The Democrats’ Complexity Problem
by Tim Wu - NYT - March 21, 2019
One bright area in these dark days of American politics has
been a blossoming of bold and interesting progressive policy ideas,
such as wealth taxes, postal banking (offering basic financial services to customers who might not otherwise have access to them) and breaking up
the giants of the tech industry. In the spirit of fresh starts,
progressives should now confront an even more basic challenge: their
complexity problem.
In recent decades progressives have not prioritized making policies and programs easy for most Americans to understand, use and benefit from. Fixing this problem will mean overcoming a streak of perfectionism and a certain intellectual defensiveness, but it must be done if progressives are to make government popular again.
The Affordable Care Act is a good example of the complexity problem. Yes, it was an important policy achievement, and yes, many of its problems can be rightly blamed on industry resistance and Republican efforts to dismantle it.
But the act is also exceptionally hard to understand and discouragingly daunting to make use of. An emphasis on “choice” and “transparency” resulted in a law that only a rational-choice theorist could love. The act made health insurance more complicated, not less, which is one reason that such a high percentage of medical bills go to paying administrative costs, and why the Affordable Care Act is much less popular than it could be.
In recent decades progressives have not prioritized making policies and programs easy for most Americans to understand, use and benefit from. Fixing this problem will mean overcoming a streak of perfectionism and a certain intellectual defensiveness, but it must be done if progressives are to make government popular again.
The Affordable Care Act is a good example of the complexity problem. Yes, it was an important policy achievement, and yes, many of its problems can be rightly blamed on industry resistance and Republican efforts to dismantle it.
But the act is also exceptionally hard to understand and discouragingly daunting to make use of. An emphasis on “choice” and “transparency” resulted in a law that only a rational-choice theorist could love. The act made health insurance more complicated, not less, which is one reason that such a high percentage of medical bills go to paying administrative costs, and why the Affordable Care Act is much less popular than it could be.
It used to be said
that a conservative is a liberal who has been mugged. Today she’s a
liberal who tried to pay a babysitter without breaking the law. It is
admirable that Democrats try to tackle society’s thorniest problems with
the often unwieldy tools of government, but that is not an excuse for
programs that are too complex for their own good.
The truth is that good public policy can actually be elegant and simple to understand, even when the social problem that it’s addressing is complex. Social Security, Medicare, bans on indoor smoking, the “do not call” list (when it worked) and public libraries are examples of government solutions that are easy to understand and to benefit from.
Avoidance of complexity and minimizing choices are hallmarks of good design, as we have learned from the technological revolution in user interfaces. The age of impossible-to-use computers and incomprehensible TV remote controls has given way to the sleek and intuitive interfaces offered by pioneers like Steve Jobs of Apple. What progressives most need now is not more brains, but better policy designers.
One major obstacle to simple, effective public policy is people like me — the expert class. Many of us are in denial, seeing complexity as a necessary evil, an unavoidable feature of answers to hard problems, even a technocratic badge of honor. We criticize conservatives for relying on simplistic slogans like “cut taxes” and “drill, baby, drill” instead of nuanced, empirically informed assessments of economic growth and environmental management.
Progressives are right to consider expertise essential to good policymaking. But policy experts are rarely good at interface design, for we have a bad habit of assuming that people have unlimited time and attention and that to respect them means offering complete transparency and a multiplicity of choices. Real respect for the public involves appreciating what the public actually wants and needs. The reality is that most Americans are short on time and attention and already swamped by millions of daily tasks and decisions. They would prefer that the government solve problems for them — not create more work for them.
The truth is that good public policy can actually be elegant and simple to understand, even when the social problem that it’s addressing is complex. Social Security, Medicare, bans on indoor smoking, the “do not call” list (when it worked) and public libraries are examples of government solutions that are easy to understand and to benefit from.
Avoidance of complexity and minimizing choices are hallmarks of good design, as we have learned from the technological revolution in user interfaces. The age of impossible-to-use computers and incomprehensible TV remote controls has given way to the sleek and intuitive interfaces offered by pioneers like Steve Jobs of Apple. What progressives most need now is not more brains, but better policy designers.
One major obstacle to simple, effective public policy is people like me — the expert class. Many of us are in denial, seeing complexity as a necessary evil, an unavoidable feature of answers to hard problems, even a technocratic badge of honor. We criticize conservatives for relying on simplistic slogans like “cut taxes” and “drill, baby, drill” instead of nuanced, empirically informed assessments of economic growth and environmental management.
Progressives are right to consider expertise essential to good policymaking. But policy experts are rarely good at interface design, for we have a bad habit of assuming that people have unlimited time and attention and that to respect them means offering complete transparency and a multiplicity of choices. Real respect for the public involves appreciating what the public actually wants and needs. The reality is that most Americans are short on time and attention and already swamped by millions of daily tasks and decisions. They would prefer that the government solve problems for them — not create more work for them.
But what the public wants from government is help with complexity, not exposure to it. This generation of progressives, to achieve lasting success, must accept that simplicity and popularity are not a dumbing-down of policy, but rather the unavoidable requirement for its success.
https://www.nytimes.com/2019/03/21/opinion/democrats-complexity.html
The Maine Millennial: There’s a better way to do health care
by Victoria Hugo-Vidal - Portland Press Herald - March 3, 2019
My grandmother was moderate in every aspect of her life. Her meal portions (low-sodium, no spices, lots of vegetables) were moderate. Her daily exercise (brisk walks, water aerobics at the community pool) was moderate. Her tone of voice? Moderate. (I don’t think I ever heard her shout.) And she voted for political candidates all across the exact middle of the spectrum, from moderate Republican to moderate Democrat.One of her political philosophies was “government should do what the free market cannot.” I like that. It makes sense. That’s why I’m for Medicare-for-All.
Maybe you’re worried my generation is drifting toward socialism. Feel free to worry about that. I personally don’t advocate for the government owning the means of production, generally speaking, but the thing about free markets is that there are winners and losers. And I think health care is too damn important for there to be losers. People’s lives are on the line.
I think of access to health care – the ability to receive necessary treatment at an affordable price – as not just an economic or a political issue, but as a moral issue. I think a lot of Americans, especially younger generations, are starting to feel that way as well. Maybe it’s the cumulative effect of seeing all the medical expense campaigns on GoFundMe – it’s pathetic that a country as wealthy as America has people begging strangers on the internet for money to buy insulin. I have a cousin with a severe peanut allergy – he has to keep an EpiPen on him at all times. When the price of EpiPens was jacked up (remember that particular scandal?), that affected my family. Corporate greed, whether stemming from the insurance industry or the pharmaceutical industry, destroys lives.
My father worked for many years as an educational technician (aka an “ed tech”) in the local public school system. His take-home pay was pretty much bupkis. (Pay ed techs more.) But the benefits were good – including the health insurance. Our whole family was on his health plan. So when he was diagnosed with cancer, we didn’t have to worry about how we were going to pay for his treatment. We were able to tell the doctors “yes” to everything they suggested, and my dad got some of the best treatment north of Boston. And when his team realized the treatment wasn’t going to work, and that he was going to die, he was able to receive top-notch hospice care.
That’s not to say we didn’t have to worry about money, of course. You still have to pay the mortgage even if you’re spending your nights curled up in a hospital armchair. You still have to buy groceries even if you never feel hungry enough to eat. But we didn’t have to worry about medical bills ruining our credit and bankrupting us; we didn’t have to worry that we would have to borrow money as well as time. And for that, at least, I’ll be grateful forever.
When Dad died, our health insurance went with him. I was lucky enough to be able to hop onto my employer’s plan. But my mom is self-employed. So at the worst possible time, she had to navigate the Affordable Care Act’s exchanges in order to get insurance for herself and my younger sister. Have you ever tried to plan a funeral while digging through years of tax and health records? It’s not fun. But despite the flaws of the ACA, without it, she would be up a creek without a paddle.
Will Medicare-for-All, or Medicare-for-Many, Highly-Regulated-Private-Insurance-For-The-Rest, or Medicare-with-a-public-option, or whichever plan you present me that makes the numbers work and has the end goal of ensuring all of us can see a doctor when we’re sick (I’m not picky) cost a lot? Sure, but we’re already paying out the nose. (The runny nose – it’s flu season!) We pay premiums, co-pays, co-insurance, travel costs, emergency care costs and, of course, the continually rising costs of prescription drugs (including, yes, my cousin’s EpiPens. Go to heck, Mylan). And I’m willing to pay more in taxes for it, I really am. After the Tax Cuts and Jobs Act of 2017 passed, I started receiving an extra $10 in my paycheck every week. That was my tax cut. And while 10 bucks a week is certainly nice enough, I will gladly give it up again if it means everyone else also pays their fair share toward universal health care, like all the other developed countries have.
In the meantime, there are always more fundraisers for my 10-buck tax cut to go to.
https://www.pressherald.com/2019/03/03/the-maine-millennial-theres-a-better-way-to-do-health-care/?
Editor's Note:
Clicking the hot-link at the end of the transcript in the following article will take you to the original version on the NPR website, where you can listen to a podcast where you can hear an audio version.
-SPC
Why An ER Visit Can Cost So Much — Even For Those With Health Insurance
by Terry Gross and Sarah Kliff - Fresh Air NPR - March 13, 2019
Vox reporter
Sarah Kliff spent over a year reading thousands of ER bills and
investigating the reasons behind the costs, including hidden fees,
overpriced supplies and out-of-network doctors.
TERRY GROSS, HOST:
This is FRESH AIR. I'm Terry Gross. You wouldn't believe what some emergency rooms charge, or maybe you would because you've gotten bills. For example, one hospital charged $76 for Bacitracin antibacterial ointment. One woman who fell and cut her ear and was given an ice pack but no other treatment was billed $5,751. My guest, Sarah Kliff, is a health policy journalist at vox.com who spent over a year investigating why ER bills are so high even with health insurance and why the charges vary so widely from one hospital to the next.
Through crowdsourcing, she collected over a thousand ER bills from around the country. She interviewed many of the patients and the people behind the billing. She's reported her findings in a series of articles on Vox. She's also spent years reporting on the battle over health insurance policy. We'll get some updates on the state of Obamacare a little later in the interview.
Sarah Kliff, welcome back to FRESH AIR. Why did you want to do an investigation into emergency room billing?
SARAH KLIFF: You know, I wanted to do this because the emergency room is such a common place where Americans interact with the health care system. There are about 140 million ER visits each year. It's a place where you can't really shop for health care. You can't make a lot of decisions about where you want to go. So I think that is big-picture what got me interested.
Small picture was actually a bill that someone sent me almost three years ago now, where they took their daughter to the emergency room. A Band-Aid was put on the daughter's finger, and they left. And they got a $629 bill. And they said - you know, they - the parents sent this to me, saying, how could a Band-Aid cost $629? And I said, I don't know, but I'm going to find out. And that kind of opened up the door to this, you know, multi-year project I've been working on right now. It started with trying to figure out why a Band-Aid would cost $629.
GROSS: OK. So let's get to that $629 for treatment that was basically a Band-Aid placed on a finger. You investigated that bill.
KLIFF: Yes.
GROSS: Why'd it cost so much?
KLIFF: So what cost so much was really the facility fee. So this is a charge I hadn't heard about before as a health care reporter. This is a charge that hospitals make for just keeping their doors open, keeping the lights on, the cost of running an emergency room 24/7. So if you look at that particular patient's bill, the Band-Aid - you know, I hesitate to say only - but the Band-Aid only cost $7, which, as anyone who's bought Band-Aids knows, is quite expensive for a single Band-Aid.
But the other $622 of that bill were the hospital's facility fees for just walking in the door and seeking service. And these fees are not made public. They vary wildly from one hospital to another. And usually patients only find out what the facility fee of their hospital is when they receive the bill afterwards, like that patient, you know, that sent me this particular bill.
GROSS: And does the facility fee vary from facility to facility?
KLIFF: It does significantly. You know, I've seen some that are in the low hundreds. I've seen some that are in the high thousands. And it's impossible to know what facility fee you're going to be charged until you actually get the billing documents from your hospital. And if you try and call up a hospital and ask what the facility fee is, usually you won't get very far.
So it's this fee that, from all the ER bills I've read, is usually the biggest line item on the bill. But it's also one that is very, very difficult to get good information about until you've already been charged.
GROSS: So you're paying the facility fee to basically share in the cost of running the emergency room.
KLIFF: Yes, that's how hospital executives would describe the fee.
GROSS: But you don't know that when you're going to the emergency room.
KLIFF: You don't, no. And you don't know how much it'll be. You don't know how it's being split up between different patients. You don't know any of that.
GROSS: So is this also why one bill had $60 for the treatment of ibuprofen and another $238 for the treatment of eyedrops?
KLIFF: Yeah. And, you know, this is something I see all the time reading emergency bills - I've read about 1,500 of them at this point - is that things you could buy in a drugstore often cost significantly more in the emergency room. And the people I talked to who run hospitals will say this is because they have to be open all the time. They have to have so many supplies ready.
But I think one of the things that I find pretty frustrating is, you know, patients aren't usually told, we can give you an ibuprofen here, or you can pick some up at the drugstore if you leave, and the cost will be a fraction of what we would charge you here. That information often isn't conveyed to patients who are well enough, you know, to go to a drugstore on their own. But it's just huge variation for these simple items.
One place I see this a lot is pregnancy tests. If you're a woman who's of childbearing age, you go to the emergency room, they will often want to check if you're pregnant. I've seen pregnancy tests that cost a few dollars in emergency room. The most expensive one I saw was over $400. I believe that was at a hospital in Texas. It's just widespread variation for, you know, some pretty simple pieces of medical equipment.
GROSS: I want to get back to the $60 ibuprofen. Is that - does that include the facility fee? Or is that just for the ibuprofen, and the facility fee is separate?
KLIFF: That's just for the ibuprofen. The facility fee is totally separate.
GROSS: So how do they justify that?
KLIFF: They say they have to stock, like, a wide array of medicine, so they have to have everything on hand from ibuprofen, from, you know, expensive rabies treatments - I've talked to a lot of people who've been to the emergency room for exposure to bats and raccoons - and that they need to have all these things in stock. And, you know, one of the things you pay for at the emergency room is the ability to get any medication at any hour of the day right when you need it. I don't necessarily buy that explanation, to be clear. That's what I've heard from hospital executives.
I think it's pretty telling that ibuprofen has a very, very different price depending on which emergency room you go to. The fact that there's so much widespread price variation suggests to me that it's not just the cost of doing business driving it, that there's also business decisions being made behind ibuprofen that are driving the prices different hospitals are setting.
GROSS: Now, of course, trips to the emergency room aren't always as simple as getting a Band-Aid or ibuprofen or some eyedrops. I want you to describe the case of a young man who was hit by a pole on a city bus in San Francisco.
KLIFF: Yeah. So this patient, his name is Justin. He was a community college student in northern California, was walking down a sidewalk in downtown San Francisco one day. And there was a pole hanging off the back of the bus that wasn't where it's supposed to be. It essentially flew off the back of the bus, hit him in the face and knocked him unconscious.
And the next thing he knows, he's waking up at Zuckerberg San Francisco General, which is the only Level I trauma center in the city. He ends up needing a CT scan to check out some brain injuries. He needs some stitches. And then he's discharged. He ends up with a bill for $27,000.
But, you know, as I began figuring out through my reporting, San Francisco General does not contract with private insurance, and they end up pursuing him for the vast majority of that bill. He has $27,000 outstanding. And somewhat ironically, San Francisco General, it is the city hospital. It is run by the city of San Francisco. So this student is hit by a city bus, taken by an ambulance to the city hospital and ends up with a $27,000 bill as a result.
GROSS: So did he have insurance?
KLIFF: He did. He had insurance through his dad.
GROSS: So why doesn't Zuckerberg San Francisco General Hospital contract with private insurers?
KLIFF: So what they have told me when I've talked to some spokespeople there is that they are a safety net hospital, and that is, you know, definitely true. They generally serve a lower-income, often indigent population in San Francisco that would have trouble getting admitted and seeking care at other hospitals in the city. So they have told me that their focus is on serving those patients and that therefore, you know, they're not going to contract with private insurance companies.
The thing I found a little bit confusing about that, though, is there are lots of public hospitals, say, that, you know, also serve low-income populations. And some of them for their inpatient units, you know, for their scheduled surgeries, they're not going to contract with private insurance because they want to make sure beds are available for the publicly insured folks and people on Medicaid and Medicare.
But when it comes to the emergency room, you know, every other public hospital I was in touch with would contract with private insurers there because people don't decide if they're going to end up in the emergency room. So, you know, that's the justification they offered, that it is a hospital meant to serve those with public insurance. But it is not something you see public hospitals typically doing.
GROSS: Isn't - I think legislation was proposed in California to change that. Did that pass?
KLIFF: It's still pending in the California State Assembly. And the hospital has also promised to reform its billing practices, although we haven't seen what exactly their new plan is yet.
GROSS: So the position that Justin was in is that, like, he's unconscious. He's not asking to be taken anyplace. (Laughter) But he's unconscious. He's taken to the emergency room and ends up getting this $27,000 bill. I mean, that just seems so unfair, especially since he has insurance.
KLIFF: Yeah.
GROSS: Like, it's supposed to cover him for things like that (laughter).
KLIFF: Yeah. You know, there's one other patient who kind of makes this point really well who was also seen at San Francisco General. Her name is Nelly. And she fell off a climbing wall and, somewhat amazingly, you know, turns out she had a concussion. But one of the first things she does is she calls her insurance's nursing hotline to ask, should I go to the ER?
And they say yes. And she says, can I go to Zuckerberg San Francisco General? It's the closest. They say, no, don't go there. It's not in network. Go to another hospital. She gets to the other hospital, but the other hospital won't see her because she's a trauma patient. She fell from a really high height. And San Francisco General is the only trauma center in San Francisco. So she tries to go to an in-network hospital. She's then ambulance-transferred to Zuckerberg San Francisco General, and she ends up with another bill over $20,000 that the hospital was pursuing from her until I started asking questions from it, and the hospital ultimately dropped the bill.
But I think it's just such a frustrating situation for someone like Justin, for someone like Nellie (ph). They're either shopping for this good unconscious, they're really trying to do the right thing, and the health care system is just so stacked against the patient. It's so stacked for the hospital to be able to bill the prices that they want to bill.
GROSS: So apparently, the moral of the story is if you want to challenge your emergency room bill, you should get Sarah Kliff to write about you. (Laughter).
KLIFF: It's - (laughter). That's what some people have said. But there's only one of me, and there's about 2,000 bills in our database. And, you know, we have had over $100,000 in bills reversed as a result of our series. But I don't think it's a great way to run a health care system where we just, you know, the people who get their bills reversed are those who are lucky enough to have a reporter write a story about them.
GROSS: Yes. Agreed. Let me reintroduce you. If you're just joining us, my guest is Sarah Kliff. She's a senior policy correspondent at Vox, where she focuses on health policy. She also hosts the Vox podcast, "The Impact," about how policy actually affects people.
So we're going to take a short break, and then we'll talk more about emergency billing. And then later, we'll talk about what's left of Obamacare, and what the president and Congress and candidates are saying about health care, after this break. This is FRESH AIR.
(SOUNDBITE OF ALEXANDRE DESPLAT'S "SPY MEETING")
GROSS: This is FRESH AIR. And if you're just joining us, my guest is Sarah Kliff. We're talking about emergency room billing and why it's so unpredictable and often so incredibly high. She's a senior policy correspondent at Vox, where she focuses on health policy. She also hosts the Vox podcast, "The Impact," about how policy affects people.
So we were talking about the hidden facility fee, which most people don't know exists, and is responsible for a large chunk of a lot of emergency room bills. There's also, like, a trauma unit fee. It's a similar hidden fee in hospitals that have trauma centers in their emergency rooms. So explain the trauma fee and how that kicks in.
KLIFF: Yeah. This is something I also had never heard of till I started reading a lot of emergency room bills, and this is the fee that trauma centers charge for essentially assembling a trauma team to meet you when you're coming in and those folks out in the field, maybe the EMTs, for example, have determined that you meet certain trauma criteria.
So I've talked to people who have been charged trauma fees who were in serious car accidents. One case was a baby who fell from more than 3 feet, and that's considered to trigger a trauma activation. So this is essentially the price for having a robust trauma team - a surgeon, an anesthesiologist, nurses - all at the ready to receive you when you get to the hospital.
And again, these fees can be pretty hefty. San Francisco General, which, I've done the most reporting on their billing, you know, they can charge up to $18,000 for their trauma activation services. I wrote about one family who was visiting San Francisco from Korea when their young son rolled out of the hotel bed. They were nervous. They didn't know the American health care system well. So they called 911, which sent an ambulance, brought him over to the hospital. Turns out, he was fine. They gave him a bottle of formula. He took a nap and went home.
And then a few months later, they get an $18,000 charge for the trauma team that assembled for when that baby came to the hospital. And these are another, you know, pretty significant fee that, again, you don't really know about. You have no idea that the trauma team is assembling to meet you when you're coming into the hospital. You just find out after the fact. And you also have no say in the decision to assemble trauma. That's really left up to the hospital, not the patient.
GROSS: So I'm going to have you compare two possibilities. You go to an emergency room, and the bill is very high. There's two people who have the same problem who go to the emergency room. One of them has a copay. One of them has a high deductible that they haven't paid off yet. How are they treated differently, in terms of what they're billed for the emergency room visit?
KLIFF: Well, the person with the deductible will likely be billed significantly more. You know, if they're just, let's say, at the start of the year, they are going to essentially have to bear the costs of that emergency room visit up until the point they hit their deductible and the insurance kicks in, whereas the person who has a co-payment, they're just going to have to pay that flat fee and, you know, probably not worry about paying more, but there's often surprise bills lurking in the corner that could affect both of those patients as well.
GROSS: Like what?
KLIFF: So one of the most common things we see is out-of-network doctors working at in-network emergency rooms. So you know, you have an emergency, you look up a hospital, you see their ER is in network, so you go there. It turns out that emergency room is staffed by doctors who aren't in your insurance. There's pretty compelling academic research that suggests 1 in 5 emergency room visits involves a surprise bill like that one.
GROSS: That seems so unfair. How are you to know - if you're choosing a hospital that's in network, how are you to know whether the doctor treating you is in network or not?
KLIFF: You know, you really - there isn't a great way to tell, to be honest. This is - you know, when I had to go to the emergency room over the summer, you know, this is something I worried about. You know, I was seeing a doctor who worked for the hospital, but they were sending off my ultrasound to be read by a radiologist who I was never going to meet. I couldn't ask them if they were in-network. I just kind of had to cross my fingers and hope for the best, and luckily, I didn't get a surprise bill.
But I've talked to multiple patients who, you know, tried to do their research, who thought they were in network, only to get a bill, often for thousands of dollars, after leaving the emergency room, from someone who, you know, never mentioned to them, hey, I'm not in your network like this hospital is.
GROSS: So the bill that you'd get would be for the difference between what you pay when somebody is - when a doctor's in network and what you pay when they're not in network?
KLIFF: Yeah, often it's just what that out-of-network doctor wants to charge. So a good example of this is a patient I wrote about in Texas named Scott (ph), who was attacked in downtown Austin, left on the street unconscious, some bystander called him an ambulance, and he woke up at a hospital. And one of the first things he does, because this is the United States, is he gets on his phone and tries to figure out which hospital he is at, and, you know, is that in his insurance network? And he finds out - good news - it is. And a surgeon comes by, tells him he's going to need emergency jaw surgery because of the attack that happened.
So he says, OK. You know, he's not really in a place to go anywhere. Gets the surgery. Goes home. A few weeks later, he gets an $8,000 bill from that oral surgeon, who the insurance companies paid a smaller amount. The oral surgeon didn't have a contract with the insurance and said, you know, I think my services are worth a lot more, so pursued the balance of the bill from Scott.
GROSS: I have to say, I mean, that does seem unfair to the patient because they haven't been informed. They can't make a choice about it if they don't know. And, like, $8,000 is a lot of money.
KLIFF: Yeah. And I think, you know, even more, let's say he did say he was out of network. It kind of puts the patient in an unfair situation, too. You know, one of the things we talk about a lot in health policy is, what if we had more transparency? What if we let patients know the prices? What if we let patients know who is in and out of network? And that - it would be a good step.
But, you know, I think with someone like Scott, sitting in a hospital with a broken jaw, there's not much you can do with that information. He doesn't have, you know, the ability to go home, like, research, like, make an appointment with a new surgeon. So, you know, it'd be great if he knew that the doctor was out of network. It'd be even better if he had some kind of protections against those type of bills.
GROSS: What kind of protection could there be?
KLIFF: So we're actually seeing a lot of action on this in Congress. There's some pretty strong bipartisan support for tackling this specific issue and essentially holding the patient harmless. When there is a situation like Scott's, for example, where there's this $8,000 bill, that's really a dispute between a health insurance company and a doctor, where the doctor says, I want more money, the insurer says, I want to pay you less money. And what Congress wants to do - what a few states have already done with their laws - is said, you can't go to the patient for that money. You, the hospital, and you, the health insurance company, you have to get down to a table and work things out together.
And some state laws will set certain amounts that are allowed to be charged, other ones will force the insurance company and the hospital into an arbitration process. But the general concept is to take the patient out of this billing situation because, like you said, Terry, they really aren't in a position to negotiate. They aren't in a position to shop. They shouldn't be the ones who are left holding the bag at the end of the day.
GROSS: My guest is Sarah Kliff. She covers health policy for Vox. After a break, we'll talk more about why ER bills can have some unpleasant surprises, and she'll give us an update on Obamacare. And Maureen Corrigan will review two books about forgotten stories from Hollywood. I'm Terry Gross, and this is FRESH AIR.
(SOUNDBITE OF JESSICA WILLIAMS TRIO'S "KRISTEN")
GROSS: This is FRESH AIR. I'm Terry Gross. Let's get back to my interview with journalist Sarah Kliff, who covers health policy and how it affects people for Vox. For the past year and a half, she's been writing about why emergency room visits can be so expensive and the pricing so secretive and mysterious, as well as inconsistent from one hospital to the next. She collected over 1,000 bills and tracked down stories behind the billing. She interviewed many of the patients and the people behind the billing to decipher why ER bills can have some surprise costs.
Here's another surprise that often awaits people who go to emergency rooms - some insurance plans only cover true emergencies, and whether it is a true emergency is sometimes determined after the diagnosis is made. So how are you supposed to know before the diagnosis whether you're going to be categorized as a true emergency or not? Like, if you go to the hospital, you don't know if you have a broken bone or not.
KLIFF: Right.
GROSS: Somebody needs to X-ray it and tell you.
KLIFF: Right. The whole point you go to the emergency room is to help them figure out what the emergency is and what treatment you need. This is a policy that the insurance company Anthem has been pioneering for a few years. It's been in Kentucky. It's been in Georgia - a few other states. And, you know, I wrote about one patient out in Kentucky named Brittany, who - she was having really severe abdominal pain. She called her mom who is a nurse, and the nurse said, that might be appendicitis. You've got to get to the emergency room. Turns out it wasn't appendicitis. It was an ovarian cyst. She got it treated elsewhere later down the line.
And Anthem, you know, sent her a letter saying, we're not going to cover that visit because it was not a true emergency. She appealed it. Her appeal was denied. This is another one where, once I started asking them about it, the bill suddenly disappeared. But - and it seems like as Anthem has gotten more attention for this policy - they haven't announced it publicly, but some pretty compelling data The New York Times got their hands on suggest they've backed off this policy.
But it's just, you know - there are so many traps you can fall into going into an emergency room. It just feels like you're walking into this minefield, and this is kind of one of those mines that's lurking in there.
GROSS: Hospital pricing and emergency room pricing seems to vary so much from hospital to hospital. Are there, like, national guidelines that help determine what a hospital or a hospital emergency room charges for services? I mean, who decides, and why is there such a variation?
KLIFF: So hospital executives get to decide, and I think that is why there is such variation. There aren't really guidelines that they're following. You know, one thing you could do as a hospital executive - you could look at what Medicare charges - those prices are public - and, you know, maybe use that as a benchmark. There are some databases. There's one called FAIR Health, for example, where you could look and see, you know, some information on what local prices typically are. But in terms of, you know, what you want to charge, that's kind of up to you as someone running a hospital.
One of the things that's really, really unique about the United States, compared to our peer countries, is that we don't regulate health care prices. Nearly every other country in the developed world - they see health care something as, you know, akin to a utility that everyone needs, like electricity or water. It's so important that the government is going to step in and regulate the prices. That doesn't happen in the United States. You know, if you're a hospital, you just choose your prices. And, you know, that is, I think, why you see so much variation and why you see some really high prices in American health care.
GROSS: So what advice do you have for people who actually need an emergency room and don't want to get hit with a shocking bill afterwards?
KLIFF: Yeah, this is, you know, one of those questions - it just makes me a little frustrated that - 'cause this is the most common question I get - right? - is, how do I - how do we - how do I prevent a surprise bill? And I find it kind of upsetting that, you know, it has to be on the patient because honestly, there really isn't a great way to do this. I've talked to so many patients who tried so hard to avoid a big medical bill and weren't able to.
You know, there's certain things, yes, you can do. You can look up the network status of your hospital. You can try and badger each doctor you see about whether they are in network. You can try to be a really proactive patient, but I think that's just such a huge burden on people who are in, like, really emergent situations. And some people don't have that opportunity, you know, like Justin Zanders, the guy we were talking about earlier who was taken to a hospital while he was unconscious. I cannot think of anything he could've done to avoid that bill. It just was not possible.
GROSS: So your advice is, good luck.
KLIFF: Short of that, I mean, good luck. You know, I'm actually in the middle of reporting a story right now about people who have successfully negotiated down their bills. And, you know, you can certainly - if you do end up with a surprise bill, you can call up the hospital, see if there's a discount. Sometimes there will be. Sometimes there won't. You can call again. Customer service representatives - different ones - often offer you different discounts, I've learned from interviewing patients. You can ask for a prompt pay discount if you pay right away.
You can - you know, one health attorney who negotiates these a lot on behalf of patients - he says one of his favorite tactics is to choose the amount you want to pay; send a check with that amount; and in the note, write, paid in full; and hope they don't come after you after that. I have no idea if that works or not, but he says it works for his patients. But it's a mixed bag. And at the end of the day, the hospital has all the power. You can ask for discounts. You can ask nicely. You can ask angrily. It's up to the hospital if they want to grant you that or not.
GROSS: So what is the status of Obamacare now? You know, Republicans promised to repeal and replace. That didn't work out. So have Republicans given up on repeal and replace?
KLIFF: For the time, it seems pretty clear that repeal and replace is dead on arrival, especially with Democrats taking control of the House this year. Those proposals aren't being talked about as much. They're not really going anywhere. The one big thing we did see Republicans succeed at is repealing Obamacare's individual mandate, the requirement that all of us carry health insurance. That happened as part of the big tax package that passed at the end of 2017.
So we've seen, you know, President Trump, for example, essentially declare victory, declare that repealing the individual mandate is repealing Obamacare, so we're good on that goal. But, you know, generally, Obamacare is still standing. There are millions of people getting their coverage through the Affordable Care Act still today.
GROSS: So now that there's no individual mandate, conservative attorney generals are challenging Obamacare - the Affordable Care Act - and saying it's no longer constitutional after Congress's repeal of the individual mandate. Could you explain that?
KLIFF: Yeah, so this is a challenge that's come up through the courts in the past few months. Obamacare is constantly being challenged in court. It's been through multiple Supreme Court suits. This one - you know, it's a multiple-part argument, so I'll try my best to walk through it.
GROSS: OK.
KLIFF: So essentially, it starts with the fact that the individual mandate - they weren't quite able to repeal it for boring technical reasons. But what they were able to do is change the fee for not having health insurance from $700 to $0. So it - in all practical terms, it feels like repealing it because there is no fee for not carrying health insurance. The individual mandate was upheld as a tax when the Supreme Court said, yes, this is constitutional. The government has a right to tax people. Now that there is no fee associated with not carrying health insurance, the conservative attorneys general who are bringing this case argue that it's not a tax anymore, and therefore, it is not constitutional. That whole defense that John Roberts wrote in 2012 is moot. So that's the first part of it.
They go even further and say the individual mandate is so core to the Affordable Care Act, it is not severable. And if you, the courts, rule the individual mandate unconstitutional, then you need to rule all of Obamacare unconstitutional. And the first judge who heard this case - he is a, you know, judge in a district court in Texas. He agreed with them. He agreed that - first step - that the individual mandate is no longer constitutional. And second step, that means that the entirety of Obamacare has to fall. This is now being appealed up to the 5th Circuit Court of Appeals.
And I will say there are a lot of critics of this case. There are a lot of people who were parties to previous Supreme Court challenges to Obamacare who think this is a bad legal argument and that it will not succeed. But it is already, you know, gone through the district court level. It's moving up to the appellate court level. It is something that is in the mix that could become a threat to the Affordable Care Act.
GROSS: Well, if it goes to the Supreme Court, it would be very interesting to see what Justice Roberts says since he voted for the ACA, saying that the individual mandate was a tax.
KLIFF: Yeah. You know, and I think where some legal scholars would see it shaking out is that the - someone like John Roberts, he might agree, OK, yeah, the individual mandate is unconstitutional, but would not make the leap to the second half of this, that the rest of the law has to fall.
I think one of the most compelling arguments against this case is that Congress knew what they were doing when they repealed the individual mandate. You know, they had the opportunity to repeal Obamacare. They didn't. They'd specifically took aim at this one specific part. So it feels like it might be a bit of a reach to argue that what Congress really meant to do was repeal all these other parts of the Affordable Care Act. But, you know, the Supreme Court is changing. We have a new justice. You know, we have a lot in the mix. So it's always an open question of how a decision like this could go.
GROSS: So correct me if I'm wrong here - the Department of Justice has sided with the conservative attorneys general who are challenging Obamacare, saying it's no longer constitutional, and I think that the Justice Department is also asking the judge to strike down the ACA's mandatory coverage of pre-existing conditions.
KLIFF: Yeah, that's right. So it's a kind of unusual situation. Usually, it's the Justice Department that is going to defend a federal law in court. But, you know, given the Trump administration's opposition to the Affordable Care Act, they have decided to side with the conservative attorneys general. They have a slightly different argument. They don't think all of Obamacare should fall if the mandate falls, but they do think some big parts, like you mentioned, the protections for pre-existing conditions, should be ruled unconstitutional if the mandate falls.
So this has led to a bit of an unusual situation where you've had this coalition of Democratic attorneys general step in and take over the case, basically saying that the federal government is going - is not going to defend the Affordable Care Act. We are going to defend the Affordable Care Act. So you have this coalition of Democratic attorneys general, led by the attorney general of California, stepping in and, you know, offering a defense as this case works its way up through the court system.
GROSS: Let's take a short break here, and then we'll talk some more. If you're just joining us, my guest is Sarah Kliff. She's senior policy correspondent at Vox, where she focuses on health policy. And she hosts the Vox podcast "The Impact," about how policy actually affects people. We'll be right back. This is FRESH AIR.
(SOUNDBITE OF THE WEE TRIO'S "LOLA")
GROSS: This is FRESH AIR. And if you're just joining us, my guest is Sarah Kliff, senior policy correspondent at Vox, where she focuses on health policy.
Do you think health insurance is shaping up to be a big issue in the 2020 campaign?
KLIFF: I do, and I think it's going to be a big issue both in the primary, where you're already seeing candidates get pressed on, should we still have private health insurance, and giving pretty different answers to that question.
And then I think one of the things you're also going to see is whoever is the Democratic nominee is probably going to run on Obamacare. They are going to point at the fact that President Trump tried to repeal the Affordable Care Act. That's pretty different than, you know, the 2012 election, where Democrats were pretty scared to run on Obamacare. It still wasn't popular. The benefits hadn't rolled out. In this past midterm and now again in the 2020 election, it seems pretty clear that Democrats are pretty excited to point out that Republicans wanted to repeal Obamacare. So I think it really will come up.
GROSS: What are some of the biggest falsehoods you've heard from politicians about health insurance costs or health insurance policy?
KLIFF: You know, one of the ones that's come up a lot is actually around the role of private health insurance. So I've - I don't know if it counts as a falsehood, but I think it's a bit of a misunderstanding of how health insurance often works is, you know, when I talk to single-payer supporters, most of them want to eliminate private insurance completely. They just don't think there is a role for it in the health care system.
And one of the things I think that's actually pretty interesting, when you look at any other country - you look at Canada, you look at the U.K., you look at France, which all have national health care systems - all of them have a private health insurance market, too. There are always some kind of gap in the system that the public insurance can't cover, where the government step - where the private industry steps in and offers coverage. In Canada, for example, their public health plan doesn't cover prescription drugs, so two-thirds of Canadians take out a private plan, often through their employer, like us, to cover prescription drugs, to cover their eyeglasses, to cover their dental. So I think that's a confusion I see a lot in the "Medicare for All" debate coming up right now.
I think the other thing I see a lot of confusion around - and we've talked about this a little bit with emergency room billing - is the role of transparency in health care. I see a lot of, you know, if we just made the prices public, like, that is what we need to do to fix the system, and I think that really misses the fact that, even if the prices were public, health care is so different from everything else we shop for. It might be - I think it is the only thing we purchase when we are unconscious.
GROSS: (Laughter).
KLIFF: And when you're unconscious, you're not really going to be great at price shopping. So I see that as, you know, a halfway solution that I often hear talked about here in Washington that would be great but is not going to suddenly result in, you know, prices dropping because they've been exposed in a spotlight.
GROSS: Is there a country that you think has a good health care model that we could borrow?
KLIFF: Oh, yeah. I've been thinking about this a lot lately actually. So I've gotten very interested in the Australia health care system, which is a little far away. But I think they're a really interesting model because they have a public system, everyone's enrolled in it, but they also really aggressively try and get people to buy a private plan, too, and that private plan will get you sometimes faster access to doctors, maybe a private room at a hospital.
It's really hard for me to see the U.S. creating a health care system, similar to Canada's actually, where you can't buy private insurance, where if you're rich or you're poor, everyone waits in the exact same queue, you can't jump to the front of the line. Because I think wealthier Americans have gotten so used to having really good access to health care that they would be very upset with a system like that.
I think Australia is a kind of interesting hybrid between, you know, where we're at in the U.S. right now and what Canada is like, where it says, yes, we're going to create a public system for everybody, but we're also going to have these private plans that compete against the public system. So I've become increasingly, you know, interested in how Australia's system works. And they have - about 47 percent of Australians are buying a private plan to cover the same benefits that the public plan does.
GROSS: So it's not supplemental. It's instead of.
KLIFF: Right. So it's very different from Canada. So in Canada, you can buy complementary insurance, you know, to cover the benefits the public plan doesn't but the government expressly outlaws supplemental insurance. You know, like, what people buy here to cover the gaps in Medicare, that is not allowed. You cannot buy your way to the front of the line in Canada.
One of my favorite sayings about the Canadian health care system is from a doctor in a book I read about Canadian health care is they said, you know, we're fine waiting in lines for health care in Canada as long as the rich people and the poor people have to wait in the exact same line. Their system is all about equality. And I just don't know that we're at a place as a country where we value the same sort of equality in our health care system.
GROSS: Is there any developed country around the world that has a system similar to ours with all these competing insurance companies and, you know, some government plans and, like, a thousand different bureaucracies that doctors have to deal with and that patients have to deal with?
KLIFF: Absolutely not. There's nothing like it. I mean, our system is so unique. I'd say the closest but it's not even close are a few countries that have national health care systems, but they do it through tightly regulated private health insurance plans. So if you look at, like, Netherlands or Israel, there isn't a government-run plan. Instead, in both countries, you actually have four tightly regulated health insurance plans that compete against each other for the citizens' business. I guess that's the closest, but that is so different from what we have here right now. There's really nothing like it in any developed country.
GROSS: Sarah Kliff, thank you so much for talking with us.
KLIFF: Well, thank you for having me.
GROSS: Sarah Kliff covers health policy for Vox, where you'll find her series about emergency room bills. After we take a short break, Maureen Corrigan will review two books about forgotten stories from Hollywood. This is FRESH AIR.
https://www.npr.org/2019/03/13/702975393/why-an-er-visit-can-cost-so-much-even-for-those-with-health-insurance
This is FRESH AIR. I'm Terry Gross. You wouldn't believe what some emergency rooms charge, or maybe you would because you've gotten bills. For example, one hospital charged $76 for Bacitracin antibacterial ointment. One woman who fell and cut her ear and was given an ice pack but no other treatment was billed $5,751. My guest, Sarah Kliff, is a health policy journalist at vox.com who spent over a year investigating why ER bills are so high even with health insurance and why the charges vary so widely from one hospital to the next.
Through crowdsourcing, she collected over a thousand ER bills from around the country. She interviewed many of the patients and the people behind the billing. She's reported her findings in a series of articles on Vox. She's also spent years reporting on the battle over health insurance policy. We'll get some updates on the state of Obamacare a little later in the interview.
Sarah Kliff, welcome back to FRESH AIR. Why did you want to do an investigation into emergency room billing?
SARAH KLIFF: You know, I wanted to do this because the emergency room is such a common place where Americans interact with the health care system. There are about 140 million ER visits each year. It's a place where you can't really shop for health care. You can't make a lot of decisions about where you want to go. So I think that is big-picture what got me interested.
Small picture was actually a bill that someone sent me almost three years ago now, where they took their daughter to the emergency room. A Band-Aid was put on the daughter's finger, and they left. And they got a $629 bill. And they said - you know, they - the parents sent this to me, saying, how could a Band-Aid cost $629? And I said, I don't know, but I'm going to find out. And that kind of opened up the door to this, you know, multi-year project I've been working on right now. It started with trying to figure out why a Band-Aid would cost $629.
GROSS: OK. So let's get to that $629 for treatment that was basically a Band-Aid placed on a finger. You investigated that bill.
KLIFF: Yes.
GROSS: Why'd it cost so much?
KLIFF: So what cost so much was really the facility fee. So this is a charge I hadn't heard about before as a health care reporter. This is a charge that hospitals make for just keeping their doors open, keeping the lights on, the cost of running an emergency room 24/7. So if you look at that particular patient's bill, the Band-Aid - you know, I hesitate to say only - but the Band-Aid only cost $7, which, as anyone who's bought Band-Aids knows, is quite expensive for a single Band-Aid.
But the other $622 of that bill were the hospital's facility fees for just walking in the door and seeking service. And these fees are not made public. They vary wildly from one hospital to another. And usually patients only find out what the facility fee of their hospital is when they receive the bill afterwards, like that patient, you know, that sent me this particular bill.
GROSS: And does the facility fee vary from facility to facility?
KLIFF: It does significantly. You know, I've seen some that are in the low hundreds. I've seen some that are in the high thousands. And it's impossible to know what facility fee you're going to be charged until you actually get the billing documents from your hospital. And if you try and call up a hospital and ask what the facility fee is, usually you won't get very far.
So it's this fee that, from all the ER bills I've read, is usually the biggest line item on the bill. But it's also one that is very, very difficult to get good information about until you've already been charged.
GROSS: So you're paying the facility fee to basically share in the cost of running the emergency room.
KLIFF: Yes, that's how hospital executives would describe the fee.
GROSS: But you don't know that when you're going to the emergency room.
KLIFF: You don't, no. And you don't know how much it'll be. You don't know how it's being split up between different patients. You don't know any of that.
GROSS: So is this also why one bill had $60 for the treatment of ibuprofen and another $238 for the treatment of eyedrops?
KLIFF: Yeah. And, you know, this is something I see all the time reading emergency bills - I've read about 1,500 of them at this point - is that things you could buy in a drugstore often cost significantly more in the emergency room. And the people I talked to who run hospitals will say this is because they have to be open all the time. They have to have so many supplies ready.
But I think one of the things that I find pretty frustrating is, you know, patients aren't usually told, we can give you an ibuprofen here, or you can pick some up at the drugstore if you leave, and the cost will be a fraction of what we would charge you here. That information often isn't conveyed to patients who are well enough, you know, to go to a drugstore on their own. But it's just huge variation for these simple items.
One place I see this a lot is pregnancy tests. If you're a woman who's of childbearing age, you go to the emergency room, they will often want to check if you're pregnant. I've seen pregnancy tests that cost a few dollars in emergency room. The most expensive one I saw was over $400. I believe that was at a hospital in Texas. It's just widespread variation for, you know, some pretty simple pieces of medical equipment.
GROSS: I want to get back to the $60 ibuprofen. Is that - does that include the facility fee? Or is that just for the ibuprofen, and the facility fee is separate?
KLIFF: That's just for the ibuprofen. The facility fee is totally separate.
GROSS: So how do they justify that?
KLIFF: They say they have to stock, like, a wide array of medicine, so they have to have everything on hand from ibuprofen, from, you know, expensive rabies treatments - I've talked to a lot of people who've been to the emergency room for exposure to bats and raccoons - and that they need to have all these things in stock. And, you know, one of the things you pay for at the emergency room is the ability to get any medication at any hour of the day right when you need it. I don't necessarily buy that explanation, to be clear. That's what I've heard from hospital executives.
I think it's pretty telling that ibuprofen has a very, very different price depending on which emergency room you go to. The fact that there's so much widespread price variation suggests to me that it's not just the cost of doing business driving it, that there's also business decisions being made behind ibuprofen that are driving the prices different hospitals are setting.
GROSS: Now, of course, trips to the emergency room aren't always as simple as getting a Band-Aid or ibuprofen or some eyedrops. I want you to describe the case of a young man who was hit by a pole on a city bus in San Francisco.
KLIFF: Yeah. So this patient, his name is Justin. He was a community college student in northern California, was walking down a sidewalk in downtown San Francisco one day. And there was a pole hanging off the back of the bus that wasn't where it's supposed to be. It essentially flew off the back of the bus, hit him in the face and knocked him unconscious.
And the next thing he knows, he's waking up at Zuckerberg San Francisco General, which is the only Level I trauma center in the city. He ends up needing a CT scan to check out some brain injuries. He needs some stitches. And then he's discharged. He ends up with a bill for $27,000.
But, you know, as I began figuring out through my reporting, San Francisco General does not contract with private insurance, and they end up pursuing him for the vast majority of that bill. He has $27,000 outstanding. And somewhat ironically, San Francisco General, it is the city hospital. It is run by the city of San Francisco. So this student is hit by a city bus, taken by an ambulance to the city hospital and ends up with a $27,000 bill as a result.
GROSS: So did he have insurance?
KLIFF: He did. He had insurance through his dad.
GROSS: So why doesn't Zuckerberg San Francisco General Hospital contract with private insurers?
KLIFF: So what they have told me when I've talked to some spokespeople there is that they are a safety net hospital, and that is, you know, definitely true. They generally serve a lower-income, often indigent population in San Francisco that would have trouble getting admitted and seeking care at other hospitals in the city. So they have told me that their focus is on serving those patients and that therefore, you know, they're not going to contract with private insurance companies.
The thing I found a little bit confusing about that, though, is there are lots of public hospitals, say, that, you know, also serve low-income populations. And some of them for their inpatient units, you know, for their scheduled surgeries, they're not going to contract with private insurance because they want to make sure beds are available for the publicly insured folks and people on Medicaid and Medicare.
But when it comes to the emergency room, you know, every other public hospital I was in touch with would contract with private insurers there because people don't decide if they're going to end up in the emergency room. So, you know, that's the justification they offered, that it is a hospital meant to serve those with public insurance. But it is not something you see public hospitals typically doing.
GROSS: Isn't - I think legislation was proposed in California to change that. Did that pass?
KLIFF: It's still pending in the California State Assembly. And the hospital has also promised to reform its billing practices, although we haven't seen what exactly their new plan is yet.
GROSS: So the position that Justin was in is that, like, he's unconscious. He's not asking to be taken anyplace. (Laughter) But he's unconscious. He's taken to the emergency room and ends up getting this $27,000 bill. I mean, that just seems so unfair, especially since he has insurance.
KLIFF: Yeah.
KLIFF: Yeah. You know, there's one other patient who kind of makes this point really well who was also seen at San Francisco General. Her name is Nelly. And she fell off a climbing wall and, somewhat amazingly, you know, turns out she had a concussion. But one of the first things she does is she calls her insurance's nursing hotline to ask, should I go to the ER?
And they say yes. And she says, can I go to Zuckerberg San Francisco General? It's the closest. They say, no, don't go there. It's not in network. Go to another hospital. She gets to the other hospital, but the other hospital won't see her because she's a trauma patient. She fell from a really high height. And San Francisco General is the only trauma center in San Francisco. So she tries to go to an in-network hospital. She's then ambulance-transferred to Zuckerberg San Francisco General, and she ends up with another bill over $20,000 that the hospital was pursuing from her until I started asking questions from it, and the hospital ultimately dropped the bill.
But I think it's just such a frustrating situation for someone like Justin, for someone like Nellie (ph). They're either shopping for this good unconscious, they're really trying to do the right thing, and the health care system is just so stacked against the patient. It's so stacked for the hospital to be able to bill the prices that they want to bill.
GROSS: So apparently, the moral of the story is if you want to challenge your emergency room bill, you should get Sarah Kliff to write about you. (Laughter).
KLIFF: It's - (laughter). That's what some people have said. But there's only one of me, and there's about 2,000 bills in our database. And, you know, we have had over $100,000 in bills reversed as a result of our series. But I don't think it's a great way to run a health care system where we just, you know, the people who get their bills reversed are those who are lucky enough to have a reporter write a story about them.
GROSS: Yes. Agreed. Let me reintroduce you. If you're just joining us, my guest is Sarah Kliff. She's a senior policy correspondent at Vox, where she focuses on health policy. She also hosts the Vox podcast, "The Impact," about how policy actually affects people.
So we're going to take a short break, and then we'll talk more about emergency billing. And then later, we'll talk about what's left of Obamacare, and what the president and Congress and candidates are saying about health care, after this break. This is FRESH AIR.
(SOUNDBITE OF ALEXANDRE DESPLAT'S "SPY MEETING")
GROSS: This is FRESH AIR. And if you're just joining us, my guest is Sarah Kliff. We're talking about emergency room billing and why it's so unpredictable and often so incredibly high. She's a senior policy correspondent at Vox, where she focuses on health policy. She also hosts the Vox podcast, "The Impact," about how policy affects people.
So we were talking about the hidden facility fee, which most people don't know exists, and is responsible for a large chunk of a lot of emergency room bills. There's also, like, a trauma unit fee. It's a similar hidden fee in hospitals that have trauma centers in their emergency rooms. So explain the trauma fee and how that kicks in.
KLIFF: Yeah. This is something I also had never heard of till I started reading a lot of emergency room bills, and this is the fee that trauma centers charge for essentially assembling a trauma team to meet you when you're coming in and those folks out in the field, maybe the EMTs, for example, have determined that you meet certain trauma criteria.
So I've talked to people who have been charged trauma fees who were in serious car accidents. One case was a baby who fell from more than 3 feet, and that's considered to trigger a trauma activation. So this is essentially the price for having a robust trauma team - a surgeon, an anesthesiologist, nurses - all at the ready to receive you when you get to the hospital.
And again, these fees can be pretty hefty. San Francisco General, which, I've done the most reporting on their billing, you know, they can charge up to $18,000 for their trauma activation services. I wrote about one family who was visiting San Francisco from Korea when their young son rolled out of the hotel bed. They were nervous. They didn't know the American health care system well. So they called 911, which sent an ambulance, brought him over to the hospital. Turns out, he was fine. They gave him a bottle of formula. He took a nap and went home.
And then a few months later, they get an $18,000 charge for the trauma team that assembled for when that baby came to the hospital. And these are another, you know, pretty significant fee that, again, you don't really know about. You have no idea that the trauma team is assembling to meet you when you're coming into the hospital. You just find out after the fact. And you also have no say in the decision to assemble trauma. That's really left up to the hospital, not the patient.
GROSS: So I'm going to have you compare two possibilities. You go to an emergency room, and the bill is very high. There's two people who have the same problem who go to the emergency room. One of them has a copay. One of them has a high deductible that they haven't paid off yet. How are they treated differently, in terms of what they're billed for the emergency room visit?
KLIFF: Well, the person with the deductible will likely be billed significantly more. You know, if they're just, let's say, at the start of the year, they are going to essentially have to bear the costs of that emergency room visit up until the point they hit their deductible and the insurance kicks in, whereas the person who has a co-payment, they're just going to have to pay that flat fee and, you know, probably not worry about paying more, but there's often surprise bills lurking in the corner that could affect both of those patients as well.
GROSS: Like what?
KLIFF: So one of the most common things we see is out-of-network doctors working at in-network emergency rooms. So you know, you have an emergency, you look up a hospital, you see their ER is in network, so you go there. It turns out that emergency room is staffed by doctors who aren't in your insurance. There's pretty compelling academic research that suggests 1 in 5 emergency room visits involves a surprise bill like that one.
GROSS: That seems so unfair. How are you to know - if you're choosing a hospital that's in network, how are you to know whether the doctor treating you is in network or not?
KLIFF: You know, you really - there isn't a great way to tell, to be honest. This is - you know, when I had to go to the emergency room over the summer, you know, this is something I worried about. You know, I was seeing a doctor who worked for the hospital, but they were sending off my ultrasound to be read by a radiologist who I was never going to meet. I couldn't ask them if they were in-network. I just kind of had to cross my fingers and hope for the best, and luckily, I didn't get a surprise bill.
But I've talked to multiple patients who, you know, tried to do their research, who thought they were in network, only to get a bill, often for thousands of dollars, after leaving the emergency room, from someone who, you know, never mentioned to them, hey, I'm not in your network like this hospital is.
GROSS: So the bill that you'd get would be for the difference between what you pay when somebody is - when a doctor's in network and what you pay when they're not in network?
KLIFF: Yeah, often it's just what that out-of-network doctor wants to charge. So a good example of this is a patient I wrote about in Texas named Scott (ph), who was attacked in downtown Austin, left on the street unconscious, some bystander called him an ambulance, and he woke up at a hospital. And one of the first things he does, because this is the United States, is he gets on his phone and tries to figure out which hospital he is at, and, you know, is that in his insurance network? And he finds out - good news - it is. And a surgeon comes by, tells him he's going to need emergency jaw surgery because of the attack that happened.
So he says, OK. You know, he's not really in a place to go anywhere. Gets the surgery. Goes home. A few weeks later, he gets an $8,000 bill from that oral surgeon, who the insurance companies paid a smaller amount. The oral surgeon didn't have a contract with the insurance and said, you know, I think my services are worth a lot more, so pursued the balance of the bill from Scott.
GROSS: I have to say, I mean, that does seem unfair to the patient because they haven't been informed. They can't make a choice about it if they don't know. And, like, $8,000 is a lot of money.
KLIFF: Yeah. And I think, you know, even more, let's say he did say he was out of network. It kind of puts the patient in an unfair situation, too. You know, one of the things we talk about a lot in health policy is, what if we had more transparency? What if we let patients know the prices? What if we let patients know who is in and out of network? And that - it would be a good step.
But, you know, I think with someone like Scott, sitting in a hospital with a broken jaw, there's not much you can do with that information. He doesn't have, you know, the ability to go home, like, research, like, make an appointment with a new surgeon. So, you know, it'd be great if he knew that the doctor was out of network. It'd be even better if he had some kind of protections against those type of bills.
GROSS: What kind of protection could there be?
KLIFF: So we're actually seeing a lot of action on this in Congress. There's some pretty strong bipartisan support for tackling this specific issue and essentially holding the patient harmless. When there is a situation like Scott's, for example, where there's this $8,000 bill, that's really a dispute between a health insurance company and a doctor, where the doctor says, I want more money, the insurer says, I want to pay you less money. And what Congress wants to do - what a few states have already done with their laws - is said, you can't go to the patient for that money. You, the hospital, and you, the health insurance company, you have to get down to a table and work things out together.
And some state laws will set certain amounts that are allowed to be charged, other ones will force the insurance company and the hospital into an arbitration process. But the general concept is to take the patient out of this billing situation because, like you said, Terry, they really aren't in a position to negotiate. They aren't in a position to shop. They shouldn't be the ones who are left holding the bag at the end of the day.
GROSS: My guest is Sarah Kliff. She covers health policy for Vox. After a break, we'll talk more about why ER bills can have some unpleasant surprises, and she'll give us an update on Obamacare. And Maureen Corrigan will review two books about forgotten stories from Hollywood. I'm Terry Gross, and this is FRESH AIR.
(SOUNDBITE OF JESSICA WILLIAMS TRIO'S "KRISTEN")
GROSS: This is FRESH AIR. I'm Terry Gross. Let's get back to my interview with journalist Sarah Kliff, who covers health policy and how it affects people for Vox. For the past year and a half, she's been writing about why emergency room visits can be so expensive and the pricing so secretive and mysterious, as well as inconsistent from one hospital to the next. She collected over 1,000 bills and tracked down stories behind the billing. She interviewed many of the patients and the people behind the billing to decipher why ER bills can have some surprise costs.
Here's another surprise that often awaits people who go to emergency rooms - some insurance plans only cover true emergencies, and whether it is a true emergency is sometimes determined after the diagnosis is made. So how are you supposed to know before the diagnosis whether you're going to be categorized as a true emergency or not? Like, if you go to the hospital, you don't know if you have a broken bone or not.
KLIFF: Right.
GROSS: Somebody needs to X-ray it and tell you.
KLIFF: Right. The whole point you go to the emergency room is to help them figure out what the emergency is and what treatment you need. This is a policy that the insurance company Anthem has been pioneering for a few years. It's been in Kentucky. It's been in Georgia - a few other states. And, you know, I wrote about one patient out in Kentucky named Brittany, who - she was having really severe abdominal pain. She called her mom who is a nurse, and the nurse said, that might be appendicitis. You've got to get to the emergency room. Turns out it wasn't appendicitis. It was an ovarian cyst. She got it treated elsewhere later down the line.
And Anthem, you know, sent her a letter saying, we're not going to cover that visit because it was not a true emergency. She appealed it. Her appeal was denied. This is another one where, once I started asking them about it, the bill suddenly disappeared. But - and it seems like as Anthem has gotten more attention for this policy - they haven't announced it publicly, but some pretty compelling data The New York Times got their hands on suggest they've backed off this policy.
But it's just, you know - there are so many traps you can fall into going into an emergency room. It just feels like you're walking into this minefield, and this is kind of one of those mines that's lurking in there.
GROSS: Hospital pricing and emergency room pricing seems to vary so much from hospital to hospital. Are there, like, national guidelines that help determine what a hospital or a hospital emergency room charges for services? I mean, who decides, and why is there such a variation?
KLIFF: So hospital executives get to decide, and I think that is why there is such variation. There aren't really guidelines that they're following. You know, one thing you could do as a hospital executive - you could look at what Medicare charges - those prices are public - and, you know, maybe use that as a benchmark. There are some databases. There's one called FAIR Health, for example, where you could look and see, you know, some information on what local prices typically are. But in terms of, you know, what you want to charge, that's kind of up to you as someone running a hospital.
One of the things that's really, really unique about the United States, compared to our peer countries, is that we don't regulate health care prices. Nearly every other country in the developed world - they see health care something as, you know, akin to a utility that everyone needs, like electricity or water. It's so important that the government is going to step in and regulate the prices. That doesn't happen in the United States. You know, if you're a hospital, you just choose your prices. And, you know, that is, I think, why you see so much variation and why you see some really high prices in American health care.
GROSS: So what advice do you have for people who actually need an emergency room and don't want to get hit with a shocking bill afterwards?
KLIFF: Yeah, this is, you know, one of those questions - it just makes me a little frustrated that - 'cause this is the most common question I get - right? - is, how do I - how do we - how do I prevent a surprise bill? And I find it kind of upsetting that, you know, it has to be on the patient because honestly, there really isn't a great way to do this. I've talked to so many patients who tried so hard to avoid a big medical bill and weren't able to.
You know, there's certain things, yes, you can do. You can look up the network status of your hospital. You can try and badger each doctor you see about whether they are in network. You can try to be a really proactive patient, but I think that's just such a huge burden on people who are in, like, really emergent situations. And some people don't have that opportunity, you know, like Justin Zanders, the guy we were talking about earlier who was taken to a hospital while he was unconscious. I cannot think of anything he could've done to avoid that bill. It just was not possible.
GROSS: So your advice is, good luck.
KLIFF: Short of that, I mean, good luck. You know, I'm actually in the middle of reporting a story right now about people who have successfully negotiated down their bills. And, you know, you can certainly - if you do end up with a surprise bill, you can call up the hospital, see if there's a discount. Sometimes there will be. Sometimes there won't. You can call again. Customer service representatives - different ones - often offer you different discounts, I've learned from interviewing patients. You can ask for a prompt pay discount if you pay right away.
You can - you know, one health attorney who negotiates these a lot on behalf of patients - he says one of his favorite tactics is to choose the amount you want to pay; send a check with that amount; and in the note, write, paid in full; and hope they don't come after you after that. I have no idea if that works or not, but he says it works for his patients. But it's a mixed bag. And at the end of the day, the hospital has all the power. You can ask for discounts. You can ask nicely. You can ask angrily. It's up to the hospital if they want to grant you that or not.
GROSS: So what is the status of Obamacare now? You know, Republicans promised to repeal and replace. That didn't work out. So have Republicans given up on repeal and replace?
KLIFF: For the time, it seems pretty clear that repeal and replace is dead on arrival, especially with Democrats taking control of the House this year. Those proposals aren't being talked about as much. They're not really going anywhere. The one big thing we did see Republicans succeed at is repealing Obamacare's individual mandate, the requirement that all of us carry health insurance. That happened as part of the big tax package that passed at the end of 2017.
So we've seen, you know, President Trump, for example, essentially declare victory, declare that repealing the individual mandate is repealing Obamacare, so we're good on that goal. But, you know, generally, Obamacare is still standing. There are millions of people getting their coverage through the Affordable Care Act still today.
GROSS: So now that there's no individual mandate, conservative attorney generals are challenging Obamacare - the Affordable Care Act - and saying it's no longer constitutional after Congress's repeal of the individual mandate. Could you explain that?
KLIFF: Yeah, so this is a challenge that's come up through the courts in the past few months. Obamacare is constantly being challenged in court. It's been through multiple Supreme Court suits. This one - you know, it's a multiple-part argument, so I'll try my best to walk through it.
GROSS: OK.
KLIFF: So essentially, it starts with the fact that the individual mandate - they weren't quite able to repeal it for boring technical reasons. But what they were able to do is change the fee for not having health insurance from $700 to $0. So it - in all practical terms, it feels like repealing it because there is no fee for not carrying health insurance. The individual mandate was upheld as a tax when the Supreme Court said, yes, this is constitutional. The government has a right to tax people. Now that there is no fee associated with not carrying health insurance, the conservative attorneys general who are bringing this case argue that it's not a tax anymore, and therefore, it is not constitutional. That whole defense that John Roberts wrote in 2012 is moot. So that's the first part of it.
They go even further and say the individual mandate is so core to the Affordable Care Act, it is not severable. And if you, the courts, rule the individual mandate unconstitutional, then you need to rule all of Obamacare unconstitutional. And the first judge who heard this case - he is a, you know, judge in a district court in Texas. He agreed with them. He agreed that - first step - that the individual mandate is no longer constitutional. And second step, that means that the entirety of Obamacare has to fall. This is now being appealed up to the 5th Circuit Court of Appeals.
And I will say there are a lot of critics of this case. There are a lot of people who were parties to previous Supreme Court challenges to Obamacare who think this is a bad legal argument and that it will not succeed. But it is already, you know, gone through the district court level. It's moving up to the appellate court level. It is something that is in the mix that could become a threat to the Affordable Care Act.
GROSS: Well, if it goes to the Supreme Court, it would be very interesting to see what Justice Roberts says since he voted for the ACA, saying that the individual mandate was a tax.
KLIFF: Yeah. You know, and I think where some legal scholars would see it shaking out is that the - someone like John Roberts, he might agree, OK, yeah, the individual mandate is unconstitutional, but would not make the leap to the second half of this, that the rest of the law has to fall.
I think one of the most compelling arguments against this case is that Congress knew what they were doing when they repealed the individual mandate. You know, they had the opportunity to repeal Obamacare. They didn't. They'd specifically took aim at this one specific part. So it feels like it might be a bit of a reach to argue that what Congress really meant to do was repeal all these other parts of the Affordable Care Act. But, you know, the Supreme Court is changing. We have a new justice. You know, we have a lot in the mix. So it's always an open question of how a decision like this could go.
GROSS: So correct me if I'm wrong here - the Department of Justice has sided with the conservative attorneys general who are challenging Obamacare, saying it's no longer constitutional, and I think that the Justice Department is also asking the judge to strike down the ACA's mandatory coverage of pre-existing conditions.
KLIFF: Yeah, that's right. So it's a kind of unusual situation. Usually, it's the Justice Department that is going to defend a federal law in court. But, you know, given the Trump administration's opposition to the Affordable Care Act, they have decided to side with the conservative attorneys general. They have a slightly different argument. They don't think all of Obamacare should fall if the mandate falls, but they do think some big parts, like you mentioned, the protections for pre-existing conditions, should be ruled unconstitutional if the mandate falls.
So this has led to a bit of an unusual situation where you've had this coalition of Democratic attorneys general step in and take over the case, basically saying that the federal government is going - is not going to defend the Affordable Care Act. We are going to defend the Affordable Care Act. So you have this coalition of Democratic attorneys general, led by the attorney general of California, stepping in and, you know, offering a defense as this case works its way up through the court system.
GROSS: Let's take a short break here, and then we'll talk some more. If you're just joining us, my guest is Sarah Kliff. She's senior policy correspondent at Vox, where she focuses on health policy. And she hosts the Vox podcast "The Impact," about how policy actually affects people. We'll be right back. This is FRESH AIR.
(SOUNDBITE OF THE WEE TRIO'S "LOLA")
GROSS: This is FRESH AIR. And if you're just joining us, my guest is Sarah Kliff, senior policy correspondent at Vox, where she focuses on health policy.
Do you think health insurance is shaping up to be a big issue in the 2020 campaign?
KLIFF: I do, and I think it's going to be a big issue both in the primary, where you're already seeing candidates get pressed on, should we still have private health insurance, and giving pretty different answers to that question.
And then I think one of the things you're also going to see is whoever is the Democratic nominee is probably going to run on Obamacare. They are going to point at the fact that President Trump tried to repeal the Affordable Care Act. That's pretty different than, you know, the 2012 election, where Democrats were pretty scared to run on Obamacare. It still wasn't popular. The benefits hadn't rolled out. In this past midterm and now again in the 2020 election, it seems pretty clear that Democrats are pretty excited to point out that Republicans wanted to repeal Obamacare. So I think it really will come up.
GROSS: What are some of the biggest falsehoods you've heard from politicians about health insurance costs or health insurance policy?
KLIFF: You know, one of the ones that's come up a lot is actually around the role of private health insurance. So I've - I don't know if it counts as a falsehood, but I think it's a bit of a misunderstanding of how health insurance often works is, you know, when I talk to single-payer supporters, most of them want to eliminate private insurance completely. They just don't think there is a role for it in the health care system.
And one of the things I think that's actually pretty interesting, when you look at any other country - you look at Canada, you look at the U.K., you look at France, which all have national health care systems - all of them have a private health insurance market, too. There are always some kind of gap in the system that the public insurance can't cover, where the government step - where the private industry steps in and offers coverage. In Canada, for example, their public health plan doesn't cover prescription drugs, so two-thirds of Canadians take out a private plan, often through their employer, like us, to cover prescription drugs, to cover their eyeglasses, to cover their dental. So I think that's a confusion I see a lot in the "Medicare for All" debate coming up right now.
I think the other thing I see a lot of confusion around - and we've talked about this a little bit with emergency room billing - is the role of transparency in health care. I see a lot of, you know, if we just made the prices public, like, that is what we need to do to fix the system, and I think that really misses the fact that, even if the prices were public, health care is so different from everything else we shop for. It might be - I think it is the only thing we purchase when we are unconscious.
GROSS: (Laughter).
KLIFF: And when you're unconscious, you're not really going to be great at price shopping. So I see that as, you know, a halfway solution that I often hear talked about here in Washington that would be great but is not going to suddenly result in, you know, prices dropping because they've been exposed in a spotlight.
GROSS: Is there a country that you think has a good health care model that we could borrow?
KLIFF: Oh, yeah. I've been thinking about this a lot lately actually. So I've gotten very interested in the Australia health care system, which is a little far away. But I think they're a really interesting model because they have a public system, everyone's enrolled in it, but they also really aggressively try and get people to buy a private plan, too, and that private plan will get you sometimes faster access to doctors, maybe a private room at a hospital.
It's really hard for me to see the U.S. creating a health care system, similar to Canada's actually, where you can't buy private insurance, where if you're rich or you're poor, everyone waits in the exact same queue, you can't jump to the front of the line. Because I think wealthier Americans have gotten so used to having really good access to health care that they would be very upset with a system like that.
I think Australia is a kind of interesting hybrid between, you know, where we're at in the U.S. right now and what Canada is like, where it says, yes, we're going to create a public system for everybody, but we're also going to have these private plans that compete against the public system. So I've become increasingly, you know, interested in how Australia's system works. And they have - about 47 percent of Australians are buying a private plan to cover the same benefits that the public plan does.
GROSS: So it's not supplemental. It's instead of.
KLIFF: Right. So it's very different from Canada. So in Canada, you can buy complementary insurance, you know, to cover the benefits the public plan doesn't but the government expressly outlaws supplemental insurance. You know, like, what people buy here to cover the gaps in Medicare, that is not allowed. You cannot buy your way to the front of the line in Canada.
One of my favorite sayings about the Canadian health care system is from a doctor in a book I read about Canadian health care is they said, you know, we're fine waiting in lines for health care in Canada as long as the rich people and the poor people have to wait in the exact same line. Their system is all about equality. And I just don't know that we're at a place as a country where we value the same sort of equality in our health care system.
GROSS: Is there any developed country around the world that has a system similar to ours with all these competing insurance companies and, you know, some government plans and, like, a thousand different bureaucracies that doctors have to deal with and that patients have to deal with?
KLIFF: Absolutely not. There's nothing like it. I mean, our system is so unique. I'd say the closest but it's not even close are a few countries that have national health care systems, but they do it through tightly regulated private health insurance plans. So if you look at, like, Netherlands or Israel, there isn't a government-run plan. Instead, in both countries, you actually have four tightly regulated health insurance plans that compete against each other for the citizens' business. I guess that's the closest, but that is so different from what we have here right now. There's really nothing like it in any developed country.
GROSS: Sarah Kliff, thank you so much for talking with us.
KLIFF: Well, thank you for having me.
GROSS: Sarah Kliff covers health policy for Vox, where you'll find her series about emergency room bills. After we take a short break, Maureen Corrigan will review two books about forgotten stories from Hollywood. This is FRESH AIR.
https://www.npr.org/2019/03/13/702975393/why-an-er-visit-can-cost-so-much-even-for-those-with-health-insurance
Medicare wellness visits are supposed to be free — unless you call it a physical.
by Michelle Andrews - Washington Post - March 18, 2019
When Beverly Dunn called her new primary care
doctor’s office last November to schedule an annual checkup, she assumed
her Medicare coverage would pick up most of the tab.
The appointment seemed like a routine physical, and she was pleased that the doctor spent a lot of time with her.
Until she got the bill: $400.
Dunn,
69, called the doctor’s office assuming there was a billing error. But
it was no mistake, she was told. Medicare does not cover an annual
physical exam.
The Austin resident was tripped up by Medicare’s confusing coverage rules.
Federal law prohibits the health-care program from paying for annual
physicals, and patients who get them may be on the hook for the entire
amount. But beneficiaries pay nothing for an “annual wellness visit,”
which the program covers in full as a preventive service.
“It’s
very important that someone, when they call to make an appointment,
uses those magic words, ‘annual wellness visit,’ ” said Leslie Fried,
senior director of the Center for Benefits Access at the National
Council on Aging. Otherwise, “people think they are making an
appointment for an annual wellness visit and it ends up they are having a
complete physical.”
An annual physical
typically involves an exam by a doctor along with bloodwork or other
tests. The annual wellness visit generally doesn’t include a physical
exam, except to check routine measurements such as height, weight and
blood pressure.
The focus of the Medicare wellness visit
is on preventing disease and disability by coming up with a
“personalized prevention plan” for future medical issues based on the
beneficiary’s health and risk factors.
At their
first wellness visit, patients will often fill out a risk-assessment
questionnaire and review their family and personal medical history with
their doctor, a nurse practitioner or physician assistant. The clinician
will typically create a schedule for the next decade of mammograms,
colonoscopies and other screenings and evaluate people for cognitive
problems and depression, as well as their risk of falls and other safety
issues.
They may also talk about advance care planning with beneficiaries to make decisions about what type of medical treatment they want in the future if they cannot make decisions for themselves.
At
subsequent annual wellness visits, the doctor and patient will review
these issues and check basic measurements. Beneficiaries can also
receive other covered preventive services, such as flu shots, at those
visits without charge.
When the Medicare
program was established more than 50 years ago, its purpose was to cover
the diagnosis and treatment of illness and injury in older people.
Preventive services were generally not covered, and routine physical
checkups were explicitly excluded, along with routine foot and dental
care, eyeglasses and hearing aids.
Over the years, preventive services have gradually been added to the program, and the Affordable Care Act established coverage of the annual wellness visit. Medicare beneficiaries pay nothing as long as their doctor accepts Medicare.
But
if a wellness visit veers beyond the bounds of the specific covered
preventive services into diagnosis or treatment — whether at the urging
of the doctor or the patient — Medicare beneficiaries may typically owe a
co-pay or other charges.
(This can be an issue
when people in private plans get preventive care, too. And it can
affect patients of all ages. The ACA requires insurers to provide
coverage, without co-pay, for a range of preventive services, including immunizations. But if a visit goes beyond prevention, the patient may encounter charges.)
And
to add more confusion, Medicare beneficiaries can opt for a “Welcome to
Medicare” preventive visit within the first year of joining Medicare
Part B, which covers physician services.
Meanwhile, some Medicare Advantage plans cover annual physicals for their members free of charge.
Many
patients want their doctor to evaluate or treat chronic conditions such
as diabetes or arthritis at the wellness visit, said Michael Munger,
who chairs the board of the American Academy of Family Physicians. But
Medicare generally won’t cover lab work, such as cholesterol screening,
unless it’s tied to a specific medical condition.
At
Munger’s practice in Overland Park, Kan., staff members routinely ask
patients who come in for a wellness visit to sign an “advance
beneficiary notice of noncoverage” acknowledging that they understand
Medicare may not pay for some of the services they receive.
As long as beneficiaries understand the coverage rules, it’s not generally a problem, Munger said.
“They don’t want to come back for a separate visit, so they just understand that there may be extra charges,” he said.
Beneficiaries
may not be the only ones who are unclear about what an annual wellness
visit involves, Munger said. Providers may be put off if they think that
it’s just another task that adds to their paperwork.
A
recent study published in the journal Health Affairs found that in 2015
just over half of practices with eligible Medicare patients didn’t
offer the annual wellness visit. That year, 18.8 percent of eligible
beneficiaries received an annual wellness visit, the analysis found.
Primary
care physicians generally want to see their patients at least once a
year, Munger said, but it needn’t be for a complete physical exam.
A
wellness visit or even a visit for a sprained ankle could give doctors
an opportunity to check in with patients and make sure they’re on track
with preventive and other care, Munger said.
Dunn
said when she called the doctor’s office about the $400 bill, the staff
told her she had signed papers agreeing to pay whatever Medicare didn’t
cover.
Dunn doesn’t dispute that.
“There were lots of papers that I signed,” she said. “But nobody told me I would get a bill for $400. I would remember that.”
In
the end, the clinic waived all but $100 of the charge, but warned her
that next year she’ll have to pay $300 if she wants an annual physical
with that doctor. If she comes in just for an annual wellness visit,
she’ll be seen by a physician assistant.
Dunn
is considering her options. She would like to stay with her new doctor,
who came highly recommended, and she’s worried she might have trouble
finding another one as good who accepts Medicare. But $300 seems steep
to her for a checkup.
“This whole thing was so
stressful for me,” she said. “I lost sleep for nights. It’s not that I
couldn’t afford it, but it didn’t seem right.”
Medicare for all is divisive, including among Democrats
by Sheryl Gay Stolberg - The Boston Globe - March 18, 2019WASHINGTON — No issue animated the Democrats’ 2018 congressional campaigns like health care and the promises to expand access to insurance and to lower costs. But as House Democrats sit down to draft their vision of governance in the coming weeks, lawmakers find themselves badly divided on the issue that delivered their majority.
Centrists from swing districts, with the tacit support of Speaker Nancy Pelosi, D-Calif., favor incremental moves to shore up the health care law and to lower the out-of-pocket costs of prescription drugs and medical care. They are pushing a variety of measures, such as shutting down cheap, short-term insurance plans that do not cover pre-existing medical conditions and allowing people to buy into Medicare at age 50 or 55.
“We have very practical solutions that we can implement immediately,” said Representative Kim Schrier, D-Wash., who is also a pediatrician. “We don’t have the luxury of time right now to wait for a full overhaul of our health care system.”
But they are butting up against an aggressive and expanding group of more than 100 outspoken Democrats — as well as at least four of the party’s presidential candidates — who want to do just that, upend the whole system with a single government insurance plan for all Americans — the old concept of single-payer, now called “Medicare for All.”
Get Ground Game in your inbox:
Daily updates and analysis on national politics from James Pindell.
Daily updates and analysis on national politics from James Pindell.
The fight will play out in the coming weeks as the new House majority assembles its first budget, a policy document that will not hold the force of law but will carry significant political weight, revealing Democrats’ intentions not only on health care but on taxation, climate change, Social Security and other hot-button issues as well. But more than any other subject, Democrats’ achievements or failures on health care may well define them as they try to defend their fragile majority next year.
“Health care was on the ballot,” Pelosi declared in November, “and health care won.”
The idea of Medicare for All is immensely controversial. It would greatly expand the federal role in health care. Critics say it would require a big increase in federal spending and proponents have not said how they would pay for it. Some versions of Medicare for All could wipe out much of the health insurance industry and replace employer-sponsored health plans that now cover more than 155 million Americans. Supporters say the proposal would guarantee universal coverage and put health care on a budget, reducing what consumers and employers spend. But many local hospitals and doctors oppose the idea, believing that it would reduce the payments they receive for providing care.
Pelosi cannot afford to put moderate freshmen in Trump-friendly districts on the spot by putting Medicare for All up to a vote.
“Most people receive health care from their employer,” said Representative Scott Peters, D-Calif., a vice chairman for the New Democrat Coalition, a centrist group. “They do not want to replace it with an untested government system.”
But that view is being challenged from some surprising corners of the party. Representative Debbie Dingell, D-Mich., and no one’s idea of an upstart firebrand, is now a champion of the Medicare for All Act. She said the government was already delivering health care to significant areas of the population — the elderly, the poor, service members, children and veterans.
“We’ve got Medicare, we’ve got Children’s Health Insurance and now it’s time for everybody,” said Dingell, whose husband, John, and his father before him pressed for universal health care when they served in Congress. Before her husband died last month, she said, he told her to “bring it over the finish line.”
The debate reflects how much the political climate around health care has changed since passage of the Affordable Care Act in 2010. President Obama had promoted the idea of a public option — a government-run health program to compete with private insurance on a federally run insurance marketplace — but moderate Democrats balked, and it was not included in the final law.
Senator Bernie Sanders, I-Vt., almost single-handedly put the idea of Medicare for All on the agenda during his 2016 presidential campaign. Since then, the concept has become a kind of litmus test for liberals. Republicans’ dismissal of it as socialism has only emboldened the new wave of liberal freshmen Democrats in the House.
Backers of Medicare for All say that, if framed correctly around saving health care costs, it can appeal to voters in more moderate districts.
“Progressives have done a very good job making the moral case for Medicare for All,” said Representative Ro Khanna, D-Calif. “What we now need to do is make the economic case.”
But with Republicans in charge of the White House and the Senate, the centrists argue that Congress needs to start with more incremental initiatives that could be slipped into larger bills, such as restoring money to enroll people in health plans on the Affordable Care Act’s exchanges. Other bills have bipartisan support; a measure drafted by Senator Susan Collins, R-Maine, would create state-based reinsurance programs to help pay large health insurance claims, thus lowering premiums on the act’s exchanges.
“After years of damage done to the ACA from past Republican Congresses and the administration, we must start by reversing the sabotage,” leaders of the New Democrat Coalition wrote in a letter to the chairmen of three House committees responsible for health legislation.
Pelosi has publicly stayed out of the fight, but with hearings on Medicare for All and other proposals scheduled in the coming weeks, that stance may not be sustainable. People close to her say she has serious reservations about the single-payer bill and believes the nation can achieve the goal of universal coverage at a more manageable cost by building on the framework of the health care law, which she worked tirelessly to secure in 2010.
https://www.bostonglobe.com/news/nation/2019/03/18/medicare-for-all-divisive-including-among-democrats/EmQre3M77RvDQPTsKusD9J/story.html?et_rid=1744895461&s_campaign=todayinpolitics:newsletter
Medicare for America, Beto O’Rourke’s favorite health care plan, explained
by Dylan Scott - VOX - March 18, 2019
In his early days as a presidential candidate, Beto O’Rourke has walked away from supporting single-payer Medicare-for-all and into the arms of another health care plan: Medicare for America.
That plan, introduced last year by Reps. Rosa DeLauro
(D-CT) and Jan Schakowsky (D-IL), was founded on the previous work of
the Center for American Progress and Yale professor Jacob Hacker. It is
the Democratic establishment’s alternative to the single-payer approach
favored by Sen. Bernie Sanders (I-VT) and the democratic socialist left.
It would not move every American into a government health care plan over the next few years, as the Medicare-for-all bill authored by Sanders would. Employer-based insurance,
which covers half of all Americans, would be preserved, though workers
would have the option of leaving their work plan to join the new
Medicare program. Over a long enough timeline, however, Medicare for
America would likely cover most and maybe all Americans under a single
government plan. The uninsured and people on Medicaid or Obamacare would
be moved into the new public coverage right away, and newborns would be
enrolled automatically in the plan as well.
O’Rourke has quickly become the bill’s most prominent
proponent, citing it on the campaign trail as the best path to universal
coverage despite his earlier support for single-payer health care. He is selling it as the more politically palatable solution. From the Texas Tribune:
“It responds to the fact that so many Americans have said, ‘I like my employer-based insurance. I want to keep it. I like the network I’m in. I like the doctor that I see,’” O’Rourke said. “It complements what already exists with the need that we have for millions of Americans who do not have insurance and ensures that each of them can enroll in Medicare. It then suggests additional investments in that program so it becomes the program of choice and people who have private insurance migrate over to the Medicare system.”O’Rourke added: “Now listen, we may disagree about the best policy path forward, but for me, that affords us the greatest buy-in from the greatest number of Americans because this cannot be the policy or plan of just one person or one party. We’re going to have to get as many people as possible into this if we’re going to achieve that goal.”
That Democrats are arguing whether their next health care
proposal should cover every American in a government plan in a matter
of years or a matter of decades shows how far to the left
the party’s internal health care debate has shifted. But in a crowded
presidential field, these distinctions are going to be treated as
meaningful. O’Rourke is allying himself with more mainstream Democrats,
setting up a collision with Sanders and the single-payer purists.
Medicare for America, explained
In brief, here’s what the bill authored by DeLauro and Schakowsky and now embraced by O’Rourke would do:
- The uninsured, people currently purchasing insurance in the Obamacare marketplaces, Medicaid beneficiaries, and newborns would automatically be enrolled into an improved Medicare program, which would continue to cover seniors as well.
- Employers could continue to offer private insurance, so long as it meets certain federal standards. Companies could also elect to send their workers to the public program and pay a contribution toward their employees’ costs. Likewise, workers could voluntarily leave their job’s insurance for the new public plan.
- Participants would be required to pay premiums, on a sliding scale based on their income; people with lower incomes would pay no premium at all. Out-of-pocket costs would also be based on income and capped at $3,500 for an individual or $5,000 for a family.
- Doctors would be paid Medicare rates, with an additional increase provided for primary care doctors and mental health services.
The plan is intentionally written to avoid disrupting
employer-sponsored insurance for people who currently get coverage
through their work. Companies could continue to offer private insurance
to their employees as long as it covers at least 80 percent of health
care costs. Businesses could also proactively choose to send their
workers into the government plan while contributing money to the program
to cover their costs. Employees would have the option of leaving their
company plan on their own as well.
The legislation’s proponents believe that moving people
into Medicare more gradually, rather than transitioning everyone in just
a few years, would weaken any Republican arguments intended to scare
seniors into believing that the Medicare they currently rely on is at
risk.
“I think it makes sense to go slowly in moving people
into Medicare to minimize backlash among those who depend on it
already,” Hacker told me during our recent interview. “Disruption is one
of the big reasons why an immediate move to a single-payer system is
probably a bridge too far in American politics for the foreseeable
future.”
So Medicare for America plainly would not eliminate private insurance,
as single-payer supporters desire. Not only would it preserve
employer-sponsored coverage, it would permit private Medicare Advantage
plans (which already provide a private alternative for current Medicare
beneficiaries) to compete with the government plan, in part to provide a
choice for people.
What about financing,
often the trickiest question for a single-payer plan? Medicare for
America would start by rolling back the Republican tax cuts. An
additional 5 percent tax on income over $500,000 would be applied.
Payroll taxes for Medicare would also be hiked, as would the net
investment income tax rate. New excise taxes on tobacco, alcohol, and
sugary drinks would be introduced. The bill also requires that states
continue making payments to the federal government equivalent to what
they pay right now for Medicaid’s costs.
Medicare for America is not really single payer. Private
insurance is preserved. Most Americans would still have to pay premiums
and out-of-pocket costs, which the Sanders Medicare-for-all bill would
effectively eliminate. It is far more ambitious than a Medicare buy-in
or other public options, but it still falls short of what the Democratic
left believes is necessary to fix American health care.
How Medicare for America fits into the 2020 Democratic debate
O’Rourke could prove a useful cipher in determining where
the Democratic Party really stands on health care. Almost every
Democratic senator running for president has signed onto Sanders’s
Medicare-for-all bill. Even though their commitment to the cause might
be less than absolute (Sanders aside), that has left little distinction
between the candidates on one of the Democratic Party’s biggest issues.
O’Rourke’s embrace of Medicare for America establishes a
clearer demarcation — and a sharp contrast with his biggest fundraising
rival. He and Sanders have proven themselves to be the most prolific
fundraisers of the 2020 field so far.
The former Texas Congress member apparently decided it is better to position himself a little closer to the middle. As Vox’s Sarah Kliff reported last week,
O’Rourke had embraced full-throated single-payer ideas in the past but
modulated his position recently, saying he’s opting for pragmatism over
ideological purity.
“If we become too ideological or too prescribed in the
solution, we may allow the perfect to become the enemy of the good,” he
told Iowa voters, according to the Texas Tribune. “And there are fellow
American human lives depending on us finding a solution.”
For Beto boosters, this could serve as an example of his
open-hearted but practical progressivism. For his detractors, it might
demonstrate a vacuous candidacy founded more in charisma and vagaries
than conviction and a sophisticated policy platform. The question we
still don’t know the answer to is what kind of candidate Democratic
voters prefer.
I have wondered for some time how many absolutist single-payer acolytes there really are within the Democratic Party. A January poll
by the Kaiser Family Foundation found that 81 percent of Democrats
support a single-payer Medicare-for-all plan — but support for a plan
like Medicare for America, opening government coverage to everyone but
allowing people to keep their current plan if they so choose, was a
little higher, at 91 percent. Like the rest of the public, Democratic
support for single-payer rose when they heard out-of-pocket costs would
be eliminated and every American would be guaranteed coverage. But then
support fell when they were told it would lead to higher taxes or delays
in medical treatment.
Another poll, taken by pollster Michael Perry, found that just 11 percent of Democrats say they would support only Medicare-for-all,
because incremental reforms prop up a broken system. The vast majority —
84 percent — said they support Medicare-for-all and more
gradual improvements to the Affordable Care Act. (The polling group
didn’t ask about a plan like Medicare for America, unfortunately.)
The point is, the broader Democratic electorate does not
seem as firmly committed to single-payer as the energized left. Sanders
can make the credible claim that the idea is still on the ascent, having
rapidly moved toward the mainstream since his 2016 campaign, and it
does already enjoy broad support within the party. But O’Rourke is
making a different bet.
In a primary and on an issue where there is so much
policy overlap between the candidates, we have now drawn clearer battle
lines. O’Rourke vs. Sanders. Medicare-for-all vs. Medicare for America.
No comments:
Post a Comment