not going anywhere, either. She’s been coming to the hospital since she was a child, when she ran through the halls while her father worked in the pharmacy. Now her husband teases her about having a standing reservation in the emergency room.
Just before discharging Rosenkrance, nurse Celeste Parson told her she needed to rest physically and mentally. The accident had left her with a concussion, a lacerated ear and a black eye. Then Parson issued her the most important instruction: Don’t do anything that could cause another blow to the head.
“We would really like you to rest up for at least a week,” Parson said. “But the doctor knows for you, two or three days is more realistic.”
As she grabbed an ice pack and her purse, Rosenkrance reflected on the importance of Lost Rivers for residents across the whole valley.
“This hospital is a big deal,” she said. “It’s saved a lot of lives.”
In November, California voters defeated a ballot proposal that would have given state government more control over drug prices. It was a victory for pharmaceutical companies, which spent more than $100 million campaigning against the measure.
Now the industry is fighting new efforts by state lawmakers to impose regulations. Drugmakers are watching Senate Bill 17, in particular. Instead of direct price controls, it calls for price transparency. Drug companies would have to announce large price hikes and give detailed justifications to explain why the prices are going up.
“If you can’t understand what’s going on, how could you possibly make efforts to change that?” said Democratic Assemblyman Jim Wood, who chairs the Assembly Health Committee. Wood voted in favor of a similar drug price transparency bill last year that stalled.
Both last year’s and this year’s drug transparency measures were authored by the Senate Health Committee Chair, Sen. Ed Hernandez (D-West Covina). SB 17 is scheduled for a hearing in theSenate Committee on Health on April 19.
Pharmaceutical manufacturers frequently argue that drug prices are high because it’s expensive to conduct the scientific research and development necessary to bring a drug to market.
But Wood says we can’t simply take their word on that.
“I would personally love to know how much they spend on advertising and marketing, versus how much they spend on R&D,” he said.
Drug industry representatives and researchers visited the state Capitol last Wednesday to meet with lawmakers and underscore their contributions to the California economy. The pharmaceutical industry employs more people in California than in any other state, with 145,880 jobs, said Priscilla VanderVeer, a spokeswoman withPharmaceutical Research and Manufacturers of America.
VanderVeer said SB 17 won’t do anything to help consumers.
“If the problem is that patients are having a hard time affording their medicines, which we know they are, then let’s come to the table and talk about solutions that can actually help them,” she said.
VanderVeer said one problem is that consumers often must pay the full list price of a drug, even if they are insured.
“Oftentimes when a patient goes to the pharmacy counter and they haven’t reached their deductible, or they have a coinsurance on their drugs, they’re paying that off the list price, not the negotiated rate their insurance has,” she said.
VanderVeer says that doesn’t happen to insured patients in other parts of the health care system.
“I give the example of the hospital. You know the $350 X-ray that your insurance brings down to $50, and then you pay your cost-sharing off the $50. That’s not happening with your drugs, that’s not happening at the pharmacy counter,” she said.
VanderVeer criticized the bill for ignoring other parts of the pharmaceutical supply chain that also affect prices.
“You’ve also got pharmacy benefit managers and insurers who negotiate the price significantly down … and then you also got wholesalers who purchase drugs directly and keep them in their warehouses and disseminate them to pharmacies. And then you’ve got pharmacies,” VanderVeer explained. She said those links in the supply chain account for one-third of the final price.
Assemblyman Wood agrees that California should pay more attention to pharmacy benefit managers. These companies act as middlemen, negotiating purchase contracts with drug manufacturers on behalf of health plans.
Wood has introduced a different bill in the Assembly that would require pharmacy benefit managers to be licensed in California. The legislation would require the managers to disclose information about their business practices, including rebates and hidden “clawback” arrangements that bring profit to them and force patients to unwittingly pay more for drugs.
Health policy experts say that creating any type of universal health plan would face enormous political and fiscal challenges—and that if it happens at all, it could take years.
As the nation's Republican leaders huddle to reconsider their plans to "repeal and replace" the nation's health law, advocates for universal health coverage press on in California, armed with renewed political will and a new set of proposals.
Organized labor and two lawmakers are leading the charge for a single, government-financed program for everyone in the state. Another legislator wants to create a commission that would weigh the best options for a system to cover everyone. And Democratic Lt. Gov. Gavin Newsom, who hopes to become the next governor, has suggested building on employer-based health care to plug holes in existing coverage.
The proposals are fueled both by a fear of losing gains under the Affordable Care Act and a sense that the law doesn't go far enough toward covering everyone and cutting costs.
But heath policy experts say that creating any type of universal health plan would face enormous political and fiscal challenges — and that if it happens at all, it could take years.
"There are different ways to get there," says Jonathan Oberlander, professor of social medicine and health policy at the University of North Carolina. "None of them is easy."
The most specific California proposal comes from state Sens. Ricardo Lara (D-Bell Gardens) and Toni Atkins (D-San Diego), co-authors of legislation that would take steps toward creating one publicly financed "single-payer" program.
The bill, co-sponsored by the California Nurses Association, would aim for something like a system of "Medicare for all" in which the government, not insurers, provides payments and sets coverage rules.
Lara said the approach would get California closer to a system "that covers more and costs less."
The bill's authors haven't announced how the program would be funded. And that's where the biggest obstacle lies, said Oberlander: It would largely uproot California's present system, in which roughly half of coverage is sponsored by employers.
If "you're going to take health insurance largely out of the market, you're going to disconnect it from employers," he said. "Then you have to make up all the financing that you're going to lose."
There's no way to make up for those lost employer contributions other than to introduce "very visible taxes," Oberlander said. And that's not the only reason why a single payer plan would be controversial. "A lot of people are satisfied with what they have," he said.
The trade group for insurers in California does not support the single-payer idea.
"A single-payer system would make the quality of our health care worse, not better," said Charles Bacchi, president and CEO of the California Association of Health Plans. "We've made substantial progress in expanding and increasing access to and quality of care — this step backwards would be particularly devastating for Californians."
Many conservatives oppose the single-payer approach. "We have come to value and expect a health care system that has private-sector market elements," said Lanhee Chen, a fellow at the Hoover Institution and former chief policy adviser to former Massachusetts governor Mitt Romney.
A single-payer system would need federal approval and likely have to overcome other bureaucratic hurdles even if approved in the state. As it stands, no state has such a system. Perhaps the best-known effort to create one was in Vermont, but it failed in 2014 after officials there couldn't figure out how to finance it.
Single-payer proposals have been put forth many times in the California Legislature since 2003, and all have hit roadblocks.
One bill, carried by former state senator Sheila Kuehl several years ago and passed by the state Legislature, would have created a payroll tax to help fund a program costing about $200 billion each year. That measure and a similar bill were vetoed by then-governor Arnold Schwarzenegger, who cited financial concerns.
Kuehl, now a Los Angeles County supervisor, said the time is as good as ever to reintroduce a proposal like single-payer because many people fear losing coverage under Republican proposals being discussed in Washington, D.C.
"The ACA created more familiarity with being insured," said Kuehl. "They've recognized the value."
Other observers say attempts to expand access should not undermine efforts to preserve insurance gains under Obamacare. The threat to Medicaid or private insurance access is still real, they say.
"California should explore all options, [but] we should not do that if it means withdrawing support for protecting the ACA," said Jerry Kominski, director of the UCLA Center for Health Policy Research. "It would take decades to get back to where we are now," he said.
In an interview with California Healthline, California Gov. Jerry Brown emphasized that financing a single-payer system would be a major challenge. Although he said he would entertain a conversation about a single-payer system, he did not say whether he would endorse creating one.
For one thing, it would require a new tax, which would have to be approved either by a two-thirds majority vote in the state Legislature or a simple-majority popular vote, he said. Even with the current Democratic supermajority, Brown said, there are always a few "outliers" who wouldn't support raising new revenues.
Brown leaves office in 2018, however, and Newsom, who hopes to succeed him, is looking into a creating a plan for universal coverage that would be an alternative to a single-payer system.
One option, according to Newsom's office, would be to use as a model the Healthy San Francisco program he introduced in 2007 as mayor. The city has used a combination of public money and contributions from employers and enrollees to plug holes in coverage and make primary care accessible to nearly everyone.
Using that model to expand health care statewide has some political advantages, Oberlander said, because it builds on the "status quo rather than radically restructuring" the current system.
Another California lawmaker proposes to keep the conversation going about universal health care, at least, by creating a commission that would make various recommendations to policymakers.
"We have to be able to move on multiple tracks at once," said Assemblyman Rob Bonta (D-Oakland), who is carrying the bill to create the Health Care for All commission, which would convene in 2018.
The debate in Washington could actually produce some surprising opportunities for California and other states. The feds might, for instance, approve waivers to allow other types of experimentation within states. Some Republicans favor an approach in which each state decides on its own coverage system, within certain limits.
That could mean a retraction of coverage in some states, but in California it might open the door to a new model.
"It is possible that some liberal-leaning states are going to do things that we didn't think possible before," Oberlander said.
GOP House members, particularly those from conservative areas, "are going to go home and get hammered for not repealing Obamacare," said Thomas Scully, a health policy official in both Bush administrations.
This week's effort to resurrect the GOP bill to overhaul the Affordable Care Act has apparently met the same end as the first try in March — not even a vote on the floor of the House. Apparently the roadblock was the same, too. Efforts to gain votes from holdout conservatives repelled moderate Republicans in the House, while efforts to placate moderates kept conservatives from signing on.
So what was the purpose of the new effort, which was led mostly from the White House?
Republican health analysts said party officials had little choice but to keep trying to reach consensus — or at least enough consensus to pass a bill out of the House.
GOP House members, particularly those from conservative areas, "are going to go home and get hammered for not repealing Obamacare," said Thomas Scully, a health policy official in both Bush administrations.
The latest Kaiser Family Foundation monthly tracking poll suggests that might well be the case. Although three-quarters of the population wants President Donald Trump and his administration to make the health law work, 54 percent of Republicans said it was "a bad thing" that the House GOP bill failed to pass in March, and 58 percent of Republicans said the bill "did not go far enough to end Obamacare." (Kaiser Health News is an editorially independent project of the foundation.)
Chris Jacobs, a longtime GOP congressional staffer, said there are two imperatives still pushing for some kind of deal. "First, a seven-year commitment by the Republican Party" to repeal and replace the health law, "and second, the administration very clearly wants a win" on some sort of major policy initiative.
But apparently the ideas put forward by the White House to gain more conservative votes without losing moderate ones did not work as the administration hoped.
Conservatives were reportedly pleased early in the week when it appeared states would be allowed to opt out of most of the ACA's insurance regulations — including rules on what benefits must be covered and whether insurers can charge sicker people higher premiums or deny them coverage.
But moderates complained that would violate promises that the GOP would keep intact protections for people with preexisting health conditions. And the proposal was apparently scaled back.
What remained "was a substantial narrowing in an unproductive way for the proposal," Michael Needham of the conservative group Heritage Action told reporters on a conference call. Needham called the new version "a nonstarter" for conservatives.
On Thursday, Republicans announced agreement on an amendment to the health bill that would provide $15 billion to help compensate insurers for very high-cost patients.
But at a hastily called meeting of the House Rules Committee, even Chairman Pete Sessions (R-Texas) conceded that the amendment, at least for now, mostly provides a way for members to say they are making progress as they head home to face their constituents.
"What we're trying to do is lock in ideas so we [Republicans] have an opportunity to go home and amplify," he said.
Now Congress is poised to leave Washington for a two-week spring recess, from Monday through April 21, without their promised health bill. And what happens when they come back is unclear.
"They put themselves in this box canyon and have no way out of it," said political scientist Norman Ornstein of the American Enterprise Institute. "I just don't see a strategy here."
Scully said it's more a matter of time. Eventually Republicans will have to come together, because the alternative — leaving the ACA in place — is not acceptable to their voters. "They'll keep going back and forth until they find something that can pass," he said.
In addition to their internal differences, the calendar is working against the GOP. When Congress returns from break, it will have only a few days to pass a new temporary spending bill or the government will shut down.
Then there is a desire to turn to a tax overhaul. But in order to do that, Congress must pass a new budget resolution for the coming fiscal year. And as soon as they do, the provisions that would allow an overhaul of the health law to pass the Senate with a simple majority and no Democratic filibuster — which were part of an earlier budget resolution — would disappear.
Jacobs said a big part of the problem is that the GOP is still divided over what should happen with the health law. While the GOP mantra has been "repeal and replace" for several years, he said, "there are differences between the repealers and the replacers. They are two fundamentally distinct approaches separated by the word 'and.'"
Even if Republicans can't resolve their differences, they have to keep trying, said Doug Badger, a longtime Senate and White House staffer now at the conservative Galen Institute. "I really don't think they can get this done," he said. "But they can't say they can't get this done, even though it's over."
This story was updated to add details from Thursday's Rules Committee meeting.
Seema Verma, the former health policy consultant now overseeing Medicare and Medicaid for the Trump administration, will not take part in one of her agency's most anticipated decisions because of a conflict of interest.
Seema Verma, the former health policy consultant now overseeing Medicare and Medicaid for the Trump administration, will not take part in one of her agency's most anticipated decisions because of a conflict of interest.
The case concerns whether to allow Kentucky to become the first state in the nation to require some Medicaid recipients to work to qualify for health coverage. That change and others in Kentucky's proposal are generally favored by conservative Republicans — and have been encouraged by the Trump administration.
The work requirement is one of the most controversial features of Kentucky's proposed strategy to drastically remake its Medicaid expansion under the Affordable Care Act, which added about 440,000 low-income adults to the program since 2014. The state wants Verma's agency, the Centers for Medicare & Medicaid Services, to grant it a waiver from federal Medicaid rules to put its plan into effect.
Verma helped write Kentucky's Medicaid overhaul plan last year through her health consulting business, which worked closely with several states. The Obama administration did not rule on Kentucky's application after its submission in August, though it consistently denied efforts by Republican-controlled states to add a work requirement to Medicaid, the federal-state health insurance program for low-income Americans.
President Donald Trump has signaled that his administration will be open to allowing such a work requirement. Trump offered to allow states to add the mandate in his failed effort last month to persuade the House to pass a partial repeal of the Affordable Care Act, known as Obamacare.
"We are going to work with both expansion and non-expansion states on a solution that best uses taxpayer dollars to serve the truly vulnerable," Health and Human Services Secretary Tom Price and Verma said about their plans for Medicaid in a joint letter to governors in March.
With the exception of the work requirement, Kentucky's waiver request is largely modeled on the Indiana Medicaid expansion, which was chiefly designed by Verma as a top consultant to the state and then-Gov. Mike Pence, now the vice president.
The complex plan requires even the poorest enrollees to make small monthly contributions toward their coverage. Advocates say that gives them "skin in the game" to encourage them to make better health decisions. Critics worry the strategy will prevent poor people from enrolling in Medicaid and erode progress in reducing the uninsured population.
Kentucky Gov. Matt Bevin, who was elected in 2015, has argued his state can't afford Medicaid in its current form. Obamacare permitted states to use federal funds to broaden Medicaid eligibility to all adults with incomes at and below 138 percent of the federal poverty level, now $16,643 for individuals.
The Medicaid expansion under Obamacare in Kentucky has led to one of the sharpest drops in any state's uninsured rate, to under 8 percent in 2016 from 20 percent two years earlier.
Bevin threatened to roll back the expansion if the government would not allow him to make major changes, such as requiring Kentucky's beneficiaries to pay monthly premiums of $1 to $37.50 and mandating nondisabled recipients to work or do community service for free dental and vision care.
Budget pressures are rising this year in the 31 states and the District of Columbia where Medicaid was expanded as the federal government reduces its share of those costs. States are picking up 5 percent of the cost in 2017 and that portion will rise gradually to 10 percent by 2020. Under the health law, the federal government paid the full cost of the Medicaid expansion population for 2014-16.
Health experts said they were not surprised by Verma's recusal, though they expect it will not prevent CMS from ultimately approving the Kentucky waiver with some type of work requirement.
"It's certainly likely to be approved — the only question is some of the details, like who may be exempted," said Judy Solomon, a health policy expert with the left-leaning Center on Budget and Policy Priorities.
A CMS spokeswoman did not respond to queries about which CMS official would decide the Kentucky waiver request or what other decisions Verma might recuse herself from.
Verma also is expected to recuse herself from CMS' decision on the latest Indiana Medicaid expansion waiver, which was submitted Jan. 31.
In her Senate confirmation hearing, Verma said she would not participate in matters involving former clients or parties represented by former clients for at least one year. In addition to consulting projects with Indiana, Kentucky and other states, Verma worked with large Medicaid contractors including Hewlett Packard Enterprise and Milliman. She sold her consulting company, SVC, to another health care consultancy, Health Management Associates.
California doctors have long decried California's Medi-Cal rates, which are lower than those of Medicaid programs in 45 other states and the District of Columbia.
California's doctors and dentists have renewed their push for more money to treat Medicaid patients now that the state has been spared the drastic cuts proposed under the failed GOP health care bill.
But Democratic Gov. Jerry Brown — and some health advocates — say they have other priorities for improving the low-income health program, which serves some 14 million residents, or about a third of the state's population.
Doctors had pinned their hopes for better pay on a new tobacco tax passed by voters in November. Proposition 56 was estimated to add about $1.2 billion to the state's Medi-Cal fund for 2017-18. But Brown's proposed budget in January disappointed providers: He did not recommend raising doctors' Medi-Cal rates, instead earmarking the money to cover the program's overall costs.
Earlier this month, the California Medical Association and the California Dental Association, representing doctors and dentists, released their own budget proposal seeking to boost those payments. The proposal suggests giving doctors annual bonuses of up to $15,000 based on the proportion of their patients on Medi-Cal. The price tag on their plan could be as much as $607.5 million.
Now that it appears unlikely California will need to cope with the massive cuts in federal Medicaid funding anticipated under the GOP health bill, discussions about how to dole out state tobacco tax money will likely restart in earnest after being in a holding pattern during the debate in Congress, said Anthony Wright, executive director of the advocacy group Health Access.
"There's a lot of things that money could go for besides provider reimbursements," Wright said, noting that he and other advocates also favor restoring some Medi-Cal benefits, such as vision care, that were cut during the recession.
Francisco Silva, general counsel and senior vice president for the California Medical Association, said voters approved the tobacco tax ballot measure to improve patients' access to care and that the governor's January budget proposal "does not follow the will of the voters."
For patients on Medi-Cal, "if you don't address their ability to see a provider, you don't address access," Silva said. "Adding more patients to the back of the line and maintaining status quo" won't work.
Gov. Brown is scheduled to release a revised budget proposal in May that could change how the tobacco money would be spent. For now, it looks as though he won't budge on his budget priorities. "We continue to make our views very clear that these are proper and appropriate uses of the proceeds of Prop. 56," said the governor's budget spokesman, H.D. Palmer.
Palmer said it's now up to state lawmakers to define their own budget priorities, which could result in higher rates for health care providers.
In a letter, seven senators called on Attorney General Jeff Sessions to assure them that any investigation of Tom Price would be "allowed to continue unimpeded."
Nine senators are pushing U.S. Attorney General Jeff Sessions to reveal what he knows about a reported investigation into Health and Human Services Secretary Tom Price's stock trades that a top federal prosecutor might have begun before being fired by the Trump administration this month.
In a letter Wednesday, seven senators — six Democrats plus Vermont independent Bernie Sanders — called on Sessions to assure them that any investigation of Price — or others connected to the Trump administration — would be "allowed to continue unimpeded." Three Democratic senators sent a different letter a day earlier, asking Sessions to "provide greater clarity" about why Manhattan's former U.S. attorney, Preet Bharara, was fired and whether any investigation of Price was a factor in Bharara's removal.
ProPublica, a nonprofit news organization, reported March 17 that Price was being investigatedby the U.S. attorney's office for his stock trades, though it did not specify which trades Bharara was investigating before his dismissal. The website attributed its report to an unnamed person familiar with the U.S. attorney's office, and neither the Justice Department nor other news media organizations have confirmed its existence.
If an investigation had begun, it would be hard to derail. But investigations of federal officials are always sensitive cases, said Donald Langevoort, a securities law professor at Georgetown University.
"The higher up the food chain you go, the more prominent the person is, the more confident you better be that you have the evidence you can present to a jury," he said. "But I think any attempt to quash an investigation would backfire considerably."
Price, a prominent Republican congressman until he joined President Donald Trump's Cabinet this year, was questioned extensively at his confirmation hearings about stock purchases he made in health care, pharmaceutical and medical device companies while serving on the House of Representatives' health subcommittee.
The activity raised conflict-of-interest concerns for some members of Congress because Price's trades overlapped with his sponsorship of bills, advocacy or votes on issues related to those companies or their industries.
The Democrats called attention to Price's investment in a small Australian biotech firm, Innate Immunotherapeutics, which Price testified he learned about from another congressman, Rep. Chris Collins (R-N.Y.), Innate's largest shareholder.
Price bought most of his shares at discounted prices in two private stock placements in 2016 offered to a small number of sophisticated investors — many with personal or professional ties to Collins.
Congressional Democrats slammed Price at his hearings for buying shares at advantageous prices not available to all investors. Some questioned whether Price had violated insider trading laws or the Stop Trading on Congressional Knowledge (STOCK) Act, which bans members of Congress from trading on stocks using information they received in carrying out their official duties.
"Despite the many unanswered questions that remained, Republicans rushed Price's nomination through the Senate without waiting for answers," seven senators said in Wednesday's letter.
When he was confirmed Feb. 10, Price agreed to divest his stock holdings within 90 days of taking his post. An HHS spokesperson said Price has completed those divestitures but declined to provide further information.
Sen. Elizabeth Warren (D-Mass.) was the only senator who signed both letters to Sessions.
Other names on Wednesday's letter were Patty Murray (D-Wash.), Ron Wyden (D-Ore.), Bernie Sanders (I-Vt.), Al Franken (D-Minn.), Tammy Baldwin (D-Wis.) and Maggie Hassan (D-N.H.).
Tuesday's letter was also signed by Richard Blumenthal (D-Conn.) and Jeff Merkley (D-Ore.).
Sessions' office confirmed it had received Tuesday's letter from the senators but declined to comment on either one. The U.S. Attorney's Office in Manhattan also had no comment.