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Movimientos en contra de las vacunas perjudican a los niños más vulnerables

Gayle Borne ha cuidado a más de 300 niños en Springfield, Tennessee. Niños que rara vez han visto a un médico y que han sido tan descuidados que ni siquiera pueden hablar.

Una ley que este estado aprobó en 2023 que requiere el consentimiento de los padres biológicos o tutores legales para que los niños reciban vacunas de rutina— vuelve a estos niños aún más vulnerables.

Los padres temporales, trabajadores sociales y otros cuidadores no pueden otorgar ese permiso.

En enero, Borne llevó a una bebé que estaba cuidando, que nació con poco apenas 2 libras, a su primera cita médica. Los proveedores de salud dijeron que sin el consentimiento de la madre de la niña, no podían vacunarla contra enfermedades como la neumonía, la hepatitis B y la polio.

La madre no ha sido localizada, por lo que un trabajador social tuvo que solicitar una orden judicial para poder vacunarla. “Estamos esperando”, dijo Borne. “Nuestras manos están atadas”.

La ley de Tennessee también impide que las abuelas y otros cuidadores que acompañan a los niños a citas de rutina cuando los padres están trabajando, en rehabilitación, o simplemente no pueden ir, otorguen ese permiso.

La ley pretende “devolverles a los padres el derecho a tomar decisiones médicas para sus hijos”.

Enmarcada en la retórica de la elección y el consentimiento, esta ley es una de más de una docena de propuestas recientes y pendientes en todo el país que usan la libertad para decidir de los padres en contra de la salud comunitaria y de los niños.

En realidad, crean obstáculos para la vacunación, el fundamento de la atención pediátrica. Siembran dudas sobre la seguridad de las vacunas en un clima lleno de desinformación médica.

Esta tendencia ha explotado a medida que políticos e influencers en las redes sociales hacen afirmaciones falsas sobre los riesgos de las vacunas, a pesar de los estudios que muestran lo contrario.

Los médicos tradicionalmente brindan información sobre vacunas a los cuidadores y obtienen su permiso antes de administrar más de una docena de inmunizaciones infantiles que protegen contra el sarampión, la polio y otras enfermedades debilitantes.

Pero ahora, la ley de Tennessee exige que los padres biológicos asistan a citas de rutina y firmen formularios de consentimiento para cada vacuna administrada durante dos años o más.

“Los formularios podrían tener un efecto disuasorio”, opinó el doctor Jason Yaun, pediatra de Memphis y ex presidente del capítulo de Tennessee de la Academia Americana de Pediatría. “Las personas que promueven los derechos parentales sobre las vacunas tienden a minimizar los derechos de los niños”, dijo Dorit Reiss, investigadora de políticas de vacunas en la Facultad de Derecho de la Universidad de California en San Francisco.

Baja en la tasa de vacunación de rutina

La desinformación, junto con un movimiento por el derecho de los padres que aleja la toma de decisiones de la salud pública, ha contribuido a las tasas de vacunación infantil más bajas en una década.

Este año, legisladores en Arizona, Iowa y West Virginia han presentado proyectos de ley relacionados con el consentimiento.

Una enmienda del Parent’s Bill of Rights en Oklahoma busca asegurar que los padres sepan que pueden eximir a sus hijos de los mandatos de vacunación escolar junto con las lecciones sobre educación sexual y el SIDA.

En Florida, el escéptico médico que lidera el Departamento de Salud del estado recientemente desafió las recomendaciones de los Centros para el Control y la Prevención de Enfermedades (CDC) diciéndoles a los padres que podían enviar a los niños no vacunados a la escuela durante un brote de sarampión.

El año pasado, Mississippi comenzó a permitir exenciones de los requisitos de vacunación escolar por motivos religiosos debido a una demanda financiada por la Informed Consent Action Network (ICAN), que está catalogada como una de las principales fuentes de desinformación antivacunas por el Center for Countering Digital Hate.

Aunque algunos proyectos de ley fracasen, Reiss teme que el resurgimiento del movimiento por los derechos de los padres pueda llevar a abolir leyes que requieren vacunas de rutina para asistir a la escuela.

En un reciente mitín de campaña, el candidato presidencial republicano Donald Trump dijo: “No daré ni un centavo a ninguna escuela que tenga un mandato de vacunación”.

Este movimiento se remonta a la pandemia de influenza de 1918, cuando algunos padres se opusieron a reformas progresistas que volvieron obligatorio asistir a la escuela y prohibieron el trabajo infantil. Desde entonces, las tensiones entre las medidas estatales y la libertad de los padres han estallado ocasionalmente sobre una variedad de temas.

Las vacunas se convirtieron en un tema prominente en 2021, cuando el movimiento encontró puntos en común con personas escépticas sobre las vacunas contra covid.

“El movimiento de derechos parentales no comenzó con las vacunas”, dijo Reiss, “pero el movimiento antivacunas se ha aprovechado, ampliando su alcance”.

Cuando legisladores callan a expertos

En Tennessee, los activistas antivacunas y las organizaciones de tendencia libertaria arremetieron contra el Departamento de Salud del estado en 2021 cuando recomendó vacunas contra covid a menores, siguiendo la orientación de los CDC.

Gary Humble, director ejecutivo del grupo conservador Tennessee Stands, pidió a los legisladores que criticaran al departamento por aconsejar el uso de máscaras y la vacunación.

También hubo repercusiones después que Michelle Fiscus, entonces directora de inmunización del estado, envió un aviso a los médicos. Les recordó que no necesitaban el permiso de los padres para vacunar a adolescentes de 14 años o más que dieran su consentimiento, según una regla estatal de décadas llamada Doctrina del Menor Maduro (Mature Minor Doctrine).

En las semanas siguientes, los legisladores estatales amenazaron con retirarle al departamento su financiamiento, y lo presionaron para que redujera la promoción de la vacuna contra covid, según reveló The Tennessean.

Fiscus fue despedida abruptamente. “Hoy me convertí en la vigésimo quinta de los 64 directores de programas de inmunización estatales y territoriales en dejar su puesto durante esta pandemia”, escribió en un comunicado. “Eso es casi el 40% de nosotros”.

La tasa de mortalidad por covid en Tennessee aumentó, convirtiéndose en una de las más altas del país a mediados de 2022.

Para cuando dos legisladores estatales presentaron un proyecto de ley para revertir la doctrina, el departamento de salud guardó silencio sobre la propuesta. A pesar de los obstáculos para los niños en hogares temporales que requerirían de una orden judicial para vacunas de rutina, el Departamento de Servicios Infantiles de Tennessee tampoco dijo nada.

El representante republicano John Ragan, quien presentó el proyecto en abril de 2023, dijo: “Los niños pertenecen a sus familias, no al estado”.

El representante demócrata Justin Pearson habló en contra del proyecto de ley. “No tiene en cuenta a las personas y niños que son descuidados”, le dijo a Ragan. “Estamos legislando desde un lugar de privilegio y no reconociendo a las personas que no tienen estos privilegios”, agregó.

El proyecto de Ragan obtuvo la mayoría y el gobernador republicano Bill Lee lo firmó en mayo, haciéndolo efectivo de inmediato.

Deborah Lowen, entonces subcomisionada de salud infantil en el Departamento de Servicios Infantiles, recibió decenas de llamadas de médicos que ahora enfrentan pena de cárcel y multas por vacunar a menores sin un consentimiento adecuado. “Me sentí, y me siento, muy descorazonada”, dijo.

Derecho a la salud

Yaun, el pediatra de Memphis, dijo que se sintió conmocionado cuando se negó a administrar una primera serie de vacunas a un bebé acompañado por un trabajador social. “Ese niño está entrando en una situación en donde está rodeado de otros niños y adultos”, dijo, “donde podría estar expuesto a algo y fracasamos en protegerlo”.

“Hemos tenido muchos abuelos enojados en nuestra sala de espera que traen a sus nietos a las citas porque los padres están trabajando o pasando por un mal momento”, dijo Hunter Butler, pediatra en Springfield, Tennessee. “Una vez llamé a una instalación de rehabilitación para encontrar a una madre y hablar con ella por teléfono para obtener su consentimiento verbal para vacunar a su bebé”, dijo. “Y no está claro si eso estuvo bien”.

Las tasas de vacunación infantil han disminuido por tres años consecutivos en Tennessee. A nivel nacional, las tendencias en baja de la vacunación contra el sarampión llevaron a los CDC a estimar que un cuarto de millón de niños de jardín de infantes están en riesgo de contraer la enfermedad altamente contagiosa.

Las comunidades con tasas bajas de vacunación son vulnerables a medida que el sarampión aumenta a nivel internacional. Los casos confirmados de sarampión en 2023 fueron casi el doble que en 2022, un año en el que la Organización Mundial de la Salud (OMS) estima que más de 136,000 personas murieron por la enfermedad en todo el mundo.

Cuando los viajeros infectados en el extranjero llegan a comunidades con bajas tasas de vacunación infantil, el virus altamente contagioso puede propagarse rápidamente entre personas no vacunadas, así como entre bebés demasiado pequeños para ser vacunados y personas con sistemas inmunes debilitados.

“Existe un aspecto de libertad en el otro lado de este argumento”, dijo Caitlin Gilmet, directora de comunicaciones del grupo de defensa de vacunas SAFE Communities Coalition and Action Fund. “Deberías tener el derecho de proteger a tu familia de enfermedades prevenibles”.

A finales de enero, Gilmet y otros defensores de la salud infantil se reunieron en una sala del Capitolio de Tennessee en Nashville y ofrecieron un desayuno gratuito. Distribuyeron folletos mientras los legisladores y sus asistentes llegaban a comer. Un folleto describía el costo de un brote de sarampión en 2018-19 en el estado de Washington que enfermó a 72 personas, la mayoría de las cuales no estaban vacunadas. El brote costó $76,000 en atención médica, $2,3 millones para la respuesta de salud pública y aproximadamente $1 millón en pérdidas económicas debido a la enfermedad, cuarentena y atención.

Barb Dentz, defensora del grupo de base Tennessee Families for Vaccines, repitió que la mayoría de los constituyentes del estado apoyan políticas sólidas a favor de las vacunas. De hecho, siete de cada 10 adultos estadounidenses sostuvieron que las escuelas públicas deberían exigir la vacunación contra el sarampión, las paperas y la rubéola, en una encuesta del Pew Research Center realizada el año pasado.

Pero las cifras han estado disminuyendo. “Proteger a los niños debería ser algo tan obvio”, le dijo Dentz al representante republicano Sam Whitson. Whitson estuvo de acuerdo y reflexionó sobre una explosión de desinformación antivacunas. “El Dr. Google y Facebook han sido un desafío tan grande”, dijo. “Combatir la ignorancia se ha convertido en un trabajo de tiempo completo”.

Whitson fue uno de los pocos republicanos que votaron en contra de la enmienda de vacunas de Tennessee del año pasado. “La cuestión de los derechos de los padres realmente se ha afianzado”, dijo, “y puede ser utilizada a nuestro favor y en nuestra contra”.

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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Tal vez tu crédito ya no se destruya por una cuenta médica impaga

Kaiser Health News:States - March 12, 2024

Rob Bonta, fiscal general de California, anunció que está apoyando una legislación para impedir que la deuda médica aparezca en los informes de crédito del consumidor, un esfuerzo liderado por demócratas para ofrecer protección a los pacientes presionados por las facturas de atención médica.

Bonta es uno de los patrocinadores del proyecto de ley de la senadora Monique Limón, que busca impedir que los proveedores de atención médica, así como cualquier agencia de cobros que contraten, compartan la deuda médica de un paciente con las agencias de informes crédito.

También evitaría que estas agencias acepten, almacenen o compartan cualquier información relacionada con la deuda médica.

La cuenta médica no es necesariamente un reflejo exacto del riesgo crediticio, y su inclusión en estos informes puede hacer que bajen los puntajes de crédito y dificultar que las personas consigan trabajo, alquilen un apartamento u obtengan un préstamo para comprarse un auto.

“Esta es una parte quebrada de nuestro sistema actual que necesita arreglarse”, dijo Bonta, quien es demócrata, a KFF Health News. “Esta es la oportunidad de California y disfrutamos de tener la capacidad de estar un paso adelante en cuestiones clave”.

Si se promulga, California se convertiría en el tercer estado en eliminar las facturas médicas de los informes de crédito de los consumidores, después de Colorado y Nueva York en 2023. Minnesota tiene una propuesta similar.

El año pasado, la administración Biden anunció planes para desarrollar reglas federales similares a través de la Oficina de Protección Financiera del Consumidor, pero aún no se han publicado.

Y si el ex presidente Donald Trump regresara a la Casa Blanca, tendría el poder para deshacer estas reglas.

Limón dijo que es importante que el estado establezca sus propias protecciones en la ley junto con el impulso federal. “Es posible que estemos esperando mucho tiempo para ver resultados que California podría lograr el próximo año”, dijo el demócrata de Santa Bárbara.

Bonta dijo que no está seguro de la oposición que enfrentará el proyecto de ley, pero se pregunta si los proveedores y las agencias de cobros ofrecerán resistencia.

Un análisis de KFF Health News encontró que amenazar con dañar el crédito es la táctica de cobro más común utilizada por los hospitales para lograr que los pacientes paguen sus facturas.

Por ejemplo, a un hospital le podría preocupar que una prohibición de estas características pudiera volver más difícil lograr que los pacientes paguen las cuentas de atención médica que ya han recibido.

Las tres agencias de crédito más grandes de Estados Unidos —Equifax, Experian y TransUnion— han dicho que, desde 2022, han dejado de incluir algunas deudas médicas en los informes de crédito. Entre las deudas excluidas se encuentran, por supuesto, las facturas pagadas y las de menos de $500. Pero estas acciones voluntarias de las agencias dejan fuera a millones de pacientes con facturas médicas más altas en sus informes de crédito.

Limón dijo que a menudo escucha a sus electores hablar sobre el impacto que la deuda médica tiene en sus vidas. La deuda médica afecta desproporcionadamente a los californianos de bajos ingresos, negros y latinos (que pueden ser de cualquier raza), según la California Health Care Foundation.

Y, cada vez más, las personas con ingresos sólidos, que a menudo cuentan con  seguro médico, están teniendo deudas médicas. Una investigación de KFF Health News-NPR encontró que alrededor de 100 millones de personas en todo el país están agobiados por deudas médicas, lo que ha obligado a algunas a tener que entregar sus casas, racionar alimentos y tener trabajos extra.

Aunque la legislación no perdonaría la deuda médica, Limón dijo que espera que anime a las personas a buscar atención médica cuando la necesiten.

“Ahora se escucha a mucha gente que está preocupada por recibir atención médica porque no pueden pagarla y en lugar de eso esperan hasta que su salud empeora”, dijo Limón. “Si se aprueba el proyecto de ley, veremos menos miedo y más personas recibiendo atención médica”.

Esta historia fue producida por KFF Health News, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation.

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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California Voters Are Skeptical That More Money Is the Answer to Homelessness

Kaiser Health News:States - March 12, 2024

SACRAMENTO, Calif. — California Gov. Gavin Newsom’s expensive ballot-box attempt to tackle the mental health and addiction crisis on the state’s streets is leading by a razor-thin margin, a week after the March 5 election. The close vote reflects growing skepticism among voters that he can effectively address the state’s homelessness epidemic.

Proposition 1 would fund thousands of new housing units and treatment beds with a $6.4 billion bond and by redirecting $3 to $4 billion in existing mental health tax revenue.

It is the latest in Newsom’s arsenal of policy ideas to attack homelessness and marks the most aggressive push in the nation to get people off the streets, into housing, and connected with health care.

Newsom argues the measure is key to gaining control of the public health crisis, in part by aggressively addressing the drug and alcohol addiction that prevents so many homeless people from getting into stable housing.

Yet Newsom, a two-term Democratic governor with national ambitions, has struggled to convince voters that California can responsibly use the money to address the epidemic.

As of March 11, Proposition 1 had a very slight lead in balloting — 50.4% for vs. 49.6% opposed. Tallying the final vote could take weeks, though Newsom advisers said they’re confident the measure will ultimately prevail.

Health and policy experts say the tight race reflects public skepticism over pouring billions more into homelessness interventions that critics argue aren’t making a visible difference.

“There’s been a ton of money going into homelessness with very little progress; the crisis is just getting worse,” said Dan Drummond, executive director of the Sonoma County Taxpayers Association. He said he is a lifelong Democrat and voted for Newsom but has lost confidence that Newsom — and state government — can handle the crisis, so he voted against the measure.

Tents and plywood lean-tos are crowding streets and sidewalks from rural Northern California to San Diego. More than 181,000 people are homeless in California, according to the most recent federal tally, and thousands who can’t afford housing are living in unsanitary and unsafe conditions, exposed to extreme cold or scorching heat. Often, they struggle with drug use and untreated mental illness.

Newsom has risked enormous political capital on the issue. During a campaign blitz in early March, Newsom promised 11,150 new housing units and treatment beds and broader mental health reforms, including ongoing money for permanent supportive housing and addiction treatment.

No other state has tried as hard as California to attack homelessness. Newsom created an initiative to convert hotels and motels into permanent housing for homeless people. He is asking the Biden administration for permission to provide six months of free rent for homeless people. He launched a Medicaid initiative to provide other social services and housing supports for those on the streets or at risk of becoming homeless. The governor has spearheaded new laws to mandate treatment for those with serious mental health conditions.

So far, Newsom has plowed more than $20 billion into the crisis, with billions more for health and social services. Newsom says at least 71,000 people have gotten off the streets, yet the public health crisis is worsening. Homelessness has risen 20% since he took office in 2019, and addiction and mental illness are more rampant, experts say.

“It is very hard to sit here and tell you that I think we’re solving the problem, or that Prop. 1 will solve the problem, even with the billions and billions we are spending,” said Stephen Manley, a Santa Clara County Superior Court judge who routinely rules on cases involving homeless people facing mental health- and drug-related misdemeanors and felonies.

“I’ve got people stuck in jail even though I’ve ordered them released because there’s no beds or housing available, and numbers on the streets just keep rising,” he said.

In California, an estimated 48% of homeless people regularly use hard drugs or drink alcohol heavily, have hallucinations, or have had a recent psychiatric hospitalization, said Margot Kushel, a primary care doctor at Zuckerberg San Francisco General Hospital and Trauma Center and a leading homelessness researcher at the University of California-San Francisco.

The missing piece, Newsom said while campaigning for the initiative in the Coachella Valley, is Proposition 1. He argued the state desperately needs the infusion of money to fund new treatment beds and housing, complemented by social services to help people get healthy and stay housed.

“All of this is considered part of this larger mosaic, but the beds are foundational,” Newsom told KFF Health News.

Tom Insel, a neuroscientist and psychiatrist who formerly led the National Institute of Mental Health, also served as Newsom’s “mental health czar.” Though he supports Proposition 1, he said it would “not be a silver bullet.”

If the measure passes, he said, “the execution and implementation on the ground is going to be critical to achieving success. We’re not great at these capital projects in California. It takes a lot of time that we don’t have.”

Insel and other addiction experts said the initiative could alleviate bottlenecks in the health care system that can lead to overcrowded emergency rooms and delay care. Homeless people experiencing drug or mental health crises regularly flock to hospitals because they have nowhere else to go.

“We need help at every single level. We need psychiatric and detox beds, long-term addiction beds, permanent supportive housing,” said PK Fonsworth, an addiction psychiatrist who treats a steady stream of patients with psychosis and addiction in the emergency room at MLK Community Hospital in South Los Angeles. “Every day in the emergency room, there’s a list of dozens of patients that need psychiatric care, especially those suffering from homelessness and addiction. But what I can offer them is extremely limited.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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 the Anti-Vaccine Movement Pits Parental Rights Against Public Health

Gayle Borne has fostered more than 300 children in Springfield, Tennessee. She’s cared for kids who have rarely seen a doctor — kids so neglected that they cannot speak. Such children are now even more vulnerable because of a law Tennessee passed last year that requires the direct consent of birth parents or legal guardians for every routine childhood vaccination. Foster parents, social workers, and other caregivers cannot provide permission.

In January, Borne took a foster baby, born extremely premature at just over 2 pounds, to her first doctor’s appointment. The health providers said that without the consent of the child’s mother, they couldn’t vaccinate her against diseases like pneumonia, hepatitis B, and polio. The mother hasn’t been located, so a social worker is now seeking a court order to permit immunizations. “We are just waiting,” Borne said. “Our hands are tied.”

Tennessee’s law has also stymied grandmothers and other caregivers who accompany children to routine appointments when parents are at work, in drug and alcohol rehabilitation clinics, or otherwise unavailable. The law claims to “give parents back the right to make medical decisions for their children.”

Framed in the rhetoric of choice and consent, it is one of more than a dozen recent and pending pieces of legislation nationwide that pit parental freedom against community and children’s health. In actuality, they create obstacles to vaccination, the foundation of pediatric care.

Such policies have another effect. They seed doubt about vaccine safety in a climate rife with medical misinformation. The trend has exploded as politicians and social media influencers make false claims about risks, despite studies showing otherwise.

Doctors traditionally give caregivers vaccine information and get their permission before delivering more than a dozen childhood immunizations that defend against measles, polio, and other debilitating diseases.

But now, Tennessee’s law demands that birth parents attend routine appointments and sign consent forms for every vaccine given over two or more years. “The forms could have a chilling effect,” said Jason Yaun, a Memphis pediatrician and past president of the Tennessee chapter of the American Academy of Pediatrics.

“People who promote parental rights on vaccines tend to downplay the rights of children,” said Dorit Reiss, a vaccine policy researcher at the University of California Law-San Francisco.

Drop in Routine Vaccination Rates

Misinformation coupled with a parental rights movement that shifts decision-making away from public health expertise has contributed to the lowest childhood vaccine rates in a decade.

This year, legislators in Arizona, Iowa, and West Virginia have introduced related consent bills. A “Parents’ Bill of Rights” amendment in Oklahoma seeks to ensure that parents know they can exempt their children from school vaccine mandates along with lessons on sex education and AIDS. In Florida, the medical skeptic leading the state’s health department recently defied guidance from the Centers for Disease Control and Prevention by telling parents they could send unvaccinated children to a school during a measles outbreak.

Last year, Mississippi began allowing exemptions from school vaccine requirements for religious reasons because of a lawsuit funded by the Informed Consent Action Network, which is listed as a leading source of anti-vaccine disinformation by the Center for Countering Digital Hate. A post on ICAN’s website said it “could not be more proud” in Mississippi to “restore the right of every parent in this country to have his or her convictions respected and not trampled by the government.”

Even if some bills fail, Reiss fears, the revived parental rights movement may eventually abolish policies that require routine immunizations to attend school. At a recent campaign rally, Republican presidential candidate Donald Trump said, “I will not give one penny to any school that has a vaccine mandate.”

The movement dates to the wake of the 1918 influenza pandemic, when some parents pushed back against progressive reforms that required school attendance and prohibited child labor. Since then, tensions between state measures and parental freedom have occasionally flared over a variety of issues. Vaccines became a prominent one in 2021, as the movement found common ground with people skeptical of covid-19 vaccines.

“The parental rights movement didn’t start with vaccines,” Reiss said, “but the anti-vaccine movement has allied themselves with it and has expanded their reach by riding on its coattails.”

When Lawmakers Silence Health Experts

In Tennessee, anti-vaccine activists and libertarian-leaning organizations railed against the state’s health department in 2021 when it recommended covid vaccines to minors, following CDC guidance. Gary Humble, executive director of the conservative group Tennessee Stands, asked legislators to blast the health department for advising masks and vaccination, suggesting the department “could be dissolved and reconstituted at your pleasure.”

Backlash also followed a notice sent to doctors from Michelle Fiscus, then the state’s immunization director. She reminded them that they didn’t need parental permission to vaccinate consenting adolescents 14 or older, according to a decades-old state rule called the Mature Minor Doctrine.

In the weeks that followed, state legislators threatened to defund the health department and pressured it into scaling back covid vaccine promotion, as revealed by The Tennessean. Fiscus was abruptly fired. “Today I became the 25th of 64 state and territorial immunization program directors to leave their position during this pandemic,” she wrote in a statement. “That’s nearly 40% of us.” Tennessee’s covid death rate climbed to one of the nation’s highest by mid-2022.

By the time two state legislators introduced a bill to reverse the Mature Minor Doctrine, the health department was silent on the proposal. Despite obstacles for foster children who would require a court order for routine immunizations, Tennessee’s Department of Children’s Services was silent, too.

Notably, the legislator who introduced the bill, Republican Rep. John Ragan, was among those simultaneously overseeing a review of the agency that would determine its leadership and budget for the coming years. “Children belong to their families, not the state,” said Ragan as he presented the bill at a state hearing in April 2023.

Democratic Rep. Justin Pearson spoke out against the bill. It “doesn’t take into account people and children who are neglected,” he told Ragan. “We are legislating from a point of privilege and not recognizing the people who are not privileged in this way.”

Rather than address such concerns, Ragan referenced a Supreme Court ruling in favor of parental rights in 2000. Specifically, judges determined that a mother had legal authority to decide who could visit her daughters. Yet the Supreme Court has also done the opposite. For instance, it sided against a legal guardian who removed her child from school to proselytize for the Jehovah’s Witnesses.

Still, Ragan swiftly won the majority vote. Tennessee Gov. Bill Lee, a Republican, signed the bill in May, making it effective immediately. Deborah Lowen, then the deputy commissioner of child health at the Department of Children’s Services, was flooded with calls from doctors who now face jailtime and fines for vaccinating minors without adequate consent. “I was and remain very disheartened,” she said.

A Right to Health

Yaun, the Memphis pediatrician, said he was shaken as he declined to administer a first series of vaccines to an infant accompanied by a social worker. “That child is going into a situation where they are around other children and adults,” he said, “where they could be exposed to something we failed to protect them from.”

“We have had numerous angry grandparents in our waiting room who take kids to appointments because the parents are at work or down on their luck,” said Hunter Butler, a pediatrician in Springfield, Tennessee. “I once called a rehabilitation facility to find a mom and get her on the phone to get verbal consent to vaccinate her baby,” he said. “And it’s unclear if that was OK.”

Childhood immunization rates have dropped for three consecutive years in Tennessee. Nationwide, downward trends in measles vaccination led the CDC to estimate that a quarter million kindergartners are at risk of the highly contagious disease.

Communities with low vaccination rates are vulnerable as measles surges internationally. Confirmed measles cases in 2023 were almost double those in 2022 — a year in which the World Health Organization estimates that more than 136,000 people died from the disease globally. When travelers infected abroad land in communities with low childhood vaccination rates, the highly contagious virus can spread swiftly among unvaccinated people, as well as babies too young to be vaccinated and people with weakened immune systems.

“There’s a freedom piece on the other side of this argument,” said Caitlin Gilmet, communications director at the vaccine advocacy group SAFE Communities Coalition and Action Fund. “You should have the right to protect your family from preventable diseases.”

In late January, Gilmet and other child health advocates gathered in a room at the Tennessee Statehouse in Nashville, offering a free breakfast of fried chicken biscuits. They handed out flyers as legislators and their aides drifted in to eat. One pamphlet described the toll of a 2018-19 measles outbreak in Washington state that sickened 72 people, most of whom were unvaccinated, costing $76,000 in medical care, $2.3 million for the public health response, and an estimated $1 million in economic losses due to illness, quarantine, and caregiving.

Barb Dentz, an advocate with the grassroots group Tennessee Families for Vaccines, repeated that most of the state’s constituents support strong policies in favor of immunizations. Indeed, seven in 10 U.S. adults maintained that public schools should require vaccination against measles, mumps, and rubella, in a Pew Research Center poll last year. But numbers have been dropping.

“Protecting kids should be such a no-brainer,” Dentz told Republican Rep. Sam Whitson, later that morning in his office. Whitson agreed and reflected on an explosion of anti-vaccine misinformation. “Dr. Google and Facebook have been such a challenge,” he said. “Fighting ignorance has become a full-time job.”

Whitson was among a minority of Republicans who voted against Tennessee’s vaccine amendment last year. “The parental rights thing has really taken hold,” he said, “and it can be used for and against us.”

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 $16,000 Postpartum Depression Drug Is Here. How Will Insurers Handle It?

A much-awaited treatment for postpartum depression, zuranolone, hit the market in December, promising an accessible and fast-acting medication for a debilitating illness. But most private health insurers have yet to publish criteria for when they will cover it, according to a new analysis of insurance policies.

The lack of guidance could limit use of the drug, which is both novel — it targets hormone function to relieve symptoms instead of the brain’s serotonin system, as typical antidepressants do — and expensive, at $15,900 for the 14-day pill regimen.

Lawyers, advocates, and regulators are watching closely to see how insurance companies will shape policies for zuranolone because of how some handled its predecessor, an intravenous form of the same drug called brexanolone, which came on the market in 2019. Many insurers required patients to try other, cheaper medications first — known as the fail-first approach — before they could be approved for brexanolone, which was shown in early trials reviewed by the FDA to provide relief within days. Typical antidepressants take four to six weeks to take effect.

“We’ll have to see if insurers cover this drug and what fail-first requirements they put in” for zuranolone, said Meiram Bendat, a licensed psychotherapist and an attorney who represents patients.

Most health plans have yet to issue any guidelines for zuranolone, and maternal health advocates worry that the few that have are taking a restrictive approach. Some policies require that patients first try and fail a standard antidepressant before the insurer will pay for zuranolone.

In other cases, guidelines require psychiatrists to prescribe it, rather than obstetricians, potentially delaying treatment since OB-GYN practitioners are usually the first medical providers to see signs of postpartum depression.

Advocates are most worried about the lack of coverage guidance.

“If you don’t have a published policy, there is going to be more variation in decision-making that isn’t fair and is less efficient. Transparency is really important,” said Joy Burkhard, executive director of the nonprofit Policy Center for Maternal Mental Health, which commissioned the study.

With brexanolone, which was priced at $34,000 for the three-day infusion, California’s largest insurer, Kaiser Permanente, had such rigorous criteria for prescribing it that experts said the policy amounted to a blanket denial for all patients, according to an NPR investigation in 2021.

KP’s written guidelines required patients to try and fail four medications and electroconvulsive therapy before they would be eligible for brexanolone. Because the drug was approved only for up to six months postpartum, and trials of typical antidepressants take four to six weeks each, the clock would run out before a patient had time to try brexanolone.

An analysis by NPR of a dozen other health plans at the time showed Kaiser Permanente’s policy on brexanolone to be an outlier. Some did require that patients fail one or two other drugs first, but KP was the only one that recommended four.

Miriam McDonald, who developed severe postpartum depression and suicidal ideation after giving birth in late 2019, battled Kaiser Permanente for more than a year to find effective treatment. Her doctors put her on a merry-go-round of medications that didn’t work and often carried unbearable side effects, she said. Her doctors refused to prescribe brexanolone, the only FDA-approved medication specifically for postpartum depression at the time.

“No woman should suffer like I did after having a child,” McDonald said. “The policy was completely unfair. I was in purgatory.”

One month after NPR published its investigation, KP overhauled its criteria to recommend that women try just one medication before becoming eligible for brexanolone.

Then, in March 2023, after the federal Department of Labor launched an investigation into the insurer — citing NPR’s reporting — the insurer revised its brexanolone guidelines again, removing all fail-first recommendations, according to internal documents recently obtained by NPR. Patients need only decline a trial of another medication.

“Since brexanolone was first approved for use, more experience and research have added to information about its efficacy and safety,” the insurer said in a statement. “Kaiser Permanente is committed to ensuring brexanolone is available when physicians and patients determine it is an appropriate treatment.”

“Kaiser basically went from having the most restrictive policy to the most robust,” said Burkhard of the Policy Center for Maternal Mental Health. “It’s now a gold standard for the rest of the industry.”

McDonald is hopeful that her willingness to speak out and the subsequent regulatory actions and policy changes for brexanolone will lead Kaiser Permanente and other health plans to set patient-friendly policies for zuranolone.

“This will prevent other women from having to go through a year of depression to find something that works,” she said.

Clinicians were excited when the FDA approved zuranolone last August, believing the pill form, taken once a day at home over two weeks, will be more accessible to women compared with the three-day hospital stay for the IV infusion. Many perinatal psychiatrists told NPR it is imperative to treat postpartum depression as quickly as possible to avoid negative effects, including cognitive and social problems in the baby, anxiety or depression in the father or partner, or the death of the mother to suicide, which accounts for up to 20% of maternal deaths.

So far, only one of the country’s six largest private insurers, Centene, has set a policy for zuranolone. It is unclear what criteria KP will set for the new pill. California’s Medicaid program, known as Medi-Cal, has not yet established coverage criteria.

Insurers’ policies for zuranolone will be written at a time when the regulatory environment around mental health treatment is shifting. The U.S. Department of Labor is cracking down on violations of the Mental Health Parity and Addiction Equity Act of 2008, which requires insurers to cover psychiatric treatments the same as physical treatments.

Insurers must now comply with stricter reporting and auditing requirements intended to increase patient access to mental health care, which advocates hope will compel health plans to be more careful about the policies they write in the first place.

In California, insurers must also comply with an even broader state mental health parity law from 2021, which requires them to use clinically based, expert-recognized criteria and guidelines in making medical decisions. The law was designed to limit arbitrary or cost-driven denials for mental health treatments and has been hailed as a model for the rest of the country. Much-anticipated regulations for the law are expected to be released this spring and could offer further guidance for insurers in California setting policies for zuranolone.

In the meantime, Burkhard said, patients suffering from postpartum depression should not hold back from asking their doctors about zuranolone. Insurers can still grant access to the drug on a case-by-case basis before they formalize their coverage criteria.

“Providers shouldn’t be deterred from prescribing zuranolone,” Burkhard 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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Fact Sheet: The Biden-Harris Administration Urges Congress to Lower Drug Costs for Americans with Commercial Insurance

HHS Gov News - March 11, 2024
Thanks to the President’s new lower cost prescription drug law, the lives of Medicare enrollees are changing for the better.

Colorado Isn’t Giving up on Its Drug Importation Dream

Colorado hopes to join Florida to become only the second state authorized to import prescription drugs from Canada. But they’re hitting the same hurdles: drugmakers — and the FDA.

Colorado officials recently amended their 2022 importation application with the Food and Drug Administration, in the process revealing new correspondence that shows the state’s so-far fruitless appeals for the agency’s help.

Drug companies typically sell medications for far less in Canada than in the United States, thanks to Canadian government-set price controls. But the companies have no interest or motivation in helping Americans — or states — obtain their drugs from north of the border.

Nearly two dozen drug companies refused Colorado’s entreaties to participate in its importation program, according to a report the state issued last year. And when the state asked the FDA for help, federal officials said the 2003 law allowing drug importation doesn’t authorize it to compel manufacturers to sell drugs intended for the Canadian market to states.

According to minutes released with Colorado’s amended application, state officials said their concerns about obtaining drugs for the program were not “adequately addressed” in a June meeting with the FDA.

Kim Bimestefer, executive director of the Colorado Department of Health Care Policy & Financing, said last week that the state still hopes for the FDA’s help.

“While we continue to reach out to manufacturers to ask them to do the right thing for consumers, employers and taxpayers, we are also working with the FDA for additional guidance on how to best navigate sourcing drugs,” she said in a statement. She has worked on Colorado’s importation strategy for more than four years.

One possibility is obtaining drugs from Canadian wholesalers rather than directly from manufacturers — something that would require FDA approval. Canada’s government has also warned that it would intervene if exports to the United States threatened its drug supply.

FDA spokesperson Jeremy Kahn said the agency “will continue to work with states and Indian tribes” that seek to develop importation programs.

The drug industry has fought importation from Canada (or elsewhere) for decades, arguing it would jeopardize the safety of the U.S. drug supply. The industry’s main lobbying group, the Pharmaceutical Research and Manufacturers of America, sued the Trump administration in 2020 after it greenlighted importation, but a judge dismissed the case for lack of standing because it was uncertain whether the FDA would approve a state’s plan.

The FDA in January approved Florida’s plan to import drugs from Canada, marking the first time it gave a state permission to do so.

While Colorado aims to import drugs for consumers in the state, Florida’s plan is intended to lower costs for state agencies such as its Health and Corrections departments.

Florida hasn’t made much headway, either.

“Our vendor is establishing relationships with drug manufacturers and working on negotiating agreements,” said Brock Juarez, a spokesperson for the Florida Agency for Health Care Administration. He said the state set a timeline for negotiations over the first six months of the year, and that “has not changed.”

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.

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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An Arm and a Leg: The Medicare Episode

Kaiser Health News:Insurance - March 11, 2024

Medicare may sound like an escape from the expensive world of U.S. health insurance, but it’s more complicated, and expensive, than many realize. And decisions seniors make when they sign up for the federal health insurance program can have huge consequences down the road. 

Host Dan Weissmann speaks with Sarah Jane Tribble, KFF Health News’ chief rural health correspondent, about one of the biggest choices seniors must make: whether to enroll in traditional Medicare or the privatized version, Medicare Advantage. 

Then, Weissmann shares practical tips about how soon-to-be seniors can avoid penalties and pick the plan that’s right for them.

Dan Weissmann @danweissmann Host and producer of "An Arm and a Leg." Previously, Dan was a staff reporter for Marketplace and Chicago's WBEZ. His work also appears on All Things Considered, Marketplace, the BBC, 99 Percent Invisible, and Reveal, from the Center for Investigative Reporting. Credits Emily Pisacreta Producer Adam Raymonda Audio wizard Ellen Weiss Editor Click to open the Transcript Transcript: The Medicare Episode

Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Dan: Hey there–

So, one thing we have never talked about on this show? Medicare. You know, that free-health-care thing you may expect to get when you turn 65.

It’s been on a list of things where I’ve been like, “that is TOO big, and TOO complicated. I can’t get my arms around that just now.” 

Especially because: There’s this thing called Medicare Advantage — a kind of privatized version, run by insurance companies? Seems controversial, and REALLY complicated. 

I’ve been like, Maybe someday.

And that someday? That’s today. Or at least, we start today. Mainly because a colleague of mine just did a BUNCH of work that we get to piggyback off of.

Sarah Jane Tribble: my name is Sarah Jane Tribble and I’m Chief Rural Health Correspondent with KFF Health News.

Dan: And as Sarah Jane reported on Medicare, she was surprised by how much she didn’t know. And how much other folks didn’t know either. 

Sarah Jane Tribble: At Thanksgiving, when I was working on some of these stories, I have friends who are nearing retirement. They’re not really close , but they’re close enough to care and they’re avid NPR listeners. And they were like, wait, so what’s the difference between Medicare Advantage and Medicare? And I was like, they should know. 

Dan: Who’s going to tell them? 

Sarah Jane Tribble: Right?

Dan: That’s us, I guess. 

Sarah Jane Tribble: This show will help tell them.

Dan-in-tape: I hope so. I hope so. 

Dan: Because this traditional-Medicare vs Medicare Advantage — it is a high stakes decision, it happens when you first sign up.

And here’s the big thing that Sarah Jane learned: if you sign up for Medicare Advantage, at that point, when you first get on Medicare, you’re pretty much stuck with it. And some people end up with buyer’s remorse. Big time.

And actually, beyond that choice — between Medicare Advantage and what’s called “traditional Medicare” –, there’s literally a whole alphabet soup of other choices you’re gonna need to make. Each with a price tag, and maybe some big trade-offs. 

And there’s been a lot of questionable information that comes at people. TV shows that older folks watch have been full of ads with People Who Were Real Famous in the 1970s.

J.J. Walker: Hi, I’m Jimmy JJ Walker. 

Joe Namath: Hi, I’m Joe Namath. 

William Shatner: William Shatner here with an important message. I’ve been on Medicare for longer than I’ll admit, and it sure has changed. 

Dan: Some of these ads make claims that sound too good to be true

J.J. Walker: And get this, I’m entitled to an extra 100 a month. That’s 1, 200 a year added to my social security check. And I was like, dyn-o-mite!

Dan: Last year, the feds finalized new rules to try and rein in sketchy claims from some ads like these. 

So understanding what’s going on, it’s a big deal. We’ll run down what I’ve learned so far, including some extremely expert guidance. 

Our expert, by the way, set me straight on a bunch of things, including, sadly, this: Medicare isn’t actually the free-health-care thingy some of us hope for.

Sarah Murdoch: Unfortunately, I think a lot of people think, Oh, Medicare is going to be free , it unfortunately is not.

Dan: The question is how much it’s going to cost you– in dollars, and maybe in your choices managing your own health care. And surprise! It’s super complicated.

So by the time we’re done, you’re gonna understand the difference between Medicare Advantage and traditional Medicare — and how to start sorting through the alphabet soup.We’ll also leave you with some solid resources to figure out what your best choice might be when the time comes, either for you or somebody you care about.

Let’s do it.

This is “An Arm and a Leg,” a show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann. I’m a reporter. I like a challenge — so the job we’ve chosen here is to take one of the most enraging, terrifying, depressing parts of American life, and bring you something entertaining, empowering, and useful.

OK, when it comes to Medicare, the biggest choice folks have to make is between traditional Medicare — run directly by the government — and Medicare Advantage plans, which are run by private insurance companies. And again, that’s plans, because a bunch of different insurance companies offer different Medicare Advantage plans. 

And last year, Sarah Jane Tribble started hearing from CEOs of rural hospitals.

They were telling her: Medicare Advantage plans are killing us. We’re spending a ton of time and money fighting with these insurance companies to get paid. And sometimes we don’t get paid.

Sarah Jane Tribble: And then I was also hearing about patients showing up at the hospital and these local hospitals saying, “oh, no, we actually don’t take your plan.” And so you’ve got these small town, you know, folks who have only one hospital and a long, you know, large radius. And they would show up and the hospital would be like, “Ah, you’re going to have to pay out of pocket because we don’t take this Medicare Advantage plan.” And the patient, of course, would be like, “but I’m on Medicare, you’re supposed to take care of me.”

Dan: Yeah. Isn’t that deal with Medicare? Everybody accepts it. You get on Medicare, you’re taken care of?

Sarah Jane Tribble: I began wondering, how much does signing up for a Medicare Advantage plan actually affect the care you get?

Dan: And the answer seems like: Maybe a lot. 

A little Google searching turns up a lot of headlines about claims getting denied, and about hospitals dropping Medicare Advantage plans. 

And it also turns up a report from the Inspector General’s office at the federal Department of Health and Human Services. 

And if you’ve got regular insurance, you may be familiar with what’s called “prior authorization.” That’s when your provider needs to get the insurance company’s OK, their authorization, before going ahead with whatever they think you need … a test, a procedure, a prescription. 

And sometimes the insurer issues a denial. They say no.

The Inspector General’s report looked at a random sample of denials by Medicare Advantage plans. They found one out of every eight denials was for care traditional Medicare totally covers. 

Which, you know, as you get older, if you got sick, you could have eight of these requests in a month. 

Sarah Jane started talking with patients.

Sarah Jane Tribble: I called one gentleman in Washington state, and he wanted out of his Medicare Advantage plan and he couldn’t get out.

Dan: That gentleman is Rick Timmins. 

Rick Timmins: I’m a retired veterinarian. I’m living on Whidbey Island in Washington, which is just north and west of Seattle.

Dan: Ooo, wow! So, is your life just a succession of paddling trips …

Rick Timmins: Ha ha ha ha ha ha. 

Dan: and swims in the sound?

Rick Timmins: Yes, sort of. Although the water is a little bit too cold for me to swim in. So, it’s kayaks when we get out into the water.

Dan: Rick signed up for Medicare Advantage in 2016 after attending an informational seminar run by an insurance agent. 

Rick Timmins: … nice guy, and he said, you know, the best thing to do is to get a Medicare Advantage plan because they cover everything, and it’s, it’s far less expensive than traditional Medicare,

Dan: OK, why would that guy say Medicare Advantage is far less expensive than traditional Medicare? I mean, for one, a lot of us think Medicare’s gonna be free. 

And even if it’s not, why should … I mean, how could … one kind of Medicare be more expensive than another? 

We’re gonna have a lot of details on this later, but here let’s just get into the difference between Medicare Advantage and traditional Medicare. Traditional Medicare is run by the government. Government pays all the bills. 

BUT traditional medicare only pays 80 percent of everything and you’re on the hook for the other 20 percent. There’s no out-of-pocket limit. Let’s bring back Sarah Jane Tribble to briefly say what that means: 

Sarah Jane Tribble: You could pay out the wazoo. It could bankrupt you. 

Dan: Out the wazoo. Because you know: Medical bills, hospital bills … they can get into the tens of thousands, hundreds of thousands of dollars. Twenty percent of that is paying out the wazoo. 

To avoid that risk, if you’re on traditional Medicare you basically need another insurance policy — a supplement, often called Medigap — like it covers the gaps that traditional Medicare leaves. 

Some people get Medigap from their old employers. But most people have to pay for it. It can get expensive. 

Medicare Advantage plans, plans run by private insurance companies, DO have an out of pocket limit. You don’t have to buy a supplement. That’s an advantage. 

Also, there are things traditional Medicare doesn’t pay for — like dental care, and glasses, and hearing aids. Medicare Advantage plans generally DO cover those things. 

And as Rick recalls, the insurance agent pushed Medicare Advantage kinda hard.

Rick Timmins: Basically what he said was, yeah, if you want to sign up for traditional Medicare, I can help you for that, but if you want Medicare Advantage, which is a much better program…

Dan: Then sign right here. So Rick did. Fast forward five years. Rick’s wife notices a little bump on his ear. 

Rick Timmins: She said, you should get that looked at. I have a family history of melanoma. My two sisters have had melanoma.

Dan: Rick says he saw his primary care doc, then started trying to get his insurance company’s promise that seeing a specialist would be covered. He says he called and called, over more than six months.

Rick Timmins: It was not a fun time. I mean, I didn’t know what it was, but I knew that it was growing and it was sore and you know, I was frightened. It’s like you can’t think about anything else when you’re wondering about what’s happening with this little lump.

Dan: Rick says when he did get seen, the thing was the size of a dime. They found it was malignant, cut his earlobe off, and scanned his lymph nodes. They were clean, but he spent a year on immunotherapy. Now he says he’s getting scans every six months.

Sarah Jane Tribble asked Rick’s insurance company about all this. They said they wouldn’t comment on his case.

Meanwhile, Rick says he’s had enough of Medicare Advantage. On traditional Medicare, you don’t need anybody’s OK to go see a specialist. You just go. 

But of course to switch to traditional Medicare, Rick would need a supplement, a Medigap policy.

Rick Timmins: Otherwise, uh, you’re just forking out thousands of dollars if you have any issues.

Dan: Because you’re on the hook for 20 percent of everything. No out of pocket limit. Paying out the wazoo.

But Rick doesn’t think he can get a medigap policy. Because in most states — including Washington, where Rick lives — insurance companies don’t have to issue you a Medigap policy if you have pre-existing conditions. 

Not unless you sign up for it when you FIRST enroll in Medicare. 

Rick Timmins: The insurance companies can tell me, no, we don’t want to insure you. You’ve had too many issues. Look, you had a knee replaced. You had cancer. 

Dan: This is what made Rick’s story, and the whole Medicare situation, so striking to Sarah Jane Tribble.

Sarah Jane Tribble: It’s sort of shocking, actually, right? The Affordable Care Act passes and makes it so that everybody with pre-existing conditions can get insurance no matter what, but it leaves out the people who might need that the most, who are 65 and older. 

Dan: Four states have laws that do require Medigap insurers to take everybody. But only four. 

Sarah Jane Tribble: If you’re Rick in Washington state, you could get rejected.

Dan: I talked to someone else who would like do-overs on signing up for Medicare Advantage. In the 1970s, in his 20s, Robert Wolpa was a professional musician, a guitar player. 

Robert Wolpa: Played in bands up and down the west coast. Went to Canada with an Elvis act. It was really a lot of fun. 

Dan: And he worked in call centers for decades. When he turned 65, he says he got inundated with ads and calls and flyers.

Robert Wolpa: I got one of the mailers says have a free dinner on us. And we’ll teach you all about Medicare, the ins and outs of Medicare.

Dan: He went, and got what he thinks of in retrospect as a hard-sell pitch for Medicare Advantage, which he bought. And, over time, he’s gotten disillusioned. 

He says, you know, it’s one thing to have to call to get a pre-authorization or a referral. “Is this doctor covered? No. Oh okay. Which doctor is covered?” It’s a lot of calls. And then there’s the difficulty of getting through the calls.

Robert Wolpa: It got harder and harder and more frustrating, talking to some of these people who didn’t know what they were doing. I mean and I’ve been a call center guy too for most of my life but these poor people. I mean they are so undertrained and underpaid.

Dan: At least, that’s the impression Robert gets, as a guy who spent years working in call centers.

Robert has priced out a Medigap plan. Because he’s got pre-existing conditions — HIV, a pacemaker — it would be expensive: four hundred seventy nine dollars. Which is almost a third of what he gets from social security. 

Robert Wolpa: And I said, okay. Next option. 

Dan: I suggest maybe his work background gives him an advantage in jumping through hoops, like making all those calls: both knowing how to navigate, and having empathy that could help him keep his blood pressure from spiking too hard. He says, yeah, up to a point … For now. 

Robert Wolpa: And I think to myself, you know, I’m 71. I just turned 71 in November and I’m, I’m a little, I’ve got, I’ve got a little of the HIV cognizant crap. Like my, my short term memory is gone.

Dan: After talking with Robert, this part really gave me pause. I mean, dealing with insurance companies and all the attendant hassles is hard work, right?

It’s not the kind of job I’d wish on somebody as they get older and start slowing down. 

And it could be a job that increasing numbers of people are signing up for: Last year the number of people in Medicare Advantage plans became the majority of people on Medicare.

Alright, I may have scared the bejesus out of you. I’m a little scared myself. 

But I’ve got some super-practical information coming your way. I talked with one of THE best people in the country to find out: What should I know BEFORE it’s time to sign up for Medicare?

Turns out the answer is … A LOT. That’s next.

This episode of “An Arm and a Leg” is produced in partnership with KFF Health News. That’s a nonprofit newsroom covering health care in America. Their reporters, like Sarah Jane Tribble, are amazing. I’m honored to work with them.

OK, so, if you want traditional Medicare, you pretty much need to choose it when you first sign up for Medicare. 

And signing up for Medicare turns out to involve a LOT of choices, and a lot of different price tags.

And some big potential pitfalls. It is wild, the things I’ve learned. 

I found maybe the best person in the country to learn from.

Sarah Murdoch: My name is Sarah Murdoch. I’m the Director of Client Services at the Medicare Rights Center, and we’re a national non profit that assists with Really any Medicare issue that you could conceive of and we serve like a massive quantity of people on our helpline, about 20, 000 people in a year. 

Dan: What would you want people to know when they’re like, say, I don’t know, 64, uh, about the choices there? Because I think a lot of us think, like, “Oh, I’m going to turn 65. I’m going to call the federal government or maybe they’ll call me and I never have to think about health insurance again, or healthcare, or you know, paying these ridiculous prices.” And I think that’s not exactly true. Right?

Sarah Murdoch: To start off, they’re not going to call you. 

Dan: And not only do I have to call THEM, I have to do it on time. Apparently, I get a seven month window — like three and a half months on either side of my 65th birthday. And I better not miss it. 

Because if I do, well, number one: I have to wait until the following January to sign up. And till then, I better have some OTHER health insurance. Because no Medicare for me. 

And not only that: When I do sign up, I’m gonna have to pay a penalty. When Sarah told me this, I was like, “are you kidding me?”

Sarah Murdoch: No, I wish I was kidding, but unfortunately, unfortunately not. So yeah, there are very stringent, kind of, enrollment windows that people need to stick to.

Dan: I kind of couldn’t take it all in at once. I was like, “So either I have to wait, or else I have to pay?” Is that it? Sarah’s like, “no, dummy.”

Sarah Murdoch: You would have to wait AND you would have to pay. So, …

Dan: You’re going to charge me for not having Medicare? That sounds awful. 

Sarah Murdoch: I love talking to people like you said when they’re 64 because you can kind of head off the pitfalls before they happen.

Dan: Oh, get this: The penalty is not a one-time late fee. It bumps up what you pay for the rest of your life. 

Holy crap! I had done some homework before talking with Sarah, but I had not seen that one coming at all. So yeah. Don’t miss that deadline! And about the rest, the part I thought I’d done my homework on, boy did Sarah fill in a lot of blanks.

So, just to get started, here’s the big picture: Medicare is alphabet soup. There’s part A, that covers hospital bills. There’s part B, that covers doctor visits. And there’s part D, for drugs.

What’s part C, you’re asking? Oh, that’s Medicare Advantage. If you’ve got that, it basically takes over for A, B and– a lot of the time, D. 

And let’s say you don’t want to go with Medicare Advantage when you first sign up for Medicare, because for most people, this is like your one shot at getting traditional Medicare, accepted just about everywhere, no questions asked.

Then, you’ll need to buy a Medigap supplement, so you don’t end up paying out the wazoo if you run into health problems– because traditional Medicare only pays 80 percent.

But no matter what you pick– Medicare Advantage or traditional Medicare … it’s gonna cost you. As we heard from Sarah right at the top of this episode…

Sarah Murdoch: I think a lot of people think, Oh, Medicare is going to be free, it unfortunately is not.

Dan: Yeah, so each part has its own price tag … Or tags. Sarah walked me through it.

And actually, the very first step involves some GOOD news.

Sarah Murdoch: Part A, which is hospital and inpatient coverage is free for most people. 

Dan: So, if you’ve paid into social security and medicare for ten years, that’s you. So, great.

And unfortunately, that’s where the easy, simple part… ends. 

Next, we move on to Part B — doctor bills. Outpatient stuff.

Sarah Murdoch: Part B has a monthly premium, uh, of $174… let me just get the exact, it’s $174 and change,

Dan: A hundred seventy-four dollars and seventy cents. 

And important to note: Picking a Medicare Advantage plan does NOT mean you skip paying this part B premium, this 174 dollars and seventy cents. It applies to pretty much everybody.

And folks with higher incomes — starting at 103,000 dollars — can pay more. 

OK, that’s part B. Doctor visits. On to part D for drugs. 

Fun fact: This is 100 percent run by private insurance companies, actually. 

Which, among other things, means it involves shopping for a plan. Every year.

Sarah Murdoch: Those plans and their premiums change year to year. In New York, like, we would see them ranging from anywhere from like $3 monthly premium to $120. So all over the place.

Dan: $3 sounds good, but I’m guessing there’s a catch.

Sarah Murdoch: Yes, so not every plan is identical. 

Dan: Some Part D plans cover more drugs than others. Some leave you paying more for the drugs they do cover. Which one is a good deal will depend on what meds you need.

Ugh, sounds fun, right? Well, Sarah tells me there’s actually a bit of good news here, because we’re not on our own with this.

Sarah Murdoch: Medicare does, on medicare.gov, have a really great tool called “plan finder” where people can enter their medications. It sort of matches up your medications with the plans that cover them in the most affordable way. 

Dan: This is a huge relief, because shopping on my own? Yeesh. It looks like there are 21 different Part D plans in my area, so comparing all of them would be a big job. 

OK! Now I’ve got Parts A, B, and D. I’m on the hook for, well start with $174.70, plus however much for drugs. 

And if I still want traditional Medicare — just about everyone takes it, hardly any pre-authorizations to worry about — I still need a Medigap plan. Also called a supplement. And, again, now I’m shopping for insurance from private companies. 

And guess what? We’ve got a whole new bowl of alphabet soup! 

Sarah Murdoch: Yeah. So there’s 10 Medigaps. They all have a letter. 

Dan: Yeah and each letter has its own set of benefits and exclusions —some have higher deductibles, others cover some extras, but they’re all supposed to protect you from paying out the wazoo.

So for example, Plan G is the most comprehensive, and the most expensive. And of course, once I’ve picked a letter, I’m sifting through however-many companies offer any given plan in my area. 

Where I live, in Illinois, it looks like there are 57 Plan G’s on offer. Prices: A hundred thirty bucks to four sixty four. 

But here’s another little bit of good news for us. Because Sarah has a super important tip.

Sarah Murdoch: I think it is very important for people to keep in mind there that all the G’s are identical, right? A G offered by company 1 that’s $500, versus the G offered by company 2 that’s $300, have identical benefits, so there’s no reason to pick the, um, more expensive. 

Dan: I ask Sarah: Wait. How are any of these companies getting away with charging more for the exact same thing? Like, why would anybody ever choose the more expensive one? She’s like, maybe they just don’t know any better.

Sarah Murdoch: Maybe they had that company, you know, when they were working and they have, you know, preconceived notions about it.

Dan: So when people call the helpline, Sarah and her colleagues tell them …

Sarah Murdoch: Pick one that’s the most affordable. Don’t make some other selection for whatever reason you might imagine in your head.

Dan: So of course it turns out in the case of Plan G, which just happens to be the example Sarah’s using, there IS a caveat: In some states, there are Plan G’s sold with a high deductible and lower premiums. Okay, more to watch out for. But in general, this is some really good advice right here.

All of this leaves me with a big take-away: 

Medicare is not free. There’s that 174 seventy for the Part B premium … and then you may be looking at a bunch of money on top of that, for a Medigap plan. 

Or, if you go with Medicare Advantage and avoid paying for a Medigap plan, you are looking at dealing with private health insurance companies that we all love so much.

All the shopping for a plan:  “Do I get an HMO? A PPO? What’s the difference again?” 

And then all the questions, all the run-arounds, all year round: “Is my doctor covered? Is my doctor still covered this year? Is the company gonna approve the care my doctor says I need? If they don’t, what the hell am I gonna do?”

All of it left my colleague Sarah Jane Tribble pretty ticked off.

Sarah Jane Tribble: The thing that blew my mind is how expensive it is to have any form of Medicare, right? It’s not a free ticket for your health care. This is to me, the most outrageous thing that you’re going into retirement, you’ve lived your life, and America is supposed to give you this promise of Medicare, and then the promise is actually hundreds of dollars a month.

Dan: Or you can save some money by signing up for Medicare Advantage, and hope it works out for you. 

And hey: It does work for some people. My mom’s on a Medicare Advantage plan — she’s 93 and definitely sees a few doctors — and she’s got no complaints. 

Here’s Sarah Murdoch from the Medicare Rights Center:

Sarah Murdoch: When people ask, I think often, like, which one is better? It’s like, that’s, that’s not … I can’t answer that because people’s needs are different. People’s doctors are different. Where they live and their access to different services might be different. If you’re in a plan that all your doctors take, then that’s great. You can save some money that way too on those premiums.

Dan: And hope the insurance company doesn’t change the deal next year. And that your doctors don’t decide to leave the plan. 

OK, I’m not trying to freak you out — or myself. And I actually have some good news, thanks to Sarah Murdoch. 

Because: We’ve covered a lot of ground on what you should know about Medicare. But holy crap, there is SO much more to know. Medigap plans are regulated by states– that’s 50 different setups right there. Not to mention the ten different flavors of Medigap. And all the kajillion and one different Medicare Advantage plans out there. 

And there’s deals we haven’t talked about too. Some people with low incomes qualify for Medicaid, which kind of serves as a Medigap. Some people can get government subsidies to cover that Medicare Part B premium. And, again, all of this is state-by-state: 50 different deals.

So if you’re looking at actually signing up for Medicare, you’re gonna have a lot more questions than I can start to answer here. 

And the good news is: You don’t have to go to an insurance broker, like Rick and Rob did, and hope they steer you right instead of, you know, chasing a higher commission.

Sarah Murdoch says every state has an agency you can call. They’re called SHIPS — for State Health Insurance Assistance Programs — the A is silent, I guess. And their job is to give unbiased advice. 

If you’re in New York, you might even end up talking with Sarah or one of her colleagues.

Sarah Murdoch: The SHIPS don’t get anything. They don’t have any financial incentive. We participate in the New York ship, like I don’t care what plan you pick. I just want to help you pick something that is going to work for you. And that may be original Medicare with a Medigap and Part D. It might be a Medicare Advantage plan. It might be, you know, Medicare and Medicaid. 

Dan: So if this episode is pitched at someone who’s at or approaching age 64, the bottom line is like, go get on a ship. Go sail on a ship. Is that right? 

Sarah Murdoch: Yeah. There’s a central website, shiphelp. org, where you can just click on your state and it will kind of direct you to the phone number to call. So, they’re there as a resource.

This was a LOT. Let’s just review:

First: Medicare isn’t free. Got it.

Second: Don’t forget to sign up on time! You could end up paying a late fee every month for the rest of your life.

“An Arm and a Leg” is a co-production of KFF Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and X, formerly known as Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

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Why Covid Patients Who Could Most Benefit From Paxlovid Still Aren’t Getting It

Kaiser Health News:States - March 11, 2024

Evangelical minister Eddie Hyatt believes in the healing power of prayer but “also the medical approach.” So on a February evening a week before scheduled prostate surgery, he had his sore throat checked out at an emergency room near his home in Grapevine, Texas.

A doctor confirmed that Hyatt had covid-19 and sent him to CVS with a prescription for the antiviral drug Paxlovid, the generally recommended medicine to fight covid. Hyatt handed the pharmacist the script, but then, he said, “She kept avoiding me.”

She finally looked up from her computer and said, “It’s $1,600.”

The generally healthy 76-year-old went out to the car to consult his wife about their credit card limits. “I don’t think I’ve ever spent more than $20 on a prescription,” the astonished Hyatt recalled.

That kind of sticker shock has stunned thousands of sick Americans since late December, as Pfizer shifted to commercial sales of Paxlovid. Before then, the federal government covered the cost of the drug.

The price is one reason Paxlovid is not reaching those who need it most. And patients who qualify for free doses, which Pfizer offers under an agreement with the federal government, often don’t realize it or know how to get them.

“If you want to create a barrier to people getting a treatment, making it cost a lot is the way to do it,” said William Schaffner, a professor at Vanderbilt University School of Medicine and spokesperson for the National Foundation for Infectious Diseases.

Public and medical awareness of Paxlovid’s benefits is low, and putting people through an application process to get the drug when they’re sick is a non-starter, Schaffner said. Pfizer says it takes only five minutes online.

It’s not an easy drug to use. Doctors are wary about prescribing it because of dangerous interactions with common drugs that treat cholesterol, blood clots, and other conditions. It must be taken within five days of the first symptoms. It leaves a foul taste in the mouth. In one study, 1 in 5 patients reported “rebound” covid symptoms a few days after finishing the medicine — though rebound can also occur without Paxlovid.

A recent JAMA Network study found that sick people 85 and older were less likely than younger Medicare patients to get covid therapies like Paxlovid. The drug might have prevented up to 27,000 deaths in 2022 if it had been allocated based on which patients were at highest risk from covid. Nursing home patients, who account for around 1 in 6 U.S. covid deaths, were about two-thirds as likely as other older adults to get the drug.

Shrunken confidence in government health programs is one reason the drug isn’t reaching those who need it. In senior living facilities, “a lack of clear information and misinformation” are “causing residents and their families to be reluctant to take the necessary steps to reduce covid risks,” said David Gifford, chief medical officer for an association representing 14,000 health care providers, many in senior care.

The anti-vaxxers spreading falsehoods about vaccines have targeted Paxlovid as well. Some call themselves anti-paxxers.

“Proactive and health-literate people get the drug. Those who are receiving information more passively have no idea whether it’s important or harmful,” said Michael Barnett, a primary care physician at Brigham and Women’s Hospital and an associate professor at Harvard, who led the JAMA Network study.

In fact, the drug is still free for those who are uninsured or enrolled in Medicare, Medicaid, or other federal health programs, including those for veterans.

That’s what rescued Hyatt, whose Department of Veterans Affairs health plan doesn’t normally cover outpatient drugs. While he searched on his phone for a solution, the pharmacist’s assistant suddenly appeared from the store. “It won’t cost you anything!” she said.

As Hyatt’s case suggests, it helps to know to ask for free Paxlovid, although federal officials say they’ve educated clinicians and pharmacists — like the one who helped Hyatt — about the program.

“There is still a heaven!” Hyatt replied. After he had been on Paxlovid for a few days his symptoms were gone and his surgery was rescheduled.

About That $1,390 List Price

Pfizer sold the U.S. government 23.7 million five-day courses of Paxlovid, produced under an FDA emergency authorization, in 2021 and 2022, at a price of around $530 each.

Under the new agreement, Pfizer commits to provide the drug for the beneficiaries of the government insurance programs. Meanwhile, Pfizer bills insurers for some portion of the $1,390 list price. Some patients say pharmacies have quoted them prices of $1,600 or more.

How exactly Pfizer arrived at that price isn’t clear. Pfizer won’t say. A Harvard study last year estimated the cost of producing generic Paxlovid at about $15 per treatment course, including manufacturing expenses, a 10% profit markup, and 27% in taxes.

Pfizer reported $12.5 billion in Paxlovid and covid vaccine sales in 2023, after a $57 billion peak in 2022. The company’s 2024 Super Bowl ad, which cost an estimated $14 million to place, focused on Pfizer’s cancer drug pipeline, newly reinforced with its $43 billion purchase of biotech company Seagen. Unlike some other recent oft-aired Pfizer ads (“If it’s covid, Paxlovid”), it didn’t mention covid products.

Connecting With Patients

The other problem is getting the drug where it is needed. “We negotiated really hard with Pfizer to make sure that Paxlovid would be available to Americans the way they were accustomed to,” Department of Health and Human Services Secretary Xavier Becerra told reporters in February. “If you have private insurance, it should not cost you much money, certainly not more than $100.”

Yet in nursing homes, getting Paxlovid is particularly cumbersome, said Chad Worz, CEO of the American Society of Consultant Pharmacists, specialists who provide medicines to care homes.

If someone in long-term care tests positive for covid, the nurse tells the physician, who orders the drug from a pharmacist, who may report back that the patient is on several drugs that interact with Paxlovid, Worz said. Figuring out which drugs to stop temporarily requires further consultations while the time for efficacious use of Paxlovid dwindles, he said.

His group tried to get the FDA to approve a shortcut similar to the standing orders that enable pharmacists to deliver anti-influenza medications when there are flu outbreaks in nursing homes, Worz said. “We were close,” he said, but “it just never came to fruition.” “The FDA is unable to comment,” spokesperson Chanapa Tantibanchachai said.

Los Angeles County requires nursing homes to offer any covid-positive patient an antiviral, but the Centers for Medicare & Medicaid Services, which oversees nursing homes nationwide, has not issued similar guidance. “And this is a mistake,” said Karl Steinberg, chief medical officer for two nursing home chains with facilities in San Diego County, which also has no such mandate. A requirement would ensure the patient “isn’t going to fall through the cracks,” he said.

While it hasn’t ordered doctors to prescribe Paxlovid, CMS on Jan. 4 issued detailed instructions to health insurers urging swift approval of Paxlovid prescriptions, given the five-day window for the drug’s efficacy. It also “encourages” plans to make sure pharmacists know about the free Paxlovid arrangement.

Current covid strains appear less virulent than those that circulated earlier in the pandemic, and years of vaccination and covid infection have left fewer people at risk of grave outcomes. But risk remains, particularly among older seniors, who account for most covid deaths, which number more than 13,500 so far this year in the U.S.

Steinberg, who sees patients in 15 residences, said he orders Paxlovid even for covid-positive patients without symptoms. None of the 30 to 40 patients whom he prescribed the drug in the past year needed hospitalization, he said; two stopped taking it because of nausea or the foul taste, a pertinent concern in older people whose appetites already have ebbed.

Steinberg said he knew of two patients who died of covid in his companies’ facilities this year. Neither was on Paxlovid. He can’t be sure the drug would have made a difference, but he’s not taking any chances. The benefits, he said, outweigh the risks.

Reporter Colleen DeGuzman contributed to this report.

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California Attorney General Boosts Bill Banning Medical Debt From Credit Reports

Kaiser Health News:States - March 11, 2024

California Attorney General Rob Bonta announced Monday that he is throwing his weight behind legislation to bar medical debt from showing up on consumer credit reports, a Democratic-led effort to offer protection to patients squeezed by health care bills.

Bonta is a sponsor of Sen. Monique Limón’s bill, which seeks to block health care providers, as well as any contracted collection agency, from sharing a patient’s medical debt with credit reporting agencies. It would also prevent credit reporting agencies from accepting, storing, or sharing any information concerning medical debt. Medical debt isn’t necessarily an accurate reflection of credit risk, and its inclusion in credit reports can depress credit scores and make it hard for people to get a job, rent an apartment, or secure a car loan.

“This is a broken part of our current system that needs to be fixed,” Bonta, a Democrat, told KFF Health News. “This is California’s opportunity, and we relish the ability to be up in front of key issues.”

If enacted, California would become the third state to remove medical bills from consumer credit reports, following Colorado and New York in 2023. Minnesota has a proposal to do the same. Last year, the Biden administration announced plans to develop similar federal rules through the Consumer Financial Protection Bureau, but they have yet to be released. And should former President Donald Trump return to the White House, he would have the prerogative to undo the rules.

Limón said it’s important for the state to enshrine its own protections into law alongside the federal push. “We may be waiting for a very long time to see outcomes that California could potentially deliver in the next year,” said the Santa Barbara Democrat.

Bonta said he’s not sure what sort of opposition to the bill to expect, but he wonders if providers and collection agencies will be resistant.

A KFF Health News analysis found that credit reporting threats are the most common collection tactic used by hospitals to get patients to pay their bills. A hospital, for example, might be concerned that a credit score ban might make it more difficult to get patients to pay for medical care they have already received.

The three largest U.S. credit agencies — Equifax, Experian, and TransUnion — have said they would stop including some medical debt on credit reports as of 2022. Among the excluded debts are paid-off bills and those less than $500, but the agencies’ voluntary actions left out millions of patients with bigger medical bills on their credit reports.

Limón said she often hears from constituents about the impact medical debt has on their lives. Medical debt disproportionately affects low-income, Black, and Latino Californians, according to the California Health Care Foundation.

And, increasingly, people with healthy incomes who often carry medical insurance are incurring medical debt. A KFF Health News-NPR investigation found that about 100 million people across the country are saddled with medical debt, which has forced some to give up their homes, ration food, and take on extra work.

Though the legislation wouldn’t forgive medical debt, Limón said she hopes it will encourage people to seek medical care when they need it.

“You hear so many people now that are concerned about getting medical care because they can’t afford it and instead wait to get worse,” Limón said. “If the bill passes, we’ll see less fear and more people going to get medical care.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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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Letter to Health Care Leaders on Cyberattack on Change Healthcare

HHS Gov News - March 10, 2024
HHS DOL Open Letter to Health Care Leaders

HHS Secretary Xavier Becerra’s Statement on Women’s History Month

HHS Gov News - March 08, 2024
Secretary Xavier Becerra released the following statement in honor of Women’s History Month

Biden-Harris Administration Announces Utah’s Medicaid and CHIP Postpartum Coverage Expansion; 45 States Now Offer Full Year of Coverage After Pregnancy

HHS Gov News - March 08, 2024
An estimated 691,000 Americans annually are now eligible for essential care for a full year after pregnancy.

HHS Announces New Smoking Cessation Framework to Support Quitting

HHS Gov News - March 08, 2024
The U.S. Department of Health and Human Services unveiled a Framework to accelerate smoking cessation and reduce smoking- and cessation-related disparities.

Biden Said State of the Union Is Strong and Made Clear His Campaign Is Off and Running

Kaiser Health News:Insurance - March 08, 2024

President Joe Biden touted his administration’s accomplishments in health care in a wide-ranging State of the Union address on Thursday evening that touched on subjects such as immigration, the economy, crime, job growth, infrastructure, and the Israel-Hamas war. 

With Biden and former President Donald Trump now the presumptive Democratic and Republican nominees, Biden used the roughly 68-minute speech to counter his lackluster public approval ratings and draw clear contrasts between his administration’s policies and those of Trump and some congressional Republicans. But he never mentioned Trump by name, instead referring to him as his “predecessor.”

Biden came out swinging, speaking about freedom and democracy, and support for Ukraine and NATO. And he reminded lawmakers that history is watching.

Our PolitiFact partners fact-checked the debate in real time. Read the full coverage here.

Early in the speech, Biden pointed to the recent Alabama Supreme Court decision that effectively shut down in vitro fertilization treatments across the state, although its governor signed a bill into law March 6 to shield patients and providers from potential legal liability.

Biden challenged his “friends across the aisle” to “guarantee the right to IVF nationwide,” and connected this issue directly to the 2022 Supreme Court decision overturning Roe v. Wade.

White House guests for the speech included Latorya Beasley of Birmingham, Alabama, whose IVF treatments were canceled because of her state’s court decision; and Kate Cox, who was denied an emergency abortion by the Texas Supreme Court. Members of the Democratic Women’s Caucus sat en bloc, wearing white to show solidarity for reproductive rights. 

“Like most Americans, I believe Roe v. Wade got it right,” Biden said, adding that his “predecessor” came to office “determined” to see it overturned and has bragged about its undoing. “Clearly, those bragging about overturning Roe v. Wade have no clue about the power of women in America.”

Biden’s other health care hits included the first steps in implementing Medicare drug price negotiations, something on Democrats’ longtime policy wish list that became law as part of the Inflation Reduction Act he signed in August 2022. He noted that the federal health insurance program for seniors is now — for the first time — negotiating lower prices for some of the costliest drugs on the market. He pointed not only to the savings it would bring seniors, but also to the federal budget. Currently, 10 drugs are on the list, which will be added to in future years. Biden called for an expansion of the program: “Now it’s time to go further and give Medicare the power to negotiate lower prices for 500 drugs over the next decade.”

He also claimed victory with other Medicare-related changes in that law — including a $35 insulin price cap and a $2,000 price cap on Medicare out-of-pocket drug expenses. In each of case, he challenged Congress to act with him to expand these steps to include everyone.

When it came to the Affordable Care Act, he said it is “still a very big deal” and pledged not only to protect it, but also to expand it by working to make permanent the tax subsidies first advanced at the height of the covid-19 pandemic to make health insurance more affordable.

“My predecessor and many in this chamber want to take that protection away by repealing the Affordable Care Act; I won’t let that happen,” he said, drawing heckles from opponents in the audience.

Afterward, some Republicans, including House Speaker Mike Johnson (R-La.), said the address was overly partisan. Trump slammed it, telling Fox News that Biden “suffers from a terminal case of Trump derangement syndrome.” And Sen. Katie Britt (R-Ala.) gave the GOP response.  

Here are health care highlights from PolitiFact:

“The Alabama Supreme Court shut down IVF treatments across the state, unleashed by a Supreme Court decision overturning Roe v. Wade.”

On Feb. 16, the Alabama Supreme Court issued a ruling that said frozen embryos should be considered children.

The decision lacks the power to shut down in vitro fertilization treatments statewide. But it caused multiple clinics in the state to pause IVF treatments as they reviewed the decision and potential liabilities.

Since then, Alabama lawmakers passed legislation to shield IVF providers from civil or criminal liability in a rush to protect fertility treatments after backlash grew. Two clinics announced they were resuming operations after Republican Gov. Kay Ivey signed the law.

Sen. Tammy Duckworth (D-Ill.) — who had two daughters using in vitro fertilization — introduced a similar federal bill aimed at protecting IVF. But Sen. Cindy Hyde-Smith (R-Miss.) blocked it Feb. 28, saying it was a “vast overreach that is full of poison pills that go way too far — far beyond ensuring legal access to IVF.”

“If you, the American people, send me a Congress that supports the right to choose, I promise you: I will restore Roe v. Wade as the law of the land again.”

PolitiFact continues to rate Biden’s promise to codify Roe v. Wade as “Stalled.”

Biden called on Congress to help him achieve his 2020 campaign promise to codify Roe v. Wade.

He can’t do it alone.

The Supreme Court ruled in 2022 to overturn Roe, ending nearly 50 years of federally protected abortion access.

Sen. Tammy Baldwin (D-Wis.) introduced the Women’s Health Protection Act of 2023, which would prohibit governmental restrictions on access to abortion. But it has no Republican co-sponsors and didn’t advance.

PolitiFact has been tracking Biden’s campaign promise to codify Roe v. Wade, one of about 100 promises on the Biden Promise Tracker. The lack of 10 Republicans needed to overcome an expected filibuster has stalled Biden’s efforts on codification. That obstacle remained even after Democrats kept narrow control of the Senate in the midterms.

Americans pay more for prescription drugs than anywhere in the world.”

PolitiFact rated a similar claim by Biden as “Mostly True.

U.S. per capita spending on prescription drugs is nearly three times the average of other advanced, industrialized countries that comprise the Organization for Economic Co-operation and Development. A study by the Rand Corp., a nonpartisan research organization, found that, across all drugs, U.S. prices were 2.78 times as high as the combined prices in 33 OECD countries.

The gap was even larger for brand-name drugs, with U.S. prices averaging 4.22 times as much as those in comparison nations. The U.S. pays less than comparable nations for unbranded, generic drugs, which account for about 90% of filled prescriptions in the country yet make up only one-fifth of prescription drug spending.

Researchers say factors including country-specific pricing, confidential rebates, and other discounts can obscure actual prices, making comparisons harder.

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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Hospitales de California y defensores buscan financiación estable para retener a navegadores de salud conductual

Proveedores de salud y expertos en adicciones advierten que una iniciativa en California, que ayuda a pacientes con trastorno por consumo de sustancias a iniciar tratamientos de largo plazo luego de recibir el alta de salas de emergencias, tiene una estructura de financiamiento inestable, por lo que algunos empleados críticos ya han renunciado.

Los partidarios del programa de navegadores de salud conductual de CA Bridge, que se lanzó en 2022, dicen que depender una sola partida de financiación dificulta que los hospitales retengan a los navegadores, en medio de una creciente crisis de drogas.

En 2022, el año más reciente del que se dispone de datos, 7,385 californianos murieron por sobredosis relacionadas con opioides, de los cuales el 88% involucró fentanilo, un opioide sintético que puede ser 50 veces más potente que la heroína.

“Esto debería ser muy básico, primeros auxilios 101 para el trastorno por consumo de opioides, y realmente estamos luchando por mantenerlo”, dijo Andrew Herring, médico de medicina de emergencias en el Highland Hospital del Sistema de Salud de Alameda en Oakland, California, y cofundador de CA Bridge.

“Todos están mirando a los demás para que paguen por esto. Los médicos, enfermeras, trabajadores sociales y administradores de atención están listos para hacer un trabajo intrínsicamente convincente y maravilloso, pero simplemente no se les paga por hacerlo”.

El programa de navegadores es uno de los múltiples componentes de CA Bridge, una iniciativa destinada a expandir el uso de medicamentos para trastornos por consumo de sustancias en salas de emergencias.

CA Bridge financia la capacitación para médicos y enfermeras para aumentar el uso de medicamentos recetados, y su programa de navegadores paga a los hospitales hasta $120,000 para contratar trabajadores de salud conductual.

Actualmente, se han asignado 284 navegadores para poner a los pacientes en tratamiento a largo plazo después de ser dados de alta de una sala de emergencias. Una vez que haya transcurrido un año, los hospitales tienen la opción de contratar a los navegadores como personal permanente o dejar que esos contratos expiren. Los funcionarios de CA Bridge confirmaron que más de 100 navegadores han dejado sus puestos.

En respuesta, funcionarios estatales dicen que están tratando de expandir el uso de Medi-Cal, el programa de Medicaid del estado que cubre a personas de bajos ingresos, para ayudar a pagar a los navegadores presionando a los planes de atención administrada para que cubran estos servicios.

Los funcionarios dijeron que el estado también está tratando de asegurar subvenciones federales adicionales hasta marzo de 2025. Sin embargo, el gobernador demócrata Gavin Newsom no incluyó nuevos fondos estatales en su último presupuesto que enfrenta un déficit de $38 mil millones.

CA Bridge comenzó en 2018, y desde entonces ha recibido casi $100 millones en financiamiento federal y estatal a medida que se ha expandido a través de California. Hasta enero de 2024, 265 hospitales con departamentos de emergencias, o el 83% de los del estado, están participando en el programa y unos 100 hospitales han contratado a navegadores como personal permanente.

Según un informe de CA Bridge de enero de 2023, 76,801 pacientes han recibido recetas de buprenorfina, y se estima que 34,560 fueron conectados con atención de seguimiento.

Representantes de la industria hospitalaria dicen que más miembros se unirían al programa si supieran que tendría un financiamiento sostenible a largo plazo.

El programa concientiza a los médicos sobre los beneficios de recetar medicamentos como la buprenorfina, que funciona uniéndose a los mismos receptores cerebrales que los opioides más peligrosos, reduciendo los síntomas de abstinencia.

La buprenorfina, la naltrexona y la metadona son los únicos medicamentos aprobados en el país para tratar el trastorno por consumo de opioides. Solo el 10% de los californianos con trastorno por consumo de sustancias recibieron tratamiento adecuado en el año anterior, según un análisis de 2022 de la California Health Care Foundation.

Mientras tanto, los navegadores de CA Bridge, que están capacitados en reducción de daños, salud conductual y alcance comunitario, ayudan a los pacientes a que inicien un tratamiento a largo plazo después del alta, un paso que puede ser vital y que el sistema de salud conductual a menudo lucha por completar.

Un estudio en Inglaterra encontró que los pacientes tenían cuatro veces más probabilidades de morir por una sobredosis de opioides dentro de las 48 horas después de visitar la sala de emergencias que en otros momentos.

Los pacientes que recibieron ayuda de un navegador tenían una probabilidad más de tres veces mayor de estar en tratamiento dentro de los 30 días posteriores a su visita a la sala de emergencias que aquellos que no habían recibido ayuda, halló un estudio realizado de septiembre de 2021 a enero de 2022 en tres hospitales públicos, incluido Highland.

Aunque los hospitales que contratan navegadores pueden recibir reembolsos ​​por facturar a Medi-Cal por servicios de atención médica comunitaria, pocos han negociado ese beneficio con los planes de salud de Medi-Cal. David Simon, vocero de la Asociación de Hospitales de California, dijo que el servicio es nuevo y que el estado aún no ha proporcionado orientación sobre cómo facturar a los planes de salud.

En el pasado, los partidarios del programa de navegadores han sugerido reducir las barreras para facturar a Medi-Cal y aprovechar varios fondos estatales.

“Aún no se ha solidificado un mecanismo de financiamiento estatal para sostener los servicios de los navegadores de manera continua”, escribió el año pasado una coalición de docenas de proveedores de salud y defensores.

Aimee Moulin, investigadora principal y cofundadora de CA Bridge, dijo que el programa necesita impulso para frenar una epidemia de muertes por sobredosis.

Agregó que, aunque el programa ha ayudado a expandir el uso de medicamentos para la adicción a los opioides, aún queda trabajo por hacer para incorporar la atención de la adicción en más hospitales, y persuadirlos para que la integren.

“Para los trastornos por uso de opioides, tenemos medicamentos altamente efectivos”, dijo Moulin. “No es como si no supiéramos qué funciona. Es solo cuestión de ponerlos al alcance”.

Esta historia fue producida por KFF Health News, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation.

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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California May Face More Than $40M in Fines for Lapses in Prison Suicide Prevention

Kaiser Health News:States - March 08, 2024

If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”

SACRAMENTO, Calif. — California could face more than $40 million in fines after it failed to improve suicide prevention measures in state prisons despite a federal judge’s warning that she would impose financial penalties for each violation.

Chief U.S. District Judge Kimberly Mueller told state officials over a year ago that she would start imposing fines unless they implemented 15 suicide prevention protocols that had been lacking for nearly a decade.

But court expert Lindsay Hayes reported March 1 that the state continues to lag on 14 of the 15 safeguards. The state even regressed in such areas as failing to house prisoners in suicide-resistant cells when they are first placed in segregation, often including solitary confinement, in which prisoners are particularly vulnerable. The special cells lack hooks, wire grates, or other protrusions from which prisoners can hang themselves, for instance.

Suicides have long been a problem in California prisons and are considered a bellwether of a broader, decades-long lack of adequate prison mental health care. They are one of several ongoing issues at the center of a class-action federal lawsuit that dates to 1990.

“Mr. Hayes’ finding of backsliding with respect to some of the remaining recommendations is deeply concerning, particularly in light of the nine years that have passed since he initially offered these recommendations,” wrote Matthew Lopes Jr., the special master retained by Mueller to help oversee prison mental health care.

California Department of Corrections and Rehabilitation spokesperson Pedro Calderón Michel said officials are reviewing the report and will file a formal response April 2. He said the department has a robust suicide prevention program, which has expanded since 2020. A team of psychologists follows a guidebook on suicide prevention practices modeled after the monitoring done by the special master’s own experts. Additionally, that team provides real-time feedback, and the department reviews each suicide.

“The health and well-being of every person in our care are of the utmost importance,” Calderón Michel said.

And as the state continues to experience a shortage of mental health care providers, he said, the department has taken steps to expand the use of telepsychiatry, as well as increasing salaries and benefits to attract more workers.

Thirty California state prisoners died by suicide last year. That’s an increase from 20 suicides in 2022 and 15 in 2021 but fewer than in the preceding two years. California’s rate of 32 suicides per 100,000 prisoners in 2023 exceeded the most recently available national state prison rate of 27 per 100,000.

Hayes’ report included eight instances in which prisoners’ bodies were not discovered until rigor mortis had set in, a stiffening of the joints and muscles that occurs several hours after death. Some of those prisoners were supposed to be monitored regularly to make sure they did not harm themselves; the delay in discovering their deaths cast doubt on whether they were being checked adequately.

In another case, a prisoner was supposed to be under constant suicide watch after he twice tried to kill himself the same day that he sent farewell notes to family members. Yet he was allowed to keep his tennis shoes against the chief psychiatrist’s orders, and he was placed unmonitored in a standard cell instead of a suicide-resistant cell.

An hour later, he was found hanging from the upper bunk by a shoestring.

“You realize this is not a game, these are human beings,” said Michael Bien, an attorney representing prisoners in the lawsuit. “Certainly, you shouldn’t be making the same mistakes that are preventable and foreseeable again and again and again.”

Mueller in a February 2023 order said she would impose $1,000 daily fines starting April 1, 2023, for each unmet safeguard at each prison that failed to comply. The protocols include such things as suicide prevention training and treatment planning, suicide risk evaluations, using suicide-resistant cells, and checking on susceptible prisoners every 30 minutes.

Hayes and Lopes did not say in their court filings how many fines accumulated. But their court filings contain identical charts outlining how many prisons still failed to meet each of the 15 standards during Hayes’ recent inspections. They tally 124 areas of ongoing noncompliance carrying $1,000 daily fines.

If Mueller levied fines for the 11 months between last April and when Hayes filed his report, they would top $41.5 million. But her order has the daily fines continuing indefinitely, and other variables might affect the total.

“No matter how you calculate it, it’s still going to be a very substantial number,” Bien said.

If Mueller follows previous practice, she will next hold a hearing on Hayes’ report and the pending fines. She has not said what the fines would be used for, but the goal is to encourage a resolution of the ongoing problems, not to punish the state.

Hayes’ report comes as Mueller is already considering collecting fines topping $95 million for state officials’ yearlong failure to hire enough mental health professionals to provide adequate treatment in state prisons.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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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VIP Health System for Top US Officials Risked Jeopardizing Care for Soldiers

Top U.S. officials in the Washington area have received preferential treatment from a little-known health care program run by the military, potentially jeopardizing care for other patients including active-duty service members, according to Pentagon investigators.

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White House officials, senior military and other national security leaders, retired military officers, and family members have all benefited. The Washington elite could jump the line when filling prescriptions, book appointments through special call centers, and receive choice parking spots and escorts at military hospitals and other facilities, including Walter Reed National Military Medical Center in Bethesda, Maryland, according to the Pentagon’s inspector general.

Through a unit at the White House, government personnel were routinely allowed to receive treatment under aliases, providing no home address or insurance information. For some of them, the care was free, as Walter Reed had no way to bill for it or waived charges.

The so-called executive medicine program was described in a report the Pentagon’s inspector general released in January. The investigation drew extensive media attention for spotlighting a history of loose prescribing practices and poor controls of powerful drugs including opioids in the White House Medical Unit, a military outfit that attends to the president, vice president, and others in the White House compound.

But the White House Medical Unit is just the tip of the broader executive medicine program, intended to provide VIP treatment to senior government and military officials. Though the program is meant largely to accommodate top officials’ busy schedules, the privileges have followed many patients into retirement. According to data from late 2019 and early 2020, the IG’s report said, 80% of the executive medicine population in the national capital region were military retirees and members of their families.

Some facilities “provided access to care for executive medicine patients over active-duty military patients that had acute needs,” according to the report, which added that prioritizing medical care by seniority rather than medical need “increased the risk to the health and safety of non‑executive general patient population.”

Much of the report was written in past tense, leaving unclear whether all the practices it described continue. Before the report was made public, a draft was under review by the White House Medical Unit for more than three years — from May 2020, when Donald Trump was in office, to last July. The delay isn’t explained in the report, and White House spokespeople didn’t respond to questions for this article.

A spokesperson for the inspector general’s office, Deputy Assistant Inspector General Reishia Kelsey, declined to elaborate on the report. A spokesperson for the Pentagon, James P. Adams, also declined to comment.

In a response included in the inspector general’s report, a Pentagon official said there were “new procedures already put in place by the White House Medical Unit.” The report didn’t detail those changes.

At Walter Reed, the program is available to Cabinet members; members of Congress; Supreme Court justices; active-duty and retired generals and flag officers and their beneficiaries; members of the Senior Executive Service who retired from the military; secretaries, deputy secretaries, and assistant secretaries of the Department of Defense and military departments; certain foreign military officers; and Medal of Honor recipients.

Walter Reed’s executive medicine program caters to the “time, privacy, and security demands” of leaders’ jobs, the hospital says on its website. The IG report makes clear that the program has, at times, provided extraordinary privileges to the government’s most elite officials.

For example, one unnamed executive medicine patient asked to have a prescription for an unspecified “controlled medication” refilled two weeks early — and complained when pharmacy staff at Fort Belvoir Community Hospital said that wasn’t allowed.

Hospital leaders told hospital staff to fill the prescription as requested. According to the report, the staff said the task required an estimated 30 hours of extra work.

Controlled medications are subject to abuse, and some, such as opioids, can be addictive. Defense Department health policy calls for minimizing the use of opioids and prescribing them only when indicated.

A spokesperson for the Fort Belvoir hospital, now known as Alexander T. Augusta Military Medical Center, said every patient is seen through the same lens and treated with the care they deserve.

The spokesperson, Reese Brown, said the facility shows military deference to top officers on account of their rank. For example, they don’t have to sit with the general population of patients.

The facility’s website mentions an “Executive Medicine Health & Wellness Clinic” for authorized patients, including eligible family members.

Brown said he was unaware of the inspector general’s account of the prescription refill and had no information about it.

The report said that at one unidentified pharmacy site, “all pharmacy staff members expressed frustration about the prioritization and filling of executive medicine prescriptions. This prioritization of executive medicine prescriptions diverted the pharmacist from filling prescriptions for patients diagnosed with conditions that are more urgent.”

Executive medicine services are also provided at the DiLorenzo Tricare Health Clinic at the Pentagon, Fort McNair Army Health Clinic, and Andrew Rader U.S. Army Health Clinic, the report said.

The inspector general recommended the Department of Defense take steps such as establishing controls for billing nonmilitary senior officials for outpatient services. The assistant secretary of defense for health affairs agreed but said the department would consider “the historical practices of the White House Medical Unit, the DoD’s health care support for non‑military U.S. Government senior officials, and the need for strict security protocols to protect the health and safety of White House principals.”

Chaseedaw Giles, KFF Health News’ digital strategy & audience engagement editor, 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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Biden Team, UnitedHealth Struggle to Restore Paralyzed Billing Systems After Cyberattack

Margaret Parsons, one of three dermatologists at a 20-person practice in Sacramento, California, is in a bind.

Since a Feb. 21 cyberattack on a previously obscure medical payment processing company, Change Healthcare, Parsons said, she and her colleagues haven’t been able to electronically bill for their services.

She heard Noridian Healthcare Solutions, California’s Medicare payment processor, was not accepting paper claims as of earlier this week, she said. And paper claims can take 3-6 months to result in payment anyway, she estimated.

“We will be in trouble in very short order, and are very stressed,” she said in an interview with KFF Health News.

A California Medical Association spokesperson said March 7 that the Centers for Medicare & Medicaid Services had agreed in a meeting to encourage payment processors like Noridian to accept paper claims. A Noridian spokesperson referred questions to CMS.

The American Hospital Association calls the suspected ransomware attack on Change Healthcare, a unit of insurance giant UnitedHealth Group’s Optum division, “the most significant and consequential incident of its kind against the U.S. health care system in history.” While doctors’ practices, hospital systems, and pharmacies struggle to find workarounds, the attack is exposing the health system’s broad vulnerability to hackers, as well as shortcomings in the Biden administration’s response.

To date, government has relied on more voluntary standards to protect the health care system’s networks, Beau Woods, a co-founder of the cyber advocacy group I Am The Cavalry, said. But “the purely optional, do-this-out-of-the-goodness-of-your-heart model clearly is not working,” he said. The federal government needs to devote greater funding, and more focus, to the problem, he said.

The crisis will take time to resolve. Comparing the Change attack to others against parts of the health care system, “we have seen it generally takes a minimum of 30 days to restore core systems,” said John Riggi, the hospital association’s national adviser on cybersecurity.

In a March 7 statement, UnitedHealth Group said two services — related to electronic payments and medical claims — would be restored later in the month. “While we work to restore these systems, we strongly recommend our provider and payer clients use the applicable workarounds we have established,” the company said.

“We’re determined to make this right as fast as possible,” said company CEO Andrew Witty.

Providers and patients are meanwhile paying the price. Reports of people paying out-of-pocket to fill vital prescriptions have been common. Independent physician practices are particularly vulnerable.

“How can you pay staff, supplies, malpractice insurance — all this — without revenue?” said Stephen Sisselman, an independent primary care physician on Long Island in New York. “It’s impossible.”

Jackson Health System, in Miami-Dade County, Florida, may miss out on as much as $30 million in payments if the outage lasts a month, said Myriam Torres, its chief revenue officer. Some insurers have offered to mail paper checks.

Relief programs announced by both UnitedHealth and the federal government have been criticized by health providers, especially hospitals. Sisselman said Optum offered his practice, which he said has revenue of hundreds of thousands of dollars a month, a loan of $540 a week. Other providers and hospitals interviewed by KFF Health News said their offers from the insurer were similarly paltry.

In its March 7 statement, the company said it would offer new financing options to providers.

Providers Pressure Government to Act

On March 5, almost two weeks after Change first reported what it initially called a cybersecurity “issue,” the Health and Human Services Department announced several assistance programs for health providers.

One recommendation is for insurers to advance payments for Medicare claims — similar to a program that aided health systems early in the pandemic. But physicians and others are worried that would help only hospitals, not independent practices or providers.

Anders Gilberg, a lobbyist with the Medical Group Management Association, which represents physician practices, posted on X, formerly known as Twitter, that the government “must require its contractors to extend the availability of accelerated payments to physician practices in a similar manner to which they are being offered to hospitals.”

HHS spokesperson Jeff Nesbit said the administration “recognizes the impact” of the attack and is “actively looking at their authority to help support these critical providers at this time and working with states to do the same.” He said Medicare is pressing UnitedHealth Group to “offer better options for interim payments to providers.”

Another idea from the federal government is to encourage providers to switch vendors away from Change. Sisselman said he hoped to start submitting claims through a new vendor within 24 to 48 hours. But it’s not a practicable solution for everyone.

Torres said suggestions from UnitedHealth and regulators that providers change clearinghouses, file paper claims, or expedite payments are not helping.

“It’s highly unrealistic,” she said of the advice. “If you’ve got their claims processing tool, there’s nothing you can do.”

Mary Mayhew, president of the Florida Hospital Association, said her members have built up sophisticated systems reliant on Change Healthcare. Switching processes could take 90 days — during which they’ll be without cash flow, she said. “It’s not like flipping a switch.”

Nesbit acknowledged switching clearinghouses is difficult, “but the first priority should be resuming full claims flow,” he said. Medicare has directed its contractors and advised insurers to ease such changes, he added.

Health care leaders including state Medicaid directors have called on the Biden administration to treat the Change attack similarly to the pandemic — a threat to the health system so severe that it demands extraordinary flexibility on the part of government insurance programs and regulators.

Beyond the money matters — critical as they are — providers and others say they lack basic information about the attack. UnitedHealth Group and the American Hospital Association have held calls and published releases about the incident; nevertheless, many still feel they’re in the dark.

Riggi of the AHA wants more information from UnitedHealth Group. He said it’s reasonable for the conglomerate to keep some information closely held, for example if it’s not verified or to assist law enforcement. But hospitals would like to know how the breach was perpetrated so they can reinforce their own defenses.

“The sector is clamoring for more information, ultimately to protect their own organizations,” he said.

Rumors have proliferated.

“It gets a little rough: Any given day you’re going to have to pick and choose who to believe,” Saad Chaudhry, an executive at Maryland hospital system Luminis Health, told KFF Health News. “Do you believe these thieves? Do you believe the organization itself, that has everything riding on their public image, who have incentives to minimize this kind of thing?”

What Happens Next?

Wired Magazine reported that someone paid the ransomware gang believed to be behind the attack $22 million in bitcoin. If that was indeed a ransom intended to resolve some aspect of the breach, it’s a bonanza for hackers.

Cybersecurity experts say some hospitals that have suffered attacks have faced ransom demands for as little as $10,000 and as much as $10 million. A large payment to the Change hackers could incentivize more attacks.

“When there’s gold in the hills, there’s a gold rush,” said Josh Corman, another co-founder of I Am The Cavalry and a former federal cybersecurity official.

Longer-term, the attack intensifies questions about how the private companies that comprise the U.S. health system and the government that regulates them are defending against cyberthreats. Attacks have been common: Thieves and hackers, often believed to be sponsored or harbored by countries like Russia and North Korea, have knocked down systems in the United Kingdom’s National Health Service, pharma giants like Merck, and numerous hospitals.

The FBI reported 249 ransomware attacks against health care and public health organizations in 2023, but Corman believes the number is higher.

But federal efforts to protect the health system are a patchwork, according to cybersecurity experts. While it’s not yet clear how Change was hacked, experts have warned a breach can occur through a phishing link in an email or more exotic pathways. That means regulators need to consider hardening all kinds of products.

One example of the slow-at-best efforts to mend these defenses concerns medical devices. Devices with outdated software could provide a pathway for hackers to get into a hospital network or simply degrade its functioning.

The FDA recently gained more authority to assess medical devices’ digital defenses and issue safety communications about them. But that doesn’t mean vulnerable machines will be removed from hospitals. Products often linger because they’re expensive to take out of service or replace.

Senator Mark Warner (D-Va.) has previously proposed a “Cash for Clunkers”-type program to pay hospitals to update the cybersecurity of their old medical devices, but it was “never seriously pursued,” Warner spokesperson Rachel Cohen said. Riggi said such a program might make sense, depending on how it’s implemented.

Weaknesses in the system are widespread and often don’t occur to policymakers immediately. Even something as prosaic as a heating and air conditioning system can, if connected to a hospital’s internet network, be hacked and allow the institution to be breached.

But erecting more defenses requires more people and resources — which often aren’t available. In 2017, Woods and Corman assisted on an HHS report surveying the digital readiness of the health care sector. As part of their research, they found a slice of wealthier hospitals had the information technology staff and resources to defend their systems — but the vast majority had no dedicated security staff. Corman calls them “target-rich but cyber-poor.”

“The desire is there. They understand the importance,” Riggi said. “The issue is the resources.”

HHS has proposed requiring minimum cyberdefenses for hospitals to participate in Medicare, a vital source of revenue for the entire industry. But Riggi says the AHA won’t support it.

“We oppose unfunded mandates and oppose the use of such a harsh penalty,” he 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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