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Biden-Harris Administration Announces New Initiative to Increase Investments in Person-Centered Primary Care

HHS Gov News - March 19, 2024
ACO Primary Care Flex Model aims to improve access to high-quality primary care for underserved Medicare populations

How National Political Ambition Could Fuel, or Fail, Initiatives to Protect Abortion Rights in States

Kaiser Health News:States - March 19, 2024

ST. LOUIS — In early February, abortion rights supporters gathered to change Missouri history at the Pageant — a storied club where rock ’n’ roll revolutionary Chuck Berry often had played: They launched a signature-gathering campaign to put a constitutional amendment to voters this year to legalize abortion in the state.

“We have fought long for this moment,” the Rev. Love Holt, the emcee, told the crowd. “Just two years after Missouri made abortion illegal in virtually all circumstances, the people of our state are going to forever protect abortion access in Missouri’s constitution.”

The ballot measure — which would allow abortions until fetal viability — outlasted 16 other related proposals and months of litigation with Republican state officials. Next, its supporters must gather more than 171,000 valid signatures by May 5.

Missouri is one of 13 states weighing abortion-related ballot measures, most of which would protect abortion rights. Abortion rights supporters hope to build on prior ballot wins in seven politically diverse states — California, Kansas, Kentucky, Michigan, Montana, Ohio, and Vermont — since the Supreme Court in 2022 overturned federal abortion protections, handing authority back to states.

In a presidential election year, national strategy also steers the money. The success of initiatives could hinge on a state’s relevance to broader party ambitions. Democrats are focused on where anger over the abortion rollback could propel voter turnout and spur party victories up and down the ballot, including in key races for the Senate and White House. Those wins would help guard against what Democrats see as a bigger threat: a national abortion ban.

Republicans are quieter about their national strategy around abortion. But at the state level, the groups mounting opposition campaigns are putting foot soldiers on the streets to deter people from signing ballot petitions.

Abortion rights supporters have raised millions more for ballot campaigns than have opponents, according to a KFF Health News review of campaign finance records in multiple states.

Still, they “don’t have unlimited resources,” said Craig Burnett, an associate professor of political science at Hofstra University and expert on ballot initiatives. They must consider, “Where am I going to get the best bang for my buck here?”

Think Big America, a nonprofit founded by J.B. Pritzker, the billionaire Democratic governor of Illinois, is giving money to abortion rights initiatives in Arizona and Nevada and plans to do so in Montana, senior adviser Mike Ollen said. All are states where abortion remains legal to varying points in pregnancy, but each could have an outsize impact on the national political balance.

Arizona and Nevada are presidential swing states viewed as crucial for President Joe Biden to win reelection. They and Montana all have races that could flip control of the U.S. Senate from Democrats to Republicans in 2025.

Ollen said electoral consequences are “part of the calculus” for Think Big America. “We want to make sure that we protect abortion in the states that we’re going into,” Ollen said. “But we’re also not naive to the threat of a national abortion ban.”

About a fifth of key voter groups — Democratic women, women who live in states where abortion is banned, women who plan to vote for Biden, and women of reproductive age — identify as abortion voters, according to new polling from KFF.

Anti-abortion groups have pressured Republican candidates to support a national ban. Presumptive GOP presidential nominee Donald Trump quietly supports a 16-week ban with some exceptions, The New York Times reported.

Susan B. Anthony Pro-Life America, one of the nation’s largest anti-abortion groups, said it plans to spend “$92 million and reach 10 million voters” to back candidates in the political battleground states of Arizona, Georgia, Michigan, Montana, North Carolina, Ohio, Pennsylvania, and Wisconsin who would “protect life across America.” It will focus on “low turnout and persuadable voters to win the presidency and a majority in Congress.”

Ballot initiatives are one way for voters to assert their power over the political whims of state legislatures or courts. They are often viewed as more stable and harder to undo.

Abortion rights supporters must fend off statehouse maneuvers by Republicans to thwart ballot initiatives, such as proposals to change how ballot measures are approved or to buttress rules on collecting signatures. Politicians are appealing to the courts to beat back abortion rights.

In Montana, abortion is legally protected as a fundamental privacy right by a 1999 court ruling. Still, supporters are seeking to enshrine abortion access in the state constitution with a ballot measure.

Republican Attorney General Austin Knudsen, who has unsuccessfully asked the courts to overturn the 1999 precedent, rejected the draft initiative because it places “multiple distinct political choices into a single initiative.” The initiative’s backers, led by Planned Parenthood of Montana’s chief medical officer, Samuel Dickman, have asked the state Supreme Court to overturn Knudsen’s ruling and allow them to start gathering signatures.

Democrats hope the ballot question will drive voter turnout and boost reelection chances for incumbent U.S. Sen. Jon Tester against the likely Republican candidate, Tim Sheehy.

Tides Foundation, a social-justice-focused charity based in California, is monitoring ballot campaigns in Montana, Arizona, and Missouri, said Beth Huang, its program officer for civic engagement and democracy. It has granted funds in Florida and is in the process of approving funds for Colorado and Nevada, she said.

As a public charity, the group “legally cannot consider the partisan implications on any set of candidate elections” in funding decisions, she said. It will fund only ballot measures that would allow abortions at least until fetal viability — generally about 24 weeks — the standard under Roe v. Wade. A proposed initiative in Arkansas is off the table because access would go to 20 weeks.

“We are not interested in policies that do less than reestablish Roe,” Huang said.

In South Dakota, Dakotans for Health wants to reinstate abortion rights in the state. But an anti-abortion campaign says out-of-state money pays for signature drives that pressure people to sign the petitions without providing sufficient information on the measure. The Republican-dominated legislature passed a bill to let people remove their signatures from such ballot petitions. An emergency clause would put the bill into effect immediately if the governor signs it — ahead of the deadline to place the abortion question on the November ballot.

Critics of other states’ measures see other avenues for defeat.

Gregg Keller, a St. Louis-based Republican political strategist, said Missouri’s proposed amendment goes further than the measure passed last year in Ohio. For example, abortions could be allowed after fetal viability to protect the mental health of a pregnant person.

If opponents can get out the word that this goes further than what was done in Ohio and other states, “we have a chance of actually beating this thing,” Keller said. “If they are able to raise money. That’s a big if.”

Ballot supporters here raised $4.2 million as of March 12, according to campaign finance records. Money has come from national groups including the American Civil Liberties Union and the Fairness Project, which has supported ballot efforts on various progressive causes. Kansas City-based Health Forward Foundation has also donated.

So far opponents of the Missouri measure have raised $55,000, nearly half of which comes from the Catholic Church, according to campaign finance records.

“We went into this knowing that we were going to be outspent,” said Missouri Catholic Conference Executive Director Jamie Morris, who said he didn’t know whether the church would spend more. “We’re still going to be out trying to educate the faithful as best as we can, with the resources we have.”

Abortion Action Missouri Executive Director Mallory Schwarz said the coalition backing the state’s abortion measure is confident it will hit the signature goal by the May deadline.

If that happens, it will be up to outgoing Republican Gov. Mike Parson, who supports Missouri’s near-total abortion ban, to decide whether to put the measure before voters in the state’s August primary or the November general election.

Keller, the GOP strategist, said the governor will face tremendous pressure to put it on the August ballot. Five of six statewide offices are on the November ballot, as is Republican Josh Hawley’s U.S. Senate seat. An abortion ballot measure could overshadow those campaigns — just based on the war chests in play: Hawley’s 2018 campaign spent about $11.5 million, for example, while the three political action committees backing Ohio’s abortion amendment last year spent over $50 million.

“I am telling anyone who is running as a Republican this year that if you want to be able to make your case about how and why you deserve to be elected, and you want to be able to get your story out,” Keller said, “then clearly you would not want to have a $50 million ballot initiative on in November.”

KFF Health News rural health care correspondent Arielle Zionts and Mountain States editor Matt Volz contributed to this report.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Health Workers Fear It’s Profits Before Protection as CDC Revisits Airborne Transmission

Kaiser Health News:States - March 19, 2024

Four years after hospitals in New York City overflowed with covid-19 patients, emergency physician Sonya Stokes remains shaken by how unprepared and misguided the American health system was.

Hospital leadership instructed health workers to forgo protective N95 masks in the early months of 2020, as covid cases mounted. “We were watching patients die,” Stokes said, “and being told we didn’t need a high level of protection from people who were not taking these risks.”

Droves of front-line workers fell sick as they tried to save lives without proper face masks and other protective measures. More than 3,600 died in the first year. “Nurses were going home to their elderly parents, transmitting covid to their families,” Stokes recalled. “It was awful.”

Across the country, hospital leadership cited advice from the Centers for Disease Control and Prevention on the limits of airborne transmission. The agency’s early statements backed employers’ insistence that N95 masks, or respirators, were needed only during certain medical procedures conducted at extremely close distances.

Such policies were at odds with doctors’ observations, and they conflicted with advice from scientists who study airborne viral transmission. Their research suggested that people could get covid after inhaling SARS-CoV-2 viruses suspended in teeny-tiny droplets in the air as infected patients breathed.

But this research was inconvenient at a time when N95s were in short supply and expensive.

Now, Stokes and many others worry that the CDC is repeating past mistakes as it develops a crucial set of guidelines that hospitals, nursing homes, prisons, and other facilities that provide health care will apply to control the spread of infectious diseases. The guidelines update those established nearly two decades ago. They will be used to establish protocols and procedures for years to come.

“This is the foundational document,” said Peg Seminario, an occupational health expert and a former director at the American Federation of Labor and Congress of Industrial Organizations, which represents some 12 million active and retired workers. “It becomes gospel for dealing with infectious pathogens.”

Late last year, the committee advising the CDC on the guidelines pushed forward its final draft for the agency’s consideration. Unions, aerosol scientists, and workplace safety experts warned it left room for employers to make unsafe decisions on protection against airborne infections.

“If we applied these draft guidelines at the start of this pandemic, there would have been even less protection than there is now — and it’s pretty bad now,” Seminario said.

In an unusual move in January, the CDC acknowledged the outcry and returned the controversial draft to its committee so that it could clarify points on airborne transmission. The director of the CDC’s National Institute for Occupational Safety and Health asked the group to “make sure that a draft set of recommendations cannot be misread to suggest equivalency between facemasks and NIOSH Approved respirators, which is not scientifically correct.”

The CDC also announced it would expand the range of experts informing their process. Critics had complained that most members of last year’s Healthcare Infection Control Practices Advisory Committee represent large hospital systems. And about a third of them had published editorials arguing against masks in various circumstances. For example, committee member Erica Shenoy, the infection control director at Massachusetts General Hospital, wrote in May 2020, “We know that wearing a mask outside health care facilities offers little, if any, protection from infection.”

Although critics are glad to see last year’s draft reconsidered, they remain concerned. “The CDC needs to make sure that this guidance doesn’t give employers leeway to prioritize profits over protection,” said Jane Thomason, the lead industrial hygienist at the union National Nurses United.

She’s part of a growing coalition of experts from unions, the American Public Health Association, and other organizations putting together an outside statement on elements that ought to be included in the CDC’s guidelines, such as the importance of air filtration and N95 masks.

But that input may not be taken into consideration.

The CDC has not publicly announced the names of experts it added this year. It also hasn’t said whether those experts will be able to vote on the committee’s next draft — or merely provide advice. The group has met this year, but members are barred from discussing the proceedings. The CDC did not respond to questions and interview requests from KFF Health News.

A key point of contention in the draft guidance is that it recommends different approaches for airborne viruses that “spread predominantly over short distances” versus those that “spread efficiently over long distances.” In 2020, this logic allowed employers to withhold protective gear from many workers.

For example, medical assistants at a large hospital system in California, Sutter Health, weren’t given N95 masks when they accompanied patients who appeared to have covid through clinics. After receiving a citation from California’s occupational safety and health agency, Sutter appealed by pointing to the CDC’s statements suggesting that the virus spreads mainly over short distances.

A distinction based on distance reflects a lack of scientific understanding, explained Don Milton, a University of Maryland researcher who specializes in the aerobiology of respiratory viruses. In general, people may be infected by viruses contained in someone’s saliva, snot, or sweat — within droplets too heavy to go far. But people can also inhale viruses riding on teeny-tiny, lighter droplets that travel farther through the air. What matters is which route most often infects people, the concentration of virus-laden droplets, and the consequences of getting exposed to them, Milton said. “By focusing on distance, the CDC will obscure what is known and make bad decisions.”

Front-line workers were acutely aware they were being exposed to high levels of the coronavirus in hospitals and nursing homes. Some have since filed lawsuits, alleging that employers caused illness, distress, and death by failing to provide personal protective equipment.

One class-action suit brought by staff was against Soldiers’ Home, a state-owned veterans’ center in Holyoke, Massachusetts, where at least 76 veterans died from covid and 83 employees were sickened by the coronavirus in early 2020.

“Even at the end of March, when the Home was averaging five deaths a day, the Soldiers’ Home Defendants were still discouraging employees from wearing PPE,” according to the complaint.

It details the experiences of staff members, including a nursing assistant who said six veterans died in her arms. “She remembers that during this time in late March, she always smelled like death. When she went home, she would vomit continuously.”

Researchers have repeatedly criticized the CDC for its reluctance to address airborne transmission during the pandemic. According to a new analysis, “The CDC has only used the words ‘COVID’ and ‘airborne’ together in one tweet, in October 2020, which mentioned the potential for airborne spread.’”

It’s unclear why infection control specialists on the CDC’s committee take a less cautious position on airborne transmission than other experts, industrial hygienist Deborah Gold said. “I think these may be honest beliefs,” she suggested, “reinforced by the fact that respirators triple in price whenever they’re needed.”

Critics fear that if the final guidelines don’t clearly state a need for N95 masks, hospitals won’t adequately stockpile them, paving the way for shortages in a future health emergency. And if the document isn’t revised to emphasize ventilation and air filtration, health facilities won’t invest in upgrades.

“If the CDC doesn’t prioritize the safety of health providers, health systems will err on the side of doing less, especially in an economic downturn,” Stokes said. “The people in charge of these decisions should be the ones forced to take those risks.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Cuando tu cobertura de salud dentro de la red… simplemente se esfuma

Sarah Feldman, de 35 años, recibió las primeras cartas amenazantes del Centro Médico Mount Sinai en noviembre pasado. El sistema hospitalario de Nueva York le advirtió que tenía problemas para negociar un acuerdo de precios con UnitedHealthcare, que incluye los planes de salud de Oxford, la aseguradora de Feldman.

“Estamos trabajando de buena fe con Oxford para alcanzar un nuevo acuerdo justo”, decía la carta, continuando con la frase tranquilizadora: “Sus médicos seguirán siendo parte de la red y debería mantener sus citas con sus proveedores”.

En los meses siguientes, llegaron una avalancha de comunicaciones sobre la disputa tanto del hospital como de la aseguradora. Pasaban de “tienes que preocuparte” a “no tienes que preocuparte'”, contó Feldman.

A fines de febrero, finalmente cayó la bomba: desde el 1 de marzo, el Mount Sinai ya no estaría en la red de la aseguradora de Feldman.

“De repente tuve que cambiar todos mis médicos, gran estrés”, dijo Feldman. Eso incluía no solo a un querido médico de atención primaria, sino también a un ginecólogo, un ortopedista y un fisioterapeuta.

Uno de los aspectos más injustos del seguro médico, en un sistema que a menudo parece diseñado para la frustración, es este: los pacientes solo pueden cambiar de seguro durante los períodos de inscripción abierta al final del año o cuando experimentan “eventos de vida” que califican para una inscripción especial, como un divorcio o un cambio de trabajo.

Pero los contratos de las aseguradoras con médicos, hospitales y farmacéuticas (o sus intermediarios, los llamados administradores de beneficios farmacéuticos) pueden cambiar abruptamente de la noche a la mañana.

Esto es particularmente irritante para los pacientes porque, ya sea que tengan cobertura a través de un empleador o compren un seguro en el mercado, generalmente eligen un plan en función de si cubre a sus médicos y hospitales preferidos, o a un medicamento costoso que necesitan.

Resulta que esa cobertura particular podría desaparecer en cualquier momento durante el término de la póliza.

Los consumidores están en riesgo, según un informe reciente de la Robert Wood Johnson Foundation, en la creciente guerra de precios entre grandes sistemas hospitalarios y mega aseguradoras en un mercado despiadado.

Estas disputas de contratos están aumentando rápidamente, el sitio web Becker’s Hospital Review cita 21 enfrentamientos entre aseguradoras y proveedores en el tercer trimestre de 2023, un aumento del 91% comparado con el mismo período el año anterior.

Por ejemplo, en septiembre pasado, los médicos de Baptist Health en Kentucky cortaron abruptamente la relación con los pacientes inscritos en los planes de Medicare Advantage de Humana, y los médicos de Vanderbilt Health en Tennessee rompieron los contratos lo hicieron con varios planes de Humana, en abril.

En ambos casos los pacientes desesperados tuvieron que buscar frenéticamente nuevos médicos dentro de la red en otros sistemas hospitalarios.

Y expertos predicen más cancelaciones de contratos en un mercado cruel. (las cancelaciones que ocurren dentro del período de inscripción, generalmente entre noviembre y enero por lo menos permite que los pacientes abandonados busquen un nuevo plan que cubra sus médicos y medicamentos).

“La respuesta humana correcta es que esto es horrible”, dijo Allison Hoffman, profesora de derecho de la Universidad de Pennsylvania, incluso si la práctica, por ahora, es “probablemente legal”.

Hoffman dijo que encontró una cláusula “enterrada” en la página 32 de su propio plan médico, de 60 páginas, que sugería que los contratos entre proveedores y aseguradoras pueden cambiar en cualquier momento.

Los reguladores estatales y federales tienen la autoridad para regular las redes de aseguradoras y podrían poner fin a la práctica, dijo Hoffman. Pero hasta ahora “no ha habido regulación federal sobre la continuidad de la cobertura”, especialmente sobre cómo definirla. Sospecha que el aparente aumento en disputas de contratos entre aseguradoras y proveedores se deriva de las regulaciones sobre la transparencia de los precios hospitalarios, que entraron en vigencia en 2022 y han permitido a los hospitales comparar tasas de reembolso entre sí.

De hecho, el Mount Sinai dijo que exigía un mejor reembolso de UnitedHealthcare porque descubrió que estaba recibiendo pagos considerablemente más bajos que otras “instituciones similares”.

Muchas aseguradoras dicen que continuarán pagando por un período después de que termine un contrato —en general de entre 60 a 90 días— o para completar un “episodio de atención” particular, como un embarazo.

Pero, por ejemplo, con el cáncer, ¿eso significaría una ronda de quimioterapia o el curso completo de un tratamiento, que podría durar muchos años? ¿Es continuidad de cobertura si un paciente debe cambiar de oncólogo en medio de una terapia, o si tiene que dejar a un terapeuta eficaz?

Erin Moses, que trabaja para una pequeña organización sin fines de lucro, encontró a un nuevo terapeuta que le gustó después que ella y su esposo se mudaron a la Costa Central de California en febrero del año pasado. En septiembre, recibió una factura de la práctica que decía que había terminado su contrato con Anthem porque la aseguradora era lenta con sus reembolsos. Esto la dejó con una factura de $814.

“No es que no pudiéramos pagarlo, pero mi esposo y yo estamos tratando de ahorrar para una casa, y eso es mucho dinero”, dijo.

A menudo, a los pacientes los toma desprevenidos, sin saber qué hacer. Cuando Laura Alley se cayó de una escalera en septiembre de 2020 y necesitó cirugía para reparar su pelvis quebrada, el hospital y el cirujano estaban en la red.

Alley escribió al proyecto “Bill of the Month” de KFF Health News y NPR y dijo: “Lo que no podía saber de ninguna manera era que el grupo que proporcionaba la anestesia estaba en disputa con el proveedor de seguros de nuestra firma, y que desde el 30 de julio de 2020, ya no estaban en la red”.

Se sintió “como un títere”, dijo. “Mientras trabajo para recuperarme de una lesión traumática, estoy atrapada en medio de una disputa entre una enorme compañía de seguros y un gran grupo de médicos”.

Alley es dueña de una pequeña firma de arquitectura con su esposo, y terminaron pagando “casi $10,000” por servicios de anestesia fuera de la red. (Este tipo de factura fuera de la red para el paciente ahora estaría prohibido por el No Surprises Act, vigente desde 2022).

Nada de esto será noticia para Feldman, la paciente del Mount Sinai que fue una inocente espectadora en la disputa del sistema hospitalario con Oxford Health Plans. Los padres de Feldman la llamaron recientemente, diciendo que recibieron una carta de su aseguradora, Anthem, diciendo que el 1 de mayo podría terminar su contrato con el Hospital NewYork-Presbyterian, en donde la madrastra de Feldman recibe tratamiento por un cáncer de mama.

Es malo para la salud —y para la cordura— de los pacientes que las promesas percibidas de atención en sus planes de seguro puedan desaparecer repentinamente a mitad de año. Y los reguladores pueden hacer algo al respecto: obligar a los proveedores y aseguradoras a mantener sus contratos entre sí durante todo el término de las pólizas de los pacientes, para que ninguno quedé atrapado en una guerra con la que no tienen nada que ver.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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HHS, DHS, and FEMA Announce Completion of Multi-Year Review of State Efforts to Provide Language Access During the COVID-19 Public Health Emergency

HHS Gov News - March 18, 2024
HHS, DHS, and FEMA complete a 19-state language access compliance on COVID-19 public health messaging.

As More States Target Disavowed ‘Excited Delirium’ Diagnosis, Police Groups Push Back

Kaiser Health News:States - March 18, 2024

Following a pivotal year in the movement to discard the term “excited delirium,” momentum is building in several states to ban the discredited medical diagnosis from death certificates, law enforcement training, police incident reports, and civil court testimony.

In January, California became the first state to prohibit the medical term from many official proceedings. Now, lawmakers in Colorado, Hawaii, Minnesota, and New York are considering bills that also would rein in how the excited delirium concept is used.

The new spate of state proposals, driven by families who lost relatives after encounters with law enforcement, marks an important step in doing away with a concept that critics say spurs police to overuse lethal force.

“It’s the law following the science, which is what we want to see,” said Joanna Naples-Mitchell, an attorney who worked on an influential Physicians for Human Rights review of how the term excited delirium evolved into a concept whose legitimacy is largely rejected by the medical community.

But initial momentum in statehouses is being met with fresh resistance from law enforcement agencies and other defenders, including some who agree that excited delirium is a sham diagnosis.

The bills “clearly run afoul of the First Amendment” and violate free speech, said Bill Johnson, executive director of the National Association of Police Organizations. He also argued that law enforcement officers do encounter symptoms and behaviors associated with excited delirium.

Excited delirium is a four-decade-old diagnostic theory that has been used to explain how a person experiencing severe agitation can suddenly die while being restrained. Last year, the American College of Emergency Physicians withdrew a 2009 report that had been the last remaining official medical pillar of support for the theory used increasingly over the prior 15 years to explain away police culpability for many in-custody deaths.

Excited delirium was cited as a legal defense in the 2020 deaths of George Floyd in Minneapolis; Daniel Prude in Rochester, New York; and Angelo Quinto in Antioch, California, among others. The theory proposed that individuals in a mental health crisis, often under the influence of drugs or alcohol, can exhibit superhuman strength as police try to control them, then die suddenly from the condition, not the police response.

The New York City Police Department issued training materials in 2021 and 2022 that tell officers to restrain and stun people they encounter who exhibit signs of excited delirium, such as “elevated body temperatures, increased physical strength and lack of physical fatigue,” according to New York Focus, a nonprofit newsroom. The NYPD did not respond to requests for comment on its training or the new state bill.

“They still have this on the books,” said Democratic New York state Assembly member Jessica González-Rojas, who introduced the bill that calls for banning the term from death certificates, autopsies, law enforcement training, incident reports, and court proceedings. “And it’s pretty concerning the types of restraints they are recommending, given lack of evidence that this is an actual medical syndrome.”

The Minneapolis Police Department, which according to the Star Tribune used the term in trainings, declined to comment on its training materials and the pending state legislation. That bill would prohibit excited delirium and similar terms from being cited as a cause of death, used as a medical diagnosis, or included in law enforcement training.

But the theory’s presence in training materials may also be starting to change. In Colorado — where the term was used, in part, to justify the 2019 killing of Elijah McClain in Aurora — a state board eliminated the term from law enforcement training starting this January. Law enforcement officers restrained the 23-year-old, and paramedics injected him with a lethal dose of ketamine.

This year, Colorado lawmakers are debating a measure that largely mirrors California’s bill but allows the term to remain in civil court proceedings.

At the bill’s hearing before the Colorado House Judiciary Committee on Feb. 6, Rebecca De Luna described her family’s anguish over the 2017 death of her daughter’s father, Alejandro Gutierrez, in Thornton police custody. She said excited delirium was classified as the cause of his death.

“His face was bruised with an imprint of a shoe. His appearance was unrecognizable,” De Luna testified. “The term has been used far too long as an excuse for law enforcement to protect themselves when someone dies in their custody, quite frankly, as a result of excessive force and what I consider police brutality resulting in death.”

Several medical service providers and educators testified in opposition. John Seward, the University of Denver’s emergency medical services program manager, told the committee that he did not object to banning “excited delirium” in death certificates and police training, as police are not health professionals. But banning the term’s use from medical personnel training would amount to legislating medicine and impeding academic freedom, he said.

“If we cannot study and learn from the past, even when that past is hurtful, we are now condemning ourselves to repeat it,” Seward told lawmakers.

Julia Sherwin, a California civil rights attorney who testified in support of the Colorado bill, was surprised by opponents’ arguments that such bills could limit free speech and discussion about the history of the idea.

“That to me felt a little ridiculous,” said Sherwin, who co-authored the Physicians for Human Rights report. Such bills keep a discredited theory from being falsely used to respond to a crisis and keep “junk science” out of official records, she said.

The Colorado bill passed the state’s House in a 42-19 vote in mid-February and is now before the state Senate. It was amended to clarify that “excited delirium” may be used when teaching about the history of the term and that EMS courses are allowed on “safe and effective medical interaction with individuals exhibiting an altered mental state” who have symptoms that include agitation, aggression, or violence.

Some of the push for such legislation comes from families whose loved ones’ deaths were blamed on excited delirium, rather than on use of force during a police encounter. The Hawaii bill was introduced after William and Verdell Haleck learned about California’s effort and began contacting lawmakers in Hawaii. Their son Sheldon died there in 2015 after he was pepper-sprayed, shocked, and restrained by Honolulu police. In a civil trial that the Halecks lost, officers blamed his death on excited delirium.

The Hawaii bill would ban excited delirium from being used in death certificates, police incident reports, and civil cases. It had not been scheduled for a legislative committee hearing as of mid-March, but the Halecks are hopeful it will eventually pass.

“It would give us some sort of closure and justice,” said William Haleck.

The Honolulu Police Department is monitoring the bill and hasn’t taken a position on it, said Michelle Yu, a spokesperson for the department. And the bill would have little impact on Honolulu’s Department of the Medical Examiner, said its director, Masahiko Kobayashi, because doctors there don’t use excited delirium as a cause of death.

One reason such bills are still important is because they prevent policies from fluctuating with each new leadership change, said David Siffert, legal director of the Surveillance Technology Oversight Project, which helped draft model legislation banning excited delirium and is pushing for the New York bill.

“Even if you are doing everything right, you don’t know if your successor will be,” Siffert said. “Historically we have seen those ups and downs in our agencies.”

Supporters of such state legislation say that banning the term excited delirium is just a first step toward reducing deaths in police custody.

“The underlying context doesn’t change with legislation alone,” Naples-Mitchell said. “It is going to take a very long time to address the root causes.”

Mountain States editor Matt Volz contributed to this article.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Covid and Medicare Payments Spark Remote Patient Monitoring Boom

Kaiser Health News:Insurance - March 18, 2024

Billy Abbott, a retired Army medic, wakes at 6 every morning, steps on the bathroom scale, and uses a cuff to take his blood pressure.

The devices send those measurements electronically to his doctor in Gulf Shores, Alabama, and a health technology company based in New York, to help him control his high blood pressure.

Nurses with the company, Cadence, remotely monitor his readings along with the vital signs of about 17,000 other patients around the nation. They call patients regularly and follow up if anything appears awry. If needed, they can change a patient’s medication or dosage without first alerting their doctor.

Abbott, 85, said he likes that someone is watching out for him outside his regular doctor appointments. “More doctors should recommend this to their patients,” he said.

Increasingly, they are.

Dozens of tech companies have streamed in, pushing their remote monitoring service to primary care doctors as a way to keep tabs on patients with chronic illnesses and free up appointment time, and as a new source of Medicare revenue.

But some experts say remote monitoring’s huge growth — spurred on during the covid-19 pandemic, when patients were hesitant to sit in crowded doctors’ waiting rooms — has outpaced oversight and evidence of how the technology is best used.

“It is the wild West where any patient can get it if a doctor decides it is reasonable or necessary,” said Caroline Reignley, a partner with the law firm McDermott Will & Emery who advises health providers.

In 2019, Medicare made it easier for doctors to bill for monitoring routine vital signs such as blood pressure, weight, and blood sugar. Previously, Medicare coverage for remote monitoring was limited to certain patients, such as those with a pacemaker.

Medicare also began allowing physicians to get paid for the service even when the monitoring is done by clinical staff who work in different places than the physician — an adjustment advocated by telemedicine companies.

In just the first two full years, remote monitoring services billed to Medicare grew from fewer than 134,000 to 2.4 million in 2021, according to federal records analyzed by KFF Health News.

Total Medicare payments for the four most common billing codes for remote monitoring rose from $5.5 million in 2019 to $101.4 million in 2021, the latest year for which data is available.

Part of the allure is that Medicare will pay for remote monitoring indefinitely regardless of patients’ health conditions as long as their doctors believe it will help.

For doctors with 2,000 to 3,000 patients, the money can add up quickly, with Medicare paying an average of about $100 a month per patient for the monitoring, plus more for setting up the device, several companies confirmed.

Medicare enrollees may face 20% in cost sharing for the devices and monthly monitoring, though certain private plans through Medicare Advantage and Medicare supplement policies may cover those costs. The government allowed insurers to waive the patient cost sharing during the pandemic.

About 400 doctors and other providers repeatedly billed Medicare for remote patient monitoring in 2019. Two years later, that had mushroomed to about 3,700 providers, according to Medicare data analyzed by KFF Health News. (The data tracks providers who billed more than 10 patients for at least one type of remote monitoring.)

Federal law enforcement officials say they are conducting investigations after a surge in complaints about some remote patient monitoring companies but would not provide details.

The Department of Health and Human Services’ Office of Inspector General in November issued a consumer alert about companies signing up Medicare enrollees without their doctors’ knowledge: “Unscrupulous companies are signing up Medicare enrollees for this service, regardless of medical necessity,” and bill Medicare even when no monitoring occurs.

In a statement to KFF Health News, Meena Seshamani, director of the federal Center for Medicare, part of the Centers for Medicare & Medicaid Services, did not say how CMS is ensuring only patients who can benefit from remote monitoring receive it. She said the agency balances the need to give patients access to emerging technology that can improve health outcomes with the need to combat fraud and make proper payments to providers.

While some small studies show remote monitoring can improve patient outcomes, researchers say it is unclear which patients are helped most and how long they need to be monitored.

“The research evidence is not as robust as we would like to show that it is beneficial,” said Ateev Mehrotra, a Harvard Medical School researcher.

A January report by the Bipartisan Policy Center, a Washington, D.C.-based think tank, warned about “a lack of robust evidence on the optimal use of remote monitoring” and said some policy and medical experts “question whether we are effectively ‘rightsizing’ the use of these services, ensuring access for patients who need it most, and spending health care dollars in effective ways.”

Denton Shanks, a medical director at the American Academy of Family Physicians, said remote monitoring helps patients manage their diseases and helps physician practices be more efficient. He has used it for the past two years as a doctor at the University of Kansas Health System.

It has worked well, he said, though sometimes it can be challenging to persuade patients to sign up if they have to pay for it.

“For the vast majority of patients, once they are enrolled, they see a benefit, and we see a benefit as their vital signs come in the normal range,” Shanks said.

The size of the market is tantalizing.

About two-thirds of the more than 66 million Medicare beneficiaries have high blood pressure, the most common metric monitored remotely, according to physicians and the monitoring companies.

“The patient need is so enormous,” Cadence CEO Chris Altchek said. The company has about 40 nurses, medical assistants, and other providers monitoring patients in 17 states. He said patients enrolled in remote monitoring experience a 40% reduction in emergency room visits. Cadence says 82% of its patients use the devices at least once every two days.

Timothy Mott, a family physician in Foley, Alabama, said valuable appointment times in his office open up as patients who previously needed vital signs to be checked there turn to remote monitoring.

Cadence nurses regularly contact Mott’s patients and monitor their readings and make changes as needed.

“I was concerned early on whether they were going to make the right decisions with our patients,” Mott said. “But over time the dosage changes or changes in medication they are making are following the best guidelines on effectiveness.”

At the six-month mark, about 75% of patients have stayed with the monitoring, Mott said.

The advantages are apparent even to some providers who do not get paid by Medicare to offer the service. Frederick Health, a Maryland health system, provides remote monitoring to 364 high-risk patients and estimates the program saves the nonprofit system $10 million a year by reducing hospital admissions and ER visits. That estimate is based on comparisons of patients’ Medicare claims before they started the program and after, said Lisa Hogan, who runs the program.

The hospital pays for the program and does not bill Medicare, she said.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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When Copay Assistance Backfires on Patients

Kaiser Health News:Insurance - March 15, 2024

In early 2019, Jennifer Hepworth and her husband were stunned by a large bill they unexpectedly received for their daughter’s prescription cystic fibrosis medication. Their payment had risen to $3,500 from the usual $30 for a month’s supply.

That must be a mistake, she told the pharmacy. But it wasn’t. It turned out that the health insurance plan through her husband’s job had a new program in which it stopped applying any financial assistance they received from drugmakers to the family’s annual deductible.

Insurers or employers can tap into funds provided to patients by drugmakers through copay assistance programs, which were designed by the companies to help patients afford increasingly expensive medications. But, because those payments are no longer counted toward the deductible, patients must pay an amount out-of-pocket, too, often for the same drugs. Those deductibles or other out-of-pocket costs can easily run into thousands of dollars.

Here’s what that meant for Hepworth, who lives in Utah. Before the change, the drugmaker’s copay assistance would almost immediately meet her family’s deductible for the year, because both Hepworth and her daughter need expensive medications. As a result, the family was responsible for copays of only 20% of their medical costs instead of the 100% required by their plan until they met their deductible. By the middle of the year, the family would have reached the plan’s out-of-pocket maximum of nearly $10,000 and would no longer owe any copays.

Hepworth ended up paying the $3,500 to the pharmacy, equivalent to the family’s annual deductible, because she didn’t want to stop giving her daughter a treatment that could extend her life. “We were struggling and everything went on credit cards.”

Why did the insurer do this?

Employers or the health insurance plans they hire are saving 10% to 15% of the cost of prescription plan claims by using these copay accumulator programs, said Edward Kaplan, a senior vice president at Segal, a benefits consulting firm. Even so, Kaplan doesn’t recommend that his clients, who include public and private employers, take advantage of the program because of the increasing pushback from lawmakers and advocacy groups. However, the majority of insured people are in plans governed by these types of programs, according to Avalere, a consulting firm.

Nineteen states now limit copay accumulator programs for some insurance plans. And patient advocacy groups have won a favorable court ruling against the programs. States’ limits on the practice, however, do not apply to larger, self-insured job-based plans, through which many Americans have coverage.

Bipartisan legislation has been introduced in both chambers of Congress that would require financial assistance to count toward deductibles and other out-of-pocket costs. Called the Help Ensure Lower Patient Copays Act, it would govern plans that are exempt from state rules.

Change is unlikely to come soon.

Insurers and employers have long complained that copay assistance programs are mainly a marketing ploy by the drug industry that encourages patients to stay on costly drugs when lower-cost alternatives might be available. Insurers say capturing more of that money themselves can help slow the rising price of premiums.

In a recent letter to regulators, the Blue Cross Blue Shield Association called the practice “a vital tool in keeping health insurance affordable.”

Patient advocacy groups, including the HIV+Hepatitis Policy Institute and two diabetes groups, disagreed and took a case against copay accumulator programs to U.S. District Court last fall.

And “we won,” said Carl Schmid, executive director of the institute. The groups argued the practice can cause some patients to skip their medications because of the unexpected costs they must now shoulder.

Some critics say it’s a form of double dipping because even though the patient hasn’t personally paid out-of-pocket, “that payment was made, and it was made on your behalf. I think that should get counted,” said Rachel Klein, deputy executive director with the AIDS Institute, an advocacy group.

The court decision, Schmid said, essentially overturns a 2021 provision in Centers for Medicare & Medicaid Services rules that allowed insurers to expand the practice to cover almost any drug. Previous rules from 2020 would now be in effect, said Schmid, and those rules say copay assistance should count toward the deductible for all drugs for which there is no medically appropriate generic alternative available.

Even so, billing changes for many insured patients may take a while.

While the Biden administration dropped an appeal of the court decision, it has filed motions noting “it does not intend to take any enforcement action against issuers or plans” until regulators draw up new rules, said Ellen Montz, deputy administrator and director of the Center for Consumer Information and Insurance Oversight at CMS, in a written statement to KFF Health News.

A version of these programs being used by insurers, sometimes called a “maximizer,” works a bit differently.

Under a maximizer program, insurers partner with outside firms such as PrudentRX and SaveOnSP. The programs declare certain drugs or classes of drugs “nonessential,” thus allowing them to circumvent some Affordable Care Act rules that limit patient cost sharing. That lets the insurer collect the maximum amount from a drugmaker’s assistance program, even if that is more than the patient would owe through deductibles or out-of-pocket maximums had the drugs remained essential benefits. These partner companies also work with large pharmacy benefit managers that oversee prescription services for employers.

Those maximizer payments do not count toward a patient’s deductible. Many insurers don’t charge patients an additional copay for the drugs deemed nonessential as a way of enticing them to sign up for the programs. If patients choose not to enroll, they could face a copayment far higher than usual because of the “nonessential” designation.

“This is a loophole in the ACA that they are exploiting,” said Schmid of the HIV+Hepatitis Policy Institute, referring to the Affordable Care Act. Johnson & Johnson filed a lawsuit in federal court in New Jersey in 2022 against such a maximizer program, saying it coerced patients into participating because if they didn’t they faced higher copays. The drugmaker warned it might reduce the amount of overall assistance available to patients because of the increasingly common practice.

Now, though, a provision in the proposed 2025 federal rules governing health insurers says plans must consider any covered drug an “essential benefit.” If finalized, the provision would hamper insurers’ ability to collect the maximum amount of drugmaker assistance.

Employers are watching for the outcome of the lawsuit and the proposed federal rules and don’t yet have clarity on how rulings or regulations will affect their programs, said James Gelfand, president and chief executive of the ERISA Industry Committee, which advocates for large, self-insured employers.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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A New Orleans Neighborhood Confronts the Racist Legacy of a Toxic Stretch of Highway

Kaiser Health News:States - March 15, 2024

Aside from a few discarded hypodermic needles on the ground, the Hunter’s Field Playground in New Orleans looks almost untouched. It’s been open more than nine years, but the brightly painted red and yellow slides and monkey bars are still sleek and shiny, and the padded rubber tiles feel springy underfoot.

For people who live nearby, it’s no mystery why the equipment is in relatively pristine shape: Children don’t come here to play.

“Because kids are smart,” explained Amy Stelly, an artist and urban designer who lives about a block away on Dumaine Street. “It’s the adults who aren’t. It’s the adults who built the playground under the interstate.”

Hunter’s Field is wedged directly beneath the elevated roadbeds of the Claiborne Expressway section of Interstate 10 in the city’s 7th Ward.

There are no sounds of laughter or children playing. The constant cuh-clunk, cuh-clunk of the traffic passing overhead makes it difficult to hold a conversation with someone standing next to you. An average of 115,000 vehicles a day use the overpass, according to a 2012 study.

“I have never seen a child play here,” Stelly said.

Stelly keeps a sharp eye on this area as part of her advocacy work with the Claiborne Avenue Alliance, a group of residents and business owners dedicated to revitalizing the predominantly African American community on either side of the looming expressway.

For as long as she can remember, Stelly has been fighting to dismantle that section of the highway. She’s lived in the neighborhood her entire life and said the noise is oftentimes unbearable. “You can sustain hearing damage,” she said. Now, she’s helping collect new noise and air pollution data to show it needs to be taken down.

The Claiborne Expressway was built in the 1960s, when the construction of interstates and highways was a symbol of progress and economic development in the U.S.

But that supposed progress often came at a great cost for marginalized communities — especially predominantly Black neighborhoods.

When it was built, the “Claiborne Corridor,” as it’s still sometimes known, tore through the heart of Tremé, one of the nation’s oldest Black neighborhoods.

For more than a century before the construction of the expressway, bustling Claiborne Avenue constituted the backbone of economic and cultural life for Black New Orleans. Back then, the oak-lined avenue was home to more than 120 businesses. Today, only a few dozen remain.

What happened to Claiborne Avenue isn’t unique. Federal planners often routed highways directly through low-income minority neighborhoods, dividing communities and polluting the air.

In Montgomery, Alabama, I-85 cut through the city’s only middle-class Black neighborhood and was “designed to displace and punish the organizers of the civil rights movement,” according to Rebecca Retzlaff, a community planning professor at Auburn University. In Nashville, planners intentionally looped I-40 around a white community, and sent it plowing through a prominent Black neighborhood, knocking down hundreds of homes and businesses. Examples like this exist in major cities across the country.

The federal government has started working on ways to confront the damage highway construction continues to do to low-income and minority communities. An initiative established in the Infrastructure Investment and Jobs Act called the Reconnecting Communities Pilot seeks to do just that: reconnect neighborhoods and communities that were divided by infrastructure.

But there’s wide disagreement on the best way to do that, and some strategies are likely to do little to limit the health effects of living near these highways. What’s unfolding in New Orleans shows how challenging it is to pick and fund projects that will help.

Competing Visions for the Claiborne Expressway

Stelly’s group, the Claiborne Avenue Alliance, submitted a proposal for Reconnecting Communities Pilot money. It wanted $1.6 million in federal funds primarily for public engagement, data collection, and feasibility planning to work to assess whether it would be possible to remove the expressway altogether, with a plan to raise $400,000 more to cover costs.

And it seemed possible its grant proposal would succeed, since even the White House cited the Claiborne Expressway as a textbook example of the biased planning history in a published statement about the Reconnecting Communities Pilot. Ultimately, though, the federal Department of Transportation, the agency charged with allocating the program’s money, denied the Claiborne Avenue Alliance’s grant request.

Instead, the Department of Transportation offered a small fraction of the money requested in a competing joint proposal made by the city of New Orleans and the state of Louisiana. That plan called for a $47 million grant from Reconnecting Communities to do overpass improvements, remove some on- and off-ramps, and, most significantly, create the “Claiborne Innovation District” to promote public life and cultural activities under the highway. DOT granted just $500,000 for the project.

Stelly said she likes a few aspects of the city-state proposal, notably the plan to remove on- and off-ramps to improve pedestrian safety beneath the expressway and other public safety projects, like better lighting and dedicated pedestrian and bicycle lanes.

But, notably, Stelly called the idea of creating an entertainment space and market beneath the highway misguided and ridiculous. Would it be a waste of scarce government funds?

“It’s a foolish idea because you’re going to be exposed to the same thing” as the neglected playground, Stelly said. “You’re going to be exposed to the same levels of noise. It’s not a wise decision to build anything under here.”

Using Science to Inform Policy

Since her group’s proposal was denied, Stelly and her organization are turning to a new strategy: helping with a new study funded by the Environmental Protection Agency on the expressway’s health impacts. They hope the data will support them in their efforts to remove the highway from their neighborhood.

In addition to noise impacts, the EPA-funded study is looking at the health impacts of pollution under the Claiborne Expressway — especially harmful pollutants like particulate matter 2.5, or PM 2.5.

These microscopic particles, measuring 2.5 microns or less in diameter, are released from the tailpipes of passing vehicles, said Adrienne Katner, an associate professor at the Louisiana State University School of Public Health, who is the principal investigator on the EPA study. They’re so small that, when inhaled, they lodge deep in the lungs. From there, they can migrate to the circulatory system, and then spread and potentially affect every system in the body.

“So the heart, the brain,” said Katner. “If a woman is pregnant, it can cross the placental barrier. So it has a lot of impacts.”

Katner and her team of researchers are beginning the study by taking preliminary readings with monitors at different points along the expressway. Completing the research and publishing the data will likely take two to three years.

One of Katner’s monitoring sites is Hunter’s Field Playground. Graduate researcher Jacquelynn Mornay said the noise levels registered there could cause permanent hearing damage after an hour or so of exposure. The pollution levels recorded hover around 18 micrograms per cubic meter.

“It should be at most — at most — 12,” said Beatrice Duah, another graduate student researcher. “So it is way over the limits.”

Residents and workers occupying the homes and businesses lining the area under the expressway are exposed daily to these levels of noise and pollution. When complete, this EPA study will join a decades-long body of research about how traffic pollution affects the human body.

“We’re not inventing the science here,” Katner said. “All I’m doing is showing them what we already know and then documenting it, giving them the data to then inform and influence policy. That’s all I can do.”

‘Removal Is the Only Cure’

Eventually, the study’s findings could help other communities divided by infrastructure across the country, Katner said.

“A lot of cities are going through this right now and they’re looking back at their highway systems,” she said. “They’re looking back at the impacts that it’s had on a community and they’re trying to figure out what to do next. I’m hoping that this project will inform them.”

Amy Stelly said she’s always known the air she and her neighbors breathe isn’t safe, but she’s hopeful that having concrete data to support her efforts will do more to persuade policymakers to address the problem. That could mean taking down the dangerous on- and off-ramps — or scrapping what she considers to be the wasteful plan of putting a market and event space under the highway overpass.

Stelly sees only one true solution to the problems posed by the Claiborne Expressway, only one way to really right the wrongs done to her community.

“Removal is the only cure,” Stelly said. “I’m insisting on it because I’m a resident of the neighborhood and I live with this every day.” And, she said, “the science tells us there’s no other way.”

This article is from a partnership that includes WWNO, NPR, and KFF Health News.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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How Your In-Network Health Coverage Can Vanish Before You Know It

Kaiser Health News:Insurance - March 15, 2024

Sarah Feldman, 35, received the first ominous letters from Mount Sinai Medical last November. The New York hospital system warned it was having trouble negotiating a pricing agreement with UnitedHealthcare, which includes Oxford Health Plans, Feldman’s insurer.

“We are working in good faith with Oxford to reach a new fair agreement,” the letter said, continuing reassuringly: “Your physicians will remain in-network and you should keep appointments with your providers.”

Over the next few months, a flurry of communications about the dispute from both the hospital and the insurance company arrived. “It was, ‘You have to worry, you don’t have to worry,’” Feldman told me.

In late February, the other shoe finally dropped. As of March 1, Mount Sinai would no longer be in-network with Feldman’s insurer.

“I suddenly have to change all my doctors — here’s some stress for you,” Feldman said. That included not only a beloved primary care physician but also a gynecologist, an orthopedist, and a physical therapist.

One of the most unfair aspects of medical insurance, in a system that often seems designed for frustration, is this: Patients can change insurance only during end-of-year enrollment periods or at the time of “qualifying life events,” such as a divorce or job change. But insurers’ contracts with doctors, hospitals and pharmaceutical companies (or their arbiters, so-called pharmacy benefit managers) can change abruptly at any time.

That is particularly galling for patients because, whether obtaining insurance through an employer or buying it on the marketplace, they generally choose a policy based on whether it covers their desired doctors and hospital or an expensive drug they need. Turns out that particular coverage could evaporate at any time during the policy term.

Consumers are put at risk, according to a recent report by the Robert Wood Johnson Foundation, in the escalating warfare over pricing between big, consolidated hospital systems and ever-bigger insurers in a cutthroat market. Such contract disputes are increasing rapidly — the Becker’s Hospital Review website cites 21 insurer-provider standoffs in the third quarter of 2023, a 91% increase over the same period the year before.

For example, last September, the physicians at Baptist Health in Kentucky abruptly cut ties with patients enrolled in Humana’s Medicare Advantage plans, and physicians at Tennessee’s Vanderbilt Health broke off contracting with a number of Humana Plans in April — in both cases sending patients scrambling to find new in-network doctors affiliated with other hospital systems. And experts predict more contract terminations in a merciless market. (That includes more Jan. 1 terminations each year — but in that case, at least, the patients cast adrift have the ability to shop for a new plan that covers their doctors and drugs.)

“The correct human response is that this is horrible,” said Allison Hoffman, a University of Pennsylvania law professor, even if the practice, for now, is “probably legal.” Hoffman said she found a clause buried on Page 32 of her own 60-page insurance policy suggesting that provider-insurance contracts may change at any time.

State and federal regulators have the authority to regulate insurers’ networks and could end the practice, Hoffman said. But until now “there hasn’t been federal regulation about continuity of coverage,” particularly how to define it. She suspects that the apparent surge in contract disputes between insurers and providers stems from hospital price transparency regulations that took effect in 2021 and have allowed hospitals to compare reimbursement rates with one another.

Indeed, Mount Sinai said it was demanding better reimbursement from UnitedHealthcare because it had discovered that it was being paid “substantially less” than “peer institutions.”

Many insurers say they will continue paying for a period after a contract ends — often 60 to 90 days — or to complete an “episode of care,” for a pregnancy, in particular. But with, say, cancer, would that mean one round of chemotherapy or the full course of treatment, which could last for many years? Is it continuity of coverage if a patient must change oncologists midstream or if a patient has to leave an effective therapist?

Erin Moses, who works for a small nonprofit, found a new therapist she liked after she and her husband moved to California’s Central Coast in February last year. In September, she received a bill from the therapy group saying it had terminated its contract with Anthem because the insurer was slow in reimbursement, leaving her with a bill of $814.

“It’s not like we couldn’t pay it, but my husband and I are trying to save for a house, and it’s a big chunk of change,” she said.

Patients are often caught unaware — and left holding the bag. When Laura Alley fell off a ladder in September 2020 and needed surgery to repair a broken pelvis, the hospital was in-network, as was the trauma surgeon.

In her submission to the “Bill of the Month” (the source of other examples in this article), a joint project of KFF Health News and NPR, Alley wrote: “What I could not possibly have known” was that the group that provided the anesthesia “was in dispute with our firm’s insurance provider, and after July 30, 2020, they were no longer in-network.”

She felt like “a pawn,” she said. “As I am working to recover from a traumatic injury, I am stuck in the middle of a dispute between an enormous insurance company and a large physicians group.”

She and her husband own a small architecture firm and ended up paying “nearly $10,000” for out-of-network anesthesia services. (This type of out-of-network bill to the patient would now be prohibited by the No Surprises Act, which took effect in 2022.)

None of this will be news to Feldman, the Mount Sinai patient who was an innocent bystander in the hospital system’s dispute with Oxford Health Plans. Feldman’s parents called her recently, saying they’d received a letter from their insurer, Anthem, that on May 1 it might end its contract with NewYork-Presbyterian Hospital — where Feldman’s stepmother is being treated for breast cancer.

It is bad for patients’ health — and sanity — that the perceived promises of care in their insurance plans can suddenly disappear midyear. And regulators can do something about that: obligate providers and insurers to maintain their contracts with one another for the full term of patients’ policies, so no patients are left in the lurch.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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KFF Health News' 'What the Health?': Maybe It’s a Health Care Election After All

The Host Julie Rovner KFF Health News @jrovner Read Julie's stories. Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

The general election campaign for president is (unofficially) on, as President Joe Biden and former President Donald Trump have each apparently secured enough delegates to become his respective party’s nominee. And health care is turning out to be an unexpectedly front-and-center campaign issue, as Trump in recent weeks has suggested he may be interested in cutting Medicare and taking another swing at repealing and replacing the Affordable Care Act.

Meanwhile, the February cyberattack of Change Healthcare, a subsidiary of insurance giant UnitedHealth Group, continues to roil the health industry, as thousands of hospitals, doctors, nursing homes, and other providers are unable to process claims and get paid.

This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Joanne Kenen of Johns Hopkins University and Politico Magazine, and Margot Sanger-Katz of The New York Times.

Panelists Anna Edney Bloomberg @annaedney Read Anna's stories. Joanne Kenen Johns Hopkins Bloomberg School of Public Health and Politico @JoanneKenen Read Joanne's articles. Margot Sanger-Katz The New York Times @sangerkatz Read Margot's stories.

Among the takeaways from this week’s episode:

  • It is unclear exactly what Trump meant in his recent remarks about possible cuts to Medicare and Social Security, though his comments provided an opening for Biden to pounce. By running as the candidate who would protect entitlements, Biden could position himself well, particularly with older voters, as the general election begins.
  • Health care is shaping up to be the sleeper issue in this election, with high stakes for coverage. The Biden administration’s expanded subsidies for ACA plans are scheduled to expire at the end of next year, and the president’s latest budget request highlights his interest in expanding coverage, especially for postpartum women and for children. Plus, Republicans are eyeing what changes they could make should Trump reclaim the presidency.
  • Meanwhile, Republicans are grappling with an internal party divide over access to in vitro fertilization, and Trump’s mixed messaging on abortion may not be helping him with his base. Could a running mate with more moderate perspectives help soften his image with voters who oppose abortion bans?
  • A federal appeals court ruled that a Texas law requiring teenagers to obtain parental consent for birth control outweighs federal rules allowing teens to access prescription contraceptives confidentially. But concerns that if the U.S. Supreme Court heard the case a conservative-majority ruling would broaden the law’s impact to other states may dampen the chances of further appeals, leaving the law in effect. Also, the federal courts are making it harder to file cases in jurisdictions with friendly judges, a tactic known as judge-shopping, which conservative groups have used recently in reproductive health challenges.
  • And weeks later, the Change Healthcare hack continues to cause widespread issues with medical billing. Some small providers fear continued payment delays could force them to close, and it is possible that the hack’s repercussions could soon block some patients from accessing care at all.

Also this week, Rovner interviews Kelly Henning of Bloomberg Philanthropies about a new, four-part documentary series on the history of public health, “The Invisible Shield.”

Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: The Washington Post’s “Navy Demoted Ronny Jackson After Probe Into White House Behavior,” by Dan Diamond and Alex Horton.

Joanne Kenen: The Atlantic’s “Frigid Offices Might Be Killing Women’s Productivity,” by Olga Khazan.

Margot Sanger-Katz: Stat’s “Rigid Rules at Methadone Clinics Are Jeopardizing Patients’ Path to Recover From Opioid Addiction,” by Lev Facher.

Anna Edney: Scientific American’s “How Hospitals Are Going Green Under Biden’s Climate Legislation,” by Ariel Wittenberg and E&E News.

Also mentioned on this week’s podcast:

Credits Francis Ying Audio producer Emmarie Huetteman Editor

To hear all our podcasts, click here.

And subscribe to KFF Health News’ “What the Health?” on SpotifyApple PodcastsPocket Casts, or wherever you listen to podcasts.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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They Were Injured at the Super Bowl Parade. A Month Later, They Feel Forgotten.

Kaiser Health News:States - March 14, 2024

KFF Health News and KCUR are following the stories of people injured during the Feb. 14 mass shooting at the Kansas City Chiefs Super Bowl celebration. Listen to how one Kansas family is coping with the trauma.

Jason Barton didn’t want to attend the Super Bowl parade this year. He told a co-worker the night before that he worried about a mass shooting. But it was Valentine’s Day, his wife is a Kansas City Chiefs superfan, and he couldn’t afford to take her to games since ticket prices soared after the team won the championship in 2020.

So Barton drove 50 miles from Osawatomie, Kansas, to downtown Kansas City, Missouri, with his wife, Bridget, her 13-year-old daughter, Gabriella, and Gabriella’s school friend. When they finally arrived home that night, they cleaned blood from Gabriella’s sneakers and found a bullet in Bridget’s backpack.

Gabriella’s legs were burned by sparks from a ricocheted bullet, Bridget was trampled while shielding Gabriella in the chaos, and Jason gave chest compressions to a man injured by gunfire. He believes it was Lyndell Mays, one of two men charged with second-degree felony murder.

“There’s never going to be a Valentine’s Day where I look back and I don’t think about it,” Gabriella said, “because that’s a day where we’re supposed to have fun and appreciate the people that we have.”

One month after the parade in which the U.S. public health crisis that is gun violence played out on live television, the Bartons are reeling from their role at its epicenter. They were just feet from 43-year-old Lisa Lopez-Galvan, who was killed. Twenty-four other people were injured. Although the Bartons aren’t included in that official victim number, they were traumatized, physically and emotionally, and pain permeates their lives: Bridget and Jason keep canceling plans to go out, opting instead to stay home together; Gabriella plans to join a boxing club instead of the dance team.

During this first month, Kansas City community leaders have weighed how to care for people caught in the bloody crossfire and how to divide more than $2 million donated to public funds for victims in the initial outpouring of grief.

The questions are far-reaching: How does a city compensate people for medical bills, recovery treatments, counseling, and lost wages? And what about those who have PTSD-like symptoms that could last years? How does a community identify and care for victims often overlooked in the first flush of reporting on a mass shooting: the injured?

The injured list could grow. Prosecutors and Kansas City police are mounting a legal case against four of the shooting suspects, and are encouraging additional victims to come forward.

“Specifically, we’re looking for individuals who suffered wounds from their trying to escape. A stampede occurred while people were trying to flee,” said Jackson County Prosecutor Jean Peters Baker. Anyone who “in the fleeing of this event that maybe fell down, you were trampled, you sprained an ankle, you broke a bone.”

Meanwhile, people who took charge of raising money and providing services to care for the injured are wrestling with who gets the money — and who doesn’t. Due to large donations from celebrities like Taylor Swift and Travis Kelce, some victims or their families will have access to hundreds of thousands of dollars for medical expenses. Other victims may simply have their counseling covered.

The overall economic cost of U.S. firearm injuries is estimated by a recent Harvard Medical School study at $557 billion annually. Most of that — 88% — represented quality-of-life losses among those injured by firearms and their families. The JAMA-published study found that each nonfatal firearm injury leads to roughly $30,000 in direct health care spending per survivor in the first year alone.

In the immediate aftermath of the shootings, as well-intentioned GoFundMe pages popped up to help victims, executives at United Way of Greater Kansas City gathered to devise a collective donation response. They came up with “three concentric circles of victims,” said Jessica Blubaugh, the United Way’s chief philanthropy officer, and launched the #KCStrong campaign.

“There were folks that were obviously directly impacted by gunfire. Then the next circle out is folks that were impacted, not necessarily by gunshots, but by physical impact. So maybe they were trampled and maybe they tore a ligament or something because they were running away,” Blubaugh said. “Then third is folks that were just adjacent and/or bystanders that have a lot of trauma from all of this.”

PTSD, Panic, and the Echo of Gunfire

Bridget Barton returned to Kansas City the day after the shooting to turn in the bullet she found in her backpack and to give a statement at police headquarters. Unbeknownst to her, Mayor Quinton Lucas and the police and fire chiefs had just finished a press conference outside the building. She was mobbed by the media assembled there — interviews that are now a blur.

“I don’t know how you guys do this every day,” she remembered telling a detective once she finally got inside.

The Bartons have been overwhelmed by well wishes from close friends and family as they navigate the trauma, almost to the point of exhaustion. Bridget took to social media to explain she wasn’t ignoring the messages, she’s just responding as she feels able — some days she can hardly look at her phone, she said.

A family friend bought new Barbie blankets for Gabriella and her friend after the ones they brought to the parade were lost or ruined. Bridget tried replacing the blankets herself at her local Walmart, but when she was bumped accidentally, it triggered a panic attack. She abandoned her cart and drove home.

“I’m trying to get my anxiety under control,” Bridget said.

That means therapy. Before the parade, she was already seeing a therapist and planning to begin eye movement desensitization and reprocessing, a form of therapy associated with treating post-traumatic stress disorder. Now the shooting is the first thing she wants to talk about in therapy.

Since Gabriella, an eighth grader, has returned to middle school, she has dealt with the compounding immaturity of adolescence: peers telling her to get over it, pointing finger guns at her, or even saying it should have been her who was shot. But her friends are checking on her and asking how she’s doing. She wishes more people would do the same for her friend, who took off running when the shooting started and avoided injury. Gabriella feels guilty about bringing her to what turned into a horrifying experience.

“We can tell her all day long, ‘It wasn’t your fault. She’s not your responsibility.’ Just like I can tell myself, ‘It wasn’t my fault or my responsibility,’” Bridget said. “But I still bawled on her mom’s shoulder telling her how sorry I was that I grabbed my kid first.”

The two girls have spent a lot of time talking since the shooting, which Gabriella said helps with her own stress. So does spending time with her dog and her lizard, putting on makeup, and listening to music — Tech N9ne’s performance was a highlight of the Super Bowl celebration for her.

In addition to the spark burns on Gabriella’s legs, when she fell to the concrete in the pandemonium she split open a burn wound on her stomach previously caused by a styling iron.

“When I see that, I just picture my mom trying to protect me and seeing everyone run,” Gabriella said of the wound.

It’s hard not to feel forgotten by the public, Bridget said. The shooting, especially its survivors, have largely faded from the headlines aside from court dates. Two additional high-profile shootings have occurred in the area since the parade. Doesn’t the community care, she wonders, that her family is still living with the fallout every day?

“I’m going to put this as plainly as possible. I’m f—ing pissed because my family went through something traumatic,” Bridget vented in a recent social media post. “I don’t really want anything other [than], ‘Your story matters, too, and we want to know how you’re doing.’ Have we gotten that? Abso-f—lutely not.”

‘What Is the Landscape of Need?’

Helped in part by celebrities like Swift and Kelce, donations for the family of Lopez-Galvan, the lone fatality, and other victims poured in immediately after the shootings. Swift and Kelce donated $100,000 each. With the help of an initial $200,000 donation from the Kansas City Chiefs, the United Way’s #KCStrong campaign took off, reaching $1 million in the first two weeks and sitting at $1.2 million now.

Six verified GoFundMe funds were established. One solely for the Lopez-Galvan family has collected over $406,000. Smaller ones were started by a local college student and Swift fans. Churches have also stepped up, and one local coalition had raised $183,000, money set aside for Lopez-Galvan’s funeral, counseling services for five victims, and other medical bills from Children’s Mercy Kansas City hospital, said Ray Jarrett, executive director of Unite KC.

Money for Victims Rolls In

Donations poured in for those injured at the Super Bowl Parade in Kansas City after the Feb. 14 shootings. The largest, starting with a $200,000 donation from the Kansas City Chiefs, is at the United Way of Greater Kansas City. Six GoFundMe sites also popped up, due in part to $100,000 donations each from Taylor Swift and Travis Kelce. Here’s a look at the totals as of March 12.United Way#KCStrong: $1.2 million.Six Verified GoFundMe AccountsLisa Lopez-Galvan GoFundMe (Taylor Swift donated): $406,142Reyes Family GoFundMe (Travis Kelce donated): $207,035Samuel Arellano GoFundMe: $11,896Emily Tavis GoFundMe: $9,518Cristian Martinez’s GoFundMe for United Way: $2,967Swifties’ GoFundMe for Children’s Mercy hospital: $1,060ChurchesResurrection (Methodist) “Victims of Violence Fund”: $53,358‘The Church Loves Kansas City’: $183,000 

Meanwhile, those leading the efforts found models in other cities. The United Way’s Blubaugh called counterparts who’d responded to their own mass shootings in Orlando, Florida; Buffalo, New York; and Newtown, Connecticut.

“The unfortunate reality is we have a cadre of communities across the country who have already faced tragedies like this,” Blubaugh said. “So there is an unfortunate protocol that is, sort of, already in place.”

#KCStrong monies could start being paid out by the end of March, Blubaugh said. Hundreds of people called the nonprofit’s 211 line, and the United Way is consulting with hospitals and law enforcement to verify victims and then offer services they may need, she said.

The range of needs is staggering — several people are still recovering at home, some are seeking counseling, and many weren’t even counted in the beginning. For instance, a plainclothes police officer was injured in the melee but is doing fine now, said Police Chief Stacey Graves.

Determining who is eligible for assistance was one of the first conversations United Way officials had when creating the fund. They prioritized three areas of focus: first were the wounded victims and their families, second was collaborating with organizations already helping victims in violence intervention and prevention and mental health services, and third were the first responders.

Specifically, the funds will be steered to cover medical bills, or lost wages for those who haven’t been able to work since the shootings, Blubaugh said. The goal is to work quickly to help people, she said, but also to spend the money in a judicious, strategic way.

“We don’t have a clear sightline of the entire landscape that we’re dealing with,” Blubaugh said. “Not only of how much money do we have to work with, but also, what is the landscape of need? And we need both of those things to be able to make those decisions.”

Firsthand Experience of Daily Kansas City Violence

Jason used his lone remaining sick day to stay home with Bridget and Gabriella. An overnight automation technician, he is the family’s primary breadwinner.

“I can’t take off work, you know?” he said. “It happened. It sucked. But it’s time to move on.”

“He’s a guy’s guy,” Bridget interjected.

On Jason’s first night back at work, the sudden sound of falling dishes startled Bridget and Gabriella, sending them into each other’s arms crying.

“It’s just those moments of flashbacks that are kicking our butts,” Bridget said.

Tell Us About Your Experience

We are continuing to report on the effects of the parade shooting on the people who were injured and the community as a whole. Do you have an experience you want to tell us about, or a question you think we should look into? Message KCUR’s text line at (816) 601-4777. Your information will not be used in an article without your permission.

In a way, the shooting has brought the family closer. They’ve been through a lot recently. Jason survived a heart attack and cancer last year. Raising a teenager is never easy.

Bridget can appreciate that the bullet lodged in her backpack, narrowly missing her, and that Gabriella’s legs were burned by sparks but she wasn’t shot.

Jason is grateful for another reason: It wasn’t a terrorist attack, as he initially feared. Instead, it fits into the type of gun violence he’d become accustomed to growing up in Kansas City, which recorded its deadliest year last year, although he’d never been this close to it before.

“This crap happens every single day,” he said. “The only difference is we were here for it.”

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Montana, an Island of Abortion Access, Preps for Consequential Elections and Court Decisions

Kaiser Health News:States - March 14, 2024

A years-long battle over abortion access in a sprawling and sparsely populated region of the U.S. may come to a head this year in the courts and at the ballot box.

Challenges to several state laws designed to chip away at abortion access are pending in Montana courts. Meanwhile, abortion rights advocates are pushing a ballot initiative that would add extra protections to the state constitution. And two open state Supreme Court seats could shape whether the high court upholds past decisions that protected abortion rights in the state.

Abortion remains legal in the conservative stronghold because of a 25-year-old state Supreme Court ruling that protected it under the right to privacy included in the state’s constitution.

So far, most efforts by Montana’s Republican governor and GOP-led legislature to overcome that obstacle have gone nowhere. Montana courts have blocked multiple laws that would have restricted abortion.

It’s “a very daunting hurdle for those who would seek to undermine abortion access,” said Kal Munis, an assistant professor of political science at Utah Valley University and expert on politics in Montana, his home state.

Munis said to outlaw abortion, voters would need to amend the state constitution or elect Supreme Court justices willing to reverse precedent.

But it is abortion rights advocates who have jumped on the chance to amend the state constitution. A legal fight is brewing over a ballot initiative proposed for the November election that would add abortion protections to the constitution.

Meanwhile, two open state Supreme Court seats are up for election, and some of the candidates are signaling that abortion access will be a campaign issue.

Voters have to be thinking about the future of abortion from “multiple fronts,” said Martha Fuller, CEO of Planned Parenthood Advocates of Montana, which is suing to block several anti-abortion laws, backing the proposed constitutional amendment, and monitoring the Supreme Court races.

Montana anti-abortion advocates celebrated when Republican Gov. Greg Gianforte was elected in 2020 after 16 years of Democratic governors and, since 2011, vetoes of anti-abortion laws passed by the Republican-controlled legislature.

From their opponents’ perspective, that change left the courts as the last line of defense of abortion rights, one they are focused on protecting.

Munis and Jessi Bennion, who teaches political science at Montana State University, said abortion rights groups in Montana have momentum after the U.S. Supreme Court’s 2022 reversal of Roe v. Wade.

That decision resulted in voters becoming motivated by the issue and a wave of ballot questions. Montanans, for example, rejected a measure that would have required doctors to provide medical care after premature births and failed abortions, which opponents said was already the law.

For now, Montanans may have abortions any time before fetal viability, which under Montana code is “presumed” to be about 24 weeks into a pregnancy. Patients can go to one of six providers in the state or make a telehealth appointment and receive pills in the mail.

That makes Montana the most abortion-friendly state in the largely conservative and rural region between Minnesota and the Pacific Northwest.

Montana is sandwiched between Idaho and the Dakotas, which severely restrict abortion. To the south is Wyoming, where abortion pills are available through telehealth, but lawmakers there have passed a bill that could temporarily shutter the only clinic in the state that provides in-person abortions, depending on what action Republican Gov. Mark Gordon takes. Abortion is legal in Canada, Montana’s northern neighbor, but Americans need a passport to travel there.

An attempt to further cement abortion rights in Montana is facing an obstacle. Republican Attorney General Austin Knudsen has rejected the proposed abortion rights constitutional amendment as being legally insufficient, which prompted the campaign behind the initiative to file a lawsuit. The State Supreme Court will now decide if initiative organizers may proceed with gathering signatures.

Analysts and Montana leaders — including some Republicans — think there’s a good chance voters will approve the constitutional amendment if it appears on the ballot.

“We’re a Republican state, but there’s always historically been a kind of a libertarian streak in it,” said Steve Fitzpatrick, an attorney and the majority leader in the Montana Senate. “It’s not unusual to see Republicans winning up and down the ballot and then seeing something like marijuana be legalized at the same time.”

Abortion will also be an undercurrent in two state Supreme Court races. Chief Justice Mike McGrath and Justice Dirk Sandefur, who both ruled against efforts to unravel the state’s abortion protections, decided not to seek reelection.

Judges don’t run as Democrats or Republicans, but Supreme Court elections have taken a distinct partisan tone in recent years.

Given the recent election wins by abortion rights advocates after Roe v. Wade was overturned, conservatives may choose not to make abortion a campaign issue for these judicial races, according to Munis.

Focusing on abortion “would be a strategic blunder given that they have so many other things that they could talk about instead,” he said.

But the candidates who are viewed as more liberal have strongly signaled their desire to protect abortion rights.

State judges Katherine Bidegaray and Dan Wilson are running for Sandefur’s seat on the high court.

During a campaign event, Bidegaray said she would defend Montanans’ constitutional right to privacy and stand up to “unprecedented attacks” on women’s rights, the Flathead Beacon reported.

Wilson and his campaign did not respond to phone and email messages from KFF Health News.

In the race for chief justice, former federal magistrate judge Jerry Lynch, who is running against Cory Swanson, a county prosecutor backed by Republicans, has been more direct than Bidegaray.

Montanans must be “free from government interference, especially when it comes to reproductive rights,” Lynch said at a campaign event, according to the Montana Free Press.

Lynch’s candidacy has triggered some early opposition spending. Montanans for Fair Judiciary, a conservative group, sent mailers calling Lynch a “liberal trial lawyer,” the outlet reported.

Swanson told KFF Health News that judges shouldn’t decide how they would rule on abortion or any other topic until a case is before the court.

Fuller said Planned Parenthood Advocates of Montana has not yet decided how it will get involved in the Supreme Court races but that it likely will.

“If people are not paying attention to who is making these decisions and who is winning these judicial races, we could lose that ability to have that backstop,” she said.

Regardless of whom voters choose to seat on the court, any change in this election is unlikely to immediately swing a majority of the seven-member court to overturn the 1999 ruling protecting abortion access, according to Bennion.

In Iowa, conservatives were able to reverse a state Supreme Court precedent similar to Montana’s after more Republican-appointed justices joined the bench.

In Montana, the abortion issue is playing out more quickly in the state’s lower courts.

In February, a state court overturned three laws that would have restricted abortion, including a ban on the procedure after 20 weeks of pregnancy. Last year, another state judge temporarily blocked several anti-abortion measures including a ban on the most common abortion procedure used in the second trimester of pregnancy.

Frustrated by the courts, Republican officials have also used the executive branch to try to restrict abortions. The Gianforte administration implemented a rule to reduce Medicaid-funded abortions by defining when an abortion is medically necessary, limiting who can perform them, and requiring preauthorization for most cases.

But that rule and a new state law that mirrors it have also been temporarily blocked by a judge. Knudsen has appealed those injunctions, as well as the judge’s ruling from February, to the Montana Supreme Court.

And this month, the high court heard oral arguments as the state attempts to overturn a judicial block of a 2013 law requiring parental consent before a minor may have an abortion.

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Exclusive: Social Security Chief Vows to Fix ‘Cruel-Hearted’ Overpayment Clawbacks

The Social Security Administration’s new chief is promising to overhaul the agency’s system of clawing back billions of dollars it claims was wrongly sent to beneficiaries, saying it “just doesn’t seem right or fair.”

In an interview with KFF Health News, SSA Commissioner Martin O’Malley said that in the coming days he would propose changes to help people avoid crushing debts that have driven some into homelessness and caused financial hardships for the nation’s most vulnerable — the poorest of the poor and people with disabilities or persistent medical conditions or who are at least age 65.

O’Malley, who took office in December, said that “addressing the injustice we do to too many Americans because of overpayments, the rather cruel-hearted and mindless way that we recover those overpayments,” is among his top priorities.

He said he has concrete steps in mind, such as establishing a statute of limitations, shifting the burden of proof to the agency, and imposing a 10% cap on clawbacks for some beneficiaries.

“We do have the ability and we do have the authority to address many of these injustices,” he said, suggesting that the SSA won’t have to wait for congressional action.

The pledge comes after an investigation by KFF Health News and Cox Media Group television stations revealed that SSA routinely reduces or halts monthly benefit checks to reclaim billions of dollars in payments it sent to beneficiaries then later said they should not have received.

In some cases, years passed before the government discovered its mistake and then imposed debts that sometimes have reached tens of thousands of dollars on people who cannot afford to pay. KFF Health News and Cox Media Group discovered that more than 2 million people a year have been hit with overpayment demands.

Most overpayments are linked to the Supplemental Security Income program, which provides money to people with little or no income, who are disabled, blind, or at least age 65. Others are connected to the Social Security Disability Insurance program, which aids disabled workers and their dependents.

O’Malley said the agency plans to cease efforts to claw back years-old overpayments and halt the practice of terminating benefits for disabled workers who don’t respond to overpayment notices because they did not receive them or couldn’t make sense of them.

“We’re not fulfilling congressional intent by putting seniors out of their homes and having them live under a bridge when they didn’t understand our notice,” O’Malley said.

Denise Woods lives in her Chevy, seeking a safe place to sleep each night at strip malls or truck stops around Savannah, Georgia. Woods said she became homeless in 2022 after the SSA — without explanation — determined it had overpaid her and demanded she send back roughly $58,000. Woods didn’t have that amount on hand, so the agency cut off her monthly disability benefits to recoup the debt.

The agency later restored some of her benefit allowance: She gets $616 a month. That’s not enough to cover rent in Savannah, where even modest studio apartments can run $1,000 a month.

In January, she fell ill and landed in intensive care with pneumonia. “I signed a [Do Not Resuscitate form] and a nurse asked, ‘Do you know what this means?'” Woods said. “I told her there was no reason to revive me if my heart stops. They have already ruined my life. I’m beyond exhausted.”

After KFF Health News and Cox Media Group published the series “Overpayment Outrage,” hundreds of disability beneficiaries came forward with troubling accounts, including how the government sent them overpayment notices without explanation and threatened to cut off their main source of income with little warning.

Members of Congress publicly demanded that SSA fix the problems. Democratic Sen. Ron Wyden of Oregon said he would meet monthly with agency officials “until it is fixed.”

Sens. Gary Peters and Debbie Stabenow, both Michigan Democrats, sent a letter dated Feb. 29 to the SSA, saying many overpayments were caused by the agency. They asked officials to explain what is causing the problems.

“It’s absolutely critical that the agency is accurately administering these benefits,” Peters said in written response to an interview request. “I’ve heard from too many people across Michigan who have faced financial hardship after the agency sent them incorrect payments.”

The agency recovered $4.9 billion of overpayments during the 2023 fiscal year, with an additional $23 billion in overpayments still uncollected, according to its latest annual financial report.

O’Malley said he wants to address overpayment clawbacks as part of a larger effort to address SSA’s “customer service crisis.” He did not provide specifics but said he anticipated plans would be implemented this year.

Officials have long acknowledged that the federal disability system is dogged by lengthy delays and dysfunction. Some people become homeless or grow sicker while waiting for an initial decision on an application, which took an average of over seven months in 2023, according to a letter signed by dozens of members of Congress.

O’Malley said the agency terminates disability benefits for some people who don’t contact the SSA after receiving a clawback letter.

“To be honest, a lot of problems [are caused by] our notices being hard to read,” O’Malley said. “In fact, one might argue that the only thing that’s really clear about the notice is to call the 800 number.”

The agency’s toll-free number, O’Malley said, is on his fix-it list, too.

Callers complain of lengthy hold times and often are unable to reach an agent for help, according to congressional members, disability attorneys, and others.

O’Malley pointed to a 27-year low in staffing. “We’ve been unpacking many of these customer service challenges,” he said. “There’s not one of them that hasn’t been made worse by the short staff.”

Still, he said, the overpayment process is unfair. Beneficiaries often must produce evidence to show they did not receive extra money, O’Malley noted.

“One would assume that in a country where people are innocent until proven guilty,” he said, “that the burden should fall more on the agency than on the unwitting beneficiary.”

Advocates for the poor and disabled said they are hopeful O’Malley will stick to his commitments.

“Overpayments have long plagued our clients and caused severe hardship,” said Jen Burdick, an attorney with Community Legal Services of Philadelphia, which represents clients who have received overpayment notices. “We are heartened to see that SSA’s new commissioner is taking a hard look at overpayment policy reforms and optimistic and hopeful his administration will provide these folks some long-needed relief.”

Mike Pistorio is worried that change won’t come fast enough for him.

A letter dated Sept. 21, 2023, that he received from the Social Security Administration says he was overpaid $9,344. The letter alleges Pistorio — a disabled 63-year-old who said he has four stents in his heart — received too much money on behalf of his children, who are now adults.

Pistorio said that he doesn’t understand why he owes the government money and that the SSA has not answered his questions. He said he and his wife live in fear of being evicted from their home because they depend on his $1,266 monthly disability benefits to pay rent.

“What makes me mad is none of this is my fault,” said Pistorio, who lives in Middletown, Pennsylvania, and worked as a plumber until his health faltered. “The stress of this has made my diabetes go up.”

Pistorio said the agency has offered to deduct $269 a month from his benefits to pay off his debt — an amount he says he cannot afford.

“I have told them ‘I will lose my housing,’” Pistorio said.

David Hilzenrath of KFF Health News and Jodie Fleischer of Cox Media Group contributed to this report.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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HHS Office for Civil Rights Issues Letter and Opens Investigation of Change Healthcare Cyberattack

HHS Gov News - March 13, 2024
HHS Office for Civil Rights Issues Letter and Opens Investigation of Change Healthcare Cyberattack

GOP-Led States Expand Crackdowns on Transgender Care

Kaiser Health News:States - March 13, 2024

South Carolina’s legislature is poised to pass a bill prohibiting doctors from offering some health-care services to transgender minors — part of a new wave of anti-trans legislation from Republican-led states.

The South Carolina bill, which passed the state House of Representatives in January and is under consideration in the Senate, would bar health-care providers from performing gender-transition surgery, prescribing puberty-blocking drugs and overseeing hormone treatments for patients under 18.

It would also mandate that school officials notify parents of a student’s transgender identity and block the state Medicaid program from paying for gender-affirming care to patients under the age of 26. 

Nationwide, high-profile Republicans including Florida Gov. Ron DeSantis have made crackdowns on transgender rights central to their political agendas, which has helped encourage state-level legislation that critics call bigoted. Twenty-three states had passed laws restricting gender-affirming care as of the end of February, according to KFF.

Anya Marino, director of LGBTQI equality at the National Women’s Law Center, a nonprofit that advocates for women’s rights, said apart from the legal concerns some of these bills raise, she also worries about other consequences, including acts of violence against transgender people.

“It’s part of a larger objective to control people through body policing to determine how they love and how they navigate their daily lives,” Marino said.

South Carolina and Virginia are the only two states in the South that haven’t passed laws or policies limiting youth access to gender-affirming care, according to KFF.

Republican-led legislatures in other states are advancing bills to restrict medical care and access to public restrooms for transgender people — so-called “bathroom bills” that have been heavily criticized by Democrats and transgender people.

In January, Utah passed a law modeled after the “Women’s Bill of Rights” created by the conservative nonprofit Independent Women’s Law Center. The bill establishes strictly biological definitions for “male,” “female” and other terms related to sex that don’t include gender identities like nonbinary and trans.

Similar bills are under consideration in Arizona, Georgia, Idaho, Iowa, New Mexico and West Virginia. Last year, leaders in Kansas, Montana, Nebraska and Oklahoma approved versions of the policy through legislation or executive order.

South Carolina Gov. Henry McMaster (R), who signed a 2022 law that bans transgender students from playing girls’ or women’s sports in public schools and colleges, said at a January news conference that he thought the transgender health-care bill was a “good idea.”

If children “want to make those decisions later when they’re adults, then that’s a different story,” McMaster said. “But we must protect our young people from making irreversible errors.”

South Carolina Senate Democratic leader Brad Hutto said the point of the bill is to boost Republican fundraising and predicted it would face immediate legal challenge if it became law. “It’s clearly a far-right agenda item that doesn’t have anything to do with reality or facts,” he said. “It’s just red meat for that segment of the far right.”

This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact NewsWeb@kff.org.

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Ya hay una droga oral para la depresión postparto… pero cuesta $16,000

En diciembre se lanzó al mercado zuranolona, un tratamiento muy esperado para la depresión postparto, con la promesa de que iba a ser un medicamento accesible y de acción rápida para una enfermedad debilitante.

Pero la mayoría de los seguros de salud privados aún no han determinado cómo, y si, la cubrirán, según un nuevo análisis de planes médicos.

La falta de orientación podría limitar el uso del medicamento, que es tanto novedoso —alivia los síntomas apuntando a la función hormonal y no a la serotonina cerebral como lo hacen los antidepresivos tradicionales— como costoso: $15,900 por un régimen de pastillas de 14 días.

Abogados, defensores y reguladores están observando de cerca cómo las aseguradoras diseñarán las normas para cubrirla.

Para su predecesora, una forma intravenosa del mismo medicamento llamada brexanolona que salió al mercado en 2019, muchas aseguradoras requirieron que las pacientes probaran otros medicamentos más baratos primero antes de aprobar su uso.

En los primeros ensayos clínicos revisados por la Administración de Drogas y Alimentos (FDA) la droga mostró que ofrecía alivio en cuestión de días. Los antidepresivos tradicionales tardan de cuatro a seis semanas en hacer efecto.

“Tendremos que ver si las aseguradoras cubren este medicamento y qué requisitos de ‘intentar primero con otro’ establecen para la zuranolona”, dijo Meiram Bendat, psicoterapeuta y abogado que representa a pacientes.

La mayoría de los planes de salud aún no han emitido ninguna guía para la zuranolona, y defensores de la salud materna se preocupan de que los pocos que lo han hecho estén adoptando un enfoque restrictivo.

Algunas pólizas requieren que los pacientes prueben primero, y fracasen, con un antidepresivo estándar antes que la aseguradora pague por la zuranolona.

En otros casos, las directrices requieren que los psiquiatras lo receten, en lugar de los obstetras, lo que podría retrasar el tratamiento, ya que los gineco-obstetras  suelen ser los primeros proveedores médicos en detectar signos de depresión posparto.

Los defensores están más preocupados por la falta de orientación sobre la cobertura.

“Si no tienes una norma publicada, se tomarán decisiones que tal vez no sean justas y sean menos eficientes. La transparencia es realmente importante”, dijo Joy Burkhard, directora ejecutiva del Centro de Política para la Salud Mental Materna, que encargó el estudio.

Con la brexanolona, que se vendía a $34,000 para un régimen de tratamiento de tres días, la aseguradora más grande de California, Kaiser Permanente, tenía criterios tan rigurosos para recetarla que expertos dijeron que la política equivalía a una denegación general para todos los pacientes, según una investigación de NPR de 2021.

Las directrices escritas de Kaiser Permanente requerían que los pacientes probaran y fallaran con cuatro medicamentos, y terapia electroconvulsiva, antes de ser elegibles para la brexanolona. Debido a que el medicamento estaba aprobado solo para los primeros seis meses postparto, y los ensayos de antidepresivos típicos toman de cuatro a seis semanas cada uno, el tiempo se agotaba antes que un paciente tuviera tiempo de probar la brexanolona.

Un análisis de NPR de una docena de otros planes de salud en ese momento mostró que la política de KP sobre la brexanolona era atípica. Algunos sí requerían que los pacientes fallaran con uno o dos medicamentos antes, pero KP fue el único que recomendó cuatro.

Miriam McDonald, quien desarrolló una grave depresión postparto e ideas suicidas después de dar a luz a finales de 2019, luchó contra Kaiser Permanente durante más de un año para encontrar un tratamiento efectivo.

Sus médicos la pusieron bajo una catarata de medicamentos que no funcionaron y que a menudo tenían efectos secundarios intolerables, dijo. Se negaron a recetarle brexanolona, el único medicamento aprobado por la FDA específicamente para la depresión postparto en ese momento.

“Ninguna mujer debería sufrir como yo después de tener un hijo”, dijo McDonald. “La política fue completamente injusta. Estaba en el purgatorio”.

Un mes después que NPR publicara su investigación, Kaiser Permanente revisó completamente sus criterios para recomendar que las mujeres probaran solo un medicamento antes de ser elegibles para la brexanolona.

Luego, en marzo de 2023, después que el Departamento de Trabajo federal lanzara una investigación contra la aseguradora —citando la investigación de NPR—, Kaiser revisó nuevamente sus directrices sobre brexanolona, eliminando todas las recomendaciones de intentar primero con otra droga, según documentos internos obtenidos recientemente por NPR. Los pacientes solo necesitan rechazar una prueba con otro medicamento.

“Desde que brexanolona fue aprobada por primera vez para su uso, más experiencia e investigación ha sumado información sobre su eficacia y seguridad”, dijo la aseguradora en un comunicado. “Kaiser Permanente se compromete a garantizar que brexanolona esté disponible cuando los médicos y los pacientes determinen que es un tratamiento apropiado”.

“Básicamente, Kaiser pasó de tener la política más restrictiva a la más sólida”, dijo Burkhard, del Centro de Política para la Salud Mental Materna. “Ahora es un estándar de oro para el resto de la industria”.

McDonald tiene la esperanza de que su disposición a hablar y las posteriores acciones regulatorias y cambios en las políticas para brexanolona lleven a Kaiser Permanente y a otros planes de salud a establecer normas favorables a los pacientes para la zuranolona.

“Esto evitará que otras mujeres tengan que pasar por un año de depresión para encontrar algo que funcione”, dijo.

Los médicos estaban emocionados cuando la FDA aprobó la zuranolona en agosto pasado, creyendo que en forma de pastilla, tomada una vez al día en casa durante dos semanas, sería más accesible para las mujeres en comparación con tres días de estadía en el hospital para la infusión intravenosa.

Muchos psiquiatras perinatales le dijeron a NPR que es imperativo tratar la depresión posparto lo antes posible para evitar efectos negativos, incluidos problemas cognitivos y sociales en el bebé, ansiedad o depresión en el padre o pareja, o la muerte de la madre por suicidio, que representa hasta el 20% de las muertes maternas.

Hasta ahora, solo una de las seis mayores aseguradoras privadas del país, Centene, ha establecido una política para la zuranolona. No está claro qué criterios establecerá Kaiser Permanente para la nueva pastilla. El programa de Medicaid de California, conocido como Medi-Cal, aún no ha establecido criterios de cobertura.

Las políticas de las aseguradoras para la zuranolona se escribirán en un momento en el que el entorno regulatorio en torno al tratamiento de la salud mental está cambiando.

El Departamento de Trabajo de Estados Unidos está tomando medidas enérgicas contra las violaciones del Mental Health Parity and Addiction Equity Act de 2008, que requiere que las aseguradoras cubran los tratamientos psiquiátricos de la misma manera que los tratamientos físicos.

Ahora, las aseguradoras deben cumplir con requisitos de informes y auditorías más estrictos destinados a aumentar el acceso de los pacientes a la atención de salud mental, los defensores esperan que los planes de salud sean más cuidados al determinar las normas de uso.

En California, desde 2021, las aseguradoras también deben cumplir con una ley de paridad de salud mental estatal aún más amplia, que requiere que se utilicen criterios y directrices basadas en la clínica y reconocidas por expertos para tomar decisiones médicas.

La ley fue diseñada para limitar los rechazos arbitrarios o impulsados por el costo de los tratamientos de salud mental y ha sido celebrada como un modelo para el resto del país. Se espera que se publiquen regulaciones muy esperadas para la ley esta primavera, que podrían ofrecer más orientación para las aseguradoras en California que establecen políticas para la zuranolona.

Mientras tanto, Burkhard dijo que las pacientes que sufren de depresión postparto no deberían dejar de preguntar a sus médicos sobre la zuranolona. Las aseguradoras aún pueden otorgar acceso al medicamento basándose en cada caso antes de formalizar sus criterios de cobertura.

“Los proveedores no deberían sentirse desalentados de recetar zuranolona”, dijo Burkhard.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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