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Biden’s Hidden Health Care Triumph
by Paul Krugman - NYT - February 10, 2022
A Republican member of Congress said something epically stupid the other day.
No, I’m not talking about Marjorie Taylor Greene’s warning about Nancy Pelosi’s “gazpacho police.” If you ask me, Greene was performing a public service; we all need some good laughs, especially given the demise of the borscht belt.
I’m talking, instead, about Representative Thomas Massie of Kentucky, who tweeted out a novel argument against universal health care: “Over 70% of Americans who died with Covid, died on Medicare, and some people want #MedicareForAll?”
To belabor a point that should be obvious, Medicare recipients have been especially vulnerable to Covid because they generally suffer from a serious pre-existing condition: advanced age.
Maybe Massie should have looked instead at Canada, which has single-payer health insurance for everyone — it’s even called Canadian Medicare. Canada, as it happens, has had only about a third as many Covid deaths per capita as we have. More generally, Canadians can expect, on average, to live almost four and a half years longer than Americans, even though health care spending per person is only about half as high as in the U.S.
In any case, whatever its intellectual merits, as a practical political matter Medicare for All isn’t coming to America any time soon. What’s actually at stake in the political arena are more incremental policy changes. Yet such changes can still have a huge effect on health care. And the partisan divide on health policy is as wide as ever.
Massie’s statistical gaffe was a reminder that Republicans still hate government programs that help Americans pay for health care. I wonder how many voters remember how close the Trump administration came to repealing the Affordable Care Act, a move that the Congressional Budget Office estimated would cause 32 million Americans to lose health insurance. That effort failed only because three Republican senators had the courage to stand up to Donald Trump.
Does anyone imagine that we’ll see a similar display of courage if a party that considers a violent attack on the Capitol “legitimate political discourse” regains control of Congress and the White House?
More immediately, if the G.O.P. regains control of either house of Congress this November, we’ll almost surely see some reversal of the major health care gains that have been taking place under President Biden.
Oh, you haven’t heard about those gains? I’m not surprised. Health care is one of the huge but hidden successes of Biden’s first year.
The story so far: Obamacare, which was enacted in 2010 but didn’t go fully into effect until 2014, was and is a bit of a Rube Goldberg device. Instead of simply paying Americans’ medical bills, it expanded Medicaid while using regulations and subsidies to encourage an expansion of private insurance. It fell far short of universally guaranteed coverage, but it nonetheless led to a large decline in the percentage of nonelderly Americans without health coverage.
Trump, as I said, tried but failed to undo this achievement. He did, however, preside over a gradual erosion of health coverage, probably reflecting a lower-profile strategy of sabotage on multiple fronts.
Despite this erosion, the core of the Affordable Care Act remained intact; in 2020 the AC.A. really proved its worth, helping (with an assist from emergency federal programs) to sustain health coverage despite huge job losses.
And the Biden administration has moved to strengthen the program. It increased outreach to potential enrollees, which Trump’s officials had drastically scaled back, while the American Rescue Plan substantially expanded subsidies for Americans buying insurance on health care exchanges. According to the National Health Insurance Survey, the percentage of nonelderly Americans without health insurance fell significantly between the fourth quarter of 2020 and the third quarter of 2021, bringing it almost back to its pre-Trump low.
The months ahead look set to be better still. Enrollment in the A.C.A.’s exchanges is limited to a few months a year, to deter people from waiting until they get sick to buy insurance. The enrollment season for 2022 coverage is just winding down now, and we’re seeing blockbuster numbers: More Americans are signing up for coverage than ever before.
We still won’t have the kind of universal health care guarantee that every other advanced nation has managed to provide its citizens, but we are getting closer.
Unfortunately, this progress faces huge political risks. The rescue plan provided only two years of enhanced subsidies; unless Democrats either pass an extension quickly or hold both houses of Congress, the subsidies will soon be gone. And if Republicans get unified control in 2024, they’ll surely send us back to the era when health insurance was available only to people who had either jobs providing good benefits or impeccable medical histories that made them attractive to private insurers.
So I hope people will remember what we almost lost in 2017 and understand that even if Republicans aren’t currently talking about it very much, health care is still very much on the ballot.
https://www.nytimes.com/2022/02/10/opinion/biden-health-care-triumph.html?
Angry Customers, More Work and Longer Hours Strain Pharmacists
by Madeline Ngo - NYT - February 10, 2022
Pharmacists and technicians, who have played a critical role in administering Covid-19 tests and vaccines, say they are burned out nearly two years into the pandemic.
WASHINGTON — Ken O’Shea spent eight years working in retail pharmacies, first as a technician and then as a pharmacist. He liked working on the front lines and seeing his patients get better over time.
But during the pandemic, Mr. O’Shea said, he had less and less time to counsel patients. On top of his regular job, he had to juggle coronavirus vaccinations and testing, more phone calls and angrier customers who would berate him if prescriptions took longer to be filled. His workload worsened after three colleagues quit in the span of two months.
Mr. O’Shea, a 28-year-old pharmacist in Virginia Beach, quit working full time at Walgreens on Dec. 30 and recently began a job at an insurance company. He has been working one shift every two weeks at Walgreens while the pharmacy is still understaffed, he said.
Nearly two years into the pandemic, pharmacists and technicians across the nation are under intense strain as their jobs shift from filling prescriptions and counseling patients to administering Covid-19 vaccines and tests, handing out masks and dealing with increasingly angry customers.
The situation has been exacerbated by a labor shortage that has squeezed most industries and that has resulted in droves of nurses and caretakers leaving their posts in a pandemic that has pushed them to the brink.
Large retail pharmacy chains have tried to respond, with some reducing store hours, increasing starting wages, offering more breaks and giving out bonuses to retain employees. But customers have felt the impact, with some experiencing disruptions in vaccine appointments, longer lines to pick up prescriptions and frustration over securing masks and at-home virus tests.
The situation is worrying the pharmacy industry. Scott Knoer, the executive vice president and chief executive of the American Pharmacists Association, said inadequate staffing posed serious health risks by increasing the chances that workers make mistakes while filling prescriptions or inoculating patients. A survey released last month from the association found that 74 percent of respondents said they did not think they had sufficient time to safely perform patient care and clinical duties.
Mr. Knoer said pharmacies were struggling to deal with a lack of pharmacists and technicians, though shortages have been most dire for technicians, who serve as support staff and help dispense medication. Technicians receive a median hourly wage of $16.87 and have more options to pursue better-paying jobs in other industries. There were 166,337 pharmacy technician job postings through the fourth quarter of 2021, up about 21,100 from the year prior, according to a Pharmacy Workforce Center report.
Some of the biggest pharmacy chains have hired thousands to deal with the increased workloads, but company representatives say stores are still struggling to fill open positions.
Fraser Engerman, a spokesman for Walgreens, said the company had responded to labor shortages by reducing some store hours, lifting wages and adjusting vaccine appointment availability. Mr. Engerman said most stores were still operating normal hours.
In October, Walgreens increased its starting wage to $15 an hour for technicians, a rate that will increase by a dollar this year. The company has also awarded bonuses of $700 to $1,250 to pharmacists and new technicians.
Rite Aid recently temporarily closed most pharmacies an hour early on weekdays to allow its pharmacy staff to “catch up from the day and prep for the next,” said Terri Hickey, a Rite Aid spokeswoman. Most of its pharmacies are limiting walk-in hours for immunizations to just one hour a day.
“Even when stretched, we are working hard to stay open and support the health of our customers,” Ms. Hickey said in a statement.
While most CVS stores are operating normal hours, some have temporarily closed on one or both days of the weekend, said Michael DeAngelis, a CVS spokesman. To attract and retain workers, he said, the company is giving employees more scheduled breaks and will raise its minimum wage to $15 an hour this summer.
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In some cases, reduced hours at pharmacies have led to disruptions in vaccine appointments with no notice.
Mark Kulhavy, 48, a sales representative in Rock Island, Ill., said he took his 16-year-old son to their local Walgreens for his booster appointment on Jan. 6. But before entering, Mr. Kulhavy saw a sign on the door that said the store could not administer vaccinations that day because of staffing shortages. The technician behind the counter told Mr. Kulhavy to try another Walgreens nearby, where they waited half an hour for his son to receive a shot.
Mr. Kulhavy said he understood that the pharmacy staff was not at fault, but he wished he had been notified about the closure.
“Part of me was frustrated,” Mr. Kulhavy said. “I jumped through hoops to get him there on time when he got out of school only to walk up to the door and see that sign.”
Nicole Christian-Brathwaite, 40, a psychiatrist in Boston, said her husband tried to pick up his medication at their local Walgreens on Jan. 12, but the drive-through was closed because there were not enough workers. After entering the store, her husband saw at least a dozen people standing in line, and he later left over fears of catching the virus.
Ms. Christian-Brathwaite said many of her patients had also started to ask for 90-day prescriptions instead of 30-day ones to avoid dealing with pharmacy delays. She called it another symptom of the nation’s “crumbling” health care system.
Michael Hogue, a former president of the American Pharmacists Association and the dean of Loma Linda University’s School of Pharmacy, said some pharmacies were already operating with fewer workers before the pandemic because some chains were trying to reduce staff and close stores to lift profitability. Once the United States started rolling out vaccines, chain pharmacies went on hiring sprees.
But companies may find it harder now to attract and retain employees who are not willing to take on the extra workload. Jon C. Schommer, a professor at the University of Minnesota’s College of Pharmacy, said wages were already stagnating before the pandemic because more pharmacy schools opened in response to a shortage of workers in the 2000s. In 2020, the median annual salary for pharmacists was $128,710, according to the Bureau of Labor Statistics.
Although some chains are offering financial incentives, a recent survey from the American Pharmacists Association found that 47 percent of respondents said they were working more hours during the pandemic, while only 12 percent reported a salary increase.
Pharmacists and technicians said they were leaving retail pharmacies for jobs at hospitals or pharmaceutical companies, while some have simply decided not to work for now.
People on social media have aired their concerns under the hashtag “PizzaIsNotWorking.” Bled Tanoe, 35, an Oklahoma City pharmacist who left Walgreens in August to work at a hospital, started the campaign to underscore the strain that pharmacists and technicians were feeling. She now is pressing pharmacies to increase pay and provide more support to staff.
Emily Sis-Sosa, a 26-year-old in Kernersville, N.C., said she could no longer work as a technician at a large retail chain after her workload swelled and some customers grew angrier during the pandemic. If prescriptions were delayed, some would throw empty prescription bottles or insurance cards at her.
“I had never experienced rage like that from people that I knew for six years,” she said.
Ms. Sis-Sosa said the job was not worth the $16.95 she made an hour. She left in September to work for a drug distribution company.
Dallas Reynolds, 35, a pharmacist in Northern Virginia, said he had felt increasingly burned out over the course of the pandemic. Although he would work longer hours to catch up, he said, the pharmacy would often be two or three days behind on filling prescriptions. Since he quit in December, he said, he has felt less anxious and depressed, even though he was unsure what he would do for work next.
“I was happier taking a break from work than I was actually having a stable job and getting a paycheck,” Mr. Reynolds said. “That’s how bad it was.”
Smaller independent pharmacies have also experienced staffing challenges. Sixty-eight percent of independent community pharmacies reported having a difficult time filling staff positions, according to a recent survey from the National Community Pharmacists Association.
Sonia Martinez, a 55-year-old pharmacist who co-owns Marco Drugs and Compounding in Miami, said it took four months to fill an open technician position, a task that would have normally taken a few weeks. Ms. Martinez works about 15 extra hours every week, she said, leaving her with less time to spend with family.
“I don’t know when it’s going to end,” Ms. Martinez said. “It’s just frustrating.”
https://www.nytimes.com/2022/02/10/us/politics/pharmacists-strain-covid.html
Why California’s Cowardly Democrats Scurried Away From Single-Payer
The corporations flexed their muscle—and won—even in this very progressive state. That’s because it was never about better health care or taxes, but corporate power.
by Abdul El-Sayed - The New Republic - February 10, 2022
Two weeks ago, Assembly Bill 1400, a bill that would have cleared a pathway for single-payer, Medicare for All–style health care for the good people of California in the form of “CalCare,” suffered an ignominious death. Its lead sponsor, Assemblymember Ash Kalra of San Jose, elected not to even bring the bill to a vote. “It became clear that we did not have the votes necessary for passage, and I decided the best course of action is to not put A.B. 1400 for a vote today,” he said.
This is California we’re talking about—possibly the most progressive state in the nation, at least west of Vermont. Democrats hold a supermajority in the House. The California Democratic Party platform explicitly claims to support “single-payer” health care. It’s a state where 95 percent of the public believes that “making sure all Californians have access to health insurance coverage” is important. And yet Democrats couldn’t pass single-payer health care.
That’s because it wasn’t about health care or the taxes to pay for it at all. It was about the remarkable power corporations continue to wield over elected Democrats.
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In response to CalCare’s failure, the California Nurses Association, longtime supporters of single-payer health care, noted Kalra’s unwillingness to expose his colleagues—that he chose to “cover for those who would have been forced to go on the record about where they stand on guaranteed health care for all people in California.” And that’s exactly it. CalCare was murdered like Caesar: betrayed by its ostensible allies, all of whom participated so that none of them could be fully blamed.
Why the betrayal? Because the bill was a nonstarter for California’s most powerful business groups. The California Chamber of Commerce led a coalition of 122 business groups in opposition to the bill. Opposition was the most vehement from the groups representing Big Health Care, including the California Association of Health Plans, the California Hospital Association, the California Medical Association, and the California Agents and Health Insurance Professionals. And these are the groups from whom too many Democrats take donations … and political orders.
Assembly Speaker Anthony Rendon, who shelved a previous version of the bill in 2017, said after the failure of A.B. 1400: “I’m deeply disappointed that the author did not bring this bill up for a vote today. I support single-payer and fully intended to vote ‘yes’ on this bill.” You might think that the Assembly speaker would have put more muscle into whipping votes from something he “supports” and “intended to vote ‘yes’” on, rather than piling on a junior member of his caucus after the fact.
Indeed, over the course of his career, Rendon’s campaigns have taken gobs of money from the very same corporations and lobby groups opposing A.B. 1400. Let’s follow the money: Rendon has taken $50,700 from the California Medical Association; $33,300 and $32,000 from UnitedHealth Group and Blue Cross Blue Shield of California, respectively; and $25,900 from the California Association of Hospitals and Health Systems.
The betrayal goes further. Governor Gavin Newsom campaigned in 2018 on single-payer health care: “I’m tired of politicians saying they support single-payer but that it’s too soon, too expensive, or someone else’s problem.” But he failed to utter a single word in support of A.B. 1400. When he was asked about it, Newsom said, “I have not had the opportunity to review that plan, and no one has presented it to me.” You mean to tell me that you’re the governor of the country’s biggest state, and you don’t have time to review a bill that would massively transform health care in a direction you claim to support? In an interview with The Mercury News, Kalra noted that “it hurts when you’re trying to garner votes for a policy that the governor is brushing aside despite a prior commitment to it.”
Indeed, Newsom’s own Healthy California for All commission to study universal health care estimated that Californians would pay $522 billion on health care in 2022. The U.C. Berkeley labor center estimates that A.B. 1400 would have cost only $222 billion a year, saving Californians nearly 60 percent on health care. Even more conservative legislative estimates put the savings at 25 percent, with most of those savings accruing to low-income people in the state. That’s because A.B. 1400 is progressively funded, raising revenue through excise and payroll taxes on businesses and raising personal income taxes on salaries higher than $149,509 a year.
For Newsom’s part, his most recent campaign for governor took $130,400 from UnitedHealth Group, $120,300 from the California Medical Association, and $98,800 from Blue Cross Blue Shield of California.
As the story of the demise of single-payer health care in California is written, much ink will be spilled over fears of tax increases or a “one-size-fits-all” program run like the Department of Motor Vehicles. These are, after all, the talking points the opponents of single-payer have promulgated. Less attention will have been paid to the way that Democrats’ addiction to corporate funding weds them to do industry’s bidding—to betray their own party platform to oppose a policy that would guarantee them health care while saving them billions.
What Physicians Need to Know About Private Equity Deals
by Ericka Adler - Medscape Internal Medicine - February 9, 2022
The sale of medical practices to private equity (PE) and related investors continues to be the trend in 2022. The primary reason private practices are so interested in selling to PE is that they typically will offer a much higher purchase price compared with either hospitals or other physician buyers.
However, the sale to any buyer comes at a cost to the physician-sellers as well, and this is something with which many physicians continue to struggle.
A PE's standard investment strategy is to acquire a practice with an existing footprint and reputation, and then grow the practice through the acquisition of additional smaller practices or by hiring more physicians. Typically, the structure of the transaction is such that the nonclinical assets of the practice are sold to a business entity owned by the PE (or a related entity) and the clinical assets are transferred into a professional entity owned by a physician, which may or may not be the physician-sellers.
The reason for this structure is that many states have a "corporate practice of medicine" doctrine, which prevents unlicensed people from owning professional entities or employing licensed providers. The PE controls the ownership and conduct of the physician-owned professional entity through written agreements, instead of directly, in order to comply with the law.
Corporate practice of medicine laws were created with the intent to avoid commercialization of medicine and to make sure physicians could exercise their own professional opinions without outside influence. Many states also have developed specific guidance in this area. Generally, to comply with the legal doctrine, documents in any kind of PE transaction are carefully written to promise providers freedom over clinical decision-making and ensure that true clinical decisions are left to physicians.
To operate a medical practice, the PE's business entity acts as a management company by providing all the nonclinical assets it just acquired and everything else the practice needs to operate: space, equipment, nonprofessional personnel, billing and collection services, et cetera. A management fee is paid by the professional entity to the management company, thus drawing profits to the PE investors.
https://www.medscape.com/viewarticle/967950?
The first public option health plan in the U.S. struggles to gain traction
Twenty-one years and more than $75,000 ago, Linda and David Brookes had a plan: With retirement on the not-too-distant horizon, they’d start funneling money into their new long-term care insurance policies. In return, when age and infirmity finally caught up with them, they’d get the help they need without going broke or becoming a financial burden on their four children.
Then came the shakedown.
“This letter is to notify you that we have recently filed for a 112% premium rate increase in your long term care insurance policy,” read the letter David received from Genworth Life Insurance Co. this fall. Linda got the same notice – except Genworth said it wants to bump her premium by 146 percent.
Typos? They wish.
Some kind of practical joke? There’s nothing funny about it.
A company passing the buck – or in this case, the bill – for its own failure? Now we’re getting warmer.
“It’s unbelievable,” Linda Brookes said in an interview last week. “I just can’t believe it.”
Nor can the hundreds of other Mainers, all in their twilight years, who logged in Thursday for an online forum on one of the insurance industry’s most colossal screw-ups in modern times. Long-term care insurance, once ballyhooed as the key to peace of mind and financial security, is fast becoming the boondoggle of the century.
The Brookeses are, by any measure, a responsible, prudent couple.
Linda, 72, is a retired social worker. David, 81, worked for Motorola. They lived for 20 years in Scarborough before moving in 2015 to Florida, confident that when the time came for long-term care – not covered by Medicare and most supplementary health plans – their Genworth policies would foot the bill. No relying on their children for money, no draining their assets and hoping their fixed incomes might qualify them for Medicaid, no dependency whatsoever beyond the coverage Genworth promised them all those years ago.
They also thought, at least at first, that their monthly premiums would remain affordable – while Genworth had the right to make occasional adjustments, any rate increases would have to first be approved by the Maine Bureau of Insurance.
But increases of 112 percent and 146 percent? Or, in the case of other Maine policyholders, 178 percent? Let me go out on a limb here and suggest that’s beyond unfair.
“It is. I couldn’t agree more,” Eric Cioppa, the bureau’s superintendent, said in an interview following last week’s forum. “If I’m not here to help out consumers in this case to the extent I can, what am I here for?”
At the root of all this is an industry-wide product in free fall. As Cioppa noted at the outset of Thursday’s four-plus-hour marathon, the long-term care insurance market arose about 40 years ago and was, from the beginning, built on a host of severely flawed assumptions:
Insurers thought they could fund future claims over the long term by investing premium payments at an annual rate of return somewhere between 6 percent and 8 percent. In reality, the bonds in which all that cash was stashed have performed, as Cioppa noted, at “well under 4 percent.” Meaning Genworth, like other companies that made the same mistake, now finds itself in a hole that will only grow deeper as more claims pour in.
The insurance companies also factored in a “lapse rate” – the number of customers who over time fail to renew their policies – at between 4 and 5 percent, just like the longstanding rate for life insurance policies. Wrong again – fewer than 1 percent of long-term care policyholders have let their plans lapse.
Finally, the companies miscalculated their morbidity projections – or, to be more blunt, they thought their customers would die sooner. Alzheimer’s and other long-lasting diseases have turned that assumption on its head.
All of which brings us to the central question that had more than 400 Genworth customers – with almost 4,100 policies in Maine, it’s the state’s largest long-term care provider – glued to their computer screens Thursday: Who should have to pay for this screw-up, the customers who signed on in good faith or the company that made a colossally bad bet?
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Linda Brookes, who along with her husband has already sunk $75,057 into their Genworth policies since 1999 and would now see their premiums jump from $5,184 to $11,868 annually, was more than ready for her turn to speak. Her deeply researched presentation initially clocked in at over seven minutes, but she trimmed it to meet the forum’s initial five-minute ground rule. Then, after the list of people wanting to speak grew beyond 200, the speaking slots were cut to a mere two minutes, forcing Brookes to further condense her outrage.
“I find myself struggling to define the difference between elder financial exploitation and coercion and the premium-raising practices of Genworth and the (Maine Bureau of Insurance). It seems a very fine distinction indeed,” she said, referring not just to the latest proposed rate hike but to other increases and benefit cuts she and her husband already have endured in recent years.
Unlike many others who used their allotted time simply to vent, Brookes then quickly listed her recommendations for cleaning up this mess: Impose a moratorium on all premium increases until solutions can be found that take customers’ concerns into account. Recognize the “erosion of trust” in not just the insurance industry but also the state officials who are supposed to regulate it. Factor in the savings Genworth will realize from people who reduce their benefits to save their policies. Account for the money Genworth has saved due to policyholders dying sooner than projected from COVID-19. And finally, allow companies like Genworth to improve their cash reserves by investing in more than just the low-yield bond market.
All good ideas. Here’s another: Shift the burden of responsibility for this circus away from the policyholders and onto Genworth and the other companies who, from the outset, were far better at selling these plans than at estimating how much they’d cost. That reckoning might start at the top – as more than one speaker noted at last week’s forum, Genworth President and CEO Thomas McInerney’s annual compensation package is north of $9 million.
“This does not appear to be reflective of a company struggling to say solvent,” Brookes observed in her pre-edited comments.
It’s hard to say where all this is headed. Genworth wants its request for a rate hike wrapped up by August, although Superintendent Cioppa won’t go beyond saying it will be resolved sometime in 2022. Genworth in all likelihood won’t get all it wants – it’s up to Cioppa to determine whether the proposed new rates are “excessive and discriminatory” – but those sitting on policies still lie awake worrying how much they’re going to get soaked this time.
As Brookes put it after giving her two minutes’ worth at the forum, “The most we can do is to educate the public on an issue that has led to serious consequences for policyholders. And hope the powers that be will pick up on the opportunity to actually do some good ‘for the people’ by legislating effective barriers” to Genworth’s and other insurers’ stunning arrogance.
Late Friday, I received an email from Danielle Bolt, senior communications manager for Genworth. Most of it was a recap of what another company official had already said at Thursday’s gathering – all rooted in the reality that Genworth’s projections, like the rest of the industry’s, “played out differently than projected.”
Bolt also listed a range of options from which Genworth policyholders now can choose: Keep paying the full premium, however jacked up it turns out to be. Accept further benefit cuts in exchange for a lower (but still higher) monthly bill. Or stop paying premiums now and, if and when need arises, Genworth will pay claims up to but not exceeding the total premiums paid to date. (That last one’s a real laugher – any policyholder could have achieved the same thing simply by putting their money in a cookie jar.)
Noted Bolt, “We are focused on leveraging the touchpoints we have with our policyholders to provide education on their coverage and potential coverage needs.”
If only they’d educated themselves first.
An $80,000 surprise bill points to a loophole in a new law to protect patients
by Jay Hancock - Kaiser Health News - February 23, 2022
When Greg and Sugar Bull were ready to start a family, health challenges necessitated that they work with a gestational surrogate. The woman who carried and gave birth to their twins lived two states away.
The pregnancy went well until the surrogate experienced high blood pressure and other symptoms of preeclampsia, which could have harmed her and the babies. Doctors ordered an emergency delivery at 34 weeks of gestation. Both infants had to spend more than a week in the neonatal intensive care unit.
It was April 2020, early in the coronavirus pandemic. Unable to take a plane, the Bulls drove from their home in Huntington Beach, Calif., to the hospital in Provo, Utah. They had to quarantine in Utah before they could see the children in the hospital.
A couple of weeks later, after the babies could eat and breathe on their own, the Bulls took them home to California.
Then the bills came.
The patients: Scarlett and Redford Bull, newborn twins covered by a Cigna policy sponsored by Greg Bull's employer. The gestational surrogate had her own insurance, which covered her care.
Medical service: Neonatal intensive care when the babies were born prematurely after emergency induced labor. Scarlett spent 16 days in the NICU; Redford, 10.
Total bill: $117,084. The hospital was out of network for the infants. Cigna paid for some of Scarlett's care, for reasons the Bulls couldn't figure out. The Bulls were left on the hook for about $80,000, for both babies. Their account was ultimately sent to collections.
Service provider: Utah Valley Hospital in Provo, Utah, one of 24 hospitals run by Intermountain Healthcare, a nonprofit with about $8 billion in revenue.
What gives: The Bulls' ordeal points up a loophole in coverage for emergency care — even under the federal No Surprises Act, which went into effect on Jan. 1 and outlaws many kinds of surprise medical bills.
Patients who need prompt lifesaving treatment often don't have time to find an in-network hospital. In the past, health plans sometimes have said they would pay for emergency care even if it's out of network. The No Surprises Act now makes this a legal requirement in every state. The provider and insurer are supposed to negotiate a reasonable payment, leaving the patient out of the equation.
But what if the insurance company denies the care is for an emergency? Or the hospital doesn't supply the paperwork to prove it?
That's what happened to the Bulls. Cigna said it lacked documentation that the NICU care for the twins qualified as an emergency.
So the Bulls began receiving insurance explanations showing huge balances owed to Utah Valley. They had expected to owe the family out-of-network, out-of-pocket maximum of $10,000 for the twins' care. They assumed most of the bills would be paid by Cigna soon. They weren't.
"I was like, there is no way this can be real," said Sugar Bull, an interior designer.
"Dear Scarlett Bull," began one of Cigna's letters, addressed to a 6-month-old baby. "We found the service requested is not medically necessary."
How could NICU care not qualify? The gestational surrogate was admitted to obstetrics by her doctor without going through the emergency department, which prompted Cigna to initially conclude there was no emergency, said Dylan Kirksey of Resolve Medical Bills, a consultancy that eventually worked with the Bulls to resolve the claims.
To establish that there was, Cigna asked for daily progress notes and other medical records on the infants. The Bulls tried to get the hospital to comply. Cigna kept saying it hadn't received the necessary documentation.
The Bulls appealed. Sugar Bull spent hours with insurance paperwork and hold music. But almost a year later, about $80,000 in bills remained. Utah Valley sent the accounts to collections, she said. It was the last thing she had time for.
"I own a company, and I am super-busy and we had twins," she said. "Every two weeks or so, I would feel a panic and righteous anger about it. And I would keep pushing and calling, and it would take, like, five hours every time."
Though they disputed what they were being charged, the Bulls agreed to pay the hospital $500 a month for five years to settle just one of the babies' bills, in an attempt to keep their good credit.
Resolution: With seemingly nowhere else to turn, the family hired Resolve, which beats a path through the claims jungle in return for a portion of the money it saves clients.
"It was a lot of prodding" to get Utah Valley to give Cigna the information it needed to pay the hospital, said Kirksey, a senior advocate with Resolve, which was founded in 2019 and has 16 employees. He said he had to give the hospital a detailed list of steps to take and then follow up with multiple calls and emails per week.
In the end, most of the errors causing the Bulls' nightmare were on the hospital's side, Kirksey said. But instead of supplying what Cigna needed, Utah Valley went after the Bulls.
"The hospital repeatedly failed to provide a detailed list of services and important clinical information, despite our continuous efforts to secure the information," said Cigna spokesperson Meaghan MacDonald.
"There were no errors on the hospital's part," said Utah Valley spokesperson Daron Cowley. "Utah Valley Hospital properly billed for services provided to the twins and provided the requested information to Cigna in a timely manner."
The hospital didn't bill the Bulls for outstanding balances until nine months after the twins were born and didn't send the accounts to collections until six months after that, "after the family did not return the legally required paperwork to set up a payment plan," he said.
Finally, in the fall of 2021, the bills were settled. The twins were 1 1/2 years old. To compensate Resolve for curing the balance, the Bulls paid the company about 10% — $8,000.
The fee, though substantial and unrelated to medical care, was worth it to avoid the much larger debt, said Greg Bull, who works in finance. "At the end of the day, it was such a relief for it to be a smaller amount," he said. Still, many families could not have afforded it.
The takeaway: About 1 in 5 emergency room visits is at a facility that is out of network for the patient's insurance, research has shown. The No Surprises Act requires insurers to cover non-network emergency treatment with the same patient cost-sharing as in-network care. It also prohibits hospitals from billing patients extra.
But if the insurer denies that the care was for an emergency or doesn't obtain documentation to prove that it was, the claim can still be rejected and the patient left on the hook.
"That's a coding issue we see a lot," said Kirksey, especially "if the person didn't literally check in through the emergency room."
If this happens, insurance experts urge patients to immediately appeal the decision to the insurance company, a process that the law requires be available. Unfortunately, that usually requires more phone calls, paperwork and waiting. (If the appeal with the insurer fails, patients can then turn to an independent reviewer, like their state insurance board, state attorney general's office or the No Surprises Help Desk.)
"It would be a critical step for the consumer to leverage their appeal rights ... and get the determination that it was an emergency service from the get-go," said Kevin Lucia, co-director of the Center on Health Insurance Reforms at Georgetown University.
Once it's established that the visit was for an emergency, he said, protections from the No Surprises Act clearly apply.
The No Surprises Act may be a step in the right direction. But it is clear that loopholes and minefields remain.
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