Tending To Patients As Her New Home Burns

KFF Health News, October 16, 2017

Wildfires threatened homes and workplaces alike for California health care providers.

This article first appeared October 16, 2017 on Kaiser Health News.

By April Dembosky, KQED

Julayne Smithson was working an overnight shift in the Intensive Care Unit at the Kaiser Permanente hospital in Santa Rosa, Calif., when massive wildfires started racing through the city. Smithson had no idea how close they were. She was too busy taking care of her patient.

“One of the nurses came up to me and she said, ‘Julayne, I’m sorry, but your house is not going to make it,’” she said.

Smithson, 55, recently moved from Indiana and had just bought the house a few weeks ago. From the hospital window, she could see the flames moving through her neighborhood a block away.

“I was so busy working the last couple of weeks that I didn’t get my insurance, which I never do. I never ever, ever go uninsured,” she said. “I kept saying, ‘Tomorrow, I’m going to do that. Tomorrow, I’m going to do that.’”

Smithson asked a colleague to watch her patient and raced home to try to save a few things.

“I knew I didn’t have much time,” she said. “So I ran inside and I thought, ‘I have to get my nursing documents, because if I’m going to lose everything I own, I have to be able to work, to care for patients.’”

She grabbed the papers, a pair of scrubs and a nightgown, and raced back to the ICU. Over the next two hours, smoke filled the hospital.

“All of a sudden the police busted in the door and they said, ‘Everybody out,’” she said. “’Grab what you can carry, get your patients, and go now.’”

One of Kaiser’s emergency room doctors took charge as the fire approached, making the call to evacuate the hospital’s 130 patients. (Kaiser Permanente is not affiliated with Kaiser Health News.)

“It’s a really challenging decision to make, one you don’t make lightly,” said Joshua Weil, Kaiser’s ER doctor in charge that night. “You have to weigh the potential risk of moving hospitalized patients and patients from the emergency department, versus the risk of keeping them where they are.”

But the fire had moved suddenly toward the hospital. Firefighters told him the blaze was 100 to 200 yards away.

“They literally used the words, ‘We’re making the last stand,’” Weil said.

Staffers immediately started assessing and triaging patients.

Patients who could walk got on a bus provided by the city. Patients who couldn’t, like Smithson’s, had to wait for ambulances.

But Sutter Santa Rosa Regional Hospital was also evacuating its 80 or so patients, so ambulances were in high demand.

“A lot of nurses and staff were putting patients in their cars and driving them to the [other] hospital,” she said. “And then other people were carrying people on blankets, people who couldn’t walk, and putting them in cars.”

In the end, Smithson said they waited about 15 minutes for an ambulance — a very stressful 15 minutes. Her team was manually pumping air into her patient’s mouth with an air bag. A team of five had to push him, in his bed with all the monitors, through the parking lot several times to get away from fast-moving smoke and flames. His medication was running low and he was getting agitated.

“The pharmacy pre-mixes those medicines for us, but we didn’t have time to prepare extra medication for a trip like that because it just came up so fast,” she said.

Three hours passed from the moment the evacuation was called to the moment the last patient was out of the hospital, Weil said.

Smithson’s patient, and several others in critical condition, made it safely to Santa Rosa Memorial Hospital, about four miles away. About a hundred less critical patients were transferred to Kaiser’s hospital in San Rafael, about 40 miles away.

Beatrice Immoos was one of the nurses in San Rafael getting prepped to receive the influx.

“We were essentially told that we were in a disaster situation and all ratios were out the window,” she said, meaning nurses would be assigned more patients than usually allowed under California law. “They were going to start triaging people through the ER.”

She said patients were arriving wearing colored armbands, indicating the severity of their condition. “This level of disaster is a new one for us,” said Immoos. “It was very emotional, but there was a lot of resolve. The hospital put out calls for volunteer nurses to come help in San Rafael. Many responded, including Julayne Smithson. Her husband was supposed to fly in from Indiana in two days, but with their new home gone, she told him to wait.

“I said, ‘Well, I don’t have anywhere to go right now. And we don’t know what’s going on,’” she said. “So I said ‘I’ll go to San Rafael and help there.’”

Another nurse offered Smithson a pullout couch in a spare room. She’s been sleeping there during the day, and working 7 p.m. to 7 a.m. every night since the fire. She says all she wants to do right now is help patients, so she doesn’t have to think about what she’s lost.

Stunner On Birth Control: Trump's Moral Exemption Is Geared To Just 2 Groups

KFF Health News, October 16, 2017

Hundreds of organizations sued the Obama administration over the contraceptive mandate. Two are anti-abortion groups that do not qualify for religious exemptions.

This article first appeared October 16, 2017 on Kaiser Health News.

By Julie Rovner

Few people were surprised last week when the Trump administration issued a rule to make it easier for some religious employers to opt out of offering no-cost prescription birth control to their female employees under the Affordable Care Act.

But a separate regulation issued at the same time raised eyebrows. It creates a new exemption from the requirement that most employers offer contraceptive coverage. This one is for “non-religious organizations with sincerely held moral convictions inconsistent with providing coverage for some or all contraceptive services.”

So what’s the difference between religious beliefs and moral convictions?

“Theoretically, it would be someone who says ‘I don’t have a belief in God,’ but ‘I oppose contraception for reasons that have nothing to do with religion or God,’ ” said Mark Rienzi, a senior counsel for the Becket Fund for Religious Liberty, which represented many of the organizations that sued the Obama administration over the contraceptive mandate.

Nicholas Bagley, a law professor at the University of Michigan, said it would apply to “an organization that has strong moral convictions but does not associate itself with any particular religion.”

What kind of an organization would that be? It turns out not to be such a mystery, Rienzi and Bagley agreed.

Among the hundreds of organizations that sued over the mandate, two — the Washington, D.C.-based March for Life and the Pennsylvania-based Real Alternatives — are anti-abortion groups that do not qualify for religious exemptions. While their employees may be religious, the groups themselves are not.

March for Life argued that the ACA requirement to cover all contraceptives approved by the Food and Drug Administration includes methods that prevent a fertilized egg from implanting in a woman’s uterus and therefore are a type of abortion. Real Alternatives opposes the use of all contraceptives.

March for Life, which coordinates an annual abortion protest each year, won its suit before a federal district court judge in Washington, D.C.

But a federal appeals court ruled in August that Real Alternatives, which offers counseling services designed to help women choose not to have an abortion, does not qualify as a religious entity and thus cannot claim the exemption. That decision cited a lower-court ruling that “finding a singular moral objection to law on par with a religious objection could very well lead to a flood of similar objections.”

The departments of Treasury, Labor and Health and Human Services, however, suggest that, at least in this case, that will not happen. The regulation issued by those departments says officials “assume the exemption will be used by nine nonprofit entities” and “nine for-profit entities.” Among the latter, it said, “we estimate that 15 women may incur contraceptive costs due to for-profit entities using the expanded exemption provided” in the rules.

The regulation also seeks comments on whether the moral exemption should be extended to publicly traded firms.

Rienzi agrees that the universe for the moral exemption is likely to be small. “The odds that anyone new is going to come up and say ‘Aha, I finally have my way out,’ ” he said, “is crazy.”

Women’s health advocates, however, are not so sure.

“The parameters of what constitutes a moral objection is unclear,” said Mara Gandal-Powers, senior counsel at the National Women’s Law Center, which is preparing to sue to stop both rules. “There is nothing in the regulatory language itself that says what a moral belief is that would rise to the level of making an organization eligible for the exemption.”

Louise Melling, deputy legal director at the ACLU, which has already filed a lawsuit, agreed. “We don’t know how many other entities are out there that would assert a moral objection,” she said. “Not everybody wanted to file a suit,” particularly smaller organizations.

All of that, however, presupposes that the rule laying out the moral objection exemption will stand up in court.

Bagley said he’s doubtful. The legal arguments making the case for the exemption, he said, are “the kind of things that would be laughed out of a [first-year] class on statutory interpretation.”

Specifically, he said, the rule lays out all the times Congress has included provisions in laws for moral objections. But rather than justifying the case, “it suggests that Congress knew a lot about how to craft a moral objection if it wanted to,” and it did not in the health law, he noted.

Bagley said the fact that the moral exemption was laid out in a separate rule from the religious one demonstrates that the administration is concerned the former might not stand up to court proceedings. “The administration must sense this rule is on thin legal ice,” he said.

Which leads to the question of why Trump officials even bothered doing a separate rule. Bagley said he thinks the act was more political than substantive. “The administration is doing something that signals to religious employers … that they are on their sides, that they have their backs.”

Anthem Eases Up On Premium Hikes After State Scrutiny

KFF Health News, October 13, 2017

Even after reducing its 2018 rate increase, Anthem's hike ranks second-highest among the 11 insurers that sell coverage in California's exchange.

This article first appeared October 12, 2017 on Kaiser Health News.

By Chad Terhune

Insurance giant Anthem Blue Cross agreed to reduce two planned premium increases for 2018 after California regulators questioned the company’s rationale for raising rates by as much as it had initially proposed.

The scaled-back rate hikes, in the individual and small-employer markets, will reduce premiums by $114 million, state officials said.

The California Department of Managed Health Care challenged Anthem’s estimates for future medical costs, in particular its prediction of a 30 percent jump in pharmacy expenses for the individual market — nearly double the estimates of two other big insurers and out of line with industry trends nationally.

As a result of the department’s intervention, the nation’s second-largest health insurer shaved 3 percentage points off its 2018 rate increase for individuals and families, still leaving a hike of 37.3 percent. That increase is the second-highest — after Molina Healthcare — among the 11 insurers that sell in the Covered California exchange. Anthem also cut its rate hike on small businesses by more than half, to 2.5 percent.

The smaller premium hikes are expected to save individuals about $21 million and small-business customers an estimated $93 million.

California’s two insurance regulators, the Department of Managed Health Care and an elected insurance commissioner, can pressure companies to reduce their rates, but neither has the authority to block rate hikes.

Shelley Rouillard, director of the managed care agency, said her department carefully scrutinizes rate filings to ensure “consumers are receiving value for their premium dollar. … Rate review is an important consumer protection and holds plans accountable to justify their rate increases.”

Anthem said in a statement that it works with regulators routinely "to revisit our assumptions and rates as more data becomes available...We are pleased that the emerging data allowed us to provide some rate relief to California individuals and small businesses versus what was originally filed."

Regulators said that during their review of Anthem’s small-group rates, the company updated its projection for medical spending, which resulted in a lower premium increase than originally proposed.

For the individual market, regulators at the managed care department dug deeper into Anthem’s forecast for prescription drug use and spending. “This is a much higher pharmacy trend than we have seen with other carriers and we will need sufficient documentation to consider it reasonable,” they wrote to Anthem.

In response to the state’s questions, Anthem lowered its estimate of the rise in pharmacy costs by 7 percentage points, to 23 percent. That led, in part, to the reduced rate increase.

Like all California insurers, Anthem had been asked by state officials to submit two rate filings for the individual market. The lower set of rates assumed that the Trump administration would continue to pay so-called cost-sharing subsidies that help low-income consumers with out-of-pocket costs. The higher rate increases, which state officials adopted on Wednesday, assume President Donald Trump might make good on his threats to end those payments.

Anthem had sought a 35.4 percent increase under the lower rate scenario and a 40.6 percent hike with a surcharge tacked on to reflect the possible loss of subsidies. That higher rate proposal was the one Anthem reduced by 3 percentage points.

The state’s examination of Anthem echoed concerns raised by the advocacy group Consumers Union in a letter to regulators on Sept. 7. The group questioned why Anthem’s projections were so much higher than its competitors’ and asked the state to demand additional documentation from the company.

Dena Mendelsohn, a staff attorney for Consumers Union in San Francisco, said she welcomed any reduction of the rate increase. “We're glad to see the pharmacy trend was brought down during the rate review process. That is exactly why we need such a rigorous rate review process,” she said.

However, the 37.3 percent average rate increase from Anthem still “poses a real concern for consumers,” especially those who do not qualify for federal tax credits that help pay for premiums, Mendelsohn said.

Some of the follow-up information Anthem submitted to regulators about its drug costs is under seal. The insurer claimed it contained confidential trade secrets that are protected from disclosure under state law.

The Department of Managed Health Care said it was looking into whether that information can be released publicly.

Another insurer, L.A. Care Health Plan, also faced questions from the managed care department. In response, the health plan dropped its proposed rate increase in the individual market by nearly 9 percentage points, to 21.7 percent. That would generate savings of $9 million, according to the state.

L.A. Care told regulators it was able to lower its rates after getting new information about the amount of federal cost-sharing subsidies it receives.

Health Net, whose rates for some plans were reviewed by the California Department of Insurance rather than the managed care agency, cut a proposed premium increase of 23 percent for individual policies nearly in half, to 12.1 percent. That yielded an estimated savings of $15.1 million, according to the insurance department.

Overall, Molina Healthcare has the highest rate increase for 2018 among insurers selling on the Covered California exchange, at 44.7 percent. Valley Health Plan comes in lowest at 9.8 percent.

Blue Shield of California, the largest insurer in the state exchange by enrollment, fell in between at 22.8 percent. HMO giant Kaiser Permanente will charge 11.6 percent more, on average, next year. (Kaiser Health News is not affiliated with Kaiser Permanente.)

California Slaps Surcharge On ACA Plans As Trump Remains Coy On Subsidies

KFF Health News, October 12, 2017

With the future of ACA subsidies unclear, Covered California decided to tack a 12.4 percent surcharge on certain health plans in 2018, with taxpayers expected to cover most of the added cost.

This article first appeared October 11, 2017 on Kaiser Health News.

By Chad Terhune

California’s health exchange said Wednesday it has ordered insurers to add a surcharge to certain policies next year because the Trump administration has yet to commit to paying a key set of consumer subsidies under the Affordable Care Act.

The decision to impose a 12.4 percent surcharge on silver-level health plans in 2018 means the total premium increase for them will average nearly 25 percent, according to Covered California. Taxpayers, not consumers, will bear the brunt of the extra rate hike because federal premium assistance for policyholders, which is pegged to the cost of coverage, will also increase.

Statewide, rate increases will vary by insurer and region. What consumers pay depends on where they live, their income, what level of coverage they want and which insurer they choose.

Californians can get their first look at next year’s health plan prices and options on the state’s rate calculator, released Wednesday.

The state’s open enrollment period, which is longer than that for the federal exchange, runs from Nov. 1 to Jan. 31. About 1.4 million Californians buy their own coverage through the state marketplace and nearly 90 percent receive financial assistance that reduces what they pay.

In August, Covered California announced that 2018 premiums would rise by 12.5 percent, on average, statewide. That ticked down slightly to 12.3 percent during regulatory review. But the exchange also warned that the additional increase, averaging 12.4 percent, would be added to the silver-tier plans if President Donald Trump failed to commit to continued funding for the so-called cost-sharing subsidies that help reduce some consumers’ out-of-pocket expenses. Those payouts total about $7 billion this year nationwide.

Trump has continued paying them on a month-to-month basis while repeatedly threatening to cut them off and repeal the entire health law. He has referred to the payments as “bailouts” for insurance companies.

Peter Lee, executive director of Covered California, said the surcharge is far from ideal but that the uncertainty in the nation’s capital left the state with no other option.

“Covered California worked hard to come up with a plan that ensures a stable market and protects as many consumers as possible from an unnecessary price hike,” Lee said in a statement Wednesday.

The exchange took several measures in an attempt to shield consumers from the effects of the surcharge. One of them was to create a new silver plan to be sold outside the exchange to individuals and families who make too much money to qualify for federal subsidies. The surcharge will not be applied to those plans, sparing unsubsidized consumers that extra cost.

The surcharge will apply only to the silver-level plans, the second-least expensive option among the exchange’s four tiers of coverage. That’s because only people enrolled in silver plans benefit from the cost-sharing subsidies that Trump has threatened to terminate.

Covered California said that 78 percent of subsidized consumers will see no change in what they pay or may pay even less despite the surcharge being imposed. The remaining 22 percent of consumers will see higher net premiums. About half of those consumers will get increases of less than $25 per month, according to the exchange.

John Baackes, chief executive of L.A. Care Health Plan, said his 2018 rates will be 11 percentage points higher because of the added surcharge — a 23 percent average increase instead of 12 percent. His health plan has about 26,000 exchange enrollees. He said the higher premiums would be “totally avoidable” if the Trump administration implemented the ACA.

“We have to lay the blame for this at the foot of the Trump administration for being so irresponsible about this major portion of the law,” Baackes said. “This will not be a burden on most consumers, but it will be a higher cost to the U.S. Treasury. It all seems so ridiculous."

Anthony Wright, executive director of the advocacy group Health Access California, criticized the Trump administration for playing "political games" with people's health coverage and forcing Covered California's hand.

"Even with Covered California's workaround, consumers are facing additional complexity and confusion, if not costs, all because of the Trump administration's contemptuous actions," Wright said.

The last-minute changes, less than three weeks before the start of open enrollment, are likely to confuse some consumers.

In addition to higher rates, Covered California faces the loss of a major insurer across much of the state. In August, Anthem Blue Cross said it was pulling out from about half of California’s counties, forcing 153,000 customers to find new coverage.

The state has boosted its marketing budget by $5.3 million for the coming year to help Anthem customers research their options and to deal with questions stemming from the surcharge.

California’s Obamacare rates have been a key barometer of how the Affordable Care Act is working since coverage began in 2014. The state held rate increases to 4 percent the first two years and then premiums jumped 13.2 percent, on average, for 2017.

These rate increases apply to people who purchase their own coverage in the individual market, not the majority of Americans who get their health insurance through work or government programs such as Medicare and Medicaid.

Some members of the U.S. Senate have attempted to craft a bipartisan deal to fund the cost-sharing subsidies for up to two years in a bid to stabilize the exchange markets nationwide. But those negotiations stalled last month when Senate Republicans pursued the Graham-Cassidy legislation, the latest GOP attempt to roll back President Barack Obama’s signature law. Like previous repeal attempts, it failed to muster enough support in the Senate.

State officials and health insurers across the U.S. have faced tough decisions on whether to proceed with higher rates to compensate for the uncertainty swirling around the Affordable Care Act. Deadlines were pushed back repeatedly as insurance commissioners and exchange directors pleaded with Trump and Congress to shore up the existing market so insurers would stick around and rate increases could be minimized.

“Carriers across the country need certainty, and a federal commitment to funding [cost-sharing reduction] payments would lower rates in many states,” Lee said Wednesday.

In Idaho, for example, the average rate for silver plans will increase 40 percent in 2018, double what the rate hike would have been had the Trump administration committed to funding the cost-sharing subsidies, according to Dean Cameron, director of the state’s Department of Insurance.

If the cost-sharing subsidies are continued into next year, the added surcharges could mean insurers will end up collecting too much in premiums, and some arrangement will have to be made to return the excess money.

Trump has continued to rail against Obamacare, pointing to huge rate increases around the country and insurance companies fleeing the market. Rather than amending the Affordable Care Act, Trump favors other proposals to help make health insurance more affordable for individuals and families.

This week, he is expected to issue an executive order that would allow people and small businesses to join together and buy health insurance through what are known as association health plans.

Details haven’t been released yet, but some health-policy experts say these new health plans could further destabilize the ACA’s insurance markets if they aren’t subject to the health law’s regulations.

On Tuesday, Trump tweeted that “since Congress can’t get its act together on HealthCare I will be using the power of the pen to give great HealthCare to many people — FAST.”

Kaiser Health News reporter Rachel Bluth in Washington, D.C., contributed to this story.

Training New Doctors Right Where They’re Needed

KFF Health News, October 10, 2017

Dozens of teaching health centers created by the ACA aim to attract and keep new physicians.

This article first appeared October 09, 2017 on Kaiser Health News.

By Ana B. Ibarra / Photos by Heidi de Marco

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BAKERSFIELD, Calif. — Dr. Olga Meave didn’t mind the dry, 105-degree heat that scorched this Central Valley city on a recent afternoon.

The sweltering summer days remind her of home in Sonora, Mexico. So do the people of the Valley — especially the Latino first-generation immigrants present here in large numbers, toiling in the fields or piloting big rigs laden with fruits and vegetables.

Meave’s sense of familiarity with the region and its residents drew her to an ambitious program in Bakersfield whose goal is to train and retain doctors in medically underserved areas.

She is now in her third and final year of the Rio Bravo Family Medicine Residency Program, operated by Clinica Sierra Vista, a chain of more than 30 clinics, mostly in the Central Valley. Meave, 34, graduated from medical school in Mexico and has pursued additional education and training in the U.S.

She plans to practice in Bakersfield after she completes her residency next year.

“The goal is for [doctors in training] to come for three years and stay for 20,” said Carol Stewart, director of the program.

Rio Bravo is one of eight teaching health centers in California and 57 nationwide that were created by the Affordable Care Act in 2010 to serve areas with large unmet medical needs.

This academic year, there are 732 residents in teaching health centers across 24 states.

Unlike the Affordable Care Act itself, these teaching centers enjoy bipartisan support among federal lawmakers, who say such hubs will alleviate the primary care doctor shortage. But long-term funding is still in question. Last week, Congress agreed to temporarily finance the teaching health centers through the end of the year while debating whether to extend funding beyond that. President Donald Trump later signed the temporary extension.

A residency is a stage of graduate medical training that’s required after medical school and before doctors can set up their own practices. Most family practice residencies last three years.

Traditional residency programs are generally based at large, urban hospitals in areas where there are typically a sufficient number of doctors to go around.

The first teaching health centers began training residents in 2011. They operate primarily out of clinics in rural communities and other areas where primary care physicians are in short supply.

The ideal ratio of primary care physicians to patients is about 1 for every 2,000, Stewart said. The ratio in east Bakersfield “is more like 1 to 6,000, so we have a lot of catching up to do.”

Though teaching health centers remain relatively new, experts say they’re already succeeding: Their residents generally stay in the regions where they trained, putting down roots in communities with a big demand for health care.

In June, the Rio Bravo program graduated its first class of six doctors. Two joined the staff at a Clinica Sierra Vista clinic in east Bakersfield. The other four are practicing in clinics serving low-income communities in Sacramento, Riverside and Los Angeles counties.

Dr. Olga Meave is a third-year resident in the Rio Bravo Family Medicine Residency Program, operated by Clinica Sierra Vista in Bakersfield, Calif. The program operates primarily out of clinics in rural or underserved communities where primary care physicians are in desperately short supply. (Heidi de Marco/KHN)

Stewart estimates that the six recent graduates together saw nearly 10,000 patients during their three years of training.

“That’s a significant contribution,” she said.

Though not all teaching health centers have affiliations with medical schools,
the Rio Bravo program has an academic partnership with the UCLA medical school, which helps develop its curriculum, Stewart said. It also coordinates with a local hospital, Kern Medical, where residents complete rotations in different specialties related to family medicine.

A 2015 survey by the American Association of Teaching Health Centers found that 82 percent of their graduates stay in primary care and 55 percent remain in underserved communities. By contrast, about a quarter of graduates from traditional residency programs remain in primary care and work in underserved areas, according to the same survey.

Many graduates of teaching health centers have an incentive to stay in these areas because they may qualify for other programs that offer perks, such as help with paying off medical school loans.

The centers take their patient populations into consideration when selecting applicants. For instance, Rio Bravo aims to train culturally sensitive doctors, given the large local immigrant population, Stewart said.

It looks for applicants with ties to the Valley or who come from the cultures — and speak the languages — that are familiar to patients they will serve.

Meave doesn’t have a personal connection to the Valley, but she worked with low-income patients in Mexico. She has found that the population in the Valley, and its needs, aren’t much different from those in her home country.

At Clinica Sierra Vista, she sees patients who haven’t been to a doctor in decades. “They’ve never had a physical exam, never had their eyes checked. … They just deal with their aches and pains,” she said. “I think they feel happy that I can understand them and excited that someone from the same background is providing them care.”

Teaching health centers are financed by federal grants administered by the Health Resources & Services Administration, part of the U.S. Department of Health and Human Services. Congress determines the amount and duration of the funding. The current allocation, an extension of the two-year funding that expired Sept. 30, runs through the end of the year.

The Rio Bravo Family Medicine Residency Program is operated by Clinica Sierra Vista, a chain of more than 30 clinics mostly located in the Central Valley. (Heidi de Marco/KHN)

In July, U.S. Rep. Cathy McMorris Rodgers (R-Wash.) introduced legislation that would fund the program for an additional three years at about $157,000 a year per student — a total of $116.5 million annually.

The amount proposed would be a 65 percent increase from the current funding of $95,000 a year per resident.

Lawmakers are likely to begin debating the funding measure this week, and it is still subject to change.

“I’m glad we moved forward with a short-term extension of the … program, but we also must advance a long-term solution to provide certainty for our teaching health centers, their residents, and their patients,” McMorris Rodgers said in a prepared statement. “Without a sustainable funding level … the program will unravel.”

Should that happen, California’s teaching health centers could draw from a pot of money administered by the Office of Statewide Health Planning and Development to pay for the remainder of the current residents’ training.

Programs in other states may not have the same safety net.

“If [federal funding] went away, our residency program would have to close,” said Dr. Darrick Nelson, director of the teaching health center at Hidalgo Medical Services in Lordsburg, N.M.

Lordsburg, with a population of roughly 2,500, is a “small railroad town,” Nelson said, and like many rural towns desperately needs versatile primary care doctors.

“What you’re getting is three doctors for the price of one,” he said. “You get someone who can do pediatrics, someone who can do obstetrical care and someone who can do internal medicine.”

In California’s Central Valley, there is no medical school, and new doctors often avoid the area in favor of richer urban centers, where they can make more money.

Earlier this year, lawmakers earmarked $465 million from the state’s new tobacco tax to boost payments for some Medi-Cal providers, which could help make poor areas like the Central Valley more attractive to doctors.

At Clinica Sierra Vista’s location in east Bakersfield, where Meave’s residency is based, 75 percent of patients are covered by Medi-Cal — the state’s version of the federal Medicaid program for low-income residents — and 15 percent are uninsured, Stewart said. Asthma, diabetes and other chronic conditions are major health problems.

Veronica Ayon, a former farmworker, is one of Meave’s patients. Like her doctor, she is a native of Sonora.

Ayon, 48, was treated for cervical cancer in 2010 and last year underwent surgery to remove a malignant brain tumor. She feels comfortable with Meave because of their similar backgrounds and language, she said.

“She is very special to me,” Ayon said, speaking in Spanish inside her home in the town of Shafter, about 20 miles north of Bakersfield. “She explains things at a level I can understand.”

New Law Challenges 'Evils' Of Pharma Profits, California Governor Claims

KFF Health News, October 10, 2017

Drug companies will be required to give health insurers and state agencies advance notice if they plan to raise the price of certain drugs by 16 percent or more over two years.

This article first appeared October 09, 2017 on Kaiser Health News.

By April Dembosky, KQED

California Gov. Jerry Brown defied the drug industry Monday by signing a sweeping drug price transparency bill that will force drugmakers to publicly justify big price hikes.

“Californians have a right to know why their medical costs are out of control, especially when pharmaceutical profits are soaring,” Brown said. “This measure is a step at bringing transparency, truth, exposure to a very important part of our lives. That is the cost of prescription drugs.”

The new law will require drug companies to give 60 days’ notice to state agencies and health insurers anytime they plan to raise the price of a drug by 16 percent or more over two years on drugs with a wholesale cost of $40 or higher. They must also explain why the increases are necessary.

The advance notification provisions take effect Jan. 1, while the other reporting requirements don't kick in until 2019.

Brown said the bill is part of a larger effort to correct growing income inequality in the United States.

He called on top pharmaceutical leaders to consider doing business in a way that helps Americans who are spending large sums of money for lifesaving medications.

“The rich are getting richer. The powerful are getting more powerful,” he said. “We’ve got to point to the evils, and there’s a real evil when so many people are suffering so much from rising drug profits.”

The drug lobby fiercely opposed the bill, SB 17, spending $16.8 million on lobbying from January 2015 through the first half of this year to kill an array of drug legislation in California, according to data from the secretary of state’s office. For the pricing bill alone, the industry hired 45 lobbyists or firms to fight it.

The bill drew support from a diverse coalition, including labor and consumer groups, the hospital industry and even health insurers, who agreed to share some of their own data. Under the new law, they will have to report what percentage of premium increases is related to drug prices.

“Health coverage premiums directly reflect the cost of providing medical care, and prescription drug prices have become one of the main factors driving up these costs,” said Charles Bacchi, CEO of the California Association of Health Plans. “SB 17 will help us understand why, so we can prepare for and address the unrelenting price increases.”

Drug companies criticized the governor’s move, saying the new law focuses too narrowly on one part of the drug distribution chain — and ultimately won’t help consumers afford their medicine.

“There is no evidence that SB 17 will lower drug costs for patients because it does not shed light on the large rebates and discounts insurance companies and pharmacy benefit managers are receiving that are not always being passed on to patients,” said Priscilla VanderVeer, spokeswoman for the Pharmaceutical Research and Manufacturers of America.

Indeed, some experts have said transparency alone is not enough to bring down drug prices, and that California’s law may lack the muscle being applied in other states to directly hold drug prices down.

This year, at least two states have passed laws that may have a more immediate effect on consumer costs than the California measure. Maryland and New York, for example, adopted bills that use a variety of legal levers to impose financial penalties or require discounts if prices are too high.

But other policy experts argue that California’s law is part of a broader campaign to adopt stronger drug price measures across the country. So it makes sense to start with the source of the drug prices: the drugmakers themselves, said Gerard Anderson, a health policy professor at Johns Hopkins Bloomberg School of Public Health who tracks drug legislation in the states.

“The manufacturers get most of the money — probably about three-quarters or more of the money that you pay for a drug, and they’re the ones that set the price initially,” he said. “So they are not the only piece of the drug supply chain, but they are the key piece to this.”

California Healthline Sacramento correspondent Pauline Bartolone contributed to this report.

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

Drug Prices Legislation

CA Governor Ponders Inking Drug Price Transparency Bill

KFF Health News, October 6, 2017

The bill would require drug companies to give 60 days’ notice to state agencies and health insurers anytime they plan to raise the price of a drug by 16 percent or more over two years.

This article first appeared October 06, 2017 on Kaiser Health News.

By April Dembosky, KQED

Insurers, hospitals and health advocates are waiting for Gov. Jerry Brown to deal the drug lobby a rare defeat, by signing legislation that would force pharmaceutical companies to justify big price hikes on drugs in California.

"If it gets signed by this governor, it's going to send shock waves throughout the country," said state Sen. Ed Hernandez, a Democrat from West Covina, the bill's author and an optometrist. "A lot of other states have the same concerns we have, and you're going to see other states try to emulate what we did."

The bill would require drug companies to give California 60 days' notice to state agencies and health insurers anytime they plan to raise the price of a drug by 16 percent or more over two years. They would also have to explain why the increases are necessary. In addition, health insurers would have to report what percentage of premium increases are caused by drug spending.

Drugmakers spent $16.8 million on lobbying from January 2015 through the first half of this year to kill an array of drug legislation in California, according to data from the secretary of state's office. For the pricing bill alone, the industry has hired 45 lobbyists or firms to fight it. Against the backdrop of this opposition campaign, Brown must decide by Oct. 15 whether to sign or veto the bill.

"When they have to justify in California, de facto, they have to justify it to the other 49 states," said Gerard Anderson, a health policy professor at Johns Hopkins Bloomberg School of Public Health in Baltimore. "Other states essentially get to piggyback on the good efforts of California, and hopefully, because they might have difficulty justifying the price increases, everybody's prices around the country will be lower."

Other states, including Maryland, Vermont, Nevada and New York, have passed similar laws aimed at bringing more transparency to prices and curbing price gouging. But the pharmaceutical industry has fought the hardest in California. If drug companies don't like the disclosure laws in smaller states, they could decide not to sell their drugs there, Anderson said, but the market in California is just too big to ignore.

"States like Maryland are just not as powerful," he said. "It just doesn't have the clout that a state like California has."

(Story continues on the next page.)

This is the second go-round for such a drug price bill. Last summer, similar legislation crashed and burned. Its intended regulations were gutted so extensively that Hernandez decided to pull it. But, he said, two key things happened after that, setting the stage for a successful second attempt.

First, in August 2016, less than a week after Hernandez pulled the bill, controversy erupted nationally over the price of EpiPens, which spiked nearly 500 percent. The increase sparked outrage from parents who carry the auto-injectors to save their children from life-threatening allergic reactions.

Momentum grew among federal lawmakers last September. They called for hearings. Several bills were proposed across the country aimed to rein in drug prices.

Then came the election of November 2016. After Donald Trump became president and Republicans took control of Congress, the No. 1 health policy priority became repealing and replacing the Affordable Care Act, President Barack Obama’s signature legislation.

As federal lawmakers focused on dismantling the ACA, Hernandez said he saw another opportunity for state lawmakers to act on drug prices. He reintroduced his bill in early 2017, and this time political support grew quickly — beyond the usual suspects.

"It wasn't just labor," he recalls. "It was consumer groups, it was health plans. It was the Chambers of Commerce, it was the hospital association."

The Pharmaceutical Research and Manufacturers of America, or PhRMA, a drug industry's trade group, argued that the bill known as SB 17 was full of "false promises" that wouldn't help consumers pay for their medicines and would instead stifle innovation with cumbersome regulatory compliance.

"That takes up a lot of resources and will take up a lot of time," said Priscilla VanderVeer, deputy vice president of public affairs for PhRMA. "And that could mean pulling resources from research and development and having to put it into the reporting structure."

Some experts say that price transparency alone is not sufficient to bring down costs and that other changes are needed.

Hernandez is optimistic the governor will sign SB 17 into law. But he knows nothing's certain. That's because of what happened on Sept. 11, the day the bill came up for a key vote in the state Assembly — the same place it went down the year before. Hernandez thought he'd secured all the votes he needed, but at the last minute the votes started slipping away.

The bill needed 41 votes to pass the Assembly. During the roll call, the tally stalled around 35. Hernandez said he had plenty of colleagues willing to cast the 42nd vote, but with drug lobbyists swarming the Capitol, no legislators wanted to be the one to cast the deciding vote.

"If the bill fails and you're stuck out there, then you're the person that's attacking the industry," Hernandez said.

Still, the bill crossed the 41-vote threshold and the remaining lawmakers joined in. In the end, the bill passed with 66 votes. All the Democrats and half of the Republicans in the state Assembly voted for it.

This was much to the dismay of drug companies, which lobbied hard and issued a blitz of advertising in the last weeks before the vote.

Experts said the drug industry doesn't want a large influential state like California forcing them to share their data.

Drugmakers are likely already devising ways to work around the California bill, warned Anderson, the Johns Hopkins professor. They've filed lawsuits to try to slow or stop laws from being implemented in other states, or to weaken the rules if and when they go into effect. Policy experts are watching to see what kinds of legal challenges the California law might be vulnerable to, and if it can withstand them.

"We learn from the mistakes of other states," Anderson said. "Legislation is an iterative process. We have 50 states and hopefully, by some time, we'll get it right. We're looking for California to take the lead on this."

Las Vegas Faced a Massacre. Did It Have Enough Trauma Centers?

KFF Health News, October 5, 2017

Despite the expanding population of Clark County, which more than doubled to 2.2 million in the past 25 years, University Medical Center has been Las Vegas’ only Level I trauma center since 1992.

This article first appeared October 04, 2017 on Kaiser Health News.

By Julie Appleby and Phil Galewitz

Las Vegas is not only a glittering strip of casinos and hotels but a fast-growing region with more than 2 million residents — and one hospital designated as a highest-level trauma center.

The deadly shooting Sunday that killed at least 59 and sent more than 500 people to area hospitals raised questions about whether that’s enough.

Las Vegas is not the only big city with just one such trauma center. Seattle and Nashville, among others, also are in this category, according to the American Trauma Society, a professional and advocacy organization focused on improving trauma care.

Casey Nolan, a hospital consultant and managing director of Navigant Consulting in Washington, D.C., said what matters most is not the number of high-level centers, but the degrees of coordination across the area’s medical network, including the first responders.

“It’s how well integrated the care is and whether there is a triage system to get patients to the right place in the right time,” he said.

What Makes Up The Network

The highest-level trauma centers are equipped and staffed around-the-clock to provide care for patients who suffer from traumatic injuries such as gunshot wounds, falls and car accidents.

The designation “trauma center” is the result of a validation process at the state or local level. Centers are categorized by Level I, II or III, for instance, in keeping with nationally accepted standards. Centers can also seek additional approval from the American College of Surgeons.

Across the country, there are 217 Level I trauma centers, up from 198 in 2012, according to the trauma society. These centers must see at least 1,200 trauma patients a year and have general surgeons and other specialists immediately available at the facility.

There are another 310 Level II centers that face similar staffing rules, but with fewer education and training requirements. Level III centers have emergency medical staff, but will stabilize severely injured patients and often transport them to higher-level trauma centers.

For decades, the hospital industry viewed trauma care as a money-losing proposition because of the high costs of keeping doctors and nurses on standby 24 hours a day. Trauma centers, particularly those in inner cities, tended to attract more patients without health insurance.

But in recent years, hospitals have been competing to get the designation as a way to increase profits, in part because trauma centers enhance demand for surgery and ancillary services like CT scans. In addition, a trauma designation can boost a facility’s overall reputation, Nolan added.

“Trauma had gotten a bad rap,” explained Nolan. “But in suburban locations, where more people have insurance, you can do pretty well on trauma.”

Some hospitals also began charging a fee — known as a “trauma activation” fee — to help pay for the extra staffing and equipment trauma units require.

Those fees could range from a few hundred dollars to several thousand dollars on patients’ bills, Nolan said.

Trauma Care In Las Vegas

Despite the burgeoning population of Las Vegas and surrounding Clark County, which more than doubled to 2.2 million in the past 25 years, University Medical Center has been Las Vegas’ only Level I trauma center since 1992.

The metro area includes two other lower-level trauma centers. Sunrise Hospital & Medical Center in Las Vegas is a Level II facility and St. Rose Dominican Hospital in nearby Henderson, Nev., is a Level III.

Even the idea of expanding Las Vegas’ trauma network has stirred controversy.

Last year, a state agency rejected applications by three hospitals in the Las Vegas area to be designated as Level III trauma centers.

HCA, the national, for-profit chain that owned two of these facilities, said adding trauma centers would help ensure quicker care to patients in the growing region. The company has made adding trauma centers a strategy across the country and has met resistance from existing centers.

But opponents argued HCA was motivated by the opportunity to boost profits. The Tampa Bay Times reported last year that the hospital chain charged significantly higher “activation fees” than other hospitals.

Opponents also countered that adding trauma centers would affect University Medical Center’s ability to provide quality care and train doctors. Some experts say it could diminish the number of patients seen at each center.

That’s because the more trauma patients a center deals with annually, the better the results, studies show.

“If you can bring all the patients to one place, then those surgeons become really good at dealing with trauma, instead of spreading it out [around a number of facilities],” said Bill Bullard, senior vice president with the Abaris Group, a California-based consulting firm that advises hospitals on emergency care.

Ian Weston, executive director of the American Trauma Society, said the trauma system worked well in Las Vegas, which is a credit to ambulances and other first responders and their ability to triage patients to hospitals across the city.

Seriously ill patients have the best outcomes when treated at a Level I trauma center, said David Callaway, a professor of emergency medicine at the Carolinas Medical Center in Charlotte, N.C. But “when you have 500-plus casualties and 58 dead … if all the patients went to a Level I, mortality would not be improved, because they would be completely overwhelmed,” Callaway added.

Bullard agreed.

“In theory, the more centers you have the more people you have to deal with injuries. However, no trauma system is able to handle a tragedy of this magnitude.”

Flat-Fee Primary Care Helps Fill Niche For Texas' Uninsured

KFF Health News, October 3, 2017

Proponents of direct primary care say it can provide a safety net for those with limited treatment options and is particularly helpful in states that have not expanded Medicaid access.

Darrell Kenyon (right), an uninsured carpenter, pays a monthly fee to receive basic office-based medical care from Dr. Loy Graham under a practice model called direct primary care. (Charlotte Huff for KHN)

This article first appeared October 03, 2017 on Kaiser Health News.

By Charlotte Huff

JARRELL, Texas — Darrell Kenyon had been punting for years on various medical issues — fatigue, headaches, mood swings. The 43-year-old uninsured carpenter was particularly worried about his blood pressure, which ran high when he checked it at the grocery store. Then he heard about a different type of physician practice, one that provided regular primary care for a monthly fee.

“Insurance for the self-employed is through the roof,” Kenyon told Dr. Loy Graham, as she examined him one morning in August. Two years ago, Graham had hung out her shingle in this central Texas town of nearly 1,400, about 40 miles north of Austin.

Under the practice model, called direct primary care, patients are charged monthly — typically $20 to $75, depending on age, in Graham’s practice — for basic, office-based medical care and frequently cell phone and other after-hours physician access. Proponents of the model, which is also supported as a practice option by the American Academy of Family Physicians, say it can provide a safety net for those with limited treatment options, including the uninsured and people in the country illegally. The alternative is particularly helpful in states like Texas that haven’t expanded Medicaid access, the advocates add.

But there’s a sizable catch: Direct primary care is not insurance.

Carolyn Engelhard worries that strapped individuals will decide the easier access to primary care is “good enough” and won’t investigate insurance options. “It can be a false security,” said Engelhard, who directs the health policy program at the University of Virginia School of Medicine in Charlottesville. “There’s sort of the illusion that it’s kind of like insurance.”

Lower-income Texans would be better off with coverage on the Affordable Care Act’s insurance exchange, where they could get a subsidy to reduce the cost of their premiums, Engelhard said. The policy would have a deductible, “which they might feel that they can’t afford,” she said. “But they would be protected if they got cancer or if they had an automobile accident.”

Graham estimates that at least three-quarters of her roughly 450 patients lack insurance, even though she advises them to carry some kind of catastrophic coverage for major health expenses. But the cost for such policies can be daunting. Like Kenyon, some of Graham’s patients are self-employed with fluctuating incomes or work for businesses that don’t offer coverage. Even if their employer offers affordable coverage for the employee, premiums for dependents might make coverage financially out of reach. Roughly 1 in 5 of her patients speak primarily Spanish. Some are undocumented, working in construction and other labor-intensive jobs in the region.

Despite her concerns, Engelhard said, such flat-fee practices might offer “one of the few viable options” for those living here under the radar, given they’re not eligible for ACA-related coverage. “So they are completely dependent on paying out-of-pocket for medical care,” she said.

‘Better Than Nothing’?

Nationally, direct primary care is relatively new and very much a niche option. Nearly 3 percent of family physicians practice it, according to a 2017 survey by the American Academy of Family Physicians. Some critics have questioned whether the model’s growth is already stalling, after one of its earliest providers, Seattle-based Qliance, closed its clinics this year.

Graham, who practiced traditional medicine in Central Texas for decades, said she was drawn to the option after growing weary of packing too many patients into each day. She was considering leaving medicine and had started developing a lavender farm as an alternative source of income when she heard about direct primary care.

In 2015, she opened her practice in a small strip mall in Jarrell, figuring that nearby residents — with limited access to primary care — might take a chance on the different style of medicine.

Dr. John Bender, an academy board member who is part of a larger practice that’s transitioning to direct primary care, said that the low monthly fees are attracting patients who view insurance as out of reach. “I think something [in terms of medical care] is better than nothing,” said the Fort Collins, Colo., family physician, who estimates that roughly half of the practice’s 800-plus direct primary care patients are uninsured.

“I can spare them quite a few urgent care and emergency room bills,” Bender said, noting that his office handles anything from strep throat to stitches for minor gashes. Moreover, the cost is within reach of people on tight budgets, he said. “In fact, a carton of cigarettes runs $49, which just happens to be the price of my monthly subscription fee [for adults].”

In Texas, 16.6 percent of the state’s residents were uninsured as of 2016, the highest rate nationally, according to the most recent Census Bureau data. The Lone Star State didn’t expand Medicaid access and has one of the nation’s lowest income-eligibility cutoffs. A single mother with two children can’t earn more than $3,781 annually to qualify for coverage herself, according to a 2017 Medicaid report by the Center for Public Policy Priorities, an Austin-based nonprofit research and advocacy organization.

Dr. Felicia Macik, who launched her direct care practice in 2014 in Waco, estimates that 10 to 15 percent of her patients are uninsured, including some who drop coverage because they can’t afford the premiums. “I’m frightened for them,” she said. “It could decimate a family if something happened and they didn’t have any coverage.”

But Macik pointed out that getting regular primary care, rather than avoiding the doctor entirely due to lack of insurance, might avert costlier complications like an asthma attack or a diabetic crisis.

Uninsured individuals who sign up for these practices are rolling the dice, said Dr. Mohan Nadkarni, an internist who co-founded the Charlottesville (Va.) Free Clinic, which treats lower-income individuals. “For routine regular care, it may work out,” he said. “But it’s gambling that you’re not going to get sicker and need further care.”

Two years ago, Dr. Loy Graham opened a flat-fee primary care practice in Jarrell, Texas. She estimates that at least 3 in 4 of her patients lack health insurance. (Charlotte Huff for KHN)

For instance, a patient can develop severe heartburn and require further tests and referrals to specialists to look for the underlying cause — potentially anything from an ulcer to esophageal cancer — that could quickly run up a hefty bill, Nadkarni said. Another patient with chest pain might need a similarly costly work-up to rule out heart problems, including a potentially life-threatening blockage, he said.

Graham said that her monthly fees cover anything that she can handle in the office. During Kenyon’s visit, she froze a small growth off one ear. Shortly afterward, she gave a steroid injection to an older woman with a painful, swollen wrist.

She has negotiated low fees with a local laboratory; the battery of blood tests and urinalysis she ordered for Kenyon cost him just under $40. “This is concierge medicine for normal people,” said the 61-year-old family physician.

Physician enthusiasts maintain that jettisoning the paperwork and other overhead costs associated with insurance enables them to take on fewer patients — roughly 600 to 800 for direct care practices compared with 2,000 to 2,500 typically, according to the family physicians academy — and thus spend more time with each one.

As A Safety Net, It’s A Stretch

Erika Miller first came to see Graham two years ago for severe headaches. The 30-year-old mother of three, who is working on her college degree and has a full-time job, doesn’t have insurance.

Graham diagnosed high blood pressure. Getting that under control helped alleviate her headaches, Miller said. She also has shed 50 pounds under Graham’s guidance.

But Graham can’t handle everything for her patients. Last year, Miller went to the emergency room at Scott & White Medical Center in nearby Temple with severe abdominal pain. It was her appendix, which had to be removed. The safety-net hospital started Miller on a payment plan based on her income, totaling roughly $500.

“If the question is: `Is [direct primary care] better than nothing?’ Then I would say, ‘Yes,’” Engelhard said. But along with leaving uninsured patients financially vulnerable to a medical curveball, she said, these smaller practices — by seeing fewer patients per doctor — risk aggravating the nation’s primary care shortage if they become more common.

Graham countered that she nearly left medicine, but these days — as she continues to build her practice — she’s reaching some patients who had previously fallen through the health system’s cracks. On that summer morning, Kenyon left Graham’s office with a prescription for a blood pressure medication and an appointment to return in several weeks to discuss his lab results.

Kenyon and his wife, Denise, later described how they had signed up last year for a family policy through the Affordable Care Act. But the monthly premium was $750 and the deductibles were $3,500 per person, Denise Kenyon said.

She called around and couldn’t find a family doctor who would take the coverage. After several months, they stopped paying the premiums, figuring that the money they saved would pay for a lot of medical care.

Both are now patients of Graham’s; their combined monthly bill totals $125, which they can budget for, Darrell Kenyon said. “I do have good months and bad months, as far as pay is concerned,” he said. “If I have a bad month, it’s still affordable.”

Latest Scandal Too Much For HHS Secretary Tom Price. He's Out.

KFF Health News, October 2, 2017

Health and Human Services Secretary Tom Price resigned Friday. The White House said President Donald Trump intends to designate Don Wright of Virginia to serve as acting secretary, effective at midnight Friday.

This article first appeared September 29, 2017 on Kaiser Health News.

By Julie Rovner

Health and Human Services Secretary Tom Price resigned Friday, amid controversy over his use of private jets for official and personal business. He promised a day earlier to pay back some of the $400,000 spent on those flights, but the offer came too late for the Trump White House.

In a statement released Friday afternoon, the White House said President Donald Trump intends to designate Don Wright of Virginia to serve as acting secretary, effective at midnight Friday. Wright serves as the deputy assistant secretary for health at HHS and he directs the Office of Disease Prevention and Health Promotion.

Price's four-paragraph resignation letter stated, in part: "I have spent forty years both as a doctor and public servant putting people first. I regret that the recent events have created a distraction from these important objectives."

Read Price's Resignation Letter To President Trump

Price, an orthopedic surgeon and former House Budget Committee chairman, was surrounded by controversy since his nomination to the nation’s top health post in January. He made questionable stock trades in health care companies while a member of the tax-writing House Ways and Means Committee and interceded on behalf of donors with federal agencies. Democrats in the Senate fought his confirmation, charging that he was too ethically challenged to serve as HHS secretary.

This summer, Price was increasingly viewed by President Donald Trump as ineffective in helping to push a GOP plan to “repeal and replace” the Affordable Care Act through Congress.

Price had been under pressure since Sept. 19, when Politico broke the news that he had taken numerous official trips via private jet, costing tens of thousands of dollars more than commercial flights.

One of those trips involved a charter flight to Philadelphia, which can be reached by car from Washington in just over two hours. Subsequent reporting by Politico revealed that Price’s more than two dozen private plane trips cost in excess of $400,000, and that some of the trips included personal as well as official business.

He also traveled with his wife to such international destinations as Africa, Europe and Asia on military flights at a cost to taxpayers of more than $500,000 — bringing the total expense to taxpayers since May to more than a million dollars, according to Politico.

Price said last weekend he would stop using private planes pending an investigation by the HHS Inspector General, but he and his staff have repeatedly defended the trips as necessary to get him to events in a timely manner.

Pressed by reporters Wednesday about the spreading scandal, Trump said he was “not happy” about the private plane travel “and I let him know it.” Asked if he would fire Price, Trump responded, “We’ll see.”

On Thursday, Price released a statement saying he would “take no more private charter flights as Secretary of HHS. No exceptions.” Price, whose net worth has been estimated at $13.6 million, also said he would “write a personal check to the US Treasury for the expenses of my travel on private charter planes.” He added that taxpayers would not “pay a dime for my seat on those planes.”

His offer for the domestic flights — about $52,000 — was a fraction of what taxpayers paid for his entourage.

House Speaker Paul Ryan (R-Wis.) said Price was “a leader in the House and a superb health secretary. His vision and hard work were vital to the House’s success passing our health care legislation.”

Democrats had a different view.

In a statement, Sen. Ron Wyden (D-Ore.), the ranking member of the Senate Finance Committee, said Price has “repeatedly abused the public trust and betrayed the agency’s mission to improve Americans’ health care.” Wyden said he hopes this will mark “the beginning of a new chapter” for the Trump administration’s health care agenda and that Price’s replacement will “be focused on implementing the law as written by Congress.”

The new HHS secretary should keep “the president’s promise to bring down the high cost of prescription drugs,” Wyden said.

Wright, Price's interim replacement, has worked for the federal government since at least 2003. A physician, he served in high-level positions at HHS under the George W. Bush, Obama and Trump administrations, according to his LinkedIn profile. At HHS, Wright oversaw many public health duties including development of the national dietary guidelines for Americans and the department’s health literacy agenda. He has also spearheaded efforts to reduce adverse drug interactions.

Wright represented the United States at the World Health Organization’s executive board and served on the National Cancer Institute Advisory Board.

According to the profile, he held management positions in the Office of the Surgeon General, National Vaccine Program Office, Office of HIV/AIDS Programs, Office of Minority Health, Office of Population Affairs, Office of Women’s Health and President’s Council on Physical Fitness and Sports.

From 2003 to 2007, Wright was director of the Occupational Medicine at the Office of Safety and Health Administration.

Wright has a bachelor’s degree in zoology from Texas Tech University and holds a medical degree from the University of Texas-Galveston. He completed a residency in family medicine at Baylor University in Dallas and practiced for 17 years in Texas as a doctor. He also holds a master's in public health from the Medical College of Wisconsin in Milwaukee, according to his LinkedIn profile.

Leah Binder, president of the Leapfrog Group, a patient advocacy organization, said she was hopeful about Wright's new role.

"I am cautiously optimistic the appointment of Don Wright signals a resurgence of federal leadership on patient safety," she said in an email. "Don Wright led development of the influential National Action Plan on Healthcare Acquired Infections in 2013. ... His work galvanized infection prevention and led to significant improvements ... that saved many lives. He has also been influential in the movement to measure the problem and tie Medicare payments to hospital safety."

KHN correspondents Phil Galewitz and Mary Agnes Carey contributed to this report.

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