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Be Aware: Someone Could Steal Your Medical Records and Bill You for Their Care

After HCA Healthcare announced this month that the personal identification data of roughly 11 million HCA patients in 20 states had been exposed in a breach, people may be justifiably concerned that their own medical data and identities could be stolen.

Consumers should realize that such “medical identity” fraud can happen in several ways, from a large-scale breach to individual theft of someone’s data.

Just ask Evelyn Miller. The first sign something was amiss was a text Miller received from an Emory University Hospital emergency department informing her that her wait time to be seen was 30 minutes to 1 hour. That’s weird, she thought. She no longer lives in Atlanta and hadn’t used that hospital system in years. Then she got a second text, similar to the first. Must be spam, she thought.

When she got a call the next day from an Emory staffer named Michael to discuss the diagnostic results from her ER visit, she knew something was definitely wrong. “It amazed me someone could get registered with another person’s name and no ID was checked or anything,” Miller said.

And while the name and date of birth the staffer had on record for her were correct, Miller’s address was not. She now lives in Blairsville, Georgia, a few hours north of Atlanta. Michael said he’d correct the problem. The next week, she got a bill from Emory for more than $3,600.

After an unsatisfactory conversation with someone in the hospital’s billing department, Miller sent a letter to the hospital’s privacy officer. Miller recalled writing: “I think there’s something going on, that someone is using my information, and the visit and the charges appear to be fraudulent.”

When contacted, Emory Healthcare spokesperson Janet Christenbury declined to comment on Miller’s case specifically but did say, “We take these matters seriously and work with our teams to ensure our processes and procedures are followed.”

Miller, 63, a retired health care administrator, was savvier than many about what might have occurred. The average person may have no idea a problem like this can arise until long after a theft occurs.

“The majority of victims find out when they’re trying to move on with their lives, if bills have gone to collections,” said Eva Velasquez, president and CEO of the Identity Theft Resource Center, a nonprofit that provides free assistance to victims of identity theft. Someone may apply for a mortgage, for example, and learn their credit is ruined due to unpaid medical bills for care they didn’t receive.

It’s a double whammy. Unlike other forms of identity fraud, medical identity thieves may steal not only their victims’ personal data — Social Security number, date of birth, address — but also information about their medical records and care, potentially putting their health at risk.

“Sometimes people can’t get their prescriptions, if their records are mixed with someone else’s,” Velasquez said. “Maybe you won’t be able to get treatment that you need. There are serious implications.”

A theft may affect just one person whose insurance card gets stolen or “borrowed” to pay for health care, or it may result from a data breach, as HCA Healthcare experienced. Such large-scale breaches are more likely to be used in financial fraud schemes than to get medical care, experts say.

Compared with other types of identity fraud, medical identity theft is rare. In 2022, for example, the Federal Trade Commission received 27,821 reports of medical identity theft, while reports for identity theft related to new credit card accounts totaled more than 400,000.

Medical identity theft also presents itself in different ways.

One Thief, One Victim

If someone gets ahold of another person’s health insurance number and driver’s license or other ID, they may be able to use it to receive medical services in someone else’s name.

Busy hospital emergency departments may make an attractive target for fraudsters. Procedures typically require patients to present insurance and photo identification information at check-in, said Rade Vukmir, an emergency physician in Pittsburgh and a spokesperson for the American College of Emergency Physicians. But these facilities also don’t want to put people off from getting care, and people who are uninsured or disadvantaged might not have those documents.

“We want to treat that population,” he said. “We’re America’s safety net. We always provide care.”

Medical identity theft can happen if someone loses a wallet with their insurance card in it, for example, or a piece of mail from their insurer goes astray. But it doesn’t occur only among strangers. The victim often knows the thief and may even be in on the “friendly fraud,” as it’s called. According to one study, nearly half of people who failed to report medical identity theft said it was because they knew the thief.

For example, one person might have a higher copayment for emergency department visits, Vukmir said, so they let a family member, such as a cousin or a sibling, use their insurance card to get medical care.

“Usually, in those cases, it wasn’t an emergency,” said Vukmir.

Gangs of Thieves, Millions of Victims

In 2022, 707 health care data breaches affected nearly 52 million patients, according to an analysis of data from the Department of Health and Human Services’ Office for Civil Rights by the HIPAA Journal, which tracks compliance with health care data privacy law. Under federal law, health care organizations must notify individuals when their medical data has been exposed through a breach.

The largest health care data breach to date occurred in 2015, when nearly 80 million Anthem records were exposed. Though the 2022 figures for incidents among all health plans were slightly lower than the year before, there has been a clear upward trend in recent years in breaches, which are typically caused by hacking or IT incidents.

The American Hospital Association is “very concerned” about foreign-based hacking groups from countries like Russia, China, North Korea, and Iran, said John Riggi, the national adviser for cybersecurity and risk for the American Hospital Association.

Riggi said the personal information in people’s medical records may be sold in bulk to criminals who create phony providers to submit fraudulent claims on a mass scale that can result in hundreds of millions of dollars in Medicaid, Medicare, or other insurance fraud. Or they may use the information to create fake identities to apply for loans, mortgages, or credit cards.

“They flee with the money, and the individual is left to deal with it,” Riggi said.

Health plans could take lessons from the financial services industry to detect red flags, Riggi said. Financial institutions have sophisticated algorithms to identify purchasing and other patterns that are out of the ordinary, Riggi said. In health care, such mechanisms could be used to flag claims in which a provider is located more than 1,000 miles from where a patient lives, for example, or sees a patient for conditions that don’t jibe with their age or health status.

AHIP, an insurance industry trade group, didn’t respond to requests for comment.

What Consumers Can Do

Consumers should generally monitor the notices and bills they receive from insurers and providers and contact them immediately about anything suspicious.

In Miller’s case, it’s unclear whether her problem was due to an administrative snafu, such as another patient with the same name, or medical identity theft. But within a month of her initial call, the hospital removed the charges and assured her that her medical record had been disentangled from the other patient’s.

Other steps to take:

Go to the FTC’s identity theft site to learn about next steps and file an identity theft report, if appropriate.
If someone has used your name, contact every provider who may have been involved and ask for a copy of your medical records, then report any errors to your medical providers.
Notify your health plan’s fraud department and send a copy of the FTC identity theft report.
File free fraud alerts with the three major credit reporting agencies and get free credit reports from them. Consider filing a police report. If your health plan offers free credit or identity theft monitoring following a breach, take advantage of it.

“It’s best to proceed as if your data has been compromised and will be for sale,” said Velasquez, whose organization offers free assistance in recovering from identity theft. “Don’t be afraid to ask for help.”

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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Sen. Sanders Says Millions of People Can’t Find a Doctor. He’s Mostly Right.

“Tens of millions of Americans live in communities where they cannot find a doctor while others have to wait months to be seen.”

Sen. Bernie Sanders (I-Vt.), in a July 19, 2023, press release

Sen. Bernie Sanders (I-Vt.) has long been a champion of a government-sponsored “Medicare for All” health program to solve long-standing problems in the United States, where we pay much more for health care than people in other countries but are often sicker and have a shorter average life expectancy.

Still, he realizes his passion project has little chance in today’s political environment. “We are far from a majority in the Senate. We have no Republican support … and I’m not sure that I could get half of the Democrats on that bill,” Sanders said in recent remarks to community health advocates.

He has switched his focus to include, among other things, expanding the primary care workforce.

Sanders introduced legislation in July that would invest $100 billion over five years to expand community health centers and provide training for primary care doctors, nurses, dentists, and other health professionals.

“Tens of millions of Americans live in communities where they cannot find a doctor while others have to wait months to be seen,” he said in a press statement issued when the bill was introduced. He noted that this scenario not only leads to more human suffering and unnecessary deaths “but wastes tens of billions a year” because people who “could not access the primary care they need” often end up in emergency rooms and hospitals.

Is that true? Are there really tens of millions of Americans who can’t find a doctor? We decided to check it out.

Our first stop was the senator’s office to ask for the source of that statement. But no one answered our query.

Primary Care, by the Numbers

So we poked around on our own. For years, academic researchers and policy experts have debated and dissected the issues surrounding the potential scarcity of primary care in the United States. “Primary care desert” and “primary care health professional shortage area” are terms used to evaluate the extent of the problem through data — some of which offers an incomplete impression. Across the board, however, the numbers do suggest that this is an issue for many Americans.

The Association of American Medical Colleges projects a shortage of up to 48,000 primary care physicians by 2034, depending on variables like retirements and the number of new physicians entering the workforce.

How does that translate to people’s ability to find a doctor? The federal government’s Health Resources and Services Administration publishes widely referenced data that compares the number of primary care physicians in an area to its population. For primary care, if the population-to-provider ratio is generally at least 3,500 to 1, it’s considered a “health professional shortage area.”

Based on that measure, 100 million people in the United States live in a geographic area, are part of a targeted population, or are served by a health care facility where there is a shortage of primary care providers. If they all want doctors and cannot find them, that figure would be well within Sanders’ “tens of millions” claim.

The metric is a meaningful way to measure the impact of primary care, experts said. In those areas, “you see life expectancies of up to a year less than in other areas,” said Russ Phillips, a physician who is director of Harvard Medical School’s Center for Primary Care. “The differences are critically important.”

Another way to think about primary care shortages is to evaluate the extent to which people report having a usual source of care, meaning a clinic or doctor’s office where they would go if they were sick or needed health care advice. By that measure, 27% of adults said they do not have such a location or person to rely on, or that they used the emergency room for that purpose in 2020, according to a primary care score card published by the Milbank Memorial Fund and the Physicians Foundation, which publish research on health care providers and the health care system.

The figure was notably lower in 2010 at nearly 24%, said Christopher Koller, president of the Milbank Memorial Fund. “And it’s happening when insurance is increasing, at the time of the Affordable Care Act.”

The U.S. had an adult population of roughly 258 million in 2020. Twenty-seven percent of 258 million reveals that about 70 million adults didn’t have a usual source of care that year, a figure well within Sanders’ estimate.

Does Everyone Want This Relationship?

Still, it doesn’t necessarily follow that all those people want or need a primary care provider, some experts say.

“Men in their 20s, if they get their weight and blood pressure checked and get screened for sexually transmitted infections and behavioral risk factors, they don’t need to see a regular clinician unless things arise,” said Mark Fendrick, an internal medicine physician who is director of the University of Michigan Center for Value-Based Insurance Design.

Not everyone agrees that young men don’t need a usual source of care. But removing men in their 20s from the tally reduces the number by about 23 million people. That leaves 47 million without a usual source of care, still within Sanders’ broad “tens of millions” claim.

In his comments, Sanders refers specifically to Americans being unable to find a doctor, but many people see other types of medical professionals for primary care, such as nurse practitioners and physician assistants.

Seventy percent of nurse practitioners focus on primary care, for example, according to the American Association of Nurse Practitioners. To the extent that these types of health professionals absorb some of the demand for primary care physician services, there will be fewer people who can’t find a primary care provider, and that may put a dent in Sanders’ figures.

Finally, there’s the question of wait times. Sanders claims that people must wait months before they can get an appointment. A survey by physician staffing company Merritt Hawkins found that it took an average of 20.6 days to get an appointment for a physical with a family physician in 2022. But that figure was 30% lower than the 29.3-day wait in 2017. Geography can make a big difference, however. In 2022, people waited an average of 44 days in Portland, Oregon, compared with eight days in Washington, D.C.

Our Ruling

Sanders’ claim that there are “tens of millions” of people who live in communities where they can’t find a doctor aligns with the published data we reviewed. The federal government estimates that 100 million people live in areas where there is a shortage of primary care providers. Another study found that some 70 million adults reported they don’t have a usual source of care or use the emergency department when they need medical care.

At the same time, several factors can affect people’s primary care experience. Some may not want or need to have a primary care physician; others may be seen by non-physician primary care providers.

Finally, on the question of wait times, the available data does not support Sanders’ claim that people must wait for months to be seen by a primary care provider. There was wide variation depending on where people lived, however.

Overall, Sanders accurately described the difficulty that tens of millions of people likely face in finding a primary care doctor.

We rate it Mostly True.

Source List

Sen. Bernie Sanders, “NEWS: In Remarks to Advocates, Sanders Proposes Major Expansion of Community Health Centers,” Feb. 8, 2023.

Sen. Bernie Sanders, “NEWS: Chairman Sanders Introduces Major Legislation on Primary Care and Announces HELP Markup Next Week,” July 19, 2023.

Senate bill, “To improve access to and the quality of primary health care, expand the health workforce, and for other purposes,” accessed July 21, 2023.

Association of American Medical Colleges, “AAMC Report Reinforces Mounting Physician Shortage,” June 11, 2021.

Health Resources and Services Administration, “What Is Shortage Designation?” June 2023.

Health Resources and Services Administration, “Health Workforce Shortage Areas,” accessed July 24, 2023.

Health Resources and Services Administration, “Designation of Health Professional(s) Shortage Areas,” accessed July 26, 2023.

KFF, “Primary Care Health Professional Shortage Areas (HPSAs),” Sept. 30, 2022.

The Milbank Memorial Fund and the Physicians Foundation, “The Health of US Primary Care: A Baseline Scorecard Tracking Support for High-Quality Primary Care,” Feb. 21, 2023.

The Milbank Memorial Fund, “The Effectiveness of Policies to Improve Primary Care Access for Underserved Populations: An Assessment of the Literature,” Jan. 24, 2022.

American Association of Nurse Practitioners, “NP Fact Sheet,” November 2022.

Meritt Hawkins, “Survey of Physician Appointment Wait Times and Medicare and Medicaid Acceptance Rates,” 2022.

Interview with Mark Fendrick, physician and director of the University of Michigan Center for Value-Based Insurance Design, July 21, 2023.

Interview with Christopher Koller, president of the Milbank Memorial Fund, July 21, 2023.

Interview with Jacquelyn Resnik, Teladoc Health, July 21, 2023.

Interview with Russ Phillips, physician and director of Harvard Medical School Center for Primary Care, July 24, 2023.

Interview with Michael Dill, director of workforce studies at the Association of American Medical Colleges, July 24, 2023.

Email interview with Martin Kramer, director of communications at Health Resources and Services Administration, July 25, 2023.

Email interview with Jewel Jordan, public affairs specialist, U.S. Census Bureau, July 26, 2023.

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His Anesthesia Provider Billed Medicare Late. He Got Sent to Collections for the $3,000 Tab.

Thomas Greene had been experiencing pain in his right leg, a complication from diabetes, when doctors recommended a procedure to increase blood flow to the limb.

Retired from a career as an electrician and HVAC technician, he had an outpatient procedure in April 2021 to alleviate his pain by dilating the clogged artery using a balloon snaked into his blood vessel.

Greene, who lives in Oxford, Pennsylvania, came through the procedure without any problems, and it reduced his discomfort, said his wife, Bluizer Greene. She spoke with KFF Health News on behalf of Greene, who is recovering from other health problems.

Greene is covered by Medicare and a supplemental policy through Humana and did not expect to pay anything for the care, Bluizer said.

Then the bills came.

The Patient: Thomas Greene, 74, who is covered by original Medicare and a Medicare supplement policy sold by Humana.

Medical Service: Peripheral artery bypass surgery on Greene’s right leg.

Service Provider: The operation was performed at Jennersville Hospital in West Grove, Pennsylvania, which closed in December 2021. Anesthesia services were provided by two providers who work for North American Partners in Anesthesia, which is private equity-owned and, with thousands of providers operating in 21 states, identifies itself as among the nation’s largest anesthesia staffing companies.

Total Bill: For the anesthesia care, North American Partners in Anesthesia billed $2,965.58: $1,334.51 for a certified nurse anesthetist and $1,631.07 for an anesthesiologist.

What Gives: North American Partners in Anesthesia, or NAPA, pursued Greene to pay for his anesthesia care instead of billing Medicare on time, sending the debt to collections before the couple discovered the problem.

Medicare eventually received the claims from NAPA, months after the couple started receiving collection letters, Bluizer said. But Medicare denied them because they were filed late — nearly 17 months after the surgery. Humana also denied the claims.

Medicare requires providers to submit claims within a year of providing their services. And Medicare supplemental policies, like Greene’s plan from Humana, generally do not pay for services if Medicare doesn’t cover them, whether because Medicare has not paid its part yet or because the program denied the claim.

A year after Greene’s surgery, in spring 2022, the couple opened a letter from a collection agency working on behalf of the anesthesia group. It demanded Greene pay about $3,000.

“Something has to be wrong, because this is the first time my husband has ever been asked to pay out-of-pocket and we’ve had the same insurance for years,” Bluizer said.

She said for several months she called NAPA and the collection agency, C.tech Collections, of Mount Sinai, New York, to determine why it was billing her husband.

Greene was also contacted by the Faloni Law Group, a second organization working on behalf of NAPA to collect the debt, and Bluizer said she followed its instructions to respond by mail, disputing the debt on the grounds that it should be billed to insurance.

But her communication attempts did not resolve the issue, and she said her husband continued to receive collection notices.

Neither debt collector responded to requests for comment.

“We were angry, and it was very upsetting because we had never had a bill put into a collection agency for any of his hospitalizations, and it was money we did not feel that we owed,” Bluizer said.

She said they may have received some letters from the anesthesia group in 2021 and 2022 that they discarded without opening because they believed her husband’s medical bills would be covered by insurance, as the rest of his surgery bills were.

Worried about the situation, including its potential impact on their credit, the couple reached out late last year to Harold Ting, a volunteer counselor for Pennsylvania’s MEDI program, which provides free assistance to Medicare beneficiaries. Medicare generally covers anesthesia services.

“This is totally unfair that a beneficiary ends up having to pay for what should be a totally covered service, when the provider is at fault,” Ting said.

Two explanation of benefits statements from Humana show the insurer received claims from NAPA in April 2021, shortly after Greene’s surgery. The statements said the claims could not be considered at that time, though, because Humana had not yet received Medicare EOBs for the services.

Kelli LeGaspi, a Humana spokesperson, declined to comment on Greene’s case. She said a Medicare EOB — a coverage statement generated when the program processes a claim — is required for the supplement carrier to consider a claim. Without it, a claim for secondary coverage cannot be considered and is denied, she said.

Supplement plans deny claims for benefits that are denied by Medicare, she said.

“If Original Medicare declines to pay the claim, then the Medicare supplement plan is required to decline the claim as well,” she said in an email.

In December 2022, a NAPA representative told Bluizer in an email that NAPA billed Medicare after the April 2021 surgery and that Medicare denied the claims in August 2021. The representative provided an account statement showing the claims were sent to collections that month.

But Bluizer said a Medicare representative told her in late 2021 that the program had received no claims from NAPA.

Greene’s Medicare account shows NAPA filed claims in September 2022, about 17 months after his surgery and about five months after he received his first collection letter. Both claims were denied.

A quarterly summary notice said while the time limit for filing the claims had expired, Greene also could not be billed.

Meena Seshamani, director of the federal Center for Medicare, said in an email to KFF Health News that if a Medicare provider sends a claim a year or more after a service is provided, it is denied except in very rare circumstances.

There is no exception for provider error, she said.

A spokesperson for NAPA declined to be interviewed on the record, despite receiving a signed release waiving federal privacy protections.

Martine G. Brousse, a billing expert and founder of the patient advocacy firm AdviMedPRO, said Greene’s Medicare notice should have reassured the couple that he did not owe anything, despite the several overdue-bill notices they received.

If the Medicare statement “shows a zero balance to the member, then the provider cannot legally go after the patient,” said Brousse, who is not involved in Greene’s case. “The patient has zero liability because it is not their fault” the provider billed Medicare a year after the surgery. “That is the end of the story.”

Another mystery about the claim is why NAPA billed separately for a nurse anesthetist and an anesthesiologist. Bluizer said her husband was not told why NAPA billed individually for the two medical professionals — a practice some insurers believe constitutes double billing.

Brousse said there could be a simple explanation, such as if the nurse anesthetist started the procedure and the anesthesiologist finished it or if the company charged for the anesthesiologist to work in a supervisory role.

But the Medicare claims document shows each provider billed for the same amount of time — a little over an hour.

“As far as I can tell, this looks like two providers billed with the same ‘I did the job’ Medicare procedure code,” she said. “Medicare cannot accept that without an explanation.”

The Resolution: Unable to get answers, Ting connected Greene to the nonprofit, Pennsylvania-based Center for Advocacy for the Rights and Interests of Elders.

In March, Ariel Rabinovic, an advocate with the center, contacted NAPA on Greene’s behalf and explained that federal law does not allow the group to bill Medicare patients for services Medicare does not cover. He said he was told the company would stop billing Greene.

Bluizer said the couple has not received any collection notices since then.

Rabinovic said he has seen other situations in which health providers who agree to accept Medicare try to bill patients for services Medicare does not cover, which is not allowed.

“Older folks have a lot of things going on, and dealing with this can be very confusing for them,” he said. “A lot of people end up paying because they don’t want to deal with it.”

Greene has faced several health issues and spent time in a rehabilitation hospital this winter. His wife said she was happy the billing issue had been resolved without their having to pay anything.

The Takeaway: When a Medicare statement says the patient may not be billed anything for a health service, that’s the bottom line. Don’t write a check, but also don’t ignore bills and collection notices, because they could ultimately hurt your credit.

Read your mail, the experts said. While Greene was not responsible for paying the anesthesia bill given that Medicare said he did not owe anything, the couple may have prevented the debt from being sent to collections if they had responded to the anesthesia group’s communications and confirmed it had Greene’s insurance information, Brousse said.

Keep copies of bills and insurance statements, especially Medicare EOB documents, or follow them on an online portal.

The couple was smart to reach out to advocates for help resolving the issue when they could not do so on their own, Rabinovic said.

“This is why people need to read their notices from Medicare even when it says ‘This is not a bill,’” he said.

Also, when an anesthesia bill includes charges for both a nurse anesthetist and an anesthesiologist, question the charges. Many insurers will not pay for both.

The Centers for Medicare & Medicaid Services recommend beneficiaries call 800-MEDICARE with questions about their care or bills or file a complaint online.

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!

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Bankrupt California Hospital Receives Lifeline From Adventist, Report Says

Bankrupt Madera Community Hospital has received a last-minute lifeline from the hospital chain Adventist Health, which reached a preliminary agreement to take over the shuttered hospital and save it from liquidation, The Fresno Bee reported July 27.

The deal comes as a federal bankruptcy court in Fresno weighs whether to force Madera to sell off its assets to satisfy creditors. The biggest creditor is Fresno’s St. Agnes Medical Center, which walked away from a deal to take over Madera and effectively forced it into bankruptcy. The hospital closed in January.

“I can confirm the [Madera Community Hospital] board accepted a letter of intent with a suitor,” Riley Walter, the hospital’s lead bankruptcy lawyer, told the Bee in an email. The paper identified the suitor as Adventist, a faith-based nonprofit health system that operates in California, Oregon, and Hawaii and recently took over another troubled hospital, in Bakersfield.

A lot still must happen for the Madera hospital to reopen. Madera County supervisors are considering whether to spend $500,000 to keep the hospital’s skeletal operations running after the bankruptcy court this week declined to authorize any spending beyond Aug. 4. The hospital has also applied for an $80 million loan from the state’s new distressed hospital fund, but it’s not clear how much it will receive.

Analysts said it would take many months to hire staff and resume operations at the hospital, the only one in the rural and majority-Hispanic agricultural county of Madera.

Rural hospitals across California and much of the country are struggling in the face of low reimbursements for low-income patients served by Medicaid, skyrocketing costs during the pandemic, and chronic staffing troubles. Madera also suffered from bad contracts with private insurers and management missteps, according to an article reported jointly by KFF Health News and The Fresno Bee.

Experts warn that reopening will be costly, and that any plan must address the underlying problems that caused Madera to go bankrupt in the first place.

Staffers said they were devastated when St. Agnes walked away from a deal to save the hospital last December. California Attorney General Rob Bonta blasted St. Agnes and its parent, Trinity Health, for trying to “extract every dollar possible” in the bankruptcy after walking away from the deal with no notice and little explanation. St. Agnes blamed the decision on complex circumstances and additional conditions imposed by Bonta, but he had agreed to most demands, experts said.

More details on the Adventist deal are expected by Aug. 1, when the Board of Supervisors will vote on whether to authorize the $500,000 to keep things running and the bankruptcy court will hold another hearing.

Madera Community Hospital board officials declined to comment to the Bee. The Adventist CEO could not immediately be reached, the newspaper reported.

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

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KFF Health News' 'What the Health?': Another Try for Mental Health ‘Parity’

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 Biden administration continued a bipartisan, decades-long effort to ensure that health insurance treats mental illnesses the same as other ailments, with a new set of regulations aimed at ensuring that services are actually available without years-long waits or excessive out-of-pocket costs.

Meanwhile, two more committees in Congress approved bills this week aimed at reining in the power of pharmacy benefit managers, who are accused of keeping prescription drug prices high to increase their bottom lines.

This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico, and Sarah Karlin-Smith of the Pink Sheet.

Panelists

Anna Edney Bloomberg @annaedney Read Anna's stories Joanne Kenen Johns Hopkins Bloomberg School of Public Health and Politico @JoanneKenen Read Joanne's stories Sarah Karlin-Smith Pink Sheet @SarahKarlin Read Sarah's stories

Among the takeaways from this week’s episode:

The Biden administration’s new rules to enforce federal mental health parity requirements include no threat of sanctions when health plans do not comply; noncompliance with even the most minimal federal rules has been a problem dating to the 1990s. Improving access to mental health care is not a new policy priority, nor a partisan one, yet it remains difficult to achieve.
With the anniversary of the 988 Suicide & Crisis Lifeline, more people are becoming aware of how to access help and get it. Challenges remain, however, such as the hotline service’s inability to connect callers with local care. But the program seizes on the power of an initial connection for someone in a moment of crisis and offers a lifeline for a nation experiencing high rates of depression, anxiety, and suicide.
In news about the so-called Medicaid unwinding, 12 states have paused disenrollment efforts amid concerns they are not following renewal requirements. A major consideration is that most people who are disenrolled would qualify to obtain inexpensive or even free coverage through the Affordable Care Act. But reenrollment can be challenging, particularly for those with language barriers or housing insecurity, for instance.
With a flurry of committee activity, Congress is revving up to pass legislation by year’s end targeting the role of pharmacy benefit managers — and, based on the advertisements blanketing Washington, PBMs are nervous. It appears legislation would increase transparency and inform policymakers as they contemplate further, more substantive changes. That could be a tough sell to a public crying out for relief from high health care costs.
Also on Capitol Hill, far-right lawmakers are pushing to insert abortion restrictions into annual government spending bills, threatening yet another government shutdown on Oct. 1. The issue is causing heartburn for less conservative Republicans who do not want more abortion votes ahead of their reelection campaigns.
And the damage to a Pfizer storage facility by a tornado is amplifying concerns about drug shortages. After troubling problems with a factory in India caused shortages of critical cancer drugs, decision-makers in Washington have been keeping an eye on the growing issues, and a response may be brewing.

Also this week, Rovner interviews KFF Health News’ Céline Gounder about the new season of her “Epidemic” podcast. This season chronicles the successful public health effort to eradicate smallpox.

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

Julie Rovner: The Nation’s “The Anti-Abortion Movement Gets a Dose of Post-Roe Reality,” by Amy Littlefield.

Joanne Kenen: Food & Environment Reporting Network’s “Can Biden’s Climate-Smart Agriculture Program Live Up to the Hype?” by Gabriel Popkin.

Anna Edney: Bloomberg’s “Mineral Sunscreens Have Potential Hidden Dangers, Too,” by Anna Edney.

Sarah Karlin-Smith: CNN’s “They Took Blockbuster Drugs for Weight Loss and Diabetes. Now Their Stomachs Are Paralyzed,” by Brenda Goodman.

Also mentioned in this week’s episode:

CNN’s “Medicaid Disenrollments Paused in a Dozen States After Failure to Comply With Federal Rules,” by Tami Luhby.
Abortion, Every Day’s “Why Are OBGYNs Being Forced to Go to Texas?” by Jessica Valenti.
Politico’s “GOP Looks to Spending Fights for Wins on Abortion, Trans Care, Contraception,” by Alice Miranda Ollstein.
KFF Health News’ “A Year With 988: What Worked? What Challenges Lie Ahead,” by Colleen DeGuzman.

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Covered California to Cut Patient Costs After Democratic Lawmakers Win Funding From Gov. Newsom

SACRAMENTO, Calif. — Weeks after Democratic lawmakers forced Gov. Gavin Newsom to make good on a four-year-old pledge to use tax penalty proceeds from fining the uninsured to increase health insurance subsidies for low- and middle-income Californians, Covered California officials announced they will funnel that money into reducing out-of-pocket spending for many enrollees struggling with the cost of care.

The state’s health insurance exchange will zero out some patients’ hospital deductibles, up to $5,400; lower the copay of primary care visits from $50 to $35; and reduce the cost for generic drugs from $19 to $15. Some enrollees will also see their annual out-of-pocket spending capped at $6,100, down from $7,500.

Covered California CEO Jessica Altman argues these are tangible reductions — savings on deductibles and copays on top of subsidies to lower monthly premiums — that will affect hundreds of thousands of people and entice them to use their coverage.

“Deductibles uniquely detract people from seeking care, so that’s a significant focus,” Altman told KFF Health News. “California is really grappling with affordability and thinking about, ‘What does affordability really mean?’ Many people simply do not have $5,000 sitting in their bank account in case they need it for health care.”

Additional reductions in patients’ out-of-pocket costs — on top of existing federal health insurance subsidies to reduce monthly premiums — will take effect in January for people renewing or purchasing coverage during Covered California’s next enrollment period, which begins in the fall. The state could go further in helping reduce patients’ costs in subsequent years with future budget increases, Altman said.

Still, those savings may be offset by higher costs elsewhere. Covered California announced July 25 that inflation and other factors are driving up annual premium rates on participating health plans by an average of nearly 10% next year, the largest average increase since 2018.

California started fining those without health coverage in the tax year 2020, establishing its own “individual mandate.” In that first year, the state raised $403 million in penalty revenue, according to the state Franchise Tax Board. It has continued to levy fines, paid for largely by low- or middle-income earners, the very people the new subsidies are intended to help.

Legislative leaders had pushed Newsom, a fellow Democrat, to funnel the tax revenue into lowering health care costs for low- and middle-income people purchasing coverage via Covered California — many of whom reported skipping or delaying care due to high out-of-pocket costs.

The governor for years resisted pleas to put penalty money into Covered California subsidies, arguing that the state couldn’t afford it and needed the money given looming economic downturns and the potential loss of federal premium subsidies — which could be threatened by a change in federal leadership.

But under ongoing pressure, Newsom relented in June and agreed to begin spending some of the money to boost state subsidies. According to the state Department of Finance, California is expected to plow $83 million next year and $165 million annually in subsequent years to expand financial assistance — roughly half the revenue it raises annually — into reducing Covered California patients’ costs. The remainder of the money will be set aside in a special health care fund that could be tapped later.

The budget deal also allows the Newsom administration to borrow up to $600 million in penalty revenue for the state general fund, which it must pay back. Penalty revenues are projected to bring in $362 million this year with an additional $366 million projected next year, according to Finance Department spokesperson H.D. Palmer.

Covered California board members approved the new plan design last week. They say the cost-sharing subsidies will lower out-of-pocket spending for nearly 700,000 people out of roughly 1.6 million enrolled in Covered California.

The boost in funding, which represents the state’s most significant effort to slash patients’ costs in Covered California, will largely benefit lower-income Californians who earn below 250% of the federal poverty level, which is $33,975 for an individual and $69,375 for a family of four for 2023, according to the exchange.

“Bringing down deductibles goes a long way to help middle-class California families struggling with increasing costs of living,” said Senate President Pro Tempore Toni Atkins, who rallied fellow Democrats to block a plan by Newsom and his administration to keep the revenue for the state general fund, which can be used for any purpose.

Atkins added, “We will continue our work to lower the costs even more in the years to come.”

Newsom spokesperson Brandon Richards defended the governor’s health care record, saying Newsom is committed to ensuring Californians can access health care. In addition to boosting assistance in Covered California, Richards said, the governor has expanded public health insurance coverage to immigrants lacking legal status and is increasing how much doctors, hospitals, and other providers get paid to see Medicaid patients.

Originally required by the federal Affordable Care Act, the so-called individual mandate to hold health coverage or pay a tax penalty was gutted by Republicans in 2017, eliminating the fine nationally. Newsom reinstated it for California when he took office in 2019 — a key component of his ambitious health care platform.

California is one of at least five states, along with Massachusetts, New Jersey, Rhode Island, and Vermont, as well as the District of Columbia that have their own health coverage mandate, though not all levy a tax penalty for remaining uninsured. Among them, California is most aggressively trying to lower health care costs and achieve universal coverage, said Larry Levitt, executive vice president for health policy at KFF.

“Even though they may disagree on the big picture of health care reform and single-payer, California Democrats have managed to come together and unify around these incremental steps to improve the current system,” Levitt said. “Step by step, they have put in place the pieces to get as close to universal coverage as they possibly can.”

Democratic leaders in the state have faced political blowback for not using the penalty revenue for health care, details first reported by KFF Health News, even though Newsom and other Democrats vowed to spend the money to make health care more affordable in Covered California.

Advocates say the deal represents a win for low- and middle-income people.

“We’re excited that this money is protected for health care, and ultimately is set aside for future affordability assistance,” said Diana Douglas, chief lobbyist with the consumer advocacy group Health Access California.

Advocates want the state to tap those health care dollars to get more people covered, such as lowering health care costs for immigrants living in the state without legal permission.

A bill this year by Assembly member Joaquin Arambula, a Fresno Democrat, would require Covered California to establish a separate health insurance marketplace so that immigrants who lack legal status and earn too much to qualify for Medi-Cal, California’s version of Medicaid, can purchase comprehensive coverage that is nearly identical to plans sold on Covered California. Currently, immigrants without legal residency are not allowed on the exchange. Other states, such as Washington and Colorado, have set up similar online marketplaces.

“We’re working hard to create a system that has equal benefits and affordability assistance for everyone,” Arambula said.

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

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A un año del lanzamiento de la línea 988, ¿Funciona? ¿Qué desafíos enfrenta?

La línea 988 de Prevención del Suicidio y Crisis celebró su primer aniversario este mes. Y expertos en salud mental afirman que el número de tres dígitos ha hecho que la ayuda sea más accesible que antes.

Esta línea directa fue diseñada con la idea de que las personas que experimentan angustia emocional se sintieran más cómodas buscando ayuda de consejeros capacitados que de la policía y otros servicios de emergencia a través del 911.

Desde que se lanzó el nuevo número en julio de 2022, ha recibido 4 millones de llamadas, según un informe de KFF, lo que representa un aumento del 33% respecto al año anterior. (La línea directa anterior era 800-273-8255, que sigue activa pero no se promociona).

En un evento de prensa en julio, políticos y expertos en salud mental celebraron los éxitos del primer año de la línea directa, así como los $1,000 millones adicionales en financiamiento proporcionados por la administración Biden.

Xavier Becerra, secretario del Departamento de Salud y Servicios Humanos (HHS), describió el 988 como “un regalo del cielo” durante sus comentarios grabados. “Puede que no sea la solución”, dijo, “pero te pone en contacto con alguien que puede guiarte hacia la ayuda que necesitas”.

Esos mismos defensores reconocieron la oscura realidad tras el alto volumen de llamadas al 988: la nación enfrenta una crisis de salud mental y aún queda mucho trabajo por hacer.

Después de un año, también está claro que la línea directa 988, una red de más de 200 centros de llamadas estatales y locales, enfrenta desafíos, incluida la desconfianza y confusión del público. También es evidente que la línea directa necesita intervención financiera federal y estatal para ser sostenible.

La siguiente es una revisión de su situación actual:

¿Qué funcionó?

La línea nacional de crisis de salud mental original, el 1-800, ha estado en funcionamiento desde 2005. El gran aumento de llamadas al 988 en comparación con el 1-800 en solo un año probablemente se debe a la simplicidad del código de tres dígitos, según Adrienne Breidenstine, vicepresidenta de políticas y comunicaciones de Behavioral Health System en Baltimore. “La gente lo está recordando fácilmente”, dijo a KFF Health News.

Según una encuesta realizada en junio por NAMI e IPSOS, el 63% de los estadounidenses habían oído hablar del 988, y los jóvenes de 18 a 29 años eran los más conscientes. Además, la encuesta encontró que las personas LGBTQ+ eran dos veces más propensas a estar familiarizadas con el 988 que las personas que no se identificaban como LGBTQ+.

El 988 ofrece apoyo las 24 horas del día, los 7 días de la semana, para personas en crisis suicidas u otras formas de angustia emocional, explicó Breidenstine. “Pueden llamar si simplemente tuvieron un mal día”, dijo. “También recibimos algunas llamadas de personas que experimentan depresión posparto”. A los que llaman, se los dirige a un menú de opciones para elegir qué tipo de servicio les ayudaría mejor, incluida una línea para veteranos.

Cuando se lanzó, expertos en salud mental se preocupaban por la capacidad de la línea directa para hacer frente a la demanda. Pero parece que se está adaptando. “A pesar de un gran aumento en la demanda del sistema, ha estado funcionando y lo ha hecho de manera excepcional”, dijo a KFF Health News Hannah Wesolowski, directora de promoción de la National Alliance on Mental Illnesses.

Según datos de la Substance Abuse and Mental Health Services Administration, ahora, con el 988, se tarda un promedio de 35 segundos para conectarse con un consejero, ya sea llamando o enviando un mensaje de texto. Hace un año, ese promedio era de un minuto y 20 segundos.

Wesolowski dijo que una de las mayores sorpresas con el lanzamiento fue la frecuencia del tráfico de mensajes de texto. En noviembre de 2022, la Comisión Federal de Comunicaciones votó para que el 988 fuera compatible con mensajes de texto.

En mayo, según SAMHSA, el 988 recibió alrededor de 71,000 mensajes de texto en todo el país con una tasa de respuesta del 99%, en comparación con los 8,300 mensajes de texto en mayo de 2022 con una tasa de respuesta del 82%.

Este mes, HHS anunció la incorporación de servicios de texto y chat en español para el 988.

Desafíos por delante

Más de la mitad de los estadounidenses han oído hablar del 988, pero solo una pequeña fracción entiende cómo funciona la línea directa. Según la encuesta de NAMI, solo el 17% de las personas que respondieron dijeron que estaban “muy/algo familiarizadas” con la línea directa.

La mayoría de las personas piensan que al llamar al 988, al igual que al 911, los servicios de emergencia irán automáticamente a su dirección, según encontró la encuesta. Actualmente, el 988 no utiliza la geolocalización, lo que significa que los centros de llamadas no reciben automáticamente información sobre la ubicación de las personas que llaman.

Vibrant Emotional Health, que opera la línea directa, está trabajando para incorporar la geo-ruta en el sistema, lo que ayudaría a identificar las zonas desde donde se realizan las llamadas, pero no sus ubicaciones exactas, lo que permitiría conectarlos con grupos de asesoramiento locales y otros servicios de salud mental.

Sin embargo, incorporar la geo-ruta en la línea directa no está exento de controversia. Cuando se lanzó, las personas respondieron en las redes sociales advirtiendo que llamar al 988 aumentaba el riesgo de que la policía interviniera, y que se hubiera tratamientos involuntarios en hospitales psiquiátricos. “Basándose en el trauma que tantas personas en la comunidad de salud mental han experimentado durante mucho tiempo cuando han estado en crisis, esas suposiciones son comprensibles”, dijo Wesolowski.

Menos del 2% de las llamadas terminan involucrando a la policía, y la mayoría se resuelven por teléfono.

“La gran mayoría de las personas piensan que habrá una respuesta en persona cada vez que llamen, y eso simplemente no es cierto”, dijo Wesolowski.

Otro desafío al que se enfrentan los defensores de la salud mental es informar a los adultos mayores sobre el 988, especialmente a los veteranos, que tienen un mayor riesgo de tener pensamientos suicidas. Según la encuesta de NAMI, los estadounidenses de entre 50 y 64 años tenían la tasa de conocimiento más baja del 988, con un 11%, entre todos los grupos de edad.

Esto es un indicio revelador de cómo las generaciones mayores son menos propensas a hablar y admitir sus luchas con la salud mental, dijo Wesolowski. “Los jóvenes están más dispuestos a ser abiertos al respecto, así que creo que derribar ese estigma en todos los grupos de edad es absolutamente vital, y tenemos mucho trabajo por hacer en ese sentido”.

El 988, ¿es sostenible?

Desde su lanzamiento, la línea directa ha dependido de subvenciones federales y asignaciones anuales. Un torrente de financiamiento fluyó cuando se lanzó el 988, “pero esas asignaciones anuales son algo por lo que tienes que seguir volviendo año tras año, por lo que el tema de la sostenibilidad es un poco más complicado”, dijo Wesolowski.

Es aquí donde entran en juego el Congreso y las legislaturas estatales.

Líderes de salud mental esperan impulsar una legislación que permita que el 988 sea financiado de la misma manera que el 911 a nivel nacional. El Wireless Communications and Public Safety Act de 1999 exigió que el 911 fuera el número de emergencia universal del país y, desde entonces, a los usuarios se les ha cobrado automáticamente, un promedio de aproximadamente un dólar al mes, en sus facturas telefónicas mensuales para financiarlo.

Seis estados han establecido un impuesto similar para el 988, y dos estados, Delaware y Oregon, tienen proyectos de ley para este impuesto en los escritorios de sus gobernadores.

La Federal Communications Commission (FCC) tiene el poder de imponer un impuesto a nivel nacional, pero la agencia federal aún no lo ha hecho.

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Pain Clinic Chain to Pay $11.4M to Settle Medicare and Medicaid Fraud Claims

SACRAMENTO, Calif. — The owner of one of California’s largest chains of pain management clinics has agreed to pay nearly $11.4 million to California, Oregon, and the federal government to settle allegations of Medicare and Medicaid fraud.

The U.S. Department of Justice and the states’ attorneys general say Francis Lagattuta, a physician, and his Lags Medical Centers performed — and billed for — medically unnecessary tests and procedures on thousands of patients over more than five years. It was “a brazen scheme to defraud Medicare and Medicaid of millions of dollars by inflicting unnecessary and painful procedures on patients whom they were supposed to be relieving of pain,” Phillip Talbert, U.S. attorney for the Eastern District of California, said in a statement this month.

The federal Medicare program suspended reimbursements to Lags Medical in June 2020, and Medi-Cal, California’s Medicaid program, followed in May 2021. Lags Medical shut down the same day the state suspended reimbursements. The company, based in Lompoc, California, had more than 30 pain clinics, most of them in the Central Valley and the Central Coast.

A KFF Health News review last year found the abrupt closure left more than 20,000 California patients — mostly working-class people on government-funded insurance — struggling to obtain their medical records or continue receiving pain prescriptions, which often included opioids.

Lagattuta and Lags Medical did not admit liability under the settlement. Lagattuta denied the governments’ claims, saying in a statement he was “pleased” to announce the settlement of a “long-standing billing dispute.” As part of the agreement, Lagattuta will be barred for at least five years from receiving Medicare and Medicaid reimbursements.

“Since the Centers have been closed for a couple of years, it made sense for Dr. Lagattuta to settle the dispute and continue to move forward with his other business interests and practice,” Malcolm Segal, an attorney for Lagattuta and the centers, said in the statement.

According to state officials, the federal government will receive the bulk of the money, about $8.5 million. California will receive about $2.7 million, and an additional $130,000 will go to Oregon. The settlement amount is based in part on Lagattuta’s and Lags Medical’s “ability to pay.” It does not cover the governments’ full losses, which the U.S. attorney’s office in Sacramento said are not public record.

A nearly four-year investigation by federal officials and the California Department of Justice found that from March 2016 through August 2021, Lagattuta and his company submitted reimbursement claims for unneeded skin biopsies, spinal cord stimulation procedures, urine drug tests, and other tests and procedures. Lagattuta began requiring all his clinics to perform various medical procedures on every patient, the officials said, no matter if they were needed or requested by patients’ medical providers. Patients who refused were told they would have their pain medication reduced and could suffer adverse medical consequences.

U.S. and California investigators piggybacked on a federal claim filed in late 2018 by a whistleblower, Steven Capeder, Lags Medical’s former operations and marketing director, who will receive more than $2 million of the settlement.

As part of the settlement, Lagattuta and his company acknowledged that in mid-2016 he began requiring his providers to do at least two to three skin biopsies on Medicare patients each day and told providers to quit if they wouldn’t comply. Such biopsies are used to measure small-fiber neuropathy, which causes burning pain with numbness and tingling in the feet and lower extremities.

According to the settlement, a monthly report in early 2018 set a goal of performing 250 biopsies a week. Lagattuta created a separate team that was required to order at least 150 biopsies weekly, often overruling providers. And the company’s chief executive officer in late 2019 texted Lagattuta to report a particularly high number of biopsies, illustrating the text with emojis of a money bag and a smiley face.

Authorities said Lagattuta violated regulations requiring that skin biopsy results be interpreted by a trained pathologist or neurologist. Instead, they say, Lagattuta had the biopsies read by a family member who had no formal medical training and by a former clinic executive’s spouse, who was trained as a respiratory therapist.

Lags Medical clinics performed more than 22,000 biopsies on Medi-Cal patients from 2016 through 2019.

The settlement also alleges Lagattuta encouraged unsuitable patients to undergo spinal cord stimulation. It describes the procedure as “an invasive surgery of last resort,” in which implants placed near the spinal cord apply low-voltage electrical pulses to nerve fibers.

Lagattuta paid a psychiatrist $3,000 each month to falsely certify that every Lags Medical candidate for the procedure had no psychological or substance use disorders that would negatively affect the outcome, according to the settlement. For instance, the settlement says the psychiatrist overruled a Lags Medical social worker to OK the procedure for a young woman who had bipolar disorder with hallucinations that included hearing a man’s voice ordering her out of bed.

He also issued blanket orders for every patient to have urine drug testing, a policy the company’s CEO said “should be a big money maker.”

KFF Health News found that from 2017 through 2019 nearly 60,000 of the most extensive urine drug tests were billed to Medicare and Medi-Cal under Lagattuta’s provider number. Medicare reimbursed Lagattuta $5.4 million for those tests.

The clinics “carefully examined, tested, and treated” more than 60,000 patients during the time covered by the settlement, “when others might have been content to prescribe medication to mask pain,” said Lagattuta’s statement.

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

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A Year With 988: What Worked? What Challenges Lie Ahead?

The Suicide & Crisis Lifeline’s 988 hotline marked its one-year milestone this month. Mental health experts say the three-digit number made help more accessible than before.

The hotline was designed with the idea that people experiencing emotional distress are more comfortable reaching out for help from trained counselors than from police and other first responders through 911.

Since the federally mandated crisis hotline’s new number launched in July 2022, 988 has received about 4 million calls, chats, and texts, according to a KFF report — up 33% from the previous year. (The hotline previously used a 10-digit number, 800-273-8255, which remains active but is not promoted.)

At a July press event, policymakers and mental health experts celebrated the hotline’s first-year successes as well as its additional $1 billion in funding from the Biden administration. Health and Human Services Secretary Xavier Becerra described 988 as a “godsend” during taped remarks. “It may not be the solution,” he said, “but it lets you touch someone who can send you on a path to where you will get the help you need.”

Those same advocates recognized the dark reality represented by 988’s high call volume: The nation faces a mental health crisis, and there is still much work to be done.

One year in, it’s also clear that the 988 hotline, a network of more than 200 state and local call centers, faces challenges ahead, including public mistrust and confusion. It’s also clear the hotline needs federal and state funding intervention to be sustainable.

Here’s a status check on where things stand:

What Worked?

The original 1-800 national mental health crisis hotline has operated since 2005. The huge increase in calls to 988 compared with those to the 1-800 number in just a year is likely linked to the simplicity of the three-digit code, said Adrienne Breidenstine, vice president of policy and communications at Behavioral Health System in Baltimore. “People are remembering it easily,” she told KFF Health News.

According to a survey by NAMI and IPSOS conducted in June, 63% of Americans had heard of 988, and those ages 18 to 29 were most aware. Additionally, the survey found that LGBTQ+ people were twice as likely to be familiar with 988 as people who don’t identify as LGBTQ+.

The 988 hotline provides 24/7 support for people in suicidal crisis or other kinds of emotional distress, Breidenstine said. “They can be calling if they really just had a bad day,” she said. “We also get some calls from people experiencing postpartum depression.” Callers are directed to a menu of options to choose which kind of service would best help them, including a veterans’ line.

As it launched, mental health experts worried about the hotline’s ability to keep up with demand. But it appears to be growing into its position. “Despite a huge increase of demand on the system, it’s been holding up, and it’s been holding up exceptionally well,” Hannah Wesolowski, chief advocacy officer at the National Alliance on Mental Illness, told KFF Health News. It now takes an average of 35 seconds for someone reaching out to 988 — by calling or texting — to reach a counselor, according to data from the Substance Abuse and Mental Health Services Administration. A year ago, that average was one minute and 20 seconds.

Wesolowski said one of the biggest surprises with the launch was the frequency of text-message traffic. In November 2022, the Federal Communications Commission voted to require 988 to be texting-friendly.

In May, according to SAMHSA, 988 received about 71,000 texts nationwide with a 99% response rate, compared with 8,300 texts in May 2022 with an 82% response rate.

This month, HHS announced the addition of Spanish text and chat services to 988.

Challenges Ahead

More than half of Americans have heard of 988, but only a small fraction understand how the hotline operates. According to NAMI’s survey, only 17% of people who responded said they were “very/somewhat familiar” with the hotline.

Most people think that by calling 988, like 911, emergency services will automatically head their way, the survey found. Currently, 988 does not use geolocation, meaning call centers don’t automatically receive information about callers’ locations. Vibrant Emotional Health, which operates the hotline, is working to incorporate geo-routing into the system, which would help identify callers’ regions — but not exact locations — making it possible to connect them to local counseling groups and other mental health services.

But incorporating geo-routing into the hotline isn’t without controversy. When it launched, people responded on social media with warnings that calling 988 brought a heightened risk for police involvement and involuntary treatment at psychiatric hospitals. “Based on the trauma that so many people in the mental health community have long experienced when they’ve been in crisis, those assumptions are very understandable,” Wesolowski said.

Fewer than 2% of calls end up involving law enforcement, she said, and most are de-escalated over the phone.

“The vast majority of people think that an in-person response is going to happen whenever you call — and that’s just simply not true,” Wesolowski said.

Another challenge mental health advocates face is informing older adults about 988, especially veterans, who are at higher risk of having suicidal ideations. Americans ages 50 to 64 had the lowest awareness rate of 988 — at 11% — among all age groups, according to NAMI’s survey.

This is a telling sign of how older generations are less willing to discuss and admit to mental health struggles, Wesolowski said. “Young people are just more willing to be open about that, so I think that breaking down that stigma across all age groups is absolutely vital, and we have a lot of work to do in that space.”

Is 988 Sustainable?

Since the hotline launched, it has been dependent on federal grants and annual appropriations. A gush of funding flowed when 988 launched, “but those annual appropriations are something you have to keep going back for year after year, so the sustainability aspect is a little more fraught,” Wesolowski said.

This is where Congress and state legislatures come in.

Mental health leaders hope to push legislation that allows 988 to be funded the same way 911 is nationwide. The Wireless Communications and Public Safety Act of 1999 mandated 911 to be the country’s universal emergency number, and ever since, users have automatically been charged — an average of about a dollar a month — on their monthly phone bills to fund it. Six states have imposed a similar tax for 988, and two states — Delaware and Oregon — have bills for this tax on their governor’s desks.

It’s under the FCC’s power to levy a nationwide tax, but the federal agency hasn’t done so yet.

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Hospitals Ask Congress to Delay ACA Medicaid Funding Cuts — For the 14th Time

It has become as familiar a sight in Washington as the cherry blossoms in spring: lobbyists from the nation’s hospitals descending on the Capitol to ask lawmakers to postpone billions in Medicaid funding cuts prescribed by the Affordable Care Act — cuts industry leaders agreed to years ago.

It is unlikely the reductions will occur this year, if history is any indication. Since 2013, Congress has voted 13 times to delay them, siding with hospitals over their claims that losing the money would hinder the delivery of care.

Unless Congress acts by October, the federal government will cut $8 billion from this year’s budget — then make the same cut each year for the next three years — for a Medicaid program intended to help safety-net facilities that serve a large share of Medicaid and uninsured patients. The amount budgeted varies annually, though in 2021 the program’s spending totaled about $19 billion.

Known as the Medicaid Disproportionate Share Hospital (DSH) payments program, it has drawn criticism amid evidence that a substantial amount of its funding goes to hospitals that do not primarily cater to low-income patients. According to industry groups, more than 2,500 hospitals — about 40% of the total in the United States — get the payments.

The cuts are part of a deal brokered with the hospital industry 14 years ago, as the fate of the ACA dangled in the balance. At the time, hospitals agreed to accept $155 billion in Medicare and Medicaid funding cuts over 10 years, assuming the legislation’s promise to insure more patients would improve their bottom lines. A portion of those cuts were to Medicaid DSH payments.

Despite record-high hospital profits and record-low uninsured rates in recent years, the hospital industry again says this is not a good time for cuts, pointing to the covid-19 pandemic and the millions of people losing Medicaid coverage as a result of pandemic-era protections ending.

Current Medicaid funding covers only about 81% of hospitals’ costs of caring for patients, said Jolene Calla, a vice president of The Hospital and Healthsystem Association of Pennsylvania.

Losing the Medicaid safety-net funding “would be devastating to hospitals,” she said.

A bipartisan group of 231 members of the House of Representatives — a majority — have signed a letter to House leaders asking for another delay. Legislation is moving in the chamber that would delay any cuts to the Medicaid safety-net program until 2026.

The postponements show the political muscle of the hospital industry, strengthened by virtually every lawmaker’s district having at least one hospital that provides care and jobs.

Hospitals have been among the biggest donors to members of Congress and have a large lobbying force.

According to the watchdog group OpenSecrets, the Greater New York Hospital Association, which represents more than 160 hospitals, gave more than $11.8 million to congressional campaigns in the 2022 cycle. The American Hospital Association spent about $27 million on lobbying to influence lawmakers in 2022, more than nearly any other organization.

Critics say the hospital industry — which often increases prices, sues patients for lack of payment, and pays big-dollar salaries to top executives — should hold up its side of the deal it made with Democrats, particularly the Obama administration, in 2009.

“Too many hospitals have for years been trying to have it both ways, benefitting from the ACA while trying to escape responsibilities they have under the law,” said Daniel Skinner, an associate professor of health policy at Ohio University. “They constantly deploy their political power to wiggle out of these responsibilities while trying to maintain the generally good feeling they have within communities.”

On July 8, 2009, the nation’s top hospital leaders stood with then-Vice President Joe Biden at a White House press conference to announce their deal to keep national health reform legislation on track after a century of failed attempts, dating as far back as Theodore Roosevelt’s push for national insurance.

At the time, ACA reform efforts teetered as interest groups feuded and Democrats struggled to settle on a plan. The agreement, which followed a similar deal with the drug industry, was part of a plan by the Obama administration to preemptively negotiate with corporate interests that had blocked previous reform efforts.

The savings from the $155 billion in hospital funding cuts would “cover health care cost reform,” Biden said during the press conference. “As more people are insured, hospitals will bear less of the financial burden of caring for the uninsured and the underinsured, and we will reduce payments to cover those costs in tandem with that reduction.”

President Barack Obama signed the ACA into law in March 2010. The number of uninsured, which was 48 million in 2010, fell to 28 million by 2016. By 2021, the uninsured rate fell to record lows, with about 27 million uninsured.

Hospital lobbyists argue the industry has already absorbed cuts in Medicare funding under the ACA and that the Medicaid cuts should not be implemented because uninsured rates have not dropped as low as the 5% rate predicted before the law’s passage.

Though the health law has been a “godsend,” it also has not met its anticipated goal of universal coverage, said Chip Kahn, the president and CEO of the Federation of American Hospitals, which represents for-profit hospitals.

Kahn, who was involved in the agreement with the Obama White House, said the ACA has fallen short of universal coverage largely because 10 states, including more populous ones like Florida and Texas, have yet to adopt Medicaid expansion.

As a result, hospitals in these states have provided more unpaid care than anticipated and need the additional Medicaid payments to cover costs, he said.

Kahn said the extra Medicaid payments also help offset shortfalls caused by Medicare and Medicaid underpaying hospitals.

The ACA called for the DSH program’s cuts to be phased in, with less than $1 billion being cut in each of the first few years. But after hospitals lobbied Congress to postpone them, the revised budget deals meant future cuts would be deeper and immediate — leading to the $8 billion annual cuts currently slated for the coming years.

In fiscal year 2021, the most recent year for which data is available, DSH spending nationwide totaled $18.9 billion. While those payments represent 3% of overall Medicaid spending, they account for as much as 10% of some states’ Medicaid spending.

The program, intended for safety-net hospitals, has been the subject of controversy for decades.

One reason is that the money does not always go to safety-net hospitals.

A study published in Health Affairs last year found 57% of hospitals received the DSH payments in 2015. About 94% of these payments went to hospitals with either a high percentage of uninsured patients or Medicaid enrollees or higher-than-average uncompensated care.

But 6% of recipient hospitals did not meet these criteria, the study showed.

The researchers estimated that about a third of the payments went to hospitals not focused on caring for low-income populations.

Paula Chatterjee, the lead author on the study and the director of health equity research at the Leonard Davis Institute of Health Economics at the University of Pennsylvania, said hospitals aren’t transparent about how they spend the extra money and that the states that receive the most money do not always have the highest rates of uninsured residents.

While the safety-net program is intended to help hospitals treating large numbers of Medicaid and uninsured patients, the formula determining how much money states get is based on historical Medicaid spending totals before limits were put in place in 1992, she said.

As a result, states like New York and New Jersey are among the largest recipients of the supplemental funding even though they have some of the lowest uninsured rates, she said.

Beth Feldpush, the senior vice president of policy and advocacy for America’s Essential Hospitals, which represents 300 safety-net hospitals, said these facilities’ 3% average operating margin would disappear if not for DSH money. “Members of Congress recognize there are pockets of underserved communities in most congressional districts,” she said.

Chatterjee said hospitals will likely argue there is never a good time to accept the cuts. She noted some rural and urban hospitals have closed in recent years even as other hospitals have made record profits.

“It’s always hard to take money away from hospitals because they hold such symbolic meaning, and legislators know that,” she said.

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from Health Industry – KFF Health News

Journalists Discuss Abortion Lawsuits and the Pros and Cons of Health Care Sharing Plans

KFF Health News senior correspondent Sarah Varney discussed the lawsuit to block the “abortion trafficking” law in Idaho on KUOW’s “Soundside” on July 13.

Click here to hear Varney on “Soundside”
Click here to read Varney’s “Groups Sue to Overturn Idaho ‘Abortion Trafficking’ Law Targeting Teens”

And on PBS NewsHour on July 20, Varney discussed a lawsuit filed by women in Texas claiming the state’s abortion restrictions put their lives in jeopardy.

Click here to watch Varney on PBS NewsHour.

KFF Health News senior Colorado correspondent Markian Hawryluk discussed health care sharing plans on “PBS News Weekend” on July 9.

Click here to watch Hawryluk on “PBS News Weekend”
Read Hawryluk’s “At Least 1.7M Americans Use Health Sharing Arrangements, Despite Lack of Protections“

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