The National Education Association, the nation’s largest union, reversed course Friday on its threat to cut off health insurance to about 300 Washington, D.C.-based workers in an effort to end a bitter contract dispute.

“The NEA is not discontinuing its unionized staff’s health insurance and will continue to pay insurance premiums as we bargain a new contract,” Kim Anderson, NEA’s executive director, said in a statement to �������ýҕ�l Health News. “Both parties have mutually agreed to mediation and we are making every effort to reach an agreement as quickly as possible.”

The NEA’s decision came just hours after �������ýҕ�l Health News reported on the union’s warning that it would cancel health benefits on Aug. 1 for striking workers, including some with ongoing medical issues. Reached Friday, officials at the NEA staff union confirmed they had been notified by the NEA.

Some private employers have used the threat of cutting off health benefits as leverage against unionized workers, a tactic that has drawn scrutiny from congressional Democrats and is prohibited for state employers in California. Experts on labor law say they’ve never seen a union make the move against its own workers.

“This is like a man-bites-dog situation where the union is now in a position as the employer,” said Paul Clark, a professor of labor and employment relations at Penn State University. “It’s not a good look for a union.”

NEA workers with pressing health needs were worried but said they wouldn’t fold. Joye Mercer Barksdale, a writer on the NEA’s government relations team, said she needs coverage for a medical procedure to address atrial fibrillation, a cardiac disorder. “This is insane for the NEA to use our health benefits as a bargaining chip,” she said.

But Barksdale had said she was “not ready to give in.” Reached Friday morning, she said she was thrilled by the reversal: “Oh my God, I am so thankful.”

The NEA Staff Organization, the union representing workers at the NEA’s headquarters, launched a strike on July 5 in Philadelphia, during the union’s annual delegate assembly. It was its second walkout this summer as the two parties negotiate a new contract, navigating sticking points such as wages and remote work.

In response, the NEA ended the conference early. President Joe Biden was supposed to speak at the event but withdrew, refusing to cross the picket line. The NEA on July 24 endorsed Kamala Harris for president.

On July 8, the day after the conference had been scheduled to end, the NEA locked out workers. In a letter the day before, the NEA informed its unionized workers that they would not be paid, effective immediately, and their health benefits would expire at the end of July unless a new deal were reached.

“NEA cannot allow NEASO to act again in a way that will bring such lasting harm to our members and our organization,” Anderson, the NEA’s executive director, wrote in the letter, obtained by �������ýҕ�l Health News. “We are, and have always been, committed both to our union values and to the importance of conducting ourselves as a model employer.”

Democrats in Congress, including Sens. Sherrod Brown of Ohio and Bob Casey of Pennsylvania, introduced legislation last year to protect striking workers from losing their health benefits, after several large companies, including General Motors, John Deere, RTX (formerly Raytheon Technologies), and the maker of Kellogg’s cereals, threatened to or did cut off coverage during labor disputes.

“Workers shouldn’t have to choose between their family’s health and a fair contract,” Brown said in a statement to �������ýҕ�l Health News.

The legislation was endorsed by large labor unions including the Service Employees International Union and United Steelworkers, according to a press release from Brown’s office. The NEA wasn’t among them.

“This tactic is immoral, and it should be illegal,” United Steelworkers’ president at the time, Thomas Conway, said in the release.

Officials at the NEA, which represents teachers and other administrators, declined an interview request. In a statement Wednesday, the organization’s president, Becky Pringle, said “we are making every effort to reach an agreement as quickly as possible” with its staff union.

“As union leaders who have been on strike, we recognize the significance and impact of these important decisions on a personal and family level. We truly value our employees and look forward to continued collaboration with NEASO to develop a new contract that benefits us all,” she said.

Kate Hilts, a digital strategist who works for the NEA, said she feared losing her coverage would leave her unable to afford treatment for a rare autoimmune disease that attacks her kidneys. Her next treatment was slated for August.

“I wake up every day and can’t believe this is happening,” she said. “You would expect this from an employer that is antiworker or has a terrible labor record, but I am totally flabbergasted that a labor union would do this that bills itself as pro-worker, pro-family, pro-education, and pro-children.”

The NEA staff union has with the National Labor Relations Board this year, including allegations that the NEA withheld holiday overtime pay and failed to provide information on the outsourcing of millions of dollars in bargaining unit work.

California is one of the only states that protect striking workers from losing health coverage. The state legislature passed a law in 2021 that blocks the tactic from being used against public employees and another law in 2022 that allows any striking workers who lose their insurance to immediately get heavily discounted coverage through the state’s Affordable Care Act marketplace.

If they had remained locked out, the NEA workers would have been eligible for coverage under COBRA, a federal program that allows people who are fired or laid off to maintain their employer-sponsored insurance for 18 months.

But the coverage can be a financial hardship, as individuals often must pay the entire cost of their insurance premiums, plus a 2% administrative fee.

Another option for workers would have been coverage through the Affordable Care Act marketplace, though that also can be costly. And it may have been unclear how soon that coverage would begin or whether insurers would cover their existing doctors.

“I’m hoping the NEA will be so ashamed of what they are doing that, at the very least, they will not take away our health benefits,” Barksdale said before the NEA’s decision.

�������ýҕ�l 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 .

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U.S. Health Care Is Harmful to One’s Health

Thank you for publishing this research (“Hundreds of Hospitals Sue Patients or Threaten Their Credit, a KHN Investigation Finds. Does Yours?” Dec. 21). I am a psychotherapist and have written about this problem in my blog. The mercenary American health care system is hypocritical in the stressful financial demands and threats it imposes on so many patients. Stress due to health care-related bankruptcy, or the threat of bankruptcy, is harmful to one’s health. A health care system that is supposed to treat illness and restore health can, in fact, cause serious illness and/or exacerbate existing medical problems. The higher levels of stress and the threat of bankruptcy that all too frequently follow needed medical care can be harmful to individuals with cardiovascular issues such as high blood pressure and heart arrhythmia, and can trigger panic attacks in those who suffer from anxiety disorders. There may be digestive issues associated with higher levels of stress, and the patient’s sleep may be adversely affected. The individual may have to cut back on essentials such as food and medications because of unpaid medical bills, aggressive calls from collection agencies, and the threat of bankruptcy.

All of this in the name of “health care” delivered by professions and organizations that proclaim the importance of beneficence, justice, and non-malfeasance within their respective codes of ethics. Curative stress? Therapeutic bankruptcy? The hypocrisy is palpable.

American history is replete with examples of discrimination against certain groups, including racial discrimination, the disenfranchisement of women, child labor, and others. Eventually, political measures were enacted to correct these injustices. It’s only a matter of time until the American health care system, including the pharmaceutical industry, is forced to reform itself for the sake of the men, women, and children in need of essential health care. It’s not a question of if, but when.

— Fred Medinger, Parkton, Maryland

I find this infuriating! Especially the nonprofit organizations. Hundreds of US Hospitals Sue Patients or Threaten Their Credit, a KHN Investigation Finds | Kaiser Health News

— Jan Oldenburg ☮️ (@janoldenburg)

— Jan Oldenburg, Richmond, Virginia

Thanks for the article about hospitals suing patients. I just switched health plans in New York state. Reasons: My previous insurer raised my premium over 90% last year, paid very little of my claims (leaving Medicare to pay most of the claims), and sent me to collections. This, even though I worked two full-time jobs for most of my 46 years of teaching. How do insurance companies and hospitals get away with this unethical and outrageous behavior?

— George Deshaies, Buffalo, New York

Great story by ' , which found that at least 297 hospitals in MN, 56%, sue patients for unpaid medical bills. 90, or 17%, can deny patients nonemergency medical care if they have past-due bills.Mayo is one of those hospitals. See🧵

— Molly Work (@mollycastlework)

— Molly Work, Rochester, Minnesota

Unhappy New Year of Deductibles and Copays

Listened to between Noam N. Levey and NPR’s Ari Shapiro, regarding Levey’s article on Germany’s lack of medical debt (“What Germany’s Coal Miners Can Teach America About Medical Debt,” Dec. 14). Levey passed along the tidbit that Affordable Care Act plans purchased through state exchanges would pay a maximum out-of-pocket amount of $9,000 a year. Likely Mr. Levey knows the actual details of the ACA at least as well as I, but I had well over $20,000 in out-of-pocket expenses for my own care last year (in addition to annual premiums of over $15,000). The deductible/copay aspect of health insurance is rigged against folks who actually use their insurance. The in-network and out-of-network provider scheme is likewise designed to benefit providers as opposed to patients.

I’ve had health insurance for about 40 years, since I graduated from college. Always a plan paid for by myself, never through an employer. I’ve had my first year of using a lot of heath care services (colon cancer surgery and chemo follow-up), and the bills are quite astronomical. Still awaiting the final negotiations between Stanford Hospital and Blue Shield of California for the $97,000 bill for services for the surgery and stay in the hospital. Though my surgery was in September, the two had not resolved the bill by year-end. Now all my copays and deductibles have reset, and I’ll be back at the starting gate, dollar-wise.

We need health care payment reform.

— George McCann, Half Moon Bay, California

Tx for this important comparative piece on how Germany's private healthcare system does not create . We need to do better.

— Allison Sesso (@AllisonSesso)

— Allison Sesso, president and CEO of RIP Medical Debt, Long Island City, New York

Greedy to the Bone?

In orthopedics, surgery is where the money is (“More Orthopedic Physicians Sell Out to Private Equity Firms, Raising Alarms About Costs and Quality,” Jan. 6). Just as a private equity-controlled ophthalmology group tried to persuade me to have unnecessary cataract surgery (three other eye doctors agreed it wasn’t necessary), too many orthopedic patients can expect to be pushed to unnecessary surgeries.

— Gloria Kohut, Grand Rapids, Michigan

As firms acquire practices, the issue of non-competes and covenants become even more relevant in

— Amit Jain, MD, MBA (@AmitJainSpine)

— Dr. Amit Jain, Baltimore

The Painful Truth of the Opioid Epidemic

In a recent article, Aneri Pattani and Rae Ellen Bichell discussed disparities in the distribution of settlement funds from lawsuits against major pharmaceutical companies, especially in rural areas (“In Rural America, Deadly Costs of Opioids Outweigh the Dollars Tagged to Address Them,” Dec. 12).

We suggest that the merit of many of the lawsuits that led to these large settlements remains unproven. While Purdue Pharma clearly of prescription opioids in treating chronic pain, judges in two high-profile cases ruled in favor of the pharmaceutical companies stating that prosecutors and noted that opioids used per FDA guidelines are safe and effective, remaining a vital means to treat chronic pain. Also, many cases involving Purdue Pharma, Johnson & Johnson, and others were settled based on expediency, rather than merit. This may have been due to the reasoning that continuing their defense against prosecutors having access to limitless public funds would lead to bankruptcy.

The primary cause of America’s overdose crisis is not physicians’ “overprescribing” opioids. Dr. Thomas Frieden, former head of the Centers for Disease Control and Prevention, noted that the rise in prescription opioids in opioid deaths up to 2010, leading the CDC to create guidelines in 2016 limiting opioid use to treat chronic pain. However, cause-and-effect relationships between the legitimate use of prescription opioids and opioid deaths remain unclear. For example, the National Institute on Drug Abuse noted in 2015 that since 2000, misuse of prescription drugs preceded the use of heroin in most cases. But legitimate prescriptions by physicians to patients with chronic pain constituted only 20% of the cases leading to heroin addiction. Prescription drugs used by heroin addicts were from family members or friends in leading to heroin use.

Since at least 2010, the volume of prescription opioids dropped by over 60% — yet overdose deaths have skyrocketed to over 100,000 cases in 2021. The opioid overdose death crisis is now driven mainly by illegally imported fentanyl and in part by a of the Drug Enforcement Administration against physicians who legitimately prescribe opioids to chronic pain patients, forcing them to seek out street drugs.

Statistics from Michigan indicate that nearly will no longer see new patients for pain management. The CDC, in its 2022 updated guidelines, attempted to clarify misunderstandings, including inappropriate rapid tapering and individualizing care. However, the public health crisis of undertreated pain remains. Some states have passed to restore access to opioids to chronic pain patients with a legitimate need, indicating the shortfalls of the CDC guidelines to treat pain.

— Richard A. Lawhern, Fort Mill, South Carolina, and Dr. Keith Shulman, Skokie, Illinois

Important reporting from and in : National settlements are being paid out by manufacturers, but communities are often getting less funds to address the than their urban and suburban counterparts.

— Joanne Conroy (@JoanneConroyMD)

— Dr. Joanne Conroy, Lebanon, New Hampshire

We’re fighting to hold accountable the companies that helped create and fuel the opioid crisis so we can help people struggling with opioid use disorder across North Carolina and the country get resources for treatment and recovery. We need this money now to save lives.

To that end, I wanted to flag one concern about the article on rural counties and opioid funding. It looks as if the comparison and the maps about North Carolina funding by county and overdose deaths may not correlate. The reporting seems to reflect overdose deaths on a per capita basis, but funding is indicated by total dollars received.

might be helpful. It ranks each North Carolina county by the amount of funds they will receive from the distributor and Johnson & Johnson settlements (as posted on ) per capita, using 2019 population figures. In per capita rankings, rural and/or less populous counties are typically receiving more funding per capita than larger counties. For example, the 10 counties receiving the most per capita funding are all rural and/or less populous counties (Wilkes, Cherokee, Burke, Columbus, Graham, Yancey, Mitchell, Clay, Swain, and Surry). Wake County, our most populous county, is ranked 80th.

It’s also important to note that the formula was developed by experts for counsel to local governments in the national opioid litigation, who represent and have duties of loyalty to both large urban and small rural local governments. It takes into account opioid use disorder in the county (the number of people with opioid use disorder divided by the total number of people nationwide with opioid use disorder), overdose deaths as a percentage of the nation’s opioid overdose deaths, and the number of opioids in the county. Click for more information.

Indeed, one of the special masters appointed by U.S. District Judge Dan Polster in the national opioid litigation found that the national allocation model “reflects a serious effort on the part of the litigating entities that devised it to distribute the class’s recovery according to the driving force at the heart of the lawsuit — the devastation caused by this horrific epidemic.” (See Page 5 of of Special Master Yanni.)

You’re absolutely right that rural counties were often the earliest and hardest hit by the opioid epidemic, and it’s critical that they receive funds to help get residents the treatment and recovery resources they need. We’re hopeful that these funds, whose allocation was determined in partnership by local government counsel, will help deliver those resources.

— Nazneen Ahmed, North Carolina Attorney General’s Office, Raleigh, North Carolina

This article is a great example of equality ≠ equity regarding opioid settlement funds disbursement. Really thoughtful article by &

— Kate Roberts, LCSW (@kate_lcsw)

— Kate Roberts, Durham, North Carolina

A Holistic Approach to Strengthening the Nursing Workforce Pipeline

As we face the nation’s worst nursing shortage in decades, some regions are adopting creative solutions to fill in the gaps (“Rural Colorado Tries to Fill Health Worker Gaps With Apprenticeships,” Nov. 29). To truly solve the root of this crisis, we must look earlier in the workforce pipeline.

The entire nation currently sits in a dire situation when it comes to having an adequate number of nurses — especially rural communities. With the tripledemic of covid-19, influenza, and RSV tearing through hospitals, it’s never been more evident how vital nurses are to the functioning of our health care system. A found that we need to double the number of nurses entering the workforce every year for the next three years to meet anticipated demand. Without support from policymakers and health care leaders, we cannot meet that.

As a health care executive myself, I’ve seen firsthand how impactful apprenticeships can be because they help sustain the health care workforce pipeline. From high school students to working adults, these “earn while you learn” apprenticeships allow students to make a living while working toward their degree, and my system’s apprenticeship program has even reduced our turnover by up to 50%. It provides a framework to support a competency-based education rooted in real-life skills and hands-on training for key nursing support roles, all while team members earn an income.

Education is key to developing competent, practice-ready nurses. Not just through apprenticeships but early on in students’ educational journey, too. According to the newest data from the , students in most states and most demographic groups experienced the steepest declines in math and reading ever recorded. As we continue to see the devastating impact the pandemic had on young learners, it’s crucial we invest more in remediation and support, so students graduate from secondary school with a deep understanding of these core competencies and are ready to pursue nursing. A of nearly 4,000 prospective nursing students from ATI Nursing Education found that a lack of academic preparedness was the top reason for delaying or forgoing nursing school.

Without intervention now, our nursing workforce shortage will only worsen in the future. We need our leaders to face these challenges head-on and invest in a holistic approach to strengthen our nursing pipeline. There’s no time to waste.

— Natalie Jones, executive director of workforce development at WellStar Health System, Atlanta

1 solution to the staffing crisis: Apprenticeship programs put students directly into long-term care professions. Rural areas benefit the most since they have more residents who are 65 or older & fewer direct care workers to help people w/ disabilities.

— OK Health Action (@ok_action)

— Oklahoma Health Action Network, Oklahoma City

Planning Major Surgery? Plan Ahead

I read Judith Graham’s good article “Weighing Risks of a Major Surgery: 7 Questions Older Americans Should Ask Their Surgeon” (Jan. 3) . Thought I should add some personal experience. At age 78, my mother had back surgery in 2016. When she was getting prepped, she was given multiple documents to sign. Once signed, she was immediately taken to surgery. There was not enough time to read any of them. In hindsight, we are certain the documents were mostly for release of liability if something goes wrong. After surgery, she had “drop foot” — total loss of use of her left foot. Never heard of it. She was told she would regain use in about six months. Never happened. She had to use a walker and still had numerous falls in which her head had hit the ground multiple times. She slowly slid into long-term “confusion” that was attributed to her falls and passed away at age 84.

My story is about my abdominal aorta aneurysm surgery in 2022 at age 62. I did not have an overnight recovery — tube taken out of my throat, catheter removed, and was immediately transferred to a room. An IV pump of saline was left on and my arm swelled up — I thought my arm was going to burst. Five days later, I was discharged. Everything seemed rushed. The only postsurgical “instructions” I received were to keep the incision clean and not to play golf, and I don’t even play golf. I recuperated at home, and after five months I still have abdominal pain that I’ll always have.

Both of our surgeries were done on a Friday. I’m certain our experiences were due to hospital staff wanting to leave early on Friday, and weekend staffers are mostly the “B” team. So, my advice is to suggest to the elderly not to have surgery scheduled on a Friday unless there is absolute urgency in choosing the date.

— Paul Lyon, Chesapeake, Virginia

Reality bites, doesn’t it.

— suzette sommer (@suzette_sommer)

— Suzette Sommer, Seattle

I am writing to express my concerns over the significant misinformation in the article about what older Americans should ask their surgeon before major surgery.

Most abdominal aortic aneurysms are treated with endovascular methods. These minimally invasive procedures still require general anesthesia (with a breathing tube), but most patients have the tube removed before leaving the operating room, and many patients leave the hospital the next day with minimal functional limitations due to surgery being performed through half-inch incisions in each groin.

The “best case” surgical scenario described in your article describes open abdominal aortic aneurysm repair, which is recommended for fewer than 20% of patients requiring aortic aneurysm repairs.

In essence, you’re threatening everyone who comes in for a tuneup with an engine rebuild.

Abdominal aortic aneurysms are still undertreated in the U.S., with many patients not receiving screening recommended by Medicare since 2006. Your article misrepresents the “best case” scenario and may dissuade patients from receiving lifesaving care.

— Dr. David Nabi, Newport Beach, California

I read, with interest, Judith Graham’s article about older Americans preparing for major surgery. But you failed to mention the life-altering effects of anesthesia. My independent 82-year-old mother had a minor fall in July and broke her hip. After undergoing anesthesia, she is required to have 24/7 care as her short-term memory has been forever altered. Was there a choice not to have hip surgery? I didn’t hear one. Did anyone explain the issues that could (and often do) occur with an elderly brain due to anesthesia? No. And now we are dealing with this consequence. And what happens when you don’t have money (like most people in the U.S.) for 24/7 care? I hope you’ll consider writing about this.

— Nancy Simpson, Scottsdale, Arizona

Shouldn't more people wonder why MA plans are profitable while our own gov't MC is losing money. Only 5% of MA plans are audited yearly. Yet they are getting 8.5% increase in payment & docs (the folks taking care of the pts) are getting cut. via

— Madelaine Feldman (@MattieRheumMD)

— Dr. Madelaine Feldman, New Orleans” (Dec. 13) provided a misleading, incomplete depiction of Medicare Advantage payment.

This story focuses largely on audits that, in some cases, are more than a decade old. While KHN’s focus is on alleged “overpayment,” the same audits show that many plans were underpaid by as much as $773 per patient.

More recent research demonstrates Medicare Advantage’s affordability and responsible stewardship of Medicare dollars. For example, an October 2021 Milliman report concludes “the federal government pays less and gets more for its dollar in MA than in FFS,” while the Department of Health and Human Services’ fiscal year 2021 report shows that the net improper payment rate in Medicare Advantage was roughly half that of fee-for-service Medicare.

KHN’s article is right about one thing: Only a small fraction of Medicare Advantage plans are audited each year — denying policymakers and the public a fuller understanding of the program’s exceptional value to seniors and the health care system. That is why has called for regulators to conduct Risk Adjustment Data Validation (RADV) audits of every Medicare Advantage plan every year.

There are opportunities, as outlined in our recent policy recommendations, to further strengthen and improve Medicare Advantage’s high bar of transparency and accountability, but that effort is not well served by this misleading article.

— Mary Beth Donahue, president and CEO of the , Chevy Chase, Maryland

Targeting Gun Violence

I’m curious why KHN neglected to actually get into all the “meat and potatoes” regarding its report on Colorado’s red flag law (“Colorado Considers Changing Its Red Flag Law After Mass Shooting at Nightclub,” Dec. 23). Specifically, it failed to report that the suspect in this case used a “ghost gun” to execute the crime in Colorado Springs, and more importantly what impact any red flag law is going to have on a person who manufactures their own illegal firearm. Lastly, why is it the national conversation regarding the illegal use and possession of firearms curiously avoids any in-depth, substantive conversation of access to firearms by mentally ill people? Quite frankly, this is the underlying cause of illegal firearms use and no one wants to step up to the plate and address the issue at any in-depth level. It’s categorically embarrassing for American journalism.

— Steve Smith, Carbondale, Colorado

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A Centene subsidiary, Operose Health, took over nearly three dozen medical practices in London — gateways for NHS care — in a deal worth tens of millions of dollars. The subsidiary became the largest private supplier of general practice services in the United Kingdom, with 67 practices accounting for 570,000 patients.

A local health commission, records show, signed off after a nine-minute review in a virtual hearing held the week before Christmas. Centene was not mentioned. Not a question was asked. It was the time of year — amid pandemic restraints — when official business in London gave way to fizzy cocktails and quiet glad tidings.

Within weeks, the acquisition set off alarms for Louise Irvine, an NHS doctor, who called it “privatization of the NHS by stealth.” Irvine, other practitioners, and residents supported a crowdfunded legal challenge to the takeover of AT Medics Holdings, the U.K. primary care company under contract to the NHS.

Centene is the largest privately managed care provider in the U.S. that offers government-sponsored insurance, such as Medicaid and Affordable Care Act plans, as well as health care to seniors, prisoners, military members, and veterans. Britons who protested its expansion saw a for-profit outsider with ambitions that could weaken the NHS. They worried Centene would decide on staffing to suit its bottom line. NHS contracts with doctors at set rates, and assistants are paid less; critics questioned whether the Centene deal would reduce more highly trained staff.

Then there was this: The corporation since 2013, over noncompliance with state or federal Medicaid contracts or rules. By mid-2021, as its legal battle intensified in London, Centene was grappling with allegations of overbilling Medicaid for pharmacy services. It has since paid about $657 million . It faces investor lawsuits as well as overbilling allegations from several more states. Centene, based in Missouri, has denied wrongdoing.

Centene’s “suitability” for doing business with the NHS was not discussed in the virtual hearing. And because of technical limitations, members of the public could review the decision only through an audio recording, released online a day later.

“It was covid time,” Irvine, now retired, said with some frustration about the public meeting. “We believe NHS should be a public service, and it is being gradually eroded.”

Centene did not respond to requests to discuss its U.K. strategy. By July 2021, Centene’s interests also acquired Circle Health Group, a private health care group based in London with 50 hospitals.

Earlier this year, a judge ruled that the 2020 public meeting was conducted lawfully. The judge questioned the relevance of raising Centene’s liabilities; she noted the American company’s counsel had documented that its “financial position was strong” and that the insurer “continues to operate successfully in the U.S. health care market.”

Advocates for market-based efficiencies, including former NHS chiefs who were hired by Centene-related businesses, portray the managed-care titan as a change agent that can innovate and trim costs.

In October, an NHS care commission declined to renew a Centene contract for Hanley Primary Care Center in north London, which . The clinic was left with too few doctors, , and patient appointments had dropped by 270 a week, representing a “huge hole” in care since the acquisition. The NHS’ decision , in which clinic employees said the practice was short eight doctors and that less qualified workers, called physician associates, filled the gaps.

Operose spokesperson Stephen Webb, in an email, said the Hanley practice “is currently rated as ‘Good’ by the national regulator” and the contract would be reviewed next year. On its website, Operose calls the BBC report “sensational.” It adds that “we have a strong track record of performance, recruitment and investment in our staff and services.”

The Hanley decision is a small validation for Irvine and others who warned that efficiencies would degrade the quality of care.

“The whole ethos of the American system, well, it is fundamentally different than how we view care in the U.K.,” Irvine said. “Our values are free and accessible health care for all.”

Cultivating Ties in Government

Centene was eyeing the British health system in winter 2011, when it hosted health advisers from across Europe to tour its facilities in Spain’s seaside region of Valencia.

In March 2011, and again in 2015, representatives from Centene’s subsidiary Ribera Salud promoted its “pioneering approach” to caregiving at hospitals and treatment centers through a public-private partnership, according to.

Like Britain, Spain faces an aging population. The subsidiary promised a model for “efficient and effective healthcare” for patients who are government-supported or pay out-of-pocket. The government paid the provider a flat rate per patient each year, and Ribera Salud operated the sites and managed staff.

The approach intrigued British politicians and advisers, conservatives as well as liberals, eager to manage health care costs by encouraging competition.

Centene cultivated its image and relationships, launching the subsidiary Centene UK in 2016. Within months, it was hiring NHS administrators for its executive ranks. Among the highest-profile recruits: Samantha Jones, a nurse and the NHS England director of “new care models,” who had championed Centene’s work in Spain.

By 2019, Jones was named CEO of Centene UK. In 2021, she left to work for Prime Minister Boris Johnson as “an expert adviser for NHS transformation and social care.”

As Johnson’s premiership came under pressure, Jones was named chief of operations at No. 10 Downing St. She left when he resigned in July.

By then, Centene had a substantial U.K. foothold and other former NHS administrators had joined its top ranks. Contacted through LinkedIn, Jones said she was “not available to do any interviews.”

For consumers intent on preserving Britain’s national health care — or just understanding who owns what and where — Centene is difficult to track. It’s the same in the U.S., where the company has more than 300 subsidiaries. Names there typically lean into local iconography such as Peach State Health Plan of Georgia and Buckeye Community Health Plan of Ohio — with no mention of Centene.

In England, Jenny Shepherd, 72, has written about Centene and its subsidiaries for years. She set up a hyperlocal news site in 2012 to track public services amid government budget restraints. She soon focused on NHS. When Centene’s operations in Spain were being floated as a model for reform, Shepherd saw little coverage of it. “Journalism was lacking,” she said.

Shepherd scours regulatory filings for her posts, published under “.” Over years, she has documented a flowchart of sorts of Centene’s businesses. She said the company routinely recasts its corporate profile. From 2016 to 2018 alone, subsidiary names, addresses, and company directors changed often, she noted.

In 2018, Centene UK was listed as controlled by a Centene subsidiary, MH Services International Holdings. In November 2019, according to regulatory filings, Centene UK formally changed its name to Operose Health.

The practices acquired in 2020, however, were still identified in March 2021 as part of AT Medics Holdings. That filing, in U.K. government records, lists Operose Health as a board member.

Centene’s stake in Circle Health was laid out in December 2021 regulatory filings. Circle Health’s parent company in the U.K. is MH Services International (UK) Ltd., “with the ultimate parent being Centene Corporation,” records show.

Centene aims to wring profit from government-guaranteed payments, Shepherd said: “The English NHS is as big as the Chinese army, and it was clear that the Americans wanted to get their hands on it.”

Such guarantees have diminished, however, as health care costs have increased. The pandemic has propelled a two-year backlog for some treatments. For the first time in history, NHS nurses in England, Wales, and Northern Ireland went on strike in December, largely over pay. Ambulance drivers and paramedics in England and Wales followed suit. Military personnel were readied to take over some services.

‘Closer to the American Model’

The rise of for-profit providers within the British NHS has sparked incendiary debates, with brute questions about costs and motives. How much is spent on patients? How much is spent on services? And could market forces plow the national health landscape into a tiered system of care?

“We are seeing a shift in care access and waiting times, and a big rise in the number of people moving toward a private system,” said Chris Thomas, principal health fellow at the Institute for Public Policy Research think tank in London. “Britain already has the largest number of private patients in the G-7, and that brings us closer to the American model.”

Centene has been welcomed by some as a way “to ease burdens within a chronically overworked NHS,” Thomas said. “But it doesn’t seem optimal to have a corporation — a for-profit organization — coming in.”

Centene has seen limits to government guarantees, particularly in Spain.

Even as British health advisers visited Ribera Salud in 2011, the Spanish press was documenting financial missteps in the venture. Fees per patient, meant to cover access to universal care, had to be renegotiated. Directors and administrators moved between public-sector jobs and Ribera through what appeared to be an unchecked .

Anne Stafford, a finance professor at University of Manchester, behind the Ribera model. The rhetoric of savings never matched reality, she said, with no clear comparison offered of labor costs, financing, wage demand, and patient ratios between Spain and Britain.

Debates over how best to deliver care often lack rigor and consistency, she added. “People say they love their NHS, but they have no concept of how it is funded or how it operates,” she said. “That allows people with an agenda to get into the market.”

British politicians have seen health care as ripe for privatization since the late 1990s, she said, but “there is very little proper accountability” for whether “the private sector, in fact, is delivering value for money.”

NHS advisers also have questioned whether the two systems could be effectively compared: Invented after World War II, the NHS was so celebrated that in 2012 doctors and nurses marched in the opening ceremony of the London Olympics. Spain’s national health care emerged in the 1980s, after the death of dictator Gen. Francisco Franco, and it struggled with costs within its first decade. The Centene model in Valencia, reliant on bank financing, was implemented in 1999.

The report found differences in size and staffing of facilities as well as how care systems were integrated. Measuring possible cost savings was difficult and, the report said,

By December 2021, it was clear that Centene no longer regarded its Ribera operations as a moneymaker. It announced it would divest “non-core assets” to improve its profit margin.

Centene executives to two international assets: Circle Health and Ribera.

Within months, the Spanish subsidiary was sold for an undisclosed figure, bundled with other health and diagnostic groups, to Vivalto Santé, the third-largest private hospital company in France. The acquisition was completed in November.

Centene, in a statement, described its excising of Ribera, with 10 hospitals, 1,650 beds, and 71 primary care and outpatient clinics, as a “significant milestone in our value creation plan.”

For now, with its Circle Health venture. Its 1,900 beds delivered two-thirds of more than $2 billion in annual revenue, according to investor guidance in December 2021. It’s now the largest private hospital care provider in England.

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Coming Full Circle on Protections for Those With Disabilities

As a retired special education teacher, I’m wondering why our elderly in retirement homes aren’t covered by the American with Disabilities Act (“‘Impending Intergenerational Crisis’: Americans With Disabilities Lack Long-Term Care Plans,” Dec. 11). The act covers all the issues faced by our elderly in retirement homes as for children with these same needs. Students get a yearly prescription plan through a meeting with their parents, all who come in contact with them to provide services, and an administrator. Why isn’t this yearly plan in place for our elderly in retirement or nursing homes? Children go from newborns to toddlers, and on up through the growth and maturity ladder. Our elderly go through these same stages but in reverse. The care we give the elderly should mirror the care given to children albeit for, perhaps, a longer time in each stage. This would necessitate some major changes to existing federal, state, and local legislation. I get that all but the most dedicated and involved would fight this idea and consider our older population as throwaways. As Florida Gov. Ron DeSantis said, “Let them die.” Thank you for allowing this opportunity to throw in my two cents.

— Judy Galt, Orange Park, Florida

I hadn’t given this much thought but I do see it. Baby-boomer generation will pass and disabled offspring may more often lack adequate plans: “Impending Intergenerational Crisis’: Americans With Disabilities Lack Long-Term Care Plans” | Kaiser Health News

— Carl Hindy, Ph.D., HSP, Clinical Psychologist (@DrCarlHindy)

— Carl Hindy, Exeter, New Hampshire

Revoking the Disability Tax

Thank you so much for highlighting the difficulty blind individuals have with medical bills (“The Disability Tax: Medical Bills Remain Inaccessible for Many Blind Americans,” Dec. 2). I almost never see anything related to blindness and accessibility go through my news feed, so even though your findings are depressing, it made my day to know this issue was being highlighted in the national news!

— Brandon Keith Biggs, Atlanta

Not surprised. I’m & medical providers still expect me to be able to hear & understand important info over the phone. The Americans With Disabilities Act has no teeth.

— Jim Hankins (@ltecato)

— Jim Hankins, Anaheim, California

I want to personally thank you for reporting on this issue. There are workarounds for many of us to get around them. Unfortunately, it’s a separate but equal predicament. And this is not just with the medical system. Persons who are blind, who utilize technology, often rely on paid subscription services for completing visual tasks. One of them is called Aira. Trained people guide blind people through various tasks like navigating and filling out forms on inaccessible websites or take pictures of bills and read it to them.

The separate-but-equal status comes in because the general population is unaware the blind are unemployed or underemployed. The employment rate for the blind is under 20% less than convicted felons. The underemployment rate is 78%, in part because of outdated subminimum wage laws under Section 14(c) of the federal Fair Labor Standards Act that allows disabled people in America to be paid below federal minimum wage by all the major corporations, and everything in between.

Again, thank you for reporting on information that most people and the media won’t because they are not the fluffy, fuzzy, feel-good issues like blind people finishing college or doing something most people with vision simply do every day.

— William F. O’Donnell, Austin, Texas

Good article on how plan sponsors grab manufacturers’ copay support & patient assistance funds for themselves (instead of for patients)Not news to Drug Channels readers, but still nice to see mainstream press coverage

— Adam J. Fein (@DrugChannels)

— Adam J. Fein, Philadelphia

A Benefit for Big Pharma

Who profits from patient assistance and copay assistance programs? It should come as no shock that the wolves in sheep’s clothes are, indeed, the pharmaceutical companies (“Employers Use Patient Assistance Programs to Offset Their Own Costs,” Dec. 6).

One point left out of KHN’s article on these schemes, which represent a massive return on investment for Big Pharma: A pharmaceutical manufacturer will cover the costs of a patient’s copay, sometimes even pay the entire deductible, to keep the patient on its more expensive product (instead of cheaper alternatives the patient’s health plan would pay for). Once the deductible is met, the patient’s employer is forced to pay 80% or more of the patient’s drug costs. And, once the patient reaches their annual maximum out-of-pocket (MOOP) threshold, their employer starts paying 100% of the costs — and the drug company returns to making 100% profit, and no longer paying any assistance.

Oftentimes this means the pharma company essentially waives the costs of one or two doses of the drug, and the employer is then forced to pay many times that to cover the drug for the rest of the year.

Pharmaceutical manufacturers say the assistance programs are evidence of their commitment to maintaining the affordability of prescription drugs, but according to a recent report by the Congressional Research Service, while a drug discount coupon may reduce the amount an insured consumer must pay out-of-pocket for a drug, it generally does not reduce the price charged to an insurer or government program for the drug. That means patients will pay higher premiums later.

The recently published by the Regence Health Policy Center, asked this intriguing question: Are copay coupons “the solution for the unreasonable cost of specialty medications or a carefully crafted trojan horse disrupting affordability in our health care system?”

If pharmaceutical manufacturers really want to assist patients, they should stop the tricks and schemes, and charge reasonable drug prices in the U.S., as they do in every other developed nation.

— James Gelfand, president of , Washington, D.C.

If companies, including insurers, channeled their creativity into making care better and more affordable for patients, what a wonderful world it would be. Comment if you agree.

— David Johnson (@4sighthealth_)

— David Johnson, Chicago

Community Health Centers Are Transparent, Trusted, and Essential

In what appears to be a pattern, the KHN article by Phil Galewitz and Bram Sable-Smith about community health centers (“,” Nov. 28) uses selective data and outlier cases to paint a grossly inaccurate picture of the life-sustaining care that community health centers provide to 30 million Americans.

Contrary to the distorted conclusions drawn by the article’s focus on very few proceedings, health centers provide high-quality care for tens of millions of underserved and vulnerable patients in the U.S.

Given the critical role health centers play in health care delivery and the substantial increase in the number of health centers and patients, malpractice claims are an unfortunate reality. KHN’s narrative focuses on a few cherry-picked cases even as it acknowledges that “settlements and court judgments do not measure the clinics’ overall performance.” The article’s focus on claims payouts during 2018 and 2021, though tragic, represents a tiny fraction of 117 million patients served and 477 million visits — meaning the reporters focused on far less than 1 percent of patients.

The larger and unassailable story is that health centers enforce rigorous safeguards to ensure the best patient care. Federal Tort Claims Act coverage — the federal coverage that is the focus of this article — is not automatically granted to health center grantees. Rather, health centers must implement solid quality improvement and risk management programs to qualify for and maintain FTCA coverage. Such coverage allows essential health care services to remain affordable and accessible to economically challenged patients when and where they need it. Additionally, health centers are subject to on-site auditing of these processes to ensure they meet appropriate standards and function as intended. FTCA coverage makes health centers even more vigilant on quality of care — not less.

Every dollar invested in health centers returns value to American taxpayers. The program generates annual system-wide savings of $24 billion yearly because fewer health center patients require emergency room visits and hospitalizations. More important than dollars saved, health centers are transparent, trusted, and essential stewards of public health. We stand by their long and successful track record.

— Rachel Gonzales-Hanson, interim CEO and president of the National Association of Community Health Centers, Bethesda, Maryland

and another recent story about malpractice at community health centers

— Taylor Emrey Glascock (@tayloremrey)

— Taylor Emrey Glascock, Chicago

STD Testing: Don’t Try This at Home?

Though home testing for sexually transmitted infections would be valuable, maximizing the testing technology we have now would be even more valuable (“A New Use for Dating Apps: Chasing STDs,” Nov. 30). Sixty percent of all STIs in high-risk persons cannot be diagnosed via a urine sample because they are extragenital (in the throat or rectum). STI testing should include screening urine as well as throat and rectum swabs for many people. This could be accomplished by labs giving clients swabs to self-collect, however Hologic (the company that produces the Aptima system pictured in your article) has not done the validation studies to allow its system to be used on self-collected extragenital tests. Thus, a patient must go to a provider to get the swabs collected, rather than just go to the lab directly after orders are submitted. This is not an issue of new technology; this is an issue of ensuring we are using what we have to its full capacity, ensuring adequate extragenital screening, and ensuring it can be done in the most convenient way possible. Molecular screens allow for home-based testing (collected at home and sent back to be processed). Halogen tests, the system used by Quest, Labcorp, CPL, etc., do not. Though having home-based rapid results would be great (which, of course, would require self-collected samples), ensuring we are able to maximize the technology we have available now would be a big step forward.

— Christine Brennan, New Orleans

The use of apps may have exploded since, but we were doing this 20 years ago when I was an officer . In fact I had to get access to certain blocked websites – it was interesting explaining that to the IT folks.

— Michael Greenberg MD (@greenbergepi)

— Dr. Michael Greenberg, Bethlehem, Pennsylvania

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Envy for-profit US healthcare? Check out this MD whose wife is a medical billing expert who spent over a year challenging an egregious billing error. After it all they still paid $1200. These are resourceful knowledgeable people who got taken for a ride.

— Raghu Venugopal MD (@raghu_venugopal)

— Dr. Raghu Venugopal, Toronto

A Plea for Sane Prices

I just read your story about the emergency room billing for a procedure that was not done (“A Billing Expert Saved Big After Finding an Incorrect Charge in Her Husband’s ER Bill,” Oct. 25). We too had a similar experience with an emergency room and a broken arm that was coded at a Level 5, and it was a simple break. No surgery needed, and it took them only 10 minutes to set and wrap the broken arm but charged us over $9,000. I disputed the charges, and it took six months to get them to reduce the bill but they never admitted that they coded a simple break incorrectly to jack up the price of the bill. If it had been a Level 5 issue, we would not have sat in the waiting room for six hours before being seen. It was a horrible experience, and I think ERs all over the nation are doing this to make up for the non-payers they treat every day. It is robbery.

— Terrence Campbell, Pocatello, Idaho

It would be great if the vaulted would clearly distinguish between the ED pro fee billing & hospital charges as it is not entirely clear here w/ in network svs.—Billing Expert Saved Big After Finding an Incorrect Charge in Her Husband’s ER Bill

— Ed Gaines (@EdGainesIII)

— Ed Gaines, Greensboro, North Carolina

As you said, CPT codes should always be examined. This case is probably more than “just an error.” As a retired orthopedic surgeon, chief of surgery, and chief of staff at a North Carolina hospital, I have seen care such as this coded exactly like this with the rationale that, “Hey, this was a fractured humerus and it was manipulated and splinted.” 24505 is correct IF that is the definitive treatment, which it was not here. Even code 24500 would indicate definitive treatment without manipulation. This was just temporary care until definitive care could be done later. It should be billed as a visit and a splint. The visit for this, if it was an isolated problem (no other injury or problems), would qualify only as a Level 2 visit. That frequently gets upcoded as well by adding a lot of non-pertinent family, medical, and social history and a complete physical exam (seven systems at least) and a whole lot of non-pertinent “medical decision making.” All of that should be documented in the medical records even if the hospital stonewalls on the CPT codes.

Look closely at medical records and you will find frequent upcoding, if you are familiar with the requirements for different levels of treatment.

— Dr. Charles Beemer, Arvada, Colorado

Never attribute to Baumol's cost disease that which is adequately explained by malice.

— Shashank Bhat (@shashank_ps)

— Shashank Bhat, San Francisco

A number of years ago, I was billed using a code that described a treatment that was not carried out. In similar fashion, I talked with my insurance company, which basically said it did not care whether the treatment took place or not as all it required was for a valid code to appear. I also contacted the Virginia Bureau of Insurance, which approves the various policies, and it said it had no jurisdiction over claims. I decided to let the hospital sue me for the disputed amount and defended myself in district court. Despite their attorney and four “witnesses,” the case was thrown out because the hospital was both unwilling and unable to justify the charges to the satisfaction of the judge. They did not want anybody in power to testify because of the questions they would have been asked, so they left it to people who were completely clueless. The takeaways from this were:

• Hospitals make up the numbers and leave them grossly inflated so they can claim that they are giving away care when they give discounts on the made-up numbers.
• Hospitals turn employees into separate billing entities so they can double-charge.
• Hospitals open facilities such as physical therapy in hospital locations because insurance companies will pay higher amounts when treatment is carried out in a hospital environment.
• Insurance companies and state insurance agencies do not act as gatekeepers to protect their clients/taxpayers.
• The insurance companies and the providers have a shared interest in the highest possible ticket prices and outrageous charges because the providers get to claim how generous they are with “unremunerated care,” and if the prices were affordable then they could not justify the high prices for insurance premiums and the allowed administration/profit share of 20% would be based on a far smaller amount.

In any other industry, this would have resulted in multiple antitrust suits. U.S. health care is a sad example of government, health care industry, and insurers all coming together against the interests of consumers. After this court case, I wanted to form a nonprofit to systematically challenge every outrageous charge against people who, unlike myself, did not believe or know how to defend themselves. If hospitals and other providers were forced to go to court to justify their charges on a systematic basis, pricing sanity would eventually prevail.

— Philip Solomon, Richmond, Virginia

The obvious solution to prosecute the hospital for fraud followed by a civil suit"A hospital charged nearly $7,000 for a procedure that was never performed"

— Barry Ritholtz (@Ritholtz)

— Barry Ritholtz, New York City

Patients as Watchdogs

Thank you for the article on Lupron Depot injections (Bill of the Month: “$38,398 for a Single Shot of a Very Old Cancer Drug,” Oct. 26). Last year, I was diagnosed with prostate cancer, though my case is not anywhere as severe as that experienced by Mr. Hinds.

Last month my urologist scheduled an MRI update for me at a facility owned by Northside Hospital Atlanta. At the suggestion of my beloved wife, I called my insurance company, UnitedHealthcare, to make sure the procedure was covered. Fortunately, it was. That being said, the agent from UnitedHealthcare mentioned that Northside Hospital’s fee was “quite a bit higher than the average for your area.” It was. Before insurance, the charge for an MRI at Northside was $6,291. I canceled the appointment at Northside and had the MRI done by a free-standing facility. Their charge, before insurance, was $1,234.

Every single encounter that I have with the health care system involves constant vigilance against price-gouging. When I have a procedure, I have to make sure that the facility is in-network,. that each physician is in-network, that any attending specialist such as an anesthesiologist or radiologist is in-network (and their base-facility as well). If I have a blood test, I have to double-check if the cost is included in a procedure or if it is separate. If it is a separate fee, I have to ensure that the analysis is also covered, and, if it is not, that it is not done through a hospital-owned facility but instead through a free-standing operation.

I have several ongoing conditions in addition to my prostate cancer — Dupuytren’s contracture, a rare bleeding disorder similar to thrombocytopenia, and arthritis. Needless to say, navigating our byzantine, inefficient, and profit-driven health care system is a total nightmare.

Health care in the United States has become so exceedingly outrageous. I cannot understand why it is not an issue that surfaces during election years or something that Congress is willing to address.

Again, thank you for your excellent reporting.

— Karl D. Lehman, Atlanta

Why capitalism without guardrails is a pipedream. Own the patent, control the pricing, and this is the result: $38,398 for a Single Shot of a Very Old Cancer Drug via

— Brian Murphy (@NorwoodCDI)

— Brian Murphy, Austin, Texas

I was a medical stop-loss underwriter and marketer for over 30 years. Most larger (company plans for 100-plus employees) are self-funded, meaning the carrier — as in this case, UnitedHealthcare — is supplying the administrative functions and network access for a fee, while using the employer’s money to pay claims.

Every administrator out there charges a case management fee, either as a stand-alone charge or buried in their fees. Either way, they all tout how they are looking out for both the employer and the patient.

Even if this plan was fully insured, wouldn’t it have been in the best interest of all parties when they became aware of the patient’s treatment (maybe after the first payment) to reach out to the patient and let them know there are other alternatives?

The question in these cases is who is minding the store for both the patient and the employer. The employer, the insurer, and the patient could have all saved a lot of money and pain, if someone from case management had actually questioned the first set of charges.

— Fred Burkacki, Sarasota, Florida 

I did a few rounds of Lupron in my 20s for severe , and I had to fight my insurance company to get approved. Now, this is how much it costs for some people.

— Amanda Oglesby 🌊 (@OglesbyAPP)

— Amanda Oglesby, Neptune, New Jersey

‘Bill of the Month’ Pays Off

I received a $1,075 refund on a colonoscopy bill I paid months earlier after listening to the KHN-NPR “Bill of the Month” segment “Her First Colonoscopy Cost Her $0. Her Second Cost $2,185. Why?” (May 31) and finding out the procedure should be covered under routine health care coverage. Thank you!

— Cynthia McBride, University Place, Washington

We have to close legal loopholes to make sure that cancer diagnostic procedures have the same insurance coverage as screening. Colonoscopies must be fully covered whether a polyp is found or not

— Erica Warner, ScD (@ewarner_12)

— Erica Warner, Boston

Removing Barriers to Benefits

In the story “People With Long Covid Face Barriers to Government Disability Benefits” (Nov. 9), you stated: “Many people with long covid don’t have the financial resources to hire a lawyer.” This is incorrect. When applying for disability, you don’t need financial resources. There are law firms that specialize in disability claims and will not charge you until you win your claim. And, according to federal law, those law firms can charge only a certain percentage of the back pay you would get once the claim has been won. Also, if you lose the claim, and the law firm has appealed as many times as possible, you don’t owe anything. Please don’t make it more difficult for those who are disabled with misinformation.

— Lorrie Crabtree, Los Angeles

People unable to work due to Long Covid are facing barriers to obtaining government disability benefits.

— Ron Chusid (@RonChusid)

— Ron Chusid, Muskegon, Michigan

Vaccine Injuries Deserve Attention, Too

I read your long-covid article with interest because many of the barriers and some of the symptoms faced by people with long covid are similar to those experienced by people with vaccine injuries. I’m really concerned about how there is even less attention and support for people who suffered adverse vaccine reactions.

Long covid and vaccine injuries are both issues of justice, mercy, and human rights as much as they are a range of complex medical conditions.

It’s nearly 20 months since someone I know sustained a serious adverse reaction, and it is heartbreaking how hard it has been for her to find doctors who will acknowledge what happened and try to help. There’s no medical or financial support from our government, and the Countermeasures Injury Compensation Program is truly a dead end, even as other countries such as Thailand, Australia, and the United Kingdom have begun to acknowledge and financially support people who sustained vaccine injuries.

I’ve contacted my congressional representatives dozens of times asking for help and sharing research papers about vaccine injuries, but they have declined to respond in meaningful ways. Similarly, my state-level representatives ignore questions about our vaccine mandate, which remains in place for state employees, despite at least one confirmed vaccine-caused fatality in a young mother who fell under the state mandate in order to volunteer at school.

There have been a few articles, such as …

… but no new ones have come to my attention recently, and it is concerning that the media and our political and public health leaders seem OK with leaving people behind as collateral damage.

Please consider writing a companion piece to highlight this need and the lack of a functional safety net or merciful response. My hope is that if long covid and vaccine injuries were both studied vigorously, new understanding would lead to therapeutics and treatments to help these people.

— Kathy Zelenka, Port Angeles, Washington

Given how long it took Congress to eventually approve "Agent Orange" and "Burn Pit" benefits for disabled veterans, it is at least a 15-20 year time frame and they don't have the backing or societal standing that veterans do.

— Matthew Guldin (@MRG_1977)

— Matthew Guldin, West Chester, Pennsylvania

More on Mammograms

The article “Despite Katie Couric’s Advice, Doctors Say Ultrasound Breast Exams May Not Be Needed” (Oct. 28) does a disservice to women and can cause harm. An ultrasound is saving my life. I had two mammograms with ultrasounds this year. Although the first mammogram showed one cyst that was diagnosed as “maybe benign,” I knew it wasn’t. Why? Because I could feel the difference. I insisted on a second, and sure enough a large-enough cyst that’s definitely malignant was found. I had breast surgery on Oct. 31, followed by radiation treatment and, if needed, chemotherapy later. This article will deprive other, less aggressive and experienced women who do not have health care credentials or a radiologist for a husband to be harmed by being lulled into complacency.

— Digna Irizarry Cassens, Yucca Valley, California

Why do some women with dense breasts get additional screening while others do not? ⁦⁩ explains. ⁦⁩

— Patricia Clark MD, FACS, FSSO (@patriciaclarkmd)

— Patricia Clark, Scottsdale, Arizona

Your article on breast cancer screening neglected to present the supplemental option of Abbreviated Breast MRI (AB-MRI). The out-of-pocket cost at many clinics ranges from $250 to $500. For a national listing of clinics that offer this supplemental screening option, please go to . For benefits, just Google “Abbreviated Breast MRI.”

— Elsie Spry, Wexford, Pennsylvania

Why didn’t more leave for safer havens during Hurricane Ian as recommended? ⁦⁩ rightfully suggests that learning why is critical as the population of older people grows and become more frequent.

— Donald H. Polite (@DonaldPolite)

— Donald H. Polite, Milwaukee

Preparation Plans for Seniors: All for One and One for All

At least 120 people died from Hurricane Ian, two-thirds of whom were 60 or older. This is a tragedy among our most vulnerable population that should have been prevented (“Hurricane Ian’s Deadly Impact on Florida Seniors Exposes Need for New Preparation Strategies,” Nov. 2).

Yes, coming together and developing preparedness plans is one way to protect seniors and avoid these kinds of tragedies in the future, but since this is not a one-size-fits-all situation, organizations that help seniors across the country must first look internally and be held accountable by making sure their teams always have a plan in place and are prepared to activate them at a moment’s notice.

During Hurricane Ian, I saw firsthand what can happen when teamwork and effective planning come together successfully to protect and prepare seniors with chronic health conditions like chronic obstructive pulmonary disease who require supplemental oxygen to breathe.

Home respiratory care providers and home oxygen suppliers worked tirelessly to ensure our patients received plenty of supplies to sustain them throughout the storm, and when some patients faced situations where their oxygen equipment wasn’t working properly inside their homes, staff members were readily available to calmly talk the patient through fixing the problem. After the winds receded, mobile vans were quickly stationed in safe spaces for patients or their family members to access the oxygen tanks and supplies they needed. If patients were unable to make it to these locations, staff members were dispatched to deliver tanks to their homes personally and check in on the patient.

Patients were also tracked down at shelters, and a team of volunteers was formed around the country to find patients who could not be reached by calling their emergency backup contacts, a friend, or family member. Through these established systems, we were able to remain in contact with all of our patients in Ian’s path to ensure their care was not impeded by the storm.

Organizations should always be ready and held accountable for the seniors they care for in times of disaster. I know my team will be ready. Will yours?

— Crispin Teufel, CEO of Lincare, Clearwater, Florida

Understanding the impact of on older people is critically important as the population expands and become more frequent and intense.

— Ashley Moore, MS, BSN Health Policy (@MooreRNPolicy)

— Ashley Moore, San Francisco

The Tall and the Short of BMI

I am amazed that in your article about BMI (“BMI: The Mismeasure of Weight and the Mistreatment of Obesity,” Oct. 12) you never mentioned anything about the loss of height. If a person goes from 5-foot-2 to 4-foot-10, the BMI changes significantly.

— Sue Robinson, Hanover, Pennsylvania

I've been against this since after gastric bypass surgery I got down to 164 pounds but at 5'7" BMI still considered me overweight. How an overreliance on BMI can stand between patients and treatment

— Steve Clark (@blindbites)

— Steve Clark, Lee’s Summit, Missouri

Caring for Nurses’ Mental Health

During the pandemic, when I read stories about how brave and selfless health care heroes were fighting covid-19, I wondered who was taking care of them and how they were processing those events. They put their own lives on the line treating patients and serving their communities, but how were these experiences affecting them? I am a mother of a nurse who was on the front lines. I constantly worried about her as well as her mental and physical well-being (“Employers Are Concerned About Covering Workers’ Mental Health Needs, Survey Finds,” Oct. 27). I was determined to find a way to honor and support her and her colleagues around the country.

I created a large collaborative art project called “The Together While Apart Project” that included the artwork of 18 other artists from around the United States. It originated during the lockdown phase of the pandemic, a time when we were all physically separated yet joined by a collective mission to create one amazing art installation to honor front-line workers, especially nurses. Upon its completion, this collaboration was recognized by the Smithsonian Institute, Channel Kindness (a nonprofit co-founded by Lady Gaga) and NOAH (National Organization of Arts in Medicine). After traveling around the Southeast to various hospitals for the past year on temporary exhibit, the artwork now hangs permanently in the main lobby at the University of Virginia Medical Center in Charlottesville, Virginia.

I wanted to do something philanthropic with this art project to honor and thank health care heroes for their dedication over the past two years. It was important to find a way to help support them and to ensure they are not being forgotten. Using art project as my platform, I partnered with the American Nurses Association and created a fundraiser. This campaign raises money for the ANA’s Well-Being Initiative programs, which support nurses struggling from burnout and post-traumatic stress disorder and who desperately need mental and physical wellness care. Fighting covid has taken a major toll on too many nurses. Some feel dehumanized and are not receiving the time off or the mental and physical resources needed to sustain them. Many are suffering in silence and have to choose between caring for themselves or their patients. They should not have to make this choice. Nurses are the lifeline in our communities and the backbone of the health care industry. When they suffer, we all suffer. Whether they work in hospitals, doctors’ offices, assisted living facilities, clinics or schools, every nurse has been negatively impacted in some way by the pandemic. They are being asked to do so much more than their jobs require in addition to experiencing greater health risks, less pay, and longer hours. Nurses under 35 and those of color are struggling in larger numbers.

The American Nurses Foundation offers many forms of wellness care at no charge. They rely heavily on donations to maintain the quality of their offerings as well as the ability to provide services to a growing number of nurses. I am an artist, not a professional fundraiser, and I have never raised money before. But I feel so strongly about ensuring that nurses receive the support and care they deserve, that I am willing to do whatever it takes to advocate and elevate these health care heroes.

The Together While Apart Project’s “Thank You Nurses Campaign” goal is $20,200, an amount chosen to reflect the numbers 2020, the year nurses became daily heroes. So far, I have raised over $15,500 through gifts in all amounts. For example, a $20 donation provides a nurse with a free one-hour call with a mental health specialist. That $20 alone makes a big difference and can change the life of one nurse for the better. The campaign has provided enough funding (year to date) to enable 940 nurses to receive free one-hour wellness calls with mental health specialists.

The online fundraiser can be found at .

— Deane Bowers, Seabrook Island, South Carolina

CEAPs, is it time to offer more services? Nearly 1/2 of employers (w/ 200 workers) report a growing share of workers using mental health services. Yet 56% report they lack providers for employees to access to timely care.

— EAPA (@EAPA)

— Employee Assistance Professionals Association, Arlington, Virginia

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The $10,563.49 in initial ER charges from a Froedtert South hospital in Pleasant Prairie, Wisconsin, seemed high considering he basically got only an exam, X-rays, pain relief, and an arm splint. His insurer negotiated the cost down to $7,922.62 — but, with Shah owing $250 for his deductible and 40% of the remaining charges, his bill of $3,319.05 still felt like too much. However, he thought, who was he to question the hospital’s billing department?

Shah’s wife, on the other hand, is highly qualified to question such charges. Sunita Kalsariya, 45, is the office manager of her husband’s medical practice, a job that includes overseeing billing. She took one look at the hospital charges and decided to investigate further.

Kalsariya had no way of knowing then that she was embarking on a crusade that would take over a year, send their bill to debt collections, lead her to complain to the Illinois attorney general, and discover that the hospital charged nearly $7,000 for a procedure that was never performed.

Froedtert South did not respond to multiple requests for comment on the case.

Here’s how Kalsariya reduced her family’s bill:

Tip 1: Start Early

Even before you know you’ll be challenging a bill, Kalsariya said, you should ask the hospital both for more information and to pause the billing process. The sooner you do that, the more time you’ll have to track down the details you need to contest a bill — and possibly reset the clock before it is sent to collections.

“Even in our case, we waited until the second bill,” Kalsariya said. “Start acting with the first bill.”

Tip 2: Get an Itemized Bill

Hospitals often have their own internal billing codes, so it’s important to ask for an itemized bill that lists “current procedural terminology” billing codes (CPT codes, for short), which are standardized across the country.

Depending on the medical procedure, Kalsariya said, a bill could contain an overwhelming number of line items that are hard to understand. She suggested focusing on the items that stand out, such as those with the highest price tag.

Kalsariya said it took months to get a bill that included CPT codes for her husband’s ER trip. Once she did, one item jumped out: $6,961.75 for CPT code 24505 — treating a fractured humerus without making an incision.

Shah didn’t remember having that treatment at Froedtert South. What he did recall was having his arm splinted in a comfortable position and making plans to have surgery the next day at a hospital in the Chicagoland area unaffiliated with Froedtert South. He returned home that night, caught maybe a couple of hours of sleep while propped up by pillows in an almost-seated position, then had a successful surgery.

Tip 3: Compare Your Charges With Those at Other Hospitals

Since January 2021, all hospitals to make their prices publicly available, although some do so in a way that is difficult to find. Still, Kalsariya was able to find the prices that other hospitals in Wisconsin and beyond charged for the same procedure. They ranged from $201 in Boise, Idaho, to $1,300 in Madison, Wisconsin, she said, but all were fractions of the nearly $7,000 that Froedtert South charged.

The website has a tool that allows consumers to search for typical patient expenses for procedures in their area. The website estimates that the out-of-network cost for the procedure Shah underwent, within the hospital’s ZIP code, would be $3,863; in network, it would be $1,707. Medicare also to find national average patient expenses searchable by CPT code. The total cost for that procedure is listed at $1,892, with Medicare paying $1,514 and the patient on the hook for $378.

Tip 4: Challenge Your Charges

Armed with the information that Froedtert South was seemingly charging more than others for the bone realignment, the couple tried appealing directly to the hospital with no luck.

“The charges incurred on your date of service were both reasonable and within the range usually charged by similar healthcare providers in the area,” the hospital’s response letter read. “Moreover, your insurance company, United Healthcare Choice-Golden Rule, entered into a long-term agreement with Froedtert South knowing the charges for its various services.”

The couple sent two complaints to their insurer asking how it could allow itself to be charged such a high amount, but response letters said the claim was processed correctly.

“We expect our in-network providers to bill appropriately for their services,” UnitedHealthcare spokesperson Maria Gordon Shydlo wrote in an email to KHN. “We paid the claim under the terms of Mr. Shah’s benefit plan based on the information we received from the provider.”

Fed up, Kalsariya filed a complaint with the Illinois attorney general’s office. After going back and forth, she eventually was told her husband could apply for the hospital’s financial assistance program to reduce his bill. But Kalsariya said they didn’t need financial assistance. They could afford $3,319.05. This, she said, was about the principle of the thing — she felt they were being egregiously overcharged.

Tip 5: Request Your Medical Records

Getting Shah’s medical records proved to be another challenge. Kalsariya said her attempt to access the records on the hospital’s website didn’t work, so instead the couple was required to send hospital officials a form to release the records.

“They wouldn’t even accept fax or email,” Kalsariya said. “They needed it mailed, specifically, and it had to be notarized.”

It almost didn’t seem worth the hassle to them. But when a KHN reporter responded to the family’s request for help investigating Shah’s hospital bill, the couple decided to send in the form to accurately document their saga.

When the records arrived, they showed the splinting that Shah remembered but not the treatment that was driving up his bill. They appealed the bill to Froedtert South once more in May 2022, this time noting the discrepancy between the charges and the medical records.

Tip 6: Tell Collections You Are Disputing the Bill

Shah had received a letter from a debt collector, which Kalsariya said came in November 2021, over his unpaid medical bill. She asked the hospital to pull the bill from collections because the dispute was unresolved, which she said it did.

Informing a collections agency that a bill is in dispute can help protect a patient’s credit score. That wasn’t an issue with Shah’s bill from the hospital because the hospital pulled it back after Kalsariya’s call.

How It All Ended

After the couple asked the hospital about the discrepancy with the procedure, Shah received a letter from the hospital dated May 27 of this year, saying it had reviewed the records and discovered the bill was inappropriately coded: The hospital should have used the code for a splint, not a treatment. A month later, Shah got a new bill with a patient balance of $1,214.91 — $2,100 less than the original balance.

Kalsariya still thought the bill seemed high and that the hospital seemed unapologetic about charging for a procedure that was never performed.

But the couple paid the new, smaller bill, and their saga was finally over. Her advice to other patients? When you get a bill, look into it before paying.

“I know it’s time-consuming. It is really taxing on our minds to do this,” Kalsariya said. “But if everybody makes that effort, then they have to be transparent.”

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Plus, Sebastian was developing well in other ways: When he was just 18 months old, for example, he could identify the magnetized letters of the alphabet on the refrigerator at their home in Bronxville, a short train ride north of New York City.

But by the time Sebastian was a little over 2 years old, his skills weren’t keeping up with those of other kids his age: He spoke only simple words, like “mama” and “dada,” and had problems interacting with people, Amparo Rios said. He didn’t know how to play with other kids and didn’t care about showing people his toys or sharing them. He made eye contact less and less.

The Rioses worried their son might have autism but didn’t know how to get a definitive diagnosis for his lagging skills or how to get him help.

with autism spectrum disorder by age 8, according to federal estimates. It is a developmental disability that affects people’s social and communication skills and their behavior to varying degrees. About a third of children with autism have intellectual disabilities as well, according to the federal Centers for Disease Control and Prevention.

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She picked a Humana drug plan for its low prices, with help from her longtime insurance agent and Medicare’s Plan Finder, an online pricing tool for comparing a dizzying array of options. But instead of the $70.09 she expected to pay for her dextroamphetamine, used to treat attention-deficit/hyperactivity disorder, her pharmacist told her she owed $275.90.

“I didn’t pick it up because I thought something was wrong,” said Griffith, 73, a retired construction company accountant who lives in the Northern California town of Weaverville.

“To me, when you purchase a plan, you have an implied contract,” she said. “I say I will pay the premium on time for this plan. And they’re going to make sure I get the drug for a certain amount.”

But it often doesn’t work that way. As early as three weeks after Medicare’s drug plan enrollment period ends on Dec. 7, insurance plans can change what they charge members for drugs — and they can do it repeatedly. Griffith’s prescription out-of-pocket cost has varied each month, and through March, she has already paid $433 more than she expected to.

A by AARP, which is lobbying Congress to pass legislation to control drug prices, compared drugmakers’ list prices between the end of December 2021 — shortly after the Dec. 7 sign-up deadline — and the end of January 2022, just a month after new Medicare drug plans began. Researchers found that the list prices for the 75 brand-name drugs most frequently prescribed to Medicare beneficiaries had risen as much as 8%.

Medicare officials acknowledge that manufacturers’ prices and the out-of-pocket costs charged by an insurer can fluctuate. “Your plan may raise the copayment or coinsurance you pay for a particular drug when the manufacturer raises their price, or when a plan starts to offer a generic form of a drug,” the warns.

But no matter how high the prices go, most plan members can’t switch to cheaper plans after Jan. 1, said Fred Riccardi, president of the , which helps seniors access Medicare benefits.

Drug manufacturers usually change the list price for drugs in January and occasionally again in July, “but they can increase prices more often,” said , an associate professor of health policy at Vanderbilt University and a member of the Medicare Payment Advisory Commission. That’s true for any health insurance policy, not just Medicare drug plans.

Like a car’s sticker price, a drug’s list price is the starting point for negotiating discounts — in this case, between insurers or their pharmacy benefit managers and drug manufacturers. If the list price goes up, the amount the plan member pays may go up, too, she said.

The discounts that insurers or their pharmacy benefit managers receive “don’t typically translate into lower prices at the pharmacy counter,” she said. “Instead, these savings are used to reduce premiums or slow premium growth for all beneficiaries.”

Medicare’s prescription drug benefit, which began in 2006, was supposed to take the surprise out of filling a prescription. But even when seniors have insurance coverage for drugs, advocates said, many still can’t afford them.

“We hear consistently from people who just have absolute sticker shock when they see not only the full cost of the drug, but their cost sharing,” said Riccardi.

The potential for surprises is growing. More insurers have eliminated copayments — a set dollar amount for a prescription — and instead charge members a percentage of the drug price, or coinsurance, , the top official at the Centers for Medicare & Medicaid Services, said in a recent interview with KHN. The drug benefit is designed to give insurers the “flexibility” to make such changes. “And that is one of the reasons why we’re asking Congress to give us authority to negotiate drug prices,” she said.

In addition to the drug tier, what patients pay can also depend on the pharmacy, their deductible, their copayment or coinsurance — and whether they opt to abandon their insurance and pay cash.

After Linda Griffith left the pharmacy without her medication, she spent a week making phone calls to her drug plan, pharmacy, Social Security, and Medicare but still couldn’t find out why the cost was so high. “I finally just had to give in and pay it because I need the meds — I can’t function without them,” she said.

But she didn’t give up. She appealed to her insurance company for a tier reduction, which was denied. The plan denied two more requests for price adjustments, despite assistance from Pam Smith, program manager for five California counties served by the . They are now appealing directly to CMS.

“It’s important to us to work with our members who have questions about any out-of-pocket costs that are higher than the member would expect,” said Lisa Dimond, a Humana spokesperson. She could not comment about Griffith’s situation because of privacy rules.

However, Griffith said she received a call from a Humana executive who said the company had received an inquiry from the media. After they discussed the problem, Griffith said, the woman told her, “The [Medicare] Plan Finder is an outside source and therefore not reliable information,” but assured Griffith that she would find out where the Plan Finder information had come from.

She won’t have to look far: CMS requires insurers to update their prices every .

“I want my money back, and I want to be charged the amount I agreed to pay for the drug,” said Griffith. “I think this needs to be fixed because other people are going to be cheated.”

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The company’s February note said its health plan sign-ups saw “extraordinary growth” — passing the “one-million-member mark” in the previous year — and tied that success to the good relationships it has with brokers. But, the note continued, the insurer wanted to “suspend growth during this special enrollment season” and thus would stop paying commissions to brokers who enroll new people in coverage starting April 1.

“Why sell something I don’t get paid for?” the Georgia-based Holtzman recalled thinking.

Bright Health is not the only company cutting commissions. Several other insurers, including Oscar, Molina Healthcare, and some Blue Cross Blue Shield plans, have taken similar steps recently — just as the Biden administration rolls out a new aimed at signing up low-income Americans into ACA coverage outside of the usual annual open period. The new sign-up program became available in mid-March for coverage starting at the beginning of April.

The insurance industry’s trade group, however, opposed the plan, saying that people who sign up outside of the end-of-the-year enrollment window tend to be sicker, drive up the price of insurance, and cost insurers more.

“We have significant concerns it would create instability in the individual market and result in higher premiums for all enrollees,” AHIP wrote in a July to federal agencies.

Consumers could, insurers warn, wait until they get sick to enroll or switch plans to one with more generous benefits. The Centers for Medicare & Medicaid Services estimates that the low-income special enrollment program could by 0.5% to 2% annually because of sicker enrollees.

periods have always been allowed under the ACA when triggered by certain life events. Everyone else signs up during the annual open enrollment, typically from November to January. That restriction is designed to reduce the incentive for people to wait until they fall ill to buy insurance, which likely would drive up premium costs for everyone.

Last year, the Biden administration added a six-month covid-related special enrollment, which resulted in a .

Still, “there is limited data on whether folks come in sicker” during the special enrollment periods that have occurred since the ACA began, said Katie Keith, a researcher at the Center on Health Insurance Reforms at Georgetown University, adding that some of the verification rules supported by the industry around previous special enrollment exceptions are onerous enough that they may discourage the healthy more than the ill. Brokers note that low-income customers do turn to brokers when considering insurance coverage.

“Those are people who often need help the most,” said Marcy Buckner, senior vice president for government affairs at the National Association of Health Underwriters, an industry trade and lobbying group. “Agents and brokers want to help consumers, but they also have to keep their doors open. If they’re not earning commissions, they may not be able to help those consumers.”

The move by some insurers to cut commissions as of April 1 has caught the attention not only of brokers but of federal regulators.

“We are concerned about the impact on consumers, particularly those consumers whose circumstances lead them to enroll mid-year, and are actively investigating this matter,” Ellen Montz, director of the Center for Consumer Information and Insurance Oversight at CMS, said in a statement.

The Biden administration program allows people who earn less than 150% of the federal poverty level — about $19,320 for a single person or $32,940 for a family of three — to sign up anytime during the year. Other special enrollment offers, such as those for people who lose job-based insurance, get married or divorced, or want to add a baby to their plans, are generally time-limited. Among those currently uninsured, an could be eligible for the new low-income enrollment option.

Many more might need help enrolling soon for another reason, said policy experts. Some estimate that millions of people once the official pandemic emergency ends because states will no longer be held to an agreement they made with the federal government not to drop enrollees during the pandemic.

Although many of those health consumers might enroll on their own through federal or state marketplaces, or seek help from federal grant-funded assisters, experts say some may turn to private brokers, who may not want to take on new customers if they’re not going to get paid for their time.

“If insurers are not paying commissions for the special enrollment period, that will diminish sign-ups,” said Sarah Lueck, vice president for health policy at the Center on Budget and Policy Priorities, a left-leaning think tank in Washington, D.C.

Agents and brokers also argue that changing commissions midyear might run afoul of federal or state rules barring discrimination.

They point to issued in 2016, when some insurers were changing commission structures, warning the industry against practices that had the effect of “discouraging the enrollment of individuals with significant health needs in health insurance coverage.”

Neither Oscar nor Molina would comment for this story. In a written statement, Bright HealthCare said the industry is trying “to ensure continued access to care at affordable prices,” and is “working closely with its brokers to implement the [special enrollment period] commissions change as part of the solution.”

The Biden administration’s new policy for low-income special enrollment automatically applies to using the federal health exchange; the remainder that run their own marketplaces have the choice of whether to offer it. Excluded are people eligible for Medicaid or who have job-based coverage that meets the ACA’s criteria as affordable.

While the new special enrollment period is considered permanent, made available through the American Rescue Plan Act to help people buy coverage, which expire at the end of 2022 unless Congress extends them.

Insurers recently have expressed concerns about costlier customers enrolling during special periods, with some toward the end of last year on new enrollment.

Some of those cutting commissions, however, , still posted profits last year.

But not all. posted a 49% jump in membership during 2021, but a net loss of $571 million. , Bright HealthCare’s parent company, also showed membership growth last year, but with a net loss of more than a billion dollars.

Brokers say federal statistics recently shared with them found that close to half of all sign-ups during special enrollment periods were aided by brokers.

Insurers should not credit brokers on one hand for their tremendous growth and then cut their pay, said Ronnell Nolan, president and CEO of Health Agents for America, a professional and advocacy group for brokers.

“They can always point to how they are losing money. I always say, ‘Let’s check top management’s income’ and, guess what, it’s not zero,” Nolan said. “If they are not doing a good job in their financials, that’s not my job. We are doing our jobs.”

Commissions are paid by the insurers, so consumers who use a broker don’t pay more than those who do not. Still, commissions are baked into premiums overall, potentially raising prices across the board, and some policy experts question whether commissions lead agents to push certain plans over others.

Unlike brokers, government-funded navigators do not earn a commission, and they cannot suggest a specific plan for clients.

“We help them filter through the plans, which can be overwhelming,” said Jodi Ray, director of the nonprofit Florida Covering Kids & Families, one of about 60 Navigator programs operating in 30 states.

Navigator programs this year when the Biden administration significantly increased funding above the levels paid during the Trump administration.

So, Ray is not worried about having enough staffers to help people with the new low-income enrollment or the expected wave of former Medicaid patients who may lose their Medicaid eligibility once the pandemic emergency ends.

Instead, she’s concerned “about whether the state is willing to let people know where they can get that free help.”

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Testing, as well as mask-wearing, is an important measure if the country ever hopes to beat covid, restore normal routines and get the economy running efficiently. To get Americans cheaper tests, the federal government now plans to have insurance companies pay for them.

The Biden administration that every person with private insurance can get full coverage for . You can either get one without any out-of-pocket expense from retail pharmacies that are part of an insurance company’s network or buy it at any store and get reimbursed by the insurer.

Congress said private insurers must cover all covid testing and any associated medical services when it passed the and . The have-insurance-pay-for-it solution has been used frequently through the pandemic. Insurance companies have been told to pay for PCR tests, covid treatments and the administration of vaccines. (Taxpayers are paying for the cost of the vaccines themselves.) It appears to be an elegant solution for a politician because it looks free and isn’t using taxpayer money.

1. Are the tests really free?

Well, no. As many an economist will tell you, there ain’t no such thing as a free lunch. Someone has to pick up the tab. Initially, the insurance companies bear the cost. , a vice president at KFF who studies the Affordable Care Act and private insurers, said the total bill could amount to billions of dollars. Exactly how much depends on “how easy it is to get them, and how many will be reimbursed,” she said.

2. Will the insurance company just swallow those imposed costs?

If companies draw from the time-tested insurance giants’ playbook, they’ll pass along those costs to customers. “This will put upward pressure on premiums,” said , vice president and coordinator for health policy at the Center for American Progress.

Major insurance companies like Cigna, Anthem, UnitedHealthcare and Aetna did not respond to requests to discuss this issue.

3. If that’s the case, why haven’t I been hit with higher premiums already?

Insurance companies had the chance last year to raise premiums but, mostly, they did not.

Why? Perhaps because insurers have so far made so much money during the pandemic they didn’t need to. For example, the industry’s profits in 2020 increased 41% to $31 billion from $22 billion, according to the National Association of Insurance Commissioners. The NAIC said the industry has continued its “tremendous growth trend” that started before covid emerged. Companies will be reporting 2021 results soon.

The reason behind these profits is clear. You were paying premiums based on projections your insurance company made about how much health care consumers would use that year. Because people stayed home, had fewer accidents, postponed surgeries and, often, avoided going to visit the doctor or the hospital, insurers paid out less. They rebated some of their earnings back to customers, but they pocketed a lot more.

As the companies’ actuaries work on predicting 2023 expenditures, premiums could go up if they foresee more claims and expenses. Paying for millions of rapid tests is something they would include in their calculations.

4. Regardless of my premiums, will the tests cost me money directly?

It’s quite possible. If your insurance company doesn’t have an arrangement with a retailer where you can simply pick up your allotted tests, you’ll have to pay for them — at whatever price the store sets. If that’s the case, you’ll need to fill out a form to request a reimbursement from the insurance company. How many times have you lost receipts or just plain neglected to mail in for rebates on something you bought? A lot, right?

Here’s another thing: The reimbursement is set at $12 per test. If you pay $30 for a test — and that is not unheard of — your insurer is only on the hook for $12. You eat the $18.

And by the way, people on Medicare will have to pay for their tests themselves. People who get their health care covered by Medicaid can obtain free test kits at community centers.

A few free tests are supposed to arrive at every American home via the U.S. Postal Service. And the Biden administration has where Americans can order free tests from a cache of a billion the federal government ordered.

5. Will this help bring down the costs of at-home tests and make them easier to find?

The free covid tests are unlikely to have much immediate impact on general cost and availability. You will still need to search for them. The federal measures likely will stimulate the demand for tests, which in the short term may make them harder to find.

But the demand, and some government guarantees to manufacturers, may induce test makers to make more of them faster. The increased competition and supply theoretically could bring down the price. There is certainly room for prices to decline since the wholesale cost of the test is between $5 and $7, analysts estimate. “It’s a big step in the right direction,” Gee said.

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