Dr. Sara McLin thought she made the right choice by going to an in-network emergency room near her Florida home after her 4-year-old burned his hand on a stove last Memorial Day weekend.

Her family is insured through her husband’s employer, HCA Healthcare, a Nashville-based health system that operates more hospitals than any other system in the nation. So McLin knew that a nearby stand-alone emergency room, HCA Florida Lutz Emergency, would be in their plan’s provider network.

But McLin said a doctor there told her she couldn’t treat her son, Keeling, because he had second- and third-degree burns that needed a higher level of care. The doctor referred them to the burn center at HCA Florida Blake Hospital, about a 90-minute drive away.

McLin, who is a dentist, said the doctor told her the stand-alone ER would not charge for the visit because they did not provide treatment.

“I don’t remember exactly how she phrased it. But something along the lines of, ‘Well, we won’t even call this a visit, because we can’t do anything,’” McLin said.

At Blake Hospital, she said, a doctor diagnosed Keeling with a second-degree burn, drained the blisters, bandaged his hand, and sent them home with instructions on how to care for the wound.

“I didn’t think anything more of it,” McLin said.

Then the bills came.

The Patient: Keeling McLin, now 5, is covered by UnitedHealthcare through his father’s employer.

Medical Service: At the stand-alone emergency room, a physician assessed Keeling and sent him to another facility for treatment. “Keeling needs a burn center,” the doctor wrote in the record of his visit.

Service Provider: Envision Physician Services, which employed the emergency room physician at HCA Florida Lutz Emergency in Lutz, Florida, near Tampa, and HCA Florida Trinity Hospital, the main, for-profit hospital to which the stand-alone emergency room belonged.

Total Bill: For the emergency room visit, Envision Physician Services billed $829 to insurance and about $72 to the family. HCA Florida Trinity Hospital billed Keeling about $129, noting it had applied an “uninsured discount.” An itemization showed the original charge had been nearly $1,509 before adjustments and discounts.

What Gives: The stand-alone emergency room and ER doctor, who saw Keeling but referred him to another hospital, billed for his visit. But McLin soon learned she was unable to dispute some of the charges — because her young child’s name was on one of the bills, not hers.

Months after the ER visit, McLin received a bill addressed to the “parents of Keeling McLin” from Envision Physician Services, the provider staffing service that employed the ER doctor at Lutz. McLin recalled the doctor’s promise that they would not be billed. “I should have made them write something down to that effect,” she said.

She said she called her insurer, UnitedHealthcare, and a representative told her not to pay the bill.

She received an insurance statement that identified the bill from Envision’s doctor — an out-of-network provider working in an in-network emergency room — as a “surprise bill” for which the provider may charge only copays or other cost-sharing costs under federal law. McLin said she had not heard anything since then about the bill.

After being contacted by KHN, Aliese Polk, an Envision spokesperson, said in an email that Envision would waive the debt, apologizing to Keeling’s family “for the misunderstanding.”

She described the ER doctor’s evaluation, determination, and referral as a medical service. She said the bill was for cost sharing for the visit — not the difference between what the doctor charged and what insurance paid, as the law prohibits.

“We recognize the patient’s family may have understood at the time of treatment that there would be no charge for the visit, including the medical service provided by our physician,” Polk said. “Unfortunately, this courtesy adjustment was not captured when the claim was processed.”

Maria Gordon Shydlo, a UnitedHealthcare spokesperson, said the insurer believed the matter had been resolved and did not follow up on requests for an interview, even after McLin waived federal health privacy protections, which would allow the insurer to speak to the reporter about the case.

McLin also received a bill from HCA Florida Trinity Hospital for its stand-alone ER at Lutz and decided to dispute the charges.

But after calling the hospital to appeal, McLin said, the billing department would not discuss the debt with her because the statement was in her young son’s name.

“They had him as the guarantor,” McLin said. Unlike Envision, which billed Keeling’s parents and their insurance, McLin said the hospital listed the child as “unemployed, uninsured.”

The child’s ER record also included his date of birth and doctor’s notes referencing his age. McLin said she wrote to HCA in November asking to appeal the bill and that a billing representative told her over the phone that it would put the debt on hold and review the dispute.

“I never heard anything back and assumed we were good,” McLin said.

Then, in January, she received a letter from Medicredit, a collection agency and an HCA subsidiary, stating that Keeling owed $129 and that he had until mid-February to contest the debt. KHN was unable to make contact with Medicredit representatives, and HCA Healthcare did not respond to requests for comment from its subsidiary.

Once again, Sara McLin’s name was not on the debt collector’s letter, and she said Medicredit representatives refused to discuss the debt with her because it was in her son’s name. She said she called HCA, too. “They said, ‘We can’t help you. We don’t have the case anymore,’” she said.

Erin Fuse Brown, a law professor and director of the Center for Law, Health & Society at Georgia State University, said McLin did everything right and that it is unusual for a parent to be barred from discussing a debt related to their minor child.

“The fact that the hospital wouldn’t even talk to her strikes me as the part that is absurd. It’s absurd as a business matter. It’s absurd as a privacy matter,” Fuse Brown said, adding that federal health privacy laws allow a parent or legal guardian to access their dependent’s medical information.

Fuse Brown said the hospital should have been able to correct the error quickly with more information, such as a birth certificate or other document establishing that McLin was Keeling’s parent. At the very least, she said, it could have given McLin notice before sending the bill to collections.

“You get the feeling that it’s this large, automated process, that there’s no human to get through to, that there’s no human to talk to and override the mistake,” Fuse Brown said. “Maybe it’s routine, but she couldn’t even talk to someone to correct a correctable billing error, and then the system just steamrolls over the patient.”

The Resolution: When the collection agency’s deadline passed without resolution, McLin said she felt frustrated. “Nobody can explain to me who has to approve talking to me,” she said. “I don’t know who that person is or what the process is.”

After KHN contacted the health system, HCA Healthcare canceled the family’s debt. HCA representatives declined to be interviewed on the record despite also receiving a privacy waiver from McLin.

“We have attempted to contact Mrs. McLin to apologize to her for the inconvenience this has caused her and to let her know that there is a zero balance on the account,” Debra McKell, marketing director for HCA West Florida Division, said in an email on March 3. “We also will be sharing with her that we are reviewing our processes to ensure this does not happen again.”

McLin later received a letter from HCA stating that the account had been cleared. She also said she received a call from a customer service representative informing her that the debt had not been reported to any credit agencies.

She said she was pleased, but that patients should not have to struggle to correct a billing error before it is sent to a collection agency and potentially ruins their credit.

“It’s the principle of the thing that’s annoying me at this point,” she said.

The Takeaway: Though the notion of a debt collector pursuing a 4-year-old boy may seem farcical, it happens. When seeking medical care for a minor, it is important for the parent or guardian to ensure their name is listed as the responsible party.

Consumers who find themselves fighting a medical billing error need to “think like a lawyer,” Fuse Brown said, including documenting every interaction with the debt collector, getting any promises in writing, and recording phone calls. (State laws vary about how many parties on a call must give permission to record a conversation.)

Patients do not have to give up once a bill goes to collections, Fuse Brown said. “Once you hear from a debt collector, it’s not like the game is over and you lose,” she said. “Consumers do have rights.”

François de Brantes, a home health company executive and expert on how money flows through the health care system, said that hospital billing errors are not uncommon but that he had never heard of a situation like the one McLin experienced. He called it “puzzling” that HCA would issue a formal claim in a dependent child’s name.

De Brantes said those in a similar situation should also ensure that the collection agency removes any record of a debt against a minor to protect the child’s financial future.

“This stuff happens, where you have children who are improperly billed for stuff that they shouldn’t be billed, and they end up in collection,” he said. “Then the kid finds themselves with a collection record and they can’t get loans in the future, potentially student loans.”

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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I was back in the crowded East Room of the White House on Thursday, as I was 13 years ago, this time standing under a portrait of first first lady Martha Washington, when President Joe Biden entered for a lunchtime event focused on the Affordable Care Act.

The room looked much the same as it did on March 23, 2010, when I had rushed over to the White House to witness President Barack Obama signing his historic health bill into law. I knew from that moment — standing under a portrait of President Teddy Roosevelt, who was the first chief executive to espouse a need for national health insurance — that my life as a health journalist would never be the same.

Yet, when Biden scheduled an event to commemorate the 13th anniversary of the health law, I was unsure of the need to keep commemorating its birthday.

After all, on the 13th anniversary of President Lyndon Johnson signing Medicare and Medicaid into law — July 30, 1978 — the Democratic president in the White House did not hold an event to commemorate the date when tens of millions of older Americans and lower-income people gained coverage. Then-President Jimmy Carter spent that Sunday at Camp David.

But with the ACA in 2010, after a century of debate, the U.S. health system was getting hit with a thunderbolt that would enable millions of people to gain medical coverage. The law made many changes affecting hospitals, doctors, insurers, drugmakers, and employers in an effort to live up to its lofty name by lowering costs.

Those sweeping provisions, the years spent implementing them, and efforts by Republicans and the courts to repeal or change the law have kept the Affordable Care Act in the news for even longer than I had anticipated. After 13 years, the job is still not done. North Carolina on Thursday became the 40th state to expand Medicaid under the ACA.

Biden used the health law anniversary to tout the law’s influence. He reminded his audience that Republicans still want to strip many of its benefits. He also stressed that the country has unfinished business to lower drug costs for many and expand health coverage to people who still don’t have it. Indeed, more than 2 million people are without coverage in the 10 states — highly populous Florida and Texas among them — that have yet to expand Medicaid.

Many former Obama staffers who helped get the law passed were there — including some who work in the Biden White House. (Obama was not there.) So, too, were several Democratic lawmakers who helped pass the law, including former House speaker Nancy Pelosi and former California congressman and now Health and Human Services Secretary Xavier Becerra.

“Look, 13 years ago today, we gathered in this room as President Obama signed into law the Affordable Health Care Act,” Biden began with his remarks. “Hard to believe 13 days ag- — 13 years ago. It seems like 13 days ago.”

“And I remember the three words I used at the time,” he said as many in the audience recalled the swear word he was caught whispering to Obama via a live microphone. “I thought it was. I thought it was a big deal. And I stand by the fact it was a big deal.”

Biden said that the health law has been called by many names, but that the most appropriate is Obamacare.

The law has become ingrained into the fabric of the country, Biden said. Over 40 million Americans are covered by Medicaid or online insurance marketplace plans, the highest on record, the Biden administration said Thursday. That’s a 36% increase from 2021.

But a 13th anniversary celebration? Jessica Altman, who helped implement Obamacare in the Obama administration and is now CEO of Covered California, one of the Obamacare exchanges, said it was important to take time to remind people what the American health system used to look like as well as the many challenges remaining to improve it. (Altman is the daughter of KFF’s president and CEO. KHN is an editorially independent program of KFF.)

“We still have places to go, and we still have work to do and the people in that room are excited to keep doing it,” Altman said.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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SACRAMENTO, Calif. — Sacramento and Solano counties are in a standoff with the state over mental health coverage for a portion of Medicaid patients in those counties — a dispute that threatens to disrupt care for nearly 50,000 low-income residents receiving treatment for severe mental illness.

The Department of Health Care Services, which administers Medi-Cal, the state’s Medicaid program, says Sacramento and Solano counties must take over managing and providing specialty mental health care for thousands of Medi-Cal patients enrolled in Kaiser Permanente plans. It insists on shifting the responsibility because California’s remaining 56 counties already operate this way. State officials argue the switch would simplify the state’s disjointed mental health system and is needed to implement a larger transformation of Medi-Cal, an initiative known as CalAIM.

State health officials gave counties until March 15 to accept Kaiser Permanente patients, so California can properly transfer their specialty mental health care to counties by July 1. But the two counties are rebuffing the transfer, arguing that without more funding they can’t adequately care for a major influx of Medi-Cal patients with severe mental health conditions, such as schizophrenia or bipolar disorder. Medi-Cal officials, meanwhile, are threatening steep penalties or potentially terminating mental health contracts with those counties.

Local officials warn that if the state follows through with its plan, about 39,000 patients in Sacramento County and about 8,000 in Solano County could see their care disrupted and, for instance, may be forced to find a new psychiatrist.

“For someone who has schizophrenia or another serious mental health disorder, it has taken a long time to build a trusted relationship with their provider, and now they are going to see that care disrupted or have to find a different provider,” said Debbie Vaughn, assistant county administrator for Solano County. “There will be risks of people going into crisis.”

Ryan Quist, director of behavioral health services for Sacramento County, said the counties need not only more funding, but also more time to transfer the patients’ care. “The state is playing chicken with their lives,” he said.

Under state law, counties are responsible for administering and delivering specialty care to Medi-Cal patients with severe mental illness. Medi-Cal managed-care insurers are responsible for providing treatment for mild or moderate mental health conditions, such as anxiety or low-level depression.

But under a decades-old arrangement between the state and the counties of Sacramento and Solano, California has been paying Kaiser Permanente to provide all mental health care for the health care giant’s Medi-Cal enrollees. Now the state is dissolving that arrangement, forcing roughly 7,000 specialty mental health patients in those two counties to move out of Kaiser Permanente and into county-run mental health plans.

State officials argue that the two counties are legally obligated to provide care for Medi-Cal patients with severe mental illness and that county behavioral health agencies would be the ones putting patients in danger if the counties continue refusing the shift. Medi-Cal patients enrolled in health plans other than Kaiser Permanente get their specialized mental health care directly from counties.

“Sacramento and Solano counties’ failure to engage in this process places Medi-Cal members at risk of losing access to critical Medi-Cal entitlement services,” said Tony Cava, a spokesperson for the Department of Health Care Services. “DHCS will have no choice but to take action if the counties continue to refuse to fulfill their obligations.”

The state is considering sanctions or terminating the counties’ contracts, but Cava said that “contract termination is not DHCS’ preferred approach.” He declined to elaborate, adding only that the agency would “identify solutions to continue coverage” for Kaiser Permanente patients.

He said transferring patients to the counties will provide “a more consistent and seamless health system by reducing complexity and increasing flexibility.”

Counties currently receive a portion of state sales tax revenue and vehicle license fees to fund specialty mental health care, but under the agreement in Sacramento and Solano, the state has been paying Kaiser Permanente from its general fund to serve a portion of the insurer’s overall Medi-Cal enrollees’ mental health needs.

Under the shift, California would stop distributing general-fund money to the counties. Instead, counties would receive a greater share of existing sales tax and vehicle license fee revenues set aside by a 2011 arrangement. But Kaiser Permanente’s specialty mental health patients, the counties argue, were not under their purview at the time that agreement was reached, underscoring their legal argument that the state should cover the costs of their care.

The state is offering an additional $11.6 million a year to Sacramento and $7.7 million a year to Solano, which would draw down additional federal funding. That money would be siphoned from revenue other counties rely on for behavioral health treatment.

“The insult to injury is this takes money from other counties,” said Michelle Doty Cabrera, executive director of the County Behavioral Health Directors Association, “and across California we’re seeing a greater demand for services, especially after the pandemic.”

Sacramento County wants $36 million more each year to cover a 16% increase in patients, or 4,836 people. Solano County seeks nearly $17 million more each year for increasing its load by 50%, or 2,091 patients.

Behavioral health officials say counties are also struggling to recruit and retain mental health professionals willing to serve Medi-Cal patients.

“Our system is already bursting at the seams,” said Le Ondra Clark Harvey, CEO of the California Council of Community Behavioral Health Agencies, which represents local mental health providers.

State officials believe that both counties have an adequate number of mental health providers, with the small exception of Sacramento County’s need for two to three additional psychiatrists to serve kids.

Kaiser Permanente told KHN that it did not ask to move patients out of its network of care and that it told the state it wanted to continue serving them. Yet it ultimately agreed to transfer care to the counties.

“While we had expressed our preference to continue to provide specialty care to this vulnerable population,” said spokesperson Gerri Ginsburg, “we respect the state’s long-term objectives.”

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

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Las protecciones federales por la pandemia de covid-19, que desde 2020 prohibieron a los estados eliminar a beneficiarios de Medicaid, incluso si ya no calificaban, lograron bajar el número de personas sin seguro de salud a un mínimo histórico.

También generaron ganancias inesperadas para los planes de salud, que los estados pagan para supervisar la atención de la mayoría de los beneficiarios de Medicaid.

Estos planes, muchos administrados por titanes de los seguros, incluidos UnitedHealthcare, Centene y Aetna, han visto aumentar sus ingresos en miles de millones a medida que su membresía aumentaba en millones.

Con los estados listos para comenzar a cancelar la inscripción de los afiliados que ya no califiquen a Medicaid en abril, la fecha final de los beneficios por la pandemia, las aseguradoras esperan retener a aquellos que aún sean elegibles. Y “capturar” a los que pierdan la cobertura con los planes de los mercados establecidos por la Ley de Cuidado de Salud a Bajo Precio (ACA).

A excepción de los propios afiliados, para quienes perder la cobertura podría restringir el acceso a la atención y dejarlos vulnerables a grandes facturas médicas, nadie tiene más en juego que estas aseguradoras. Los planes tienen un fuerte incentivo financiero para mantener a sus miembros inscritos porque los estados les pagan por miembro, por mes: cuántas más personas cubren, más dinero obtienen.

La administración Biden estima que 15 millones, de los más de 91 millones de inscritos en Medicaid, perderán esta cobertura, casi la mitad porque sus ingresos superan los límites del programa y el resto porque no completan el papeleo de reinscripción.

De las personas que pierdan la elegibilidad, alrededor de dos tercios se inscribirán en un plan de salud a través de sus trabajos, predicen las aseguradoras de salud, y el otro tercio se dividirá equitativamente entre los que adquieran un plan de ACA y los que se queden sin seguro.

Las ramificaciones financieras para los planes de salud del llamado “desmantelamiento” de Medicaid son enormes, dijo Gary Taylor, analista de valores de Cowen and Co. “Son miles de millones de dólares”, dijo sobre los cinco planes de salud de Medicaid más grandes: Centene, UnitedHealthcare, Aetna, Elevance Health (ex Anthem) y Molina Healthcare.

Las empresas propiedad de inversionistas obtienen márgenes de ganancias antes de impuestos de alrededor del 3% en promedio de la atención administrada de Medicaid, ligeramente por debajo de lo que obtienen en los negocios del mercado de ACA, dijo Taylor.

Por lo tanto, pasar a los miembros a un plan de ACA podría aumentar las ganancias de estas empresas.

Funcionarios estatales de Medicaid dicen que necesitan la ayuda de los planes de salud durante este proceso para evitar un gran salto en el número de residentes sin seguro. Las aseguradoras de salud podrían ayudar a quienes pierden la cobertura de Medicaid a encontrar alternativas, como los planes subsidiados por el gobierno que se ofrecen en los mercados de ACA.

“En Nevada, nuestros planes de atención administrada están motivados para mantener a los miembros inscritos”, dijo Sandie Ruybalid, administradora adjunta de la división del departamento de salud del estado de Nevada que supervisa Medicaid, a una junta asesora del Congreso en enero. “Nuestros planes de atención administrada son innovadores y nos apoyamos en ellos para que nos ayuden a superar esto”.

Ruybalid dijo que su estado no tiene un gran presupuesto de marketing, como los tienen las aseguradoras gigantes, para educar a los afiliados sobre cómo permanecer inscritos.

Una forma en que algunas empresas esperan compensar la pérdida de ingresos de Medicaid será agregando clientes a sus planes de ACA.

Centene, la aseguradora de salud de Medicaid más grande del país, con 16 millones de miembros, pronostica que perderá más de 2 millones de beneficiarios durante la reversión. Pero espera que entre 200,000 y 300,000 personas que se queden sin cobertura de Medicaid se inscriban en un plan de ACA de Centene, dijo la directora ejecutiva Sarah London a analistas de inversiones en febrero.

En 15 de los 25 estados donde Centene ofrece planes de Medicaid y del mercado, la compañía se comunicará con los miembros sobre sus opciones de cobertura de ACA.

Aunque los programas estatales de Medicaid han utilizado durante años a aseguradoras privadas para controlar sus costos y mejorar la salud, reclutarlas para que asistan en la elegibilidad de sus beneficiarios es algo nuevo.

Los planes de salud a menudo están en una mejor posición que las agencias estatales de Medicaid para conectarse con los beneficiarios porque es más probable que tengan su información de contacto actualizada, dijeron funcionarios estatales.

“No tenemos contacto directo con nuestros miembros todo el tiempo, y los planes de salud interactúan más con ellos”, dijo Chris Underwood, director administrativo del Departamento de Políticas y Financiamiento de Atención Médica de Colorado, la agencia estatal de Medicaid.

Como el estado tiene contratos con planes de salud para ayudar a los afiliados a encontrar médicos o ayudar con otras necesidades de atención, no es un gran paso que los planes ayuden con la elegibilidad, agregó.

Funcionarios de salud de Colorado se comunicarán inicialmente con los beneficiarios de Medicaid y contarán con los planes de salud para hacer un seguimiento con correos electrónicos, llamadas y mensajes de texto, dijo Underwood.

Los planes de salud también guiarán a los afiliados que ya no sean elegibles para Medicaid al mercado de ACA del estado, que los ayudará a inscribirse.

AmeriHealth Caritas, que tiene alrededor de 2,8 millones de afiliados de Medicaid en todo el país, trabajará con organizaciones comunitarias como iglesias, refugios para personas sin hogar y bancos de alimentos para transmitir el mensaje sobre la necesidad de volver a inscribirse.

También enviará correos electrónicos, mensajes de texto y llamará a los afiliados para recordarles, dijo Courtnay Thompson, presidenta de mercado de Select Health, el plan de Carolina del Sur de AmeriHealth Caritas.

Thompson dijo que las estrategias para llegar a los beneficiarios variarán según el estado. Algunos intentarán reevaluar la elegibilidad de todos los miembros en seis meses, mientras que otros tardarán más de un año. Algunos estados compartirán con los planes el estatus de inscripción de sus beneficiarios antes de que pierdan la cobertura.

UnitedHealthcare, que tiene alrededor de 8 millones de afiliados en Medicaid, dijo que los representantes de su centro de llamadas recordarán a los miembros que se vuelvan a inscribir en el programa.

La compañía también pondrá información sobre la necesidad de reinscribirse en las farmacias de su red y utilizará publicidad en línea, en Facebook y Google. Y trabajará con sus proveedores médicos para asegurarse de que los miembros comprendan los cambios.

“Somos muy conscientes de los desafíos históricos que enfrentan las personas cuando se reinscriben”, dijo Tim Spilker, director ejecutivo de la unidad de Comunidad y Estado de UnitedHealthcare. “Somos optimistas con la magnitud del alcance que ayudará a aumentar la conciencia entre las personas sobre lo que deben hacer”.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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