Editor's Note -
Be sure to check out the second story in the December 13, 2020 60 Minutes show, about the abuses of the Sutter Health System in California, and Xavier Becerra's response to it. If you have any doubts about what the American healthcare system has become, watching this short (10 minute) clip should put them to rest.
If that doesn't work, try this:
A transcript of this video story follows.
- SPC
How a hospital system grew to gain market power and drove up California health care costs
Sutter Health is in the midst of a lawsuit for business practices that drove up health care prices for Californians.
The coronavirus pandemic has unleashed more than a flood of disease in this country. It's also expected to accelerate a wave of hospital mergers and acquisitions – with big hospitals buying up smaller ones. This consolidation, economists say, is one of the main reasons the cost of health care in this country is going through the roof.
There's a lawsuit over this in COVID-ravaged California, with the state attorney general claiming that Sutter Health, a hospital chain based in Sacramento, got so big it had essentially become a monopoly.
On the eve of the trial, Sutter tentatively agreed to a settlement that's awaiting a judge's approval. But this is, even at this stage, a landmark case because it pulled back the curtain on what has rarely been seen or so thoroughly documented before: how and why hospital prices have been skyrocketing.
Sutter is a sprawling health care system that's the largest and most dominant provider in Northern California.
Xavier Becerra: They're like the bully on the block. They were able to bully everyone else to conform; it was my way or the highway.
The state's attorney general, Xavier Becerra, filed a civil lawsuit against Sutter in 2018. We interviewed him before the pandemic and before he was nominated for secretary of Health and Human Services.
Xavier Becerra: They were gobbling up hospitals. They were gobbling up physicians through these physician practices. They were just munching away, getting bigger and bigger.
Till they amassed a conglomerate of 24 hospitals, 12,000 physicians, and a string of cancer, cardiac and other health care centers.
Xavier Becerra: Sutter got big enough that it could use its market power to dominate, to dictate. It was abusing of its power.
The suit accuses Sutter of embarking on "…an intentional, and successful, strategy…" of cornering much of the market in Northern California, and then jacking up prices -- for example, on the price of delivering a baby.
Xavier Becerra: You live in Sacramento, you can expect to pay twice as much to deliver that baby here than in your hometown of New York City.
Lesley Stahl: I actually heard that it costs more to deliver a baby here in Sacramento than anywhere else in the entire country.
Xavier Becerra: Why Sacramento should be the most expensive place to have a baby-- there's no way to explain it.
Caring for a premature baby in Northern California, for example, costs about $605,000. In Southern California: $343,000. In all, he says, the average cost of in-patient care in Northern California is 70% higher than in Southern California.
Lesley Stahl: When you did the investigation, did you look at other variables that might have been the reason for the higher prices? Quality might have been better? Maybe equipment was better? Did you take all that into consideration?
Xavier Becerra: That's why this investigation took years, because you have to eliminate all the other reasons that might be out there. And you can't explain it away by the cost of living, cost of labor.
Lesley Stahl: Or quality of care?
Xavier Becerra: Or quality of care.
Lesley Stahl: It's just Sutter hiking prices.
Xavier Becerra: It's domination of the market.
Sutter's quest to dominate the market, Attorney General Becerra says, began in the 1990s with a campaign of mergers and acquisitions that enabled it to grow from two hospitals into the behemoth it is today.
Glenn Melnick: They really pioneered this model of reducing competition to raise prices. They were the first one to do it. And the prices continually grew faster and faster than other comparable hospitals.
Glenn Melnick is a health care economist at the University of Southern California who consulted on the lawsuit and was one of the first researchers to document Sutter's strategy of making itself indispensable. He found, for instance, that in 11 counties of Northern California...
Glenn Melnick: They're either the only one hospital, or one of two hospitals. And some of these counties are 1,000 square miles. So--
Lesley Stahl: And there's one or two hospitals in a thousand square miles?
Glenn Melnick: Right.
Lesley Stahl: Oh.
Glenn Melnick: That's right. So they have monopoly powers in a number of these counties, right? And their prices went up. The next year, they went up even faster. And they figured out, "Wow, this really works!"
Lesley Stahl: You might look at that and say, "That's monopolistic." Someone else might look at it and say, "Wow, that's smart business. That's- that's really clever. Good for them!"
Glenn Melnick: If Sutter is able to raise their prices by improving quality, value, and service, that's fine. What they came up with is a model that allowed them to acquire market power, and get higher prices without doing any of those good things for consumers.
In the lawsuit, evidence showed that Sutter's quality of care, while well-regarded, was generally comparable to other hospitals in California, and that its higher prices have been contagious.
Glenn Melnick: So we called it the "Sutter effect," where if you have a large, dominant system like this, they raise their prices high, all their competitors can raise their prices higher. So there's kind of this second-order effect: that this type of behavior leads to much higher prices across the board.
Hillary Ronen: It's outrageous.
Hillary Ronen is a member of San Francisco's city and county board of supervisors and sits on its budget committee.
Hillary Ronen: We have so many difficult problems in San Francisco that we're trying to fix.
Lesley Stahl: I understand that the City and County of San Francisco spends roughly $800 million a year in health costs.
Hillary Ronen: That's right. That money comes from the same pot of money that we use to build new homeless shelters to hire firefighters, to pave our streets, to repair our parks. And the more we're paying on employee health care, the less we're paying on the toughest entrenched problems we're trying to fix in San Francisco.
A reason their health costs were so high, she says, is because Sutter was able to block the city and its insurer, Blue Shield of California, from steering employees to hospitals with lower prices. And it was able to prevent Blue Shield from telling the city what Sutter's hospitals would charge for individual procedures.
Hillary Ronen: Sutter won't allow us to see how much they charge for their services. It-- it's unbelievable. And so we can't comparison shop. And they keep naming their price, and I feel like I'm handcuffed to do anything about it.
Lesley Stahl: The insurance company, Blue Shield?
Hillary Ronen: Yes.
Lesley Stahl: They can't fight either? They are also blocked?
Hillary Ronen: They are. Blue Shield is as at the whim of Sutter naming its price as we are. For once in their life the insurance company is not the worst actor in the room, it's Sutter.
The state accused Sutter of using its "windfall" from its "excessive pricing" to finance the acquisition of new hospitals and physicians groups. And to pay its outgoing CEO $13 million in 2016, and a year later, paid its new CEO $6 million. It galls Hillary Ronen that Sutter is a not-for-profit company, meaning legally it pays no taxes even though it earned $13 billion in revenue last year.
Hillary Ronen: Sutter avoids tens of millions of dollars a year in local property taxes. And at one hospital alone they're avoiding $20 million a year.
Lesley Stahl: Wow. And business taxes that they don't pay are added on top of that.
Hillary Ronen: Are added on top of that.
Lesley Stahl: Sutter's a not-for-profit hospital--
Hillary Ronen: Exactly.
Lesley Stahl: --which suggests that they're not out for financial gain.
Hillary Ronen: Right.
Lesley Stahl: So how does that square?
Hillary Ronen: At any way you look at it, any path you look, we are getting screwed. (LAUGH)
That sentiment is shared by one of the state's largest labor unions, the United Food and Commercial Workers, as well as many of the state's large employers that belong to the Pacific Business Group on Health headed by CEO Elizabeth Mitchell.
Elizabeth Mitchell: Collectively our members spend $100 billion a year purchasing health care on behalf of 15 million Americans.
Lesley Stahl: So who are some of these big companies?
Elizabeth Mitchell: Walmart, Boeing, Cisco, Intel, really the biggest companies in the world. Very sophisticated.
Lesley Stahl: So here you have these giant companies. You think of them as being all-powerful. And they could not control Sutter? Wow.
Elizabeth Mitchell: They could not. The more hospitals they acquired, the more physicians they employed, the more leverage they had in the market. And they did this very strategically. So, if there was a specialty, say maternity, that they knew every employer would need, they created a monopoly around maternity. So if an employer would try to exclude the system, they said, "Well, you can't do that because you have to have our maternity services."
Lesley Stahl: Now they control the maternity care in Northern California--
Elizabeth Mitchell: As an example, they control the maternity care.
According to the lawsuit, Sutter used its leverage to force the big companies and their insurers into what are called "all-or-nothing" contracts, meaning that they had to include all 24 of Sutter's hospitals in their health plans.
Elizabeth Mitchell: And sometimes they would have to include hospitals that were in regions that the employers didn't even have employees in.
Lesley Stahl: Sutter was forcing big companies to cover hospitals in places where nobody worked for the company lived?
Elizabeth Mitchell: That's right. It was all or nothing and no employer could do without all of the Sutter system.
We asked Sutter for an interview, but the hospital declined and instead sent us a statement saying, in part, that it's committed "…to high-quality, affordable care…" and that its coordinated health care network "delivers healthier patient outcomes at a lower total cost of care," something that "…has proven even more critical during the COVID-19 pandemic."
Lesley Stahl: Sutter says that when you have a system as big as theirs, what they can offer is coordinated care. They can reduce duplication and they can cut costs. Now that sounds reasonable.
Elizabeth Mitchell: Well, that is true in every other industry. That they use their size to reduce their prices. And yet the opposite has been true in health care. They merge and then they use their market leverage to increase prices.
Lesley Stahl: But what about this idea of coordinated care? I think that was one of the reasons that these mergers were allowed to happen.
Elizabeth Mitchell: Coordinated care is what everybody wants. The problem is it has not been achieved in these mergers. We're not getting better outcomes. We're not getting, you know, healthier people.
Most alarming, she says, hospitals across the country have been following Sutter's lead.
Elizabeth Mitchell: This is happening in Maine. It's happening in Texas. It's happening across the country, the largest health systems are buying up everything.
Lesley Stahl: Do you think that this is the main reason that health costs are going up?
Elizabeth Mitchell: We have seen the data. It is the largest driver of health care cost increases. It's hospital prices. And they're not providing more services. And the quality isn't increasing. They are just charging more for the same thing. It is just the prices. And they do it because they can.
Attorney general Becerra and Sutter are waiting to see if the tentative, out-of-court settlement they reached is approved. If so, Sutter will admit no wrongdoing, but will pay $575 million and agree to stop blocking patients' access to less expensive hospitals and requiring "all-or-nothing" contracts.
Lesley Stahl: You called this case a "big effing deal." Why?
Xavier Becerra: This settlement is gonna change the life for hundreds of thousands of Californians. And I'd say millions of Americans because I think you're gonna see other states take what we did and say, "Ah-hah. We've got some facilities that are behaving the same way. Let's push."
Lesley Stahl: So you think this-- what you did'll become a model.
Xavier Becerra: I think it's a game changer.
Produced by Richard Bonin. Associate producers, Magalie Laguerre-Wilkinson and Mirella Brussani. Broadcast associate, Claire Fahy. Edited by Jorge J. García.
‘Like a Hand Grasping’: Trump Appointees Describe the Crushing of the C.D.C.
Kyle McGowan, a former chief of staff at the Centers for Disease Control and Prevention, and his deputy, Amanda Campbell, go public on the Trump administration’s manipulation of the agency.
by Noah Weilland - NYT - December 16, 2020
ATLANTA — Kyle McGowan, a former chief of staff at the Centers for Disease Control and Prevention, and his deputy, Amanda Campbell, were installed in 2018 as two of the youngest political appointees in the history of the world’s premier public health agency, young Republicans returning to their native Georgia to dream jobs.
But what they witnessed during the coronavirus pandemic this year in the C.D.C.’s leadership suite on the 12-floor headquarters here shook them: Washington’s dismissal of science, the White House’s slow suffocation of the agency’s voice, the meddling in its messages and the siphoning of its budget.
In interviews this fall, the pair decided to go public with their disillusionment: what went wrong, and what they believe needs to be done as the agency girds for what could be a yearslong project of rebuilding its credibility externally while easing ill feelings and self-doubt internally.
“Everyone wants to describe the day that the light switch flipped and the C.D.C. was sidelined. It didn’t happen that way,” Mr. McGowan said. “It was more of like a hand grasping something, and it slowly closes, closes, closes, closes until you realize that, middle of the summer, it has a complete grasp on everything at the C.D.C.”
Last week, the editor in chief of the C.D.C.’s flagship weekly disease outbreak reports — once considered untouchable — told House Democrats investigating political interference in the agency’s work that she was ordered to destroy an email showing Trump appointees attempting to meddle with their publication.
The same day, the outlines of the C.D.C.’s future took more shape when President-elect Joseph R. Biden Jr. announced a slate of health nominees, including Dr. Rochelle Walensky, the chief of infectious diseases at Massachusetts General Hospital, as the agency’s new director, a move generally greeted with enthusiasm by public health experts.
“We are ready to combat this virus with science and facts,” she wrote on Twitter.
Mr. McGowan and Ms. Campbell — who joined the C.D.C. in their early 30s, then left together in August — said that mantra was what was most needed after a brutal year that left the agency’s authority crippled.
In November, Mr. McGowan held conversations with Biden transition officials reviewing the agency’s response to the pandemic, where he said he was candid about its failures. Among the initiatives he encouraged the new administration to plan for: reviving regular — if not daily — news briefings featuring the agency’s scientists.
Mr. McGowan and Ms. Campbell, both 34, say they tried to protect their colleagues against political meddling from the White House and Department of Health and Human Services. But an agency created to protect the nation against a public health catastrophe like the coronavirus was largely stifled by the Trump administration.
The White House insisted on reviewing — and often softening — the C.D.C.’s closely guarded coronavirus guidance documents, the most prominent public expression of its latest research and scientific consensus on the spread of the virus. The documents were vetted not only by the White House’s coronavirus task force but by what felt to the agency’s employees like an endless loop of political appointees across Washington.
Mr. McGowan recalled a White House fixated on the economic implications of public health. He and Dr. Robert R. Redfield, the C.D.C. director, negotiated with Russell T. Vought, the White House budget director, over social distancing guidelines for restaurants, as Mr. Vought argued that specific spacing recommendations would be too onerous for businesses to enforce.
“It is not the C.D.C.’s role to determine the economic viability of a guidance document,” Mr. McGowan said.
They compromised anyway, recommending social distancing without a reference to the typical six-foot measurement.
One of Ms. Campbell’s responsibilities was helping secure approval for the agency’s Morbidity and Mortality Weekly Reports, a widely followed and otherwise apolitical guide on infectious disease renowned in the medical community. Over the summer, political appointees at the health department repeatedly asked C.D.C. officials to revise, delay and even scuttle drafts they thought could be viewed, by implication, as criticism of President Trump.
On Politics with Lisa Lerer: A guiding hand through the political news cycle, telling you what you really need to know.
“It wasn’t until something was in the M.M.W.R. that was in contradiction to what message the White House and H.H.S. were trying to put forward that they became scrutinized,” Ms. Campbell said.
Dr. Tom Frieden, the C.D.C. director under President Barack Obama, said it was typical and “legitimate” to have interagency process for review.
“What’s not legitimate is to overrule science,” he said.
Often, Mr. McGowan and Ms. Campbell mediated between Dr. Redfield and agency scientists when the White House’s requests and dictates would arrive: edits from Mr. Vought and Kellyanne Conway, the former White House adviser, on choirs and communion in faith communities, or suggestions from Ivanka Trump, the president’s daughter and aide, on schools.
“Every time that the science clashed with the messaging, messaging won,” Mr. McGowan said.
Episodes of meddling sometimes turned absurd, they said. In the spring, the C.D.C. published an app that allowed Americans to screen themselves for symptoms of Covid-19. But the Trump administration decided to develop a similar tool with Apple. White House officials then demanded that the C.D.C. wipe its app off its website, Mr. McGowan said.
Ms. Campbell said that at the pandemic’s outset, she was confident the agency had the best scientists in the world at its disposal, “just like we had in the past.”
“What was so different, though, was the political involvement, not only from H.H.S. but then the White House, ultimately, that in so many ways hampered what our scientists were able to do,” she said.
Top C.D.C. officials devised workarounds. Instead of posting new guidance for schools and election officials in the spring, they published “updates” to previous guidance that skipped formal review from Washington. That prompted officials in Washington to insist on reviewing updates.
Brian Morgenstern, a White House spokesman, said that “all proposed guidelines and regulations with potentially sweeping effects on our economy, society and constitutional freedoms receive appropriate consultation from all stakeholders, including task force doctors, other experts and administration leaders.”
A C.D.C. spokesman declined to comment.
Mr. McGowan and Ms. Campbell both attended the University of Georgia and saw their C.D.C. positions as homecomings. Mr. McGowan said the two institutions he revered most during his Georgia childhood were the C.D.C. and Coca-Cola.
He arrived with a résumé that made the agency’s senior ranks suspicious, he said. Like Ms. Campbell, he worked for former Representative Tom Price, first in his House office, then when he was health secretary under Mr. Trump. When he arrived at the C.D.C., Mr. McGowan told his new colleagues that he was there not to spy on or undermine them, but to support them.
Mr. McGowan and Ms. Campbell, who have since opened a health policy consulting firm, said they saw themselves as keepers of the agency’s senior scientists, whose morale had been sapped. Dr. Redfield, whose leadership has been criticized roundly by public health experts and privately by his own scientists, was rarely in Atlanta, consumed by Washington responsibilities.
That often left Mr. McGowan and Ms. Campbell as the agency’s most senior political appointees in Atlanta — two of only four at an 11,000-person agency.
Mr. McGowan, who talked to Dr. Redfield throughout the day by phone, worked in the office next to Dr. Anne Schuchat, a 32-year career staff member who is the agency’s principal deputy director and one of the country’s most respected scientists, and became a sounding board for her.
Earlier this year, Dr. Schuchat was targeted by political appointees at the health department, who began interrogating C.D.C. officials about her public comments acknowledging the seriousness of the pandemic. Dr. Schuchat asked Mr. McGowan whether she would be fired.
“I don’t know,” Mr. McGowan recalled telling her. “Not yet.”
Mr. McGowan said he was especially unnerved last winter when officials in Washington told the C.D.C. that regular telephone briefings with another senior scientist, Dr. Nancy Messonnier, were no longer needed because Mr. Trump had his own daily briefings. Dr. Messonnier angered the White House in late February when she issued a public warning that the virus was about to change Americans’ lives.
“There’s not a single thing that she said that didn’t come true,” Mr. McGowan said. “Is it more important to have her telling the world and the American public what to be prepared for, or is it just to say, ‘All is well?’”
“It’s demoralizing to spend your entire career preparing for this moment, preparing for a pandemic like this. And then not be able to fully do your job,” Mr. McGowan said. “They need to be allowed to lead.”
Agency scientists have privately fretted about the pandemic permanently damaging the C.D.C.’s authority, with the public as well as state and international health partners. The C.D.C. was wounded by its initial struggles to develop reliable tests for the coronavirus. Scientists have discussed resigning, including some in the senior ranks who told Mr. McGowan that even though they flirted with leaving, they would have a hard time walking away from the agency at its lowest point.
Dr. Frieden said the agency had done “a lot of good work that they haven’t been able to tell anyone about,” including investigating outbreaks in prisons and meatpacking facilities. But he said its leaders had to speak out more.
“C.D.C. has a big podium,” he said. “You have to tell people what you know, when you know it. Otherwise you get a lack of alignment. It’s not just the public. When you do those briefings, the public health departments and the doctors also learn.”
This fall, senior C.D.C. officials turned bolder. They resumed regular news media briefings by agency scientists. Without seeking permission from Washington, they revised guidance documents on schools and asymptomatic testing, health officials said.
Fears of mixing politics and science linger, like when Vice President Mike Pence visited the agency this month with Georgia’s Republican senators, who are in critical runoff campaigns. Dr. Jay Butler, a top agency official, told a colleague that he worried that if Mr. Pence discussed the campaign, C.D.C. employees at the event might violate the law prohibiting federal workers from engaging in political activities on the job, according to someone with knowledge of his concern. A White House lawyer wrote Dr. Butler to say that the event was unrelated to a campaign stop later in the day, and would not be political.
Among the obvious targets for reform is the agency’s budget, which has been micromanaged, especially by Mark Meadows, the White House chief of staff, who has argued against C.D.C. funds in coronavirus stimulus negotiations.
Dr. Barry R. Bloom, an infectious disease expert and public health professor at Harvard, said the C.D.C.’s money problems could help explain its predicament. Unlike some federal health agencies, such at the National Institutes of Health, the C.D.C. typically receives what public health experts see as paltry funding — a reflection of its often low-profile work.
“They track down everything from pollution to outbreaks in prisons,” Dr. Bloom said. “That’s the daily work of C.D.C. If it’s well done and tracked down, it will not appear in the pages of your newspaper.”
The funding the C.D.C. did receive this year was cannibalized. Dr. Redfield told lawmakers that $300 million was steered from the C.D.C.’s budget to a vaccine public relations campaign that recently collapsed under scrutiny from reporters and lawmakers.
The redirecting of the funding was just one more blow to an agency brought low by a pandemic it was alerted to only a year ago. Mr. McGowan has held on to the email thread from Dec. 31, 2019, about a “cluster of pneumonia cases in Wuhan, China,” a haunting artifact.
“Damage has been done to the C.D.C. that will take years to undo,” he said. “And that’s terrible to hear, because it happened under my time there.”
https://www.nytimes.com/2020/12/16/us/politics/cdc-trump.html?
Biden team looks at expanding access to ACA insurance marketplaces
by Amy Goldstein - Washington Post - December 15, 2020
President-elect Joe Biden’s transition team is contemplating a pair of steps for his early days in office that would quickly establish that the Trump era’s disdain for the Affordable Care Act has come to an end at the White House.
Insurance marketplaces, created under the law for people to buy ACA health plans if they cannot obtain affordable coverage through a job, could be reopened as part of a list of ideas being considered by a small crew of health-policy advisers on the transition team.
To attract people to those marketplaces, the advisers are interested in restoring millions of dollars that federal health officials cut during President Trump’s first two years in office for advertising and other outreach strategies to motivate consumers to sign up.
Firm decisions have not been made, according to three people familiar with this thinking, who spoke on the condition of anonymity about matters that are not public. A transition spokesman declined to discuss the possibilities.
But the idea of opening ACA insurance marketplaces outside their usual sign-up cycle has been a bedrock approach Biden has espoused since shortly after the coronavirus arrived. He has maintained that making it easier for people to turn to ACA health plans would help buffer Americans who have lost work because of the pandemic’s economic ripple effects and forfeited job-based health coverage as a result.
Since Trump has been in office, the sign-up time for ACA health plans has been restricted to a six-week window late every year instead of the previous three months; the deadline for the most recent open enrollment is this week. When Trump resisted entreaties to reopen sign-ups in late March, Biden tweeted his displeasure: “I can’t believe this needs to be said, but President Trump needs to reopen Obamacare enrollment, and he needs to do it now. Lives are at stake.”
More broadly, the two steps being considered would serve as tangible evidence of the incoming president’s determination to use the decade-old legislation as a basis for improving the nation’s health-care system.
“Biden’s health reform agenda is grounded in reinvigorating the Affordable Care Act, which has been probably the most politically divisive issue in the last decade,” said Larry Levitt, executive vice president of the Kaiser Family Foundation, a health policy group.
During the Democratic presidential primaries, many of Biden’s opponents favored the more left-leaning idea of switching to a version of single-payer health care called Medicare-for-all. One of them, Sen. Bernie Sanders (I-Vt.), has championed such proposals for much of his political career.
Biden stood out for his opposition to Medicare-for-all, insisting that the government could expand Americans’ access to health insurance and affordable care by embellishing upon the ACA, the statute that passed a Democratic Congress in the second of his eight years as vice president under President Barack Obama.
In his main campaign health plan, Biden said the government should create a new public insurance alternative alongside the private health plans sold in ACA marketplaces. He also wants to lower the age at which people typically become eligible for Medicare, the vast federal insurance program for older Americans, from 65 to 60.
And in a dozen states that have not expanded Medicaid as the ACA allows, Biden wants to offer people who could otherwise be folded into that safety-net program a chance to receive insurance through the new public alternative without paying monthly premiums.
The catch for Biden is that all three of these changes to the ACA would require Congress to agree. How likely it is that he would be successful is unclear, depending in large part on two Senate runoff elections in Georgia next month that will decide whether that chamber will join the House in being controlled by the incoming president’s fellow Democrats.
Which party controls the Senate also will determine Biden’s odds of being able to blunt a possible adverse decision in a case before the Supreme Court in which a group of Republican attorneys general, accompanied by the Trump administration, is trying to get the law overturned. The case will continue after Biden takes office.
A central legal question in the case is whether all or part of the ACA is now invalid after a Republican Congress in late 2017 lowered to zero a tax penalty the ACA created for people who violated the law’s requirement that most people carry health coverage. With a cooperative Congress, Biden could shield the legal risk by reinstating a penalty — or by clarifying the law’s language to say explicitly that the rest of the ACA can remain without it.
Unlike the court case and the president-elect’s goals for expanding coverage, the two steps being considered by the transition’s health policy team could be accomplished through executive powers.
ACA health plans represent a small portion of private insurance in the United States, with nearly 11 million people having chosen a marketplace plan for 2020. That enrollment has stayed relatively stable over the past few years, despite the Trump administration’s efforts to weaken the law.
Three dozen states rely on the federal online marketplace, HealthCare.gov. In those states, a consumer can ask for the government to allow them a “special enrollment period” if they undergo a life-changing event, such as marriage, the birth of a child or a move to a different area. Losing a job qualifies, but many people are unaware of that, prompting Biden and other Democrats to say it would be better during the coronavirus pandemic to open the enrollment doors to everyone without requiring individual permission.
Many of the other states, which run their own ACA marketplaces, already have opened the doors.
Maine group launches campaign to put universal health care on the ballot
With many Mainers going without health insurance and an unemployment crisis throwing even more off their plans during a pandemic, a health care advocacy group is launching an effort to gather signatures for a 2022 ballot initiative directing the legislature to establish a universal, publicly-funded health care system that will cover everyone in the state.
The initiative is being put forward by Maine Health Care Action, a campaign launched by the organization Maine AllCare. A summary of the ballot measure says it would direct state lawmakers to “develop legislation to establish a system of universal health care coverage in the State,” calling for “the joint standing committee to report out a bill to the Legislature to implement, by 2024, its proposal.”
Abbie Ryder, campaign manager for Maine Health Care Action, said the group will begin gathering signatures in January for the ballot initiative. A little over 63,000 signatures are needed to put the issue before the voters. But Ryder said the goal is to gather 80,000 given that some signatures will likely be deemed invalid.
She said once the group starts collecting signatures, they have 12 months to gather the necessary amount. If they do, the initiative will be placed on the November 2022 ballot.
Ryder said having a universal health care system in Maine is important because it doesn’t appear that the federal government will pass such a system anytime soon. With a divided Congress and a president-elect who has stopped short of advocating for universal health care, Ryder said now is the time to take action in Maine.
“People are dying and they’re suffering. Sixty percent of all bankruptcies are due to medical bills,” Ryder said, adding that the continued coronavirus pandemic has laid bare the need for a universal health care system.
Ryder said it is not unprecedented for localities to move ahead of countries when it comes to universal health care. She pointed to former Saskatchewan Premier Tommy Douglas, who passed universal health care in the province years before a nationwide system was implemented in Canada.
Maine Health Care Action also decided to act now because bills put forward by progressive lawmakers to create a universal health care system have stalled in the legislature in recent years, Ryder said.
“Every two years, we’re gonna lose health care advocates in the legislature … it’s starting over from scratch each time,” she said. “And it just didn’t seem like anything was going to come of it going that route.”
If the initiative passes, Ryder said the group expects the legislature to honor the will of the people and work in good faith to set up and implement a universal health care system.
“[The ballot measure] is really about making them know that this many Mainers really want to see this happen,” she said. “And then we’ll be applying pressure and will be going to the public hearings and will be in contact with them as much as possible.”
Gathering signatures in a pandemic
Ryder said Maine Health Care Action’s first job is to collect the signatures needed to get the measure on the ballot. She said while the pandemic will make that process trickier, the group’s plan is to open up an office soon where people can safely come in and add their signature as well as pick up petitions.
Ryder said Maine Health Care Action will also be doing pop-up signature-gathering efforts in various places around the state. She added that next year’s primary and November elections will present additional opportunities to get signatures.
Maine activists rally for universal health care in Lewiston in 2017.
To help with the effort, Ryder said the group has already raised more than $70,000 and hopes to raise around $200,000 in total. If they are successful in collecting the signatures needed, she said Maine Health Care Action hopes to raise around $400,000 to campaign in favor of the ballot measure.
Ryder said the group will focus on raising money in-state, noting that influxes of out-of-state funds usually don’t sit well with Mainers. She added that the organization will follow the fundraising model of amassing a multitude of small donations used by Vermont Sen. Bernie Sanders — an ardent supporter of universal health care — in his presidential campaigns.
Ryder said for the month of December, an in-state donor will match every dollar donated to the group, up to $50,000. She said the money the group raises will go toward launching a large digital and email campaign to get the word out about the signature-gathering effort.
Ryder acknowledged that the initiative will likely draw significant opposition from the health insurance industry, particularly if the group gathers the necessary signatures.
However, she said since Maine Health Care Action is not pushing a specific bill, but rather a resolve directing the legislature to craft a measure, it will be more difficult for the industry to launch a campaign attacking more than the general concept of universal health care.
In 2001, a similar, non-binding referendum supporting the idea of state-level universal health care was placed on the ballot in Portland, Maine’s largest city. It attracted hundreds of thousands of dollars in opposition spending from insurance companies and passed with 52 percent of the vote.
How would universal health care work in Maine?
Ryder also pointed to a 2019 study done by the Maine Center for Economic Policy (MECEP) that examined how a hypothetical universal health care system would work in the state as a document that will be helpful in countering claims by opponents.
James Myall, an economic policy analyst at MECEP — which has not endorsed any specific single-payer health care proposal — and the author of that report, said universal health care is a feasible undertaking at the state level.
“I don’t think it’s the case that it’s impossible for states to do this, at least from an economic standpoint,” he said. “It’s just whether that’s where people want to spend their financial resources and their political capital.”
The MECEP report found that about 652,000 people, including 74,000 people who are uninsured, would receive health coverage under the hypothetical state universal health care system the group devised.
Myall said while such a program would require raising taxes, most people would likely save money overall because they would receive virtually free care and wouldn’t be paying premiums to insurance companies.
He added that such a program would have the additional benefit of unburdening businesses of the cost of providing health insurance to their employees and would also prevent large numbers of people from losing health insurance when there is an economic crisis by decoupling health care from employment.
“I think the COVID situation has really demonstrated to a lot of folks, some of them painfully firsthand, the deficiencies of tying health care to employment,” Myall said.
Recent polling shows that many Mainers are also questioning the wisdom of privatized health insurance.
In an exit poll conducted during the presidential primary in March, 69 percent of voters in Mainers said they support a government plan that covers everyone over a private insurance system.
A less-scientific 2019 survey conducted by volunteers for Maine AllCare that featured respondents from all 16 counties found that 81 percent of those surveyed said they would support “a publicly funded healthcare system that covered everyone in Maine” if the federal government doesn’t pass a universal health care system.
Ryder added that five municipalities — Bangor, Blue Hill, Penobscot, Brunswick and Orono — have passed resolutions in 2020 encouraging the legislature to implement universal health care in Maine.
Those who want to get involved in Maine Health Care Action’s campaign can do so at their website.
https://mainebeacon.com/maine-group-launches-campaign-to-put-universal-health-care-on-the-ballot/
Projected costs of single-payer healthcare financing in the United States: A systematic review of economic analysesPLOS Medicine - January 15, 2020Abstract
Background
The United States is the only high-income nation without universal, government-funded or -mandated health insurance employing a unified payment system. The US multi-payer system leaves residents uninsured or underinsured, despite overall healthcare costs far above other nations. Single-payer (often referred to as Medicare for All), a proposed policy solution since 1990, is receiving renewed press attention and popular support. Our review seeks to assess the projected cost impact of a single-payer approach.
Methods and findings
We conducted our literature search between June 1 and December 31, 2018, without start date restriction for included studies. We surveyed an expert panel and searched PubMed, Google, Google Scholar, and preexisting lists for formal economic studies of the projected costs of single-payer plans for the US or for individual states. Reviewer pairs extracted data on methods and findings using a template. We quantified changes in total costs standardized to percentage of contemporaneous healthcare spending. Additionally, we quantified cost changes by subtype, such as costs due to increased healthcare utilization and savings due to simplified payment administration, lower drug costs, and other factors. We further examined how modeling assumptions affected results. Our search yielded economic analyses of the cost of 22 single-payer plans over the past 30 years. Exclusions were due to inadequate technical data or assuming a substantial ongoing role for private insurers. We found that 19 (86%) of the analyses predicted net savings (median net result was a savings of 3.46% of total costs) in the first year of program operation and 20 (91%) predicted savings over several years; anticipated growth rates would result in long-term net savings for all plans. The largest source of savings was simplified payment administration (median 8.8%), and the best predictors of net savings were the magnitude of utilization increase, and savings on administration and drug costs (R2 of 0.035, 0.43, and 0.62, respectively). Only drug cost savings remained significant in multivariate analysis. Included studies were heterogeneous in methods, which precluded us from conducting a formal meta-analysis.
Conclusions
In this systematic review, we found a high degree of analytic consensus for the fiscal feasibility of a single-payer approach in the US. Actual costs will depend on plan features and implementation. Future research should refine estimates of the effects of coverage expansion on utilization, evaluate provider administrative costs in varied existing single-payer systems, analyze implementation options, and evaluate US-based single-payer programs, as available.
Author summary
Why was this study done?
- As the US healthcare debate continues, there is growing interest in “single-payer” also known as “Medicare for All.” Single-payer uses a simplified public funding approach to provide everyone with high-quality health insurance.
- Public support for provision of universal health coverage through a plan like Medicare for All is as high as 70%, but falls when costs are emphasized.
- Economic models help assess the financial viability of single-payer. Yet, models vary widely in their assumptions and methods, and can be hard to compare.
What did the researchers do and find?
- We found and compared cost analyses of 22 single-payer plans for the US or individual states.
- Nineteen (86%) of the analyses estimated that health expenditures would fall in the first year, and all suggested the potential for long-term cost savings.
- The largest savings were predicted to come from simplified billing and lower drug costs.
- Studies funded by organizations across the political spectrum estimated savings for single-payer.
What do these findings mean?
- There is near-consensus in these analyses that single-payer would reduce health expenditures while providing high-quality insurance to all US residents.
- To achieve net savings, single-payer plans rely on simplified billing and negotiated drug price reductions, as well as global budgets to control spending growth over time.
- Replacing private insurers with a public system is expected to achieve lower net healthcare costs.
What to Do About Doctors Who Push Misinformation?
They have crossed the line from free speech to medical practice — or in this case, something akin to malpractice.
by Richard Friedman - NYT - December 11, 2020
It’s bad enough when our political leaders promote quack theories about coronavirus and its treatment; but what do we do about the doctors who enable them and use their medical authority to promote pseudoscience?
Take Scott Atlas, a former Stanford University radiologist with no training or expertise in public health or infectious disease. As President Trump’s special adviser on coronavirus, he cast doubt on the efficacy of face masks, long after science had confirmed their efficacy. He was a staunch proponent of herd immunity — a recommendation that would almost certainly have resulted in vast mortality.
And on Dec. 8, Ron Johnson, the Republican senator of Wisconsin, known for his allegiance to fringe theories, called two doctors with such beliefs to testify before his committee.
One was Ramin Oskoui, a cardiologist in Washington who said that “masks do not work” and that “social distancing doesn’t work.” In fact, there is indisputable scientific evidence that all three are effective in preventing or limiting the spread of coronavirus.
The other was Jane M. Orient, a doctor who has cast doubt on vaccines and, like President Trump, promotes hydroxychloroquine, an antimalarial drug, to treat coronavirus. But hydroxychloroquine is considered either ineffective or possibly even harmful in this setting.
When doctors use the language and authority of their profession to promote false medical information, they are not simply expressing their own misguided opinions. Rather, they have crossed the line from free speech to medical practice — or, in this case, something akin to malpractice.
These doctors might argue that they are not actually “practicing” medicine, that they are only providing an alternative opinion — one that is unconventional. But there is no getting around the fact that their expert views, made from the powerful perch of a Senate hearing or White House briefing, will be reasonably taken by the public as medical advice. And if that is not a form of medical practice, what is?
As doctors, we are sworn by the Hippocratic oath to do no harm. And there are potentially lethal consequences in telling the public that hydroxychloroquine is a remedy or that face masks don’t prevent the spread of infection.
But where is the outcry from medical leaders and various professional organizations in the face of this betrayal of public trust? Where was Stanford University, for example, when its faculty member Scott Atlas was telling Americans that they could forget face masks?
Typically, rogue physicians come to the attention of their state’s medical board only because a patient makes a formal complaint to the board. But many state medical boards have the authority under law to initiate an investigation of a dangerous doctor on their own, according to Dr. Humayan Chaudhry, president of the Federation of State Medical Boards.
Shouldn’t all state medical boards have such authority — especially when the “patient” in question is the nation? Arguably, the harm done by a doctor who knowingly pushes misleading medical information can be vastly more dangerous than whatever he or she does in a single patient encounter.
To date, there are no reports that a doctor has lost his medical license for spreading disinformation, according to Dr. Chaudhry. But some states are beginning to act. For example, the Oregon medical board recently suspended the license of a doctor who boasted on video about not wearing a mask at his clinic.
Doctors who provide outrageous advice that is far outside the bounds of accepted standards should be investigated by their state board and subject to sanctions, including revocation of their medical license.
The question, of course, is what constitutes “accepted medical standards.” Since medicine is not an exact science, reasonable minds can and should differ about the optimal treatment for a given medical disorder. There are many different ways, for example, to safely and effectively treat depression or high blood pressure.
But there are limits to what’s allowed, and no doctor should get away with pushing bad advice, especially during a pandemic. Even if a regulatory board doesn’t take action, one’s peers certainly can. Earlier this week, for example, nearly 1,500 lawyers urged the American Bar Association to investigate the conduct of President Trump’s legal team, including Rudy Giuliani, for making indefensible claims of widespread voting fraud and actively seeking to undermine public faith in the election’s integrity.
Doctors should realize that their advice is, in effect, a form of medicine. If they step outside accepted standards of practice, based on empirical evidence, it’s time for the state boards to take disciplinary action and protect the public from these dangerous doctors.
https://www.nytimes.com/2020/12/11/opinion/scott-atlas-doctors-misinformation.html?
It’s Not Just You: Picking a Health Insurance Plan Is Really Hard
Most Americans make poor choices. So do most professional insurance brokers, a new study finds. But robots may help.
by Margot Sanger-Katz - NYT - December 11, 2020
Anya Samek, an economist, has found that consumers make better choices among health plans when presented with a few simple calculations. So when she switched jobs last year and had to choose a plan herself, she tried entering the various plan features into a spreadsheet to replicate her tool. She gave up, determining the task too complicated.
“I picked a plan because in my research I tend to show that high-deductible plans do better for people,” said Ms. Samek, an associate professor at the University of California, San Diego. “But it’s just a guess.”
When Paul Krugman, the Nobel-winning economist and a New York Times columnist, started a teaching job at the City University of New York, he had a choice between one union health plan at The Times and an array of university options, “which I found incomprehensible,” he said in an email.
“I asked H.R. at CUNY if they could explain the differences; they said no. So I went with The Times, precisely because it didn’t require that I make a choice!”
For most Americans, with or without a Ph.D in economics, right now is the time to pick your health insurance. Medicare beneficiaries can choose a Medicare Advantage plan or a Part D prescription drug plan. People with coverage at work can choose from the options their employers offer. People who buy their own insurance can make a choice on the Obamacare marketplace in their state. In Seminole County, Fla., right now, Obamacare customers can choose among 174 different health plans.
The range of choice is generally heralded as a good thing: Not everyone wants the same plan, the thinking goes, so offering multiple options helps people shop for the one that is best for them. That logic drove the creation of Medicare Advantage, with legislation passed by Republicans, and drove the design of Obamacare, with legislation passed by Democrats.
But it turns out in real life most people are terrible at picking the health plan that is right for them. Health insurance is a complicated financial product, and study after study has shown that people routinely pick bad plans, even choosing options that leave them worse off financially in every possible scenario. And, because people are so bad at choosing good plans, the market often sends weird signals to insurance companies, encouraging them to offer more of the wrong plans instead of the right ones.
People struggle to make good choices when it comes to all kinds of financial products, but health insurance is especially confusing, with its mix of technical benefits and fees. Many Americans don’t understand terms like “deductible” or “coinsurance” very well. And few are good at predicting what sort of health care needs they will have in the coming year. Picking an ideal health plan requires combining all of these features — knowing what you might use, what it might cost you, and how those expenses combine with the plan’s monthly premium.
Online brokerages have found that recommending certain plans has a huge effect on what people pick, a sign that few people are doing this complex math themselves. Noah Lang, the C.E.O. of Stride Health, which helps people shop for health plans including Obamacare plans, said so many people would pick the first plan presented to them that the company changed its website to offer a handful of recommended “green” plans. Last year, more than 70 percent of customers bought one of those plans.
“People want advice, they want guidance,” Mr. Lang said. “And it’s pretty hard.”
The people most likely to make bad choices appear to be those least able to afford it. A recent study in the Netherlands, which offers insurance to everyone through an Obamacare-like marketplace, found that only 5 percent of Dutch customers did a better job at choosing an ideal plan than they would have by choosing a plan at random. And the people in that top 5 percent tended to be have college degrees and jobs in technical fields. People with less education and income, who tend to be in worse health, were very likely to choose a plan that cost them more to cover their health care — a situation that might leave them skimping on needed medicine or procedures.
But even highly educated Dutch professionals struggled. People who worked in the insurance industry and had advanced degrees made a good choice about 30 percent of the time. And only about 40 percent of trained statisticians — the group with the best performance — chose good plans for their needs.
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In the United States, a working paper has found that many professionals who help people select health insurance are also bad at picking plans, performing substantially worse than a computer algorithm.
“These people who are supposed to make the market work can’t do it at all,” said Jonathan Kolstad, an associate professor of economics at the University of California, Berkeley, who was a co-author on both studies. Professor Kolstad said the work had made him reconsider why we value markets for health insurance so highly when they are so hard to use.
Picking a plan is hard, but some simple guidelines can help a little. It’s helpful to know whether a given plan covers the doctors and hospitals you use, for example. And if you’re willing to take more financial risk, you may prefer a higher-deductible plan with lower premiums, while if you value more predictable expenses, a lower-deductible plan may work better. But people’s actual health care needs and insurance fine print vary enough that those guides can lead you astray. The literature shows that it’s not uncommon for people to choose a plan that costs them $1,000 more than the best plan, over the course of the year.
Most of the research on plan choice looks at the financial design of the plan. Researchers can look at the options, then see which health services people end up using, and can tally total costs for various choices. That approach leaves out some other elements of health plans, like the choice of doctors, or whether the company offers good customer service. The study on brokers found that people whose plan selection was aided by the computer program were less likely to switch plans the next year than those who took the unassisted advice of the broker, a sign that they were happier with the overall package.
But what is the alternative to choice? Amanda Starc, an associate professor of management at Northwestern University, said there was evidence that people really did want different things from health insurance. About a third of people 65 and older are currently enrolled in private Medicare Advantage plans, a share that is large enough to suggest that many would be less happy with only the choice of government Medicare.
“I don’t think the answer is obvious, and yet I think there is real value in choice,” said Professor Starc, whose recent work shows that some Medicare Advantage plans may leave patients better off than others in terms of health, not just finances. She, like Mr. Kolstad, thought tools like the broker algorithm could steer people into better options.
But she acknowledged the difficulty. Colleagues and family friends frequently ask her for advice about the best health plan. She tends to steer her higher-earning professor colleagues to a high-deductible plan that covers the university’s hospitals, figuring they can afford it. Finding the best choice for other people, she said, requires more work.
“Whenever anybody asks me about this, I say my dad is the only Medicare beneficiary who could figure this out, because he could call me,” she said.
Other economists use the same rules of thumb that cause many Americans to choose bad plans: They pick a plan based on simple features, select a preferred brand, or ask their friends.
Brigitte Madrian, the dean of the Marriott School of Business at Brigham Young University, has also studied health insurance, but said picking a plan for her family when she arrived in Utah was a heavy lift. She set aside an entire Saturday for the task, scouring websites and constructing spreadsheets. Ultimately, she asked her fellow health economists what they had chosen.
“If I’m having a hard time, what is the rest of the population doing?” she said she wondered. “They must be throwing darts.”
https://www.nytimes.com/2020/12/11/upshot/choosing-health-insurance-is-hard.html?
The Vaccines Are Supposed to Be Free. Surprise Bills Could Happen Anyway.
“It is the American health care system, so there are bound to be loopholes.”
by Sarah Kliff - NYT - December 17, 2020
When Americans receive a coronavirus vaccine, federal rules say they shouldn’t have to pay anything out of pocket.
Congress passed legislation this spring that bars insurers from applying any cost sharing, such as a co-payment or deductible. It layered on additional protections barring pharmacies, doctors and hospitals from billing patients.
To consumer advocates, the rules seem nearly ironclad — yet they still fear that surprise vaccine bills will find their way to patients, just as they did with coronavirus testing and treatment earlier this year.
“It is the American health care system, so there are bound to be loopholes we can’t anticipate right now,” said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University.
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Americans vaccinated this year and next generally will not pay for the vaccine itself, because the federal government has purchased hundreds of millions of doses on patients’ behalf. It has agreed to buy 100 million doses from Pfizer-BioNTech — and is in negotiations for more — and 200 million from Moderna, enough to inoculate 150 million Americans (the vaccines require two shots). It also has orders in to purchase more vaccines still undergoing trials.
The Affordable Care Act provides additional protections, because it requires most health insurers to fully cover all federally recommended preventive care. The CARES Act, passed this spring, supercharged these Obamacare rules.
Usually, insurers have about two years to start covering a newly approved preventive service. The CARES Act required coverage 15 days after a recommendation from the federal Advisory Committee on Immunization Practices.
Some insurers, including Aetna and certain Blue Cross Blue Shield plans, have already announced that they will not bill patients for the vaccine or its administration.
“Health insurance providers pay for the administrative fees associated with administering the Covid-19 vaccine,” said David Allen, a spokesman for America’s Health Insurance Plans. “The administration fee covers clinicians providing the vaccine to patients, public health reporting, and addressing patient questions.”
The federal government has used other levers to curtail surprise vaccine bills. When it offered enhanced Medicaid payment rates this spring, it required states to fully cover coronavirus vaccines for all their enrollees as a condition of receipt. All 50 states accepted the extra funding, and are now subject to those requirements.
Elsewhere, the Centers for Disease Control and Prevention requires vaccine providers to sign a contract agreeing not to bill patients for the vaccine and the cost of administering it. Out-of-network doctors who do not have a contract with a patient’s private insurance will be required to accept the Medicare rate for administering the vaccine — $16.94 for the first dose and $28.39 for the second, according to rules published in October. For uninsured patients, health providers will need to send those charges to a provider relief fund for reimbursement.
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That’s different from the rules around coronavirus treatment, which regulated insurers’ cost sharing but did not take steps to curtail billing by doctors and hospitals. That meant some patients received bills they didn’t expect.
“What makes the vaccine protections unique is that there are requirements on both the insurers and the providers,” said Karyn Schwartz, a senior fellow at the Kaiser Family Foundation. “It’s a belt-and-suspenders approach that makes the consumer protections much stronger.”
Even with these protections, experts do see some weak spots. One has to do with the type of health coverage Americans carry. Millions are still covered by “grandfathered” health insurance plans, which existed before the Affordable Care Act and are exempt from its rules. So those plans are not required to fully cover the coronavirus vaccine, or any other preventive service.
Experts also worry about uninsured Americans. The United States does not have a national program to cover vaccination costs for them. For coronavirus, it is instructing health providers to submit costs associated with vaccination to a $175 billion Provider Relief Fund created last spring.
The fund had $30 billion remaining as of Nov. 10. There’s no backup source of funding for the uninsured to get covered if it’s depleted.
“The question marks for me are the uninsured, and the folks that are in the unregulated plans,” Ms. Corlette said.
Additional fees could accompany a vaccine. Some providers are accustomed to charging a visit fee for all in-person patients. Most emergency rooms charge “facility fees,” the price of coming in the door and seeking care, as do some hospital-based doctors. Some patients receiving coronavirus tests at emergency rooms faced facility fees higher than $1,000, according to billing documents submitted to The New York Times. These fees typically do not exist at retail pharmacies, where many Americans may get vaccinations.
Federal law is quite clear that patients should not have to pay for the vaccine and its administration. But there isn’t language that defines what counts as “vaccine administration,” and whether the visit fee makes the cut.
“The question that I’m still not clear on is what happens if someone walks into an outpatient department that charges a facility fee and gets a vaccine,” said Kao-Ping Chua, an assistant professor of pediatrics at the University of Michigan who has studied coronavirus medical billing. “Is there a possibility they could get charged? I think the answer is yes.”
If patients have adverse reactions to the vaccine and require medical care — as one health care worker in Alaska did earlier this week — they will not have special protections against those charges. If a visit for a vaccine delves into other medical issues — if a patient, for example, also has blood drawn or discusses pre-existing conditions with a provider — that could also mean regular fees for care.
Then there is the prospect of Obamacare repeal. Last month the Supreme Court heard oral arguments in a case aiming to end the Affordable Care Act. If the challenge is successful, it will invalidate the Obamacare mandate to cover preventive services like the coronavirus vaccine.
Insurers may still choose to cover the vaccine — and find it cost-effective to do so, if it prevents hospitalizations — but they could charge a co-payment, just as they do for doctor’s visits and prescription drugs.
“All the vaccine coverage hinges on the Affordable Care Act,” Ms. Corlette said. “So if that goes away, that is another very big problem.”
https://www.nytimes.com/2020/12/17/upshot/vaccines-surprise-bills.html?
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