Explanation of Healthcare Tax Subsidies in the USA-Medicaid-Insurance Exchanges-Group Insurance Programs-Medicare

 

Health Care is Not Free

In an election year, it is important to discern facts from fiction and this article addresses the subject of free or subsidized health care in the United States. First, there is no free health care, someone is paying for the care. For Medicaid eligible persons or families, the state and federal government do provide health care without an insurance premium to those who qualify. This does not mean there are no copayments for the Medicaid participants, but these are generally modest. Access to health care providers is not guaranteed, because many clinics and clinicians do not treat Medicaid patients or have a limit on the number they will accept. This is because of the low level of reimbursement from the government for providing care.

 Medicaid-Eligibility

Medicaid, also known as Apple Health, Medi-Cal or whatever label each state chooses, is a government run medical insurance program for low-income residents. To be eligible for Medicaid, the individual or family must meet certain criteria, for example, living within the United States for at least five years, having legal residency status, meaning a work permit, student visa, permanent resident status, or citizenship. Citizenship in the USA is based on birthright, taking the oath of citizenship, or marriage. The funding for the Affordable Care Act requires legal residency criteria, to control costs and to avoid adverse selection from potential high-medical-needs immigrants. There are exceptions to this, which are for immigrants who have refugee status for humanitarian reasons (torture), Protected Juvenile Status, Temporary Protected Status and Victims of Trafficking. Here is a complete list of the immigrant standards for qualification for Medicaid or government health care subsidies, like tax credits under the insurance exchange plans for the Affordable Care Act (Obamacare): https://www.healthcare.gov/immigrants/immigration-status/

 Finally, if someone is blind, disabled, pregnant, or caring for a child on public support (foster child) you may be eligible for Medicaid, if you meet the residency status requirements. In other words, people without means who are immigrants do NOT have unlimited access for free or subsidized health care. Wealthy people, including medical tourists with private insurance, who can pay, will be able to have carte blanche access to the US healthcare system.

 State Medicaid Eligibility Varies

Most states have now expanded their Medicaid eligibility to match the 2010 Patient Protection and Affordable Care Act standard of 133% of the federal poverty level (FPL). In 2024, this is $15,060 for a single individual and $31,200 for a family of four. So, the baseline for receiving medical insurance through a state Medicaid program which has chosen the Affordable Care Act standard and receives federal matching funds is: $20,030 for a single individual and $41,496 for a family of four. Some states, where the cost of living is very high, have more generous subsidies, like California, which offers pregnant women with incomes up to 208% of the FPL and children under 18 are covered up to 261% of the FPL.

Federal government handy interactive chart to determine your state’s Medicaid eligibility standards.

https://www.medicaid.gov/state-overviews/state-profiles/index.html

 The federal Children’s Health Insurance Plan or CHIP has been around since 1997 and was reauthorized by both Democrats and Republicans in 2009.This is a positive thing because it is good public health investment to make sure we are creating healthy children, which is after all our future work force. Investing in the health and well-being of our citizens is a public good. This is why we have parks and recreation, air and water quality standards, sanitation systems, and standards for food safety.

Tax Credits Under Affordable Care Act

All the insurance exchange enrollments require persons applying for medical insurance coverage to disclose their incomes, because the Affordable Care Act provides federal tax credits for the purchase of the insurance. The government is advancing an income tax credit, that you would be expected to receive upon filing your annual tax return. If your income varies from this declaration, the government will refund any unused tax credits or require you to pay back some of the advance credits you received. It is the onus of the insurance exchange participant to notify the agency of any material change while enrolled. The tax credits are not free, but reflect earned income federal taxes. If someone has no earned income and qualifies for some insurance subsidy, this is determined through the process.

 Tax Credits Under Employer Group Insurance Plans

The federal government provides significant tax incentives for employers to provide health insurance, by allowing a tax deduction for the entire expense which are paid by the company. Additionally, employees are often given the opportunity to use pre-tax income to pay for their covered dependents or elective benefits, through a Section 125 plan. These tax credits do not have to be repaid, as long as the programs are administered correctly.

 Medicare Eligibility

For persons reaching age 62, their eligible spouses, and certain disabled people, the federal government provides Medicare, which has components which are fully paid by the government, Part A for hospitalizations and Part B, which is for outpatient care and requires an insurance payment monthly. There is also a prescription drug program which requires an insurance premium, unless the enrollee chooses a Medicaid Advantage Plan with an integrated drug program.  And there are Medicare supplements, which cover the many deductibles and co-payments that Medicare requires.

 Obtaining age 62, 65, or 70 does not automatically mean that person is enrolled in Medicare. The individual must apply for Social Security Benefits first, and that process takes two months. During this time, the Social Security Administration will verify residency status, address, and determine the number of quarters the applicant paid the necessary payroll taxes to qualify. Social Security is NOT FREE, the applicant must have earned wages and paid payroll taxes for Social Security and Medicare for no less than ten years. Some, myself included, think this is too liberal, because what other entity, government or private provides a pension after only a decade? Social Security is financed through a trust fund and current payroll taxes from employees and the self-employed whom are still working.

 In addition to the age qualification, Social Security is eligible to persons who have end-stage renal failure (kidney) and are on dialysis and for those who are blind. It is possible for other individuals with disabilities to qualify for benefits, but this is not easy and is not guaranteed.

 Conclusion

The United States does not offer FREE HEALTH CARE, rather it provides various targeted programs for enrollment, based on eligibility. These standards require individual tax contributions at all levels, based on the Internal Revenue Service Code. Only billionaires and a few hedge funders seem to manage tax exemptions. If you earn wages in the U.S.A. you will pay into the Social Security and Medicare programs. Residents in the country may be eligible for Medicaid or Insurance Exchange subsidies based on the duration of their residency and their immigration status. Americans are raised with the ethos that we work and earn that which we acquire and utilize. Though our tax code is arcane, it does provide incentives for programs the nation is trying to encourage and those it discourages. Universal healthcare is a myth, for even in countries with national health systems (France, Germany), there are populations whom are not covered under the safety net, primarily based on residency status.  Where the US goes off the rails is in the affordability of health care, ranked as the most expensive health care in the world. And of course, there are more persons without medical insurance and access to care in the US than in other nations with national healthcare systems. That said, this bellicose nation does not appear ready to move away from its current system in the near future.

 And this is the healthpolicymaven signing off, encouraging you not to sign blanket releases when you agree on a surgical procedure or a hospitalization, do specify that for which you agree and decline. It is best to do this with an Advanced Medical Directive or a POLST agreement. Make sure your emergency contact is aware of this document and be prepared to present to healthcare administrators.

 Roberta Winter is an independent healthcare analyst and journalist who receives no money from any sector of US healthcare. She is the author of Unraveling US Healthcare-A Personal Guide, published by Rowman & Littlefield in 2013. She has been a speaker at international and national healthcare events.

https://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972

Hospitals Across the Country Forced to Return Millions for Overcharging Patients

Behemoth Providence Health Care abandoned their defense for avoidance of providing charitable care to eligible patients and settled with Washington State’s Attorney General only weeks prior to trial, because they knew they would lose. Attorney General, Bob Ferguson (gubernatorial candidate) and his team, compelled Providence to refund 20 million dollars and forgive medical debt of 137 million, all owed to low-income patients. The suit impacts over 100,000 state residents. (Washington Attorney General, 2024)

Providence operates 14 hospitals in Washington State under that moniker as well as Swedish and Kadlec hospitals. Washington State was able to achieve this result for the people of the state because of the strength of its charitable care laws. For more information on Providence’s reach in other states, including Oregon, California, and New Mexico, read my former post from September 25, 2022.

https://healthpolicymaven.blogspot.com/2022/09/opportunistic-practices-based-on.html

 Summary of Charitable Care Standards in Other States

State	State Mandates for Charitable Care at Hospitals (Bosco, 2021)
California	Families without medical insurance, those with high medical costs, and people within 400% of the federal poverty rate are eligible for financial assistance.
Colorado	A 2022 law strengthens protections from medical debt and requires all hospitals to provide medical assistance.
Connecticut	Requires all hospitals to screen for financial aid, but only mandates aid consideration for persons not covered on Medicare, Medicaid, or other coverage and whose income is below 250% of the federal poverty rate.
Illinois	Hospitals must offer financial assistance to families within 600% of the poverty rate, free care is mandated for those within 200% of the poverty rate, and hospitals are prohibited from collecting more than 20% of a patient’s income for payment in a twelve-month period.
Massachusetts	Families whose incomes are within 200% of the federal poverty rate are eligible to receive financial assistance.
New Jersey	Specifies families without medical insurance and those with low reimbursement from insurance plans are eligible for charity care. Also stipulates that healthcare providers can only collect a portion of patient income for repayment and the law stipulates what that payment ceiling is based on income.
Oregon	Requires hospitals provide full financial aid for those within 200% of the federal poverty rate and a sliding fee scale for those within 400% of the poverty rate.
Texas	Requires financial aid for those with incomes equal or less than 21% of the federal poverty rate. And individuals must be ineligible for Medicaid.
Washington	Families with incomes below 100% of the federal poverty rate must receive free care; families within 200% of the poverty rate are eligible for financial assistance.

 Lawsuits Against Hospitals Elsewhere

North Carolina

HCA (Health Care of America) is once again charged in North Carolina in a case against Team Health brought by heroic emergency doctors at Mission Hospital. The lawsuit alleged:

HCA-Team Health used unnecessary trauma coding to get more money from insurers, the government, and patients. On average, patients using this trauma facility were overcharged $40,000 through unnecessary specialists, procedures, and drugs through this “upcoding scheme.” Doctors alleged that nonphysicians made these coding decisions in Mission Hospital, as a part of HCA’s business practices to optimize reimbursement. Most of the upcoding and overcharging were done on geriatric patients.

Tennessee

HCA and Team Health are also being sued in Tennessee for overcharging practices for billing practices in Bucumb County. (Jones, 2023)

HCA has the distinction of having the largest (2003) settlement of 631 million with the US government for overcharging Medicare and Medicaid. Interesting factoid, HCA was helmed by android Rick Scott, who went on to become Governor of Florida, and then Senator during the Trump Administration. Unfortunately, being a shyster, does not appear to hurt your chances of doing even greater damage to the American people.

 Widespread Aggressive Collection Practices

Kaiser Family Foundation found in 2022 that thousands of hospitals bring lawsuits against patients to collect unpaid bills, regardless of the patient’s ability to pay. They found at least 5,100 used aggressive collection practices, despite charitable care eligibility and other mitigating factors. Worse yet, 20% of these hospitals deny emergency care to patients who are in collections, which may be illegal under the federal Emergency Medical Treatment Act. And because these hospitals know the public would not approve of their collection practices, they do not make this information available to the public. And many directly flout their own edicts on charitable care, Lourdes, an Ascension Hospital in New York said they no longer practiced this technique in 2019, but New York court records show they were still doing it in 2021. (Levy, 2022)

Here is a nationwide map of the hospitals who have been found to practice aggressive collection:

https://kffhealthnews.org/news/article/medical-debt-hospitals-sue-patients-threaten-credit-khn-investigation/

 By shining a light on egregious and often illegal collection practices of healthcare organizations we can create some reforms.  Through the power of the free press and our collective actions we can make a difference. Remember, you do NOT have to let a collection action or lawsuit go unchallenged and it is highly likely a judge will take a more favorable view towards an individual than a large corporation, but you do need to show up in court. Get a nonprofit legal organization to assist in your action if you cannot afford legal representation. Any Google search will show plenty of law firms which specialize in defense of medical claim actions brought by hospitals.

 And this is the healthpolicymaven encouraging you not to sign blanket releases when you are going to have medical procedures, do stipulate that for which you agree and which you decline. No money was accepted from anyone in the healthcare industry for this article. Roberta Winter is an independent healthcare analyst and journalist.

 References

Jones, B. D. (2023, June 14). Doctors’ lawsuit: HCA Healthcare and TeamHealth overcharged patients. Retrieved from Asheville Watchdog.org: https://avlwatchdog.org/doctors-lawsuit-hca-healthcare-and-teamhealth-overcharged-patients/

Levy, N. M. (2022, December 21). Hundreds of Hospitals Sue Patients or Threaten Their Credit, a KHN Investigation Finds. Does Yours? Retrieved from KFF Health News.org: https://kffhealthnews.org/news/article/medical-debt-hospitals-sue-patients-threaten-credit-khn-investigation/

Washington Attorney General. (2024, February 1). AG Ferguson: Providence must provide $157.8 million in refunds and debt relief for unlawful medical charges to low-income Washingtonians. Retrieved from Washington State Office of the Attorney General: https://www.atg.wa.gov/news/news-releases/ag-ferguson-providence-must-provide-1578-million-refunds-and-debt-relief

 

Drug Shortages in the US-Solutions

 Acute shortages in prescription drugs in the United States are deferring and changing treatment for everything from cancer to antibiotics. Medical centers have succumbed to warehousing supplies for fear of running out. Global manufacturing and distribution centers for drugs have not kept up with demand. Pharmaceutical companies indicate there is not enough money in generic drugs to economically afford to manufacture them. Policymakers also blame the gatekeepers, the pharmacy group purchasing organizations or PBM’s, which exert outsize control over the supply of drugs by depressing the price for large employer groups. Group purchasing organizations are generally located outside the U.S. and are not subject to national regulations. Group purchasing organizations are designed to leverage volume to lower prices. Some pharmacy benefit management groups have created their own group purchasing entities. In general, PBM’s dictate which drugs the insurance plan will cover, hence driving utilization, but not necessarily the public price of drugs, whereas GPOs are all about price reduction. Clinicians and pharmaceutical companies indicate this is restricting the availability of life saving medications.

Companies that Control Drug Pricing and Supply in the US

The largest pharmacy benefit managers (PBM’s) are:

 Caremark-CVS

Express Scripts-Cigna

Optum-United Healthcare

According to the Drug Channels web site, the largest drug group purchasing organizations are:

Ascent Health Services-based in Switzerland but licensed as an LLC in Delaware. Cigna, Kroger, and Prime Therapeutics, own stakes in this company. (Adam Fein, 2023)

Emisar Pharma Services is part of United Healthcare’s Optum, headquarter in Ireland and an LLC in Delaware.

Zinc Health Services, owned by CVS is US based

 What Can We Do

Senator Ron Wyden, Chairman of the Senate Finance Committee convened a hearing on drug shortages December 5, 2023. Findings included the recommendation that Congress reform the Medicare Drug Rebate Program which encourages these large drug purchasing entities to capture up to 13% of drug costs in the form of rebates. The rebates which were meant to lower the cost of drugs are not necessarily shared with customers, instead add to corporate profits. Reform ideas include mandating the drug companies repay rebates if they raise prices faster than inflation and exempting some sterile injectables from the rebate program, which could increase supply. (Hunt, 2023) Both federal and state governments are reviewing anti-trust behavior for price collusion for these behemoth drug purchasing entities.

 The Government Accountability Agency, a nonpartisan analyst entity of the federal government convened a group of pharmaceutical company and other industry experts to discuss the dearth of generic drugs and potential causes within the FDA regulation. (Government Accountability Office, 2023)

Findings include:

1. Drug maker reformulations of drugs with minor modifications extend patents, keeping prices higher, and restricting the availability of generic drugs.

2. FDA’s rules regarding labeling also prevent generic drug manufacturers from entering the US market, even though their drugs are safe and used in other markets.

3. Half of the pharmaceutical manufacturers said the FDA needs to take a more active role in tracking generic drug-device combinations, because brand name sponsors are not required to submit information on identifying which patents are related to the device part of a drug-device combination product (example-insulin pump).

4. Half of the stakeholders indicated confusion or unnecessary delays in market entry are due to the overly broad and ambiguous codes for labeling (page 19 of the GAO report) and the FDA agreed with this conclusion.

5. Two of the participants felt that brand name sponsors may delay entry of generic drug device combination products by shifting active ingredients from older products into newer ones with patent extensions, and in some cases, remove their older more affordable products from the marketplace altogether. A literature review found that this practice led to 28 years of extended patent protection on inhalers from 1986 to 2020, which is another form of price gouging.

6. Many of the conference participants expressed concern that the FDA was outgunned by the legal resources of the pharmaceutical companies. There has not been an FDA rule change on drug-device combination products since 2016.

The American Medical Association has recently announced its support for government or a greater role for nonprofits to manufacture drugs. Of course, this would not work for the biologics, which are subject to trademark protection, but it would work for generic drugs. The federal government already provides most of the funding for initial research on drug development through National Institutes of Health grants to universities and health centers. The private market approach to supply and demand is failing at the cost of human lives. It is well known people died during Covid because they could not obtain their infusions or other drugs, but this phenomenon is still ongoing. A recent New York Times article cited severe shortages in chemotherapy even at well-funded medical centers like the Mayo Clinic. (Jewitt, 2023).

 Much of the drug supplies for the US and other nations are manufactured in India, due to consolidation and sheer economics. The Food and Drug Administration does inspect pharmaceutical manufacturing facilities offshore and in February 2023, shortages of supplies in generic drugs were directly related to a surprise FDA inspection that found numerous failures at Intas Pharmaceuticals. (Jewitt, 2023)

 The US successfully created incentives for large pharmaceutical manufacturing companies in the country to create the Covid vaccines, because the national government quickly provided funding for a national emergency. It is time we establish a government run generic drug manufacturing entity to assure supply of essential medicines for our residents. As a nation we must quit running the provision of health care like a lottery, as winner-take-all for the lucky ones and low or no treatment for others. This is no way to run a healthcare system.

 And this is the healthpolicymaven signing off wishing you a healthy new year and remember, don’t sign generic releases when you agree to inpatient medical procedures, do stipulate that for which you agree and that which you decline. Your health is after all, up to you.

This column has been in continuous publication since 2007 and is written by Roberta E. Winter, an independent healthcare analyst and journalist who accepts no money from any sector of US healthcare. Opinions are strictly her own and supported by full citations. She is the author of Unraveling U.S. Healthcare-A Personal Guide, published by Rowman & Littlefield in 2013.

https://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972

References

Adam Fein, P. (2023, May 24). Five (or Maybe Six?) Reasons that the Largest PBMs Operate Group Purchasing Organizations. Retrieved from Drug Channels: https://www.drugchannels.net/2023/05/five-or-maybe-six-reasons-that-largest.html

Government Accountability Office. (2023, March). Generic Drugs-Stakeholder Views on Improving FDA's Information on Patents. doi:GAO 43-105477

Hunt, S. (2023, December 8). WASHINGTON HIGHLIGHTS-Senate Finance Committee Holds Hearing Examning Drug Shortages. Retrieved from AAMC.org: https://www.aamc.org/advocacy-policy/washington-highlights/senate-finance-committee-holds-hearing-examining-drug-shortages

Jewitt, C. (2023). "I'm Scared to Death,"Behind the Shortage Keeping Cancer Patients from Chemo. New York City: The New York Times. Retrieved 12 19, 2023, from https://www.nytimes.com/2023/12/19/health/cancer-drug-shortage.html

 

 

Virtual Reality Therapy Can Improve Learning For Children With ADHD

 Children with Attention Deficit Hyperactive Disorder have numerous challenges with attention, organization, and impulse control and studies have shown this is because the prefrontal cortex takes longer to mature. The cerebellum is also thought to be smaller, which is the part of the brain that controls motor response inhibition, such as staying seated in class. (Faith Wilkins, 2023) The ability to pay attention is essential for learning and when this is impacted by too much disruption it affects everything in life from social, academic, to employment. Endeavor RX is using Virtual Reality technology to impact brain activity to enhance learning and after scientific study, was given approval by the Food and Drug Administration in June 2020. (Endeavor RX, 2020)

https://play.google.com/store/apps/details?id=com.akiliinteractive.t01a

Apple https://apps.apple.com/us/app/endeavorotc/id6447322997?platform=iphone

 Breakthrough Treatment

According to Adam Gazzaley, the best way to harness the brain’s plasticity and improve attention is through immersive experiences. Adam invented the video game Neuro Racer, to boost attention and impulse control for children and youth with ADHD. After a placebo-controlled trial, Adam’s virtual reality game was approved by the FDA as a medical device, with thirty minutes as a designated dose. (Ross, 2023) An innovative treatment that does not involve drugs is now available through a smartphone app, in which thirty minutes a day of game time is a prescribed treatment for ADHD. FDA approval generally means insurance reimbursement will follow.

 Scientific Review

In 2022, a U.S. study on the use of virtual reality technology to help children and youth with Attention Deficit Hyperactive Disorder was published in Digital Health. (Zangiacomi A, 2022) The same study is referenced in the National Institute of Health, PubMed Central. (An immersive virtual reality-based application for treating ADHD: A remote evaluation of acceptance and usability, 2022) The use of a video game as a tool to help the ADHD brain organize and function better is a new treatment for children and youth.Study participants used the VR game tool virtually due to Covid restrictions, rather than in a controlled environment. Results showed the technology was helpful as a therapy for those with ADHD. Ease of use with the technology was deemed suitable for children aged six years and up.   Twenty clinical experts reviewed the study findings to arrive at these conclusions, which had a high degree of statistical validity. Another benefit of the virtual reality program was improved quantifiability of behavioral testing over traditional measures.

Findings

1.  VR demonstrated clinical value as a tool to improve cognition through increased attention and control of impulsivity

 2. VR can also be useful in identifying attention deficit disorders

3. VR Technology was found to treat some symptoms of ADHD better than Pharmacology

 A concern cited in the study was the lack of device customization by child, since there is so much variability in attention deficit disorder symptoms and severity.

 Global View

A systematic review of scientific studies analyzing Virtual Reality interventions on children with Attention Deficit Hyperactive Disorder from the International Cochrane Library for statistical efficacy was published in January 2021. The meta-analysis reviewed four studies and included 125 participants who were children. Here are the findings: (Romero-Ayuso, 2021)

Findings

VR-based interventions were found:

1. Effective in improving sustained attention

2. Improve vigilance measures and increase the number of correct responses

3. Decrease the number of omissions

4. No improvements were observed in impulsivity responses

 A systematic review and metanalysis of Virtual Reality technology to treat Attention Deficit Hyperactive Disorder was shown to improve memory in children with ADHD, similar or better than pharmacological treatments. However, the VR-intervention does not have the metabolic side affects of ADHD drugs, which include weight loss, ticks, insomnia, depression, and more. Further studies are needed on the long term affects, but this is a breakthrough treatment for this neurodevelopmental disorder! Response by parents should be thunderous applause. Treatment of learning and behavioral problems can happen without drugs. As someone who struggled with medications for my own son’s ADHD, compliance and dosage were always concerns and it would have been wonderful to have something he would have embraced and I daresay, enjoy as a treatment.

 And this is the healthpolicymaven signing off encouraging you not to sign blanket release forms when consenting to inpatient medical procedures, do stipulate that for which you agree and decline. Roberta Winter is an independent healthcare journalist who accepts no money from any healthcare sector to publish this column. She is the 2013 author of a guidebook to the US healthcare system, which is still in print. https://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972

 

References

An immersive virtual reality-based application for treating ADHD: A remote evaluation of acceptance and usability. (2022). National Library of Medicine, 8. doi:PMC9747881

Endeavor RX. (2020, April 16). Denovo Classification Request for Endeavor RX. Retrieved from Food and Drug Administration: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.accessdata.fda.gov/cdrh_docs/reviews/DEN200026.pdf

Faith Wilkins, A. N. (2023, May 2). How Is the ADHD Brain Different? Retrieved September 25, 2023, from Child Mind.org: https://childmind.org/article/how-is-the-adhd-brain-different/#full_article

Romero-Ayuso, D. &.-G.-M.-V.-F. (2021). Effectiveness of Virtual Reality-Based Interventions for Children and Adolescents with ADHD: A Systematic Review and Meta-Analysis. Children, 18-70. doi:10.3390/children8020070.

Ross, S. M. (2023). Your Brain on Art How Art Transforms Us. In S. M. Ross, Your Brain on Art How Art Transforms Us (pp. 154-157). New York : Random House.

Zangiacomi A, F. V. (2022). An immersive virtual reality-based application for treating ADHD: A remote evaluation of acceptance and usability. Digital Health, 10. doi: doi:10.1177/20552076221143242, 8.

 

Does Your Hospital Owe You Money-An Examination of Charitable Care Standards in the US

 

Hospitals Forced to Comply with Charitable Care Standards in the US

Charitable care nationally represents only 1.4% of hospital operating costs, yet these behemoth money making corporations still seek to deny care to those most in need, often causing people to defer medically necessary procedures or forcing them into bankruptcy. Does being a working-class person mean your health is less important-I think not. Read this article to learn more about laws that protect your rights to obtain health care in the United States. The Patient Protection and Affordable Care Act requires hospitals to offer charity care and to inform patients of their rights and eligibility for free or reduced cost health care if those facilities accept any federal reimbursements. (Congress, 2010)Many hospitals have not complied with this federal law, resulting in multitudes of lawsuits from Attorneys Generals and private citizenry. This article reviews these actions and results benefiting patients and the general public.

A 2019 lawsuit against St. Joseph Hospital of Tacoma, Washington by State Attorney General, Bob Ferguson found that the hospital had repeatedly violated the state Consumer Protection Act by not informing patients of their right to reduced cost health care under charitable care provisions. As a result, this hospital and all the others owned by CHI Franciscan, a nonprofit Catholic health care entity, were required to forgive 20 million in debt, refund 2.22 million for patients who were hornswoggled, and to restore their credit. Most egregious was the hospital’s practice of turning its own employees over to debt collection rather than providing them care assistance. Additionally, the hospital group had to pay the Attorney General’s Office 2.46 million. Further, this settlement was only for a five-year period from 2012-2017 and impacted over 5,400 people who had received care. (Washington State Attorney General's Office, 2019)

This opportunistic behavior continues unabated, in 2022, State Attorney General, Ferguson sued Providence and its Swedish Hospital affiliates for failing to provide patients with the charitable care to which they were legally entitled.  Providence hospitals are located across the state, from Seattle to Walla Walla and in many cases are the only hospital in a community. As a testament to Providence’s management, 54,000 people were sent to collections even though it knew they were eligible for charitable assistance and many should have had their bills forgiven in entirety. In this lawsuit the Attorney General is asking for 70 million in damages. (Washington State Office of the Attorney General, 2022)

 As cited in the Center for American Progess, seven of the ten most profitable hospital groups in the country were nonprofits. (Gee, 2022)

State Charitable Care Mandates

Washington

Requires hospitals to make charity care accessible to patients whose income is at or below 200 percent of the Federal Poverty Guidelines. Hospitals are required to:

• Provide notice of the availability of charity care both verbally and in writing
• Screen patients for charity care eligibility before attempting to collect payment
• Only require patients to provide one income-related document to prove charity care eligibility

Oregon 

In 2019, Oregon began mandating charitable care standards for hospitals and clinics to offer free or reduced-price health care. It requires free care for anyone within 200% of the federal poverty limit (FPL) and discounted care for those within 400% of the FPL. (Tiel, 2019)

California

California has had a Hospital Fair Pricing Act since 2007 and California’s largest public hospital was found to have violated the act and as of June 2023, to notify its 43,000 patients they may be eligible for charitable care refunds and billing corrections because of this settlement. This settlement was with Santa Clara Valley Healthcare. (Work, 2023)

In order to receive a state tax exemption, hospitals must offer reduced price or charitable care to those whose incomes are within 400% of the federal poverty level.

Charitable Care Mandates for Other States

In 2019, states requiring nonprofit hospitals to provide a minimum level of charity care were; Illinois, Nevada, Rhode Island, Pennsylvania, Texas, and Utah.

Colorado and New Mexico have new laws that require medical facilities to assess a patient’s eligibility for financial assistance before billing them. (Pitsor, 2022) Check your state legislative site for updates on consumer protection regulations for healthcare as there is much activity on this issue nationally.

Even during the corona virus, hospitals have not stopped suing patients for unpaid bills. A Yale University found that nonprofit hospitals were more likely to sue patients for unpaid bills than for profit entities. (Gee, 2022)

Determining Community Benefit

After the passage of the Affordable Care Act spending on uncompensated care for hospitals declined from 6% to 4% of operating revenues, which is nearly half. So, as taxpayers we are subsidizing their gratuitous profit making at the expense of people who need care. Definitions of community benefit do not necessarily include care for those who need it the most, and can include less medically urgent things like building walking tracks and various classes. This needs to change, because hospital care is critical access and people who need it should not be bankrupt because of the avaricious behavior of a few in corporate finance.

Studies have shown that some nonprofit hospitals spend only a small portion of their community benefit spending on services that help the community and a much greater percentage on services that benefit the hospital (Wen et al., 2022). One study found that for-profit hospitals spent a greater share of the total revenues on charity care than nonprofit hospitals (Bai et al., 2021). These studies have raised interest among policymakers in how to provide incentives for nonprofits to increase the level of community benefit and charity care they provide. (Hossein, 2023)

Human Rights Watch published an article on the predatorial behavior of US healthcare hospital groups in 2023 and it is worth a read. https://www.hrw.org/report/2023/06/15/sheeps-clothing/united-states-poorly-regulated-nonprofit-hospitals-undermine

What You Can Do to Make Sure You Are Not Overcharged

Federal law requires hospitals operating as nonprofits to provide some level of charitable care and 58% of all local community hospitals are in this category. Here is how you can assess whether your hospital is within the guidelines and what you can do to make sure you and your loved ones obtain the fair-priced health care that you deserve. Federal poverty standards, which determine assistance eligibility  are listed in this link.

https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines

 At a minimum if  your family's income falls within 200% of the federal poverty level range you may be eligible for free or discounted health care. Ask about charity care and demand to see the eligibility standards for the facility which is billing you. If they are reluctant to provide the information, this is all the more reason to discover it, because you probably are eligible for some discount. If you need someone to advocate for you, have someone with healthcare finance experience write a letter on your behalf. Document everything. Record the meeting with the financial representatives of the facility. And reach out to your state Attorney General for guidance on how to proceed.

Hospitals, which are making tons of money in the US do not want to appear “greedy,” but it is much too late for that moniker for these behemoths. By way of example, Seattle-based Providence Health Care, makes so much money it has its own venture capital fund. Methinks Americans would rather pay less for their health care then finance someone else’s capitalistic dream.

And this is the healthpolicymaven signing off encouraging you not to sign blanket authorizations when you agree to health care procedures. Do stipulate that for which you agree and which you don’t and do have a medical guardianship or POLST agreement to see that is enforced.

Roberta Winter is a freelance journalist who accepts no money from healthcare industries for this column, opinions here are her own. She is the author of a guidebook to the US healthcare system, which focused on consumer information on how to access quality in care. https://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972

References

Gee, E. W. (2022, October 2022). Policies to Hold Nonprofit Hospitals Accountable. American Progress. Retrieved September 1, 2023, from https://www.americanprogress.org/article/policies-to-hold-nonprofit-hospitals-accountable/

Hossein, Z. P. (2023, March 9). When States Mandate Hospital Community Benefit; Provision Increases. doi:https://doi.org/10.1097%2FJHM-D-22-00156

Tiel, R. (2019, September 17). WHAT OREGON’S NEW HOSPITAL CHARITY CARE LAW MEANS FOR YOU. Retrieved from Our Health Oregon.org: https://ourhealthoregon.org/news/what-oregons-new-hospital-charity-care-law-means-for-you

Washington State Attorney General's Office. (2019, April 26). Following AG’s charity care lawsuit, St. Joseph parent company CHI Franciscan will provide up to $25 million in restitution, debt relief and fees. Washington. Retrieved September 1, 2023, from https://www.atg.wa.gov/news/news-releases/following-ag-s-charity-care-lawsuit-st-joseph-parent-company-chi-franciscan-will

Work, M. C. (2023, August 14). Patients in California County May See Refunds, Debt Relief From Charity Care Settlement. KFF Healthcare News. Retrieved September 1, 2023, from https://kffhealthnews.org/news/article/charity-care-settlement-debt-relief-patient-refunds-santa-clara-california/?utm_campaign=KHN%3A%20Daily%20Health%20Policy%20Report&utm_medium=email&_hsmi=270170941&_hsenc=p2ANqtz-8SNEPlsuaEb7MYh2zoC5ruEMhnT1k7kNjPPr7

 

 

 

U.S. Healthcare Outcomes and State Initiatives To Lower Costs

 Due to federal failure to enact meaningful healthcare reforms, this article reviews states that are making a difference. Three states which have taken steps to control the cost of healthcare without adversely impacting patient outcomes are Maryland, Montana, and Oregon and this article reviews what they have done. But before we get to that let’s review the current status of U.S. healthcare.

 Washington State’s 2022 report on evidence-based methods to control costs, increase equity, and improve industry transparency and regulation stated three truths that should shock the nation, if voters were only aware. Globally, U.S. healthcare continues to be the most expensive healthcare but health quality metrics continually show the results are not worth it. In 2019, the U.S. spent 16.8% of all gross national product (GNP) on healthcare. Norway, the top scoring nation for health outcomes spent 10.5%. How much longer are the American people going to have to listen to how more expensive their health care will be in a national healthcare system-clearly this is not the case. Here are the Commonwealth Funds 2021 findings for the latest metrics on global healthcare outcomes compared to the rest of industrialized nations: (Eric C. Schneider, 2021)

 U.S. ranks last in healthcare outcomes (we spend 60% more on healthcare than Norway, the top nation for outcomes)

               1. Highest infant mortality 

               2. lowest life expectancy 

               3. Lowest rate of reduction in avoidable deaths (which is what healthcare is supposed to do)

              4. Last on access to care 

              5. Last in administrative efficiency

              6. Last in health equity (discrimination in health services)

              7. Second on measures of care process (we are tracking it all as the outcomes decline)

The Commonwealth Fund has for years done an excellent job of finding methods to compare different healthcare systems and this latest report reviewed 71 measures for 2019 to arrive at its conclusions. Nations reviewed were: U.S., Switzerland, Germany, France, Sweden, Canada, Norway, United Kingdom, Netherlands, Australia, and New Zealand. Here are the metrics reviewed:

 Cost-U.S. Healthcare is 50% more expensive than other industrialized nations

Gross domestic product, which is essentially a measure of all goods services produced over a specific period of time for the country is a measure of wealth and how much of that wealth is spent on things, such as housing, education, and healthcare. It is one measure to assess a cost comparison for health systems which has been widely used. New Zealand spent the least on its healthcare, at 9.1% and one could argue that it is a tiny nation and not comparable to the complexity of the U.S., but Australia, also spent 9.4%. For nations with larger populations, France spent 11.1% of its GNP on healthcare and Germany spent 11.7%. And unlike the U.S. these nations cover most of their populations and their residents don't pay thousands of dollars out of pocket for services.

 Infant Mortality-U.S. Deaths are 70% higher than other industrialized nations

Infant mortality is a measure of babies who die and is a direct reflection on maternal child healthcare and access to care. In this forlorn measure, the U.S. has 5.7 deaths per 1,000 infant births, compared to the other nations, which had less than 4 deaths. Switzerland boasted only  3.3 deaths per 1,000 births.  

 Maternal Mortality-U.S. deaths are 5 times higher than other industrialized nations

The U.S. also has an abysmal maternal mortality rate, which is going to increase with the latest century rollback of women’s health in many states, which seek to outlaw termination of pregnancy for any reason. To be clear there were 17.4 American women who died as a result of childbirth per 100,00.  France loses only 3.2 women, even if you are math impaired that is five times the number of women who die from childbirth in the USA. Expect more to perish from ectopic pregnancies, hemorrhaging (bleeding out), cardiac conditions, and other preventable causes. In 2020, 24 women per 100,000 died from childbirth in the United States. 

In 2021, 32 women out of 100,000 died from childbirth, an astounding increase of 25% in preventable deaths. The Centers for Disease Control 2022 analysis found that 4 out of 5 pregnancy related deaths are preventable-80%. (Centers for Disease Control and Prevention, 2022) This is an appalling statistic! The U.S. is ranked 55^th for maternal mortality-a metric that clearly shows how little our females are valued.  U.S. legislators would rather a women die as a result of childbirth than alter a pregnancy. Current maternal mortality in the U.S. is equivalent to many less developed countries including: Mexico, Egypt, and much worse than Cuba (which has a national healthcare system). (Ritchie, 2023) While evaluating healthcare outcomes for women more than a decade ago I was astounded to learn of the disparities in maternal mortality and the high rate of deaths for pregnant women in Washington D.C. is seared into my mind.[1] Seemingly people don’t want to believe how bad things are for pregnant women in the U.S. or they don’t care. It feels like people are looking away as they do for the poor souls  living in tents in every U.S. city.

 Life Expectancy-Americans pay more for their healthcare and don’t live as long

The Commonwealth metrics uses the number of years attained on average by nation as the measure of life expectancy. All of the top nations had average life expectancies beyond age 80, but Americans (83.1 years) can expect to live 2.5 years less than the rest. And only in the U.S. are there sharp differences based on race, mortality for black (74.9 years) and American Indian (73 years) populations are much worse than the average.

 Reduction of Avoidable Deaths-U.S. ranks the worst

The Commonwealth Fund 2021 Report on global health outcomes reviewed the reduction of avoidable deaths and Switzerland reduced avoidable deaths by 25%,  five times the U.S. rate, which was only 5%. The next worst performer in this group of 11 nations was Germany which still reduced deaths by 13% This is another metric where the residents of the states, who are gouged and underserved for health care should be electing officials who are going to take action. Leaving it to the marketplace isn’t working.

 Administrative Efficiency-U.S. ranks the worst

Anyone who has had to obtain healthcare in the United States knows what a nightmare it is to find affordable insurance, obtain a clinician whom is accepting new patients, and choke down the copayments and fees from excluded charges for anesthesiologists, labs, and other out-of-network care thrust upon them.

 We know what we must do to improve healthcare outcomes:

1. Provide universal coverage to remove cost barriers to obtain health care-stop gearing health care investments just for wealthy suburbs. 

2. Invest in primary health care systems-not money makers for huge hospital corporations 

3. Reduce administrative burdens on patients and clinicians-integrated health systems work best

4.  Invest in social services-nutrition, education, childcare, safety, housing, transportation

 State Actions to Control Healthcare Costs

 Capitation-fixing fees

Maryland enacted a regulatory body to control hospital costs in an all-payor-model and all hospitals must participate. Maryland received a CMS waiver to use this model instead of the DRG system adopted by most other states, which is highly inflationary. The agency reviews hospital rates and has the ultimate authority on approval of changes. This governing authority has not resulted in hospital closures or patient care, but it has produced the lowest hospital prices in the country. This model is a capitation model which has worked for Maryland and was launched in 2014.

 Linking fees to a multiple of Medicare Rates

Montana, through the leadership of Marilyn Bartlett pegged state employee healthcare costs to a percentage of Medicare rates and saved the state thirty million dollars. Even the Republicans in Montana appreciate a taxpayer savings. Barlett had to fight the deep pockets of the healthcare industry, to enact this contract provision, but she won. Prior to her administration, hospitals were charging the Montana State Employees Plan five times the Medicare rates. Barlett, a CPA, has taken her leadership skills on the road advising states and business coalitions on methods to control costs. (Walker, 2021)

 Payment caps and Reference based pricing

Oregon caps state employee health plan payments for 24 of its 62 hospitals, because of differing needs of rural hospitals, critical access hospitals (urban trauma centers), and hospitals that served 40% or more of Medicaid patients (low income). Oregon also plans to limit cost increases to 3.4% per member per year. (Rakotoniaina, 2021)

 Washington’s report concludes with four recommendations to reduce the costs of healthcare including: targeted price growth regulation, expanded transparency and cost-growth benchmarks, strengthened anti-trust enforcement and consumer protection, and improved drug affordability. At least, on the latter, the federal government did finally come out with some affordable insulin mandates. But what really needs to happen is for the government to be restored to the people, by overturning the Citizens United ruling which allows corporations to make unlimited political donations. Given the current makeup of the Supreme Court, who seem intent on settling their own scores versus representing the will of the people, this seems unlikely. However, lifetime appointments does not mean we can't take administrative action under the constitution to remove court members from hearing cases. It’s time to bring in the back bench of the federal courts.

 And this is the healthpolicymaven signing off encouraging you not to sign blanket releases when obtaining medical care, do stipulate that for which you agree and for which you decline. For example, if your hospital refuses to recognize your medical directive, find another one for your procedure.

 Roberta Winter is an independent health policy analyst and journalist, who has published this blog since 2007. In 2013 her guidebook to the U.S. healthcare system was published by Rowman and Littlefield.

References

Centers for Disease Control and Prevention. (2022, September 19). Four in 5 pregnancy-related deaths in the U.S. are preventable. Retrieved from Centers for Disease Control and Prevention: https://www.cdc.gov/media/releases/2022/p0919-pregnancy-related-deaths.html

Eric C. Schneider, A. S. (2021). Mirror Mirror 2021; Healthcare in the U.S. Compared to Other High Income Countries. The Commonwealth Fund. Retrieved May 9, 2023, from https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly

Rakotoniaina, A. (2021, August 31). How Oregon is Limiting Hospital Payments and Cost Growth for State Employee Health Plans. Retrieved from National Academy For State Health Policy: https://nashp.org/how-oregon-is-limiting-hospital-payments-and-cost-growth-for-state-employee-health-plans/

Ritchie, M. R. (2023, May 9). Maternal Deaths By Country. Retrieved from Ourworldindata.org: https://ourworldindata.org/maternal-mortality#maternal-deaths-by-country

Walker, D. G. (2021, February 18). Montanas Health Policy MVP Takes Her Playbook on the Road. Retrieved from Kaiser Family Foundation Health News: https://kffhealthnews.org/news/article/montanas-health-policy-mvp-takes-her-playbook-on-the-road/

 

 

---

[1]  https://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972

 

Reducing Environmental Harm From Rechargeable Batteries

 Consumers lack good access to data on the chemical components of rechargeable batteries and the environmental and personal health consequences. The world is migrating away from the internal combustion engine and a huge movement for electrification of vehicles is underway, as a direct response to global warming. It is still more environmentally friendly to ride a regular bike than one with a motor. If someone is riding an ebike instead of walking or using public transit, is that an environmental improvement? The electrification movement is hailed as an environmental coupe, which is true in the reduction of global warming gases and air pollution, but not for all environmental factors. This article digs into the toxic aspects of materials used in electrification of vehicles, bikes, and smart phones.

 Toxic components of Rechargeable Batteries

Rechargeable batteries don’t last forever and disposal of them is not universally secure. The process of creating the batteries that power Priuses, Teslas, ebikes, laptops, and smart phones creates toxic waste. Not all batteries are toxic, but lithium-ion ones are. Toxic chemicals produced include; lithium compounds, nickel compounds, arsenic compounds, and dimethoxyethane. Lithium batteries are not hazardous until they are charged and then they become toxic, which is why there are restrictions on the transportation of lithium-ion batteries. A “dry battery” means a non-lithium carbon electrode battery and is not considered hazardous. (Laura J. Vimmerstedt, 1995) Most smart phones use the lithium-ion battery because it holds a charge the longest, given the increased demands of the data required for these handheld devices. Older models, in particular, the Nokia, used Nickel -Cadmium or Nickel-Metal-Hydride and are not hazardous.

 The tech industry isn’t exactly clean, Silicon Valley has been a superfund site since 1989 from forty years of contamination of the ground water supply by tech manufacturers. Santa Clara County has twenty-three active superfund sites. Trichloroethylene used to clean semi-conductors has been found to increase miscarriage, and create endocrine disruption. (EPA, n.d.)And though the sites are being monitored and cleaned up here, there are myriad locations throughout the U.S. and the world that aren’t.

 Cobalt Mining

Cobalt is a precious metal found in most rechargeable batteries used in devices that need a long-lasting charge. Prevalent use of child labor, lack of any environmental safeguards, and literal enslavement of workers through indentured contracts are all occurring in the Democratic Republic of the Congo (DRC). The DRC, formerly known as Zaire which produces the vast majority of cobalt for the developed world. Siddharth Kara exposes the depravity in his latest, Cobalt Red-How the Blood of the Congo Powers Our Lives. (Kara, 2023) Over multiple trips to mining regions of this mineral rich land he was eye witness to unbelievable cruelty and apathy towards human suffering. It seems no matter what the agreements are with purchasers (Tesla, Apple), there are always end runs around compliance. Even if the no-child labor rules are enforced, the reason these children are forced to work at the age of ten or twelve is to provide food for their families, for often they may be the next provider after a parent is maimed or killed when a tunnel wall collapses.

 Remedies for this horror:

1. Workers need to be paid a living wage, not two dollars a day and a dollar for children. The Global Living Wage Coalition indicates a living wage is nine dollars in the DRC. Absolutely no one should be working for free or forced into labor.

2. Public schools should be free for children, because many of these families are unable to afford the six dollars monthly tuition, thrusting their children into the work place. 

3. Safety standards should be adhered to and any abrogation of them subject to heavy fines, deportation and imprisonment of contractors whom do not comply. 

4. Inspections by an independent third-party entity, similar to the global nuclear inspections would help with the clean up of this industry. There are enough profits in this industry to improve this assualt on humanity.

 Sources of Cobalt Outside of Africa

Given the fact 60% of the world’s Cobalt supply is in the Congo and controlled by the Chinese, the rest of the world is racing to shore up supply lines and develop alternatives. Russia and Australia are the next largest producers. Canada, the Philippines, and Cuba all produce a similar amount. The United States has a single cobalt mine in Idaho, which opened in October of 2022 and will contribute 10% of the global supply. The entire mine is underground and high tech. However, since the volume generated by this mine will initially be so small the processing of the cobalt ore will take place off shore in Sao Paulo, Brazil. This company is owned by Australian mining corporation, Jervois Global. (Kirk Seigler, 2022) Though the US has cobalt minerals in several locations, only the Idaho mine is active. (Burger, 2018)

 Cobalt-free Batteries

Researchers at the University of California Irvine in cooperation with four national labs have found a way to make a rechargeable cobalt-free lithium-ion battery. Huolin Xin and his colleagues were able to show that with an amalgamation of other metals, including titanium, magnesium, and manganese the battery could withstand high temperatures from repeated charges and remain stable. This research was funded by the US government, Department of Energy Efficiency and Renewable Energy. (Bell, 2022) Transitioning away from dependence on cobalt to power devices is smart. Creating a cleaner battery from manufacturing to distribution is smartest.

 The next time you hear an ebook reader tell someone who is reading a hardcover or paperback book that they are more environmentally friendly because they didn’t kill a tree (which are farmed and are a renewable resource), remember how many children die for the minerals in those devices. And this is the healthpolicymaven signing off encouraging you not to sign blanket releases when you agree to inpatient medical procedures. Do stipulate that for which you agree and decline.

 Healthpolicymaven is a trademark which has been in continuous use since 2007. Roberta Winter is the author of  a guidebook to the healthcare system, Unraveling US Healthcare-A Personal Guide, published by Roman & Littlefield in 2013. This column provides no healthcare advice and opinions here are her own.

 References

Bell, B. (2022, September 21). Cobalt-free Cathode Could Lead to Safer, Longer-lasting Batteries for Electric Vehicles. (B. N. Laboratory, Ed.) Brookhaven National Laboratory.gov. Retrieved March 27, 2023

Burger, M. S. (2018). Cobalt Deposits in the United States: US Geological Survey Data Release. doi:doi.org/10.5066/P9V74HIU

EPA. (n.d.). Superfund Sites in Reuse in California. Retrieved March 23, 2023, from United States Environmental Protection Agency: https://www.epa.gov/superfund-redevelopment/superfund-sites-reuse-california

Kara, S. (2023). Cobalt Red-How The Blood of The Congo Powers Our Lives. In S. Kara, Cobalt Red-How The Blood of The Congo Powers Our Lives. St. Martin's Press. Retrieved March 28, 2023, from https://www.amazon.com/Cobalt-Red-Blood-Congo-Powers-ebook/dp/B09Y462D6Z

Kirk Seigler, E. W. (2022, October 8). In Idaho, America's first, and only, cobalt mine in decades is opening. (NPR.org, Ed.) NPR.org. Retrieved March 27, 2023, from https://www.npr.org/2022/10/08/1127310649/in-idaho-americas-first-and-only-cobalt-mine-in-decades-is-opening#:~:text=%22Idaho's%20is%20the%20only%20cobalt,important%20asset%20for%20the%20country.%22

Laura J. Vimmerstedt, S. R. (1995, September). Current Status of Environmental, Health, and Safety of Lithium Ion Electric Vehicle Batteries. Golden, CO: US Department of Energy. Retrieved March 27, 2023, from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://afdc.energy.gov/files/pdfs/