Montana’s proposal to increase oversight is part of a national trend by states to ensure nonprofit hospitals act as charitable organizations as they claim tax-exempt status. LISTEN here:

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The proposal comes some four years after a state audit found shortcomings in the health department’s oversight. The rules largely mirror federal requirements that national health policy analysts said have yet to lead to any meaningful enforcement.

“What is being proposed in Montana doesn’t really move the needle,” said Kevin Barnett, a researcher with the California-based nonprofit Public Health Institute who has studied hospital community benefits for decades. “It kicks the can down the road to say ‘we’ll consider this another day.’”

State officials would now be paying more attention, he said, but the impact depends on what they do with the information.

Montana’s plan is part of a national trend by states to try to cover federal enforcement gaps. The state would join at least 10 others that require nonprofit hospitals to create a broad community benefit plan and 25 states that mandate the facilities publicly share their financial assistance policies, according to The Hilltop Institute, a think tank at the University of Maryland-Baltimore County.

Policymakers have focused on nonprofit hospitals as a growing number of people in the U.S. struggle to afford medical care and, altogether, owe at least $220 billion in medical debt. The debt disproportionately affects people in poverty and Black people, according to data analyzed by KFF, a health information nonprofit that includes KFF Health News.

States with set giving standards take different approaches. In recent years, California adopted new reporting requirements for hospitals to show how they serve vulnerable populations. Oregon created new rules for when and how hospitals must provide patients discounted care. And five states — Illinois, Nevada, Pennsylvania, Texas, and Utah — have set minimums that hospitals must spend toward community benefits.

Just over half of the hospitals in the U.S. are nonprofits. While each must report the “community benefits” they provide, federal law doesn’t specify which services qualify or how much to give. Inconsistent hospital reports make it difficult to distinguish between low and high givers.

Montana’s 2020 state audit found that hospitals report benefits vaguely and inconsistently. The following year, a KFF Health News investigation found that, even by hospitals’ own reports, some of Montana’s richest facilities fell behind the national average in community benefit spending.

A Montana law passed in 2023 requires the state health department to track hospitals’ giving and to define standards. The department’s proposed rules spell out some requirements, such as calling on hospitals to post financial assistance policies prominently online. But mostly, the list of requirements sets the stage for more to come.

Holly Matkin, a health department spokesperson, said the agency will establish standards that are “fair to all nonprofit hospitals.” The state plans to collect data over a three-year period to begin establishing standards in 2026.

The state’s proposed rules have some differences from federal requirements, such as mandating hospital-level reports as opposed to systemwide information that covers numerous hospital locations. They also leave room for the state to seek more details about how hospitals provide care at reduced prices, such as the number of people who receive financial aid or the average amount given per person.

But the Montana Hospital Association lobbied legislators against including too many reporting rules, arguing it would increase hospitals’ administrative burden. State lawmakers then narrowed the data the state can collect to largely the information hospitals already provide to the federal government. The association supports the state’s rules as proposed but has said any state standards need flexibility.

“The truth is that most communities have more health needs than they can effectively address,” said Bob Olsen, president and CEO of the Montana Hospital Association. “Models that apply a one-size-fits-all standard on communities take decision-making out of local communities, and have the potential to do more harm than good.”

Adam Zarrin, director of state government affairs with the Leukemia & Lymphoma Society, supported Montana’s proposal during a June 18 public hearing. But he testified that Montana could do more, such as mandating screening for financial assistance and requiring that hospitals provide it to patients at particular income levels.

“These rules could go even further to provide greater access and protections for Montanans who need and apply for financial assistance,” Zarrin said.

Health department officials said they plan to create numerical or narrative standards for judging how hospitals say they’ve responded to people’s needs — or a combination of the two. Officials are still vague on what either standard could entail. But they have said the benchmarks would be set each year based on each hospital’s size and patient revenue. Hospitals with operating losses wouldn’t have to meet the forthcoming rules.

Ge Bai, a health policy professor at Johns Hopkins University who has long studied hospitals’ community benefits, said such standards come with trade-offs. For example, standards that can be met through words rather than numbers might allow large hospitals to pay consultants to window-dress the story of their benefits while smaller systems struggle to show their worth. She said numerical rules, such as spending minimums, could cause some hospitals to slow efforts once they meet the state’s requirement.

“It’s not perfect,” Bai said. “But If we don’t do anything, well, that’s the status quo.”

In 2020, Oregon set minimums for the free or discounted care hospitals must provide, but even with those rules, the state’s overall charity care spending didn’t increase, Bai said. Last summer, lawmakers there added a new set of rules, including that hospitals must screen patients with large hospital bills to see if they qualify for financial assistance.

California also has implemented a combination of standards. In recent years, the state expanded reporting requirements, mandating that nonprofit hospitals explain the math behind their community benefits tally and detail how they’re serving vulnerable populations such as people who are homeless. The state also mandated that hospitals offer discounted care to uninsured patients or some people with costly medical bills.

Even in states like California, it can be hard to see how those policies affect patients who struggle to access care, said Barnett of the Public Health Institute. He said he’d like to see states require hospitals to reduce health disparities with specific outcomes, such as lowering preventable emergency room visits by people from especially poor neighborhoods.

In 2025, California will start requiring hospitals to submit annual reports that include an analysis of access to care and a plan to address disparities. The state is still defining those reporting rules.

Whatever standard states employ, health policy researchers said promoting transparency is key, such as by standardizing reporting rules to provide a clear picture across systems. Bai said Montana’s rules are a good first step.

Matkin, from the state health department, said whatever giving benchmarks Montana sets won’t be a copy-and-paste of what others have tried. The department plans to create standards unique to Montana.

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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WALL, S.D. — Stacey Schulz parks in a rear lot to avoid the crowded Main Street entrances to her local pharmacy.

“During the summer, it’s kind of hectic,” she said after greeting the pharmacist and technician by name.

That’s because Schulz’s pharmacy is tucked inside Wall Drug, a tourist attraction that takes up almost an entire block and draws more than 2 million visitors a year to a community of fewer than 700 residents.

The business is named after the town of Wall, which is just off Interstate 90 near Badlands National Park. Colorful, hand-painted billboards dot the roadside for hundreds of miles, telling motorists how far they are from Wall Drug’s free ice water, 5-cent coffee, and homemade doughnuts. Visitors can pan for gold, listen to singing animatronic cowboys, try on Western wear, and shop for souvenirs, including plush jackalopes — mythical jackrabbits with antelope horns.

Despite being part of a booming tourist attraction, Wall Drug’s pharmacy faces challenges common to independent rural pharmacies.

It’s the lone pharmacy in Wall, serving locals year-round. Some, like Schulz, live in town, while others live on ranches as far as 60 miles away. The next-nearest pharmacy is a 30-minute drive northeast.

Wall Drug also serves tourists who forget their prescriptions at home, get sick while roaming the country in their RVs, or hurt themselves while hiking through the otherworldly rock formations of the scorching Badlands, said Cindy Dinger, its sole pharmacist.

Wall has no hospital, but a clinic is open four days a week. Schulz, a medical assistant there, said she and her co-workers see a lot of summer tourists. They send them to Wall Drug to pick up prescriptions.

“And then we tell them to get fudge before they leave,” Schulz said.

Rural pharmacies, especially independent ones, closed at a higher rate from 2003 to 2021 than pharmacies in other areas, according to a study by the Rural Policy Research Institute. By 2021, the institute found, nearly 8% of rural counties were left with no pharmacy. The Wall Drug pharmacy has fewer customers than a typical city pharmacy, which can mean less profit, Dinger said.

She said some of its prices are higher because the store can’t negotiate discounts as steep as the deals suppliers grant chain pharmacies. Rural drugstores also lack leverage with insurers, and they face increasing competition from mail-order pharmacies.

Another challenge is staffing. When Dinger needs time off, she finds a fill-in from Rapid City, nearly an hour’s drive away.

“It’s a challenge getting relief if I want to go on vacation or if I need a cover so that I can go to a doctor’s appointment,” she said. “You take what you can get and try to schedule around it.”

Dinger said her pharmacy would struggle without the rest of Wall Drug.

“All this stuff around us — the poster and print shop, the boot shop, the fudge shop, the café — they pay our bills,” she said.

The pharmacy’s white facade, with stained-glass signs and windows, is modeled after that of the original drugstore, which was across the street. The window displays and top shelves inside the store are filled with vintage pharmacy supplies, including manuals, glass medicine bottles, and a suppository-making machine.

Tourists carrying shopping bags and sporting new cowboy hats stop to look at the displays. “It’s a real pharmacy,” a woman said, sounding surprised.

Dinger and Sylvia Smith, the store’s only pharmacy tech, ring customers up below a Tiffany-style light fixture and retrieve prescriptions stored behind a wooden desk and wall.

Customer Will Lovitt said a friend advised him and his wife to stop at Wall Drug during their drive from Indiana to the Black Hills in western South Dakota. Lovitt developed a rash on the trip and ended up using the visit to get Dinger’s advice on treating it.

He said it can be difficult for tourists to know where to find medical help, especially when driving through rural states like South Dakota.

“I think it’s time that America gets back to the grass roots of the small-town doctor and the small-town pharmacist,” Lovitt said.

Alex Davis and a friend decided to visit Wall Drug on their road trip from Kansas to Yellowstone National Park.

“Then, when I saw there was a little pharmacy, I thought I’d grab something that I needed,” she said.

Davis bought Dramamine to treat car sickness on the long drive.

Dinger said she occasionally sees unusual situations, like the time several years ago when a park ranger needed antibiotics after getting bitten by a prairie dog.

“You never know what kind of diseases they might be carrying,” she said of the animals, which recently were hit with an outbreak of plague.

Rick Hustead is the chairman of Wall Drug. The store was opened in 1931 by his grandfather, pharmacist Ted Hustead. Ted’s wife, Dorothy, had the idea to advertise its soda fountain and free ice water to tourists traveling along unpaved roads during the hot years of the Dust Bowl era. Rick’s father, pharmacist Bill Hustead, began expanding the store in the ’50s, turning it into the tourist magnet it is today.

Rick Hustead didn’t follow his father and grandfather’s path to pharmacy school, so he had to recruit pharmacists from elsewhere.

Hustead found Dinger in 2010 after writing a letter to each pharmacist in the state.

Dinger said she was living at the time in Sioux Falls, South Dakota’s most populous city. But she and her husband were interested in raising their kids in a small town, the way she grew up. Dinger was also attracted by the store’s limited hours: She’d be done working by 5 p.m. on weekdays and have the weekends off.

Hustead said his family has never considered closing the pharmacy, even though it’s not the main attraction for most visitors.

“We can’t be Wall Drug without being a drugstore,” he said.

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Louisiana lawmakers have added two drugs commonly used in pregnancy and reproductive health care to the state’s list of controlled dangerous substances, a move that has alarmed doctors in the state.

Mifepristone and misoprostol have many clinical uses, and one use approved by the FDA is to take the pills to induce an abortion at up to 10 weeks of gestation.

The bill that moved through the Louisiana Legislature this spring lists both medications as Schedule IV drugs under the state’s Uniform Controlled Dangerous Substances Law, creating penalties of up to 10 years in prison for anyone caught with the drugs without a valid prescription. Gov. Jeff Landry, a Republican, signed the bill into law in May. It takes effect Oct. 1.

The new law is the latest move by anti-abortion advocates trying to control access to abortion medications in states with near-total abortion bans, such as Louisiana. The law is the first of its kind, opening a new front in the state-by-state battle over reproductive medicine.

Republican-controlled states have passed various laws regulating medication abortion in the past, said Daniel Grossman, an OB-GYN and a reproductive health researcher at the University of California-San Francisco.

But after the Dobbs v. Jackson Women’s Health Organization decision in 2022, in which the Supreme Court ruled there was no constitutional right to an abortion, scrutiny of medication abortions escalated as clinics in certain states shuttered completely or were required to stop offering in-clinic procedures.

“It’s not surprising that states are trying everything they can to try to restrict these drugs,” Grossman said. “But this is certainly a novel approach.”

Before the Louisiana bill passed, more than 250 OB-GYNs and emergency, internal medicine, and other physicians from across the state signed a letter to the bill’s sponsor, state Sen. Thomas Pressly, a Republican, arguing the move could threaten women’s health by delaying lifesaving care.

“It’s just really jaw-dropping,” said Nicole Freehill, a New Orleans OB-GYN who signed the letter. “Almost a day doesn’t go by that I don’t utilize one or both of these medications.”

Mifepristone and misoprostol are routinely used to treat miscarriages, stop obstetric hemorrhaging, induce labor, or prepare the cervix for a range of procedures inside the uterus, such as inserting an IUD or taking a biopsy of the uterine lining.

Bill Born From a Family’s Misfortune

The proposal to reschedule the drugs as controlled dangerous substances was introduced as amendments to Pressly’s original bill creating the crime of “coerced criminal abortion” — where someone “knowingly” gives abortion pills to a pregnant woman to cause or attempt to cause an abortion “without her knowledge or consent.”

Pressly’s sister, Catherine Pressly Herring, testified at the hearing on the bill that she had been given abortion drugs without her knowledge by her former husband. Pressly said his sister’s story prompted the legislation.

In a statement, Pressly said that he added the new amendments to “control the rampant illegal distribution of abortion-inducing drugs.” He did not respond to requests for comment.

“By placing these drugs on the controlled substance list, we will assist law enforcement in protecting vulnerable women and unborn babies,” Pressly wrote in this statement.

Louisiana Right to Life, the state’s most influential anti-abortion group, helped draft the bill. And the group’s communications director, Sarah Zagorski, said that claims that rescheduling the drugs as dangerous could harm women’s health are “fearmongering.”

The real problem, she said, is that mifepristone and misoprostol are too accessible in Louisiana and are being used to induce abortions despite the state’s ban.

“We’ve had pregnancy centers email us with many stories of minors getting access to this medication,” Zagorski said.

Studies have shown a surge in the ordering of abortion pills online in states that have severe restrictions on abortion.

In the Louisiana Legislature committee hearing on the bill, anti-abortion advocates said that physicians would still be allowed to dispense mifepristone and misoprostol for lawful medical care, and that women who give themselves abortions using the medications would be exempted from criminal liability.

“Under this law, or any abortion law, in Louisiana we see the woman as often the second victim,” testified Dorinda Plaisance, a lawyer who works with Louisiana Right to Life. “And so Louisiana has chosen to criminalize abortion providers” rather than women who use the medications for their own abortions.

Move ‘Not Scientifically Based,’ Doctors Say

The U.S. Drug Enforcement Administration and individual states have the power to list drugs as controlled dangerous substances.

State and federal regulations aim to control access to drugs, such as opioids, based on their medical benefit and their potential for abuse, according to Joseph Fontenot, executive director of the Louisiana Board of Pharmacy, the agency that monitors drugs listed as controlled dangerous substances.

Like other states, Louisiana tracks prescriptions in databases that include the name of the patient, the health provider who wrote the prescription, and the dispensing pharmacy.

Physicians need a special license to prescribe the drugs — in 2023, there were 18,587 physicians in Louisiana, 13,790 of whom had a license to prescribe controlled dangerous substances, according to data from the Louisiana State Board of Medical Examiners and the Board of Pharmacy.

“Every state has a prescription drug monitoring program. And they really are designed to identify prescription drug mills that are hawking fentanyl and opioid painkillers,” said Robert Mikos, a professor of law and a drug policy expert at Vanderbilt University.

What happened to Pressly’s sister — being tricked into taking mifepristone or misoprostol — is a form of drug abuse, said Zagorski of Louisiana Right to Life, which is why the drugs should be more strictly controlled.

But Fontenot, of the Louisiana Board of Pharmacy, said that under Louisiana’s law, abuse refers to addiction. Jennifer Avegno, a New Orleans emergency physician and the director of the New Orleans Health Department, agrees. “There is no risk of someone getting hooked on misoprostol,” Avegno said.

Under the new law, mifepristone and misoprostol will be added to a list comprised of opioids, depressants, and stimulants. “To classify these medications as a drug of abuse and dependence in the same vein as Xanax, Valium, Darvocet is not only scientifically incorrect, but [a] real concern for limiting access to these drugs,” Avegno said.

Doctors worry that the bill could set a dangerous precedent for state officials who want to restrict access to any drug they consider dangerous or objectionable, regardless of its addictive potential, Avegno said.

Fears Over Delays in Care

In their letter opposing the reclassification, doctors said the “false perception that these are dangerous drugs” could lead to “fear and confusion among patients, doctors, and pharmacists, which delays care and worsens outcomes” in a state with high rates of maternal injury and death.

The increased scrutiny could have a statewide chilling effect and make doctors, pharmacists, and even patients more reluctant to use these drugs, the doctors wrote.

The state database allows any doctor or pharmacist to look up the prescription history of his or her patient. The data is also accessible by the Louisiana State Board of Medical Examiners, which licenses physicians and other providers, and by law enforcement agencies with a warrant.

“Could I be investigated for my use of misoprostol? I don’t know,” said Freehill, the New Orleans OB-GYN.

Pharmacists could become more reluctant to dispense the medications, Freehill said, exacerbating a problem she and other OB-GYNs have been dealing with since Louisiana banned nearly all abortions. That reluctance could lead to patients miscarrying without timely treatment.

“They could be sitting there bleeding, increasing their risk that they would have a dangerous amount of blood loss” or risking infection, she said.

Before the bill passed, Freehill routinely phoned in every prescription for misoprostol when her patients were miscarrying so she could explain to the pharmacist why she was prescribing it. Once the bill goes into effect in the fall and the drug becomes a controlled dangerous substance, that will no longer be possible because those types of prescriptions must be written on a pad or sent electronically.

In hospitals, the drugs will also have to be locked away. That could potentially cause delays getting the drug when a patient is hemorrhaging after childbirth.

Doctors worry some patients might be afraid to take the medications once they’re listed as dangerous, Avegno said.

In a written response to the Louisiana physicians who signed the protest letter, Pressly said the doctors whom he’s spoken with feel the bill “will not harm health care for women.”

Criminalizing Support for Abortions

Louisiana’s abortion ban already makes it a crime to provide an abortion, including by giving someone medications used to induce abortion. And a 2022 law added up to 50 years in prison for mailing mifepristone or misoprostol.

Because the new law explicitly exempts pregnant women, opponents like Elizabeth Ling believe it is meant to isolate those women from others who would help them. Ling, a reproductive rights attorney at If/When/How, is particularly concerned about the prison penalties, which she believes are intended to frighten and disrupt underground networks of support for patients seeking the pills.

Pregnant patients might worry about ordering online or enlisting a friend to help obtain the pills: “Is my friend who is simply just providing me emotional support going to somehow, you know, be punished for doing that?” Ling said.

Ling added that there’s concern that the law could also be used to target people who aren’t pregnant but who want to order abortion pills online and stock them in case of a future pregnancy. That practice has become increasingly popular in states with abortion bans.

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

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

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El farmacéutico Mark Mikhael ha perdido 50 libras en los últimos 12 meses. Ya no tiene diabetes y está “en un peso corporal ideal”, con su colesterol por debajo de 200 por primera vez en 20 años. “Me siento fantástico”, dijo.

Al igual que millones de personas, Mikhael atribuye su éxito a la nueva clase de medicamentos para la pérdida de peso. Pero no está usando Wegovy o Zepbound, que son medicamentos de marca. Mikhael, director ejecutivo de Olympia Pharmaceuticals, con sede en Orlando, Florida, se ha arreglado con su propio suministro: inyectándose versiones formuladas por su empresa.

No está solo. Mikhael y otros funcionarios de la industria estiman que varias grandes farmacias de compuestos como la suya están proporcionando dosis regulares de semaglutida a hasta 2 millones de estadounidenses, el nombre científico de las formulaciones Wegovy, Ozempic y Rybelsus de Novo Nordisk, o tirzepatida, el ingrediente activo en las formulaciones Zepbound y Mounjaro de Eli Lilly.

Un compuesto es un medicamento preparado de forma personalizada en farmacias especializadas. Estas farmacias también pueden producir un fármaco génerico o de marca cuando  hay escasez.

Los gigantes de la industria de medicamentos se oponen ferozmente al negocio de compuestos.

Novo Nordisk y Lilly colocan a los fabricantes de compuestos junto con “cowboys” de internet y spas médicos no regulados que venden semaglutida falsa, y tienen feroces equipos legales tratando de detenerlos.

Novo Nordisk ha presentado al menos 21 demandas en todo el país contra empresas que fabrican supuestas copias de sus medicamentos, dijo Brianna Kelley, vocera de la empresa, e insta a los médicos a evitarlas. La Administración de Drogas y Alimentos (FDA) también ha advertido sobre el peligro potencial de los compuestos, y los principales grupos de medicina de obesidad advierten enfáticamente a los pacientes contra su uso.

Pero esto no es un mercado negro ilegal, aunque tiene matices grises.

La FDA permite e incluso fomenta que las farmacias de compuestos produzcan y vendan copias cuando un medicamento está en escasez, y los populares medicamentos GLP-1 han sido escasos por un tiempo: la semaglutida desde marzo de 2022, y la tirzepatida desde diciembre de 2022.

Estos medicamentos han mostrado un éxito sin precedentes para la pérdida de peso. También revelan promesas contra enfermedades del corazón, riñón y hígado, y se están probando contra condiciones tan diversas como el Alzheimer y la adicción a drogas.

En los últimos años, el sistema de atención médica del pais ha llegado a depender de las farmacias de compuestos, muchas de las cuales son administradas como organizaciones sin fines de lucro, para tapar los agujeros de suministro de medicamentos cruciales como los medicamentos contra el cáncer cisplatino, metotrexato y 5-fluorouracilo.

La mayoría de los medicamentos compuestos son genéricos viejos y baratos. Pero la semaglutida y la tirzepatida están bajo patente y generan miles de millones de dólares al año para Novo Nordisk y Lilly. Las ventas de los medicamentos para la diabetes y la pérdida de peso este año hicieron de Novo Nordisk la empresa más valiosa de Europa, y de Lilly la mayor compañía farmacéutica del mundo.

Mientras las empresas no pueden mantenerse al día con la demanda, disputan acaloradamente el derecho de los fabricantes de compuestos a hacer y vender copias. Kristiane Silva Bello, vocera de Lilly, dijo que su empresa estaba “profundamente preocupada” por los “graves riesgos para la salud” de los medicamentos compuestos que “no deberían estar en el mercado”.

Pero están. Incluso Hims & Hers Health, que comenzó con medicamentos para la disfunción eréctil, ahora está vendiendo semaglutida compuesta. Puso anuncios de los medicamentos durante los partidos de playoffs de la NBA. (Según un informe de Hunterbrook Media, el proveedor de semaglutida de Hims & Hers ha enfrentado escrutinio legal).

Las formas compuestas son significativamente más baratas que los medicamentos de marca. Los pacientes pagan entre $100 y $450 al mes, en comparación con los precios de lista de aproximadamente $1,000 a $1,400 para los productos de Lilly y Novo Nordisk.

Cinco fabricantes de compuestos y distribuidores entrevistados para este artículo dijeron que realizan las debidas diligencias en cada lote de semaglutida o tirzepatida que compran o producen, manteniendo estándares de pureza, esterilidad y consistencia similares a los practicados en la industria comercial de medicamentos. Los fabricantes de compuestos operan bajo estrictas normas federales y estatales, enfatizaron.

Sin embargo, las materias primas utilizadas en las formas compuestas pueden diferir de las producidas para Novo Nordisk y Lilly, dijo Jens Juul Holst, co-inventor de GLP-1 de la Universidad de Copenhague, y agregó que se debe tener cuidado en la producción de medicamentos para evitar reacciones inmunes potencialmente dañinas.

Hasta la fecha, los informes de efectos secundarios por el uso de versiones compuestas no han generado grandes alarmas, según voceros de la FDA. Pero todos los que tienen conocimiento de la industria, incluidos los propios fabricantes de compuestos, temen que un solo lote de un medicamento mal hecho podría matar o mutilar a personas, y destruir la confianza en su negocio.

“Comparo la industria de compuestos con la industria aérea”, dijo Mikhael. “Cuando ocurre un accidente aéreo, perjudica a todos”.

Advertencias del pasado

La industria sufrió una catástrofe en 2012, cuando el New England Compounding Center lanzó un esteroide inyectable contaminado que mató al menos a 64 personas e hirió a cientos más.

En respuesta, el Congreso y la FDA fortalecieron la supervisión. La empresa de Mikhael es una instalación de outsourcing, o farmacia de compuestos 503B, llamada así por una sección de la ley de 2013 que estableció nuevos requisitos para los fabricantes de compuestos.

Las empresas están autorizadas a hacer versiones ligeramente diferentes de medicamentos aprobados por la FDA en respuesta a una escasez o necesidad especiales de los pacientes.

La ley creó dos clases de farmacias de compuestos: La FDA regula los mayores fabricantes de compuestos 503B con estándares similares a las compañías de medicamentos comerciales, mientras que las farmacias 503A hacen lotes más pequeños de medicamentos y están supervisadas en gran medida por juntas farmacéuticas estatales.

Las instalaciones 503A también están produciendo semaglutida y tirzepatida compuestas para cientos de miles de pacientes. Al igual que las 503B, estas operaciones toman el ingrediente activo, producido como un polvo en fábricas registradas por la FDA, principalmente en China, y luego lo reconstituyen con agua estéril y un antimicrobiano en pequeños viales de vidrio.

En conjunto, las farmacias de compuestos pueden representar hasta el 30% de la semaglutida vendida en el país, dijo Mikhael, aunque advierte que es una “cifra aproximada” ya que nadie, incluida la FDA, está rastreando las ventas en la industria.

Los fabricantes de compuestos dicen que las empresas deberían aumentar la producción si les preocupa la competencia. Al igual que las docenas de otros medicamentos que producen para hospitales y consultorios médicos, los fabricantes de compuestos dicen que los dos medicamentos dietéticos son productos esenciales.

“Si no quieres que una instalación 503B haga una copia, es bastante simple: no tengas escasez”, dijo Lee Rosebush, presidente de una asociación comercial para farmacias 503B. “La FDA creó este sistema porque estos son medicamentos necesarios”.

Novo Nordisk no ha especificado por qué no puede mantenerse al día con la demanda, pero el cuello de botella aparentemente radica en la incapacidad de la empresa para llenar y esterilizar suficientes de sus inyectores automáticos especiales, dijo Evan Seigerman, director gerente de BMO Capital Markets.

La empresa anunció el 24 de junio que estaba invirtiendo $4.1 mil millones en nuevas líneas de producción en su sitio de Clayton, Carolina del Norte. El año pasado, la FDA emitió una advertencia por violaciones de procedimiento en el sitio y advertencias separadas en una instalación en Indiana que Novo Nordisk tomó recientemente.

Composición para tontos

Al menos 28 empresas, en su mayoría en China, están registradas ante la FDA para producir o distribuir semaglutida. Al menos la mitad de las empresas han ingresado al mercado en los últimos 12 meses, reduciendo el precio de la materia prima en un 35%, según Scott Welch, quien dirige una farmacia 503A en Arlington, Virginia.

Los fabricantes de compuestos pueden comprar semaglutida en polvo de algunos distribuidores estadounidenses por menos de $4,000 el gramo, dijo Matthew Johnson, presidente y director ejecutivo del distribuidor Pharma Source Direct. Eso resulta en tan solo $10 por dosis semanal de 2.5 microgramos.

Mientras que los pacientes de Ozempic o Wegovy usan un dispositivo de Novo Nordisk para inyectar el medicamento, los pacientes que usan productos compuestos los extraen de un vial con una pequeña aguja, como el dispositivo que usan las personas que viven con diabetes para la insulina.

Algunas prácticas médicas proporcionan el medicamento compuesto a los pacientes como parte de un paquete de pérdida de peso, con recargos. El pasado julio, Tabitha Ries, madre soltera de seis hijos que trabaja como asistente de atención médica a domicilio en Garfield, Washington, encontró una clínica en línea que le cobró $1,000 por tres meses de semaglutida junto con asesoramiento. Ha perdido 35 libras.

Obtiene el medicamento de Mindful Weight Loss, una operación principalmente basada en telemedicina dirigida por el médico Vivek Gupta de Manhattan Beach, California. Gupta dijo que ha recetado los medicamentos para la pérdida de peso a 1,500 pacientes, con aproximadamente el 60% usando versiones compuestas de una farmacia 503A.

No ha visto ninguna diferencia esencial en los pacientes que usan las formas de marca y compuestas, aunque “algunas personas dicen que el compuesto es un poco menos efectivo”, dijo Gupta.

Hay algún riesgo en usar el producto no aprobado por la FDA, reconoció, y requiere que los pacientes firmen un formulario de consentimiento informado.

“Nada en la vida está exento de riesgos, pero también argumentaría que el statu quo no es seguro para las personas que necesitan el medicamento y no pueden obtenerlo”, dijo. “Están constantemente desencadenados por toda esta comida que está causando que su peso aumente y su azúcar suba, aumentando su resistencia a la insulina y afectando sus extremidades y ojos”.

Componer semaglutida es una ayuda para los farmacéuticos como él, dijo Welch, especialmente dado el aprieto en los ingresos por la venta de medicamentos que ha llevado a muchos independientes a cerrar en los últimos años. Calcula que gana el 95% de sus ingresos con medicamentos compuestos, en lugar de recetas tradicionales.

Es importante distinguir la semaglutida compuesta de los polvos no regulados vendidos como “Ozempic genérico” y similares, que pueden estar contaminados o ser falsificados, dijo Amanda Hils, vocera de la FDA. Pero dado que las formas compuestas del medicamento no están aprobadas por la FDA, quienes las fabrican, recetan o usan también deben tener “un mayor nivel de responsabilidad o conciencia”, dijo.

Batallas corporativas

En demandas que cada empresa ha presentado contra competidores, Novo Nordisk y Lilly dicen que sus propias pruebas han encontrado bacterias y otras impurezas en productos hechos por farmacias de compuestos.

Las empresas también informan de infracción de patentes, pero los fabricantes de compuestos, señalando la laguna de la FDA para medicamentos en escasez, parecen haber derrotado ese argumento por ahora.

Cuando la FDA retira los medicamentos de la lista de escasez, los fabricantes de compuestos 503B deben dejar de venderlos de inmediato. Los fabricantes de compuestos más pequeños pueden producir sus productos para un número reducido de pacientes, dijo Scott Brunner, director ejecutivo de la Alliance for Pharmacy Compounding, que representa a los fabricantes de compuestos 503A.

Que se evaporara el suministro de medicamentos compuestos podría ser un shock para los pacientes.

“Lo temo”, dijo David Wertheimer, internista en Franklin Lakes, Nueva Jersey, que receta semaglutida compuesta a algunos pacientes. “La gente no va a poder desembolsar mil dólares cada mes. Mucha gente dejará el medicamento, y eso es una lástima”.

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Pharmacist Mark Mikhael has lost 50 pounds over the past 12 months. He no longer has diabetes and finds himself “at my ideal body weight,” with his cholesterol below 200 for the first time in 20 years. “I feel fantastic,” he said.

Like millions of others, Mikhael credits the new class of weight loss drugs. But he isn’t using brand-name Wegovy or Zepbound. Mikhael, CEO of Orlando, Florida-based Olympia Pharmaceuticals, has been getting by with his own supply: injecting himself with copies of the drugs formulated by his company.

He’s far from alone. Mikhael and other industry officials estimate that several large compounding pharmacies like his are provisioning up to 2 million American patients with regular doses of semaglutide, the scientific name for Novo Nordisk’s Wegovy, Ozempic, and Rybelsus formulations, or tirzepatide, the active ingredient in Eli Lilly’s Zepbound and Mounjaro.

The drug-making behemoths fiercely oppose that compounding business. Novo Nordisk and Lilly lump the compounders together with internet cowboys and unregulated medical spas peddling bogus semaglutide, and have high-powered legal teams trying to stop them. Novo Nordisk has filed at least 21 lawsuits nationwide against companies making purported copies of its drugs, said Brianna Kelley, a spokesperson for the company, and urges doctors to avoid them. The FDA, too, has cautioned about the potential danger of the compounds, and leading obesity medicine groups starkly warn patients against their use.

But this isn’t an illegal black market, though it has shades of gray.

The FDA allows and even encourages compounding pharmacies to produce and sell copycats when a drug is in short supply, and the wildly popular GLP-1 drugs have enduring shortages — first reported in March 2022 for semaglutide and in December 2022 for tirzepatide. The drugs have registered unprecedented success in weight loss. They are also showing promise against heart, kidney, and liver diseases and are being tested against conditions as diverse as Alzheimer’s disease and drug addiction.

In recent years, the U.S. health care system has come to depend on compounding pharmacies, many of which are run as nonprofits, to plug supply holes of crucial drugs like cancer medicines cisplatin, methotrexate, and 5-fluorouracil.

Most compounded drugs are old, cheap generics. Semaglutide and tirzepatide, on the other hand, are under patent and earn Novo Nordisk and Lilly billions of dollars a year. Sales of the diabetes and weight loss drugs this year made Novo Nordisk Europe’s most valuable company and Lilly the world’s biggest pharmaceutical company.

While the companies can’t keep up with demand, they heatedly dispute the right of compounders to make and sell copies. Lilly spokesperson Kristiane Silva Bello said her company was “deeply concerned” about “serious health risks” from compounded drugs that “should not be on the market.”

Yet marketed they are. Even Hims & Hers Health — the telemedicine prescriber that got its start with erectile dysfunction drugs — is now peddling compounded semaglutide. It ran ads for the drugs during NBA playoff games. (According to a Hunterbrook Media report, Hims & Hers’ semaglutide supplier has faced legal scrutiny.)

The compounded forms are significantly cheaper than the branded drugs. Patients pay about $100 to $450 a month, compared with list prices of roughly $1,000 to $1,400 for Lilly and Novo Nordisk products.

Five compounders and distributors interviewed for this article said they conduct due diligence on every lot of semaglutide or tirzepatide they buy or produce, upholding standards of purity, sterility, and consistency similar to those practiced in the commercial drug industry. Compounders operate under strict federal and state standards, they noted.

However, the raw materials used in the compounded forms may differ from those produced for Novo Nordisk and Lilly, said GLP-1 co-inventor Jens Juul Holst, of the University of Copenhagen, adding that care must be taken in drug production lest it cause potentially harmful immune reactions.

To date, according to FDA spokespeople, reports of side effects from taking compounded versions haven’t raised major alarms. But everyone with knowledge of the industry, including the compounders themselves, worry that a single batch of a poorly made drug could kill or maim people and destroy confidence in their business.

“I liken the compounding industry to the airline industry,” Mikhael said. “When you have an airline crash, it hurts everybody.”

Warnings From the Past

The industry endured just such a catastrophe in 2012, when the New England Compounding Center released a contaminated injectable steroid that killed at least 64 people and harmed hundreds more.

In response, Congress and the FDA had strengthened oversight. Mikhael’s company is an outsourcing facility, or 503B compounding pharmacy — so-named for a section of the 2013 law that set new requirements for drug compounders. The companies are licensed to make slightly different versions of FDA-approved drugs in response to shortages or a patient’s special needs.

The law created two classes of compounding pharmacies: The FDA regulates the larger 503B compounders with standards like commercial drug companies, while 503A pharmacies make smaller lots of drugs and are largely overseen by state boards of pharmacy.

The 503A facilities also are producing compounded semaglutide and tirzepatide for hundreds of thousands of patients. Like the 503Bs, these operations take the active ingredient, produced as a powder in FDA-registered factories, mostly in China, then reconstitute it with sterile water and an antimicrobial in small glass vials.

Together, the compounding pharmacies may account for up to 30% of the semaglutide sold in the U.S., Mikhael said, although he cautions that is a “wild ballpark figure” since no one, including the FDA, is tracking sales in the industry.

The compounders say the companies should increase production if they’re worried about competition. Like the dozens of other drugs they produce for hospitals and medical practices, the compounders say, the two diet drugs are essential products.

“If you don’t want a 503B facility to make a copy, it’s pretty simple: Don’t go short,” said Lee Rosebush, chair of a trade association for 503B pharmacies. “FDA created this system because these are necessary drugs.”

Novo Nordisk hasn’t specified why it can’t keep up with demand, but the bottleneck apparently lies in the company’s inability to fill and sterilize enough of its special drug auto-injectors, said Evan Seigerman, a managing director at BMO Capital Markets.

The company announced June 24 that it was investing $4.1 billion in new production lines at its Clayton, North Carolina, site. The FDA last year issued a warning over procedural violations at the site and separate cautions at an Indiana facility that Novo Nordisk took over recently.

Compounding for Dummies

At least 28 companies mostly in China, are registered with the FDA to produce or distribute semaglutide. At least half the companies have entered the market in the past 12 months, driving the raw material’s price down by 35%, according to Scott Welch, who runs a 503A pharmacy in Arlington, Virginia.

Compounders can buy powdered semaglutide from some U.S. distributors for less than $4,000 a gram, said Matthew Johnson, president and CEO of distributor Pharma Source Direct. That comes out to as little as $10 per weekly 2.5-microgram dose – not including overhead and other costs.

While Ozempic or Wegovy patients use a Novo Nordisk device to inject the drug, patients using compounded products draw them from a vial with a small needle, like the device diabetics use for insulin.

Some medical practices provide the compounded drug to patients as part of a weight loss package, with markups. Last July, Tabitha Ries, a single mother of six who works as a home health care aide in Garfield, Washington, found an online clinic that charged her $1,000 for three months of semaglutide along with counseling. She has lost 35 pounds.

She gets the drug from Mindful Weight Loss, a mostly telehealth-based operation led by physician Vivek Gupta of Manhattan Beach, California. Gupta said he’s prescribed the weight loss drugs to 1,500 patients, with about 60% using compounded versions from a 503A pharmacy.

He hasn’t seen any essential difference in patients using the branded and compounded forms, although “some people say the compounding is a little less effective,” Gupta said.

There’s some risk in using the non-FDA-approved product, he acknowledged, and he requires patients to sign an informed consent waiver.

“Nothing in life is without risk, but I would also argue that the status quo is not safe for people who need the medicine and can’t get it,” he said. “They’re constantly triggered by all this food that’s causing their weight to go up and their sugar to go high, increasing their insulin resistance and affecting their limbs and eyes.”

Compounding semaglutide is a helpful sideline for pharmacists like him, Welch said, especially given the pinch on drug sale revenue that has led many independents to close in recent years. He figures he earns 95% of his revenue from compounding drugs, rather than traditional prescriptions.

It’s important to distinguish compounded semaglutide from unregulated powders sold as “generic Ozempic” and the like, which may be contaminated or counterfeit, said FDA spokesperson Amanda Hils. But since compounded forms of the drug are not FDA-approved, those who make, prescribe, or use them also should have “an increased level of responsibility or awareness,” she said.

Corporate Battles

Novo Nordisk and Lilly, in lawsuits each company has filed against competitors, say their own testing has found bacteria and other impurities in products made by compounding pharmacies. The companies also report patent infringement, but compounders, pointing to the FDA loophole for drugs in shortage, appear to have defeated that argument for now.

When the FDA removes the drugs from the shortage list, 503B compounders must immediately stop selling them. Smaller compounders may be able to produce their products for a reduced number of patients, said Scott Brunner, CEO of the Alliance for Pharmacy Compounding, which represents 503A compounders.

The evaporation of the compounded drug supply could come as a shock to patients.

“I dread it,” said David Wertheimer, an internist in Franklin Lakes, New Jersey, who prescribes compounded semaglutide to some patients. “People are not going to be able to plunk down a grand every month. A lot of people will go off the drug, and that’s a shame.”

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The drones are coming.

Starting in September, if someone in Clemmons, North Carolina, calls 911 to report a cardiac arrest, the first responder on the scene may be a drone carrying an automated external defibrillator, or AED.

“The idea is for the drone to get there several minutes before first responders,” such as an emergency medical technician or an ambulance, said Daniel Crews, a spokesperson for the sheriff’s office in Forsyth County, where Clemmons is located. The sheriff’s office is partnering on the project with local emergency services, the Clinical Research Institute at Duke University, and the drone consulting firm Hovecon. “The ultimate goal is to save lives and improve life expectancy for someone experiencing a cardiac episode,” Crews said.

The Forsyth County program is one of a growing number of efforts by public safety and health care organizations across the country to use drones to speed up lifesaving treatment in situations in which every second counts.

More than 356,000 people have a cardiac arrest outside of a hospital setting every year in the United States, according to the American Heart Association. Most people are at home when it happens, and about 90% die because they don’t get immediate help from first responders or bystanders. Every minute that passes without medical intervention decreases the odds of survival by 10%.

“We’ve never been able to move the needle for cardiac arrest in private settings, and this technology could meet that need,” said Monique Anderson Starks, a cardiologist and associate professor of medicine at Duke University. Starks is leading pilot studies in Forsyth County and James City County, Virginia, to test whether drone AED delivery can improve treatment response times. The work is funded by a four-year grant from the American Heart Association.

A 2017 study found it takes an emergency medical services unit seven minutes, on average, to arrive on the scene following a 911 call, though response times vary considerably by region, and rural wait times can be much longer. Starks said she believes the drone-delivered AEDs in the pilot study could reduce the time to treatment by four minutes compared with first responders.

Unlike a heart attack, which occurs when blood flow to the heart is blocked, a cardiac arrest happens when a heart malfunction causes it to stop beating, typically because of an arrhythmia or an electrical problem. Eighty percent of cardiac arrests start as heart attacks. The only way to get the heart restarted is with CPR and a defibrillator.

In Forsyth County, a drone pilot from the sheriff’s department will listen in on 911 calls. If there’s a suspected cardiac arrest, the pilot can dispatch the drone even before emergency medical services are contacted. The drone, which weighs 22 pounds and can travel 60 mph, will fly to the location and hover 125 feet in the air before lowering an AED to the ground on a winch. The AED provides simple verbal instructions; the 911 dispatcher on the phone can also help a bystander use the AED.

Eventually there will be six drone bases in Forsyth and James City counties, Starks said.

While the technology is promising and research has often found that drones arrive faster than first responders, there’s little conclusive evidence that drones improve health outcomes.

A Swedish study published in The Lancet in 2023 compared the response times between drones and ambulances for suspected cardiac arrest in 58 deployments in an area of about 200,000 people. It found that drones beat the ambulance to the scene two-thirds of the time, by a median of three minutes and 14 seconds.

In the United States, most programs are just getting started, and they are exploring the use of drones to also provide remedies for drug overdoses and major trauma or potential drowning rescues.

In Florida, Tampa General Hospital, Manatee County, and Archer First Response Systems, or AFRS, began a program in May to deliver AEDs, a tourniquet, and Narcan, a nasal spray that can reverse an opioid overdose. The program initially covers a 7-square-mile area, and EMS dispatchers deploy the drones, which are monitored by drone pilots.

There were nearly 108,000 drug overdose deaths in the United States in 2022, according to the National Institute on Drug Abuse.

As of early July, the Tampa program hadn’t yet deployed any drones, said Gordon Folkes, the founder and chief executive of AFRS, which develops and deploys emergency drone logistics systems. One request in June to send a drone to an overdose couldn’t be fulfilled because of a violent thunderstorm, Folkes said. In the testing area, which covers about 7,000 residents, Folkes estimates that 10 to 15 drones might be deployed each year.

“The bread and butter for these systems is suburban areas” like Manatee County that are well-populated and where the drones have the advantage of being able to avoid traffic congestion, Folkes said.

There are other uses for drones in medical emergencies. The New York Police Department plans to drop emergency flotation devices to struggling swimmers at local beaches. In Chula Vista, California, a police drone was able to pinpoint the location of a burning car, and then officers pulled the driver out, said Sgt. Tony Molina.

Rescue personnel have used drones to locate people who wander away from nursing homes, said James Augustine, a spokesperson for the American College of Emergency Physicians who is the medical director for the International Association of Fire Chiefs.

In the United States, one hurdle for drone programs is that the Federal Aviation Administration typically requires that drones be operated within the operators’ visual line of sight. In May, when Congress passed the FAA reauthorization bill, it gave the FAA four months to issue a notice of proposed rulemaking on drone operations beyond the visual line of sight.

“The FAA is focused on developing standard rules to make [Beyond Visual Line of Sight] operations routine, scalable, and economically viable,” said Rick Breitenfeldt, an FAA spokesperson.

Some civil liberties groups are concerned that the FAA’s new rules may not provide enough protection from drone cameras for people on the ground.

Jay Stanley, a senior policy analyst at the American Civil Liberties Union, acknowledged the benefits of using drones in emergency situations but said there are issues that need to be addressed.

“The concern is that the FAA is going to significantly loosen the reins of drones without any significant privacy protections,” he said.

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A partir de septiembre, si alguien en Clemmons, Carolina del Norte, llama al 911 para pedir ayuda porque una persona está sufriendo un paro cardíaco, el primero en intervenir en la escena podrá ser un dron que lleve un Desfibrilador Externo Automático, o DEA.

“La idea es que el dron llegue varios minutos antes que los primeros socorristas”, como un técnico en emergencias médicas o una ambulancia, dijo Daniel Crews, vocero de la oficina del sheriff en el condado de Forsyth, donde se encuentra Clemmons.

La oficina del sheriff está llevando adelante este proyecto en alianza con los servicios de emergencia locales, con el Instituto de Investigación Clínica de la Universidad de Duke y con Hovecon, una empresa de consultoría en drones. “El objetivo final es evitar muertes y aumentar la esperanza de vida de quienes sufren un episodio cardíaco”, dijo Crews.

Cada vez con más frecuencia, en todo el país, las organizaciones de emergencias médicas y  las de seguridad pública están utilizando drones para acelerar la intervención en situaciones en las que cada segundo es importante para salvar vidas. El Programa del Condado de Forsyth es una de esas iniciativas.

En Estados Unidos cada año más de 356,000 personas sufren un paro cardíaco fuera de un hospital, según la Asociación Americana del Corazón (AHA). La mayoría se descompensa estando en su casa y alrededor del 90% muere porque no recibe ayuda inmediata del personal de emergencias médicas o de los transeúntes. Cada minuto que pasa sin intervención médica disminuye las probabilidades de supervivencia en un 10%.

“Nunca hemos podido alcanzar una mejora significativa en el tiempo de atención de los accidentes cardiológicos cuando se producen en entornos privados, y esta tecnología podría ayudarnos a lograr ese objetivo”, dijo Monique Anderson Starks, cardióloga y profesora asociada de Medicina en la Universidad de Duke.

Starks lidera estudios piloto en los condados de Forsyth y James City, en Virginia, que están midiendo si efectivamente la entrega de DEA con drones puede mejorar los tiempos de respuesta al tratamiento. El trabajo está financiado por una subvención de cuatro años de la AHA.

Según un trabajo de 2017, después de una llamada al 911 una unidad de servicios médicos de emergencia necesita un promedio de siete minutos para llegar al lugar. Sin embargo, los tiempos de respuesta varían considerablemente según la región. Y en el caso de las áreas rurales pueden ser muchísimo más largos.

Starks dijo que cree que los DEA entregados por drones podrían reducir el tiempo de intervención en cuatro minutos respecto de lo que tardan los primeros socorristas.

A diferencia de un ataque cardíaco, que ocurre cuando está bloqueado el flujo sanguíneo al corazón, un paro cardíaco sucede cuando este órgano deja de latir, generalmente debido a una arritmia o a un problema eléctrico. El 80% de los paros cardíacos comienzan como ataques cardíacos. La única manera de reiniciar el corazón es con resucitación cardiopulmonar (RCP) y un desfibrilador.

En el condado de Forsyth, un piloto de drones de la oficina del sheriff escuchará las llamadas al 911. Si sospecha que se está ante un paro cardíaco, el piloto puede despachar el dron incluso antes de que se contacten los servicios de emergencia médica.

El dron, que pesa 22 libras y puede viajar a 60 mph, volará hasta el lugar y se mantendrá a 125 pies de altura antes de bajar un DEA al suelo, ayudado por un dispositivo mecánico.

El DEA imparte instrucciones verbales simples y, desde su puesto, también el operador de la línea 911 podrá ayudar a usar el desfibrilador a cualquier persona sin experiencia que esté cerca. Con el tiempo se espera que haya seis bases de drones en los condados de Forsyth y James City, dijo Starks.

Sin embargo, aunque la tecnología es prometedora y la investigación a menudo ha comprobado que los drones llegan más rápido que los primeros equipos de emergencia, existe poca evidencia concluyente de que mejoren los resultados de los socorristas.

Un estudio realizado en Suecia y publicado en 2023 por The Lancet comparó los tiempos de respuesta entre drones y ambulancias para casos sospechosos de paros cardíacos en 58 intervenciones que abarcaron una población de alrededor de 200,000 personas.

El estudio llegó a la conclusión de que en el 66,67% de las ocasiones analizadas, los drones llegaron antes que las ambulancias y que esto significó que, en promedio, se anticiparon 3 minutos y 14 segundos.

En Estados Unidos, la mayoría de los programas recién están comenzando. Se está explorando el uso de drones para intervenir en casos de sobredosis de drogas, de traumas mayores y en los rescates a personas que estuvieron en riesgo de ahogarse.

En Florida, el Hospital General de Tampa, el condado de Manatee y los Sistemas de Respuesta Inmediata Archer o AFRS, iniciaron un programa en mayo para entregar DEA, torniquetes y Narcan, un spray nasal que puede revertir la sobredosis de opioides.

El programa inicialmente cubre un área de 7 millas cuadradas y los operadores de los servicios médicos de emergencia (EMS) despliegan los drones, que son monitoreados por pilotos especializados. En 2022, hubo casi 108,000 muertes por sobredosis de drogas en el país, según el Instituto Nacional sobre el Abuso de Drogas.

Hasta principios de julio, el programa de Tampa aún no había enviado ningún dron, explicó Gordon Folkes, fundador y director ejecutivo de AFRS, que desarrolla y despliega sistemas de logística de drones de emergencia.

Una solicitud recibida en junio para que enviaran un dron en un caso por sobredosis no pudo cumplirse por razones climáticas, lo impidió una tormenta violenta, dijo Folkes. En el área de prueba, que cubre aproximadamente a 7,000 residentes, Folkes estima que se podrían desplegar de 10 a 15 drones cada año.

“El punto fuerte de estos sistemas son las áreas suburbanas muy pobladas, como el condado de Manatee, porque los drones tienen la ventaja de poder evitar las congestiones de tráfico”, agregó Folkes.

Hay otros usos para los drones en emergencias médicas. El Departamento de Policía de Nueva York planea lanzar dispositivos de flotación de emergencia a los nadadores que se encuentren en problemas en las playas locales. Además, en Chula Vista, California, un dron de la policía pudo identificar la ubicación de un auto en llamas, y eso permitió que los oficiales sacaran al conductor, dijo el sargento Tony Molina.

El personal de rescate ha utilizado drones para localizar a personas que se alejan de los hogares de adultos mayores, dijo James Augustine, vocero del Colegio Americano de Médicos de Emergencia, quien es el director médico de la Asociación Internacional de Jefes de Bomberos.

En Estados Unidos, un obstáculo para los programas de drones es que la Administración Federal de Aviación (FAA) generalmente requiere que los drones sean manejados dentro de la línea de visión de los operadores. En mayo, cuando el Congreso aprobó la ley de reautorización de la FAA, se le otorgó un plazo de cuatro meses para emitir una propuesta de reglamentación sobre las operaciones de drones más allá de la línea de visión.

“La FAA se está concentrando en desarrollar reglas estándar para hacer que las operaciones (más allá del campo visual) sean rutinarias, y económicamente viables”, dijo Rick Breitenfeldt, vocero de la FAA.

Por otro lado, algunos grupos de libertades civiles están preocupados porque las nuevas reglas de la FAA no proporcionen suficiente protección contra las cámaras de los drones para las personas en tierra.

Jay Stanley, analista de políticas senior de la Unión Americana de Libertades Civiles, reconoció los beneficios de usar drones en situaciones de emergencia pero consideró que aún hay problemas que deben abordarse.

“La preocupación es que la FAA va a flexibilizar significativamente las restricciones a los drones sin ninguna protección significativa de la privacidad”, expresó.

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The Biden administration on Friday put in place stringent curbs aimed at thwarting rogue insurance brokers from switching consumers’ Affordable Care Act plans without their consent.

The announcement came in response to mounting complaints from consumers. The Centers for Medicare & Medicaid Services said Friday that, in the first six months of the year, more than 200,000 people reported to the agency that they were either enrolled in Obamacare plans or switched from one plan to another without their permission.

KFF Health News began reporting on Affordable Care Act enrollment schemes this spring.

CMS said insurance agents will be blocked from making changes to any Obamacare enrollments made through the federal marketplace, healthcare.gov, unless the agent is already “associated” with a consumer’s policy.

Additionally, agents who can’t prove an association — which is undefined in the agency directive — will have to take additional steps to make changes even if they have a consumer’s consent.

The changes are effective immediately, an unusually rapid move by the agency that may reflect the urgency of the problem. Republicans have alleged that enhanced subsidies backed by the Biden administration provide incentive for brokers or consumers to fraudulently misstate their incomes to qualify for ACA tax credits, while some Democrats have also been critical of CMS, saying the agency needs to take a tougher stand against rogue brokers who are switching people without their consent in order to gain commissions.

Consumers, meanwhile, can face higher out-of-pocket costs for medical services or unexpected tax bills if they get signed up for subsidized plans they’re not eligible for.

To show they have consumers’ consent for enrollment changes, CMS said, unassociated agents must do three-way calls with the healthcare.gov call center or ask their clients to make changes themselves, either through healthcare.gov or one of the private sector enrollment websites allowed to link with it.

“CMS anticipates these updates will help block unauthorized changes by agents and brokers,” the agency said in a notice posted on its website Friday afternoon.

Ellen Montz, a deputy administrator at CMS and the director of its Center for Consumer Information and Insurance Oversight, in a written statement to KFF Health News, said “CMS will do everything it can to protect consumers from bad actors and will assist consumers who have experienced a change that they didn’t authorize.” She added that the “consumer experience” would not change for people who continue to work with agents who are already associated with their policies.

The rules drew concern as well as some cautious optimism from agents and their professional associations, which have been calling on CMS to act for months.

“On paper, it protects consumers, so that’s a good thing,” said Joshua Brooker, founder of PA Health Advocates in Pennsylvania, who has followed the issue closely. But he and others said the directive raises many questions about how it will work in practice, especially during the busy open enrollment period at the end of the year.

The requirements will be a burden on consumers, predicted Ronnell Nolan, president of the agent trade group Health Agents for America.

“They will be responsible for calling the marketplace call center, which is a nightmare in itself, to change their agent,” Nolan said. “Why is it their responsibility?”

The directive applies only to existing coverage, not brand-new ACA enrollments.

Complaints about unauthorized enrollment or plan-switching are not new but accelerated during the last open enrollment period for the ACA. President Joe Biden has boasted of record enrollment for 2024 ACA plans. More than 21 million people signed up nationally during the most recent open enrollment period.

The agency said Friday it has resolved more than 97% of the reported complaints about enrollment or switching.

For the first time, the agency also reported on enforcement action, saying that between June 21 and July 10 it had suspended 200 agents or brokers “for reasonable suspicion of fraud or abusive conduct related to unauthorized enrollments or unauthorized plan switching.”

The new rules don’t apply to the 18 states, and the District of Columbia, that run their own Obamacare insurance marketplaces. Many of them use security procedures that healthcare.gov does not, including two-factor authentication.

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Los Ángeles, California. — Distribuyen dispositivos GPS para poder rastrear a sus pacientes sin hogar. Abastecen sus kits de calle con pipas de vidrio que se usan para fumar metanfetamina, crack o fentanilo. Mantienen tarjetas de crédito de la empresa a mano en caso que un paciente necesite de urgencia alimentos o agua, o un viaje en Uber al médico.

Estos médicos, enfermeros y trabajadores sociales se están desplegando en las calles de Los Ángeles para ofrecer atención médica y servicios sociales a las personas sin hogar: soldados de un nuevo modelo de negocio que está arraigándose en comunidades de toda California.

Su estrategia: construir confianza con las personas sin hogar para darles medicinas dondequiera que estén… y ganar dinero haciéndolo.

“La mayor población de personas sin hogar en este país está aquí en el sur de California”, dijo Sachin Jain, ex funcionario de salud de la administración Obama que es CEO de SCAN Group, que dirige un plan de Medicare Advantage que cubre a unas 300,000 personas en California, Arizona, Nevada, Texas y Nuevo México.

“El segmento de más rápido crecimiento de personas que experimentan la falta de vivienda son en realidad los adultos mayores”, dijo. “Dije, ‘Tenemos que hacer algo al respecto'”.

La organización de Jain creó hace tres años Healthcare in Action, un grupo médico que envía a los practicantes a las calles de California exclusivamente para atender a personas sin hogar. Ha crecido rápidamente, estableciendo operaciones en 17 comunidades, incluyendo Long Beach, West Hollywood y el condado de San Bernardino.

Desde su lanzamiento, Healthcare in Action ha atendido a unos 6,700 pacientes sin techo y ha realizado aproximadamente 77,000 diagnósticos, desde esquizofrenia hasta diabetes. Ha puesto a unas 300 personas en viviendas permanentes o temporales.

En la mayor parte del país, la medicina de calle o callejera se practica como una labor caritativa, dirigida a servir a una población de pacientes compleja que ha sido desatendida por la medicina tradicional, dicen sus defensores.

Llevando vidas nómades y caóticas, las personas sin hogar sufren desproporcionadamente de afecciones mentales, adicciones y enfermedades crónicas, y a menudo no tienen seguro médico o si lo tienen no lo usan.

Eso hace que diseñar un negocio alrededor de atenderlos sea un riesgo, dicen ejecutivos de seguros y economistas de la salud.

“Es realmente innovador y emprendedor tomar toda esta energía y coraje para tratar de mejorar las cosas para una población a la que generalmente se ignora”, dijo Mark Duggan, profesor de economía en la Universidad de Stanford que se especializa en política de falta de vivienda y Medicaid. “Los incentivos financieros importan muchísimo en la atención médica. Son todo”.

Se estima que 181,000 personas no tenían hogar en California en 2023, aproximadamente el 30% del total nacional. El número de personas viviendo en la calle, más de dos tercios del total del estado, aumentó 6.9% con respecto al año anterior.

A los líderes estatales, incluido el gobernador demócrata Gavin Newsom, les ha costado luchar contra la creciente crisis de salud pública y política, a pesar de reunir recursos sin precedentes de los contribuyentes.

“Tenemos un gran problema entre manos, y tenemos muchos planes de salud y municipios diciendo, ‘Te necesitamos'”, dijo Jain.

En las calles

Una mañana nublada de abril, en Long Beach, Daniel Speller manejaba su furgoneta médica móvil entre las tiendas de campaña y lonas que llenaban las calles residenciales, buscando a un par de pacientes sin hogar. Speller, que es asistente médico de Healthcare in Action, dijo que estaba particularmente preocupado por las heridas gravemente infectadas que habían desarrollado en sus extremidades después de usar la droga callejera xilazina, un tranquilizante para animales que a menudo se mezcla con fentanilo.

“Estas heridas están en todas partes. Es realmente malo”, dijo Speller. Si las infecciones avanzan, pueden requerir amputaciones de dedos, pies o brazos.

“Hombre, ésta todavía está muy profunda”, dijo Speller mientras despegaba los jeans de la pierna hinchada de Robert Smith, de 66 años.

Después de limpiar y vendar la pierna de Smith, Speller le preguntó si necesitaba algo más. “Perdí mis cupones de alimentos”, respondió Smith.

En menos de una hora, el equipo de trabajadores sociales y enfermeros de Speller habían llamado a un Uber para llevar a Smith a una oficina estatal, donde recibió una nueva tarjeta CalFresh.

Después, Speller dobló hacia una calle lateral llena de más tiendas de campaña y autos convertidos en refugios. Nick Destry Anderson, de 46 años, estaba durmiendo en la acera y necesitaba con urgencia que le curaran su herida.

“Tenía tanto miedo. Antes de conocerlos pensé que iba a perder mi pierna”, dijo Anderson, haciendo un gesto mientras Speller rociaba su pierna con un aerosol antibiótico. “Estas personas salvaron mi vida”.

Anderson dijo que se sentía mareado, así que Speller pidió a otro miembro del equipo que usara la tarjeta de crédito de la empresa para comprarle una hamburguesa con queso y una Sprite.

Muchas personas sin hogar languidecen en las calles, tan arraigadas en crisis de salud mental o adicciones que no les importa mucho ver a un médico o tomar su medicación. Las enfermedades crónicas empeoran. Las heridas se infectan. Las personas sufren sobredosis o mueren por afecciones tratables.

Parte de la medicina callejera consiste en vendar heridas infectadas, administrar inyecciones de antipsicóticos y tratar enfermedades crónicas. Los proveedores de la calle a menudo reparten parafernalia de drogas como agujas limpias y pipas de vidrio para prevenir que se compartan y prevenir infecciones. Quizás más importante, estos trabajadores construyen confianza.

Que los pacientes sin hogar s conecten con médicos y enfermeros de atención primaria, que los visitan en las calles, en los parques o dondequiera que estén, puede prevenir visitas frecuentes y costosas a salas de emergencia y hospitalizaciones, potencialmente ahorrando dinero a las aseguradoras y a los contribuyentes, argumenta Jain.

Aunque los refugios y la vivienda son escasos, el objetivo de Healthcare in Action es lograr que los pacientes estén lo suficientemente saludables como para vivir vidas estables e independientes, dijo.

Pero eso es más fácil decirlo que hacerlo. En West Hollywood esa semana de abril, Isabelle Peng, coordinadora clínica de Healthcare in Action, encontró a Lisa Vernon, una mujer sin hogar, desplomada en su silla de ruedas en una parada de autobús concurrida. Vernon es una habitual del cercano Centro Médico Cedars-Sinai, dijeron Peng y su colega, David Wong.

Cuando Peng y Wong intentaron examinar su pierna hinchada, Vernon les gritó y rechazó la ayuda. “¡Los antibióticos no van a salvar mi vida!”, gritó Vernon mientras un ratón corría hacia las migajas de patatas fritas que estaban a sus pies.

Pasaron a su siguiente paciente, un hombre que estaban rastreando con un dispositivo GPS que a veces colocan en las pertenencias de las personas sin hogar. El uso de los dispositivos es voluntario. Funcionan mejor que los teléfonos móviles porque es menos probable que la policía los confisque durante redadas de campamentos, o que se los roben.

“Nuestros pacientes realmente cambian mucho de ubicación, así que esto nos ayuda a encontrarlos cuando tenemos que darles medicación o hacer seguimiento”, dijo Wong. “Ya hemos desarrollado un vínculo con estos pacientes y ellos quieren que los veamos”.

Aumento de ingresos

Los equipos de medicina de calle están en demanda, en gran parte debido a la creciente frustración pública con la falta de vivienda. Por ejemplo, La ciudad de West Hollywood otorgó a Healthcare in Action un contrato de tres años que paga $47,000 al mes. La organización sin fines de lucro también puede facturar por sus servicios a Medi-Cal, el programa de Medicaid de California.

Mari Cantwell, consultora de atención médica que se desempeñó como directora del Medicaid de California desde 2015 hasta principios de 2020, dijo que los reembolsos de Medicaid por sí solos no son suficientes para financiar a los proveedores de medicina de calle. Para seguir siendo viables, dijo, deben dar pasos financieros creativos, como hace Healthcare in Action.

“Medicaid nunca va a pagar altos márgenes, así que tienes que pensar en cómo sostener las cosas”, dijo.

Healthcare in Action generó unos $2 millones en ingresos en su primer año, $6 millones en 2022 y $15,4 millones en 2023, según Michael Plumb, director financiero de SCAN Group.

Healthcare in Action y el plan de seguro Medicare Advantage de SCAN generan ingresos sirviendo a pacientes sin hogar de múltiples maneras:

• Ambos están aprovechando miles de millones de dólares en fondos de Medicaid que los estados y el gobierno federal están gastando para tratar a personas sin hogar en sus lugares y para proporcionar nuevos servicios sociales como asistencia de vivienda y alimentos. Por ejemplo, Healthcare in Action ha recibido $3,8 millones de la iniciativa de Medicaid de Newsom de $12 mil millones llamada CalAIM, que le permite contratar trabajadores sociales, médicos y proveedores para los equipos de medicina callejera, según el estado. También contrata con aseguradoras de salud, incluidas L.A. Care y Molina Healthcare en el sur de California, para identificar viviendas para pacientes sin hogar, negociar con propietarios, y proporcionar ayuda financiera como cubrir depósitos de seguridad.
• Healthcare in Action recibe donaciones caritativas de algunos hospitales y aseguradoras, incluidas CalOptima en el condado de Orange y su propio plan Medicare Advantage, SCAN Health Plan.
• Healthcare in Action se asocia con ciudades y hospitales para proporcionar tratamiento y servicios. En 2022, inició un contrato con Cedars-Sinai para atender a pacientes que deambulan fuera del hospital.
• También inscribe a pacientes sin hogar elegibles en SCAN Health Plan porque muchas personas mayores de bajos ingresos califican tanto para la cobertura de Medicaid como para Medicare. El plan tuvo ingresos de $4,9 mil millones en 2023, frente a los $3,5 mil millones de 2021.

“Ha habido un ajuste de mercado increíble, desafortunadamente”, dijo Jain. “No puedes caminar o conducir por una calle en Los Ángeles, ya sea rica o pobre, y no encontrarte con este problema”.

Jim Withers, quien acuñó el término “medicina de calle” hace décadas y atiende a personas sin hogar en Pittsburgh, dio la bienvenida a la entrada de más proveedores dada la enorme necesidad. Pero advirtió sobre un modelo con motivos financieros.

“Me preocupa la corporativización de la medicina de calle y el capitalismo invadiendo lo que hemos estado construyendo, en gran parte como una misión de justicia social fuera del sistema tradicional de atención médica”, dijo. “Pero nadie posee las calles, y tenemos que encontrar la manera de trabajar juntos”.

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LOS ANGELES — They distribute GPS devices so they can track their homeless patients. They stock their street kits with glass pipes used to smoke meth, crack, or fentanyl. They keep company credit cards on hand in case a patient needs emergency food or water, or an Uber ride to the doctor.

These doctors, nurses, and social workers are fanning out on the streets of Los Angeles to provide health care and social services to homeless people — foot soldiers of a new business model taking root in communities around California.

Their strategy: Build trust with homeless people to deliver medicine wherever they are — and make money doing it.

“The biggest population of homeless people in this country is here in Southern California,” said Sachin Jain, a former Obama administration health official who is CEO of SCAN Group, which runs a Medicare Advantage insurance plan covering about 300,000 people in California, Arizona, Nevada, Texas, and New Mexico.

“The fastest-growing segment of people experiencing homelessness is actually older adults,” he said. “I said, ‘We’ve got to do something about this.’”

Jain’s organization three years ago created Healthcare in Action, a medical group that sends practitioners onto California’s streets solely to care for homeless people. It has grown rapidly, building operations in 17 communities, including Long Beach, West Hollywood, and San Bernardino County.

Since its launch, Healthcare in Action has cared for about 6,700 homeless patients and managed roughly 77,000 diagnoses, from schizophrenia to diabetes. It has placed about 300 people into permanent or temporary housing.

Street medicine in most of the country is practiced as a charitable endeavor, aimed at serving a challenging patient population failed by traditional medicine, its proponents say. Living transient, chaotic lives, homeless people suffer disproportionately from mental illness, addiction, and chronic disease and often don’t have health insurance — or don’t use it if they do.

That makes designing a business around caring for them a risk, insurance executives and health economists say.

“It’s really innovative and entrepreneurial to take all this energy and grit to try and improve things for a population that is too often ignored,” said Mark Duggan, a professor of economics at Stanford University who specializes in homelessness and Medicaid policy. “Financial incentives matter massively in health care. It’s everything.”

An estimated 181,000 people were homeless in California in 2023 — about 30% of the nation’s total. The number living outside, more than two-thirds of California’s total, increased 6.9% over the previous year.

The state’s leaders, including Democratic Gov. Gavin Newsom, have struggled to make inroads against the mounting public health and political crisis — despite marshaling unprecedented taxpayer resources.

“We have a huge problem on our hands, and we have a lot of health plans and municipalities saying, ‘We need you,’” Jain said.

On the Streets

On a cloudy April morning in Long Beach, Daniel Speller navigated his mobile medical van among the tents and tarps that crowded residential streets, searching for a couple of homeless patients. A physician assistant for Healthcare in Action, Speller said he was particularly worried about the badly infected wounds they developed on their limbs after they used the street drug xylazine, an animal tranquilizer often mixed with fentanyl.

“These wounds are everywhere. It’s really bad,” Speller said. If infections progress, they can require toe, foot, or arm amputations.

“Man, this one is still so deep,” Speller said as he peeled denim pants from the swollen leg of Robert Smith, 66.

After cleaning and wrapping Smith’s leg, Speller asked him if he needed anything else. “I lost my food stamps,” Smith replied.

Within the hour, Speller’s team of social workers and nurses had summoned an Uber to take Smith to a state office, where he received a new CalFresh card.

Speller then turned his medical van onto a side street lined with more tents and cars-turned-shelters. Nick Destry Anderson, 46, was sleeping on the sidewalk and badly in need of wound care.

“I was so scared. I thought I was going to lose my leg before I met them,” Anderson said, grimacing as Speller sprayed his leg with antibiotic mist. “These people saved my life.”

Anderson reported feeling lightheaded, so Speller asked another team member to use the company credit card to get him a cheeseburger and a Sprite.

Many homeless people languish on the streets, so entrenched in mental health crises or addiction that they don’t much care about seeing a doctor or taking their medication. Chronic diseases worsen. Wounds grow infected. People overdose or die from treatable conditions.

Part of street medicine is bandaging infected sores, administering antipsychotic injections, and treating chronic diseases. Street providers often hand out drug paraphernalia such as clean needles and glass pipes to reduce sharing and prevent infections. Perhaps more importantly, these workers build trust.

Getting homeless patients established with primary care doctors and nurses — who visit them on the streets, in parks, or wherever they happen to be — can prevent frequent and expensive emergency room trips and hospitalizations, potentially saving money for insurers and taxpayers, Jain argues. Even though shelter and housing are scarce, Healthcare in Action’s goal is to get patients healthy enough to live stable, independent lives, he said.

But that’s easier said than done. In West Hollywood that week in April, Healthcare in Action clinical coordinator Isabelle Peng found Lisa Vernon, a homeless woman, slumped over in her wheelchair at a busy bus stop. Vernon is a regular at nearby Cedars-Sinai Medical Center, Peng and her colleague David Wong said.

When Peng and Wong attempted to examine her swollen leg, Vernon shouted at them and declined aid. “Antibiotics aren’t going to save my life!” Vernon yelled as a mouse scurried for the potato chip shrapnel at her feet.

They moved on to their next patient, a man they were tracking with a GPS device they sometimes affix to homeless people’s belongings. Use of the devices is voluntary. They work better than cellphones because they less often get taken by law enforcement during encampment sweeps or stolen by thieves.

“Our patients really move around a lot, so this helps us go find them when we have to get them medication or do follow-up care,” Wong said. “We have already developed rapport with these patients, and they want us to see them.”

Growing Revenue

Street medicine teams are in demand, largely because of growing public frustration with homelessness. The city of West Hollywood, for instance, awarded Healthcare in Action a three-year contract that pays $47,000 a month. The nonprofit can also bill Medi-Cal, California’s Medicaid program, which covers low-income people, for its services.

Mari Cantwell, a health care consultant who served as California’s Medicaid director from 2015 until early 2020, said Medicaid reimbursements alone aren’t enough to fund street medicine providers. To remain viable, she said, they need to take creative financial steps, like Healthcare in Action has.

“Medicaid is never going to pay high margins, so you have to think about how to sustain things,” she said.

Healthcare in Action brought in about $2 million in revenue in its first year, $6 million in 2022, and $15.4 million in 2023, according to Michael Plumb, SCAN Group’s chief financial officer.

Healthcare in Action and SCAN’s Medicare Advantage insurance plan generate revenue by serving homeless patients in multiple ways:

• Both are tapping into billions of dollars in Medicaid money that states and the federal government are spending to treat homeless people in the field and to provide new social services like housing and food assistance.For instance, Healthcare in Action has received $3.8 million from Newsom’s $12 billion Medicaid initiative called CalAIM, which allows it to hire social workers, doctors, and providers for street medicine teams, according to the state.It also contracts with health insurers, including L.A. Care and Molina Healthcare in Southern California, to identify housing for homeless patients, negotiate with landlords, and provide financial help such as covering security deposits.
• Healthcare in Action collects charitable donations from some hospitals and insurers, including CalOptima in Orange County and its own Medicare Advantage plan, SCAN Health Plan.
• Healthcare in Action partners with cities and hospitals to provide treatment and services. In 2022, it kicked off a contract with Cedars-Sinai to care for patients milling outside the hospital.
• It also enrolls eligible homeless patients into SCAN Health Plan because many low-income, older people qualify for both Medicaid and Medicare coverage. The plan had revenue of $4.9 billion in 2023, up from $3.5 billion in 2021.

“There’s been an incredible market fit, unfortunately,” Jain said. “You can’t walk or drive down a street in Los Angeles, rich or poor, and not run into this problem.”

Jim Withers, who coined the term “street medicine” decades ago and cares for homeless people in Pittsburgh, welcomed the entry of more providers given the enormous need. But he cautioned against a model with financial motives.

“I do worry about the corporatization of street medicine and capitalism invading what we’ve been building, largely as a social justice mission outside of the traditional health care system,” he said. “But nobody owns the streets, and we have to figure out how to play nice together.”

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

The Republican National Convention highlighted a number of policy issues this week, but health care was not among them. That was not much of a surprise, as it is not a top priority for former President Donald Trump or most GOP voters. The nomination of Sen. J.D. Vance of Ohio adds an outspoken abortion opponent to the Republican ticket, though he brings no particular background or expertise in health care.

Meanwhile, abortion opponents are busy trying to block state ballot questions from reaching voters in November. Legal battles over potential proposals continue in several states, including Florida, Arkansas, and Arizona.

This week’s panelists are Julie Rovner of KFF Health News, Alice Miranda Ollstein of Politico, Sarah Karlin-Smith of the Pink Sheet, and Joanne Kenen of the Johns Hopkins schools of public health and nursing and Politico Magazine.

Panelists Alice Miranda Ollstein Politico @AliceOllstein Read Alice's stories. Joanne Kenen Johns Hopkins University and Politico @JoanneKenen Read Joanne's articles. Sarah Karlin-Smith Pink Sheet @SarahKarlin Read Sarah's stories.

Among the takeaways from this week’s episode:

• Sen. J.D. Vance of Ohio has cast few votes on health policy since joining Congress last year. He has taken a doctrinaire approach to abortion restrictions, though, including expressing support for prohibiting abortion-related interstate travel and invoking the Comstock Act to block use of the mail for abortion medications. He also speaks openly about his mother’s struggles with addiction, framing it as a health rather than criminal issue in a way that resonates with many Americans.
• Although Republicans have largely abandoned calls to repeal and replace the Affordable Care Act, it would be easy for former President Donald Trump to undermine the program in a second term; expanded subsidies for coverage are due to expire next year, and there’s always the option to cut spending on marketing the program, as Trump did during his first term.
• Trump’s recent comments to Robert F. Kennedy Jr. about childhood vaccinations echoed tropes linked to the anti-vaccination movement — particularly the false claim that while one vaccine may be safe, it is perhaps dangerous to receive several at once. The federal vaccination schedule has been rigorously evaluated and found to be safe and effective.
• Covid is surging once again, with President Joe Biden among those testing positive this week. The virus is proving a year-round concern and has peaked regularly in summertime; covid spreads best indoors, and lately millions of Americans have taken refuge inside from extremely high temperatures. Meanwhile, the virology community is concerned that the nation isn’t testing enough animals or humans to understand the risk posed by bird flu.

Also this week, Rovner interviews KFF Health News’ Renuka Rayasam, who wrote the June installment of KFF Health News-NPR’s “Bill of the Month,” about a patient who walked into what he thought was an urgent care center and walked out with an emergency room bill. If you have an exorbitant or baffling medical bill, you can send it to us here.

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

Julie Rovner: Time magazine’s “‘We’re Living in a Nightmare:’ Inside the Health Crisis of a Texas Bitcoin Town,” by Andrew R Chow.

Joanne Kenen: The Washington Post’s “A Mom Struggles To Feed Her Kids After GOP States Reject Federal Funds,” by Annie Gowen.

Alice Miranda Ollstein: ProPublica’s “Texas Sends Millions to Crisis Pregnancy Centers. It’s Meant To Help Needy Families, but No One Knows if It Works,” by Cassandra Jaramillo, Jeremy Kohler, and Sophie Chou, ProPublica, and Jessica Kegu, CBS News.

Sarah Karlin-Smith: The New York Times’ “Promised Cures, Tainted Cells: How Cord Blood Banks Mislead Patients,” by Sarah Kliff and Azeen Ghorayshi.

Also mentioned on this week’s podcast:

The Wall Street Journal’s “Mail-Order Drugs Were Supposed To Keep Costs Down. It’s Doing the Opposite,” by Jared S. Hopkins.

Credits Francis Ying Audio producer Emmarie Huetteman Editor

To hear all our podcasts, click here.

And subscribe to KFF Health News’ “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

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

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Antes de dejar de usar drogas para siempre, Cierra Coon estima que sufrió ocho sobredosis en un lapso de dos semanas, en el otoño de 2022. En una de esas ocasiones, la naloxona, el medicamento para revertir la sobredosis de opioides, ayudó a salvarle la vida.

Coon estaba en un auto por los caminos secundarios de la Reserva India Flathead en el oeste de Montana cuando perdió el conocimiento. Alguien en el auto tomó una pequeña botella de naloxona, la roció en su nariz y realizó resucitación (CPR) hasta que recuperó el conocimiento.

Coon dijo que tener acceso rápido al agente de reversión de sobredosis, también conocido por su nombre comercial, Narcan, fue muy afortunado.

“Es un milagro que haya sobrevivido las veces que no me administraron naloxona”, dijo Coon. “La gente me devolvió la conciencia echándome agua fría y haciendo CPR. Pero eso no garantiza que te vayan a devolver a la vida”, agregó Coon.

Casi dos años después, Coon es entrenadora de recuperación para un programa local, Never Alone Recovery Support Services, y está obteniendo un título como consejera de adicciones en Salish Kootenai College. Lleva dosis de naloxona en su auto por si necesita ayudar a otras personas.

Pero dijo que le preocupa la falta de acceso al medicamento, particularmente en áreas rurales como la suya. El canal de distribución de los departamentos de salud estatal y tribal ha sido inconsistente, y el precio de $50 por un paquete de dos dosis de naloxona en el Walmart más cercano lo vuelve inaccesible para muchas personas.

“¿Cómo se supone que vamos a poder pagar por este medicamento que en última instancia es para salvar nuestras vidas y las de los que nos rodean?” dijo.

Oficiales de salud de Montana están considerando una nueva estrategia para hacer que la naloxona sea más accesible.

Basándose en un fondo de salud conductual reservado por los legisladores en 2023, oficiales de salud de la administración del gobernador Greg Gianforte han propuesto instalar dos docenas de máquinas expendedoras de naloxona y tiras reactivas de fentanilo alrededor del estado, en centros de salud conductual y lugares de servicio para personas sin hogar.

El plan de $400,000 para construir, abastecer y mantener 24 máquinas expendedoras durante un año aún no ha sido aprobado por el gobernador republicano, que se postula para un segundo mandato, quien en última instancia decide cómo se gastan los fondos asignados a la Comisión del Sistema de Salud Conductual para las Generaciones Futuras.

Los detalles del Departamento de Salud Pública y Servicios Humanos del estado sobre dónde se colocarían las máquinas y cómo se operarían siguen siendo escasos.

La tasa de muertes relacionadas con opioides se ha triplicado en Montana en los últimos años, de 3,6 muertes por cada 100,000 residentes en 2017 a 11,3 por cada 100,000 residentes en 2023.

La tasa de mortalidad es más alta entre los nativos americanos: las personas nativas en Montana murieron por sobredosis de opioides a una tasa de 33 muertes por cada 100,000 personas en 2023, más de tres veces la tasa de las personas blancas no hispanas.

La naloxona ha surgido como una herramienta importante para combatir las sobredosis de opioides. Cuando se administra rápidamente, se adhiere a los receptores del cerebro a los que se dirigen los opioides, bloqueando los efectos de las drogas.

En todo Estados Unidos, las máquinas expendedoras que distribuyen naloxona y otros suministros de salud de forma gratuita se están convirtiendo en elementos de primera línea en la lucha contra las sobredosis de opioides. Diferentes versiones del modelo se están probando en al menos 33 estados.

En un informe de 2023, el Consejo Nacional para el Bienestar Mental describió el uso de máquinas expendedoras para distribuir naloxona y otros suministros de “reducción de daños”, como kits de primeros auxilios, pruebas de embarazo, jeringas estériles y más, como una herramienta de salud pública que se hizo más común durante la era del distanciamiento social durante la pandemia de covid-19.

Pero la popularidad del modelo ha seguido creciendo desde entonces, especialmente en lugares con poblaciones a las que es difícil llegar.

“Proporcionan servicios a [personas que usan drogas] con muchas menos barreras que los programas en un sitio fijo e incluso la divulgación móvil”, afirmó el informe. Las máquinas expendedoras de reducción de daños “también pueden proporcionar mayor privacidad y anonimato”.

La propuesta del departamento de salud estatal sería el primer caso en Montana de máquinas expendedoras financiadas directamente por el estado, a diferencia de las pocas que ahora se financian a través de subvenciones públicas o filantropía privada.

Jami Hansen, jefe de la oficina de prevención de la División de Salud Conductual y Discapacidades del Desarrollo del departamento, habló sobre la propuesta durante una reunión de mayo de la comisión estatal de salud conductual. Dijo que las máquinas expendedoras son una forma específica de llenar vacíos en un estado escasamente poblado que no ofrece acceso consistente a tratamientos para la adicción y naloxona.

“Tener algo disponible que puedan utilizar ellos mismos sería muy, muy beneficioso”, agregó Hansen.

Algunos grupos locales de salud pública en Montana, incluidos los de Missoula, Helena, Kalispell y el condado de Big Horn, ya han comenzado a usar máquinas expendedoras para distribuir naloxona gratuita, tiras reactivas para drogas y otros suministros de salud.

En Helena, tres máquinas compradas por el condado de Lewis y Clark han estado distribuyendo aerosol nasal Narcan gratuito y bolsas para la eliminación segura de drogas (usadas para disolver pastillas recetadas y recreativas) durante más de un año.

Kellie Goodwin McBride, directora del departamento de servicios de justicia penal del condado, dijo que su equipo intentó inicialmente integrar las máquinas en negocios locales, como un bar céntrico, una lavandería y un mercado, pero fallaron repetidamente.

A veces, no había suficiente espacio para las máquinas. En otros casos, dijo McBride, los dueños se preocupaban de que una máquina expendedora de Narcan diera la impresión de que el negocio toleraba o acogía el uso de drogas.

En su lugar, el condado instaló máquinas expendedoras en un refugio sin fines de lucro que atiende a residentes locales sin hogar, el edificio del tribunal de distrito estatal y el Centro de Justicia y Leyes en el centro, que alberga el tribunal municipal y el departamento del sheriff del condado. Esa máquina, es la que más se utiliza, dijo McBride.  

A diferencia de algunos otros modelos, las máquinas expendedoras de Narcan en Helena no requieren registro de usuarios ni códigos para acceder a los materiales dentro, lo que hace imposible rastrear quién está tomando naloxona o si se está utilizando.

McBride y su equipo reconocen que no hay una forma consistente de saber cuántas muertes relacionadas con opioides han ayudado a prevenir las máquinas expendedoras.

Jessica Johnson es la supervisora de educación sanitaria en el Distrito de Salud del Sur de Nevada, que ayudó a crear la primera colaboración de máquinas expendedoras en el país. Dijo que el proyecto fue diseñado para distribuir naloxona y jeringas estériles para reducir la propagación de enfermedades infecciosas entre las personas que se inyectan drogas.

Un estudio de 2022 registró 41 muertes por sobredosis menos de las esperadas en el condado de Clark, donde se ubicaron las máquinas, durante el primer año de distribución.

Johnson dijo que una de sus conclusiones del programa es la importancia de escuchar a las personas que están en más riesgo de la comunidad. Los quioscos o máquinas expendedoras de reducción de daños resultantes pueden ser tan diversos como los lugares en los que se encuentran.

Trabajadores de salud pública de todo el país han agregado cepillos de dientes, kits para dejar de fumar tabaco y otros suministros a sus máquinas expendedoras según las sugerencias de las poblaciones a las que sirven, dijo Johnson.

Aunque aún no se han elegido a los organizadores, Jon Ebelt, vocero del departamento de salud de Montana, dijo que la recomendación de la agencia de colocar máquinas en refugios y sitios que atienden a personas sin hogar se basa en el deseo de llegar a personas con enfermedades mentales graves, y a otras que ya están buscando servicios en esos lugares.

Ebelt confirmó que el departamento no se basó en datos de sobredosis de opioides ni en información demográfica sobre las personas que más a menudo sufren sobredosis en Montana al decidir dónde colocar las máquinas. En su lugar, la decisión se basó en “programación comunitaria y contratos existentes con sitios de servicios de salud mental y adicciones”.

Agregó que, según la propuesta, los anfitriones comunitarios de las máquinas expendedoras podrán seleccionar muchos tipos de suministros adicionales de reducción de daños para distribuir, “ya que cada comunidad tiene diferentes necesidades”, pero las jeringas estériles no estarán entre los productos disponibles en las máquinas de Montana.

El estado planea pagar un año de suministros, después del cual puede utilizar subvenciones federales para abastecer las máquinas, y los fondos federales no pueden utilizarse para comprar jeringas para el uso ilegal de drogas. Ebelt no respondió a otras preguntas sobre esa decisión o si los sitios podrían agregar jeringas y otros materiales suministrados a través de financiación independiente.

Este artículo se produjo a través de una asociación entre KFF Health News y Montana Free Press.

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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“Low INSULIN PRICING was gotten for millions of Americans by me, and the Trump Administration, not by Crooked Joe Biden. He had NOTHING to do with it.”

Former President Donald Trump in a Truth Social post, June 8

Former President Donald Trump has repeatedly claimed that he — and not President Joe Biden — deserves credit for lowering older Americans’ prescription drug prices, specifically for insulin.

In a June 8 post on Truth Social, the former president’s social platform, Trump wrote: “Low INSULIN PRICING was gotten for millions of Americans by me, and the Trump Administration, not by Crooked Joe Biden. He had NOTHING to do with it.”

Trump again claimed sole credit for lowering insulin prices during the June 27 presidential debate in Atlanta. After Biden touted the $35 monthly out-of-pocket cap for Medicare patients mandated by the Inflation Reduction Act, Trump responded: “I’m the one that got the insulin down for the seniors. I took care of the seniors.”

It’s not just the former president making such claims. Fox News anchor John Roberts and former Arkansas Gov. Mike Huckabee, a Republican, both have said the Biden administration is wrong to take credit for lowering insulin costs.

Because drug prices and Medicare will likely be issues in the presidential campaign, we dug into the facts surrounding those claims.

The Trump Administration’s Program

Trump is correct that his administration enacted a program to lower insulin costs for some patients on Medicare.

In July 2020, Trump signed an executive order establishing the “Part D Senior Savings Model,” a temporary, voluntary program run by the Centers for Medicare & Medicaid Services that let some Medicare Part D prescription drug plans cap monthly out-of-pocket insulin copay costs at $35 or less. It covered at least one insulin product of each dosage and type.

The program began Jan. 1, 2021, and ran through Dec. 31, 2023. In 2022, the Trump-era program included a total of 2,159 Medicare drug plans, and CMS estimated that more than 800,000 Medicare beneficiaries who use insulin could have benefited from it that year.

The Department of Health and Human Services has estimated that more than 1.5 million Medicare beneficiaries paid more than $35 a month for insulin in 2020, before Trump’s program took effect. An analysis by the Rand Corp., a nonpartisan think tank, showed the program reduced participants’ out-of-pocket insulin costs by $198 to $441 per year on average, depending on their Medicare plan.

The Inflation Reduction Act Provisions

The Inflation Reduction Act, which Congress passed and Biden signed into law in August 2022, included an insulin provision that went further than Trump’s voluntary initiative.

The act did cap out-of-pocket costs of insulin for Medicare patients at $35 per month. But whereas the Trump program applied only to certain Medicare Part D plans, the act mandated that all Medicare drug programs cap out-of-pocket insulin costs — including those in what’s known as Medicare Part B, which pays for medical equipment such as insulin pumps. The act’s insulin provisions took effect Jan. 1, 2023, for Part D plans and July 1 of that year for Part B.

The act also mandated that the out-of-pocket price cap apply to all insulin products a given Medicare plan covers, not just a subset.

Taken together, those provisions mean a far greater number of Medicare beneficiaries stand to benefit from the act’s insulin provisions — including people receiving insulin via a pump, who were left out of the Trump-era program.

CMS estimates that more than 3.3 million Medicare beneficiaries use one or more of the common forms of insulin. Although some of those people were likely already paying less than $35 per month for their medications, the Inflation Reduction Act benefited far more than the 800,000 patients affected by Trump’s program.

“It’s likely a larger population than under the Trump administration’s model,” said Juliette Cubanski, deputy director of the Program on Medicare Policy at KFF, a health information nonprofit that includes KFF Health News.

“The Trump administration did establish this voluntary model, and one perhaps could view that as some precedent for what we saw in the Inflation Reduction Act,” Cubanski added. “But I think it’s inaccurate to state that President Biden had nothing to do with enabling millions of Americans to benefit from lower insulin copayments.”

Preliminary research shows the Inflation Reduction Act’s insulin provisions had a greater average financial benefit than those in Trump’s program. Insulin-using older Americans were estimated to save an annual average of $501 per person, HHS figures show.

The Inflation Reduction Act has also had an impact beyond Medicare. After the law passed, some pharmaceutical companies — including Eli Lilly and Co., Novo Nordisk, Sanofi, and Civica Rx — self-imposed price caps for all insured insulin users, not just Medicare patients. During his 2023 State of the Union address, Biden proposed expanding this benefit to all insulin patients, and he’s made that point a staple of his campaign appearances.

“I’m determined to make that apply to every American, not just seniors, in the second term,” he said at a campaign event in May in Philadelphia.

The Stakes for the 2024 Election

Beyond insulin products, the Inflation Reduction Act caps total out-of-pocket prescription costs at $2,000 annually for people with Medicare drug plans starting in 2025, down from $3,300 this year for most Medicare beneficiaries.

But every congressional Republican opposed the Inflation Reduction Act, including its insulin savings provisions, in 2022, and the law is vulnerable to repeal should Trump take the White House. Trump has repeatedly criticized the law and called for overturning some of its provisions. He has not specified how he would address its health measures.

In an email exchange with KFF Health News, Trump campaign spokesperson Karoline Leavitt highlighted drug savings programs the former president instituted during his term in office, but repeatedly declined to extrapolate on, or defend, Trump’s claim that Biden deserves no credit for lowering insulin costs.

Asked whether Trump intended to maintain the Inflation Reduction Act’s insulin provisions should he win a second term in office, Leavitt wrote, “President Trump will do everything possible to lower drug costs for Americans when he’s back in the White House, just like he accomplished in his first term.”

Our Ruling

Trump can claim some credit for lowering insulin costs for seniors, as his administration advanced a voluntary program to do so.

But his claim that Biden had “NOTHING to do with it” is patently false. The Inflation Reduction Act, which Biden signed into law, imposed a mandatory Medicare insulin price cap that applied across the program, benefiting a significantly larger number of insulin users — including people not enrolled in Medicare. 

We rate Trump’s claim False.

Sources:

Civica Rx, “Civica to Manufacture and Distribute Affordable Insulin,” March 3, 2022

Centers for Medicare & Medicaid Services, “Part D Senior Savings Model,” accessed July 2, 2024

CMS, “President Trump Announces Lower Out of Pocket Insulin Costs for Medicare’s Seniors,” May 26, 2020

CNN, “READ: Biden-Trump Debate Transcript,” June 28, 2024

Eli Lilly and Co., “Lilly Cuts Insulin Prices by 70% and Caps Patient Insulin Out-of-Pocket Costs at $35 Per Month,” March 1, 2023

Email exchange with Karoline Leavitt, Donald J. Trump 2024 campaign national press secretary, July 1, 2024

Facebook.com, post by @MikeHuckabee, June 10, 2024

Federal Registrar, “Access to Affordable Life-Saving Medications,” July 24, 2020

Department on Health and Human Services, “Insulin Affordability and the Inflation Reduction Act: Medicare Beneficiary Savings by State and Demographics,” Jan. 24, 2023

KFF, “Changes to Medicare Part D in 2024 and 2025 Under the Inflation Reduction Act and How Enrollees Will Benefit,” April 20, 2023

Novo Nordisk, “Novo Nordisk To Lower U.S. Prices of Several Pre-Filled Insulin Pens and Vials up to 75% for People Living With Diabetes in January 2024,” March 14, 2023

Phone interview with Juliette Cubanski, deputy director of KFF’s Program on Medicare Policy, June 16, 2024

Rand Corp., “Evaluation of the Part D Senior Savings Model,” May 2023

Republican Study Committee, “Fiscal Sanity to Save America,” March 20, 2024

Sanofi, “Sanofi Capping Its Insulin to a $35 Out-of-Pocket Costs in the U.S.,” June 1, 2023

Stat, “Biden and Trump Are Fighting To Claim Credit for $35 Insulin. It Was Actually a Pharma Giant’s Idea,” June 13, 2024

The White House, “FACT SHEET: President Biden’s Cap on the Cost of Insulin Could Benefit Millions of Americans in All 50 States,” March 2, 2023

The White House, “Remarks by President Biden and Vice President Harris at a Campaign Event | Philadelphia, PA,” May 29, 2024

The White House, “Remarks of President Joe Biden — State of the Union Address as Prepared for Delivery,” Feb. 7, 2023

Truthsocial.com, post by @realDonaldTrump, June 8, 2024

X.com, post by @justinbaragona, June 3, 2024

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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Before she stopped using drugs for good, Cierra Coon estimates that she overdosed eight times in a span of two weeks in the fall of 2022. One of those times, the opioid overdose reversal drug naloxone helped save her life.

She was riding in a car on the back roads of the Flathead Indian Reservation in western Montana when she lost consciousness. Someone in the car grabbed a small bottle of naloxone, sprayed it up her nose, and performed CPR until she came to. Coon said having quick access to the overdose reversal agent, also known by the brand name Narcan, was incredibly lucky.

“The times I wasn’t administered naloxone, it’s a miracle that I made it out,” Coon said. “People brought me back by shocking me with cold water and doing CPR. But that’s not a for-sure ‘I’m going to bring you back to life,’” Coon said.

Nearly two years later, Coon is a recovery coach for a local program, Never Alone Recovery Support Services, and earning a degree as an addiction counselor from Salish Kootenai College. She keeps doses of naloxone in her car in case she needs to help other people.

But, she said, she worries about the drug’s lack of accessibility, particularly in rural areas like her own. The state and tribal health departments’ distribution pipeline has been inconsistent, and the $50 price tag for a two-dose package of naloxone at the nearest Walmart puts it out of reach for many people.

“How are we supposed to afford this drug that’s ultimately to save the lives of ourselves and those around us?” she said.

Montana health officials are considering a new strategy to make naloxone more accessible. Drawing on a pool of behavioral health funds set aside by lawmakers in 2023, health officials within Gov. Greg Gianforte’s administration have proposed installing two dozen naloxone and fentanyl testing strip vending machines around the state at behavioral health drop-in centers and service locations for homeless people.

The $400,000 plan to build, stock, and maintain 24 vending machines for a year has not yet been approved by the governor, a Republican running for a second term, who ultimately decides how the funds allocated to the Behavioral Health System for Future Generations Commission are spent.

Details from the state’s Department of Public Health and Human Services about where the machines would be located and how they would be operated remain scarce.

The opioid-related death rate has tripled in Montana in recent years, from 3.6 deaths per 100,000 residents in 2017 to 11.3 per 100,000 residents in 2023. The death rate is higher among Native Americans: Native people in Montana died of opioid overdoses at a rate of 33 deaths per 100,000 people in 2023 — more than three times the rate for white people.

Naloxone has emerged as an important tool to combat opioid overdoses. When administered quickly, it attaches to receptors in the brain targeted by opioids, blocking the drugs’ effects.

Across the U.S., vending machines that distribute naloxone and other health supplies free of charge are becoming front-line features of the battle against opioid overdoses. Different versions of the model are being tried in at least 33 states.

In a 2023 report, the National Council for Mental Wellbeing described the use of vending machines to distribute naloxone and other “harm reduction” supplies — first-aid kits, pregnancy tests, sterile syringes, and more — as a public health tool that became more widespread during the social distancing era of the covid-19 pandemic. But the popularity of the model has continued to grow since, especially in places with hard-to-reach populations.

“They provide services to [people who use drugs] with far fewer barriers than fixed-site programs and even mobile outreach,” the report stated. Harm-reduction vending machines, it continued, “may also provide greater privacy and anonymity.”

The proposal from the state health department would be the first instance in Montana of vending machines being funded directly by the state, as opposed to the few now funded through public grants or private philanthropy.

Jami Hansen, prevention bureau chief for the state health department’s Behavioral Health and Developmental Disabilities Division, spoke about the proposal during a May meeting of the state behavioral health commission. She framed vending machines as a targeted way to fill gaps in a sparsely populated state that doesn’t offer consistent access to addiction treatment and naloxone.

“Having something available that they could utilize themselves would be very, very beneficial,” Hansen said.

Some local public health groups in Montana — including those in Missoula, Helena, Kalispell, and Big Horn County — have already begun using vending machines to distribute free naloxone, drug testing strips, and other health supplies. In Helena, three machines purchased by Lewis and Clark County have been distributing free Narcan nasal spray and safe drug disposal pouches — used to dissolve prescription and recreational pills — for more than a year.

Kellie Goodwin McBride, director of the county’s criminal justice services department, said her team originally tried to embed the machines within local businesses — a downtown bar, a laundromat, and a convenience store — but repeatedly struck out. Sometimes, there wasn’t enough space for the machines. In other cases, McBride said, owners worried that a Narcan vending machine would convey that the business condoned or welcomed drug use.

Instead, the county installed vending machines in a nonprofit drop-in center serving local homeless residents, the state district court building, and the Law and Justice Center downtown, which houses the municipal court and county sheriff’s department. That machine, McBride said, gets the most use.

Unlike some other models, the Narcan vending machines in Helena don’t require user registration or codes to access the materials inside, making it impossible to track who is taking naloxone or if it is being used. McBride and her team acknowledge there is no consistent way to know how many opioid-related deaths the vending machines have helped prevent.

Jessica Johnson is the health education supervisor at the Southern Nevada Health District, which helped create the first vending machine collaborative in the contiguous U.S. Johnson said the project was designed to distribute naloxone and sterile syringes to reduce the spread of infectious diseases among people who inject drugs. A 2022 study found 41 fewer overdose deaths than expected were recorded in Clark County, where the machines were located, during the first year of distribution.

Johnson said one of her takeaways from the program is the importance of listening to the community’s most at-risk people. The resulting harm-reduction kiosks or vending machines can look as diverse as the places they’re located.

Public health workers across the nation have added toothbrushes, tobacco-use cessation kits, and other supplies to their vending machines based on feedback from the populations they serve, Johnson said.

While organizational hosts have not yet been chosen, Montana health department spokesperson Jon Ebelt said the agency’s recommendation to place machines at drop-in centers and sites serving homeless people is based on a desire to reach people with serious mental illnesses and others who are already seeking services at those locations.

Ebelt confirmed the department did not reference opioid overdose data or demographic information about people who most often overdose in Montana when deciding where to place the machines. Rather, he said, the decision was “based on community-based programming and existing contracts with low barrier service sites.”

Under the proposal, Ebelt said, community hosts of the vending machines will be able to select many types of additional harm-reduction supplies to distribute, “as each community has different needs,” but sterile syringes will not be among the products available in Montana’s machines. The state plans to pay for one year of supplies, after which it may use federal grants to stock the machines, and federal funds may not be used to purchase syringes for illegal drug use. Ebelt did not respond to additional inquiries about that decision or whether sites would be able to add syringes and other materials supplied through independent funding.

This article was produced through a partnership between KFF Health News and Montana Free Press.

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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Just after lunchtime on June 18, Massachusetts’ leaders discovered that the statewide 911 system was down.

A scramble to handle the crisis was on.

Police texted out administrative numbers that callers could use, Boston Mayor Michelle Wu gave outage updates at a press conference outlining plans for the Celtics’ championship parade, and local officials urged people to summon help by pulling red fire alarm boxes.

About 7 million people went roughly two hours with no 911 service. Such crashes have become more of a feature than a bug in the nation’s fragmented emergency response system.

Outages have hit at least eight states this year. They’re emblematic of problems plaguing emergency communications due in part to wide disparities in the systems’ age and capabilities, and in funding of 911 systems across the country. While some states, cities, and counties have already modernized their systems or have made plans to upgrade, many others are lagging.

911 is typically supported by fees tacked on to phone bills, but state and local governments also tap general funds or other resources.

“Now there are haves and have-nots,” said Jonathan Gilad, vice president of government affairs at the National Emergency Number Association, which represents 911 first responders. “Next-generation 911 shouldn’t be for people who happen to have an emergency in a good location.”

Meanwhile, federal legislation that could steer billions of dollars into modernizing the patchwork 911 system remains waylaid in Congress.

“This is a national security imperative,” said George Kelemen, executive director of the Industry Council for Emergency Response Technologies, a trade association that represents companies that provide hardware and software to the emergency response industry.

“In a crisis — a school shooting or a house fire or, God forbid, a terrorist attack — people call 911 first,” he said. “The system can’t go down.”

The U.S. debuted a single, universal 911 emergency number in February 1968 to simplify crisis response. But instead of a seamless national program, the 911 response network has evolved into a massive puzzle of many interlocking pieces. There are more than 6,000 911 call centers to handle an estimated 240 million emergency calls each year, according to federal data. More than three-quarters of call centers experienced outages in the prior 12 months, according to a survey in February by NENA, which sets standards and advocates for 911, and Carbyne, a provider of public safety technology solutions.

In April, widespread 911 outages affected millions in Nebraska, Nevada, South Dakota, and Texas. The shutdown was blamed on workers’ severing a fiber line while installing a light pole.

In February, tens of thousands of people in areas of California, Georgia, Illinois, Texas, and other states lost cellphone service, including some 911 services, from an outage.

And in June, Verizon agreed to pay a $1.05 million fine to settle a Federal Communications Commission probe into a December 2022 outage that affected 911 calls in Alabama, Florida, Georgia, North Carolina, South Carolina, and Tennessee.

The fires that raced across the Hawaiian island of Maui last August highlighted the critical importance of 911 systems. Dispatchers there fielded more than 4,500 contacts, meaning calls and texts, on Aug. 8, the day the fires broke out, compared with about 400 on a typical day, said Davlynn Racadio, emergency services dispatch coordinator in Maui County.

“We’re dying out here,” one caller told 911 operators.

But some cell towers faltered due to widespread service outages, according to county officials. Maui County in May filed a lawsuit against four telecommunications companies, saying they failed to inform dispatchers about the outages.

“If 911 calls came in with no voice, we would send text messages,” Racadio said. “The state is looking at upgrading our system. Next-generation 911 would take us even further into the future.”

Florida, Illinois, Montana, and Oklahoma passed legislation in 2023 to advance or fund modernized 911 systems, according to the National Conference of State Legislatures. The upgrades include replacing analog 911 infrastructure with digital, internet-based systems.

Instead of just fielding calls, next-generation systems can pinpoint a caller’s location, accept texts, and enable residents in a crisis to send videos and images to dispatchers. While outages can still occur, modernized systems often include more redundancy to minimize the odds of a shutdown, Gilad said.

Lawmakers have looked at modernizing 911 systems by tapping revenue the FCC gets from auctioning off the rights to transmit signals over specific bands of the electromagnetic spectrum.

But the U.S. Senate, in March 2023, for the first time allowed a lapse of the FCC’s authority to auction spectrum bands.

Legislation that would allocate almost $15 billion in grants from auction proceeds to speed deployment of next-generation 911 in every state unanimously passed the House Energy and Commerce Committee in May 2023. The bill, HR 3565, sponsored by Rep. Cathy McMorris Rodgers (R-Wash.), would also extend the FCC’s auction authority.

Other bills have been introduced by various lawmakers, including one in March from Sen. Ted Cruz (R-Texas) and legislation from Sen. Maria Cantwell (D-Wash.) to extend the auction authority. For now, neither effort has advanced. Nine former FCC chairs wrote lawmakers in February, urging them to make 911 upgrades a national priority. They suggested Congress tap unspent federal covid-19 money.

“Whatever the funding source, the need is urgent and the time to act is now,” they wrote.

Ajit Pai, who served as chair of the FCC from 2017 to 2021, said outages often occur in older, legacy systems.

“The fact that the FCC doesn’t have authority to auction spectrum is a real hindrance now,” Pai told KFF Health News. “You may never need to call 911, but it can make the difference between life and death. We need more of an organized effort at the federal level because 911 is so decentralized.”

Meanwhile, some safety leaders are making backup plans for 911 outages or conducting investigations into their causes. In Massachusetts, a firewall designed to prevent hacking led to the recent two-hour outage, according to the state 911 department.

“Outages bring to everyone’s attention that we rely on 911 and we don’t think about how we really rely on it until something happens,” said April Heinze, chief of 911 operations at NENA.

Mass General Brigham, a health system in the Boston area, sent out emergency alerts when the outage happened letting clinics and smaller practices know how to find their 10-digit emergency numbers. In the wake of the outage, it plans to keep the backup numbers next to phones at those facilities.

“Two hours can be a long time,” said Paul Biddinger, chief preparedness and continuity officer at the health system.

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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Hospital facility fees. They can feel like a charge just for walking in the door. Hospitals say they go toward overhead on facilities with lots of specialized equipment and staff, like emergency rooms.

But these fees have grown and become more common in recent years. And as hospitals buy up outpatient facilities, patients are starting to get charged facility fees for routine tests, procedures, and visits to the doctor’s office.

In this episode of “An Arm and a Leg,” host Dan Weissmann speaks with Georgann Boatright, a retired speech pathologist from Oxford, Mississippi, who was told by her local hospital that she needed to pay an $8,000 “operating room fee” for a routine test. She was determined not to get overcharged, even if it meant driving hours out of state to get the test someplace cheaper.

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 Claire Davenport Producer Adam Raymonda Audio wizard Ellen Weiss Editor Click to open the Transcript Transcript: The Woman Who Beat an $8,000 Hospital Fee

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! A couple of months ago, we asked you to help us report on a type of fee that seems to be sneaking onto more and more medical bills. They’re often called “facility fees.” It’s like a cover charge just for walking in the door. And these kinds of fees are familiar to a lot of folks from places like emergency rooms, which do have a LOT of specialized equipment and staff in the facility behind that door. That’s basically the case for a cover charge: Once you get in the door, there’s a lot of stuff there. But in some cases, with facility fees, the door is just the entrance to a doctor’s office. Because facility fees– they’re often charged by hospitals. And hospitals own a lot of doctors’ offices these days. And once they take over, there’s no law that says they can’t just call that doctor’s office part of their facility and start charging. 

We asked what you’d been seeing. A bunch of you sent us stories, and copies of your bills, and your insurance statements. And when we called to follow up, you took our calls. You had A LOT to say. 

Teresa: Oh, it made me so mad, so mad. Anne: I mean, it’s a 10-minute appointment for a prescription. 

Amanda: I don’t understand any of it. Where did this number come from? 

Dan: We learned a bunch. Especially from those of you who are not new to this kind of thing. 

Francesca: It was a running joke with my husband and myself that like, okay, it’s time for my weekly, one-to-two hour phone call with Cigna. 

Dan: People who’ve been contending with the health care system for a while, dealing with chronic illnesses, or going to the doctor for monitoring, or having some kind of ongoing treatment. 

Anne: I see her once a year. I’ve seen her once a year for 18 years at the time. And then they started charging the facility fee. 

Dan: And I’ve always said here, we have a lot to learn from each other. And what we learned here is a lot more than is gonna fit in one episode. So we’re gonna start here with one story that really stood out. Partly because it involved the biggest dollar amount we saw: An eight-thousand dollar facility fee. And partly because the person we heard from … didn’t end up paying it. And partly because of what it took for her to avoid paying it. She had what I might call a lifetime of preparation– including lessons I think a lot of us can learn from. And she has the kind of grit that not all of us have. But I’m hoping that some of it might rub off. So let’s meet her. 

Georgann Boatright: My name is Georgann Boatright, and I am a retired speech pathologist. 

Dan: Georgann lives in Oxford, Mississippi. She works for the university there, Ole Miss, coordinating special events. 

Georgann Boatright: It’s lots of fun. Never a dull moment. Everything from weddings to conferences. 

Dan: The day we talked, she had made coffee for 500 people. Before eight am. And here’s how she describes her response to that eight-thousand dollar charge. 

Georgann Boatright: I was like, that’s insane. And of course, being the obnoxious human being that I can be at times, and a little bit pushy, you know; sometimes you got to do that. I’ve always been that advocate for everybody else, so sometimes I have to advocate for me.

Dan: Georgann pushed back– we will talk about how far she had to go. And among other things, we’re talking about actual miles she had to travel. It was not easy. But it was worth it. Let’s take a ride. 

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, and 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 a show that’s entertaining, empowering, and useful. 

Georgann Boatright grew up in Oxford, went to Ole Miss– the University of Mississippi, right in town. And after a decade and change in places like Huntsville, Arkansas, and towns near Springfield, Missouri, she moved back to Oxford about 15 years ago. 

Georgann Boatright: My mom came ill. And so I moved back to Mississippi to be with her for the end. 

Dan: Georgann herself had a health scare not long after– it turned out to be a non-cancerous tumor. Her local doctors couldn’t figure out the problem, but she found good treatment at West Cancer Center in Memphis, about an hour and a half away. And then, in 2022, an actual breast cancer diagnosis. She went back to the West Cancer Center in Memphis for treatment. And while she was being treated for breast cancer, her doctors found a thyroid problem. 

Georgann Boatright: But they were kind of like, okay, we’ll put that on a back burner for right now because we got to take care of this first. 

Dan: So, they did! And you know, that took months, of course. Once she was done– and no evidence of cancer for a few months!– they picked up the thyroid thread. Her endocrinologist in town suggested what’s called a needle biopsy: no incision, just pulling a sample with basically a syringe, guided by ultrasound. And Georgann was plenty familiar with the procedure because she’d had two of them for her breast cancer.

Georgann Boatright: Well, of course, having just done all this other stuff, I was kind of like, oh, okay, just another biopsy. No big deal. 

Dan: Her endocrinologist suggested the local hospital, Baptist Memorial, North Mississippi. And started getting her scheduled there. 

Georgann Boatright: I was just sitting in my office doing my thing and, you know, answering emails, trying to get people to sign up and do a wedding. So, they called me and said, “Hey, you know, we need a thousand dollars up front.” And I’m like, why? I’ve already met my deductible. Da, da, da. You know, and they’re like, Oh, well, this is just this is just your copay.” 

Dan: None of this sounded right to Georgann, based on her experience. 

Georgann Boatright: I’d had two biopsies done in the past year, just in the process of doing the breast stuff. And I was like, that’s not normal. 

Dan: At the cancer center in Memphis, a thousand dollars was in the ballpark for the whole procedure, like before insurance paid anything. And Georgann’s share, after insurance, was like a fraction of that. 

Georgann Boatright: And I went, excuse me, because of course I was expecting, you know, under a hundred bucks, you know. And they acted very offended that I questioned. She was like, “Well, this is standard.” And I was like, “But I’m confused,” and, you know, and the more questions, she got kind of defensive. 

Dan: Georgann says she quickly developed a little sympathy for the woman on the other side of the call. 

Georgann Boatright: I was like, this person has no clue. This is their job. They’re given this information. They’re given my phone number. They’re told to collect a thousand dollars from me. You know, I mean, it’s not her fault. 

Dan: So, Georgann quickly made a new plan. First step: get a line-item version of that estimate, in writing. And next: find somebody else to talk with. 

Georgann Boatright: I was like, “Well, hey, how about you just do me a printout and I’ll come by the hospital and pick that up. If you’ll just leave it with somebody near the desk …” 

Dan: … Then Georgann figured she can actually see what these charges are for and you know, maybe talk to somebody who’ll know a little more. She went that same day. 

Georgann Boatright: I wanted to get the biopsy done. I wanted to find out what was going on. You know, once you’ve had cancer, it kind of, that C word just does not sit well with your brain. You kind of, it starts eating at you and you’re like, I really want to know. 

Dan: And she wanted to know why the hospital wanted a thousand dollars from her. She got that printout– the line item estimate. It showed thirteen thousand dollars in charges. And the single biggest charge– more than half of the whole bill– eight thousand dollars– was for an “operating room” charge. It wasn’t labeled “facility fee,” but that’s exactly what it was. Georgann sent us this line-item estimate. We showed it to a medical-bill coding expert; she confirmed– this is a facility fee. And I’ll just mention again: Of all the people who sent us bills with facility fees on them, this was the highest by a LOT. Alot a lot. And seeing this “operating room” charge really set off alarm bells for Georgann. Because Georgann had just had TWO needle biopsies. And they sure as heck had not taken place in an operating room. 

Georgann Boatright: It’s a needle aspiration. It is ultrasound-guided. So it’s done in radiology. This is not in an operating room. 

Dan: When she got to Baptist, Georgann did get to talk in person with a billing specialist. It wasn’t a satisfying heart-to-heart, but it gave Georgann the clarity she needed. 

Georgann Boatright: At a certain point in the conversation, I was just kind of like, “You do realize that there is not an operating room involved in this?” And she said, “Well, of course, there is.” I was like, “No, there really isn’t.” “Oh, well, that’s just our standard procedure.” And so she stuck with that. And so I was like, okay, well, since you’re going to just stick with this, I’m going to just let this go. Because if I can’t seem to get you to understand that I’m not going to pay you 8,000 dollars for an operating room that I’m not going to go in, we’re not going to get anywhere. 

Dan: And Georgann knew she had an alternative: She could go back to the cancer center in Memphis. It was a bit of a drive, but she trusted them to do good work and not to overbill her. So that’s what she did. Her out of pocket cost was eighty dollars. We asked Baptist all about Georgann’s experience, and what was behind this eight-thousand dollar charge. Especially since medical and surgical supplies were listed as separate line items. 

A hospital spokesperson wrote back: “The price a patient sees on the hospital bill also reflects all the people who care for them and keep the hospital operating, not just the services provided, such as nurses and caregivers at the bedside, pharmacists, lab technicians, food service staff, environmental service professionals and security personnel who, among many others, keep the hospital running 24/7. We believe we charge fair and reasonable prices for our expert care.” 

Of course, we also asked Baptist why there would be an operating room charge at all, when the patient didn’t expect to be seen in an operating room. The spokesperson wrote back: “I’m not sure why there was a discrepancy. But, in general, the pricing information we share with patients is only an estimate, and the final bill can vary. We encourage patients to contact us with any questions.” OK, then. And I just want to say: I think– well, I KNOW– that I’ve undersold what it took for Georgann to make that decision. I mean, yeah, we’ve seen, Georgann showed a lot of initiative, and savvy, and decisiveness, and a certain amount of grace in navigating a couple of conversations with her local hospital’s billing department. But we haven’t seen EXACTLY what made her so prepared for those conversations, and to make her decision so quickly. And if we’re gonna learn from Georgann’s example, we’ve gotta look at that. That’s coming right up. 

This episode of An Arm and a Leg is a co-production of Public Road Productions and KFF Health News. Public Road is the organization I founded to make this show. The name comes from Walt Whitman; I’ll tell you about it sometime. KFF Health News is a nonprofit newsroom covering healthcare in America. Their journalists do amazing work– win all kinds of awards, every year. I’m honored to work with them. So, what allowed Georgann Boatright to navigate those conversations with her hospital billing department so skillfully? And to quickly decide to drive to another city for care? Well, let’s start with her old job as a speech pathologist. You might remember, when she did that job, she was living in places like Huntsville, Arkansas. Or, as Georgann describes it … 

Georgann Boatright: … Absolutely the middle of nowhere, Arkansas. 

Dan: It’s not like a speech therapist is gonna have a ton of clients in town. Georgann worked for an agency that sent her all over the place. 

Georgann Boatright: I was driving about three- to five-hundred miles a day when I retired. 

Dan: A day! 

Georgann Boatright: Yeah, well, they’re spread a little thin in that area. 

Dan: Yeah. Yeah. Right. How fast were you driving? Like, how many hours are we talking about being on the road? 

Georgann Boatright: I was usually on the road 12 to 14 hours a day. 

Dan: Oh my god. 

Georgann Boatright: Yeah, but that’s because, you know, I was bouncing in and out everywhere from Liberty, Missouri, which is outside of Kansas City, all the way down into Arkansas. 

Dan: So, we start to get the idea that driving an hour and a half from Oxford to Memphis is, you know, not such a big deal to Georgann. But there’s this other thing. Which is what Georgann spent all those hours in her car actually doing. Because she was not listening to podcasts, I can tell you that. She was dealing with health insurance. On behalf of her colleagues and her patients. 

Georgann Boatright: I was the person in our company that would do all the appeals. I got really good at getting Medicare, Medicaid, Blue Cross Blue Shield– all the insurances to pay. 

Dan: Georgann did all this by phone, with somebody back at the home office transcribing for her. It was part of her gig– because she had all that time in the car. The agency she worked with also employed physical therapists and occupational therapists, sending them out to nursing homes. And those colleagues would have multiple appointments a day at the same spot. 

Georgann Boatright: I would only have like, maybe one or two patients during the course of the day, and then I would end up doing paperwork the rest of the day or helping someone else do paperwork. 

Dan: Because not only did Georgann have time with all those hours in the car. She had something else: language skills. 

Georgann Boatright: The crew that I worked with, they were mostly from the Philippines, and we partied very well. And I ate a lot of good food, and I gained weight. And no fault of their own, English wasn’t their first language. So that was part of my job was to make sure that the language barrier wasn’t the problem for the physical and occupational therapists getting paid. 

Dan: So for five years, she spent most of her long workday dealing with insurance. 

Georgann Boatright: That was what I did, and I was really, really good at it. You know, when you get on a first name basis with the reps in your area, you know that you’re a thorn in their side. When they would see my name, they’d be like, “We might as well just go ahead and pay this one because she’s going to find a way to get it through.” 

Dan: So when Georgann ended up talking with those folks at her local hospital’s billing office– the folks who were trying to tell her that an eight-thousand-dollar operating-room fee was just standard– she had a pretty good idea of what their jobs were: Just getting the hospital’s money. 

Georgann Boatright: I get that. And I understand that, but you know, you have to understand when you’re calling people and asking them for money that you have to know why they’re paying you money and whether or not you can justify how much they’re paying you. 

Dan: So, just to recap: When Georgann was in those conversations with the local hospital billing department, she had years and years of experience in medical billing. She was, by her account, really really good at it. It doesn’t seem like a stretch to guess that when she talked with these folks at the local hospital’s billing department, she knew a lot more about medical billing than they did. And she knew that this hospital wasn’t her only option. She had just done cancer treatment at West Cancer Center in Memphis. She trusted them, and they hadn’t overbilled her. And she wasn’t afraid of a road trip. That 300-mile, 500-mile-a-day job was a while ago, but just in the last year she’d made the trek to Memphis for cancer treatments, several times. In fact, the story of the wrap-up to that treatment gave me real appreciation for Georgann Boatright’s brand of cheerful grit and determination. For more than a year, Georgann had been planning a big family reunion for Christmas: Her kids, their kids, gathered from across the country, to a lodge near her husband’s mom. 

Georgann Boatright: I wanted his mom who has been getting on in age to get a chance to see the great grands and this kind of stuff. 

Dan: Georgann had made the reservation for the lodge months before her cancer diagnosis. And then, the last day of her radiation treatment got scheduled for December 23. The reunion was scheduled to start that very night. In Branson, Missouri– a five-hour drive from Memphis. 

Georgann Boatright: And I was like, I am not canceling this. Everybody’s like, “Mom, you don’t have to do this,” blah, blah, blah. I was like, “No, I’m going to be healthy and done with this treatment. By the time of this reservation.” I said, “I don’t care what happens!” 

Dan: The procedure that last day was to remove a device that had been delivering targeted radiation doses. And when the day came, an ice storm knocked out the power at West Cancer Center. The medical staff suggested, you know, rescheduling. 

Georgann Boatright: They’re like, “Well, do you want to come … No! I want this done. I am not coming back tomorrow. 

Dan: Wow. 

Georgann Boatright: I am going to make this reservation. I’m going to spend the night in a very nice place in Branson, Missouri and play in the snow. 

Dan: It wasn’t gonna be easy. 

Georgann Boatright: There was no power. There was no lights. There was only the little emergency generator lights that come on in a hospital. 

Dan: But they made it work. 

Georgann Boatright: I had it taken out that day. By the flashlights of the nurses 

Dan: The flashlights on the nurses phones! Georgann says she slept in the car while her husband drove them to Branson that day. Mission accomplished. 

Georgann Boatright: It was a great trip, and everybody was there, and it was wonderful to kind of celebrate at the end of that. I was done with radiation. I was like, I’m going to get well now and just keep kicking cancer’s butt. Because I was like, I am not giving up. 

Dan: I said right at the top: This story is epic, right? And I said that whatever’s powering Georgann Boatright, I hope just a little bit of it can rub off on us– on me. So, when Georgann talked with the folks in the billing department at her local hospital, she knew just what she was capable of. Also, it’s worth mentioning, she knew she had some other things that not everybody has: She knew she had excellent insurance because she’d seen it at work when she got the bills for her breast cancer treatment. And she knew she had someone to drive her to Memphis and back. Uber? That would’ve cost a LOT. Actually, Georgann says she priced it recently for her job. 

Georgann Boatright: It’s 145 dollars, and I was like, you got to be kidding me! 

Dan: I believe I could fly to Memphis from Chicago for 145 dollars one way. 

Georgann Boatright: I could get a flight to Southwest for 120. Believe me, I do it. That’s my thing. If I do it during the week, I can go from here to Midway. Yeah. 

Dan: Wait, why is flying to Chicago’s Midway airport Georgann’s thing? Well, the answer actually relates to one more thing Georgann had going for her in this whole scenario. Something– someone– I left out before. 

Melissa McChesney: My name is Melissa McShesney. I live in Chicago, Illinois. 

Dan: Melissa is Georgann’s daughter. She is the mom of two of Georgann’s grandkids. Melissa’s brother– dad to three more grandkids– he also lives in Chicago. Those kids and grandkids are, all of them, the reason Georgann has that airfare at the tip of her tongue. But it’s Melissa who plays a role in this story. Because Melissa works for CMS, the Centers for Medicare and Medicaid Services– the federal agency that oversees Medicaid and Medicare. So health insurance is her job. I mean, at least government-funded insurance. 

Melissa McChesney: I only know enough to be dangerous on the private side. But, you know, I have colleagues that know a lot more. 

Dan: Melissa and her mom– two health-insurance experts– can back each other up. 

Melissa McChesney: It’s always great to have another set of eyes. So, sometimes I call her, sometimes she calls me. 

Dan: This time– after those conversations with the hospital billing department– it was Georgann who did the dialing. 

Melissa McChesney: She called me to say, “This doesn’t make any sense. Why is this the most expensive procedure I’ve seen in a year when I just went through breast cancer treatment? At least from the out-of-pocket cost. And I quite frankly didn’t fully know either. 

Dan: So some poking around led Melissa to a story from the Bill of the Month series our pals at KFF Health News do with NPR. 

NPRHost: For our September bill of the month, we’re taking a close look at facility charges … 

Dan: And this story was a pretty exact match with Georgann’s situation: An operating room charge for a needle biopsy. NPR’s website even had a PDF of the original bill, with the billing codes.  

Melissa McChesney: Which was very helpful, actually, because I was able to see the fee that the article was focused on. And I was like, “This is the exact same thing, mom.” 

Dan: And that bit of context? It confirmed for Georgann that she could trust her initial impression: That this “operating room” fee seemed out of whack. And that she could do better. So she had that biopsy at West Cancer Center in Memphis before the week was out. And good news: She’s OK! The biopsy came back benign. Her local endocrinologist has been monitoring her bloodwork. 

Georgann Boatright: And so right at the moment, my thyroid levels are all staying normal. So they’re not concerned that it’s throwing off everything unless it becomes like a huge thing that grows in my neck. 

Dan: And she gets an occasional ultrasound at a local clinic. No needle, no hospital, no facility fees– and keeping an eye on the bills. 

Georgann Boatright: They have been very reasonable. That’s why I was like, okay, well I’ll continue doing this as long as y’all don’t screw me over anymore. 

Dan: One last thing I should tell you about Georgann and how she handled that eight thousand dollar charge the hospital had wanted: This is something she did after her daughter Melissa sent her that NPR story– you know, the one that helped her decide she was definitely going to Memphis. Melissa’s got this part of the story. 

Melissa McChesney: She sent the NPR article and her estimate to her endocrinologist and said, “Just so you know, this is what happens when you refer individuals to this hospital. And you know, it would cost them a lot of money.” I was so proud of her for doing that. it just speaks to my mom and trying to be a person who’s not just worried about her own experience, but the experience of others in her community.

 Dan: I’m telling you, we all want some of Georgann Boatright to rub off on us.An ArmandaLeg Season 12, Episode 1 July, 11, 2024 p.14 You sent us SO MANYstories about facility fees. I hope you can see why we wanted to bring you this one first, but we are not done. We talked with a bunch of you– and we talked with some experts who gave us some insights … and some lessons. 

Shelley Safian: Sometimes you talk to the physician, sometimes you talk to the facility, sometimes you got to go to the president and say, “You know what? This is not right.” 

Dan: And we talked to experts who gave us a look at what policy makers all over the country are doing– or trying to do– about these fees. Because they’re definitely paying attention. Because a lot of people are recognizing: You should not need to be Georgann Boatright to find a way around fees like this. Most of us aren’t. 

Christine Monahan: There’s bipartisan interest in this issue. We are seeing these reforms bubble up across the states. 

Dan: So over the next couple of months, we’ll be sharing a LOT more of what you’ve been helping us learn. Meanwhile, because you’ve been so incredibly helpful here, I’m going to come back to you soon asking for more help on a different story. That’s coming next time. Till then, take care of yourself. 

This episode of An Arm and a Leg was produced by Emily Pisacreta and Claire Davenport, with help from me, Dan Weissmann, and edited by Ellen Weiss. Adam Raymonda is our audio wizard. Our music is by Dave Weiner and Blue Dot Sessions. Gabrielle Healy is our managing editor for audience. Gabe Bullard is our engagement editor. Bea Bosco is our consulting director of operations. Sarah Ballama is our operations manager. 

An Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in-depth journalism about healthcare in America and a core program at KFF, an independent source of health policy research, polling, and journalism. Zach Dyer is senior audio producer at KFF Health News. He’s editorial liaison to this show. 

And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor. They allow us to accept tax-exempt donations. You can learn more about INN at INN.org. 

Finally, thank you to everybody who supports this show financially. You can join in any time at https://armandalegshow.com/support/. Thanks so much for pitching in if you can– and, thanks for listening.

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

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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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The largest private company that brokers use to enroll people in Affordable Care Act health plans said it’s joining with insurers to thwart unauthorized Obamacare sign-ups and plan switches.

HealthSherpa, which has its own sales team, announced the new initiative — called “Member Defense Network” — July 16. It will cut off commissions for unscrupulous insurance brokers believed to be signing up thousands of Americans for health plans they don’t need or switching their coverage without express consent.

Federal regulators say at least 90,000 Obamacare customers have complained about unauthorized enrollments or plan switches in the first quarter of the year. The changes can leave consumers without access to their preferred doctors and increase their deductibles or saddle them with tax bills.

Amy Shepherd of Georgia said that while the carrier of her ACA plan has remained the same, the agent who collects the commission has been switched three times — all people she doesn’t know and without her consent. Even worse, she said, are the multiple calls she gets daily, at all hours, from other agents apparently trying to persuade her to switch plans.

“These spam calls are stressing me beyond words,” said Shepherd, who wants to remain in her current plan and has enlisted the help of a friend, who happens to be an insurance agent, to help.

Whether the network would help in situations like Shepherd’s remains to be seen. When duplicative enrollments are identified, it will use automation to check whether agents have filed written or recorded consent by the consumer, something they are supposed to do under federal rules. But agents say they are rarely asked to provide those documents by regulators.

If there’s no valid consent on file, or if an agent is caught submitting fake consents, they’re not going to get paid commissions while the situation is investigated, said George Kalogeropoulos, CEO of HealthSherpa. The firm has set up a website separate from its enrollment platform to run the network, and it may spin it off to another organization, he added.

HealthSherpa is one of more than a dozen private sector web brokers allowed by federal regulators to directly link to the federal health insurance marketplace, healthcare.gov, to sign people up for ACA coverage. Other web brokers can join the new program, Kalogeropoulos said.

But there are already doubts about HealthSherpa’s plan. Without all health insurers participating, some agents said, fraudulent enrollment may shift to those remaining outside HealthSherpa’s program. At its launch this week, the network included health insurers Ambetter, Molina Healthcare, and Highmark Blue Cross Blue Shield, representing about half the people who selected coverage during the ACA’s most recent open-enrollment period, said Kalogeropoulos, and more may follow.

Smaller brokerages worry that HealthSherpa’s algorithms may incorrectly flag transactions with their customers as suspicious.

“This could disrupt the market,” said Ronnell Nolan, president of Health Agents for America, a trade group. “This could put good agents out of business.”

Federal regulators say they are working on several regulatory and technical ways to address unauthorized sign-ups and switches but have released few details. Last week, the Centers for Medicare & Medicaid Services quietly put in place new rules requiring agents to log in to their own ACA enrollment accounts every 12 hours, instead of every 30 days, as a security measure.

CMS knows of the network initiative and said it will be required to conform to security and privacy standards.

“We expect and encourage all of our partners, including issuers, direct enrollment partners, and agents and brokers, to take steps to detect and prevent fraudulent actions against consumers,” said Jeff Wu, deputy director for policy at the Center for Consumer Information and Insurance Oversight, in a written statement.

Under HealthSherpa’s plan, participating Obamacare insurers will each day submit data on all plan changes and new enrollments. Then the network’s software will look for duplicate enrollments or other suspicious patterns across carriers — which can’t currently be done by the private sector — and automatically verify that agents have filed proof of consumer consent.

Most situations would be resolved without the need for human intervention, said Kalogeropoulos — unless the system discovers fake consent. Those cases would be reported to federal and state regulators.

Private sector enrollment sites like HealthSherpa help millions of people legitimately in ACA plans each year. Most brokers use such platforms as an alternative to what they consider the more clunky healthcare.gov site, yet they also complain that the private enrollment websites make fraud too easy. Armed with nothing more than a name, date of birth, and state of residence, unscrupulous insurance agents can switch healthcare.gov customers’ insurance plans or change the authorized agent on their policies to collect commissions from insurers.

“No other industry works this way,” said Arthur Barlow, CEO and president of Utah-based Compass Insurance Advisors. His firm, which includes 500 independent agents, supports the ideas behind HealthSherpa’s Member Defense Network, which he called “a step in the right direction to have a third party validate consent.”

More efforts to address the problem of easy access to healthcare.gov accounts are needed, said Aaron Arenbart, the ACA/Medicare director at DigitalBGA, an Austin, Texas-based firm that assists brokers.

He’s skeptical that HealthSherpa’s network is the answer, however. He’d rather see federal regulators require the private platforms use some form of two-factor authentication before agents can log in to consumers’ accounts.

“I can’t see it working at all,” Arenbart said of the network. “A lot of carriers are not even on board.” Rogue agents “will just move to those carriers,” he said.

Kalogeropoulos said that not all the unauthorized enrollments and plan switches are necessarily fraud. Some may be the result of confusion among agents as to whether they represent certain clients, he said — particularly when agents buy contact information from lead-generating firms that may sell the same names to multiple brokerages.

“In the most extreme example, we saw one member submitted 70 times by five different agents,” he said. HealthSherpa’s new system, he said, would determine which agent had the most valid consent.

It’s a multistep process that, in some cases, would be decided by which agent can first get a client to complete a third-party identity-proofing process using a driver’s license or other official documents.

One concern with HealthSherpa’s network, Barlow said, is the possibility that some cases won’t be resolved automatically, and consumers who are switched may have to remain in new plans while conflicts between agents are adjudicated.

Another problem, said Washington, D.C.-based attorney James Napoli, is that the network’s solution to check for consent “is one that occurs after the horse has left the barn.”

Napoli’s clients include Nelson’s group, Health Agents for America. “The fix ought to be much easier on the front end,” he said. “For example, two-factor authentication. There are ways to stop this fraud before it’s already occurred.”

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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The national 911 emergency response system is in the midst of its own code red.

The lack of federal funding to upgrade aging 911 systems has created significant disparities in state emergency response services, with older operations plagued by outages and longer response times.

Last month, for instance, Massachusetts was hit with a statewide 911 outage that lasted about two hours — making it at least the eighth state with a service interruption in the United States this year. The outage was blamed on a safety feature that was supposed to provide protection against cyberattacks and hacking. But it was just one more such episode in the headlines.

More than three-quarters of call centers experienced outages in the past year, based on the latest Pulse of 9-1-1 Survey by the National Emergency Number Association and Carbyne, which makes public safety technology products.

In Congress, lawmakers have looked at ways to pay to modernize 911 systems by using revenue from the Federal Communications Commission — specifically, revenue that comes from the FCC’s auctioning of the rights to transmit signals over specific bands of the electromagnetic spectrum. There’s a catch: The Senate in March 2023 let the FCC’s authority to auction spectrum bands lapse.

Lawmakers have floated proposals, but final plans are in limbo. For example, legislation sponsored by Rep. Cathy McMorris Rodgers (R-Wash.) would renew the auction authority until September 2026 and provide almost $15 billion in grants from auction proceeds for upgrading 911 systems. The bill unanimously passed the House Energy and Commerce Committee in May 2023.

With funding attempts in Congress stalled, states and localities are taking a piecemeal approach — tapping general funds or other resources to modernize operations. Florida, Illinois, Montana and Oklahoma passed legislation in 2023 to advance or fund next-generation 911 systems, according to the National Conference of State Legislatures.

Most of the country’s roughly 6,000 call centers were built using analog rather than digital technologies. Next-generation 911 systems are more resilient, with better backups in case of an outage, advocates say. They allow callers to share photos and videos or text messages, and they also improve location accuracy.

But upgrades by states, cities and counties are spotty — generally happening in jurisdictions with deeper pockets. Proponents say billions of dollars in federal funding is urgently needed to ease disparities and build a stronger national emergency response system.

“Now there are haves and have-nots,” said Jonathan Gilad, vice president of government affairs at NENA, which represents 911 first responders. “Next-generation 911 shouldn’t be for people who happen to have an emergency in a good location.”

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OSKALOOSA, Iowa — Rural regions like the one surrounding this southern Iowa town used to have a lot more babies, and many more places to give birth to them.

At least 41 Iowa hospitals have shuttered their labor and delivery units since 2000. Those facilities, representing about a third of all Iowa hospitals, are located mostly in rural areas where birth numbers have plummeted. In some Iowa counties, annual numbers of births have fallen by three-quarters since the height of the baby boom in the 1950s and ’60s, when many rural hospitals were built or expanded, state and federal records show.

Similar trends are playing out nationwide, as hospitals struggle to maintain staff and facilities to safely handle dwindling numbers of births. More than half of rural U.S. hospitals now lack the service.

“People just aren’t having as many kids,” said Addie Comegys, who lives in southern Iowa and has regularly traveled 45 minutes each way for prenatal checkups at Oskaloosa’s hospital this summer. Her mother had six children, starting in the 1980s, when big families didn’t seem so rare.

“Now, if you have three kids, people are like, ‘Oh my gosh, are you ever going to stop?’” said Comegys, 29, who is expecting her second child in late August.

These days, many Americans choose to have small families or no children at all. Modern birth control methods help make such decisions stick. The trend is amplified in small towns when young adults move away, taking any childbearing potential with them.

Hospital leaders who close obstetrics units often cite declining birth numbers, along with staffing challenges and financial losses. The closures can be a particular challenge for pregnant women who lack the reliable transportation and flexible schedules needed to travel long distances for prenatal care and birthing services.

The baby boom peaked in 1957, when about 4.3 million children were born in the United States. The annual number of births dropped below 3.7 million by 2022, even though the overall U.S. population nearly doubled over that same period.

West Virginia has seen the steepest decline in births, a 62% drop in those 65 years, according to federal data. Iowa’s births dropped 43% over that period. Of the state’s 99 counties, just four — all urban or suburban — recorded more births.

Births have increased in only 13 states since 1957. Most of them, such as Arizona, California, Florida, and Nevada, are places that have attracted waves of newcomers from other states and countries. But even those states have had obstetrics units close in rural areas.

In Iowa, Oskaloosa’s hospital has bucked the trend and kept its labor and delivery unit open, partly by pulling in patients from 14 other counties. Last year, the hospital even managed the rare feat of recruiting two obstetrician-gynecologists to expand its services.

The publicly owned hospital, called Mahaska Health, expects to deliver 250 babies this year, up from about 160 in previous years, CEO Kevin DeRonde said.

“It’s an essential service, and we needed to keep it going and grow it,” DeRonde said.

Many of the U.S. hospitals that are now dropping obstetrics units were built or expanded in the mid-1900s, when America went on a rural-hospital building spree, thanks to federal funding from the Hill-Burton Act.

“It was an amazing program,” said Brock Slabach, chief operations officer for the National Rural Health Association. “Basically, if you were a county that wanted a hospital, they gave you the money.”

Slabach said that in addition to declining birth numbers, obstetrics units are experiencing a drop in occupancy because most patients go home after a night or two. In the past, patients typically spent several days in the hospital after giving birth.

Dwindling caseloads can raise safety concerns for obstetrics units.

A study published in JAMA in 2023 found that women were more likely to suffer serious complications if they gave birth in rural hospitals that handled 110 or fewer births a year. The authors said they didn’t support closing low-volume units, because that could lead more women to have complications related to traveling for care. Instead, they recommended improving training and coordination among rural health providers.

Stephanie Radke, a University of Iowa obstetrics and gynecology professor who studies access to birthing services, said it is almost inevitable that when rural birth numbers plunge, some obstetrics units will close. “We talk about that as a bad event, but we don’t really talk about why it happens,” she said.

Radke said maintaining a set number of obstetrics units is less important than ensuring good care for pregnant women and their babies. It’s difficult to maintain quality of care when the staff doesn’t consistently practice deliveries, she said, but it is hard to define that line. “What is realistic?” she said. “I don’t think a unit should be open that only delivers 50 babies a year.”

In some cases, she said, hospitals near each other have consolidated obstetrics units, pooling their resources into one program that has enough staffers and handles sufficient cases. “You’re not always really creating a care desert when that happens,” she said.

The decline in births has accelerated in many areas in recent years. Kenneth Johnson, a sociology professor and demographer at the University of New Hampshire, said it is understandable that many rural hospitals have closed obstetrics units. “I’m actually surprised some of them have lasted as long as they have,” he said.

Johnson said rural areas that have seen the steepest population declines tend to be far from cities and lack recreational attractions, such as mountains or large bodies of water. Some have avoided population losses by attracting immigrant workers, who tend to have larger families in the first generation or two after they move to the U.S., he said.

Katy Kozhimannil, a University of Minnesota health policy professor who studies rural issues, said declining birth numbers and obstetric unit closures can create a vicious cycle. Fewer babies being born in a region can lead a birthing unit to shutter. Then the loss of such a unit can discourage young people from moving to the area, driving birth numbers even lower.

In many regions, people with private insurance, flexible schedules, and reliable transportation choose to travel to larger hospitals for their prenatal care and to give birth, Kozhimannil said. That leaves rural hospitals with a larger proportion of patients on Medicaid, a public program that pays about half what private insurance pays for the same services, she said.

Iowa ranks near the bottom of all states for obstetrician-gynecologists per capita. But Oskaloosa’s hospital hit the jackpot last year, when it recruited Taylar Swartz and Garth Summers, a married couple who both recently finished their obstetrics training. Swartz grew up in the area, and she wanted to return to serve women there.

She hopes the number of obstetrics units will level off after the wave of closures. “It’s not even just for delivery, but we need access just to women’s health care in general,” she said. “I would love to see women’s health care be at the forefront of our government’s mind.”

Swartz noted that the state has only one obstetrics training program, which is at the University of Iowa. She said she and her husband plan to help spark interest in rural obstetrics by hosting University of Iowa residency rotations at the Oskaloosa hospital.

Comegys, a patient of Swartz’s, could have chosen a hospital birthing center closer to her home, but she wasn’t confident in its quality. Other hospitals in her region had shuttered their obstetrics units. She is grateful to have a flexible job, a reliable car, and a supportive family, so she can travel to Oskaloosa for checkups and to give birth there. She knows many other women are not so lucky, and she worries other obstetrics units are at risk.

“It’s sad, but I could see more closing,” she said.

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SACRAMENTO — When then-Gov. Arnold Schwarzenegger called for nearly all Californians to buy health insurance or face a penalty, Anthony Wright slammed the 2007 proposal as “unwarranted, unworkable, and unwise” — one that would punish those who could least afford coverage. The head of Health Access California, one of the state’s most influential consumer groups, changed course only after he and his allies extracted a deal to increase subsidies for people in need.

The plan was ultimately blocked by Democrats who wanted the state to adopt a single-payer health care system instead. Yet the moment encapsulates classic Anthony Wright: independent-minded and willing to compromise if it could help Californians live healthier lives without going broke.

This summer, Wright will assume the helm of the health consumer group Families USA, taking his campaign for more affordable and accessible health care to the national level and a deeply divided Congress. In his 23 years in Sacramento, Wright has successfully lobbied to outlaw surprise medical billing, require companies to report drug price increases, and cap hospital bills for uninsured patients — policies that have spread nationwide.

“He pushed the envelope and gave people aspirational leadership,” said Jennifer Kent, who served as Schwarzenegger’s head of the Department of Health Care Services, which administers the state Medicaid program. The two were often on opposing sides on health policy issues. “There was always, like, one more thing, one more goal, one more thing to achieve.”

Recently, Wright co-led a coalition of labor and immigrant rights activists to provide comprehensive Medicaid benefits to all eligible California residents regardless of immigration status. The state funds this coverage because the federal government doesn’t allow it.

His wins have come mostly under Democratic governors and legislatures and when Republican support hasn’t been needed. That will not be the case in Washington, D.C., where Republicans currently control the House and the Senate Democratic Caucus has a razor-thin majority, which has made it extremely difficult to pass substantive legislation. November’s elections are not expected to ease the partisan impasse.

Though both Health Access and Families USA are technically nonpartisan, they tend to align with Democrats and lobby for Democratic policies, including abortion rights. But “Anthony doesn’t just talk to his own people,” said David Panush, a veteran Sacramento health policy consultant. “He has an ability to connect with people who don’t agree with you on everything.”

Wright, who interned for Vice President Al Gore and worked as a consumer advocate at the Federal Communications Commission in his 20s, acknowledges his job will be tougher in the nation’s capital, and said he is “wide-eyed about the dysfunction” there. He said he also plans to work directly with state lawmakers, including encouraging those in the 10, mostly Republican states that have not yet expanded Medicaid under the Affordable Care Act to do so.

In an interview with California Healthline senior correspondent Samantha Young, Wright, 53, discussed his accomplishments in Sacramento and the challenges he will face leading a national consumer advocacy group. His remarks have been edited for length and clarity.

Q: Is there something California has done that you’d like to see other states or the federal government adopt?

Just saying “We did this in California” is not going to get me very far in 49 other states. But stuff that has already gone national, like the additional assistance to buy health care coverage with state subsidies, that became something that was a model for what the federal government did in the American Rescue Plan [Act] and the Inflation Reduction Act. Those additional tax credits have had a huge impact. About 5 million Americans have coverage because of them. Yet, those additional tax credits expire in 2025. If those tax credits expire, the average premium will spike $400 a month.

Q: You said you will find yourself playing defense if former President Donald Trump is elected in November. What do you mean?

Our health is on the ballot. I worry about the Affordable Care Act and the protections for preexisting conditions, the help for people to afford coverage, and all the other consumer patient protections. I think reproductive health is obviously front and center, but that’s not the only thing that could be taken away. It could also be something like Medicare’s authority to negotiate prices on prescription drugs.

Q: But Trump has said he doesn’t want to repeal the ACA this time, rather “make it better.”

We just need to look at the record of what was proposed during his first term, which would have left millions more people uninsured, which would have spiked premiums, which would have gotten rid of key patient protections.

Q: What’s on your agenda if President Joe Biden wins reelection?

It partially depends on the makeup of Congress and other elected officials. Do you extend this guarantee that nobody has to spend more than 8.5% of their income on coverage? Are there benefits that we can actually improve in Medicare and Medicaid with regard to vision and dental? What are the cost drivers in our health system?

There is a lot we can do at both the state and the federal level to get people both access to health care and also financial security, so that their health emergency doesn’t become a financial emergency as well.

Q: Will it be harder to get things done in a polarized Washington?

The dysfunction of D.C. is a real thing. I don’t have delusions that I have any special powers, but we will try to do our best to make progress. There are still very stark differences, whether it’s about the Affordable Care Act or, more broadly, about the social safety net. But there’s always opportunities for advancing an agenda.

There could be a lot of common ground on areas like health care costs and having greater oversight and accountability for quality in cost and quality in value, for fixing market failures in our health system.

Q: What would happen in California if the ACA were repealed?

When there was the big threat to the ACA, a lot of people thought, “Can’t California just do its own thing?” Without the tens of billions of dollars that the Affordable Care Act provides, it would have been very hard to sustain. If you get rid of those subsidies, and 5 million Californians lose their coverage, it becomes a smaller and sicker risk pool. Then premiums spike up for everybody, and, basically, the market becomes a death spiral that will cover nobody, healthy or sick.

Q: California expanded Medicaid to qualified immigrants living in the state without authorization. Do you think that could happen at the federal level?

Not at the moment. I would probably be more focused on the states that are not providing Medicaid to American citizens [who] just happen to be low-income. They are turning away precious dollars that are available for them.

Q: What do you take away from your time at Health Access that will help you in Washington?

It’s very rare that anything of consequence is done in a year. In many cases, we’ve had to run a bill or pursue a policy for multiple years or sessions. So, the power of persistence is that if you never give up, you’re never defeated, only delayed. Prescription drug price transparency took three years, surprise medical bills took three years, the hospital fair-pricing act took five years.

Having a coalition of consumer voices is important. Patients and the public are not just another stakeholder. Patients and the public are the point of the health care system.

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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