KFF Health News chief Washington correspondent Julie Rovner discussed abortion in the GOP platform on KMOX’s “Total Information AM” on July 17.

• Click here to hear Rovner on “Total Information AM”
• Hear Rovner in “GOP Platform Muddies Abortion Waters”

KFF Health News contributor Andy Miller discussed a rise in covid cases on WUGA’s “The Georgia Health Report” on July 12.

• Click here to hear Miller on “The Georgia Health Report”

KFF Health News Nevada correspondent Jazmin Orozco Rodriguez discussed Idaho’s worsening OB-GYN shortage on Apple News’ “Apple News Today” on July 8.

• Click here to hear Orozco Rodriguez on “Apple News Today”
• Read Orozco Rodriguez’s “Idaho’s OB-GYN Exodus Throws Women in Rural Towns Into a Care Void”

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 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.

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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Ni una palabra sobre el Obamacare o el aborto.

En la Convención Nacional Republicana en Milwaukee esta semana, donde los delegados nominaron oficialmente a Donald Trump como candidato presidencial del partido para 2024, los oradores principales le dieron poco lugar a los temas de atención médica.

Este silencio es sorprendente, dado que la atención médica constituye la mayor parte del presupuesto federal, casi $2 mil millones, así como el 17% de la producción económica del país.

También muestra un contraste marcado con las prioridades del Partido Republicano cuando nominó a Trump por primera vez.

En 2016, la última vez que los republicanos se reunieron en masa para una convención presidencial, derogar la Ley de Cuidado de Salud a Bajo Precio (ACA) fue un tema favorito. También anular Roe vs. Wade y sus protecciones constitucionales para el aborto.

El cambio de tono refleja las sensibilidades políticas de Trump. En 2017, el intento fallido del ex presidente de derogar Obamacare contribuyó a una aplastante derrota del partido en las elecciones congresionales de medio término de 2018, y la ley ahora tiene un amplio apoyo.

El aborto también se ha convertido en un tema peligroso para los republicanos desde que Roe fuera anulado en 2022, con la mayoría de los estadounidenses oponiéndose a una prohibición nacional.

En una de las pocas piezas de política de salud en la plataforma del Partido Republicano para 2024, el ex presidente promete no recortar el Seguro Social ni Medicare, el programa de salud para estadounidenses mayores y que viven con discapacitados, ni cambiar la edad federal para jubilarse.

En su discurso de aceptación el jueves 18, Trump prometió proteger Medicare y encontrar curas para el Alzheimer y el cáncer. Pero no delineó ninguna propuesta de atención médica para un segundo mandato. “Los demócratas van a destruir el Seguro Social y Medicare”, dijo.

La atención médica no es un tema ganador para los republicanos, dijo Charles Coughlin, CEO de una firma de asuntos públicos de Phoenix que fue un órgano político republicano durante mucho tiempo antes de convertirse en independiente en 2017.

Los oradores en la convención se han centrado en cambios en la inflación, el crimen y la inmigración. “Tienen los datos de encuestas probados y verdaderos que muestran que, para ellos, esos son temas ganadores, y ahí es donde quieren mantener el foco narrativo”, dijo.

La inmigración se ha mezclado con algunos problemas de salud, incluida la crisis de opioides nacional y la cobertura de seguro público.

Algunos republicanos, incluida la representante por Georgia Marjorie Taylor Greene, quien se dirigió a la convención el 15 de julio, han afirmado que un aumento en las personas que cruzan la frontera sur ha causado más sobredosis de drogas y más muertes.

Sin embargo, la mayor parte del fentanilo incautado en la frontera con México entra por puertos de entrada legales, según el Instituto Cato, un grupo de expertos libertarios, y la mayoría de las personas sentenciadas en el país por tráfico de fentanilo son ciudadanos estadounidenses, según la Comisión de Sentencias de Estados Unidos.

Hablando el 17 de julio, la representante por Texas, Monica De La Cruz, afirmó que las políticas demócratas permiten que las personas que ingresan al país sin autorización reciban beneficios gubernamentales, aunque en gran medida no son elegibles para programas de salud federales.

De La Cruz también dijo que la administración Biden había recortado Medicare Advantage para los adultos mayores. Si bien la administración Biden este año recortó modestamente el gasto en planes privados, el gobierno federal aún gasta más dinero por beneficiario en Medicare Advantage que en los del programa tradicional de Medicare.

La escasez de oradores de la convención enfocados en la atención médica refleja la nueva plataforma del Partido Republicano, un documento que se ajusta estrechamente tanto al contenido como al tono de las opiniones de Trump.

Junto con su promesa de proteger Medicare, el documento de 28 páginas promete que los republicanos expandirán las opciones de atención médica para veteranos, así como el acceso a “nuevas opciones asequibles de atención médica y medicamentos recetados” de manera más amplia, sin dar más detalles.

Sobre el aborto, el partido eliminó de la plataforma su llamado de décadas a límites federales, incluyendo en cambio un lenguaje que sugiere que la Enmienda 14ª prohíbe el aborto. La plataforma también dice que el partido apoya elecciones a nivel estatal sobre la política de aborto y se opone al “Aborto tardío”.

Solo alrededor del 1% de los abortos en el país ocurren después de las 21 semanas de embarazo, según KFF, una organización sin fines de lucro de información sobre salud que incluye a KFF Health News.

En contraste, la plataforma de 2016 —un documento de 66 páginas— pedía convertir la financiación federal abierta de Medicaid en subvenciones en bloque e introducir un “modelo de apoyo premium” para Medicare para limitar el gasto. También pedía limitar los pagos de demandas por negligencia médica y combatir el abuso de drogas.

La palabra “aborto” aparece 32 veces en la plataforma de 2016, en comparación con una sola vez en el documento de 2024.

“El Partido Republicano está huyendo a toda velocidad de ese tema”, dijo Coughlin.

Durante la semana de la convención, apareció en internet el video de una llamada entre el candidato presidencial independiente Robert F. Kennedy Jr. y Trump. En el video, se escucha a Trump compartiendo afirmaciones refutadas sobre las vacunas infantiles, diciendo falsamente que las inyecciones pueden hacer que un bebé “cambie radicalmente” y descartando sus beneficios para la salud.

Como candidato, Kennedy ha hecho repetidamente afirmaciones falsas sobre la seguridad y eficacia de las vacunas. Trump le ha seguido la corriente durante mucho tiempo a los escépticos de las vacunas. Pero como presidente, en 2020, ordenó la creación del programa “Operación Warp Speed” que ayudó a impulsar el desarrollo de vacunas contra covid-19.

Desde el inicio de la pandemia, sin embargo, el escepticismo sobre las vacunas ha explotado en el Partido Republicano. Solo el 36% dicen tener confianza en que las vacunas contra covid son seguras, y el 44% de los republicanos e independientes inclinados hacia los republicanos dicen que los padres deberían poder decidir no vacunar a sus hijos contra el sarampión, las paperas y la rubéola “incluso si eso puede crear riesgos de salud para otros niños y adultos”, según encuestas de KFF.

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No talk of Obamacare. Or abortion.

At the Republican National Convention in Milwaukee this week, where delegates officially nominated Donald Trump as the party’s 2024 presidential candidate, health care issues received little attention from prime-time speakers.

The silence is surprising, given health care makes up the largest chunk of the federal budget, nearly $2 trillion, as well as 17% of U.S. economic output.

It also stands in stark contrast to the GOP’s priorities when it first nominated Trump.

In 2016, the last time Republicans gathered en masse for a presidential convention, repealing the Affordable Care Act was a favorite topic. So was overturning Roe v. Wade and its constitutional protections for abortion.

The change in tone reflects Trump’s political sensitivities. The failed attempt under the former president to repeal Obamacare in 2017 contributed to a crushing GOP defeat in the 2018 congressional elections, and the law now enjoys broad support. Abortion, too, has become a treacherous topic for Republicans since Roe was overturned in 2022, with most Americans opposed to a national ban.

In one of the only pieces of health policy in the GOP’s 2024 platform, the former president vows not to cut Social Security or Medicare, the health program for older and disabled Americans, or change the federal retirement age.

In his speech accepting the nomination Thursday night, Trump promised to protect Medicare and find cures for Alzheimer’s disease and cancer. But he did not outline any health care proposals for a second term. “Democrats are going to destroy Social Security and Medicare,” he said.

Health care isn’t a winning subject for Republicans, said Charles Coughlin, CEO of a Phoenix public affairs firm who was a longtime GOP political operative before he became an independent in 2017.

Speakers at the convention have instead focused on inflation, crime, and immigration. “They have the tried-and-true polling data to show those are winning issues for them, and that’s where they want to keep the narrative focused,” he said.

Immigration has bled into a few health issues, including the U.S. opioid crisis and public insurance coverage. Some Republicans — including Georgia U.S. House Rep. Marjorie Taylor Greene, who addressed the convention on July 15 — have claimed an increase in people crossing the southern border has caused a surge of drug overdoses and deaths.

However, most fentanyl seized at the border with Mexico enters through legal ports of entry, according to the Cato Institute, a libertarian think tank, and most people sentenced in the U.S. for fentanyl trafficking are American citizens, according to the U.S. Sentencing Commission.

Speaking on July 17, U.S. House Rep. Monica De La Cruz of Texas claimed Democratic policies allow people who come into the country without authorization to receive government benefits, even though they are largely not eligible for federal health programs.

De La Cruz also said the Biden administration had cut Medicare Advantage for seniors. While the Biden administration this year modestly cut spending on the private plans, the federal government still spends more money per beneficiary on Medicare Advantage than for those in the traditional Medicare program.

The paucity of convention speakers focused on health care reflects the new GOP platform, a document hewing closely to both the substance and tone of Trump’s views. Along with its promise to protect Medicare, the 28-page document vows that Republicans will expand veterans’ health care choices, as well as access to “new Affordable Healthcare and prescription drug options” more broadly, without elaboration.

On abortion, the party stripped from the platform its decades-old call for federal limits, including instead language suggesting the 14th Amendment prohibits abortion. The platform also says the party supports state-level elections on abortion policy and opposes “Late Term Abortion.” Only about 1% of abortions in the U.S. occur after 21 weeks of pregnancy, according to KFF, a health information nonprofit that includes KFF Health News.

In contrast, the 2016 platform — a 66-page document — also called for shifting open-ended federal Medicaid funding into block grants and introducing a Medicare “premium-support model” to cap spending. It also called for limiting payouts from medical malpractice lawsuits and combating drug abuse.

The word “abortion” appears 32 times in the 2016 platform, compared with once in the 2024 document.

“The GOP is in a headlong sprint away from that issue,” Coughlin said.

During the week of the convention, video of a call between independent presidential candidate Robert F. Kennedy Jr. and Trump appeared online. In the video, Trump is heard sharing disproven claims about childhood vaccines, saying falsely that the shots can cause a baby to “change radically” and dismissing their health benefits.

As a candidate, Kennedy has repeatedly made false claims about the safety and efficacy of vaccines. Trump has long entertained vaccine skeptics. (Before Trump took the oath of office in 2017, Kennedy told reporters Trump had invited him to chair a presidential commission on vaccines, though the commission never materialized.) But as president, Trump ordered the creation of the “Operation Warp Speed” program in 2020 that helped drive development of covid-19 vaccines.

Since the start of the pandemic, however, vaccine skepticism has blossomed in the Republican Party. Just 36% of Republicans say they’re confident covid vaccines are safe, and 44% of Republicans and Republican-leaning independents say parents should be able to decide not to vaccinate their children against measles, mumps, and rubella “even if that may create health risks for other children and adults,” according to KFF polling.

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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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The government is giving away money! So say ads on a variety of social media platforms. Consumers, the ads claim, can qualify for $1,400 or even $6,400 a month to use on groceries, rent, medical expenses, and other bills. Some mention no-cost health insurance coverage.

But that’s not the whole story.

And here’s the spoiler — no one is getting monthly checks to help with these everyday expenses.

Such ads are now under scrutiny for the role they may play in helping rogue insurance agents and companies sign up tens of thousands of consumers for Affordable Care Act coverage — or switch them from their existing ACA plans — without their express permission.

The Centers for Medicare & Medicaid Services, which oversees the federal ACA marketplace, also known as Obamacare, has reported at least 90,000 complaints about unauthorized enrollment or plan-switching in the first quarter of the year.

Those numbers have also caught the attention of House Republicans, who on June 28 requested investigations by the Government Accountability Office and the Office of Inspector General at the Department of Health and Human Services.

Fraud — including from unauthorized switches by brokers, as reported by KFF Health News in recent months and noted in the congressional requests — might be part of the problem, House members wrote. They cited an analysis from a conservative group that estimated that millions of people — or their brokers — reported incorrect financial information to qualify for large ACA tax credits.

Whether advertising efforts will be part of any such investigation is unknown.

Details on how an alleged scheme used misleading ads are included in a Florida lawsuit filed in April. The suit claims that several marketing and insurance sales firms used misleading ads as part of a collaborative effort to gin up questionable, commission-earning business. The firms named in the case say the allegations are meritless.

“Telling someone they are going to get $6,400 a month in a cash card for rent or groceries or whatever else, that is a lie, that’s fraud, even if you put in a small boilerplate on the bottom trying to say something different,” said Jason Kellogg, one of two attorneys who filed the complaint in U.S. District Court for the Southern District of Florida.

Here’s how it worked, according to the suit and interviews with the attorneys who filed it: When consumers responded to the ads by phone, they were not connected with a government program. Instead, they were linked directly to insurance call centers, which paid the lead-generating firms placing the ads to transfer the calls.

At best, consumers who respond to the ads might find out they qualify for ACA tax credits, which vary in size, to help offset the premiums for zero-cost or low-cost coverage. Those payments, though, are sent directly to insurers. At worst, according to allegations in the lawsuit, consumers wind up with coverage they didn’t select and that might not meet their needs, or their existing coverage is switched to a new plan, which might have a different network of doctors and hospitals or higher deductibles and copays. The suit alleges much of this was accomplished without consumers’ “proper knowledge and consent.”

Depending on how it’s done, creating ads and gathering names to sell to insurance sales firms is not illegal, but deceptive ads are.

The Federal Trade Commission defines a deceptive ad as one that “contains a misrepresentation or omission that is likely to mislead consumers acting reasonably under the circumstances to their detriment.”

Even that isn’t always clear-cut.

“I get into talks with attorneys all the time,” said Bonnie Burns, a consultant with the nonprofit California Health Advocates. “Is this language I’m seeing that I think is fraudulent — does it actually meet that test? It’s frustrating and maddening as hell.”

After looking at several ads that have appeared recently on social media — but not specifically the ones included in the lawsuit — one marketing expert had no doubt.

“This clearly crosses the line to deception,” said Charles R. Taylor, a professor of marketing at Villanova University. “It is a form of bait and switch, by leading people to think they are going to get cash payments.”

In the U.S., oversight of advertising historically falls to the FTC.

“Investigating deceptive lead generation and marketing practices is a big part of what we do around consumer protection,” said Elizabeth Scott, an FTC attorney who has worked on several recent cases, including a $195 million judgment against Florida-based Simple Health Plans, which the FTC alleged used misleading advertising and sales tactics to sell consumers low-quality coverage when they thought they were buying comprehensive health insurance.

But states also have regulatory authority. They issue licenses to insurance agents and oversee insurance carriers. Most of this crop of ACA ads, however, are from lead-generating companies, which, under some states’ rules, fall into a gray area.

An FTC spokesperson would not comment on whether the agency was looking at any such advertising issues currently.

CMS does not have regulatory authority over marketing entities doing advertising but is working with other federal agencies that do, said Ellen Montz, deputy administrator and director of the Center for Consumer Information and Insurance Oversight at CMS. It does, however, have authority over agents and brokers, who can be barred from using the federal ACA marketplace if they are found to have broken rules, including using “leads generated from advertisements that an agent or broker knows is misleading or coercive,” Montz said.

So far, the Florida lawsuit filed in April remains the most public challenge to the ACA-related advertisements.

The case was filed by Kellogg, along with attorney Jason Doss of Georgia. It alleges that several marketing firms, insurance brokerages, and privately held ACA enrollment websites knowingly relied on misleading advertisements — and told their call center staffers to be vague about the subsidies they promised.

“It’s not about selling people health insurance. It’s about tricking people into enrolling in health insurance,” Doss said.

Consumers often didn’t know they were being signed up for coverage, the lawsuit alleges, and some were switched multiple times. While unscrupulous agents or call centers then gained the monthly commissions, consumers faced a range of financial and other problems, including losing access to their doctors or treatments, the suit claims.

Named as defendants are TrueCoverage and Enhance Health, which operate insurance call centers in Florida and other states; Speridian Technologies, a New Mexico-based limited liability company that owns and controls TrueCoverage; and Number One Prospecting, doing business as Minerva Marketing, which is also a lead-generating company. The lawsuit also names two people: Brandon Bowsky, founder and CEO of Minerva; and Matthew Herman, CEO of Enhance Health.

TrueCoverage spokesperson Catherine Riedel told KFF Health News the firm approves all ads from lead-generating marketing firms and “has not knowingly approved any misleading content.” Furthermore, “in our research, we haven’t found anyone who got enrolled connected to misleading content.”

Olga Vieira, an attorney representing Enhance Health, said in a statement to KFF Health News: “This lawsuit is without legal merit and we will vigorously defend against these baseless claims.” Attorneys representing the other defendants did not respond to requests for comment.

The suit was filed on behalf of agents who lost business when their clients were switched and consumers like Texas resident Angelina Wells, who responded to an advertisement she saw on Facebook in November that touted $6,400 cash cards.

“Wells never received the cash card she was promised,” the lawsuit says, “and she did not recall enrolling into the health plan at all.”

From November to January, call center agents switched Wells at least three times, to three insurance carriers, without her consent, the lawsuit says.

Doss said agents, armed with only a person’s name, date of birth, and state of residence, can make switches through private-sector direct enrollment websites that integrate with the federal healthcare.gov marketplace.

While dozens of these enrollment sites operate with CMS approval, the lawsuit focuses mainly on two: Benefitalign, which was developed by the parent company of the defendant TrueCoverage, and Jet Health Solutions, which was purchased by the other call center defendant, Enhance Health, in mid-2023.

Having access to proprietary enrollment platforms allowed the call centers to sign up “the maximum number of consumers in the shortest amount of time without outside scrutiny,” according to the lawsuit. TrueCoverage spokesperson Riedel said all transactions on private enrollment sites “are audited and logged” by the federal marketplace, so “it is not true” that such transactions lack scrutiny. Enhance Health didn’t provide specific comments on this topic.

The lawsuit says Enhance launched in 2021, not long after receiving a $150 million capital infusion from Bain Capital Insurance, a private investment firm. Initially, it planned to market and sell Medicare Advantage policies, but it switched to ACA policies after rules went into effect in 2022 allowing low-income people to enroll in coverage year-round.

“The biggest problem is that these agencies are trying to do a high-volume ACA business model that targets poor people,” Doss said, based on assertions made in the lawsuit. “In order to get those people to enroll, they have to entice them using false advertisements.

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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

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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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Justo después del mediodía del 18 de junio, líderes de Massachusetts descubrieron que el sistema estatal de emergencias 911 estaba fuera de servicio.

Fue cuando comenzó una carrera para manejar la crisis.

La policía envió mensajes de texto con números alternativos al que las personas podían llamar, la alcaldesa de Boston, Michelle Wu, habló sobre la interrupción del 911 en una conferencia de prensa por el desfile de campeonato de los Celtics, y funcionarios locales instaron a las personas a pedir ayuda activando las alarmas rojas contra incendios.

Unas 7 millones de personas estuvieron por cerca de dos horas sin el servicio del 911. Estas fallas ya no son una excepción sino una constante en un sistema de respuesta a emergencias quebrado.

Este año, las interrupciones han afectado al menos a ocho estados. Y son emblemáticas de los problemas que aquejan a las comunicaciones de emergencia, en parte debido a las grandes disparidades en la antigüedad y las capacidades de los sistemas, y en la financiación también dispar que recibe el sistema del 911 a lo largo del país.

Mientras que algunos estados, ciudades y condados ya han modernizado sus sistemas o han hecho planes para actualizarlos, muchos otros están rezagados.

El 911 suele financiarse a través de tarifas agregadas a las facturas telefónicas, pero los gobiernos estatales y locales también recurren a fondos generales u otros recursos.

“Ahora hay quienes tienen y quienes no tienen”, dijo Jonathan Gilad, vicepresidente de asuntos gubernamentales de la Asociación Nacional de Números de Emergencia (NENA), que representa a los trabajadores de primeros auxilios del 911. “El 911 de próxima generación no debería ser solo para las personas que tienen una emergencia en un buen lugar”.

Mientras tanto, la legislación federal que podría dirigir miles de millones de dólares para modernizar el sistema fragmentado del 911 sigue estancada en el Congreso.

“Esto es algo imperativo para la seguridad nacional”, dijo George Kelemen, director ejecutivo del Consejo de la Industria para Tecnologías de Respuesta a Emergencias, una asociación comercial que representa a empresas que proveen hardware y software a la industria de respuesta a emergencias.

“En una crisis, un tiroteo en una escuela o un incendio en una casa o, Dios no lo quiera, un ataque terrorista, la gente llama al 911 primero”, dijo. “El sistema no puede fallar”.

Estados Unidos inauguró un número de emergencia universal único, el 911, en febrero de 1968 para simplificar la respuesta a las crisis.

Pero en lugar de un programa nacional sin fisuras, la red de respuesta del 911 se ha convertido en un enorme rompecabezas de muchas piezas interconectadas. Hay más de 6,000 centros de llamadas del 911 para manejar un estimado de 240 millones de llamadas de emergencia cada año, según datos federales.

Más de tres cuartos de los centros de llamadas experimentaron interrupciones en los últimos 12 meses, según una encuesta realizada en febrero por NENA, que establece estándares y aboga por el 911, y Carbyne, un proveedor de soluciones tecnológicas de seguridad pública.

En abril, las interrupciones generalizadas del 911 afectaron a millones en Nebraska, Nevada, Dakota del Sur y Texas. La interrupción se atribuyó a trabajadores que cortaron una línea de fibra mientras instalaban un poste de luz.

En febrero, decenas de miles de personas en áreas de California, Georgia, Illinois, Texas y otros estados perdieron el servicio de telefonía móvil, incluidos algunos servicios del 911, debido a una interrupción.

Y en junio, Verizon acordó pagar una multa de $1.05 millones para resolver una investigación de la Comisión Federal de Comunicaciones sobre una interrupción en diciembre de 2022 que afectó las llamadas al 911 en Alabama, Florida, Georgia, Carolina del Norte, Carolina del Sur y Tennessee.

Los incendios que arrasaron la isla hawaiana de Maui en agosto pasado destacaron la importancia crítica de los sistemas del 911. Los despachadores atendieron más de 4,500 contactos, es decir, llamadas y mensajes de texto, el 8 de agosto, el día en que se desataron los incendios, en comparación con unos 400 en un día típico, dijo Davlynn Racadio, coordinadora de despachos de servicios de emergencia en el condado de Maui.

“Nos estamos muriendo”, dijo una persona a los operadores del 911.

Pero algunas torres de telefonía móvil fallaron debido a interrupciones generalizadas del servicio, según funcionarios del condado. El condado de Maui presentó en mayo una demanda contra cuatro compañías de telecomunicaciones, alegando que no informaron a los despachadores sobre las interrupciones.

“Si las llamadas al 911 llegaban sin voz, enviábamos mensajes de texto”, dijo Racadio. “El estado está considerando actualizar nuestro sistema. El 911 de próxima generación nos lanzaría al futuro”.

En 2023, Florida, Illinois, Montana y Oklahoma aprobaron legislaciones para impulsar o financiar sistemas de 911 modernizados, según la Conferencia Nacional de Legislaturas Estatales. Las actualizaciones incluyen reemplazar la infraestructura analógica del 911 con sistemas digitales basados en Internet.

En lugar de solo atender llamadas, los sistemas de próxima generación pueden localizar la ubicación del que llama, aceptar mensajes de texto y permitir que los residentes en una crisis envíen videos e imágenes a los despachadores.

Aunque aún pueden ocurrir interrupciones, los sistemas modernizados a menudo incluyen más componentes para minimizar las probabilidades de una interrupción, dijo Gilad.

Los legisladores han considerado modernizar los sistemas del 911 aprovechando los ingresos que la Comisión Federal de Comunicaciones (FCC) obtiene de subastar los derechos para transmitir señales sobre bandas específicas del espectro electromagnético.

Pero, en marzo de 2023, el Senado de Estados Unidos, permitió por primera vez la expiración de la autoridad de la FCC para subastar bandas de espectro.

La legislación que asignaría casi $15 mil millones en subvenciones de los ingresos de las subastas para acelerar el desarrollo del 911 de próxima generación en cada estado fue aprobada por unanimidad por el Comité de Energía y Comercio de la Cámara de Representantes en mayo de 2023. El proyecto de ley, HR 3565, patrocinado por la representante Cathy McMorris Rodgers (republicana de Washington), también extendería la autoridad de la FCC para subastar.

Otros legisladores han presentado proyectos, incluyendo uno en marzo del senador Ted Cruz (republicano de Texas) y de la senadora Maria Cantwell (demócrata de Washington) para extender la autoridad de subasta. Por ahora, ninguno de los esfuerzos ha avanzado.

Nueve ex presidentes de la FCC escribieron a los legisladores en febrero, instándolos a hacer de las actualizaciones del 911 una prioridad nacional. Sugirieron que el Congreso utilizara el dinero federal para covid-19 que no se gastó.

“Cualquiera que sea la fuente de financiamiento, la necesidad es urgente y el momento de actuar es ahora”, escribieron.

Ajit Pai, quien se desempeñó como presidente de la FCC de 2017 a 2021, dijo que las interrupciones a menudo ocurren en sistemas de computación obsoletos.

“El hecho de que ahora la FCC no tenga autoridad para subastar espectro es un verdadero obstáculo”, dijo Pai a KFF Health News. “Es posible que nunca necesites llamar al 911, pero puede marcar la diferencia entre la vida y la muerte. Necesitamos un esfuerzo más organizado a nivel federal porque el 911 está demasiado descentralizado”.

Mientras tanto, algunos líderes de seguridad están haciendo planes de respaldo para las interrupciones del 911 o realizando investigaciones sobre sus causas. En Massachusetts, un firewall diseñado para prevenir piratería provocó la reciente interrupción de dos horas, según el departamento del 911 del estado.

“Las interrupciones llaman la atención de todos sobre el hecho de que dependemos del 911 y no pensamos en cómo realmente dependemos de este número hasta que ocurre algo”, dijo April Heinze, directora de operaciones del 911 en NENA.

Mass General Brigham, un sistema de salud en el área de Boston, envió alertas de emergencia cuando ocurrió la interrupción, informando a las clínicas y prácticas más pequeñas sobre cómo encontrar sus números de emergencia de 10 dígitos. A raíz de la interrupción, planea mantener los números de respaldo junto a los teléfonos en esas instalaciones.

“Dos horas pueden ser mucho tiempo”, dijo Paul Biddinger, director de preparación y continuidad del sistema de salud.

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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

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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.

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The Tennessee government has agreed to begin scrubbing its sex offender registry of dozens of people who were convicted of prostitution while having HIV, reversing a practice that federal lawsuits have challenged as draconian and discriminatory.

For more than three decades, Tennessee’s “aggravated prostitution” laws have made prostitution a misdemeanor for most sex workers but a felony for those who are HIV-positive. Tennessee toughened penalties in 2010 by reclassifying prostitution with HIV as a “violent sexual offense” with a lifetime registration as a sex offender — even if protection is used.

At least 83 people are believed to be on Tennessee’s sex offender registry solely because of these laws, with most living in the Memphis area, where undercover police officers and prosecutors most often invoked the statute, commonly against Black and transgender women, according to a lawsuit filed last year by the American Civil Liberties Union and four women who were convicted of aggravated prostitution. The Department of Justice challenged the law in a separate suit earlier this year.

Both lawsuits argue that Tennessee law does not account for evolving science on the transmission of HIV or precautions that prevent its spread, like use of condoms. Both lawsuits also argue that labeling a person as a sex offender because of HIV unfairly limits where they can live and work and stops them from being alone with grandchildren or minor relatives.

“Tennessee’s Aggravated Prostitution statute is the only law in the nation that treats people living with HIV who engage in any sex work, even risk-free encounters, as ‘violent sex offenders’ subjected to lifetime registration,” the ACLU lawsuit states.

“That individuals living with HIV are treated so differently can only be understood as a remnant of the profoundly prejudiced early response to the AIDS epidemic.”

In a settlement agreement signed by Tennessee Gov. Bill Lee on July 15 and filed in both lawsuits on July 17, the Tennessee Bureau of Investigation said it would comb through the state’s sex offender registry to find those added solely because of aggravated prostitution convictions, then send letters alerting those people that they can make a written request to be removed. The language of the settlement suggests that people will need to request their removal from the registry, but the agency said in the agreement it will make “its best effort” to act on the requests “promptly in the order in which they are received.”

The Tennessee attorney general’s office, which represents the state in both the ACLU and DOJ lawsuits and approved the settlement agreement, said in an email statement it would “continue to defend Tennessee’s prohibition on aggravated prostitution.”

In an email statement, the ACLU celebrated the settlement as “one step toward remedying the harms by addressing the sex offender registration,” but said its work in Tennessee was not done because aggravated prostitution remained a felony charge that it would “fight to overturn.”

Molly Quinn, executive director of LGBTQ+ support organization OUTMemphis, another plaintiff in the ACLU lawsuit, said both organizations would help eligible people with the paperwork to get removed from the registry.

“We would not have agreed to settle if we did not feel like this was a process that would be extremely beneficial,” Quinn said. “But, we’re sad that the statute existed as long as it did and sad that there is any process at all that folks have to go through after living with this extraordinary burden of being on the sex offender registry for really an irrelevant reason.”

Michelle Anderson, a Memphis resident who is one of the plaintiffs in the ACLU lawsuit, said in court records that since being convicted of aggravated prostitution, the sex offender label has made it so difficult to find a home and a job that she was “unhoused for about a year” and has at times “felt she had no option but to continue to engage in sex work to survive.”

Like the other plaintiffs, Anderson said her conviction kept her minor relatives at a distance.

“Ms. Anderson has a nephew she loves, but she cannot have a close relationship with him,” the lawsuit states. “Even though Ms. Anderson’s convictions had nothing to do with children, she cannot legally be alone with her nephew.”

The Tennessee settlement comes months after state lawmakers softened the law so no one else should be added to the sex offender registry for aggravated prostitution. Lawmakers removed the registration requirement and made convictions eligible for expungement if the defendant testifies they were a victim of human trafficking.

State Sen. Page Walley (R-Savannah), who supported the original aggravated prostitution law passed in 1991 and co-sponsored the recent bill to amend it, said on the floor of the legislature that the changes do not prevent prosecutors from charging people with a felony for aggravated prostitution. Instead, he said, the amendments undo the 2010 law that put those who are convicted on the registry “along with pedophiles and rapists for a lifetime, with no recourse for removal.”

“Having stood, as I mentioned, in 1991 and passed this,” Walley said, “it is a particular gratifying moment for me to see how we continue to evolve and seek what’s just and what’s right and what’s best.”

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About every 12 minutes, someone is killed on America’s roads and countless others are injured.

More than 42,500 people died in car crashes in 2022, a death toll that rivals or surpasses those of other major public health threats, such as the flu and gun violence.

“We have not recognized that traffic violence is a preventable public health crisis,” said Amy Cohen, a co-founder of Families for Safe Streets.

Traffic-related injuries and deaths cost the health-care system more than $55 billion in 2022, according to the Centers for Disease Control and Prevention. And pedestrian deaths have spiked, reaching 7,522in 2022, the highest level in more than four decades, according to the federal government.

“The transportation system shouldn’t hurt us, and it shouldn’t harm the environment,” said Johnathon Ehsani, an associate professor at the Johns Hopkins Bloomberg School of Public Health who uses policy and behavioral research to try to prevent car crashes.

Transportation experts blame traffic deaths on more reckless driving and less traffic enforcement than before the coronavirus pandemic, combined with larger and deadlier SUVs and trucks. But they primarily fault a transportation system that was designed for efficient movement and economic development — not safety.

To reverse that, the Biden administration is looking to the “safe system approach,” a transportation strategy that has achieved piecemeal adoption across the country.

The approach puts safety at the core of road and vehicle design and transportation policies, forcing traffic to move more slowly through communities, Ehsani said.

This translates into lowering speed limits, narrowing roads and creating separate lanes for bicyclists, and more buffers for pedestrians. He said the approach also de-emphasizes cars — which make people more sedentary and cause air pollution — and boosts public transportation.

The Biden administration in 2021 injected more than $20 billion in funding for transportation safety programs through the Infrastructure Investment and Jobs Act.

Some states and localities are also taking steps.

New York and Michigan adopted laws this spring allowing local jurisdictions to lower speed limits, and voters in Los Angeles approved a resident-sponsored ballot initiative to redesign streets, invest more in public transportation, add bike lanes and widen sidewalks to protect pedestrians.

But in a country where cars are inextricably linked to the culture and economy, political resistance remains entrenched.

Stuck in the middle are people whose lives and health have been devastated. I visited a Latino working-class neighborhood in Los Angeles where I met María Rivas Cruz, who in February 2023 was struck along with her fiancé, Raymond Olivares, by a driver going 70 in a 40-mph zone.

Rivas Cruz was severely injured. Olivares died at the scene.

Residents had pleaded for years for lower speed limits, safety islands and more marked crosswalks. After the crash, the county installed protective steel posts midway across the street, which Rivas Cruz called a “band-aid.”

“There’s so much death going on,” said Rivas Cruz, who now at age 28 walks with a cane and lives with chronic pain. “The representatives have failed us.”

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Caitlyn Mai woke up one morning in middle school so dizzy she couldn’t stand and deaf in one ear, the result of an infection that affected one of her cranial nerves. Though her balance recovered, the hearing never came back.

Growing up, she learned to cope — but it wasn’t easy. With only one functioning ear, she couldn’t tell where sounds were coming from. She couldn’t follow along with groups of people in conversation — at social gatherings or at work — so she learned to lip-read.

For many years, insurers wouldn’t approve cochlear implants for single-sided deafness due to concerns that it would be hard to train the brain to manage signals from a biological ear and one that hears with the aid of an implant. But research on the detrimental effects of single-sided deafness and improvements in technique changed all that.

So Mai, now 27 and living near Oklahoma City, was thrilled last fall to get a prior authorization letter from her insurer saying she was covered for cochlear implant surgery.

She had successful outpatient surgery to implant the device in December and soon after was eagerly attending therapy to get her brain accustomed to its new capabilities.

“It was amazing. When I’d misplaced my phone and it rang, I could tell where the sound was coming from and find it,” she said.

Then the bill came.

The Patient: Caitlyn Mai, who is insured through her husband’s job by HealthSmart, which is owned by UnitedHealth Group.

Medical Services: Cochlear implant surgery, including the operating room, anesthesia, surgical supplies, and drugs.

Service Provider: SSM Health Bone & Joint Hospital at St. Anthony, an orthopedic hospital in Oklahoma City that is part of SSM Health, a Catholic health system in the central U.S.

Total Bill: $139,362.74 — or, with a “prompt pay discount” if she paid about two months after surgery, $125,426.47.

What Gives: Providers and insurers often have disagreements over how a bill is submitted or coded, and as they work through them (or don’t), the patient is left holding the bag, facing sometimes huge bills.

“I almost had a heart attack when I opened the bill,” Mai said of the first monthly missive, which arrived in late December. She said she was so upset she left work to investigate. Before surgery, “I’d even checked that all hospitals and doctors were in-network and that I’d met my deductible,” she said.

While she was never threatened with having her bill sent to collections, she said she worried about that possibility when the same bills arrived in January, February, and March, with ominous warnings that “your balance is now past due.”

Mai said she first called the hospital billing office but that the representative could tell her only that the claim had been denied and didn’t know why. She called her insurer, and a representative there said the hospital didn’t adequately itemize its charges or include billing codes. She then called the hospital back and relayed exactly what her insurer said must be done to rectify the bill — and the name and number of the insurance employee to fax it to.

When her insurer told her a week or two later it hadn’t received a corrected bill, Mai said, she called the hospital again … and again.

“I said, ‘I’ve done your job for you — now can you please take it from here?’” she said.

Mai said a hospital staffer promised to fax over the corrected, itemized bill in two to three weeks. “How does it take that long to send a fax,” she wondered. She said she asked to speak with a supervisor and was told the person wasn’t available but would call her back. No one did.

After receiving another $139,000 bill in late February, Mai said, she checked back in with her insurer, but a representative said it had not yet received the revised bill.

Finally, she said, she told the hospital to “just send it to me and I’ll send it over.” This time, she forwarded the bill to her insurer herself. But in late March she got another bill demanding the full amount — and offering an $11,000-a-month payment plan.

Mai said she had met her out-of-pocket deductible and, with prior authorization in hand, expected the surgery to be fully covered.

SSM Health did not respond to multiple requests for comment about why it billed Mai.

“It’s outrageous that the patients end up umpiring the decisions,” said Elisabeth Ryden Benjamin, vice president of health initiatives at the Community Service Society of New York, an advocacy organization. “And it’s outrageous that providers are allowed to bill patients while they’re haggling with the insurer.”

Indeed, more and more patients are stuck with such bills as insurers and hospitals spend more and more time arguing in the trenches, data shows. A recent report by Crowe, an accounting firm that works with a large number of hospitals, found that more than 30% of claims submitted to commercial insurers early last year weren’t paid for more than 90 days — striking compared with the lower rates of such delays in Medicare, which were 12% for inpatient claims and 11% for outpatient claims.

The Crowe report found a particular justification for denying claims was cited at 12 times the rate by commercial insurers as by Medicare: that they needed more information before they would process the submission. Such a request allows insurers to sidestep laws in most states that require claims be paid in 30 to 40 days, automatically granting health plans the right to delay payment.

In a separate analysis, the American Hospital Association complained that increases in insurance denials and delays “strain hospital resources” and “inhibit medically necessary care.”

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• He Fell Ill on a Cruise. Before He Boarded the Rescue Boat, They Handed Him the Bill. May 22, 2024
• Sign Here? Financial Agreements May Leave Doctors in the Driver’s Seat Apr 30, 2024

More from the series

But perhaps no one is harmed as gravely as the patient, who is barraged with bills and believes they must pay up — particularly when the missives are stamped “past due” and contain offers of prompt-payment discounts or no-interest payment plans. “The stress and anxiety was huge,” Mai said.

Caroline Landree, a spokesperson for UnitedHealth Group, said the insurer could pay Mai’s claims only “after receiving a detailed bill from her provider.”

“We encourage our members to contact the number on their insurance cards for more information on the status of payments,” she added.

The Resolution: Mai estimated she spent at least 12 hours on the phone doing tasks that typically fall to someone working in a hospital billing department: making sure the bill was coded as needed and that the insurer had what it wanted to process the payment.

More than 90 days after her surgery, after Mai had received four terrifyingly huge bills, her insurance finally paid the claim. Mai owed nothing more.

She added: “I’ve never got that call back from a supervisor to this day.”

The Takeaway: It’s not uncommon for an insurer to delay paying a claim until it receives an itemized bill; providers sometimes get creative with billing codes to increase revenue, and studies show that more than half of hospital bills contain errors. But studies also suggest insurers are wont to drag their feet, niggling over coding and charges — and, in doing so, delaying reimbursement and holding on to the cash.

Medical billing experts say it may not seem right for patients to receive bills as this process plays out but that it’s probably legal.

“Laws say ‘hold the patient harmless,’” Benjamin said. “What we didn’t say is, ‘Don’t send them a bill.’” She said it is also unfair that patients may be forced to act as the go-between for providers and insurers who should be talking to each other.

What’s a patient to do? First step: Don’t pay the bill (aside from a copay or coinsurance) for care or services preapproved by insurance. Call the health care provider and explain they should take up their bill with the insurer.

Second, ask the provider to send an itemized bill with all billing codes used, then review it for errors. As the patient, you would know that you never had an MRI, for example. Your insurer wouldn’t.

If submissions to “Bill of the Month” are reflective of trends, many patients these days are finding themselves ping-ponging between representatives for providers and insurers to get bills resolved and paid.

“Bravo for Ms. Mai for having the energy to keep at it and get resolution,” Benjamin said.

Bill of the Month is a crowdsourced investigation by KFF Health News 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!

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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During the Republican National Convention’s opening night, Sen. J.D. Vance (R-Ohio) spoke to Fox News for his first interview as former President Donald Trump’s vice presidential nominee.

Sitting in the Fiserv Forum, the convention’s Milwaukee venue, Vance took questions from host Sean Hannity and addressed criticism about his previous comments on domestic violence, abortion, and his 2016 disapproval of Trump.

A couple of times, Vance accused the media of twisting controversial comments about violent marriages and abortion exemptions. We took a closer look at four of his claims.

Vance Mischaracterizes Biden’s Stance on Abortion

Vance addressed his own and Trump’s position on abortion. He described Trump’s position “to let voters in states” decide abortion laws as “reasonable,” contrasting it with Biden’s. 

“Donald Trump is running against a Joe Biden president who wants taxpayer-funded abortions up until the moment of birth,” Vance said.

This is False and misleads about how rarely abortions are performed late in pregnancy. 

The vast majority of abortions in the U.S. — about 91% — occur in the first trimester. About 1% take place after 21 weeks, and far fewer than 1% occur in the third trimester and typically involve emergencies such as fatal fetal anomalies or life-threatening medical emergencies affecting the pregnant woman.

Biden has said he supported Roe v. Wade, the landmark 1973 U.S. Supreme Court ruling that legalized abortion and was overturned in June 2022, and wants federally protected abortion access. 

Roe didn’t provide unrestricted access to abortion. It legalized abortion federally but also enabled the states to restrict or ban abortions once a fetus is viable, typically around 24 weeks into pregnancy. Exceptions to that time frame typically were allowed when the pregnant woman’s life or health was at risk.

The Democratic-led Women’s Health Protection Act of 2021, which failed to pass the Senate, would have effectively codified a right to abortion while allowing for post-viability restrictions similar to Roe‘s.

During the 2020 presidential campaign, Biden promised to repeal the Hyde Amendment, which says federal funds can’t be used to pay for abortions, except in cases of rape or incest or to save the woman’s life. However, the amendment has continued to be included in congressional spending bills. 

Vance’s Comments About Women in Violent Marriages

Hannity asked Vance to explain controversial 2021 comments about women staying in violent marriages. 

“Both me and my mom actually were victims of domestic violence,” Vance told Hannity. “So, to say ‘Vance has supported women staying in violent marriages,’ I think it’s shameful for them to take a guy with my history and my background and say that that’s what I believe. It’s not what I believe. It’s not what I said.” 

The comments in question came from a 2021 event Vance participated in at Pacifica Christian High School in California. In a conversation about his 2016 memoir “Hillbilly Elegy,” the event moderator asked Vance about his experience being raised by his grandparents, following his mother’s divorces and struggles with drug addiction. 

“What is causing one generation to give up on fatherhood when the other one was so doggedly determined to stick it out even in tough times?” the moderator asked. 

Vance talked about the economic effect of men losing manufacturing jobs then discussed his grandparents’ marriage. 

In his memoirs, Vance detailed his grandparents’ relationship and told a story about Vance’s grandmother pouring lighter fluid on his grandfather and striking a match after he came home drunk. She had previously threatened to kill her husband if he came home drunk again, according to a 2016 book review published by The Washington Post. 

Vance commended his grandparents for staying together, comparing it with younger generations. 

“This is one of the great tricks that I think the sexual revolution pulled on the American populace, which is the idea that, like, ‘Well, OK, these marriages were fundamentally, you know, they were maybe even violent, but certainly they were unhappy. And so getting rid of them and making it easier for people to shift spouses like they change their underwear, that’s going to make people happier in the long term.’ 

“And maybe it worked out for the moms and dads, though I’m skeptical. But it really didn’t work out for the kids of those marriages.”

In response to a 2022 Vice News story highlighting the comments, Jai Chabria, a strategist for Vance, said the media missed Vance’s point.

“This is a comment that he made where he’s talking about how it’s important that couples stay together for the kids, that we actually have good kids first,” he said. “All he is saying is that it is far too often the case where couples get divorced, they split up, and they don’t take the kids’ needs into consideration.”

Vance’s Comments About Rape, Abortion, and ‘Inconvenience’

Hannity asked Vance to discuss his position on abortion, allowing the senator to address his past comments that have been criticized. 

“Let me go back to the issue of abortion,” Hannity said. “And there was this article that said, ‘Oh, J.D. Vance said it’s inconvenient.'”

Vance told Hannity, “The Democrats have completely twisted my words. What I did say is that we sometimes in this society see babies as inconveniences, and I absolutely want us to change that.”

We looked into comments Vance made on abortion while he was running for Senate in 2022. His opponent claimed Vance had said that rape was inconvenient, but we found that’s not directly what Vance said. 

In a 2021 interview, Vance was asked whether laws should allow women to get abortions if they were victims of rape or incest. He said society should not view a pregnancy or birth resulting from rape or incest as “inconvenient.” 

“My view on this has been very clear, and I think the question betrays a certain presumption that is wrong,” Vance said in 2021. “It’s not whether a woman should be forced to bring a child to term, it’s whether a child should be allowed to live, even though the circumstances of that child’s birth are somehow inconvenient or a problem to the society. The question really, to me, is about the baby.”

Editor’s note: This is excerpted from PolitiFact’s full coverage. You can read the full story here.

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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President Biden’s Lower Cost Prescription Drug Law Will Allow People with Medicare to Spread Out-of-Pocket Prescription Drug Costs into Monthly Payments.