Children With Disabilities Face Special Back-to-School Challenges

KFF Health News, October 19, 2021

The return to school raises particular health issues for children with disabilities who are at increased risk for serious bouts of COVID-19.

This article was published on Tuesday, October 19, 2021 in Kaiser Health News.

By Heidi de Marco   

LOS ANGELES — Christopher Manzo, a boy with curly brown hair and bright-blue-and-yellow glasses, has lived a third of his five years at home because of the pandemic.

And he is more than ready for kindergarten.

Hand in hand with his mother, Martha Manzo, he walks into the Blind Children's Center, a low-rise building nestled among apartment complexes in East Hollywood. In the brightly colored hallway, filled with paintings of animals, Manzo kneels to hug Christopher before he scurries unsteadily to his cubby.

"God take care of you and be with you," she says. "And have fun."

Born with congenital hydrocephalus that damaged his brain and left him with severely impaired vision, cognitive difficulties and a lack of coordination, Christopher hasn't missed only school the past 18 months — he's missed out on a host of vital occupational, physical and language therapies, as well as socialization with other kids.

At home, Christopher couldn't look at a computer screen long enough to attend therapies or classes on Zoom, said Manzano, in an interview conducted in Spanish. "He would strain his eyes, look away, and his attention would falter," she said. "He couldn't devote the same attention as a kid without disabilities.''

Christopher "could have advanced much more" since the pandemic hit if he hadn't missed so much school, said Manzano, who is 36 and has three other children, ages 12, 10 and 8, whom she also has had to guide through months of home-schooling.

Yet the return to school raises particular health issues for Christopher and other children with disabilities who are at increased risk for serious bouts of COVID-19, said his pediatrician at Children's Hospital Los Angeles, Dr. Liza Mackintosh. Though he isn't immunosuppressed, Christopher has trouble coughing up secretions, which leaves him vulnerable to lung and respiratory infections, she said.

Compared with other adults in contact with children, his parents, teachers and therapists "have to be more vigilant about mask-wearing, hand hygiene and social distancing," she said.

In short, Manzo was deeply worried about the threat of COVID exposure Christopher faced at school. But it was a risk she felt he could no longer avoid, to get on with his life.

Trying to learn from home was "really hard on him," Manzo said. "He couldn't understand why he couldn't go to school or the park or to his therapies."

"I know COVID is still among us, but I also can't keep him at home like he's a crystal bubble and protect him," she said. "He needs contact with other kids and his teachers."

The challenges faced by Christopher during the pandemic have been shared by many of the roughly 7 million U.S. children and young adults, ages 3 to 21, with special needs. Online platforms usually don't work for them. For example, Christopher needs to feel Braille letters to read — he can't do that on a computer screen.

Students with disabilities had "sort of this double hit where it was very hard to access school services and very challenging to continue to work on developing new skills," said Dr. Irene Koolwijk, a specialist in developmental-behavioral pediatrics at UCLA Health.

It took a lot of preparation to get Christopher and the 40 or so other children attending the Blind Children's Center back into the building of the private, infant-to-kindergarten school. All the children are blind or visually impaired, and most also have disorders ranging from autism and albinism to cerebral palsy and epilepsy. The school practices reverse mainstreaming, in which a few children with typical development share the classroom with children with disabilities.

Months before the school doors reopened, the center started teaching the students about wearing masks.

"Little by little, we started training the kids to wear masks on Zoom. It started off with the duration of a song, then two songs," said Rosalinda Mendiola, adaptive services specialist at the Blind Children's Center. "Our goal was that by the time we opened back up, they would be used to them."

But it was difficult. Many children with special needs have a hard time wearing their masks and understanding the concept of distancing, said Mackintosh. Children with some forms of autism, in particular, have sensory issues that make it bothersome to have something on their faces.

"Children learn the most from modeling. They watch their parents, their teachers, their friends," said Bianca Ciebrant, the center's director of early childhood education. "But children who are visually impaired and blind can't see the mask-wearing. That's probably one of the harder barriers."

It took Christopher seven months to start wearing a mask. "At first, he didn't even want it in front of his face," said Manzo. "He started to slowly accept it when he saw his siblings wear it."

To reopen in September, the school also adopted new COVID safety protocols. All 30 staff members are vaccinated, temperature checks are performed at drop-off, and parents aren't allowed inside classrooms.

All students wear masks except for three of them who have limited motor ability and couldn't safely remove a mask or don't understand the mask-wearing process "and therefore it becomes sensory overload and behavior breakdown," Ciebrant said.

There are six kids in each class, overseen by a teacher and two assistants. Christopher needs someone near him to remind him where to walk and to hold on to the banister for balance.

With so many staffers around, "creating a shield of vaccinated individuals around the child is important to making the transition back to school as safe as possible," said Dr. Christine Bottrell Mirzaian, a pediatrician at Children's Hospital Los Angeles.

Martha and her husband, Fausto Manzo, were vaccinated last March, and their 12-year-old daughter, Samantha, also has been immunized against COVID.

"Our health is important to be able to continue taking care of him," Martha Manzo said.

On a recent Wednesday, Christopher wore a teddy bear mask and a Ryan's World backpack to school. This is his last year at the center. When he started, he was only 2 and hadn't learned to walk.

"He has received a lot of help," Manzo said. "His movements have improved, and his communication skills."

Christopher toddles around the playground during recess and greets his friends with a wave. "His balance is off, but he's walking now," his mother said. "I always wanted to see him run and explore."

School staff members were happy to have their students back.

"We all felt this little warmth in our heart to hear their voices back in the hallway, whether it was crying or laughing or talking to their friends," said Ciebrant. "This is what we've been waiting for, to hear those moments."

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Healthcare Foundation.

Heidi de Marco: heidid@kff.org, @Heidi_deMarco

What Will It Take to Boost Vaccinations? The Scene From Kentucky's Back Roads

KFF Health News, October 18, 2021

Kentucky is in the midst of a COVID-19 wildfire sparing no part of the state; new case counts topped 4,000 a day for much of September, before easing somewhat this month.

This article was published on Monday, October 18, 2021 in Kaiser Health News.

By Sarah Varney   

SMILAX, Ky. — In the end it was the delta variant that drove Rose Mitchell, 89, down the winding mountain road to the Full Gospel Church of Jesus Christ to get the shot. Her pastor, Billy Joe Lewis, had told his congregation that, No, ma'am, a COVID vaccine would not leave the "mark of the beast" nor rewrite their genetic codes.

Mitchell, who has known the deaths of eight of her 13 children over the years, was done taking chances with the virus stealing up the hollers along Cutshin Creek.

"That stuff's getting so bad, I was afraid to not take it," she said, sitting in her daughter's car in the church parking lot. "I said, 'Well, if all the rest of them are going to take it, I'll take it too.'"

Kentucky is in the midst of a COVID-19 wildfire sparing no part of the state; new case counts topped 4,000 a day for much of September, before easing somewhat this month. Hospital intensive care units are still at capacity in some regions, with COVID patients occupying half the beds. Gov. Andy Beshear has called the situation "dire."

Across the nation, older people have been steadfast takers of the COVID vaccines: About 95% of people 65 and older have received at least one shot. But geographic variations cloud that math. Older Kentuckians in rural hamlets far from Louisville and Lexington are trailing in vaccination, with rates as low as 55% in Wayne County, on the Tennessee state line.Bottom of Form

While seniors are still more likely to be vaccinated than younger adults in Kentucky, the simple truth of the pandemic is that older people who forgo the shots face a far greater chance of severe sickness and death. People 60 and older account for nearly 90% of the 9,184 COVID-related deaths in Kentucky. Residents 80 and older account for 41% of deaths.

In Leslie County, in the foothills of the rugged Pine Mountain ridge that anchors the state's eastern coalfields, gravel roads wind through thick forests blanketed with kudzu vines. House by house, church by church, public health workers are trying to outsmart the fantastical tales about the COVID vaccines spread on Facebook and overcome the everyday hurdles of financial hardship and isolation.

"Some of our older people don't have access to vehicles because their family works," said Maxine Shepherd, a regional health coordinator for Leslie County and four-decade-long member of Full Gospel Church. Even for those with a car, gas is expensive, she said, and trips from secluded hollers to town are rationed out carefully.

While Kentuckians watched the devastating early months of the pandemic from afar, COVID has long since made its arrival — and it hasn't spared the church on Cutshin Creek. In recent weeks, Pastor Lewis held a funeral service for a 53-year-old unvaccinated former coal miner, suspended Sunday services after more members fell ill, and with heavy heart canceled Homecoming, a cherished yearly gathering of area churches that marks the fall foliage with a celebration of the gospel and shared faith.

Local health agencies have been eager to enroll churches in the all-hands-on-deck vaccination effort; older residents are more likely to attend religious services, and in communities like Smilax, ministers are trusted advisers.

Some church leaders have refrained, afraid of offending congregants in a state where distrust of government intrusion runs deep. But not Lewis, who helped build Full Gospel Church on a rare flat parcel of land in 1972 and has led it ever since. With a smooth pelt of silver hair and a luminous smile, Lewis spends long stretches of the day in prayer, and he says God told him to protect his flock.

When "Sister Maxine" from the regional health department suggested a drop-in vaccine clinic in the church parking lot, Lewis was all in favor. He promoted it from the pulpit and on the church's must-read Facebook page.

Some church leaders in Kentucky have refrained from promoting COVID vaccination, afraid of offending congregants. But Pastor Billy Joe Lewis, leader of the Full Gospel Church of Jesus Christ in Smilax, says God told him to protect his flock. He promoted vaccination from the pulpit and on the church's lively Facebook page.

"We've still got to use common sense," he said. "Anything that can ward off suffering and death, I think, is a wonderful thing."

Vexed by the slow uptake in vaccinations by some Americans, President Joe Biden has mandated shots for healthcare workers in facilities such as hospitals and nursing homes, as well as for federal workers and employees of large companies. While the exact timing and details of the private-sector mandates are still being hammered out, the specter of coercion outrages many Kentuckians, particularly in Appalachia, where government directives have been met with derision.

"We do not like to be shoved," said David McKenzie, who grew up in Louisa, a once-booming coal town on the West Virginia border, and now owns the local nursing home. "We resent it, and we shove back."

Opposition to the vaccines in Lawrence County, where the vaccination rate is 39%, is not overtly political so much as willful. "They're fearful of 'the Man,'" McKenzie said. "The Man could be your employer, it could be the government, it could be a newspaper reporter." People who boasted about refusing the vaccines cannot change their minds, or "they'll look like they're weak, or they caved to the Man."

In nearby Salyersville, the virulence of the delta variant has shaken some holdouts. Santana Salyers, 22, braved torrential rain to get her shot at the county health department, a one-story building on a stretch of freshly paved road. In her third trimester of pregnancy, she feared the hospital would not let her hold her newborn if she wasn't vaccinated. Salyers works at the IGA grocery store and says to vax or not to vax comes up there almost every day. "I'm a fence-straddler," she said. But around town, "you're either against it or for it."

Turnout for the Salyersville health fair was muted by the remnants of a tropical storm, but a few dozen people still showed up to get their shots. In the waiting room, vaccine takers received $25 Walmart cards and a chance to win a Fitbit or Instant Pot. The prizes were a big draw.

James Shepherd, who is both the town's mayor and director of the Magoffin County Health Department, bemoans the county's 44% vaccination rate: "In a small community like this, they make up their mind 'yes' or 'no,' and that's it." What will it take to boost vaccinations? "A miracle," he said with an exasperated laugh.

Shepherd's close friend Carter Conley, the beloved captain of the county rescue squad, died last month of COVID, despite being vaccinated. Conley's death has been deeply felt around town, but also has given fuel to those who see vaccination as pointless.

Doubts about the vaccines' effectiveness extend to nursing homes in Kentucky despite the persistent correlations between nursing home outbreaks and low vaccination rates among staff.

On a mid-September weekday in Danville, a small city southwest of Lexington, residents at the Landmark of Danville Rehabilitation and Nursing Center sat on a quaint covered porch playing a game of 20 questions with the activities staff. Although 80% of the residents in the facility were fully vaccinated as of September, according to the Centers for Medicare & Medicaid, that was true for just 28% of healthcare personnel, who dash out and back at lunchtime ferrying takeout fast food.

A short drive away, the city's other nursing home, the Danville Centre for Health and Rehabilitation, also had a staff vaccination rate of 28% in September, according to federal records. (A month later, staff vaccination rates at both facilities are still below 60%.)

The unprotected workforce does not faze one man who is moving his elderly father into Landmark. The man, who works as a registered nurse at the local hospital, and a family friend accompanying him did not want to give their names, but they doubt the vaccines' efficacy.

The man's parents were vaccinated in March but fell ill with COVID in August, he said. His mother was put on a ventilator and died; his father was still in the hospital recovering and would soon be moved to the nursing home.

The facility's low staff vaccination rate is "not necessarily pertinent," he said, since his father would be receiving "end-of-life care." His companion said she personally knew four people who died of COVID and that two had been vaccinated and two had not. These cases, she said, "don't get reported because they don't fit the narrative."

Standing on the porch amid festive fall decorations, Landmark's administrator, Cindy Hollins, declined to discuss what might account for her staff's low uptake and politely asked a reporter to leave.

In Louisa, three hours east of Danville, David McKenzie believes the high rates of vaccination among residents and staff at his Jordan Center will be a selling point. "I advertise I'm the safest nursing home in the state of Kentucky to live and work in," he said.

McKenzie and his sister lived in the nursing home as kids; their parents opened the home and couldn't find another house to rent when the town was overflowing with coal miners. He learned to play piano from a resident, down a few fingers from diabetes, who had once played in Duke Ellington's band.

Last winter, COVID ravaged the nursing home for months, infecting nearly every resident. An employee's 33-year-old daughter, who didn't want the vaccine, was buried in early September; then a former employee, who had quit to work at a hospital that didn't require vaccination, died.

As soon as vaccines became available, McKenzie and his staff went room to room, explaining the science to residents. Only one family refused. Then he gathered the staff, many shaken by the loss of residents who were family members and friends.

Now, nearly every resident of the Jordan Center is vaccinated with three shots, and the staff vaccination rate hovers at 85%. But the holdouts keep McKenzie on edge.

"I sat over here on this front porch until 2 o'clock in the morning talking to two of the nurses that don't want to vaccinate," McKenzie said. "One has been here for 37 years and the other for 15 years. They're dug in. They're adamant."

Testing staff members who refuse to get vaccinated falls to Misty Robertson, a registered nurse who has worked at the facility for decades. She views every interaction as a chance to educate her co-workers about why they should get the shot. "I'm not mean about it," she said. "I say, 'I really don't want you to be on a vent and die.'"

Robertson's father, who lived at the Jordan Center, died of COVID in January. Her entire family is vaccinated, including her three children and her husband, who works at Walmart. Everyone except her twin sister, a receptionist for a local pediatrician. She tells Robertson COVID is fake and "it's all because of Biden."

"I get mad," said Robertson. She vehemently disputes the conspiracy theories circulating through the town's social networks, but, she said with a sour laugh, that she sometimes goes too far. "I was put in Facebook jail."

McKenzie's public stance has made him a pariah in some quarters, too. A customer attacked him at Walmart and threatened to wait for him in the parking lot. The darkened mood has carved the town into opposing camps, and he thinks Biden's vaccine mandates will just stiffen that divide.

Certainly, they are proving too much for some of his nursing home staffers. Many of the unvaccinated workers at the Jordan Center are on the same shift, and McKenzie fears he may lose his entire night crew.

"They told me Sunday night they were going to leave healthcare and work at Tractor Supply," he said, "where they can make more money per hour."

Sarah Varney: svarney@kff.org, @SarahVarney4

Watch: Going Beyond the Script of 'Dopesick' and America's Real-Life Opioid Crisis

KFF Health News, October 18, 2021

The Hulu series dovetails with the broader reality KFF's journalists and analysts have been documenting in their work for the past few years.

This article was published on Monday, October 18, 2021 in Kaiser Health News.

KHN and policy colleagues at our parent organization KFF teamed up with Hulu for a discussion of America's opioid crisis, following the Oct. 13 premiere of the online streaming service's new series "Dopesick."

The discussion explored how the series' writers worked with journalist Beth Macy, author of the book "Dopesick: Dealers, Doctors, and the Drug Company That Addicted America," and showrunner Danny Strong to create and fact-check scripts and develop characters. It quickly moved on to a deeper discussion of how the fictionalized version of the opioid epidemic portrayed in the Hulu series dovetailed with the broader reality KFF's journalists and analysts have been documenting in their work for the past few years.

Providing perspective on the role of public health and treatment were KHN correspondent Aneri Pattani, who has reported extensively on opioid policy, substance use and mental health, and KFF senior policy analyst Nirmita Panchal, whose analytical work focuses on mental health and substance use.

The forum was moderated by Chaseedaw Giles, audience engagement editor and digital strategist at KHN who has written about hip-hop music's relationship with opioid abuse. It was filmed in KFF's Washington, D.C., conference center to an audience of no one (courtesy of COVID-19).

You can read a transcript of the forum by clicking here.

 

'An Arm and a Leg': Hello? We Spend 12M Hours a Week on the Phone With Insurers

KFF Health News, October 18, 2021

In many cases, the companies are not actually getting paid to provide insurance.

This podcast was published on Monday, October 18, 2021 in Kaiser Health News.

By Dan Weissmann

Can't see the audio player? Click here to listen.

After Stanford professor Jeffrey Pfeffer got back surgery years ago, he kept a file folder labeled "Blue Shield Troubles."

When Pfeffer got an offer to collaborate with the polling company Gallup, he suggested a study on how much time Americans spend on the phone with their health insurers. Gallup agreed.

Their finding: We spend about 12 million hours a week calling our health insurance. (They also found that, as workers, calling our health insurance companies means we're more likely to miss work, and to be more checked-out and burned-out on the job.)

And given all that … it's important to know as much as possible about who we're actually on the phone with when we make those calls. Like, how do they make money? What are the incentives?

Here's something few of us know: In many cases, the companies are not actually getting paid to provide insurance. If you get your insurance through work, your employer probably "self-insures." (That's true for about two-thirds of all workers, and more than 90% of people who work for companies with more than 1,000 employees.)

But it isn't obvious if your job self-insures. You'll have an insurance card that says Cigna or United or Aetna etc. But you're operating in a different universe. For instance, self-funded plans are governed by federal law, so your state insurance commission can't step in and help. And that's just a start. 

In this episode, we start to get our bearings on that different universe. We talk to Pfeffer, to one of our favorite insurance brains, Karen Pollitz of KFF and to journalist Leslie Walker, whose reporting for the podcast "Tradeoffs" indicates that when companies are playing their role in "self-insured" setups, they can get up to some shady practices. And the employers they're working for — even big, powerful outfits — often don't exercise a lot of oversight or even have a lot of leverage.

Here's a transcript for this episode.

"An Arm and a Leg" is a co-production of KHN and Public Road Productions.

To keep in touch with "An Arm and a Leg," subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you've got stories to tell about the healthcare system, the producers would love to hear from you.

To hear all KHN podcasts, click here.

And subscribe to "An Arm and a Leg" on Spotify, Apple Podcasts, Stitcher, Pocket Casts, or wherever you listen to podcasts.

How to Crush Medical Debt: 5 Tips for Using Hospital Charity Care

KFF Health News, October 15, 2021

Many people who qualify for financial assistance never apply.

This article was published on Friday, October 15, 2021 in Kaiser Health News.

By Emily Pisacreta  

What if a law passed but no one enforced it? That's essentially what has happened with one small but helpful rule about hospitals and financial assistance for medical bills.

The Affordable Care Act, the health law also known as Obamacare, requires nonprofit hospitals to make financial assistance available to low-income patients and post those policies online. Across the U.S., more than half of hospitals are nonprofit — and in some states all or nearly all hospitals are nonprofit. But many people who qualify for financial assistance — or "charity care," as it is sometimes known — never apply.

Jared Walker is helping get the word out. He founded Dollar For, an organization that directly helps people use hospital financial assistance policies to overcome unaffordable medical bills. Walker earned the public's attention early this year through a viral TikTok he made on a lark, late one night.

In the 60-second video, Walker outlines the basics of applying for hospital financial assistance, in response to a prompt that asks TikTokers to share "something you've learned that feels illegal to know."

"Most hospitals in America are nonprofits, which means they have to have financial assistance or charity care policies," he says in the video. "This is going to sound weird, but what that means is if you make under a certain amount of money the hospital legally has to forgive your medical bills."

The video outlines the basics of applying for hospital charity care, which he says he uses to "crush" medical bills.

"An Arm and a Leg," a podcast about the cost of healthcare, has been covering Walker and his organization's work since the video's viral moment, as well as the decades-long fight to establish charity care rules that preceded it.

Here are five strategies Walker endorses and shares during monthly volunteer training sessions:

1. How do you find the policy?

Walker's trick for finding a hospital's financial assistance policy is as straightforward as it gets: Google it. Enter the hospital's name, followed by "financial assistance policy" or "charity care policy." The first search results are likely to be an outline of the policy and an application to submit.

Your first instinct might be to go to your hospital's home page. But that's likely a mistake. Policies tend to be hidden from hospital website menus, according to Walker. In many states, charity care laws are more specific than what's outlined in the ACA, and hospitals may be required to display their financial assistance policies prominently.

It's rare for the policies not to be available online at all, but in some cases, Walker said, you may need to call the hospital and ask for an application.

2. Who qualifies?

Most hospital charity care policies are income-based, using percentages of the federal poverty guidelines to define eligibility. In an example, Walker showed the guidelines for St. Luke's Hospital of Kansas City, where patients earning 200% of the federal poverty guidelines were responsible for 0% of their bill. That figure was just over $2,000 a month in 2021. Those making 201% to 300% were eligible for certain discounts.

Not sure how your income compares to the federal poverty guidelines? Here's one of many helpful online calculators. Remember, your household is you, plus your spouse, plus anyone you claim as a dependent on your taxes. Roommates don't count.

Applications typically require documentation to prove your income. Hospitals ask for things like recent pay stubs, proof of unemployment, Social Security award letters and tax returns, according to Walker. Exactly which documents the hospital may ask for can vary. But a hospital can't deny you for failing to provide a document that isn't spelled out in the application.

3. In collections? You may still have time.

The IRS requires nonprofit hospitals to give patients a grace period of 240 days (about eight months) from the initial billing date to apply for financial assistance. But hospitals are allowed to send bills to collection agencies much earlier than that — often after just 120 days.

At that point, patients often feel as though they're being hounded by notifications from collection agencies. Still, patients may have months remaining to apply for financial assistance, and alerting the collection agents that an application with the hospital is in process can sometimes stop the letters.

"The hospital can take you out of collections just as easily as they put you there," Walker said.

In some cases, hospitals will forgive bills that are much older than 240 days. When in doubt, applying may be worth it even for bills that are several years old, Walker said. It does not hurt to ask for help.

4. Looks like you won't qualify? Write a letter.

If you don't qualify on income alone but you still can't afford your hospital bills, don't rule yourself out. The same applies if the hospital's financial aid policy specifies that only uninsured people qualify; you might have insurance but are still looking at giant bills you can't pay.

Walker said a letter of financial hardship attached to an application can help. In fact, he encourages each patient to attach a letter, no matter how strong their application seems.

"These are real people reading these and the letters go a long way," he said. Ultimately, each hospital is making a judgment call about who gets the assistance it is legally obligated to provide. Make your case.

5. Yes, you may need to fax it in.

While many hospitals have digital portals to enable online bill-paying, there's usually no equivalent for applying for financial assistance. Many applications offer only a mailing address. But Walker and his team have found that applications sent by mail frequently get lost.

Instead, they recommend either walking the application into the hospital and delivering it by hand or faxing it. Public libraries, packaging stores like FedEx and certain online services make faxing possible even if, like most people, you haven't used a fax machine since the late 1990s.

When it comes to accessing charity care, "you're gonna have to jump through a lot of hoops," Walker said, "but it's worth it."

Emily Pisacreta is a reporter and producer with "An Arm and a Leg," a podcast about the cost of healthcare that is co-produced with KHN.

Schedule Online Visits First? It's the Next Big Thing in Health Insurance

KFF Health News, October 15, 2021

Many insurers offering virtual-first plans hire outside firms to provide medical staff.

This article was published on Friday, October 15, 2021 in Kaiser Health News.

By Julie Appleby  

At the height of the COVID-19 pandemic, people often relied on telemedicine for doctor visits. Now, insurers are betting that some patients liked it enough to embrace new types of health coverage that encourages video visits — or outright insists on them.

Priority Health in Michigan, for example, offers coverage requiring online visits first for nonemergency primary care. Harvard Pilgrim Healthcare, selling to employers in Connecticut, Maine and New Hampshire, has a similar plan.

"I would describe them as virtual first, a true telehealth primary care physician replacement product," said Carrie Kincaid, vice president of individual markets at Priority Health, which launched its plans in January as an addition to more traditional Affordable Care Act offerings.

The often lower-premium offerings capitalize on the new familiarity and convenience of online routine care. But skeptics see a downside: the risk of overlooking something important.

"There's a gestalt of seeing a patient and knowing something is not right, such as maybe picking up early on that they have Parkinson's," or listening to their heart and discovering a murmur, said Dr. David Anderson, a cardiologist affiliated with Stanford Healthcare in Oakland, California. He said online medicine is a great tool for follow-up visits with established patients but is not optimal for an initial exam.

When enrolling in one of the new plans, patients are encouraged to select an online doctor, who then serves as the patient's first point of contact for most primary care services and can make referrals for in-person care with an in-network physician, if needed. It's possible patients never meet their online doctor in person.

Many insurers offering virtual-first plans hire outside firms to provide medical staff. The physicians may hold licenses in several states and not be located nearby. Insurers say participating online doctors can access patients' medical information and test results through the insurers' electronic medical records system or those of the third-party online staffing firm. What might prove tricky, experts warn, is transferring information from physicians, clinics or hospitals outside of an insurer's network. Sharing patient information via EMRs is challenging even for doctors operating under traditional insurance plans with in-person visits — especially moving data between different health systems or specialty practices.

The virtual-first concept was so new that Priority Health called those enrolling this year to ensure they understood how it worked. "If people were more comfortable with brick-and-mortar, they should choose other options," Kincaid said, adding that the plans have drawn 5,000 enrollees since January, a number she hopes will double next year.

Other versions of telehealth plans are available, offered by big names such as Humana, Kaiser Permanente, Oscar and UnitedHealthcare. Some emphasize but don't require that primary care starts online. Some are aimed directly at consumers. Others are sold to employers.

Oscar Virtual Care health plans, sold in several states including Texas, Florida and New York, allow patients to choose between online or in-person services.

"These are not virtual-only plans," said Marianna Spanos, an Oscar vice president and general manager of its virtual care division. "You can always opt to see a more traditional provider."

Although Kaiser Permanente uses its own in-house medical staff, most insurers rely on contracted physicians, mental health therapists and other staff members, often provided by San Francisco-based Doctor on Demand.

Doctor on Demand launched in 2013, aimed at individual consumers. Starting with a Humana contract in 2019, it has since expanded to offer staffing for several other insurers. The company, which has its own electronic medical records system, hires a range of primary care, mental health and other medical providers. Physicians must be board-certified. Pay is partly based on how many patients they see, and there is no upper limit. Some want to work part time, for example, and many work from home.

In general, virtual-first health plans may carry lower premiums or provide such financial incentives as no copays for online visits. All boast that members can get appointments quickly, sometimes within minutes. Patients with serious problems are assisted in arranging emergency help. If online physicians determine patients need a blood test, immunization or a visit with a specialist, they refer them to a local practice, clinic or specialist within the insurer's network.

As a strategy to contain costs, think HMO 2.0.

"There's more control over the patient interaction and where they get referred," said Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.

Still, patients should be aware that some of these plans may allow a brick-and-mortar visit only if their virtual doctor, who may have never examined them in person, deems it necessary.

Skeptics note that many circumstances demand in-person care. One recent study estimated about 66% of primary care visits required it. For example, it's impossible to check reflexes and difficult to examine tonsils for infection virtually.

Patients in some programs, including Harvard Pilgrim's, are sent kits that can include devices like blood pressure cuffs and thermometers — though at-home medical measuring devices are often not as accurate as those used in offices. Online physicians may also ask a patient to feel for swollen lymph nodes, shine a light into their throat while on camera or take other actions to help the physician diagnose a problem.

Kincaid, at Priority Health, noted that Doctor on Demand also sets protocols on children's wellness visits, which it says must be done in person.

"It's important for children's wellness visits to get accurate height and weight measures and immunizations," Kincaid said.

When considering virtual-first plans, advocates say, patients should look closely not just at premiums but also at deductibles and copayments, which may be set at levels that discourage in-person care. Rules are varied and dizzying.

The VirtualBronze plan offered through the federal ACA marketplace in parts of Texas by Community Choice Health, for example, requires hefty patient contributions for many types of in-person visits.

Patients incur no copay for using online Doctor on Demand physicians for primary care visits or for accessing in-person preventive services as defined by the ACA, such as immunizations or cancer screenings. But for other in-person services, Community Choice's virtual plan will cost patients out-of-pocket because they pay the cost of the care until they meet an annual $8,530 deductible.

Kaiser Permanente's Virtual Complete plan offered to large employers carries no copay for online care. Patients can opt to see an in-person doctor three times a year for primary care if they're willing to pay a copay. After those three visits, any additional in-person visits are subject to a deductible.

Plans sold through federal or state marketplaces and those offered by employers must meet the ACA's requirements. That includes a range of services, from doctor visits to hospital care.

Corlette, at Georgetown, said consumers should be wary of plans that are not ACA-compliant.

She fears the advent of plans that give patients "access to online providers, but nothing else." And that, she said, "would not be considered major medical insurance."

Julie Appleby: jappleby@kff.org, @Julie_Appleby

Q&A: How Will California's New 988 Mental Health Line Actually Work?

KFF Health News, October 14, 2021

States are required to have some version of the 988 system up and running by July 2022. But the actual shape it takes is up to each state.

This article was published on Thursday, October 14, 2021 in Kaiser Health News.

By Jenny Gold  

In September 2020, Congress passed bipartisan legislation creating a three-digit national suicide hotline: 988. Think of it as an alternative to 911 for mental health emergencies.

The system is intended to make it easier to seek immediate help during a mental health crisis. Instead of calling 911 or the 10-digit national suicide hotline, Americans theoretically will be able to speak to a trained counselor by calling 988 from most any phone line.

The federal law allows states to raise funds for the effort by levying a surcharge on monthly bills for mobile and landline phone service. The money can be used to support the dedicated call centers, pay for trained mobile response teams to be dispatched instead of armed law enforcement officers, and bolster stabilization services for people in crisis.

States are required to have some version of the 988 system up and running by July 2022. But the actual shape it takes is up to each state.

In California, the state Department of Healthcare Services announced in September it would spend $20 million to help launch the 988 system. AB 988 is legislation that would tack on up to 80 cents a month on phone lines in the state — both wireless and landline services — to provide ongoing funding for the system and associated services. The bill has faced opposition from the telecommunications industry, which argues the fee should be capped at 10 cents and fund only the cost of routing 988 calls to an appropriate crisis center. The bill has passed the Assembly and is expected to be taken up by the Senate next year.

Assembly member Rebecca Bauer-Kahan, an Orinda Democrat, is the principal author of AB 988, which she called the "Miles Hall Lifeline Act" in honor of a 23-year-old man who was fatally shot by police in Walnut Creek during a mental health crisis. His family said he had been diagnosed with schizoaffective disorder.

Bauer-Kahan, a Bay Area lawyer, talked to KHN's Jenny Gold about efforts to get 988 operational in California and what the new system might be able to accomplish. The conversation has been edited for length and clarity.

Q: The new federal law requires that every state have a 988 phone system in place by July. How is California doing, and will we be ready?

I'm hopeful that we will. We definitely have more work to do. We appropriated $20 million in September to ensure that we have the startup costs to build up our call centers. The data is showing that we should expect about a 30% increase in call volume [for California's 13 suicide prevention call centers] when the rollout happens for 988 in July. So, it's really critical to ensure that the call centers have the ability to increase staffing, and train people so that we're prepared.

Q: Why is it important to have an emergency system dedicated exclusively to mental health?

This is a healthcare issue, but currently it's being treated as a public safety issue. And that's leading to a whole host of problems. I'd say the largest problem is that [an estimated] 25% of all officer-involved shootings are people in mental health crisis. So that tells us that we aren't getting the support we need to the people who need it.

Our law enforcement has been incredibly supportive of this effort because they know that there are people better trained to manage people who are in crisis. The largest mental health provider in the nation is the L.A. County jail, which is just the most upsetting thing I've heard. People shouldn't be treated in our jails.

Q: What does the completed 988 system look like?

The federal legislation dictated that 988 calls have to be answered by certified suicide prevention call centers. We have 13 of those call centers in California, so they will be the people who answer.

Behind the call, the county where you live would be listening and determining whether you need dispatch. We believe, actually, a good percentage of callers will be served via just a phone call. But for those that need a response on the ground, there would be a warm handoff to county services.

People who have law enforcement showing up today would instead get a mobile crisis team show up to support them in that moment of crisis. Then they'd be handed off to stabilization services and long-term care for their mental health needs.

Q: What happens after emergency personnel respond to a 988 call? Would the patient be routed into a system that looks different from the one we have now, where people are so often taken to an emergency room or jail?

The goal is yes. They wouldn't go to jail, because law enforcement isn't the responder. So our jails would not continue to be our largest mental healthcare providers, but we would be building up a network of services.

Some people do need in-patient care that cannot be provided outside of the hospital, and we should make sure we have the [necessary] beds, which we don't today. If somebody needs somebody to talk to weekly, then the county will be able to provide those services.

[We need to ensure that] the counties, who really should be the service providers, have the resources to provide care to those in need. And, currently, we just are woefully inadequate in the services that we can provide. The bill really defers to the counties with appropriate funding to create a system that will work for the community.

Q: We have a crisis that extends well beyond the point of police intervention, considering we don't have places to treat people during mental health emergencies. Is that part of the vision for 988, or does it deal mostly with this very specific moment of initial contact?

I've always said in thinking about this legislation that this is a small piece of the puzzle. I will not say that I'm solving mental health in one piece of legislation. I am really focused on this piece of where we have law enforcement responding inappropriately today. How do we turn that into a healthcare response?

Now, do we need a complete, robust healthcare, mental health system underneath it? Yes. Am I creating that all through 988? No.

So there's a lot of work that I think will go with this. I think it's this incredible step in the right direction, but I by no means believe that it is going to solve all of our problems. The end goal is to have a complete continuum of care, so that the counties are able to provide the services that each individual needs to get them to a healthy place.

Q: Is there a way to raise funding through 988 to help with that broader continuum?

The bill funds both the mobile crisis response and stabilization services. So, we anticipate funding more than just the telephone operators. And we have fought tooth and nail to ensure that funding remains in the bill, because we believe that the phone system will be inadequate unless we have the services behind it to actually provide folks with the ability to be stabilized by their local counties.

[Having] the resources to provide exactly what each person in crisis needs is absolutely the goal. 988 is a piece of that puzzle. Sometimes you take the first step.

NEED HELP?

If you or someone you know is in a crisis, please call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or contact the Crisis Text Line by texting HOME to 741741.

Jenny Gold: jgold@kff.org, @JennyAGold

Surprise-Billing Rule 'Puts a Thumb on the Scale' to Keep Arbitrated Costs in Check

KFF Health News, October 14, 2021

What's not clear is whether the new law will have the unintended consequences of shifting costs and leading to higher insurance premiums.

This article was published on Thursday, October 14, 2021 in Kaiser Health News.

By Julie Appleby 

Patients are months away from not having to worry about most surprise medical bills — those extra costs that can amount to hundreds or thousands of dollars when people are unknowingly treated by an out-of-network doctor or hospital.

What's not clear is whether the changes in law made by the No Surprises Act — which takes effect Jan. 1 — will have the unintended consequences of shifting costs and leading to higher insurance premiums.

Probably not, many policy experts told KHN. Some predict it may slightly slow premium growth.

The reason, said Katie Keith, a research faculty member at the Center on Health Insurance Reforms at Georgetown University, is that a rule released Sept. 30 by the Biden administration appears to "put a thumb on the scale" to discourage settlements at amounts higher than most insurers generally pay for in-network care.

That rule drew immediate opposition from hospital and physician groups, with the American Medical Association calling it "an undeserved gift to the insurance industry," while the American College of Radiology said it "does not reflect real-world payment rates" and warned that relying on it so heavily "will cause large imaging cuts and reduce patient access to care."

Such tough talk echoes comments made while Congress was hammering out the law.

The most recent guidance is the third issued to implement the law, which passed in late 2020 after a years-long battle. It was signed by then-President Donald Trump.

The No Surprises Act takes aim at a common practice: large, unexpected "balance bills" being sent to insured patients for services such as emergency treatment at out-of-network hospitals or via air ambulance companies. Some patients get bills even after using in-network facilities because they receive care from a doctor who has not signed on with an insurer's network.

Patients were caught in the middle and liable for the difference between what their insurer paid toward the bill and the often-exorbitant charges they received from the provider.

Once the law takes effect next year, patients will pay only what they would have if their care had been performed in network, leaving any balance to be settled between insurers and the out-of-network medical providers. The law also gives insurers and providers 30 days to sort out discrepancies.

After that, unsettled bills can enter "baseball-style" arbitration, in which both sides put forth their best offer and an arbitrator picks one, with the loser paying the arbitration cost, which the rule sets for next year as between $200 and $500.

Uninsured patients who are billed more than $400 over an upfront estimate of the cost of their care may also bring cases to arbitration for a $25 administrative fee.

Businesses, like government services companies or those that review coverage disputes, can start applying now for certification as arbitrators. The rule estimates that about 50 will be selected by the three agencies overseeing the program, the Departments of Health and Human Services, Labor and Treasury, after showing "expertise in arbitration, healthcare claims experience, managed care, billing and coding, and healthcare law." The rule also spells out that either party can object to a chosen arbitrator, and the one that is selected cannot be associated with an insurer or medical provider.

But which price to pick in arbitration?

The new rule specifies that the arbitrator generally should pick the amount closest to the median in-network rate negotiated by insurers for that type of care. Other factors, such as the experience of the provider, the type of hospital or the complexity of the treatment, can be considered in some circumstances, but not given equal weight.

By contrast, some of the more than a dozen state laws taking aim at surprise bills allow arbitrators to consider higher rates, such as billed charges set by hospitals or doctors, rather than negotiated rates, which potentially drive up spending.

A recent study, for example, found that in New Jersey — which has different arbitration rules than what is being set up for the federal program — cases were settled at a median of 5.7 times higher than in-network rates for the same services.

Unlike New Jersey, the federal government is specifically barring consideration of the highest amounts — the billed charges — and the lowest payment amounts, including those from Medicaid and Medicare programs.

"This seems likely to reduce premiums in addition to protecting patients from surprise bills," said Loren Adler, associate director of the University of Southern California-Brookings Schaeffer Initiative for Health Policy, who co-authored the New Jersey study.

Still, the law's impact on premiums is open to debate. Keith doubts they will change either way, although Adler thinks the slowdown in premium growth would be small.

Even the final rule says "there is uncertainty around how premiums will be ultimately affected" with much depending on how often disputed bills go to arbitration.

The latest rule cited a Congressional Budget Office estimate that provisions in the No Surprises Act could reduce premium growth by 0.5% to 1% in most years, but also noted an estimate from the Centers for Medicare & Medicaid Services that premiums  could slightly increase. Neither study isolated the effect of the arbitration guidelines from the rest of the statute.

Adler noted that relying heavily on the median in-network price likely means lower payments as compared with other measures but, still, "by definition a median is what half of doctors get paid, so this could, in theory, raise that for the other half."

What's likely, health policy experts said, is that the new law will prompt more providers to join insurer networks.

Some physicians — most often, emergency room doctors, anesthesiologists and radiologists — have avoided signing contracts with insurers. Instead, they typically set charges above the level of insurers' reimbursement and sent surprise bills to patients for the difference.

The rule undercuts the incentive to use this business model.

It makes it "pretty clear" that hospitals, physicians, air ambulances and other medical professionals "should not count on staying out of network and then trying to use the federal process to capture higher reimbursement," said Keith.

Some medical societies and advocacy groups predicted the law could have the opposite effect.

Insurers will use the disputes to "drive down payment to the point that it is no longer feasible for many providers to take that, or any insurance," warned Katie Keysor, senior director of economic policy for the American College of Radiology, in an emailed statement.

Adler said that argument doesn't fly when looking across the experience of states with similar laws. (Those state rules don't apply to many types of job-based health insurance, but the federal rule will.)

"Every single surprise billing debate has done the opposite and pushed more people into the network," he said.

Whether a group signs a contract with an insurer may matter less in the future, he said.

Once the law takes effect, "it's completely irrelevant whether an emergency room doctor is in network or not," he said. "For all intents and purposes, that doctor is in network. The patient will pay the in-network cost sharing and there is a price the provider has to accept, and the insurer has to pay."

Julie Appleby: jappleby@kff.org, @Julie_Appleby

Reluctant Localities Are Being Dragged Into Court to Fix Sidewalks for People With Disabilities

KFF Health News, October 13, 2021

In Baltimore and many other communities across the U.S., there has been widespread noncompliance with parts of the ADA.

This article was published on Wednesday, October 13, 2021 in Kaiser Health News.

By Maureen O'Hagan   

From her Baltimore dining room, Susan Goodlaxson can see her neighbor gardening across the street. But while other neighbors stop to chat, Goodlaxson just watches from the window. She uses a wheelchair, and there isn't a single curb ramp on her block.

If the 66-year-old wanted to join, she'd have to jump her wheelchair down the 7½-inch curb and risk a fall. Ditto if she wanted to wheel over to the library, a trip that would require riding in the street to avoid rampless curbs and broken sidewalks.

"I don't feel like it's asking too much to be able to move your wheelchair around the city," she said.

Federal law backs her up. Since 1990, the Americans With Disabilities Act has required governmental entities to provide people with disabilities access to programs and services enjoyed by their nondisabled peers. That includes sidewalks and curb ramps that make it possible to safely cross the street.

In Baltimore and many other communities across the U.S., there has been widespread noncompliance with this part of the law.

"An awful lot of [communities] have either disregarded their obligations under the ADA or made it the last priority," noted Tom Stenson, a lawyer with Disability Rights Oregon, a nonprofit advocacy group. "There's a culture throughout America of not taking the needs of people with disabilities seriously."

In Baltimore, just 1.3% of curb ramps meet federal standards, according to the city's own figures. In Oregon, about 9% of corners maintained by the state transportation department are compliant. San Jose, California, counted 27,621 corners with faulty or nonexistent curb ramps. Boston estimates fewer than half of its curb ramps are compliant.

In recent years, there's been a flurry of class-action lawsuits, including one filed against Baltimore in June, with Goodlaxson among the plaintiffs.

Philadelphia was sued in 2019 over the condition of its sidewalks. Chicago was sued the same year for failure to install audible pedestrian signals, more than a decade after settling a suit over curb ramps. In 2018, Atlanta was sued. A survey there determined that only 20% of sidewalks were in sufficient condition to be used by people in wheelchairs or motorized scooters and about 30% had curb ramps. Seattle settled a class-action suit in 2017. San Francisco and Long Beach, California, were sued in 2014 to make their sidewalks more accessible to wheelchairs.

The city of New York and its transit authority have faced repeated major ADA lawsuits, some alleging the same lack of access for people with disabilities that was supposed to be addressed in a lawsuit that was filed in the 1990s and later settled.

Los Angeles settled what is believed to be the largest of these suits in 2015. Its problems with sidewalks and curb ramps were so widespread that the city estimated it would cost $1.4 billion and take 30 years to get into compliance. In the years leading up to the suit, the city wasn't allocating money for sidewalk repairs, for the ADA or otherwise, even while paying out millions in injury claims.In all, hundreds of jurisdictions have faced lawsuits or entered settlement agreements after failing to meet ADA requirements for pedestrians and mass transit users.

The sheer number of noncompliant sidewalks, curb ramps, pedestrian signals and subway stations illustrates the challenges for people with disabilities. It also leaves cities in a legal and financial squeeze, with the average curb ramp costing between $9,000 and$19,000. When the court requires a jurisdiction to build thousands of them to catch up, it can strain budgets.

The ADA and the 1973 Rehabilitation Act resulted in significant changes that improved access and accommodations for people with disabilities. The ADA is clear that people with disabilities have the same right to pedestrian infrastructure as anyone else.

There are requirements covering a curb ramp's width, slope and other specifications. Even a 1-inch lip can be too high for a wheelchair user to navigate. A slope that is a few degrees too steep can tip someone to the ground. Sidewalks that are crumbling, pothole-filled or otherwise obstructed — with utility poles, for example — force wheelchair users into the street for a dangerous ride.

No one expected the ADA to fix all these problems immediately. Under the law, new sidewalks must be built for accessibility. As for existing sidewalks, a federal appeals court in 1993 ruled that curb ramps must be installed or regraded when the road is altered — say, when it's repaved.

Yet by 1999 it was clear many jurisdictions were ignoring the law. The U.S. Department of Justice began enforcement efforts, entering into settlement agreements with more than 200 noncompliant jurisdictions representing every state since 2000.

Still, compliance still lags.

Officials in Baltimore, New York and Los Angeles declined to comment for this article. Tony Snyder, manager of the Oregon Department of Transportation's ADA program, said siloed funding sources, strict regulations and costs have been among the hurdles over the years.

"It wasn't that ODOT doesn't value accessibility," he said. While fewer than 10% of the state's ramps meet standards, he said, a lot of noncompliant ramps are nonetheless "usable."

Kelly Lynch, deputy director and general counsel for the Montana League of Cities and Towns, an association that represents 127 municipal governments, agreed that costs can add up. She's been working to help fellow Montanans —and, she hopes, officials in other jurisdictions across the country through the National League of Cities — find a path toward full accessibility, even if the steps are incremental.

Some changes, including educating road crews on the rules, are relatively simple. But a bigger problem is a widespread lack of spending on the nation's infrastructure. "Our streets are falling apart, and so are our sidewalks," Lynch said.

In August, the Senate defeated an amendment by Sen. Tammy Duckworth (D-Ill.) to a $1 trillion infrastructure bill that would have required state and local entities to describe how they would use federal dollars to improve accessibility for people with disabilities and for underserved communities. Sen. Pat Toomey (R-Pa.) called Duckworth's amendment "politically correct virtue signaling" and argued that transit agencies don't need that kind of federal oversight.

On top of the broader infrastructure issues, many officials don't fully understand the ADA or its requirements, Lynch believes. And as the mother of a disabled son, she also said there's another big factor at play: "People still discriminate against people with disabilities."

As for Baltimore, Goodlaxson said she repeatedly called the city asking for curb cuts and sidewalk repairs. She remembers a crew coming to look at the sidewalks — and then nothing happening. Advocacy organizations tried to negotiate with city officials, hoping to get Baltimore's infrastructure brought into compliance on a timetable. When that didn't work, they filed suit.

Most of these kinds of ADA cases begin similarly, with negotiations long before lawsuits. Some jurisdictions settled quickly and worked hard at improvements. Other cases go less smoothly. Oregon's transportation department, which was also sued, is in danger of missing its construction deadlines under the settlement. Some repairs had to be redone because they still fell short of ADA requirements.

Sometimes cities try to get cases thrown out of court by pointing to the 1993 appeals court decision and arguing there's no evidence the road has been altered since then, so ADA requirements haven't kicked in. In New York, the transit authority argues in an ongoing lawsuit that while wheelchair users can't ride, say, three-quarters of the city's subways because there are no elevators, they can instead take the bus.

Some jurisdictions fight bitterly. Los Angeles spent five years in court before agreeing to settle. Linda Dardarian, one of the plaintiff's attorneys, said cities don't fully recognize sidewalk and curb ramp accessibility as a civil right. "They have viewed it as just another maintenance obligation, [like] grooming street trees."

When the case was settled, the judge ordered Los Angeles to pay nearly $12 million to cover the other side's legal fees and costs, on top of the estimated $1.4 billion it will cost to come into compliance.

Under these settlements, repairs often stretch a decade or more, and the city or town typically must pay for surveys, measurements and disability consultants to ensure compliance.

From the plaintiffs' point of view, the challenge of these lawsuits is that there isn't a huge hammer to hold governments accountable.

"If you don't build the ramps, the penalty is you have to build the ramps," said Stenson of Disability Rights Oregon, which provided legal representation to a plaintiff in the Oregon transportation department suit.

For those who can easily get around town, the issue can be invisible.

Goodlaxson didn't see the problem until she began using a wheelchair five years ago, after surgery for a brain tumor. She remembers seeing people riding their wheelchairs in the street, thinking, "that doesn't look safe. But I didn't give it any more thought."

Now, she realizes "people are terrified, but they can't do it any other way."

Health Industry Wields Power in California's High-Stakes Battle to Lower Healthcare Costs

KFF Health News, October 13, 2021

Lobbyist used their political clout and close ties with the governor to devise a friendlier alternative that doctors, hospitals and insurance companies could live with.

This article was published on Wednesday, October 13, 2021 in Kaiser Health News.

By Angela Hart and Samantha Young  

SACRAMENTO — Gavin Newsom put California's healthcare industry on notice when he was a candidate for governor, vowing in 2018 to go after the insurance companies, doctors and hospitals that leave many Californians struggling with enormous medical bills and rising insurance premiums.

He pledged to lead California's single-payer movement, a high-stakes liberal dream that would eliminate private health insurance and slash how much providers are paid. The tough rhetoric continued after he was elected, when Newsom told insurers to "do their damn job" to improve mental health treatment or face fines, and he vowed to cut the healthcare industry's soaring revenues.

"We've got to get serious about reducing healthcare costs," the first-term Democrat said in January 2020 as he unveiled his proposal to establish an Office of Healthcare Affordability that would do the unthinkable in a system powered by profits: set caps on healthcare spending and require doctors and hospitals to work for less money. "We mean business."

Industry leaders were rattled. But rather than mobilize a full-throttle defense to sink Newsom's effort to regulate them, they have used their political clout and close ties with the governor to devise a friendlier alternative that doctors, hospitals and insurance companies could live with.

When Newsom ultimately drafted legislation for the office, he took an idea healthcare executives had pitched and made it his own: Instead of capping prices or cutting revenues, he would allow industry spending to grow — but with limits.

Political infighting killed the legislation this year, but it is expected to come back in January and spark one of next year's blockbuster healthcare battles.

"They're fearful of what might happen to them, and they're trying to protect their interests because they're threatened," David Panush, a veteran Sacramento health policy consultant, said about healthcare industry players. They know "there's blood in the water and the sharks are coming."

If Newsom's plan to rein in healthcare spending succeeds, it could provide him some political cover as he campaigns for reelection next year, giving him a major healthcare win even as he sidesteps progressive demands such as creating a single-payer system.

But it could also cement the power of an industry that continues to wield immense influence — negotiating behind the scenes to protect its massive revenues and secure exemptions and side deals in exchange for its support.

"Every time we try to do something to reduce healthcare costs, it meets with huge opposition," said state Assembly member Jim Wood (D-Santa Rosa), head of the Assembly Health Committee, who is working closely with the Newsom administration on this proposal.

Industry power players have only pushed back harder as lawmakers have tried to take them on, Wood said. "Anybody or anything that disrupts the status quo is met with huge resistance and huge resources to fight it," he said.

◆◆◆

When Newsom took office in 2019, he knew public sentiment was turning against the healthcare industry. On average, healthcare costs were around $11,600 per person that year, up from $4,600 in 1999, according to federal data. In California, hospitals account for the biggest share of spending, nearly one-third, while 20% of healthcare dollars goes to doctors.

California consumers are demanding action, with 82% of state residents saying it's "extremely" or "very" important for the governor and legislature to make healthcare more affordable, according to a 2021 poll from the California Healthcare Foundation.

Much of Newsom's tough talk on industry spending came early in his term. "We're going to create specific cost targets for all sectors to achieve, and we are going to assess penalties if they don't achieve those targets," Newsom said in January 2020. "If that didn't wake up members of the system, I don't know what will."

Newsom's wake-up call came on the heels of tense legislative debates on bills that would have empowered the state to set healthcare prices and created a single-payer system. The measures gained surprising momentum but ultimately buckled under opposition from healthcare giants.

Then the COVID-19 crisis hit and propelled the recall effort to oust him from office — and the wake-up call was met with a slap of the snooze button. The governor and his health industry allies nestled closer. Just as he needed them to be the state's front line of defense, they needed him to keep hospitals from overflowing, to secure protective gear and to push vaccinations.

Healthcare titans became regular fixtures in Newsom's orbit. His calendars, obtained by KHN, show that doctors, hospitals and health insurance leaders have routinely received access to the governor.

Carmela Coyle, head of the California Hospital Association, stood beside Newsom at the state emergency operations center in the early days of the COVID crisis, and Paul Markovich, CEO of Blue Shield of California, obtained a lucrative no-bid state vaccination contract to implement Newsom's vaccination effort.

The coziness of the industry's relationship with Newsom burst into public view in late 2020 when he was photographed dining at the ritzy French Laundry restaurant with Dustin Corcoran and Janus Norman, the CEO and top lobbyist, respectively, of the state doctors' lobby, the California Medical Association.

"There is no possible way we could have come out of this COVID crisis where the healthcare industry was given so much power without influence coming along with that," said Carmen Balber, executive director of the advocacy group Consumer Watchdog.

Newsom did not respond to questions about the industry's influence, but spokesperson Alex Stack said his proposal to regulate healthcare spending "is a priority for this administration, and we look forward to continuing to work on this issue to get it done."

Doctors and Blue Shield have given Newsom millions of dollars to support his political career over many years, including a $20 million donation in September 2020 from Blue Shield for his homelessness initiatives.

The recall effort earlier this year only solidified Newsom's relationship with healthcare executives. Industry groups wrote checks to the California Democratic Party, which fought to keep Newsom in office. It received $1 million each from Blue Shield and the hospital lobby and $875,000 from the doctors' lobby, according to state campaign finance records.

◆◆◆

Though Newsom vowed to go after the industry, he hasn't aggressively taken it on, and healthcare executives and lobbyists continue to wield their influence as they shape the debate over the Office of Healthcare Affordability.

That could put Newsom in a political bind as he runs for reelection — first in the June 2022 primary and then the November general election — because he will face intense opposing political pressure from liberal Democrats who want him to keep his campaign promise and adopt single-payer.

Health and political experts say Newsom can help alleviate that pressure by adopting a strict law going after spiraling healthcare spending.

"This issue isn't going away — it does need to be addressed," acknowledged Corcoran. The push to control costs "should be uncomfortable for everybody, but not horribly so."

But it won't be easy. After powerful industry leaders joined forces with organized labor and consumer advocates to propose a plan to the governor, they jammed negotiations with their demands, splintering the coalition and killing the effort this year.

Coyle, with the hospital association, had left the coalition early out of concern that hospitals were the primary target, and approached the Newsom administration independently. She is also asking Newsom to relax stringent earthquake safety standards for hospitals.

Corcoran wants to exempt "small" doctor practices — which he defines as practices with up to 100 doctors — from regulation, arguing that restrictive government cost controls could put them out of business, leading to increased industry consolidation and higher prices.

"The goal posts were constantly shifting," said Yasmin Peled, a lobbyist for the advocacy group Health Access California, which was involved in negotiations. "The asks were constantly changing."

Before negotiations completely broke down, Newsom embraced the idea floated by Coyle: The state should control growth, not impose revenue cuts. And it should not focus only on hospitals, but apply to all healthcare sectors, including doctors and insurers. (The pharmaceutical industry would not be subject to the cost control provisions of the measure because of restrictions in federal law, according to Wood's office.)

With battle lines drawn, industry groups are poised for a major fight next year as Newsom and state Democratic lawmakers muscle through legislation. Their primary goal will be to protect their interests, said Mark Peterson, a professor of public policy, political science and law at UCLA.

"There's no question this industry has power. The real question is what they do with it," Peterson said. "They're getting wins, and important ones."

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Healthcare Foundation.

Angela Hart: ahart@kff.org, @ahartreports

Samantha Young: syoung@kff.org, @youngsamantha

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