Some Medicaid Providers Borrow or Go Into Debt Amid ‘Unwinding’ Payment Disruptions
George said the company didn’t have enough money to pay its employees. When he called state health and public assistance officials for help, he said, they told him they were swamped processing a high load of Medicaid cases, and that his residents would have to wait their turn.
“I’ve mentioned to some of them, ‘Well what do we do if we’re not being paid for four or five months? Do we have to evict the resident?’” he asked.
Instead, the company took out bank loans at 8% interest, George said.
Montana officials finished their initial checks of who qualifies for Medicaid in January, less than a year after the federal government lifted a freeze on disenrollments during the height of the covid-19 pandemic. More than 127,200 people in Montana lost Medicaid with tens of thousands of cases still processing, according to the latest state data, from mid-February.
Providers who take Medicaid have said their state payments have been disrupted, leaving them financially struggling amid the unwinding. They’re providing care without pay, and sometimes going into debt. It’s affecting small long-term care facilities, substance use disorder clinics, and federally funded health centers that rely on Medicaid to offer treatment based on need, not what people can pay.
State health officials have defended their Medicaid redetermination process and said they have worked to address public assistance backlogs.
Financial pinches were expected as people who legitimately no longer qualify were removed from coverage. But the businesses have said an overburdened state workforce is creating a different set of problems. In some cases, it has taken months for people to reapply for Medicaid after getting dropped, or to access the coverage for the first time. Part of the problem, providers said, are long waits on hold for the state’s call center and limited in-person help.
The problem is ongoing: George said two Guardian residents were booted from Medicaid in mid-March, with the state citing a lack of information as the cause.
“I have proof we submitted the needed information weeks ago,” he said.
Providers said they’ve also experienced cases of inconsistent Medicaid payments for people who haven’t lost coverage. It can be hard to disentangle why payments suddenly stop. Patients and providers are working within the same overstretched system.
Jon Forte is the head of the Yellowstone County health department in Billings, which runs health centers that provide care regardless of patients’ ability to pay. He said that at one point some of the clinics’ routine Medicaid claims went unpaid for up to six months. Their doctors are struggling to refer patients out for specialty care as some providers scale back on clientele, he said.
“Some have honestly had to stop seeing Medicaid patients so that they can meet their needs and keep the lights on,” Forte said. “It is just adding to the access crisis we have in the state.”
Payment shortfalls especially hurt clinics that base fees on patient income.
David Mark, a doctor and the CEO of One Health, which has rural clinics dotted across eastern Montana and Wyoming, said the company anticipated making about $500,000 in profit through its budget year so far. Instead, it’s $1.5 million in the red.
In Yellowstone County, Forte said, the health department, known as RiverStone Health, is down $2.2 million from its anticipated Medicaid revenue. Forte said that while state officials have nearly caught up on RiverStone Health’s direct Medicaid payments, smaller providers are still seeing delays, which contributes to problems referring patients for care.
Jon Ebelt, a spokesperson for the Montana Department of Public Health and Human Services, said Medicaid can retroactively pay for services for people who have lost coverage but are then found eligible within 90 days. He said the state’s average redetermination processing time is 34 days, the average processing time for applications is 48 days, and, when processing times are longer, it’s often due to ongoing communication with a client.
Ebelt didn’t acknowledge broader Medicaid payment delays, but instead said a provider may be submitting claims for Medicaid enrollees who aren’t eligible. He rejected the idea that individual examples of disruptions amount to a systemic problem.
“We would caution you against using broad brush strokes to paint a picture of our overall eligibility system and processes based on a handful of anecdotal stories,” Ebelt said in an emailed response to a KFF Health News query.
Ebelt didn’t directly answer questions about continued long waits for people seeking help but instead said continued coverage depends on individual beneficiaries submitting information on time.
Federal data shows Montana’s average call center wait time is 30 minutes — putting it among states with the highest average wait times. Mike White, co-owner of Caslen Living Centers, which has six small assisted living facilities across central and southwestern Montana, said some family members allowed the company to manage residents’ Medicaid accounts to help avoid missing deadlines or paperwork. Even so, he said, the company is waiting for about $30,000 in Medicaid payments, and it’s hard to reach the state when problems arise.
When they do get through to the state’s call center, the person on the other end can’t always resolve their issue or will answer questions for only one case at a time.
“You don’t know how long it’s going to take — it could be two months, it could be six months — and there’s nobody to talk to,” White said.
Ebelt said long-term care facilities were provided information on how to prepare for the unwinding process. He said new Medicaid cases for long-term care facilities are complicated and can take time.
Stan Klaumann lives in Ennis and has power of attorney for his 94-year-old mom, who resides in one of Guardian’s assisted living homes. Klaumann said that while she never lost coverage, the state didn’t make Medicaid payments toward her long-term care for more than four months and he still doesn’t know why.
He said that since last fall the state hasn’t consistently mailed him routine paperwork he needs to fill out and return in exchange for Medicaid payments to continue. He tried the state’s call center, he said, but each time he waited on hold for more than two hours. He made four two-hour round trips to his closest office of public assistance to try to get answers.
Sometimes the workers told him that there was a state error, he said, and other times that he was missing paperwork he’d already submitted, such as where money from selling his mom’s car went.
“Each time I went, they gave me a different answer as to why my mother’s bills weren’t being paid,” Klaumann said.
Across the nation, people have reported system errors and outdated contact information that led states to drop people who qualify. At least 28 states paused procedural disenrollments to boost outreach to people who qualify, according to federal data. Montana stuck to its original time frame and has a higher procedural disenrollment rate than most other states, according to KFF.
Stephen Ferguson, executive director of Crosswinds Recovery in Missoula, said the substance use disorder program doesn’t have a full-time person focused on billing and sometimes doesn’t realize clients lost Medicaid coverage until the state rejects thousands of dollars in services that Crosswinds submits for reimbursement. After that, it can take months for clients to either get reenrolled or learn they truly no longer qualify.
Ferguson said he’s writing grant proposals to continue to treat people despite their inability to pay.
“We’re riding by the seat of our pants right now,” he said. “We are unsure what next month or the next quarter looks like.”
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.
USE OUR CONTENTThis story can be republished for free (details).
This State Isn’t Waiting for Biden To Negotiate Drug Prices
As the federal government negotiates with drugmakers to lower the price of 10 expensive drugs for Medicare patients, impatient legislators in some states are trying to go even further. Leading the pack is Colorado, where a new Prescription Drug Affordability Review Board is set to recommend an “upper payment limit” for drugs it deems unaffordable.
In late February the board selected Enbrel, Amgen’s blockbuster drug for autoimmune conditions (list price $1,850 per week), as the first medication that would go through its process. Novartis’s Cosentyx and Johnson & Johnson’s Stelara (both treat autoimmune conditions) will undergo affordability reviews later this year.
Enbrel and Stelara are also on the list of drugs whose prices the federal government is negotiating — but only for Medicare patients. Prices may be published Sept. 1 — in time for President Biden to cheer the results in his reelection campaign. But they won’t take effect until 2026, while the drug industry pursues a raft of lawsuits to stop the initiative.
Colorado’s plan is, in many ways, both broader and more prescriptive than the feds’, covering all patients and potentially fixing an upper price limit rather than squabbling with the industry over an acceptable figure.
Colorado’s government said it anticipates similar litigation. A spokesperson for the state’s Division of Insurance, which oversees the program, declined to make anyone available for an interview.
The Pharmaceutical Research and Manufacturers of America, the industry’s main trade group, said in a blog post: “Policymakers in Colorado have created a system in which patients may face significant barriers to lifesaving medicines because of government price setting.”
The state has already said 604 drugs met the first criteria to undergo an affordability review. The full list of drugs is linked from the board’s webpage, along with a list — in order — of those it has slated for priority review.
The Colorado board will spend the summer setting upper payment levels for drugs selected for price reviews. Drugmakers can then appeal.
The board plans to examine how manufacturers price — and raise prices — for drugs. For generics, the board’s director, Lila Cummings, said at a Feb. 23 meeting, the criteria could include whether the price paid by wholesalers before discounts has increased at least 200 percent in the past year and whether a 30-day supply costs more than $100. Branded drugs that cost more than $30,000 a year or whose wholesale price has increased at least 10 percent in the past year could land in the board’s sights, as could biosimilars that aren’t at least 15 percent cheaper than the brand-name biologics they’re intended to replace, Cummings said.
The five-member board, appointed by Gov. Jared Polis (D), includes two medical doctors, two pharmacists and a hospital executive. A 15-member advisory council includes patient advocates, insurers, pharmacists and representatives of drug manufacturers.
The Colorado law creating the board set out a lengthy process for any drugmaker that decides to withdraw its product from the state over the price caps. (Note that the state is also exploring importing cheaper drugs from Canada, without much success so far.)
More than a dozen states are attempting to rein in drug prices through a variety of tactics. It’s early in U.S. regulators’ work to control drug prices, and it’s unclear whether the federal or state efforts will prevail.
What is clear is that patients need some relief: Over 30 percent of adults report not taking medications as prescribed because of costs, and 1 in 5 didn’t fill a prescription, according to KFF survey results published in August.
This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact NewsWeb@kff.org.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
USE OUR CONTENTThis story can be republished for free (details).
HHS Announces Savings for 41 Prescription Drugs Thanks to Inflation Rebates from the Biden-Harris Administration’s Lower Cost Prescription Drug Law
Overdosing on Chemo: A Common Gene Test Could Save Hundreds of Lives Each Year
One January morning in 2021, Carol Rosen took a standard treatment for metastatic breast cancer. Three gruesome weeks later, she died in excruciating pain from the very drug meant to prolong her life.
Rosen, a 70-year-old retired schoolteacher, passed her final days in anguish, enduring severe diarrhea and nausea and terrible sores in her mouth that kept her from eating, drinking, and, eventually, speaking. Skin peeled off her body. Her kidneys and liver failed. “Your body burns from the inside out,” said Rosen’s daughter, Lindsay Murray, of Andover, Massachusetts.
Rosen was one of more than 275,000 cancer patients in the United States who are infused each year with fluorouracil, known as 5-FU, or, as in Rosen’s case, take a nearly identical drug in pill form called capecitabine. These common types of chemotherapy are no picnic for anyone, but for patients who are deficient in an enzyme that metabolizes the drugs, they can be torturous or deadly.
Those patients essentially overdose because the drugs stay in the body for hours rather than being quickly metabolized and excreted. The drugs kill an estimated 1 in 1,000 patients who take them — hundreds each year — and severely sicken or hospitalize 1 in 50. Doctors can test for the deficiency and get results within a week — and then either switch drugs or lower the dosage if patients have a genetic variant that carries risk.
Yet a recent survey found that only 3% of U.S. oncologists routinely order the tests before dosing patients with 5-FU or capecitabine. That’s because the most widely followed U.S. cancer treatment guidelines — issued by the National Comprehensive Cancer Network — don’t recommend preemptive testing.
The FDA added new warnings about the lethal risks of 5-FU to the drug’s label on March 21 following queries from KFF Health News about its policy. However, it did not require doctors to administer the test before prescribing the chemotherapy.
The agency, whose plan to expand its oversight of laboratory testing was the subject of a House hearing, also March 21, has said it could not endorse the 5-FU toxicity tests because it’s never reviewed them.
But the FDA at present does not review most diagnostic tests, said Daniel Hertz, an associate professor at the University of Michigan College of Pharmacy. For years, with other doctors and pharmacists, he has petitioned the FDA to put a black box warning on the drug’s label urging prescribers to test for the deficiency.
“FDA has responsibility to assure that drugs are used safely and effectively,” he said. The failure to warn, he said, “is an abdication of their responsibility.”
The update is “a small step in the right direction, but not the sea change we need,” he said.
Europe Ahead on Safety
British and European Union drug authorities have recommended the testing since 2020. A small but growing number of U.S. hospital systems, professional groups, and health advocates, including the American Cancer Society, also endorse routine testing. Most U.S. insurers, private and public, will cover the tests, which Medicare reimburses for $175, although tests may cost more depending on how many variants they screen for.
In its latest guidelines on colon cancer, the Cancer Network panel noted that not everyone with a risky gene variant gets sick from the drug, and that lower dosing for patients carrying such a variant could rob them of a cure or remission. Many doctors on the panel, including the University of Colorado oncologist Wells Messersmith, have said they have never witnessed a 5-FU death.
In European hospitals, the practice is to start patients with a half- or quarter-dose of 5-FU if tests show a patient is a poor metabolizer, then raise the dose if the patient responds well to the drug. Advocates for the approach say American oncology leaders are dragging their feet unnecessarily, and harming people in the process.
“I think it’s the intransigence of people sitting on these panels, the mindset of ‘We are oncologists, drugs are our tools, we don’t want to go looking for reasons not to use our tools,’” said Gabriel Brooks, an oncologist and researcher at the Dartmouth Cancer Center.
Oncologists are accustomed to chemotherapy’s toxicity and tend to have a “no pain, no gain” attitude, he said. 5-FU has been in use since the 1950s.
Yet “anybody who’s had a patient die like this will want to test everyone,” said Robert Diasio of the Mayo Clinic, who helped carry out major studies of the genetic deficiency in 1988.
Oncologists often deploy genetic tests to match tumors in cancer patients with the expensive drugs used to shrink them. But the same can’t always be said for gene tests aimed at improving safety, said Mark Fleury, policy director at the American Cancer Society’s Cancer Action Network.
When a test can show whether a new drug is appropriate, “there are a lot more forces aligned to ensure that testing is done,” he said. “The same stakeholders and forces are not involved” with a generic like 5-FU, first approved in 1962, and costing roughly $17 for a month’s treatment.
Oncology is not the only area in medicine in which scientific advances, many of them taxpayer-funded, lag in implementation. For instance, few cardiologists test patients before they go on Plavix, a brand name for the anti-blood-clotting agent clopidogrel, although it doesn’t prevent blood clots as it’s supposed to in a quarter of the 4 million Americans prescribed it each year. In 2021, the state of Hawaii won an $834 million judgment from drugmakers it accused of falsely advertising the drug as safe and effective for Native Hawaiians, more than half of whom lack the main enzyme to process clopidogrel.
The fluoropyrimidine enzyme deficiency numbers are smaller — and people with the deficiency aren’t at severe risk if they use topical cream forms of the drug for skin cancers. Yet even a single miserable, medically caused death was meaningful to the Dana-Farber Cancer Institute, where Carol Rosen was among more than 1,000 patients treated with fluoropyrimidine in 2021.
Her daughter was grief-stricken and furious after Rosen’s death. “I wanted to sue the hospital. I wanted to sue the oncologist,” Murray said. “But I realized that wasn’t what my mom would want.”
Instead, she wrote Dana-Farber’s chief quality officer, Joe Jacobson, urging routine testing. He responded the same day, and the hospital quickly adopted a testing system that now covers more than 90% of prospective fluoropyrimidine patients. About 50 patients with risky variants were detected in the first 10 months, Jacobson said.
Dana-Farber uses a Mayo Clinic test that searches for eight potentially dangerous variants of the relevant gene. Veterans Affairs hospitals use a 11-variant test, while most others check for only four variants.
Different Tests May Be Needed for Different Ancestries
The more variants a test screens for, the better the chance of finding rarer gene forms in ethnically diverse populations. For example, different variants are responsible for the worst deficiencies in people of African and European ancestry, respectively. There are tests that scan for hundreds of variants that might slow metabolism of the drug, but they take longer and cost more.
These are bitter facts for Scott Kapoor, a Toronto-area emergency room physician whose brother, Anil Kapoor, died in February 2023 of 5-FU poisoning.
Anil Kapoor was a well-known urologist and surgeon, an outgoing speaker, researcher, clinician, and irreverent friend whose funeral drew hundreds. His death at age 58, only weeks after he was diagnosed with stage 4 colon cancer, stunned and infuriated his family.
In Ontario, where Kapoor was treated, the health system had just begun testing for four gene variants discovered in studies of mostly European populations. Anil Kapoor and his siblings, the Canadian-born children of Indian immigrants, carry a gene form that’s apparently associated with South Asian ancestry.
Scott Kapoor supports broader testing for the defect — only about half of Toronto’s inhabitants are of European descent — and argues that an antidote to fluoropyrimidine poisoning, approved by the FDA in 2015, should be on hand. However, it works only for a few days after ingestion of the drug and definitive symptoms often take longer to emerge.
Most importantly, he said, patients must be aware of the risk. “You tell them, ‘I am going to give you a drug with a 1 in 1,000 chance of killing you. You can take this test. Most patients would be, ‘I want to get that test and I’ll pay for it,’ or they’d just say, ‘Cut the dose in half.’”
Alan Venook, the University of California-San Francisco oncologist who co-chairs the National Comprehensive Cancer Network, has led resistance to mandatory testing because the answers provided by the test, in his view, are often murky and could lead to undertreatment.
“If one patient is not cured, then you giveth and you taketh away,” he said. “Maybe you took it away by not giving adequate treatment.”
Instead of testing and potentially cutting a first dose of curative therapy, “I err on the latter, acknowledging they will get sick,” he said. About 25 years ago, one of his patients died of 5-FU toxicity and “I regret that dearly,” he said. “But unhelpful information may lead us in the wrong direction.”
In September, seven months after his brother’s death, Kapoor was boarding a cruise ship on the Tyrrhenian Sea near Rome when he happened to meet a woman whose husband, Atlanta municipal judge Gary Markwell, had died the year before after taking a single 5-FU dose at age 77.
“I was like … that’s exactly what happened to my brother.”
Murray senses momentum toward mandatory testing. In 2022, the Oregon Health & Science University paid $1 million to settle a suit after an overdose death.
“What’s going to break that barrier is the lawsuits, and the big institutions like Dana-Farber who are implementing programs and seeing them succeed,” she said. “I think providers are going to feel kind of bullied into a corner. They’re going to continue to hear from families and they are going to have to do something 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.
USE OUR CONTENTThis story can be republished for free (details).
A Paramedic Was Skeptical About This Rx for Stopping Repeat Opioid Overdoses. Then He Saw It Help.
OCALA, Fla. — Fire Capt. Jesse Blaire steered his SUV through the mobile home park until he spotted the little beige house with white trim and radioed to let dispatchers know he’d arrived.
There, Shawnice Slaughter waited on the steps, wiping sleep from her eyes.
“Good morning, Shawnice,” Blaire said. “How are you feeling today?”
“I’ve been good, I’ve been good,” Slaughter said. “Much better.”
Three days earlier, Blaire — a paramedic who leads the fire department’s emergency medical team — met Slaughter at a nearby hospital. She had overdosed on opioids. It took four vials of an overdose reversal medication and dozens of chest compressions to get her breathing again.
At the hospital, Blaire told Slaughter about a free program that could help. It wouldn’t just connect her with a recovery center but would also get her doctors’ appointments, plus rides there. More important, she would get medicine to alleviate withdrawal symptoms so she wouldn’t search for drugs to ease the sickness. Blaire would bring that medication, daily, to her home.
“I have a son,” Slaughter, 31, told Blaire. “I need to be alive for him.”
Every morning since, Blaire had driven over for a check-in. He reminded Slaughter of appointments and took note of what she needed: clothes, food, help with bills.
And at the end of each visit, from a lockbox in the back of his car, he dispensed to her a couple of tiny, lifesaving tablets.
Those tablets — a medicine called buprenorphine — represent a tidal change in the way counties in Florida and other states are addressing the opioid crisis. The idea: Get addiction medication to people who need it by meeting them where they are. Sometimes, that’s on the street. Sometimes, it’s in the driveway of a big house with a swimming pool. Sometimes on the steps of a modest home like Slaughter’s.
********
For a long time, many people who could benefit from buprenorphine, commonly known by the brand name Subutex, couldn’t get it.
Until recently, doctors needed a federal waiver to prescribe it to treat opioid use disorder. Amid misconceptions about treating opioid use disorder with medication, only about 5% of doctors nationally underwent the training to qualify. And in 2021, only 1 in 5 people who could have benefited from opioid addiction medication were receiving buprenorphine or another drug therapy.
But as evidence supporting the drug’s efficacy grew and the urgency mounted to curb opioid deaths, Congress axed the waiver requirement in late 2022, clearing the way for greater availability.
And in rare cases, such as in Ocala, medics on the front lines began bringing treatment to patients’ front doors.
In Florida, the state-run Coordinated Opioid Recovery Network, known as the CORE Network, provides guidelines on medicine distribution to areas hit hard by overdoses. Services through the network are free for patients, funded by money from the state’s opioid settlement.
The network looks different in each of its 13 counties. Not all hand-deliver buprenorphine. But the common goal is to create a single entry point for services that have typically been siloed and difficult for patients to navigate, such as mental health care and housing support.
In a recovery landscape rife with shoddy facilities and prohibitive price tags, simplifying the path for patients stands to make a meaningful difference.
“We know that the more people are in contact with services, the more they’re treated with respect, the more likely they are to reduce or cease drug use,” said Susan Sherman, a public health professor at Johns Hopkins University.
As opioid settlement dollars continue to come in, state officials have said they hope to expand to more counties.
********
Becoming a firefighter and paramedic satisfied Blaire’s craving for adrenaline and his conviction, informed in part by his Christian background, that he was put on this Earth to help others.
At 20, he imagined responding to car crashes and heart attacks, broken bones and punctured flesh. But after years on the job with Ocala Fire Rescue, the calls began to change.
At first, Blaire felt some resentment toward the people overdosing. His team was suddenly responding to hundreds of such calls a year. He viewed drug use as a moral failure. What if a grandmother had a heart attack or a kid drowned while his team was on an overdose call?
Unlike with other emergencies, he never really felt he was saving a life when responding to an overdose. It was more like delaying death.
Over and over, he’d pump a patient full of naloxone, an overdose reversal medication often known by one of its brand names, Narcan, and drop them at the hospital, only to find they’d overdosed again after being discharged. One Christmas, he said, he responded to the same person overdosing five times on a single shift.
“I didn’t understand it. I thought that they wanted to die,” said Blaire, 47. “I’m embarrassed to say that now.”
About a decade ago, the scope of the epidemic had already come into full view to Blaire’s crew. It seemed the team was responding to overdoses at big houses in wealthy neighborhoods nearly as often as they were in the park and under the bridge.
One week, his team went to a home on a cul-de-sac with two kids and a swing set — the kind of place families take their children trick-or-treating.
The dad had overdosed. The next week, it was the mom.
“Money can mask any problem, but we’ve seen it from the top to the bottom,” Blaire said.
Over time, Blaire began to understand addiction as the disease it is: a physiological change to someone’s brain that traps them in a dangerous cycle. Maybe it started with a prescription painkiller after surgery, or an indulgence at a party, but the majority of people weren’t using drugs to get high, he realized. They were using them to avoid being sick.
“Imagine the worst flu you’ve ever had, then make it a lot worse,” Blaire said.
When a person dependent on opioids stops taking them, their body goes into withdrawal, often accompanied by shakes, nausea, fever, sweating, and chills. Though rare, people can die from opioid withdrawal syndrome. Still, historically, the emergency health care system has focused on reversing overdoses, rather than treating the withdrawal side effects that keep people returning to drugs.
In the past, Blaire said, he saw patients released from the hospital with little more than a phone number for a recovery center. Getting an appointment could be challenging, not only because of wait times or insurance complications, but because the patients weren’t stable — they were in withdrawal. To make it through the day, Blaire said, they’d often use again.
“‘Good luck, you’re on your own,’” Blaire said. “That’s how it was. And that doesn’t work for somebody who is sick.”
Under Blaire’s leadership, Ocala Fire Rescue sought to stop the revolving door by launching its Community Paramedicine program and the Ocala Recovery Project in 2020.
They modeled it after overdose quick-response teams around the country, which vary in makeup. These mobile teams, typically helmed by paramedics like Blaire, connect people who have overdosed with services aimed at stabilizing them long-term. On some, a registered nurse embeds with paramedics in an ambulance or SUV. Others have a therapist or peer recovery coach on board. Some are bare-bones: a single responder with a phone on 24 hours a day. Some get in touch with patients through a call or a home visit after a reported overdose.
Others, like Blaire’s team, intercept patients at the hospital.
Blaire likens the system to that of a trauma alert — a message sent to medical centers to ready a response to near-fatal car wrecks or shootings. When a trauma alert goes out, operating tables are cleared, CT scanners are prepped, and responders stand by for arrival.
“We set the same system up for overdoses,” Blaire said.
Now, when somebody in Ocala overdoses, whether it’s on opioids, alcohol, meth, or cocaine, an alert goes out, notifying Blaire and his team, a peer recovery coach, a behavioral health specialist, and a local recovery center.
His team usually beats the ambulance to the hospital.
The next day, team members follow up at the patient’s home.
Then, last May, under the guidance of the EMS medical director, Blaire’s team started offering addiction medication to opioid users, too.
Since then, Blaire said, his team has connected 149 patients with treatment. Only 28 of them have needed additional intervention, he said.
********
When Blaire first heard about buprenorphine, he was skeptical.
How could giving somebody with an addiction more narcotics help?
That common response misunderstands the reality of addiction, said Nora Volkow, director of the National Institute on Drug Abuse.
People perceive that one drug is being substituted for another, Volkow said. Instead, the use of medications like buprenorphine is more akin to those that treat other psychiatric conditions, like mood disorders or depression.
Research shows that opioid addiction medication — including drugs like methadone — can greatly reduce the risk of overdose deaths, and increase a person’s retention in treatment. But a study out of the New York University Grossman School of Medicine found that nearly 87% of people with opioid use disorders don’t receive any.
Such addiction medications work by stimulating opioid receptors in the brain.
Opioids — like oxycodone or fentanyl — are what experts refer to as “full agonists.” Imagine an opioid receptor as a rounded bowl. A full agonist — like fentanyl — fits perfectly in that bowl and latches tightly to the receptor.
Buprenorphine is a “partial agonist.” It fits in the bowl — and satiates a craving — but doesn’t completely bind like a full agonist. Instead, it eliminates withdrawal symptoms so people won’t get sick or crave illicit drugs, without producing a high. Second, it counteracts the effects of other drugs, so a person can’t overdose on other opioids like fentanyl or heroin while taking it.
And for somebody who already uses opioids, overdosing from buprenorphine is nearly impossible.
“They help a person regain control of their everyday life,” Volkow said.
********
On this Monday in January, Blaire pulled into Beacon Point, a local treatment center, just past 2 p.m.
He’d spent his morning calling on people like Slaughter, but now he was meeting paramedics from his team. After nearly three weeks of home visits, a man in the recovery network program was set to have his first appointment with a doctor.
Blaire has found that once people are stable on buprenorphine, more often than not they want to get into a treatment program.
While Blaire waited, a woman walking out of the center approached, smiling.
“I just got my first clean urine analysis,” she said. “I’m doing great, I’m so excited.”
“That’s awesome news,” Blaire said, a smile stretched across his face. He’s often stoic, straight-laced, with combed hair and aviators. But when he lights up, his all-business exterior gives way to gentleness.
Jacqueline Luciano is sober for the first time in 30 years. She’s proud, glowing, and Blaire is proud, too.
Luciano first came to Blaire through a referral when she was living at a women’s shelter. She said she had $20 in her pocket and wanted to get high — needed to.
Fentanyl withdrawal had left her shaky and cold. Her stomach was seizing, her muscles spasming. To quell the agony that day in early January, she went on the hunt.
Luciano said she had first used drugs when she was 9. Her family had been torn apart by pills and powders, she said, a sickness she’d inherited.
But this time, a woman — “like an angel” — passed her a number for someone who she promised could guide her into a brighter future, blame-free. Luciano, 39, paused, skeptical.
Then she gave Blaire a call.
For about a week, Blaire delivered her a daily dose of buprenorphine using a Safe RX bottle — essentially a trackable pill bottle with a lock code to limit who can open it. He helped connect her with food and clothing donations.
And as Luciano started to feel more like herself, absent of cravings, she began to hope.
Blaire got her an appointment with doctors at Beacon Point, then drove her to her first screening. Now, in the parking lot, she thanked him for everything.
“It made all the difference in the world,” Luciano told Blaire. “I really didn’t think that I could get better. I didn’t. But I am.”
As a tear rolled down Luciano’s face, Blaire’s phone rang.
********
The call came from the health department. A man in his 40s or 50s had come some 40 miles from Gainesville, Florida, for help, steered through word of mouth.
He’d tried to get into a recovery center there but said he was turned away. Something about insurance and a criminal record had stood in the way.
It’s a pattern that drives Blaire crazy. He’d seen it a lot before his team was formed. People would get a moment of courage or clarity, only to be told “not yet.”
“Your first answer has to be ‘yes,’” he said. “‘Yes, I can help you.’”
He knew about a woman who had come from 25 miles out of town, then was told to come back days later. She didn’t have a car or a home to return to.
“They didn’t even offer her a ride,” Blaire said. “Sometimes you only have one shot.”
Blaire has learned that building trust starts with a small offering. A car ride. A sandwich. Help getting a government ID. Anything to show that you care, that you’re useful. That you see someone trying.
Outside the health department, a man in muddied jeans and a frayed T-shirt stood waiting on the curb. He introduced himself as Jetson and didn’t give a last name. Blaire shook his hand before they loaded into the car.
“So what brings you this way?” Blaire asked, once both were buckled in.
“I heard there were services here,” Jetson said, his voice gruff, quivering. “I’ve tried to stop using so many times, but I keep messing it up.”
Jetson shook his head.
“Well, I’m glad you found us,” Blaire said. He asked the man if he wanted to go to the recovery center for a screening. He did.
Over the 10-minute drive to Beacon Point, Blaire and Jetson talked, not about drugs or meds, but life. Baseball. Cabbage (good when fried).
When they pulled up, Blaire handed Jetson a card.
“Please call me,” Blaire said. “If you need anything. We can get you help.”
For a moment, the men sat there. Jetson pulling at his fingers. Taking deep breaths.
Then, he got out of the car — Blaire’s card in hand — and walked through the glass door.
This article was produced in partnership with the Tampa Bay Times.
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.
USE OUR CONTENTThis story can be republished for free (details).
A Mom’s $97,000 Question: How Was Her Baby’s Air-Ambulance Ride Not Medically Necessary?
Sara England was putting together Ghostbusters costumes for Halloween when she noticed her baby wasn’t doing well.
Her 3-month-old son, Amari Vaca, had undergone open-heart surgery two months before, so she called his cardiologist, who recommended getting him checked out. England assigned Amari’s grandparents to trick-or-treat duty with his three older siblings and headed to the local emergency room.
Once England and the baby arrived at Natividad Medical Center in Salinas, California, she said, doctors could see Amari was struggling to breathe and told her that he needed specialized care immediately, from whichever of two major hospitals in the region had an opening first.
Even as they talked, Amari was declining rapidly, his mother said. Doctors put a tube down his throat and used a bag to manually push air into his lungs for over an hour to keep his oxygen levels up until he was stable enough to switch to a ventilator.
According to England, late that night, when doctors said the baby was stable enough to travel, his medical team told her that a bed had opened up at the University of California-San Francisco Medical Center and that staffers there were ready to receive him.
She, her son, and an EMT boarded a small plane around midnight. Ground ambulances carried them between the hospitals and airports.
Amari was diagnosed with respiratory syncytial virus, or RSV, and spent three weeks in the hospital before recovering and returning home.
Then the bill came.
The Patient: Amari Vaca, now 1, who was covered by a Cigna policy sponsored by his father’s employer at the time.
Medical Services: An 86-mile air-ambulance flight from Salinas to San Francisco.
Service Provider: Reach Medical Holdings, which is part of Global Medical Response, an industry giant backed by private equity investors. Global Medical Response operates in all 50 states and has said it has a total of 498 helicopters and airplanes. It is out-of-network with Amari’s Cigna plan.
Total Bill: $97,599. Cigna declined to cover any part of the bill.
What Gives: Legal safeguards are in place to protect patients from big bills for some out-of-network care, including air-ambulance rides.
Medical billing experts said the No Surprises Act, a federal law enacted in 2022, could have protected Amari’s family from receiving the $97,000 “balance bill,” leaving the insurer and the air-ambulance provider to determine fair payment according to the law. But the protections apply only to care that health plans determine is “medically necessary” — and insurers get to define what that means in each case.
According to its coverage denial letter, Cigna determined that Amari’s air-ambulance ride was not medically necessary. The insurer cited its reasoning: He could have taken a ground ambulance instead of a plane to cover the nearly 100 roadway miles between Salinas and San Francisco.
“I thought there must have been a mistake,” England said. “There’s no way we can pay this. Is this a real thing?”
In the letter, Cigna said Amari’s records did not show that other methods of transportation were “medically contraindicated or not feasible.” The health plan also noted the absence of documentation that he could not be reached by a ground ambulance for pickup or that a ground ambulance would be unfeasible because of “great distances or other obstacles.”
Lastly, it said records did not show a ground ambulance “would impede timely and appropriate medical care.”
When KFF Health News asked Cigna what records were referenced when making this decision, a spokesperson declined to respond.
Caitlin Donovan, a spokesperson for the National Patient Advocate Foundation, said that even though Amari’s bill isn’t technically in violation of the No Surprises Act, the situation is exactly what the law was designed to avoid.
“What they’re basically saying is that the parents should have opted against the advice of the physician,” Donovan said. “That’s insane. I know ‘medical necessity’ is this nebulous term, but it seems like it’s becoming a catch-all for turning down patients.”
On Feb. 5, the National Association of Emergency Medical Services Physicians said that since the No Surprises Act was enacted two years ago, it has seen a jump in claim denials based on “lack of medical necessity,” predominantly for air-ambulance transports between facilities.
In a letter to federal health officials, the group cited reasons commonly given for inappropriate medical-necessity denials observed by some of its 2,000 members, such as “the patient should have been taken elsewhere” or “the patient could have been transported by ground ambulance.”
The association urged the government to require that health plans presume medical necessity for inter-facility air transports ordered by a physician at a hospital, subject to a retrospective review.
Such decisions are often “made under dire circumstances — when a hospital is not capable of caring for or stabilizing a particular patient or lacks the clinical resources to stabilize a patient with a certain clinical diagnosis,” the group’s president, José Cabañas, wrote in the letter. “Clinical determinations made by a referring physician (or another qualified medical professional) should not be second-guessed by a plan.”
Patricia Kelmar, a health policy expert and senior director with the U.S. Public Interest Research Groups, noted, however, that hospitals could familiarize themselves with local health plans, for example, and establish protocol, so that before they call an air ambulance, they know if there are in-network alternatives and, if not, what items the plan needs to justify the claim and provide payment.
“The hospitals who live and breathe and work in our communities should be considering the individuals who come to them every day,” Kelmar said. “I understand in emergency situations you generally have a limited amount of time, but, in most situations, you should be familiar with the plans so you can work within the confines of the patient’s health insurance.”
England said Cigna’s denial particularly upset her.
“As parents, we did not make any of the decisions other than to say, yes, we’ll do that,” she said. “I don’t know how else it could have gone.”
The Resolution: England twice appealed the air-ambulance charge to the insurer, but both times Cigna rejected the claim, maintaining that “medical necessity” had not been established.
The final step of the appeals process is an external review, in which a third party evaluates the case. England said staff members at Natividad Medical Center in Salinas — which arranged Amari’s transport — declined to write an appeal letter on his behalf, explaining to her that doing so is against the facility’s policy.
Using her son’s medical records, which the Natividad staff provided, England said she is writing a letter herself to assert why the air ambulance was medically necessary.
Andrea Rosenberg, a spokesperson for Natividad Medical Center, said the hospital focuses on “maintaining the highest standards of health care and patient well-being.”
Despite receiving a waiver from England authorizing the medical center to discuss Amari’s case, Rosenberg did not respond to questions from KFF Health News, citing privacy issues. A Cigna spokesperson told KFF Health News that the insurer has in-network alternatives to the out-of-network ambulance provider, but — despite receiving a waiver authorizing Cigna to discuss Amari’s case — declined to answer other questions.
“It is disappointing that CALSTAR/REACH is attempting to collect this egregious balance from the patient’s family,” the Cigna spokesperson, Justine Sessions, said in an email, referring to the air-ambulance provider. “We are working diligently to try to resolve this for the family.”
On March 13, weeks after being contacted by KFF Health News, England said, a Cigna representative contacted her and offered assistance with her final appeal, the one reviewed by a third party. The representative also told her the insurer had attempted to contact the ambulance provider but had been unable to resolve the bill with them.
Global Medical Response, the ambulance provider, declined to comment.
England said she and her husband have set aside two hours each week for him to take care of their four kids while she shuts herself in her room and makes calls about their medical bills.
“It’s just another stress,” she said. “Another thing to get in the way of us being able to enjoy our family.”
The Takeaway: Kelmar said she encourages patients to appeal bills that seem inaccurate. Even if the plan denies it internally, push forward to an external review so someone outside the company has a chance to review, she said.
In the case of “medical necessity” denials, Kelmar recommended patients work with the medical provider to provide more information to the insurance company to underscore why an emergency transport was required.
More from Bill of the Month- Without Medicare Part B’s Shield, Patient’s Family Owes $81,000 for a Single Air-Ambulance Flight Feb 27, 2024
- The Colonoscopies Were Free. But the ‘Surgical Trays’ Came With $600 Price Tags. Jan 25, 2024
- When a Quick Telehealth Visit Yields Multiple Surprises Beyond a Big Bill Dec 19, 2023
Doctors who write a letter or make a call to a patient’s insurer explaining a decision can also ask for a “peer-to-peer review,” meaning they would discuss the case with a medical expert in their field.
Kelmar said patients with employer-sponsored health plans can ask their employer’s human resources department to advocate for them with the health plan. It’s in the employers’ best interest since they often pay a lot for these health plans, she said.
No matter what, Kelmar said, patients shouldn’t let fear stop them from appealing a medical bill. Patients who appeal have a high likelihood of winning, she said.
Patients with government health coverage can further appeal insurance denials by filing a complaint with the Centers for Medicare & Medicaid Services. Those who believe they have received an inappropriate bill from an out-of-network provider can call the No Surprises Act help desk at 1-800-985-3059.
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!
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.
USE OUR CONTENTThis story can be republished for free (details).
After Appalachian Hospitals Merged Into a Monopoly, Their ERs Slowed to a Crawl
In the small Appalachian city of Bristol, Virginia, City Council member Neal Osborne left a meeting on the morning of Jan. 3 and rushed himself to the hospital.
Osborne, 36, has Type 1 diabetes. His insulin pump had malfunctioned, and without a steady supply of this essential hormone, Osborne’s blood sugar skyrocketed and his body was shutting down.
Osborne went to the nearest hospital, Bristol Regional Medical Center. He said he settled into a wheelchair in the emergency room waiting area, where over the next few hours he drifted in and out of consciousness and retched up vomit, then bile, then blood. After 12 hours in the waiting room, Osborne said, he was moved to an ER bed, where he stayed until he was sent to the intensive care unit the next day. In total, the council member was in the ER for about 30 hours, he said.
Osborne said his ordeal echoes stories he’s heard from constituents for years. In his next crisis, Osborne said, he plans to leave Bristol for an ER about two hours away.
“I want to go to Knoxville or I want to go to Roanoke, because I do not want to further risk my life and die at a Ballad hospital,” he said. “The wait times just to get in and see a doctor in the ER have grown exponentially.”
Ballad Health, a 20-hospital system in the Tri-Cities region of Tennessee and Virginia, benefits from the largest state-sanctioned hospital monopoly in the United States. In the six years since lawmakers in both states waived anti-monopoly laws and Ballad was formed, ER visits for patients sick enough to be hospitalized grew more than three times as long and now far exceed the criteria set by state officials, according to Ballad reports released by the Tennessee Department of Health.
Tennessee and Virginia have so far announced no steps to reduce time spent in Ballad ERs. The Tennessee health department, which has a more direct role in regulating Ballad, has each year issued a report saying the agreement that gave Ballad a monopoly “continues to provide a Public Advantage.” Department officials have twice declined to comment to KFF Health News on Ballad’s performance.
According to Ballad’s latest annual report, which was released this month and spans from July 2022 to June 2023, the median time that patients spend in Ballad ERs before being admitted to the hospital is nearly 11 hours. This statistic includes both time spent waiting and time being treated in the ER and excludes patients who weren’t admitted or left the ER without receiving care.
The federal government once tracked ER speed the same way. When compared against the latest corresponding federal data from 2019, which includes more than 4,000 hospitals but predates the covid-19 pandemic, Ballad ranks among the 100 hospitals with the slowest ERs. More current federal data is not available because the Centers for Medicare & Medicaid Services retired this statistic in 2020 in favor of other measurements.
Newer data tells a similar story. The Joint Commission, a nonprofit that accredits health care organizations, collected this same measurement for 2022 from about 250 hospitals that volunteered the data, finding a median ER speed of five hours and 41 minutes — or about five hours faster than Ballad’s latest annual report.
Ballad Health spokesperson Molly Luton said in an email statement that, by holding patients in the ER, where they are observed while waiting for a bed, Ballad avoids “overwhelming” its staff. Luton said ER delays are also caused by two nationwide crises: a nursing shortage and fewer admissions at nursing homes and similar facilities, which can create a backlog of patients awaiting discharge from the hospital.
Luton added that Ballad’s ER time for admitted patients has dropped to about 7½ hours in the months since the company’s latest annual report.
“On those issues Ballad Health can directly control, our performance has rebounded from 2022, and is now among the best in the nation,” Luton said.
Luton also noted that Ballad performs better than or close to the national average on several other measurements of ER performance, including having fewer patients who leave without being treated. CMS data shows the national average is about 3%. Ballad reported 1.4% in its latest annual report.
Osborne, the Bristol council member, attributed this statistic to Ballad’s monopoly.
“Just because they aren’t leaving the ER doesn’t mean they are happy where they are,” he said. “It just means they don’t have anywhere else they could be.”
Ballad’s Big Monopoly
Ballad Health was formed in 2018 after state officials approved the nation’s biggest hospital merger based on a so-called Certificate of Public Advantage, or COPA, agreement. COPAs have been used in about 10 hospital mergers over the past three decades, but none has involved as many hospitals as Ballad’s.
State lawmakers in Tennessee and Virginia waived federal anti-monopoly laws so rival hospital systems — Mountain States Health Alliance and Wellmont Health System — could merge into a single company with no competition. Ballad is now the only option for hospital care for most of about 1.1 million residents in a 29-county region at the nexus of Tennessee, Virginia, Kentucky, and North Carolina.
The Federal Trade Commission warns that hospital monopolies lead to increased prices and decreased quality of care. To offset the perils of Ballad’s monopoly, officials required the new company to commit to a long list of special conditions, including dozens of quality-care metrics spelled out with specific benchmarks.
In its latest annual report, Ballad improved on many quality-of-care metrics over the prior year, including several that the company prioritized, but still fell short on 56 of 75 benchmarks.
ER time for admitted patients is one of those. The benchmark was set at three hours and 47 minutes in the original COPA agreement. Ballad met or nearly met this goal for three years, according to its annual reports. Then the ERs slowed.
In 2022, Ballad reported a median ER time for admitted patients of about six hours.
In 2023, it reported the same statistic at seven hours and 40 minutes.
In the latest report, ER time for admitted patients had reached 10 hours and 45 minutes.
CMS, which grades thousands of hospitals nationwide, warns on its website that timely ER care is “essential for good patient outcomes,” and that more time spent in the ER has been linked to higher complication rates and delays in patients getting pain medication and antibiotics.
Ben Harder, chief of health analysis for U.S. News & World Report, said extensive ER times can be a symptom of slowdowns throughout a hospital, including in the operating room.
“A long delay in getting patients admitted is both a risk in itself, in that a test may not get conducted as promptly,” Harder said. “But it’s also an indication that the hospital is backed up, and that there are problems getting patients moved from one unit to another.”
Bill Christian, a spokesperson for the Tennessee Department of Health, said Ballad’s rising ER times had been “noted” but did not say if the agency had taken or was considering any action. Christian directed questions about Ballad’s latest stats to the company itself.
‘A Nightmare for Community Members’
Ballad has also fallen short — by about $191 million over the past five years — of its obligation to Tennessee to provide charity care, which is free or discounted care for low-income patients, according to health department documents and Ballad’s latest report. The health department waived this obligation in each of the past four fiscal years. Ballad has said it would ask for another this year.
In a two-hour interview last year, Ballad CEO Alan Levine defended his company and said that because the Tri-Cities region could not support two competing hospital companies, the COPA merger had likely prevented at least three hospital closures. Levine attributed Ballad’s failure to meet quality benchmarks to the pressure of the covid pandemic and said charity care shortfalls were partly caused by Medicaid changes beyond Ballad’s control.
“Our critics say, ‘No Ballad. We don’t want Ballad.’ Well, then what?” Levine said. “Because the hospitals were on their way to being closed.”
Some residents see Ballad as a savior. John King, who runs a physical therapy clinic in the core of Ballad’s region, said at a public hearing last June that in multiple visits to Ballad ERs, including one for a stroke, he found their care to be quick and compassionate.
“If it weren’t for Ballad Health, I literally would not be here today,” King said, according to a hearing transcript.
Ballad’s failures to live up to the terms of the COPA agreement were detailed in a KFF Health News investigation last September, and the company faced a new wave of criticism in the months that followed.
Local leaders in Carter County, Tennessee, in October debated but did not pass a resolution calling for Ballad to be better regulated or broken up. Tennessee Attorney General Jonathan Skrmetti, a Republican, said in an interview with the Tennessee Lookout published in November that Ballad must be constantly monitored in light of community complaints. Earlier this month, Tennessee state Rep. David Hawk (R-Greeneville), who represents a region within Ballad’s monopoly, called for Levine’s resignation, according to wjhl.com.
In response, Ballad Health said in a statement it has “strong relationships with the majority of elected officials” in Carter County and welcomed scrutiny from the Tennessee attorney general. Ballad said Hawk’s “opinion certainly does not reflect our broader relationships” within the area. Tennessee lawmakers are also considering legislation to forbid future COPA mergers in the state, which Ballad said “risks putting more hospitals at risk for closure.”
The bill was introduced by state Sen. Heidi Campbell (D-Nashville) and state Rep. Gloria Johnson (D-Knoxville), who is running for the U.S. Senate. Johnson said the bill would end Ballad’s protection from antitrust laws.
“It’s just been a nightmare for community members out there,” Johnson said. “And they have no other option.”
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.
USE OUR CONTENTThis story can be republished for free (details).
Readout of HHS Roundtable with Africa CDC on Ongoing Global Health Security Partnership
Journalists Track Efforts to Curb the Opioid Crisis and Put Catholic Hospitals Under the Scope
KFF Health News senior correspondent Aneri Pattani discussed her experiences reporting on addiction and offers advice to journalists starting on this beat for the American Society of Addiction Medicine’s “The Treat Addiction Save Lives Podcast” on March 18. She also discussed the spending questions surfacing as $1 billion flows into Massachusetts to fight opioids on WCVB NewsCenter 5’s “5 Investigates” on March 6.
- Click here to hear Pattani on “The Treat Addiction Save Lives Podcast”
- Click here to watch Pattani on “5 Investigates”
- Read Pattani’s series “Payback: Tracking the Opioid Settlement Cash”
KFF Health News correspondent Rachana Pradhan discussed the constraints on women’s health care at Catholic and Catholic-affiliated hospitals for PBS’ “PBS News Weekend” on March 17.
- Click here to watch Pradhan on “PBS News Weekend”
- Read Pradhan’s “The Powerful Constraints on Medical Care in Catholic Hospitals Across America”
KFF Health News ethnic media editor Paula Andalo discussed how Colorado students are pushing for the ability to carry naloxone on Radio Bilingüe’s “Linea Abierta” on March 14.
- Click here to hear Andalo on “Linea Abierta” (in Spanish)
- Read Rae Ellen Bichell’s “How a Friend’s Death Turned Colorado Teens Into Anti-Overdose Activists“
- Leer Rae Ellen Bichell’s “Cómo la muerte de un amigo hizo que adolescentes de Colorado se volvieran activistas contra las sobredosis”
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.
USE OUR CONTENTThis story can be republished for free (details).
En California, la cobertura de salud ampliada a inmigrantes choca con las revisiones de Medicaid
OAKLAND, California – El Medi-Cal llegó a Antonio Abundis cuando el conserje más lo necesitaba.
Poco después que Abundis pasara de tener cobertura limitada a una cobertura completa en 2022, bajo la expansión del Medi-Cal de California para adultos mayores sin papeles, fue diagnosticado con leucemia, un tipo de cáncer que afecta las células de la sangre.
El padre de tres hijos, de voz suave, tomó la noticia con calma cuando su médico le dijo que sus análisis de sangre sugerían que su cáncer no estaba en una etapa avanzada. Sus siguientes pasos fueron hacerse más pruebas y tener un plan de tratamiento con un equipo de cáncer en Epic Care, en Emeryville.
Pero todo eso se fue por la borda cuando se presentó en julio pasado para hacerse un análisis de sangre en La Clínica de La Raza en Oakland, y le dijeron que ya no era beneficiario de Medi-Cal.
“Nunca mandaron una carta ni nada de que a mí me la había negado”, dijo Abundis, ahora de 63 años, sobre la pérdida de su cobertura.
Abundis es uno de los cientos de miles de latinos de California que han sido expulsados de Medi-Cal —el programa estatal de Medicaid para personas de bajos ingresos— a medida que los estados reanudaban las verificaciones de elegibilidad, que se habían suspendido en el punto más álgido de la pandemia de covid-19.
El proceso de redeterminación ha afectado de forma desproporcionada a los latinos, que constituyen la mayoría de los beneficiarios de Medi-Cal.
Según el Departamento de Servicios de Salud de California (DHCS), más de 613,000 de los 1,24 millones de residentes que fueron dados de baja se identifican como latinos. Algunos, incluido Abundis, habían obtenido la cobertura poco tiempo antes, cuando el estado comenzó a expandir Medi-Cal para ofrecer cobertura a inmigrantes indocumentados.
El choque entre las políticas estatales y las federales no sólo ha significado un duro golpe para los beneficiarios: también disparó la demanda de asistencia para realizar los trámites de inscripción.
Esto ocurre porque muchas personas son excluidas de Medi-Cal por cuestiones administrativas.
Los grupos de salud que trabajan con las comunidades latinas informan que están inundados de solicitudes de ayuda. Al mismo tiempo, una encuesta patrocinada por el estado sugiere que los hogares hispanos tienen más probabilidades que otros grupos étnicos o raciales de perder la cobertura porque tienen menos información sobre el proceso de renovación.
También pueden tener dificultades para defenderse por sí solos.
Algunos defensores de salud están presionando para que haya una pausa en este proceso. Advierten que las desafiliaciones no solo socavarán los esfuerzos del estado para reducir el número de personas sin seguro, sino que podrían exacerbar las disparidades en salud, especialmente para un grupo étnico que sufrió fuerte el peso de la pandemia.
Un estudio nacional encontró que los latinos en el país tuvieron tres veces más probabilidades de desarrollar covid y el doble de probabilidades de morir a causa de la enfermedad que la población en general, en parte porque tienden a vivir en hogares más hacinados o multigeneracionales y tienen trabajos en servicios, de cara al público.
“Estas dificultades nos colocan a todos como comunidad en un estatus más frágil, en el cual la red de seguridad es aún más significativa”, dijo Seciah Aquino, directora ejecutiva de la Latino Coalition for a Healthy California, una organización de defensa de salud.
La asambleísta Tasha Boerner (demócrata de Encinitas) ha presentado un proyecto de ley que desaceleraría las bajas permitiendo que las personas de 19 años o más mantengan automáticamente su cobertura durante 12 meses, y extendiendo las políticas flexibles de la era pandémica, como no requerir prueba de ingresos para renovar la cobertura en ciertos casos. Esto beneficiaría a los hispanos, que representan casi el 51% de la población de Medi-Cal en comparación con el 40% de la población total del estado.
La oficina del gobernador dijo que no comenta sobre proyectos legislativos que están aún en proceso.
Tony Cava, vocero del Departamento de Servicios de Atención Médica (DHCS), dijo en un correo electrónico que la agencia ha tomado medidas para aumentar el número de personas reinscritas automáticamente en Medi-Cal y no cree que sea necesaria una pausa. La tasa de desafiliación disminuyó un 10% de noviembre a diciembre, apuntó Cava.
Sin embargo, funcionarios estatales reconocen que se podría hacer más para ayudar a las personas a completar sus solicitudes. “Todavía no estamos llegando a ciertos sectores”, dijo Yingjia Huang, subdirectora adjunta de beneficios de atención médica y elegibilidad del DHCS.
California fue el primer estado en ampliar la elegibilidad de Medicaid a todos los inmigrantes que calificaran, sin importar su estatus migratorio, implementándolo gradualmente durante varios años: niños en 2016, adultos jóvenes de 19 a 26 años en 2020, personas de 50 años en adelante en 2022, y todos los adultos restantes este año.
Pero California, como otros estados, reanudó las verificaciones de elegibilidad en abril pasado, y se espera que el proceso continúe hasta mayo. El estado ahora está viendo que las tasas de desafiliación vuelven a los niveles previos a la pandemia, o el 19%-20% de la población de Medi-Cal cada año, según el DHCS.
Jane García, directora ejecutiva de La Clínica de La Raza, testificó ante el Comité de Salud de la Junta de Supervisores del condado de Alameda que las desafiliaciones siguen siendo un desafío, justo cuando su equipo intenta inscribir a residentes recién elegibles. “Es una carga enorme para nuestro personal”, les dijo a los supervisores en enero.
Aunque muchos beneficiarios ya no califican porque sus ingresos aumentaron, muchos más han sido eliminados de los registros por no responder a avisos o devolver documentos. En muchos casos, los paquetes de documentos para renovar la cobertura se enviaron a direcciones antiguas. Muchos se enteran de que perdieron la cobertura recién cuando van al médico.
“Sabían que algo estaba pasando”, dijo Janet Anwar, gerenta de elegibilidad en el Tiburcio Vásquez Health Center, en East Bay. “No sabían exactamente qué era, cómo los iba a afectar hasta que llegó el día y fueron desafiliados. Y estaban haciéndose un chequeo, o programando una cita, y luego… ‘Oye, perdiste tu cobertura'”.
Y la reinscripción es un desafío. Una encuesta patrocinada por el estado publicada el 12 de febrero por la California Health Care Foundation halló que el 30% de los hogares hispanos intentaron completar un formulario de renovación sin suerte, en comparación con el 19% de los hogares blancos no hispanos. Y el 43% de los hispanos informaron que les gustaría volver a comenzar con Medi-Cal, pero no sabían cómo, en comparación con el 32% de las personas en hogares blancos no hispanos.
La familia Abundis está entre las que no saben dónde obtener respuestas a sus preguntas. Aunque la esposa de Abundis envió la documentación de renovación de Medi-Cal para toda la familia en octubre, ella y dos hijos que aún viven con ellos pudieron mantener la cobertura; Abundis fue el único que la perdió.
No ha recibido una explicación de por qué lo sacaron de Medi-Cal ni ha sido notificado de cómo apelar o volver a solicitarlo.
Ahora se preocupa de que tal vez no califique por sí solo según sus ingresos anuales de aproximadamente $36,000, ya que el límite es de $20,121 para un individuo, pero de $41,400 para una familia de cuatro.
Es probable que un navegador pueda verificar si él y su familia califican como un hogar o ayudarlo a inscribirse en un plan privado que puede costar menos de $10 al mes en primas en Covered California. Este mercado de seguros de salud permite la inscripción especial cuando las personas pierden la cobertura de Medi-Cal o la que tienen a través de sus trabajos.
Pero Abundis supone que no podrá pagar primas o copagos, así que no ha presentado una solicitud.
Abundis, quien visitó a un médico por primera vez en mayo de 2022 debido a una fatiga sin causa aparente, dolor constante en la espalda y las rodillas, falta de aliento y pérdida de peso inexplicable, teme no poder pagar la atención médica. La Clínica de La Raza, el centro de salud comunitario en donde le hicieron análisis de sangre, lo ayudó ese día a que no tuviera que pagar por adelantado, pero desde entonces dejó de buscar atención médica.
Más de un año después de su diagnóstico, todavía no sabe en qué etapa del cáncer se encuentra ni cuál debería ser su plan de tratamiento. Aunque la detección temprana del cáncer puede aumentar las posibilidades de supervivencia, algunos tipos de leucemia avanzan rápidamente. Sin más pruebas, Abundis no conoce su pronóstico.
Yo estoy mentalizado”, dijo Abundis sobre su cáncer. “Lo que pase, pase”.
Incluso aquellos que buscan ayuda se topan con desafíos. Marisol, una inmigrante mexicana sin papeles, de 53 años, que vive en Richmond, California, intentó restablecer la cobertura durante meses. Aunque el estado experimentó una caída del 26% en las bajas de diciembre a enero, la proporción de latinos a los que se les canceló la cobertura durante ese período permaneció casi igual, lo que sugiere que enfrentan más barreras para la renovación.
Marisol, quien pidió que se usara su nombre de pila por temor a la deportación, también calificó para la cobertura completa de Medi-Cal durante la expansión estatal a todos los inmigrantes de 50 años en adelante.
En diciembre, recibió un paquete informándole que los ingresos de su hogar excedían el umbral de Medi-Cal, algo que ella creyó que era un error. El esposo de Marisol está sin trabajo debido a una lesión en la espalda, dijo, y sus dos hijos mantienen a su familia principalmente con trabajos de medio tiempo en Ross Dress for Less.
Ese mes, Marisol visitó una sucursal de Richmond del Departamento de Empleo y Servicios Humanos del condado de Contra Costa, con la esperanza de hablar con un navegador. En cambio, le dijeron que dejara su documentación y que llamara a un número de teléfono para verificar el estatus de su solicitud.
Desde entonces, llamó muchas veces y pasó horas en espera, pero no ha podido hablar con nadie. Los funcionarios del condado reconocieron tiempos de espera más prolongados debido al aumento de llamadas, y dijeron que el tiempo promedio es de 30 minutos.
“Entendemos la frustración de los miembros de la comunidad cuando a veces tienen dificultades para comunicarse”, escribió la vocera Tish Gallegos en un correo electrónico. Gallegos señaló que el centro de llamadas aumenta la dotación de personal durante las horas pico.
Después que El Tímpano contactara al condado para hacer comentarios, Marisol dijo que un trabajador de elegibilidad la contactó, y le explicó que su familia fue dada de baja porque sus hijos habían presentado impuestos por separado, por lo que el sistema de Medi-Cal determinó su elegibilidad individualmente en lugar de como familia.
El condado reintegró a Marisol y a su familia el 15 de marzo. Marisol dijo que recuperar Medi-Cal fue un final alegre pero agridulce para una lucha de meses, especialmente sabiendo que otras personas son desafiliadas por cuestiones de procedimiento. “Tristemente, tiene que haber presión para que arreglen algo”, dijo.
Jasmine Aguilera de El Tímpano está participando de la Journalism & Women Symposium’s Health Journalism Fellowship, apoyada por The Commonwealth Fund. Vanessa Flores, Katherine Nagasawa e Hiram Alejandro Durán de El Tímpano colaboraron con este artículo.
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.
USE OUR CONTENTThis story can be republished for free (details).
California’s Expanded Health Coverage for Immigrants Collides With Medicaid Reviews
OAKLAND, Calif. — Medi-Cal health coverage kicked in for Antonio Abundis just when the custodian needed it most.
Shortly after Abundis transitioned from limited to full-scope coverage in 2022 under California’s expansion of Medi-Cal to older residents without legal immigration status, he was diagnosed with leukemia, a cancer affecting the blood cells. The soft-spoken father of three took the news in stride as his doctor said his blood test suggested his cancer wasn’t advanced. His next steps were to get more tests and formulate a treatment plan with a cancer team at Epic Care in Emeryville. But all of that was derailed when he showed up last July for bloodwork at La Clínica de La Raza in Oakland and was told he was no longer on Medi-Cal.
“They never sent me a letter or anything telling me that I was removed,” Abundis, now 63, said in Spanish about losing his insurance.
Abundis is among hundreds of thousands of Latinos who have been kicked off Medi-Cal, California’s Medicaid program for low-income people, as states resume annual eligibility checks that were paused at the height of the covid-19 pandemic. The redetermination process, as it is known, has disproportionately affected Latinos, who make up a majority of Medi-Cal beneficiaries. According to the California Department of Health Care Services, more than 653,000 of the more than 1.3 million residents who have been disenrolled over eight months identify as Latino. Some, including Abundis, had only recently gained coverage as the state expanded Medi-Cal to residents without legal residency.
The collision of state and federal policies has not only set off enrollee whiplash but swelled demand for enrollment assistance as people are dropped from Medi-Cal, often for procedural issues. Health groups serving Latino communities report being inundated by requests for help, but at the same time, a state-sponsored survey suggests Hispanic households are more likely than other ethnic or racial groups to lose coverage because they’re less knowledgeable of the renewal process. They may also struggle to advocate for themselves.
Some health advocates are pressing for a pause. They warn that disenrollments will not only undercut the state’s effort to reduce the number of uninsured but could exacerbate health disparities, particularly for an ethnic group that bore the brunt of the pandemic. One national study found that Latinos in the U.S. were three times as likely to contract covid and twice as likely to die of it than the general population, in part because they tend to live in more crowded or multigenerational households and work in front-line jobs.
“These difficulties place all of us as a community in this more fragile state where the safety net means even more now,” said Seciah Aquino, executive director of the Latino Coalition for a Healthy California, a health advocacy organization.
Assembly member Tasha Boerner, an Encinitas Democrat, has introduced a bill that would slow disenrollments by allowing people 19 and older to keep their coverage automatically for 12 months and extend flexible pandemic-era policies such as not requiring proof of income in certain cases for renewals. That would benefit Hispanics, who make up nearly 51% of the Medi-Cal population compared with 40% of the overall state population. The governor’s office said it does not comment on pending legislation.
Tony Cava, a spokesperson for the Department of Health Care Services, said in an email that the agency has taken steps to increase the number of people automatically reenrolled in Medi-Cal and does not consider a pause necessary. The disenrollment rate dropped 10% from November to December, Cava said.
Still, state officials acknowledge more could be done to help people complete their applications. “We’re still not reaching certain pockets,” said Yingjia Huang, assistant deputy director of health care benefits and eligibility at DHCS.
California was the first state to expand Medicaid eligibility to all qualified immigrants regardless of legal status, phasing it in over several years: children in 2016, young adults ages 19-26 in 2020, people 50 and older in 2022, and all remaining adults this year.
But California, like other states, resumed eligibility checks last April, and the process is expected to continue through May. The state is now seeing disenrollment rates return to pre-pandemic levels, or 19%-20% of the Medi-Cal population each year, according to DHCS.
Jane Garcia, CEO of La Clínica de La Raza, testified before the Alameda County Board of Supervisors’ health committee that disenrollments continue to pose a challenge just as her team tries to enroll newly eligible residents. “It’s a heck of a load on our staff,” she told supervisors in January.
Although many beneficiaries no longer qualify because their incomes rose, more have been dropped from the rolls for failing to respond to notices or return paperwork. Often, renewal packets were sent to old addresses. Many find out they’ve lost coverage only upon seeking medical care.
“They knew something was happening,” said Janet Anwar, eligibility manager at Tiburcio Vasquez Health Center in the East Bay. “They didn’t know exactly what it was, how it was gonna affect them until actually the day came and they were disenrolled. And they were getting checked in or scheduling an appointment, then, ‘Hey, you lost your coverage.’”
But reenrollment is a challenge. A state-sponsored survey published Feb. 12 by the California Health Care Foundation found 30% of Hispanic households tried but were unable to complete a renewal form, compared with 19% for white non-Hispanic households. And 43% of Hispanics reported they would like to restart Medi-Cal but did not know how, versus 32% of people in white non-Hispanic households.
The Abundis family is among those who don’t know where to get their questions answered. Though Abundis’ wife submitted the family’s Medi-Cal renewal paperwork in October, his wife and two children who still live with them were able to maintain coverage; Abundis was the only one dropped. He hasn’t received an explanation for being disenrolled nor been notified how to appeal or reapply. Now he worries he may not qualify on his own based on his roughly $36,000 annual income since the limit is $20,121 for an individual but $41,400 for a family of four.
It is likely an eligibility worker could check if he and his family qualify as a household or assist him with signing up for a private plan that can run less than $10 a month for premiums on Covered California. The health insurance exchange allows for special enrollment when people lose Medi-Cal or employer-based coverage. But Abundis assumes he won’t be able to afford premiums or copays, so he hasn’t applied.
Abundis, who first visited a doctor in May 2022 about unrelenting fatigue, constant pain in his back and knees, shortness of breath, and unexplained weight loss, worries he’s unable to afford medical care. La Clínica de La Raza, the community health clinic where he received blood testing, worked with him that day so he didn’t have to pay upfront, but he has since stopped seeking medical care.
More than a year after his diagnosis, Abundis still doesn’t know which stage cancer he has, or what his treatment plan should be. Though early cancer detection can lead to a higher chance of survival, some types of leukemia advance quickly. Without further testing, Abundis does not know his outlook.
“I’ve mentally prepared,” Abundis said of his cancer. “What happens, happens.”
Even those who seek help run into challenges. Marisol, a 53-year-old immigrant from Mexico who lives in Richmond, California, without legal permission, tried to reestablish coverage for months. Although the state saw a 26% drop in disenrollments from December to January, the share of Latinos disenrolled during that period remained nearly the same, suggesting they face more barriers to renewal.
Marisol, who requested her last name be withheld out of fear of deportation, also qualified for full-scope Medi-Cal during the state expansion to all immigrants 50 and older.
She received a packet in December letting her know that her household income exceeded Medi-Cal’s threshold — something she believed was an error. Marisol’s husband is out of work due to a back injury, she said, and her two children primarily support their family with part-time jobs at Ross Dress for Less.
That month, Marisol visited a Richmond branch office of the Contra Costa County Employment and Human Services Department, hoping to speak to an eligibility worker. Instead, she was told to leave her paperwork and to call a phone number to check her application status. Since then, she made numerous calls and spent hours on hold, but has not been able to speak with anyone.
County officials acknowledged longer wait times due to increased calls and said the average wait time is 30 minutes. “We understand community members’ frustration when they have difficulty getting through at times,” spokesperson Tish Gallegos wrote in an email. Gallegos noted the call center increases staffing during peak hours.
After El Tímpano reached out to the county for comment, Marisol said she was contacted by an eligibility worker, who explained that her family was dropped because their children had filed taxes separately, so the Medi-Cal system determined their eligibility individually rather than as one household. The county reinstated Marisol and her family on March 15.
Marisol said regaining Medi-Cal was a joyous but bittersweet ending to a months-long struggle, especially knowing that other people get dropped for procedural issues. “Sadly, there has to be pressure for them to fix something,” she said.
Jasmine Aguilera of El Tímpano is participating in the Journalism & Women Symposium’s Health Journalism Fellowship, supported by The Commonwealth Fund. Vanessa Flores, Katherine Nagasawa, and Hiram Alejandro Durán of El Tímpano contributed to this article.
Medi-Cal Resources (in Spanish):
How to get insurance and low-cost health care in California
How to apply for Covered California
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.
USE OUR CONTENTThis story can be republished for free (details).
Facebook
Twitter
LinkedIn