Judgments against patients in these suits can derail someone’s life but, according to experts, they don’t bring hospitals much money.

So why do hospitals do it?

Host Dan Weissmann investigates this practice with The Baltimore Banner and Scripps News and speaks to patients who’ve found themselves on the receiving end of such lawsuits.

Weissmann also speaks with Nick McLaughlin, an entrepreneur who’s making the business case for hospitals to stop trying to collect money from people who simply don’t have it.

Credits

Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

[birds singing]

Dan: Hey there. Starting this episode with a field trip.

[dogs barking]

Dan (from field tape): I hear dogs. I’m in the right place.

Dan: Nick McLaughlin lives outside Kalamazoo, Michigan. The email with his address said: Long gravel driveway, blue house. He’d said he’d be outside with his dogs, enjoying a cup of coffee. This is a big lot, with a pond on one side, a lake on the other, and huge trees all around.

Nick: So yeah, when I said I was sitting out enjoying a cup of coffee, this is a pretty good spot to do it. Pretty cool bird action. We had some neat, red headed woodpeckers going this morning.

Dan: He’s lived in the area since he was in high school. His parents still live nearby. So do his in laws. He’s married to his high school sweetheart — they got married while they were still in college. That’s also when Nick started working in medical collections.

Nick: I just saw a part time job listing in the college job website for a patient financial counselor. Didn’t know what that meant. Uh, and next thing I knew I had a, uh, headset on and was talking to patients about two and three year old hospital bills that they had. And my parents about disowned me. My mom’s a nurse, uh, and my dad’s a PhD environmental scientist. And so, um, Their line was, what are you doing calling sick people asking for money?

Dan: He says they came around. After a couple of years, he quit the call center and ended up in sales for a company called AmeriCollect. As the name suggests, they’re a collection agency. Specifically, medical-bill collections. Hospitals and medical groups are their clients. Nick started as Americollect’s first sales rep in Michigan, then after a year or so, branched out.

Nick: It was Michigan, Indiana. Ohio. Pennsylvania, and then North Carolina and, then we’re just kinda all over.

Dan: You were really good at this. 

Nick: I was good at this.

Dan: Nick spent a decade at AmeriCollect. The company’s slogan was, is — and I swear this is true: “ridiculously nice.” It’s on their website — and Nick says it was part of their pitch to clients.

Nick: The pitch was, we’re going to be more effective in connecting with your people, maintaining your reputation, with them and your community, and, oh, by the way, we’re also effective at recovering the dollars that are owed to you, uh, by being ridiculously nice, was the line.

Dan: I’ve come to Nick for insights on one of the most ridiculously nasty parts of American health care: Because some hospitals and medical providers don’t just send bill collectors — nice or otherwise– after patients. Some hospitals sue their patients over unpaid bills — filing lawsuits by the hundreds, or even thousands, every year. And here’s a twist: These lawsuits don’t bring hospitals much money. So why do they do it? I’ve been interested in this question for years. And this year, I’ve had a lot of help chasing it, working with amazing journalists from two incredible news outlets. We had some ideas when we started — hypotheses, that we tested together. And those hypotheses… they were wrong. But we discovered something along the way that, well, no one else seems to have discovered yet. And for once, it’s actually not-bad news. Surprisingly hopeful. Of course we also learned things that made me super-mad… and the whole inquiry absolutely made clear some ways we can all look out for ourselves and each other. It’s a bunch. So we’re bringing it to you in a two-parter. Strap in.

With Scripps News and the Baltimore Banner, this is “An Arm and a Leg” — a show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann. I’m a reporter, and I like a challenge. So our job on this show is to take one of the most enraging, terrifying, depressing parts of American life, and bring you something entertaining, empowering, and useful. Before we get into big trends, numbers, all that– let’s start with just one family’s story.

Casey and Ron Gasior live in South Milwaukee. Our summer intern, Bella Czakowski, met them there in August.

Bella Czajkowski: Hi, Bella, nice to meet you. My husband, Ron.

Dan: Casey and Ron met in a bar almost 20 years ago. He was working there, and

then so was she. They were close– as friends.

Ron: A lot of people thought that we were together because we were so close.

Casey: But we never had anything to do with each other and that’s a sore subject. On his part. Because …

Bella: Because you were interested back then?

Ron: Yes. Yeah. Who knows, I mean, if we would have been together back then, it might not have lasted. She was young, I was older, but I still …I didn’t have my stuff together, you know. Whatever.

Dan: They married other people, drifted apart, and reconnected as friends years later –by which time both marriages were in trouble. Casey and Ron both got divorces, then got together, then bought this house eight months later. They got married in 2017. And then came the wave — waves– of medical issues.

Casey: His back, his knee, my heart.

Dan: Atrial fibrillation. That’s three procedures between them. And time off work to recover, less income. Another two procedures for Casey– carpal tunnel– more time away from work.

Casey: And at that time, too, I was also diagnosed with diabetes. So there was, there was a lot.

Dan: And there were lots of bills. They had insurance, but there’s always “Your portion.” It adds up. Plus Casey’s meds for diabetes and a-fib.

Casey: we would dig little bit out of our hole, and then we’d go right back down. And it to the where we we can’t even pay these

Dan: And then they started falling behind on house payments too.

Casey: There was a few nights in the garage, trying to figure out what our next step was.

Dan: In the garage, where Ron’s teenage daughter couldn’t hear.

Casey: We tried to do all of this without our daughter knowing, you know, cause

you don’t want to stress a kid out.

Dan: They decided the best of their bad options was Chapter 13 bankruptcy: Wrapping all their debts into a giant five-year payment plan. It would let them keep the house and their cars, if they were able to make the payments. It was really tough. The pandemic didn’t help. But in the spring of 2023, they were a couple months away from getting discharged, when they got a letter from a law firm– looking to collect money on a medical bill. It said…

Casey: That I needed to call them to make payment arrangements by a certain date Ron: Well, not to make arrangements. They wanted to payments. To make payments.

Casey: By a certain date. Otherwise, we’d be going to court.

Dan: The bill was three thousand dollars– for a medical procedure that happened before the bankruptcy. But the bill had come after. They say they called the lawyer, explained: Until we’re discharged from bankruptcy — which we will be soon — we’re actually not allowed to pay you. According to Casey and Ron, the lawyer was rude and said, essentially: See you in court. When they did, Casey says, the judge told the lawyer on the other side: These folks aren’t allowed to pay you anything until their bankruptcy is done. And told the Gasiors: When you’re discharged, do make arrangements to pay. So that’s one story– a lawsuit against folks who literally weren’t allowed to pay.

And every story is gonna be different, but the big picture: Lawsuits filed against people who — even without a court order — just couldn’t pay — that’s not a one-off. Lots of folks — reporters, researchers, advocates — have been documenting this phenomenon — hospitals suing patients by the hundreds or even thousands– for a long time. For instance, in Maryland, a study from 2020 found a hundred and forty thousand lawsuits that hospitals had filed against patients over a ten-year period. In New York, a series of reports looked at more than 50,000 lawsuits over just five years. 

Elisabeth Benjamin co-wrote those New York reports. She’s the vice president for health initiatives at the Community Service Society of New York. And one of the findings that shocked her was: how small the amounts were that folks were being sued for– like, compared to a hospital’s bottom line. Or even compared to an average hospital bill.

Elisabeth Benjamin: They’re suing people for pennies. right. The average lawsuit is maybe 1900 bucks. So they’re suing them for chump change, but that $1,900 is like life ruining for the patient.

Dan: Because the people getting sued tend to be people who are just getting by– if they’re even getting by. Elisabeth Benjamin found: People whose wages get garnished to pay medical debts tend to work for low-wage employers. And our colleagues at the Baltimore Banner found that in Maryland, people who get sued over medical bills tend to live in census tracts where poverty is high. Elisabeth Benjamin turned up another finding that surprised her: The hospitals filing the most lawsuits were not always the kinds of places that were hard-up for money. And lots of hospitals that were hard up for money weren’t filing any lawsuits.

Elisabeth Benjamin: In other words, there’s many hospitals that are either making it or not making it, but are not suing people. At least in New York, most hospitals are good guys. I mean, they wouldn’t dream of suing people. And then there’s like this cruddy, top 20, top 15 that are responsible for huge amounts of the lawsuits. And it doesn’t seem like the amounts they’re suing for really has any bearing on any hospitals bottom line. So then it begs the question of, well, what are they doing this for in the first place?

Dan: That’s basically the question I started with. What are they doing this for in the first place? And I just want to underline one of Elisabeth Benjamin’s findings: not all hospitals do this– file lawsuits in bulk. Most hospitals don’t. Other studies have found the same thing. So, it’s not a necessity. It’s a choice. And for the majority of hospitals, it’s a choice that seems to run counter to a pretty important fact: They’re organized as non-profit charities. They pay no taxes, and they give donors big tax write-offs. And they’re legally obligated to provide charity care: To have policies saying how they’ll write off bills for folks who can’t pay. 

I mean, even for-profit hospitals tend to have policies like that, without a legal obligation. So, suing people in bulk, … it’s an interesting choice. I wanted to talk with people who were part of the conversations where hospitals give the order: This is how we’re going to collect. And I got to talk with a couple of those people. One of them was Nick McLaughlin. Because Nick says, when a hospital sues patients– especially if they’re filing lawsuits in bulk, by the hundreds or thousands– a lot of the time, they’re not sending a staff attorney, or even picking a lawyer directly. The collection agency handles all that. But as Nick tells me: the strategy, the question of whether or not to sue, how hard to chase people– that all comes from the client, someone like the hospital’s revenue director.

Nick: We had clients at AmeriCollect where, they’d say, collect on it for six months and afterwards cancel it back.

Dan: Cancel it back. Meaning, cancel the assignment. Just don’t even bother trying to collect after six months. We’ll write it off.

Nick: And we’d say, you sure? Six months isn’t very long. And they’d say, “That’s what we want.” it’s more standard to be, two years.

Dan: What’s the recovery like in those intervening 18 months? Like how much more you get?

Nick: Not a ton.

Dan: Because — and this was the part that stuck with me the most– by the time a bill gets sent to a collection agency, it’s unlikely to actually be collected. When Nick was pitching AmeriCollect’s services, the pitch wasn’t, “We collect more than anybody else.” Because: that wasn’t a relevant pitch.

Nick: You’re normally not really gonna move the needle much from one collection agency to another. Meaning one collection agency might collect 10 percent, the next collection agency might collect 12 percent.

Dan: That’s a difference of two percent– but two percent of WHAT? Two percent of what’s already a very narrow slice of hospitals’ income.

I talked with an analyst for a consulting company called Kodiak– they run the numbers on this kind of thing. He said hospitals get about 90 percent of their money from insurance. By the time they send us bills, hospitals have already got 90 percent of their money. And then: a lot of people are able to pay their bills before getting sent to collections. Nick says maybe five or six percent of hospital bills– in dollars– get sent to collections at all. And Nick says, when you’re looking for someone to chase folks for that five or six percent, the difference between one agency and another is… not much.

Nick: One agency is collecting 10 percent of 5 percent and one agency is collecting 12 percent of 5%. We’re talking about a difference of, fractions of a fraction of a percent.

Dan: And even if ALL of the difference — the fractions of a fraction of a percent — is because you went hard after people, took them to court… it really looks like peanuts. 

This lines up with what journalists and advocates have documented in their reports: They compare the total, aggregate amounts hospitals are suing for, and compare it to the institution’s annual surplus. Or pay for top executives. The amounts their suing for– total– always look tiny in comparison. So the decision to do something like sue people in bulk, it doesn’t seem to Nick like it’s based on numbers. In fact, here’s where the mystery gets deeper. Because: You may have noticed, Nick’s been talking about Americollect in the past tense. He doesn’t work there anymore. These days he runs his own business, pitching his old clients — and any other hospital system he can get to listen — on a completely different approach: No matter how ridiculously nice your collections agents may be, he tells them, you should be sending them a lot less business. You’d be better off forgiving those debts, through charity care, before ever sending the first bill. He’s pitching tech to help hospitals do that. And he’s not telling hospitals, you should do this to be nice. He’s telling them: this is better for your bottom line. How he got there, and the pitch he makes now– that’s next.

This episode of An Arm and a Leg is produced in partnership with KFF Health News– that’s a nonprofit newsroom covering health care in America. They are amazing journalists, and I learn from them all. The. Time. We’ll have a little more information about KFF Health News at the end of this episode.

This part of Nick’s story starts at a family holiday gathering in 2019. And a conversation with his wife’s grandfather, who was 86 at the time.

Nick: He and grandma were on social security and not a whole lot of extra resources. Pretty much your, standard salt of the earth, awesome people that serve everybody else and don’t have a ton. But are just fine with that.

Dan: But now grandpa had a 750 dollar hospital bill. Not so fine.

Nick: He said, Hey Nick, I know you know a lot about hospital bills. That’s a lot of money for an old guy like me. Do you know if there are any options ? And I said, Well, sure, Grandpa.Have you ever, looked into financial assistance? And he looked at me and said, What’s that?

Dan: Financial assistance — also known as charity care — is when a hospital agrees to reduce your bill, or just write it off, because you don’t make enough money to pay it.

And Nick knew all about charity care because since he’d started working at Americollect, having a charity care policy had become a legal obligation for nonprofit hospitals — which is to say, the majority of American hospitals — thanks to a provision in the Affordable Care Act.

Nick’s company, AmeriCollect, had kept on top of that new law, and he says they helped hospitals make sure they were complying with it.

Nick: We put together policy templates and sample financial assistance policies and application forms

Dan: He says it was, in its way, a long-game sales strategy. If you develop a reputation among hospitals as someone who’s trustworthy and helpful and smart, then next time they need a new bill collector, they’ll keep you in mind. Anyway, when Nick’s grandpa said, “What’s financial assistance?” Nick was ready to go.

Nick: I said, let’s see if you qualify um, so I pulled up, the hospital’s website and pulled up their financial assistance policy, um, which was 16 pages long. And I thought to myself, how in the world would grandpa get an answer to the question, do I qualify for financial assistance?

Dan: Nick has looked at a lot of super-long financial-assistance forms since then, and he can rattle off the kinds of questions they ask:

Nick: What kind of cars do you drive? Your make and model. How much do you think that it’s worth? And how much do you owe on it? What is the value of your primary residence? How much are you spending each month on house payment, car payment, groceries, cell phone bill, a breakdown of a monthly budget?

Dan: In other words, a LOT. Nick says some of the detailed questions were put there in anticipation of proposed federal laws and regulations that never got adopted. So, Nick was super well versed in all this stuff. He’d helped hospitals design their charity care policies.

Nick: But I hadn’t spent a whole lot of time thinking about what it would be like from the patient’s perspective to try to navigate a hospital’s financial assistance program.

Dan: He was like, before jumping into all this, Grandpa, let’s just figure out if it’s worth it. Are you likely to qualify? And Nick knew how to get an answer: Because he knew, the way hospital charity-care policies work is: They compare your income to a multiple of the federal poverty level. At this hospital it was 250 percent. Nick learned what grandma and grandpa got from social security, compared it to that federal poverty number.

Nick: And so I was like, all right, well, hey grandpa, it looks like you’re going to qualify for financial assistance, let’s print out an application and start filling it out. It was bare because it was a beast of an application. But eventually he was approved for Medicaid and never received another hospital bill for the rest of his life.

Dan: And the 750 bucks? 

Nick: Disappeared.

Dan: It got Nick thinking about a presentation he’d seen a couple of years before. This was when a lot of hospitals were first rolling out their charity-care policies to comply with the new law. One of the national Catholic hospital chains was giving a talk about their policy.

Nick: We offer 75 percent discounts up to 400 percent of the federal poverty level. And I just kind of sat back in my chair and thought, 400 percent of the federal

poverty level.

Dan: That sounded like it might cover a lot of people. Like, how many people in this country make less than that? Maybe a lot. He looked it up later, and I did too:

4 times the federal poverty level for a single person is about 58 thousand a year. And almost 60 percent of Americans make less than that.

Nick: So the next logical step is, Okay, well, uh, People that hospitals send to collections, would you imagine that they have higher incomes or lower incomes than your average American? I think it’s fair to say that we can guess that they’re lower on the income scale than the average American.

Dan: So it would seem like most people who get sent to collections… would’ve qualified for financial assistance. And since, according to industry consultants, most BILLS that get sent to collections never get collected it also seems like: A lot of people who are getting chased by collections agents, maybe getting sued, would have qualified for charity care. Which, duh, maybe. I mean, a lot of reporters and advocates have written a lot of reports showing exactly that. To a lot of people, it looks like an outrage. But with Nick’s knowledge of hospital revenue departments, he saw it as something else: An opportunity. By spending all that effort on chasing folks who wouldn’t and couldn’t pay, hospitals were WASTING MONEY on that effort. And– again, because Nick really knows the nerdy details– he figured hospitals were also leaving other money on the table. Like from Medicaid, which would be paying for Grandpa’s hospital bills– not just for that first 750 dollar charge, but on every bill for the rest of his life. That’s money the hospital would’ve had a hard time getting from grandpa. And Nick thought: A guy could build a business helping hospitals save money over here and pick up money over there. So he quit his job at AmeriCollect to start that business. I asked him to do his pitch for me.

Nick: Uh, pitch. Are you looking for basically what we present to hospitals and stuff like that? Yeah.

Dan: He does this at conferences a few times a year. He pulled up PowerPoint, put it in Presenter View.

Nick: Love presenter view. Hey, let me just fire away. Yeah.

Dan: And we were off.

Nick: So, as the host mentioned, I spent my first 12 years in the industry in the hospital billing and collections world.

Dan: Nick skipped a few details– actually, looking over his shoulder I noticed a key one.

Dan (from field tape): this paragraph that you skipped, like, the cost of sending those bills, you’re saying, like, 2 dollars per.

Nick: Oh, yeah

Dan: Two bucks out of pocket. Even though it’s all automated, you’re spending a lot on the machines, the software, the paper– not to mention postage. And if someone’s headed to collections, you’re not just sending them one bill.

Nick: if you think about three statements and a final notice, and customer service cost for supporting all of that, it’s not insignificant.

Dan: Oh yeah: Customer service cost. That’s the call center. So that’s savings. Then there’s money you pick up. Nick proposes that hospitals basically just ask people their income up front, along with their insurance information. He’s offering them an easy web form to give patients. And he says when hospitals use that form, like ten percent of patients turn out to be eligible for Medicaid. He tells hospitals:

Nick: These are great opportunities to help them get on the Medicaid program, and help you get paid for the care that you provided.

Dan: And Nick says Medicaid isn’t the only opportunity to get paid. Lots of people with regular insurance also have deductibles and other “patient responsibilities” that can get into the thousands of dollars. Which makes a lot of people think twice about going in for care, if they can avoid it. And: Not only could a lot of those people meet the income requirements for charity care– remember, almost 60 percent could meet those requirements at some hospitals — hospitals can adopt charity-care policies that cover people who do have insurance. Which, Nick argues can be a money-making opportunity.

Nick: Um, a question I like to pose is: If a low income patient is on the fence about getting a procedure at your hospital, for example, a knee replacement, that will get you paid 15,000 by their insurance…

Dan: … then wouldn’t it be smart to offer them charity care so they don’t worry about their deductible? You’d be unlocking that 15 thousand dollars from their insurance company. Nick’s pitch sounded pretty solid to me. He’s got some clients, and a backer — a bigger company that’s investing in his work. He says people chat him up after he gives these talks… but he does hear some — not pushback, exactly. More like…

Nick: Eh, we’ll do what we need to do to be compliant, but we’ve got other things to deal with that, we’re not really going to worry about this too much.

Dan: In other words, it’s not a priority. Maybe not where the big money is. But then, lawsuits — especially lawsuits against people who can’t pay– aren’t where the big money is either. Why do these folks allow themselves to be literally party to them?

Nick: It’s really, I would say philosophically-based.

Dan: Philosophically-based. Up to the philosophy of the collection agency and the hospital revenue director. In part two of this story, we’ll hear from someone in the collections world who’s ready to argue, philosophically, that it’s OK to sue people for medical bills they just can’t pay.

Scott Purcell: If you just sued somebody who can’t pay, they’re not out any money. So you made a bad business decision. But truly Dan, what is the harm they’re experiencing?

Dan: And we’ll hear about the case of the disappearing lawsuits’

Ryan Little: So on September 18th, I said, Maryland hospitals are dot, dot, dot…

Basically not suing anyone for medical debt anymore. 

Dan: Yep!

Meanwhile, this is a GREAT time to make a donation to keep this show going. Projects like this take a TON of time and money. And right now, every dollar you give is being MATCHED by other “Arm and a Leg” listeners.

The NewsMatch program from the Institute for Nonprofit News has matched as much as they can for this year, and a few super-generous listeners have put up MORE matching funds. Go take them up on it!

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Thank you so much! Your help makes a huge difference. We’ll be back in two weeks with part two. 

Till then, take care of yourself.

This episode of An Arm and a Leg was produced by me, Dan Weissmann, with help from Bella Czakowski and  Emily Pisacreta in partnership with the Scripps News, the Baltimore Banner, and the McGraw Center for Business Journalism at the Craig Newmark Graduate School of Journalism at the City University of New York.

Our work on this story is supported by the Fund for Investigative Journalism, and edited by Ellen Weiss.

Daisy Rosario is An Arm and a Leg’s consulting managing producer.

Gabrielle Healy is our managing editor for audience — she edits the First Aid Kit newsletter.

Sarah Ballema is our Operations Manager. 

Bea Bosco is our Consulting Director of Operations.

An Arm and a Leg is produced in partnership with KFF Health News.

That’s a national newsroom producing in-depth journalism about health care in America, and a core program at KFF — an independent source of health policy research, polling, and journalism.

You can learn more about KFF Health News at arm and a leg show dot com, slash KFF. (https://armandalegshow.com/about-x/partners-and-supporters/kaiserhealthnews/)

Zach Dyer is senior audio producer at KFF Health News. He is editorial liaison to this show.

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If you haven’t yet, we’d love for you to pitch in to join us. Again, the place for that is arm and a leg show dot com, slash support.(https://armandalegshow.com/support/)

“An Arm and a Leg” is a co-production of KFF Health News and Public Road Productions.

This episode was produced in partnership with Scripps News, The Baltimore Banner, and the McGraw Center for Business Journalism at the Craig Newmark Graduate School of Journalism at the City University of New York.

Work by “An Arm and a Leg” on this article is supported by the Fund for Investigative Journalism.

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KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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This story can be republished for free (details).

The award-winning project has exposed the enormous scale of this problem, finding, among other things, that 100 million people in the U.S. are saddled with some kind of health care debt.

KFF Health News senior correspondent Noam N. Levey joined NPR’s “The Sunday Story” to talk about the project, its findings, and the impact the reporting has had on policymakers and patients across the country. Listen to the program here.

About This Project

“Diagnosis: Debt” is a reporting partnership between KFF Health News and NPR exploring the scale, impact, and causes of medical debt in America.

The series draws on original polling by KFF, court records, federal data on hospital finances, contracts obtained through public records requests, data on international health systems, and a yearlong investigation into the financial assistance and collection policies of more than 500 hospitals across the country. 

Additional research was conducted by the Urban Institute, which analyzed credit bureau and other demographic data on poverty, race, and health status for KFF Health News to explore where medical debt is concentrated in the U.S. and what factors are associated with high debt levels.

The JPMorgan Chase Institute analyzed records from a sampling of Chase credit card holders to look at how customers’ balances may be affected by major medical expenses. And the CED Project, a Denver nonprofit, worked with KFF Health News on a survey of its clients to explore links between medical debt and housing instability. 

KFF Health News journalists worked with KFF public opinion researchers to design and analyze the “KFF Health Care Debt Survey.” The survey was conducted Feb. 25 through March 20, 2022, online and via telephone, in English and Spanish, among a nationally representative sample of 2,375 U.S. adults, including 1,292 adults with current health care debt and 382 adults who had health care debt in the past five years. The margin of sampling error is plus or minus 3 percentage points for the full sample and 3 percentage points for those with current debt. For results based on subgroups, the margin of sampling error may be higher.

Reporters from KFF Health News and NPR also conducted hundreds of interviews with patients across the country; spoke with physicians, health industry leaders, consumer advocates, debt lawyers, and researchers; and reviewed scores of studies and surveys about medical debt.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

But in her mid-40s, Woodward retired after being diagnosed with a debilitating form of arthritis. Her condition required expensive drugs and regular medical care, which left her with more than $20,000 in medical debts.

She had no option but to move out of her home and restart her life in a small town in Virginia’s Shenandoah Valley. At times, she has relied on food banks to get enough to eat.

Woodward is one of 100 million people in the U.S. with health care debt. Watch her story here.

About This Project

“Diagnosis: Debt” is a reporting partnership between KFF Health News and NPR exploring the scale, impact, and causes of medical debt in America.

The series draws on original polling by KFF, court records, federal data on hospital finances, contracts obtained through public records requests, data on international health systems, and a yearlong investigation into the financial assistance and collection policies of more than 500 hospitals across the country. 

Additional research was conducted by the Urban Institute, which analyzed credit bureau and other demographic data on poverty, race, and health status for KFF Health News to explore where medical debt is concentrated in the U.S. and what factors are associated with high debt levels.

The JPMorgan Chase Institute analyzed records from a sampling of Chase credit card holders to look at how customers’ balances may be affected by major medical expenses. And the CED Project, a Denver nonprofit, worked with KFF Health News on a survey of its clients to explore links between medical debt and housing instability. 

KFF Health News journalists worked with KFF public opinion researchers to design and analyze the “KFF Health Care Debt Survey.” The survey was conducted Feb. 25 through March 20, 2022, online and via telephone, in English and Spanish, among a nationally representative sample of 2,375 U.S. adults, including 1,292 adults with current health care debt and 382 adults who had health care debt in the past five years. The margin of sampling error is plus or minus 3 percentage points for the full sample and 3 percentage points for those with current debt. For results based on subgroups, the margin of sampling error may be higher.

Reporters from KFF Health News and NPR also conducted hundreds of interviews with patients across the country; spoke with physicians, health industry leaders, consumer advocates, debt lawyers, and researchers; and reviewed scores of studies and surveys about medical debt.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

With other GOP presidential candidates following Donald Trump’s lead in calling for an end to the Affordable Care Act, Democrats are jumping on an issue they think will favor them in the 2024 elections. The Biden administration almost immediately rolled out a controversial proposal that could dramatically decrease the price of drugs developed with federally funded research dollars. The drug industry and the business community at large are vehemently opposed to the proposal, but it is likely to be popular with voters.

Meanwhile, the Supreme Court hears arguments in a case to decide whether the Sackler family should be able to shield billions of dollars taken from its bankrupt drug company, Purdue Pharma, from further lawsuits regarding the company’s highly addictive drug OxyContin.

This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Alice Miranda Ollstein of Politico, and Rachana Pradhan of KFF Health News.

Panelists

Among the takeaways from this week’s episode:

• The ACA may end up back on the proverbial chopping block if Trump is reelected. But as many in both parties know, it is unlikely to be a winning political strategy for Republicans. ACA enrollment numbers are high, as is the law’s popularity, and years after a failed effort during Trump’s presidency, Republicans still have not unified around a proposal to replace it.
• Democrats are eager to capitalize on the revival of “repeal and replace.” This week, the Biden administration announced plans to exercise so-called “march-in rights,” which it argues allow the government to seize certain patent-protected drugs whose prices have gotten too high and open them to price competition. The plan, once largely embraced by progressives, could give President Joe Biden another opportunity to claim his administration has proven more effective than Trump’s heading into the 2024 election.
• The Senate voted to approve more than 400 military promotions this week, effectively ending the 10-month blockade by Republican Sen. Tommy Tuberville of Alabama over a Pentagon policy that helps service members travel to obtain abortions. At the state level, the Texas courts are considering cases over its exceptions to the state’s abortion ban, while in Ohio, a woman who miscarried after being sent home from the hospital is facing criminal charges.
• Meanwhile, the Supreme Court soon could rule on whether EMTALA, or the Emergency Medical Treatment and Active Labor Act, requires doctors to perform abortions in emergencies. And justices are also considering whether to allow a settlement deal to move forward that does not hold the Sacker family accountable for the harm caused by opioids.
• “This Week in Medical Misinformation” highlights a lawsuit filed by Texas Attorney General Ken Paxton accusing Pfizer of failing to end the covid-19 pandemic with its vaccine.

Also this week, Rovner interviews Dan Weissmann, host of KFF Health News’ sister podcast, “An Arm and a Leg,” about his investigation into hospitals suing their patients for unpaid medical bills.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: The Wisconsin State Journal’s “Dane, Milwaukee Counties Stop Making Unwed Fathers Pay for Medicaid Birth Costs,” by David Wahlberg.  

Anna Edney: Bloomberg News’ “Tallying the Best Stats on US Gun Violence Is Trauma of Its Own,” by Madison Muller.  

Alice Miranda Ollstein: Stat’s “New Abortion Restrictions Pose a Serious Threat to Fetal Surgery,” by Francois I. Luks, Tippi Mackenzie, and Thomas F. Tracy Jr. 

Rachana Pradhan: KFF Health News’ “Patients Expected Profemur Artificial Hips to Last. Then They Snapped in Half,” by Brett Kelman and Anna Werner, CBS News.

Also mentioned in this week’s episode:

• Bloomberg News’ “The Pentagon Wants to Root Out Shoddy Drugs. The FDA Is in Its Way,” by Anna Edney and Riley Griffin.
• Ars Technica’s “Texas Sues Pfizer With COVID Anti-Fax Argument That Is Pure Stupid,” by Beth Mole.

KFF Health News’ ‘What the Health?’Episode Title: Democrats See Opportunity in GOP Threats to Repeal Health LawEpisode Number: 325Published: Dec. 7, 2023

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest reporters in Washington. We’re taping this week on Thursday, Dec. 7, at 10 a.m. As always, news happens fast, and things might’ve changed by the time you hear this. So here we go. Today, we are joined via video conference by Alice Miranda Ollstein of Politico.

Alice Miranda Ollstein: Good morning.

Rovner: Anna Edney of Bloomberg News.

Anna Edney: Hello.

Rovner: And my KFF Health News colleague Rachana Pradhan.

Rachana Pradhan: Good morning, Julie.

Rovner: Later in this episode we’ll have my interview with Dan Weissmann, host of our sister podcast, “An Arm and a Leg.” Dan’s been working on a very cool two-part episode about hospitals suing their patients that he will explain. But first, this week’s news. So now that former President [Donald] Trump has raised the possibility of revisiting a repeal of the Affordable Care Act, all of the other Republican presidential wannabes are adding their two cents.

Florida Gov. Ron DeSantis says that rather than repeal and replace the health law, he would “repeal and supersede,” whatever that means. Nikki Haley has been talking up her anti-ACA bona fides in New Hampshire, and the leading Republican candidate for Senate in Montana is calling for a return to full health care privatization, which would mean getting rid of not only the Affordable Care Act, but also Medicare and Medicaid.

But the Affordable Care Act is more popular than ever, at least judging from this year’s still very brisk open enrollment signups. Alice, you wrote an entire story about how the ACA of 2023 is not the ACA of 2017, the last time Republicans took a serious run at it. How much harder would it be to repeal now?

Ollstein: It would be a lot harder. So, not only have a bunch of red and purple states expanded Medicaid since Republicans took their last swing at the law — meaning that a bunch more constituents in those states are getting coverage they weren’t getting before and might be upset if it was threatened by a repeal — but also just non-Medicaid enrollment is up as well, fueled in large part by all the new subsidies that were implemented over the last few years. And that’s true even in states that resisted expansions.

DeSantis’ Florida, for instance, has the highest exchange enrollment in the country. There’s just a lot more people with a lot more invested in maintaining the program. You have that higher enrollment, you have the higher popularity, and we still haven’t seen a real replacement or “supersede” plan, or whatever they want to call it. And folks I talk to on Capitol Hill, Republican lawmakers, even those that were pretty involved last time, do not think such a plan is coming.

Rovner: It did get asked about at the “last” Republican presidential primary debate last night, and there was an awful lot of hemming and hawing about greedy drug companies and greedy insurance companies, and I heard exactly nothing about any kind of plan. Has anybody else seen any sign of something that Republicans would actually do if they got rid of the Affordable Care Act?

Pradhan: No. There was a time, immediately after the ACA’s passage, that health care was a winning political issue for Republicans, right? It was multiple election cycles that they capitalized on Obamacare and used it to regain House majorities, Senate majorities, and the presidency eventually. But that has not been true for multiple years now. And I think they know that. I think establishment Republicans know that health care is not a winning issue for the party, which is why Democrats are so eager to capitalize on this reopening of ACA repeal, if you will.

Rovner: What a perfect segue, because I was going to say the Biden administration is wasting no time jumping back into health care with both feet, trying to capitalize on what it sees as a gigantic Republican misstep. Just this morning, they are rolling out new proposals aimed at further lowering prescription drug prices, and to highlight the fact that they’ve actually gotten somewhere in some lowering of prescription drug prices.

Now they would like to make it easier to use government “march-in rights,” which would let the government basically tell prescription drug companies, “You’re going to lower your price because we’re going to let other people compete against you, despite your patent.” They’re also doing, and I will use their words, a cross-government public inquiry into corporate greed in health care. Now, some of these things are super controversial. I mean, the march-in rights even before this was unveiled, we saw the drug industry complaining against. But they could also have a real impact if they did some of this, right? Anna, you’ve watched the drug price issue.

Edney: Yeah, I think they definitely could have an impact. This is one of those situations with the march-in rights where we don’t have any clue on where or how exactly, because we haven’t been told that this drug or this class of drugs are kind of what we’re aiming at at this point. It sounds like maybe there’s a little bit more of the plan to be baked, but I am sure there are a lot of progressives, particularly, who had pushed for this that, over the years, who are very excited to even see it mentioned and moving in some sort of way, which hasn’t really happened before.

And, clearly, the Biden administration wants to, like you said, capitalize on health care being part of the campaign. And they’ve done a lot on drug prices, at least a lot in the sense of what can be done. There’s negotiation in Medicare now for some drugs. They kept insulin for Medicare as well. So this is just another step they can say, “We’re doing something else,” and we’d have to see down the line exactly where they’d even plan to use it.

And, of course, as pharma always does, they said that this will hurt innovation and we won’t get any drugs. Not that things have been in place that long, but, clearly, we haven’t seen that so far.

Rovner: Yes, that is always their excuse. I feel like this is one of those times where it doesn’t even matter if any of these things get done, they’re putting them out there just to keep the debate going. This is obviously ground that the Biden campaign would love to campaign on — rather than talking about the economy that makes people mostly unhappy. I assume we’ll be seeing more of this.

Edney: Yeah. Your food prices and other things are very high right now. But if they can talk about getting drug prices lower, that’s a totally different thing that they can point to.

Ollstein: And it’s an easy way to draw the contrast. For people who might be apathetic and think, “Oh, it doesn’t matter who wins the presidential election,” this is an area where the Biden administration can credibly claim, based on what Trump recently said, “This is what’s at stake. This is the difference between my opponent and me. The health care of millions is on the line,” which has been a winning message in past elections.

And what’s been really striking to me is that even talking to a bunch of conservatives now, even though they don’t like the Affordable Care Act, they even are starting to argue that full-scale repeal and replace — now that it’s the status quo — that’s not even a conservative proposal.

They’re saying that it’s more conservative to propose smaller changes that chip around the edges and create some alternatives, but mainly leave it in place, which I think is really interesting, because for so long the litmus test was: Are you for full repeal, root and branch? And we’re just not really hearing that much anymore — except from Trump!

Rovner: The difficulty from the beginning is that the basis of the ACA was a Republican proposal. I mean, they were defanged from the start. It’s been very hard for them to come up with a replacement. What it already is is what Mitt Romney did in Massachusetts. Well, let us turn to the other big issue that Democrats hope will be this coming election year, and that’s abortion, where there was lots of news this week.

We will start with the fact that the 10-month blockade of military promotions by Alabama Republican Sen. Tommy Tuberville is over. Well, mostly over. On Tuesday, the Senate approved by voice vote more than 400 promotions that Tuberville had held up, with only a few four-star nominees still in question. Tuberville’s protests had angered not just Senate Democrats and the Biden administration, who said it was threatening national security, but increasingly his own Senate Republican colleagues.

Tuberville said he was holding up the nominations to protest the Biden administration’s policy of allowing active-duty military members and their dependents to travel out of state for an abortion if they’re stationed where it’s illegal, like in, you know, Alabama. So Alice, what did Tuberville get in exchange for dropping his 10-month blockade?

Ollstein: So, not much. I mean, his aim was to force the Biden administration to change the policy, and that didn’t happen — the policy supporting folks in the military traveling if they’re based in a state where abortion is banned and they need an abortion, supporting the travel to another state, still not paying for the abortion itself, which is still banned. And so that was the policy Tuberville was trying to get overturned, and he did not get that. So he’s claiming that what he got was drawing attention to it, basically. So we’ll see if he tries to use this little bit of remaining leverage to do anything. It does not seem like much was accomplished through this means, although there is a lot of anxiety that this sets a precedent for the future, not just on abortion issues, but, really, could inspire any senator to try to do this and hold a bunch of nominees hostage for whatever policy purpose they want.

Rovner: I know. I mean, senators traditionally sit on nominees for Cabinet posts. And the FDA and the CMS [Centers for Medicare & Medicaid Services] didn’t have a director for, like, three administrations because members were angry at the administration for something about Medicare and Medicaid. But I had never seen anybody hold up military promotions before. This was definitely something new. Rachana, you were going to add something?

Pradhan: Oh, I mean, I was just thinking on Alabama specifically. I mean, I don’t claim to know, even though there was rising anger in Sen. Tuberville’s own party about this move. I mean, I’m not saying I know that this is a factor or not, but in Alabama, regardless of what he tried to do, I think that the attorney general in Alabama has made it clear that he might try to prosecute organizations that help people travel out of state to get abortions.

And so, it’s not like this is only the last word when you’re even talking about military officers or people in the military. Even in his home state, you might see some greater activity on that anyway, which might make it easier for him to honestly, in a way, give it up because it’s not the only way that you could presumably prosecute organizations or people who tried to help others go out of state to access abortion.

Rovner: Yeah, it’s important to say that while he irritated a lot of people in Washington, he probably had a lot of support from people back home in Alabama, which he kept pointing out.

Ollstein: Right. And I saw national anti-abortion groups really cheering him on and urging their members to send him thank-you letters and such. And so definitely not just in his home state. There are conservatives who were backing this.

Rovner: Well, moving on to Texas, because there is always abortion news out of Texas, we have talked quite a bit about the lawsuit filed by women who experienced pregnancy complications and couldn’t get abortions. Well, now we have a separate emergency lawsuit from a woman named Kate Cox, who is currently seeking an abortion because of the threat to her health and life.

Both of these lawsuits aren’t trying to strike the Texas ban, just to clarify when a doctor can perform a medically needed abortion without possibly facing jail time or loss of their medical license. Alice, I know the hearing for Kate Cox is happening even now as we are taping. What’s the status of the other case? We’re waiting to hear from the Texas Supreme Court. Is that where it is?

Ollstein: Yeah. So oral arguments were the other day and a bunch of new plaintiffs have joined the lawsuit. So it’s expanded to a few dozen people now, mostly patients, but some doctors as well who are directly impacted by the law. There was some interesting back and forth in the oral arguments over standing.

And one of the things the state was hammering was that they don’t have standing to sue because they aren’t in this situation that this other woman is in today, where they’re actively pregnant, actively in crisis, and being actively prevented from accessing the health care that they need that their doctor recommends, which in some circumstances is an abortion. And so I think this is an interesting test of the state’s argument on that front.

Rovner: Also, the idea, I mean, that a woman who literally is in the throes of this crisis would step forward and have her name in public and it’s going to court in an emergency hearing today.

Ollstein: Right, as opposed to the other women who were harmed previously. By the time they are seeking relief in court, their pregnancy is already over and the damage has already been done, but they’re saying it’s a threat of a future pregnancy. It’s impacting their willingness to become pregnant again, knowing what could happen, what already happened. But the state was saying like, “Oh, but because you’re not actively in the moment, you shouldn’t have the right to sue.” And so now we’ll see what they say when someone is really in the throes of it.

Rovner: In the moment. Well, another troubling story this week comes from Warren, Ohio, where a woman who experienced a miscarriage is being charged with “abuse of a corpse” because she was sent home from the hospital after her water broke early and miscarried into her toilet, which is gross, but that’s how most miscarriages happen.

The medical examiner has since determined that the fetus was, in fact, born dead and was too premature to survive anyway. Yet the case seems to be going forward. Is this what we can expect to see in places like Ohio where abortion remains legal, but prosecutors want to find other ways to punish women?

Ollstein: I mean, I also think it’s an important reminder that people were criminalized for pregnancy loss while Roe [v. Wade] was still in place. I mean, it was rare, but it did happen. And there are groups tracking it. And so I think that it’s not a huge surprise that it could happen even more now, in this post-Roe era, even in states like Ohio that just voted overwhelmingly to maintain access to abortion.

Pradhan: Julie, do we know what hospital? Because when I was looking at the story, do we know what kind of hospital it was that sent this person away?

Rovner: No. The information is still pretty sketchy about this case, although we do know the prosecutor is sending it to a grand jury. We know that much. I mean, the case is going forward. And we do know that her water broke early and that she did visit, I believe, it was two hospitals, although I have not seen them named. I mean, there’s clearly more information to come about this case.

But yeah, Alice is right. I mean, I wrote about a case in Indiana that was in 2012 or 2013, it was a long time ago, about a woman who tried to kill herself and ended up only killing her fetus and ended up in jail for a year. I mean, was eventually released, but … it’s unusual but not unprecedented for women to be prosecuted, basically, for pregnancy loss.

Ollstein: Yeah, especially people who are struggling with substance abuse. That’s been a major area where that’s happened.

Pradhan: I would personally be very interested in knowing the hospitals that are a part of this and whether they are religiously affiliated, because there’s a standard of care in medicine for what happens if you have your water break before the fetus is viable and what’s supposed to happen versus what can happen.

Rovner: There was a case in Michigan a few years ago where it was a Catholic hospital. The woman, her water broke early. She was in a Catholic hospital, and they also sent her home. I’m trying to remember where she finally got care. But yeah, that has been an issue also over the years. Well, meanwhile, back here in Washington, the Supreme Court is likely to tell us shortly, I believe, whether the 1986 Emergency Medical Treatment and Active Labor Act, known as EMTALA, requires doctors to perform abortions in life-threatening situations, as the Biden administration maintains.

Alice, this case is on what’s known as the “shadow docket” of the Supreme Court, meaning it has not been fully briefed and argued. It’s only asking if the court will overturn a lower court’s ruling that the federal law trumps the state’s ban. When are we expecting to hear something?

Ollstein: It could be after justices meet on Friday. Really, it could be whenever after that. As we’ve seen in the last few years, the shadow docket can be very unpredictable, and we could just get, at very odd times, major decisions that impact the whole country or just one state. And so, yes, I mean, this issue of abortion care and emergency circumstances is playing out in court in a couple different states, and the federal government is getting involved in some of those states.

And so I think this could be a big test. Unlike a lot of lawsuits going on right now, this is not seeking to strike down the state’s abortion ban entirely. It’s just trying to expand and clarify that people who are in the middle of a medical emergency shouldn’t be subject to the ban.

Rovner: It’s similar to what they’re fighting about in Texas, actually.

Ollstein: Yeah, exactly. And this is still playing out at the 9th Circuit, but they’re trying to leapfrog that and get the Supreme Court to weigh in the meantime.

Rovner: Yeah, and we shall see. All right, well, while we’re on the subject of “This Week in Court,” let us move on to the case that was argued in public at the Supreme Court this week about whether the Sackler family can keep much of its wealth while declaring bankruptcy for its drug company, Purdue Pharma, that’s been found liable for exacerbating, if not causing much of the nation’s opioid epidemic.

The case involves basically two bad choices: Let the Sacklers manipulate the federal bankruptcy code to shield billions of dollars from future lawsuits or further delay justice for millions of people injured by the company’s behavior. And the justices themselves seem pretty divided over which way to go. Anna, what’s at stake here? This is a lot, isn’t it?

Edney: Yeah. I mean, it’s interesting how it doesn’t exactly break down on ideological lines. The justices were — I don’t want to say all over the place, because that sounds disrespectful — but they had concerns on many different levels. And one is that the victims and their lawyers negotiated the settlement because for them it was the best way they felt that they could get compensation, and they didn’t feel that they could get it without letting the Sacklers off the hook, that the Sacklers basically would not sign the settlement agreement, and they were willing to go that route.

And the government is worried about using that and letting the Sacklers off the hook in this way and using this bankruptcy deal to be able to shield a lot of their money that they took out of the company, essentially, and have in their personal wealth now. And so that’s something that a lot of companies are, not a lot, but companies are looking to hope to use the sign of bankruptcy protection when it comes to big class-action lawsuits and harm to consumers.

And so I think that what the worry is is that that then becomes the precedent, that the ones at the very top will always get off because it’s easier to negotiate the settlement that way.

Rovner: We’ll obviously have to wait until — as this goes a few months — to see the decisions in this case, but it’s going to be interesting. I think everybody, including the justices, are unhappy with the set of facts here, but that’s why it was in front of the Supreme Court. So our final entry in “This Week in Court” is a twofer. It is also “This Week in Health Misinformation.”

Texas Attorney General Ken Paxton has filed suit against Pfizer for allegedly violating Texas’ Deceptive Trade Practices Act because its covid vaccine did not, in fact, end the covid epidemic. Quoting from the attorney general’s press release, “We are pursuing justice for the people of Texas, many of whom were coerced by tyrannical vaccine mandates to take a defective product sold by lies.” It’s hard to even know where to start with this, except that, I guess, anyone can sue anyone for anything in Texas, right?

Edney: Yeah, that’s a very good point. The entire concept of it feels so weird. I mean, a vaccine doesn’t cure anything, right? That’s not the point of a vaccine. It’s not a drug. It is a vaccine that is supposed to prevent you from getting something, and not everybody took it. So that feels like the end of the story, but, clearly, the attorney general would prefer attention, I think, on this, and to continue to sow doubt in vaccines and the government and the Food and Drug Administration seems to be maybe more of the point here.

Rovner: I noticed he’s only suing for, I think, it’s $10 million, which is frankly not a ton of money to a company as big as Pfizer. So one would assume that he’s doing this more for the publicity than for the actual possibility of getting something.

Pradhan: Yeah, I think Pfizer’s CEO’s annual salary is more than the damages that are being sought in this case. So it’s really not very much money at all. I mean, more broadly speaking, I mean, Texas, Florida, I think you see especially post-public-health-emergency-covid times, the medical freedom movement has really taken root in a lot of these places.

And I think that it just seems like this is adding onto that, where doctors say they should be able to give ivermectin to covid patients and it helped them and not be at risk of losing their license. And that’s really kind of an anti-vaccine sentiment. Obviously, it’s very alive and well.

Rovner: We are post-belief-in-scientific-expertise.

Edney: Well, I was going to say, I appreciated The Texas Tribune’s story on this because they called out every time in this lawsuit that he was twisting the truth or just completely not telling the truth at all in the sense that he said that more people who took the vaccine died, and that’s clearly not the case. And so I appreciated that they were trying to call him out every time that he said something that wasn’t true, but was just completely willing to put that out in the public sphere as if it was.

Rovner: There was also a great story on Ars Technica, which is a scientific website, about how the lawsuit completely misrepresents the use of statistics, just got it completely backwards. We’ll post a link to that one too. Well, while we are talking about drug companies, let’s talk about some drugs that really may not be what companies say they are.

Anna, you have a new story up this week about the Pentagon’s effort to ensure that generic drugs are actually copies of the drugs they’re supposed to be. That effort’s running into a roadblock. Tell us a little about that.

Edney: Yeah, thanks for letting me talk about this one. It’s “The Pentagon Wants to Root Out Shoddy Drugs. The FDA Is in Its Way.” So the FDA is the roadblock to trying to figure out whether the drugs, particularly that the military and their family members are taking, work well and don’t have side effects that could be extremely harmful. So what’s going on here is that the Defense Department and others, the White House even, has grown skeptical of the FDA’s ability to police generic drugs, largely that are made overseas.

We did some analysis and we found that it was actually 2019 was the first time that generic drug-making facilities in India surpassed the number of those in the U.S. So we are making more, not just active ingredients, but finished products over in India. And the FDA just doesn’t have a good line into India. They don’t do many unannounced inspections. They usually have to tell the company they’re coming weeks in advance. And what we found is when the Defense Department started looking into this, they partnered with a lab to test some of these drugs.

They got some early results. Those results were concerning, as far as the drug might not work, and also could cause kidney failure, seizures. And even despite this, they’ve been facing the FDA around every corner trying to stop them and trying to get them not to test drugs. They say it’s a waste of money, when, in fact, Kaiser Permanente has been doing this for its 12.7 million members for several years.

And it just seems like something is going on at the FDA and that they don’t want people to have any questions about generic drugs. They really just want everyone to accept that they’re always exactly the same, and they even derail the White House effort to try to look into this more as well. But the Pentagon said, “Thank you very much, FDA, but we’re going forward with this.”

Rovner: Yeah. I mean, I could see that the FDA would be concerned about … they’re supposed to be the last word on these things. But, as you point out and as much of your reporting has pointed out over the last couple of years, the FDA has not been able to keep up with really making sure that these drugs are what they say they are.

Edney: One thing I learned that was interesting, and this is that in Europe, actually, there’s a network of 70 labs that do this kind of testing before drugs reach patients and after they reach patients. So it’s not a totally unusual thing. And for some reason, the FDA does not want that to happen.

Rovner: Well, finally on the drug beat this week, CVS announced earlier that it would overhaul its drug pricing to better reflect how much it pays for the drugs, all of which sounds great, but the fact is that how much CVS pays for the drugs doesn’t have all that much effect on how much we end up paying CVS for those same drugs, right? They’re just changing how they get the drugs from the manufacturers, not necessarily how they price it for the customers.

Pradhan: I think my main question would be, what does that mean for a patient’s out-of-pocket cost for prescriptions? I don’t know how much of this has to do with … for CVS as the pharmacy, but we have CVS Caremark, which is a major PBM, and how this affects the pricing models there. And PBMs, of course, have been under scrutiny in Congress. And there’s outside pressure too, right? The story that you highlighted, Julie, talks about Mark Cuban’s affordable-drug effort. And so, yeah, I don’t know. I mean, I think it sounds good until maybe we see some more details, right?

Rovner: I saw one story that said, “This could really help lower drug prices for consumers,” and one that said, “This could actually raise drug prices for consumers.” So I’m assuming that this is another one where we’re going to have to wait and see the details of. All right, well, that is this week’s news.

Now we will play my interview with Dan Weissmann of the “Arm and a Leg” podcast, and then we will come back with our extra credits. I am pleased to welcome back to the podcast Dan Weissmann, host of KFF Health News’s sister podcast, “An Arm and a Leg.” Dan has a cool two-part story on hospitals suing patients for overdue bills that he’s here to tell us about. Dan, welcome back.

Dan Weissmann: Julie, thanks so much for having me.

Rovner: So over the past few years, there have been a lot of stories about hospitals suing former patients, including a big investigation by KFF Health News. But you came at this from kind of a different perspective. Tell us what you were trying to find out.

Weissmann: We were trying to figure out why hospitals file lawsuits in bulk. Investigative reporters like Jay Hancock at KFF [Health News] have documented this practice, and one of the things that they note frequently is how little money hospitals get from these lawsuits. Jay Hancock compared the amount that VCU [Health] was seeking from patients and compared it to that hospital system’s annual surplus, their profit margin, and it looked tiny. And other studies document essentially the same thing. So why do they do it?

And we got a clue from a big report done by National Nurses United in Maryland, which, in addition to documenting how little money hospitals were getting compared to the million-dollar salaries they were paying executives in this case, also noted that a relatively small number of attorneys were filing most of these lawsuits. Just five attorneys filed two-thirds of the 145,000 lawsuits they documented across 10 years, and just one attorney filed more than 40,000 cases. So we were like, huh, maybe that’s a clue. Maybe we found somebody who is getting something out of this. We should find out more.

Rovner: So you keep saying “we” — you had some help working on this. Tell us about your partners.

Weissmann: Oh my God, we were so, so lucky. We work with The Baltimore Banner, which is a new daily news outlet in Baltimore, new nonprofit news outlet in Baltimore, that specializes in data reporting. Their data editor, Ryan Little, pulled untold numbers of cases, hundreds of thousands of cases, from the Maryland courts’ website and analyzed them to an inch of their life and taught us more than I could ever have imagined.

And Scripps News also came in as a partner and one of their data journalists, Rosie Cima, pulled untold numbers of records from the Wisconsin court system and worked to analyze data that we also got from a commercial firm that has a cache of data that has more detail than what we could pull off the website. It was a heroic effort by those folks.

Rovner: So what did you find? Not what you were expecting, right?

Weissmann: No. While Rosie and Ryan were especially gathering all this data and figuring out what to do with it, I was out talking to a lot of people. And what I found out is that in the main, it appears that frequently when these lawsuits happen and when hospitals file lawsuits in general, they’re not being approached by attorneys. They’re working with collection agencies. And most hospitals do work with a collection agency, and it’s essentially like, I put it like, you get a menu, oh, I’m having a hamburger, I’m going to pursue people for bills.

Like, OK, do you want onions? Do you want mustard? Do you want relish? What do you want on it? And in this case, it’s like, how hard do you want us to go after people? Do you want us to hit their credit reports — if you still can do that, because the CFPB [Consumer Financial Protection Bureau] has been making regulations about that — but do you want us to do that? How often can we call them? And do you want us to file lawsuits if we don’t get results? And so that is essentially in consultation with the hospital’s revenue department and the collection agency, and it’s a strategic decision between them.

That was what we found out through talking to people. What Rosie and Ryan turned up, and the data we had from the folks in New York backed up, is that, surprisingly, in the three states that we looked at, there’s just so much less of this activity than we had expected to find. In Maryland, Ryan sent me a series of emails, the first saying, like, “I’m not actually seeing any this year. That’s got to be wrong. They must be hiding them somewhere. I’m going to go investigate.” And a week later he was like, “I think I found them, and then we’ll go run some more numbers.”

And then a week later, after going to the courthouse and looking at everything you could find, he was like, “No, actually Maryland hospitals just do not seem to be suing anybody this year.” And we had expected there to be fewer lawsuits, but zero was a surprise to everybody. In New York, we appear to have found that two of those three law firms handling all those cases are no longer handling medical bill cases. And in Wisconsin, final numbers are still being crunched. Our second part will have all those numbers.

The Banner is coming out with their numbers this week. But Scripps News and us are still crunching numbers in Wisconsin. But what was the biggest shocker was, I can just tell you, there were so many fewer lawsuits than we had expected, and many of the most active plaintiffs had either cut the practice entirely, like filing zero lawsuits or filing hardly any. One of the things that a lot of these reports that look at across a state, like in New York and the Maryland report, note, and that we found in Wisconsin too, is that most hospitals don’t do this.

Noam Levey at KFF [Health News] found that many hospitals have policies that say, “We might file a lawsuit,” and some larger number of hospitals file some lawsuits. But in all these cases where you’re seeing tons of lawsuits filed, the phenomenon of suing people in bulk is actually not business as usual for most hospitals. That is driven by a relatively small group of players. There was a study in North Carolina by the state treasurers, obviously and Duke University, that found 95% of all the lawsuits were filed by just a few institutions.

The New York people found this. We’ve seen it in Wisconsin. So I mean, it’s another very interesting question when you’re looking at why does this happen. It’s like it’s not something that most institutions do. And again, in Wisconsin, we found that most of the players that had been the most active had basically stopped.

Rovner: Do we know why? Is it just all of the attention that we’ve seen to this issue?

Weissmann: Probably the answer is we don’t know why. Our colleagues at The Banner called every hospital in Maryland and were not told very much. We emailed all the hospitals in Wisconsin that we could that we had seen dramatically decrease, and nobody came to the phone. So we don’t really know.

But it does seem like, certainly in Maryland and New York, there were these huge campaigns that got tons of publicity and got laws changed, got laws passed. And there has been attention. The reports that Bobby Peterson put out in Wisconsin got attention locally. Sarah Kliff of The New York Times, who’s been writing about these kinds of lawsuits, has written multiple times about hospitals in Wisconsin. So it seems like a good first guess, but it’s a guess. Yeah.

Rovner: Well, one thing that I was interested that you did turn up, as you pointed out at the top, hospitals don’t get very much money from doing this. You’re basically suing people for money that they don’t have. So you did find other ways that hospitals could get reimbursed. I mean, they are losing a lot of money from people who can’t pay, even people with insurance, who can’t pay their multi-thousand-dollar deductible. So what could they be doing instead?

Weissmann: They could be doing a better job of evaluating people’s ability to pay upfront. The majority of hospitals in the United States are obligated by the Affordable Care Act to have charity care policies, financial assistance policies, in which they spell out, if you make less than a certain amount of money, it’s a multiple of the federal poverty level that they choose, we’ll forgive some or all of your bill. And, frequently, that number is as much as four times the federal poverty level. They might knock 75% off your bill, which is a huge help.

And as a guy that I met noted, using data from KFF, 58% of Americans make less than 75% of the federal poverty level. That is a lot of people. And so if you’re chasing someone for a medical bill, they might very well have been someone you could have extended financial assistance to. This guy, his name is Nick McLaughlin, he worked for 10 years for a medical bill collections agency. Someone in his family had a medical bill they were having a hard time paying, and he figured out that they qualified for charity care, but the application process, he noted, was really cumbersome, and even just figuring out how to apply was a big process. And so he thought, I know that chasing people for money they don’t have isn’t really the best business model and that we’re often chasing people for money they don’t have. What if we encourage hospitals to be more proactive about figuring out if someone should be getting charity care from them in the first place?

Because, as he said, every time you send someone a bill, you’re spending two bucks. And you’re not just sending one bill, you’re sending like three bills and a final notice. That all adds up, and you’re manning a call center. You’re spending money and you’re missing opportunities by not evaluating people. Because while you’re asking about their income, you might find out they’re eligible for Medicaid, and you can get paid by Medicaid rather than chasing them for money they don’t have.

And two, they might update their insurance information from you and you can get money from their insurance. You can extend financial assistance to somebody, as you said, who has a deductible they can’t pay, and they might actually come to you for care that you can unlock money from their insurance if they’re going to come to you because they’re not afraid of the bill.

I should absolutely say, while Nick McLaughlin is selling hospitals on the idea of adopting new software, which is a great idea, they should do that, they should be more proactive, an entity called Dollar For, a nonprofit organization out of the Pacific Northwest that’s been doing work all over the country, has been beating the drum about this and has a tool that anybody can use.

Essentially, go to their website, dollarfor.org, and type in where you were seen and an estimate of your income, and they will tell you, you’re likely to qualify for charity care at this hospital, because they have a database of every hospital’s policy. And if you need help applying, because some of these applications are burdensome, we’ll help you. So this exists, and everybody should know about it and everybody should tell everybody they know about it. I think the work they’re doing is absolutely heroic.

Rovner: Well, Dan Weissmann, thank you so much for joining us. We will post a link to Dan’s story in our show notes and on our podcast page.

Weissmann: Julie, thanks so much for having me.

Rovner: OK, we are back. And it’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Anna, why don’t you go first this week?

Edney: Sure. This is from my colleague Madison Muller, “Tallying the Best Stats on US Gun Violence Is Trauma of Its Own.” And I thought she just did such an amazing job with this story, talking to Mark Bryant, who helped start an organization, Gun Violence Archive, which is essentially the only place that is trying to tally every instance of gun violence.

And because of a lot of the restrictions that the NRA has helped get into government regulations and things, some of them which are more recently loosening, but because of those in the past, this is really the only way you could try to look up these statistics. And he’s just given the last decade of his life, with no breaks, trying to do this and his health is failing. And I thought it was just a really poignant look at somebody who has no skin in the game, but just wanted the right information out there.

Rovner: Yeah, obviously this is a big deal. Alice.

Ollstein: I did an op-ed that was published in Stat by a group of fetal medicine specialists who are writing about how their work is being compromised by state abortion bans right now. They were saying these are very risky, high-stakes procedures where they perform operations in utero, latent pregnancy usually, and it’s an attempt to save the pregnancy where there is a big risk. But with all of these, there are risks that it could end the pregnancy, and now they’re afraid of being prosecuted for that.

And they describe a bunch of challenging situations that, even without these bans are challenging, things where there’s twins and something to help one could harm the other twin, and this could all affect the health and life of the parent as well. And so they’re saying that they’re really in this whole new era and have to think about the legal risks, as well as the medical and bioethical ones that they already have to deal with.

Rovner: I’ve reported about this over the years, and I can tell you that these are always really wrenching family decisions about trying to desperately save a pregnancy by doing this extraordinarily difficult and delicate kind of procedure. Rachana.

Pradhan: My extra credit is a story from our colleague Brett Kelman, who worked on this investigation with CBS News. It is about a type of artificial hip known as Profemur that literally were snapping in half in patients’ bodies. I told Brett earlier this week that I was cringing at every line that I read. So if folks want to get a really, frankly, pretty gruesome, awful story about how people around the country have received these artificial hips, and the fact that they broke inside their bodies has really caused a lot of damage.

And, frankly, I know we talked about the FDA, but also this story really sheds light on how the FDA has dropped the ball in not acting with more urgency. And had they done that, many of these injuries likely would’ve been avoided. So, I urge everyone to read it. It’s a great story.

Rovner: It is. I also flinched when I was reading a lot of it. Well, my story is from the Wisconsin State Journal by David Wahlberg, and it’s called “Dane, Milwaukee Counties Stop Making Unwed Fathers Pay for Medicaid Birth Costs.” And while I have been covering Medicaid since the 1980s, and I never knew this even existed, it seems that a handful of states, Wisconsin among them, allows counties to go after the fathers of babies born on Medicaid, which is about half of all births — Medicaid’s about half of all births.

Not surprisingly, making moms choose between disclosing the father to whom she is not married to the state or losing Medicaid for her infant is not a great choice. And there’s lots of research to suggest that it can lead to bad birth outcomes, particularly in African American and Native American communities. I have long known that states can come after the estates of seniors who died after receiving Medicaid-paid nursing home or home care, but this one, at the other end of life, was a new one to me.

Now, I want to know how many other states are still doing this. And when I find out, I’ll report back.

OK, that is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcast. We’d appreciate it if you left us a review. That helps other people find us too. Thanks, as always, to our tireless tech guru, Francis Ying, who’s back from vacation. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, @jrovner, or @julierovner at Bluesky and Threads. Anna?

Edney: @anna_edneyreports on Threads and @annaedney on X.

Rovner: Rachana.

Pradhan: I’m @rachanadpradhan on X.

Rovner: Alice.

Ollstein: I’m @AliceOllstein on X, and @AliceMiranda on Bluesky.

Rovner: We will be back in your feed next week. Until then, be healthy.

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El informe del 1 de diciembre, preparado para la legislatura estatal por el Departamento de Política y Financiamiento de Atención Médica del estado, indica que los funcionarios estatales se acercaron a 23 fabricantes de medicamentos en el último año para proponer un programa de importación. Solo cuatro accedieron a discutir la propuesta, y ninguno mostró interés en participar.

“En general, los desafíos que persisten están fuera de la autoridad estatal y dependen de la acción de la FDA y/o de los fabricantes de medicamentos”, dice el informe.

Legisladores de ambos partidos, a nivel estatal y nacional, han buscado durante décadas legalizar la importación de medicamentos desde Canadá.

Desde 2020, cuando la administración del presidente Donald Trump abrió la puerta a la importación de medicamentos canadienses con regulaciones emitidas pocas semanas antes de perder la reelección, solo algunos estados han presentado solicitudes a la Administración de Alimentos y Medicamentos (FDA) para crear programas de importación.

La FDA aún no ha tomado decisiones al respecto. Colorado presentó su solicitud en diciembre de 2022. Florida, que presentó la solicitud en 2020, ha estado esperando casi tres años por una decisión de la administración Biden sobre su plan de importación, impulsado por el gobernador Ron DeSantis, ahora candidato presidencial republicano.

Cherie Duvall-Jones, vocera de la FDA, dijo que la entidad federal no ha actuado sobre las solicitudes de importación de los estados porque no ha determinado si ahorrarían dinero significativo para los consumidores sin plantear riesgos para la salud pública.

Los consumidores estadounidenses pagan algunos de los precios más altos del mundo por medicamentos de marca. Los medicamentos suelen ser más baratos en Canadá, donde el gobierno controla los precios.

Bajo el gobierno de Trump, el gobierno federal declaró que la importación de medicamentos desde Canadá se podía hacer de manera segura, cumpliendo por primera vez con una condición establecida en una ley de 2003.

Pero los funcionarios de Colorado mencionaron otro inconveniente: la regla no tuvo en cuenta que los estados tendrían que negociar directamente con las farmacéuticas, que se oponen a vender sus medicamentos de marca en Estados Unidos a precios canadienses.

“Como la Regla Final federal no contempló la necesidad de este paso de negociación, hemos instado a la FDA a emitir más guías sobre cómo los estados pueden poner en práctica el programa teniendo esto en cuenta, pero hasta la fecha, no se ha emitido ninguna orientación”, dice el informe de Colorado.

A diferencia de lo que hizo con muchas otras políticas de salud de la administración Trump, Biden no ha revocado ni revisado la regla de importación. Pero su administración tampoco ha mostrado mucho apoyo a la idea. El secretario del Departamento de Salud y Servicios Humanos (HHS), Xavier Becerra, dijo a KFF Health News en diciembre pasado que no se comprometería a que la FDA resolviera alguna solicitud estatal en 2023.

El presidente ha sugerido repetidamente que durante su mandato los estadounidenses podrían importar medicamentos de Canadá. Durante su campaña de 2020, Biden dijo que permitiría la importación de medicamentos certificados como seguros por el gobierno. En 2021, ordenó a la FDA trabajar con los estados para importar medicamentos recetados desde Canadá. En un discurso de 2022 sobre cómo planeaba reducir los precios de los medicamentos, citó estimaciones de Colorado sobre cuánto podrían ahorrar las personas en el estado a través de la importación.

Los funcionarios de la FDA respondieron a la solicitud de Colorado en marzo pidiendo más información y una lista más pequeña de medicamentos a los que apuntar, para demostrar que la importación podría ahorrar dinero. La solicitud inicial de Colorado enumeraba 112 medicamentos de alto costo. El estado estima que los residentes y empleadores podrían ahorrar un promedio de 65% en los costos de esos medicamentos, incluidos fármacos para la diabetes, el asma y el cáncer.

Colorado dijo que planea presentar una solicitud actualizada a principios del próximo año. Para entonces, es posible que la FDA haya tomado una decisión sobre la solicitud de Florida.

Las propuestas de importación de Colorado y Florida son diferentes. El programa de Colorado tiene como objetivo ayudar directamente a los consumidores a obtener medicamentos más baratos. El plan de Florida busca reducir el gasto en medicamentos en programas gubernamentales como Medicaid, el sistema penitenciario y las instalaciones dirigidas por el Departamento de Niños y Familias del estado.

La industria farmacéutica ha argumentado que la administración Trump no certificó adecuadamente que los medicamentos importados de Canadá serían seguros, poniendo en peligro la salud de los estadounidenses. El gobierno de Canadá también ha expresado preocupación de que las importaciones de Estados Unidos generen escasez y precios más altos en su país.

“Los fabricantes de medicamentos harán cualquier cosa para proteger a su gallina de los huevos de oro que son los consumidores y pacientes estadounidenses que pagan los precios más altos por medicamentos en el mundo”, dijo la senadora estatal de Colorado, Sonya Jaquez Lewis, demócrata, farmacéutica y defensora líder de la importación de medicamentos.

Jaquez Lewis dijo que la Casa Blanca y el Congreso deberían obligar a los fabricantes de medicamentos a negociar con los estados para iniciar programas de importación.

En su respuesta inicial a la solicitud de Colorado, la FDA enumeró varios tipos de información que aún necesitaba, incluidos planes sobre etiquetado y elegibilidad de medicamentos, según una carta de marzo de la FDA al estado. Otro problema, dijo la FDA: el estado planeaba importar medicamentos a través de la frontera en Buffalo, Nueva York. La FDA dijo que el único puerto de entrada permitido para medicamentos está en Detroit.

Los funcionarios de Colorado le dijeron a la FDA en marzo que, sin la aprobación federal de su solicitud, estaban teniendo dificultades para obtener compromisos de los fabricantes de medicamentos para obtenerlos.

“Se ha dejado claro que los posibles socios estarán más interesados en comprometerse una vez que nuestro programa haya sido aprobado por la FDA”, escribió Kim Bimestefer, directora ejecutiva del Departamento de Política y Financiamiento de la Atención Médica de Colorado, a la FDA.

“Aunque entendemos que el marco regulatorio no permite una aprobación provisional, sabemos que mostrar progreso hacia un programa aprobado ayudará en nuestras negociaciones con los fabricantes de medicamentos”, agregó.

Otro inconveniente es que la regla de la FDA no permite a los estados comprar medicamentos directamente a distribuidores secundarios. En cambio, deben comprarlos directamente a los fabricantes, dijo Marc Williams, vocero de la agencia de Colorado.

Esto ha resultado difícil porque los fabricantes de medicamentos han prohibido la exportación de productos destinados a la venta en Canadá a los Estados Unidos, dijo Williams.

“Sin su permiso y un acuerdo de suministro directo con un fabricante, Colorado no puede comprar e importar estos medicamentos a precios más bajos que ahorrarían dinero a las personas”, dijo.

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Pero esta compra era diferente de las que ocurren cada día en miles de farmacias de todo Estados Unidos. A Phoenix, de 50 años, que vive en la cercana comunidad de Falcon y no tiene seguro médico, estos medicamentos no le costaron nada.

Open Bible Medical Clinic and Pharmacy gestiona el único programa de donación de medicamentos de Colorado. La mayoría de los fármacos proceden de residencias de adultos mayores en el estado.

“Los aceptamos todos”, explicó la farmacéutica fundadora, Frieda Martin, que el año pasado utilizó esas donaciones para dispensar 1,900 recetas a 200 adultos con bajos ingresos y sin seguro médico. Los participantes pagan una cuota de inscripción anual de $15 para obtener medicamentos gratuitos y atención en la clínica.

Los programas de donación de medicamentos, como éste de Colorado y otro de California, recogen de centros de salud, residentes, farmacias o prisiones los medicamentos sin abrir y sin caducar que se acumulan cuando los pacientes son dados de alta, cambian de medicina o mueren, y los redistribuyen a pacientes vulnerables.

Un 8% de los adultos de Estados Unidos que tomaron medicamentos recetados en 2021, unas 9 millones de personas, no los tomaron según indica la receta debido al costo, y aquellos sin seguro fueron más propensos a saltarse la medicación que los que tenían seguro, según la Encuesta Nacional de Entrevistas de Salud.

Los programas varían en tamaño, pero a menudo están a cargo de farmacias de caridad, organizaciones sin fines de lucro o gobiernos, y mantienen los medicamentos fuera de los vertederos o incineradores, donde se estima que se desechan $11 mil millones en medicamentos no utilizados cada año.

Cuarenta y cuatro estados cuentan ya con leyes que permiten la donación de medicamentos, según la Conferencia Nacional de Legislaturas Estatales. Muchos programas, como el de Colorado, son pequeños o están subutilizados. Ahora, Colorado y otros estados pretenden ampliar su enfoque.

“Los programas de donación de fármacos son eficaces. Existe una gran necesidad. Y hay oportunidades para que los estados ayuden a sus residentes promulgando nuevas leyes”, dijo George Wang, cofundador de SIRUM, siglas de Supporting Initiatives to Redistribute Unused Medicine, una organización sin fines de lucro que cuenta con la mayor red de donantes y distribuidores de medicamentos en el país.

El líder de la mayoría del Senado de Colorado, el demócrata Robert Rodríguez, dijo que planea presentar un proyecto de ley el próximo año para crear un programa de donación de medicamentos que ayude al 10% de los residentes del estado que no pueden comprar sus recetas debido al costo.

Del mismo modo, una ley del año pasado en California permite ampliar el primer y único programa de donación de medicamentos del estado, Better Health Pharmacy en el condado de Santa Clara, a los condados de San Mateo y San Francisco. Kathy Le, farmacéutica supervisora de Better Health, señaló que se está “en las primeras fases” de colaboración con otras farmacias en condados de California para desarrollar programas similares.

El Programa de Donación de Medicamentos de Wyoming, con sede en Cheyenne, utiliza la distribución por correo para llegar a los residentes, incluidos los de zonas remotas del estado que pueden no tener farmacias locales, dijo Sarah Gilliard, farmacéutica y directora del programa. Esta iniciativa envía por correo un total aproximado de 16,000 recetas gratuitas al año a 2,000 residentes de Wyoming con bajos ingresos, sin seguro o con seguro insuficiente.

“El acceso es sin duda un factor importante a la hora de diseñar nuestro programa”, afirmó.

Muchos de los participantes en el programa de Wyoming son mayores de 65 años, beneficiarios de Medicare, con ingresos fijos y copagos inasequibles, pero Gilliard apuntó que ha habido un aumento reciente de participantes de entre 20 y 40 años. Wyoming es uno de los 10 estados que no han ampliado Medicaid para dar cobertura a más residentes con bajos ingresos, lo que podría ser un factor en ese aumento, según Gilliard.

Las donaciones proceden de los 50 estados, y la mayoría son de personas que descubren el programa en Internet o a través del boca en boca. A veces, los donantes introducen en los paquetes notas manuscritas sobre el elevado costo de la medicación o el recuerdo de un familiar fallecido.

Gilliard las guarda y las pega a la pared de la farmacia.

El programa de Wyoming, con su farmacia central gestionada por el estado que recibe, procesa y envía por correo las recetas a los residentes, podría ser un modelo para Colorado, según Gina Moore, farmacéutica y decana de la Facultad de Farmacia y Ciencias Farmacéuticas Skaggs de la Universidad de Colorado en Aurora. Moore fue coautora del informe de un grupo de trabajo para el gobierno estatal, el pasado diciembre, sobre la viabilidad de un programa de donación de medicamentos.

El informe señalaba el éxito de los programas con financiación externa que, en el caso de Wyoming, procede directamente del dinero de los contribuyentes. Utilizando el presupuesto de Wyoming, preveía que un programa de donación de medicamentos en Colorado costaría unos $431,000 el primer año, con un farmacéutico y un técnico farmacéutico que atenderían a unos 1,500 pacientes.

En Colorado Springs, Martin y su marido, Jeff Martin, director ejecutivo de la Open Bible Medical Clinic and Pharmacy, creen que un modelo como el suyo, de carácter benéfico y gestionado por voluntarios, sería viable en Colorado, y se preguntan cómo encajaría su farmacia, de larga trayectoria, con los posibles esfuerzos estatales. En el informe del grupo de trabajo, Moore y sus colegas escriben que el modelo estatal y el programa de los Martin podrían coexistir.

Desde que Colorado promulgó una ley para permitir la donación de fármacos en 2005, se ha modificado varias veces en un intento de ayudar a su crecimiento. Pero el estado no ha invertido dinero ni infraestructura para que despegue un programa de donación de medicamentos.

Las donaciones de fármacos enviadas por correo a Open Bible disminuyeron durante la pandemia y sólo ahora se están recuperando lentamente. La farmacia envía aproximadamente la mitad de todos los medicamentos donados a clínicas de Colorado que atienden a pacientes sin seguro y con bajos ingresos en otras ciudades como Denver, Loveland y Longmont.

En otros lugares de Estados Unidos, SIRUM se asegura de que los donantes dispongan de envases para enviar los medicamentos donados, y proporciona programas informáticos para facilitar el inventario y la distribución. Recientemente, creó un inventario en línea de medicamentos para Good Pill, una farmacia sin fines de lucro que envía recetas para 90 días por unos $6 a residentes de Illinois y Georgia.

SIRUM ayuda a facilitar las donaciones para Better Health Pharmacy de California, que ha dispensado medicamentos a 15,000 residentes del condado de Santa Clara desde su apertura en 2015, dijo Le. Muchos no tienen seguro, tienen un seguro insuficiente y hablan español o vietnamita. Diez voluntarios, a menudo estudiantes, ayudan a registrar las donaciones, y Better Health Pharmacy surte aproximadamente 40,000 recetas al año con costos operativos anuales de poco más de $1 millón, según Le y los funcionarios de salud pública del condado de Santa Clara.

Además de recetas, Better Health Pharmacy ofrece pruebas gratuitas de covid y vacunas contra la gripe para atender las necesidades de su comunidad. “Intentamos encontrar soluciones creativas para ampliar el alcance de nuestros servicios”, añadió Le.

Este compromiso de subsanar las deficiencias en el acceso a la salud y reducir el impacto sobre el medio ambiente significa que “es el momento oportuno” para ampliar los programas de donación de medicamentos en California y fuera, afirmó Monika Roy, subdirectora de salud y controladora de enfermedades transmisibles del Departamento de Salud Pública del condado de Santa Clara.

“Durante la pandemia, las desigualdades en el acceso a la salud se magnificaron”, señaló Roy. “Cuando tenemos soluciones como estas, es un paso adelante para abordar tanto la equidad como el cambio climático en el mismo modelo”.

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But then something caught her attention: When she went to her doctor last month, she learned that the doctor and the hospital where she works will not accept her insurance next year.

Faced with either finding a new doctor or finding a new plan, Du Bois said the decision was easy. “I’m sticking with her because she knows everything about me,” she said of her doctor, whom she’s been seeing for more than a decade.

Du Bois isn’t the only one tuning out when commercials about the open enrollment deadline flood the airwaves each year — even though there could be good reasons to shop around. But sifting through the offerings has become such an ordeal that few people want to repeat it. Avoidance is so rampant that only 10% of beneficiaries switched Medicare Advantage plans in 2019.

Once open enrollment ends, there are limited options for a do-over. People in Medicare Advantage plans can go to another Advantage plan or back to the original, government-run Medicare from January through March. And the Centers for Medicare & Medicaid Services has expanded the criteria for granting a “special enrollment period” to make changes in drug or Advantage plans anytime.

But most seniors will generally allow their existing policy to renew automatically, like it or not.

Keeping her doctor was not Du Bois’ only reason for switching plans, though. With help from Senior PharmAssist, a Durham nonprofit that advises seniors about Medicare, she found a Humana Medicare Advantage plan that would not only be accepted by her providers but also cover her medications — saving her more than $14,000 a year, said Gina Upchurch, the group’s executive director.

Senior PharmAssist is one of the federally funded State Health Insurance Assistance Programs, known as SHIPs, available across the country to provide unbiased assistance during the open enrollment season and year-round to help beneficiaries appeal coverage denials and iron out other problems.

“Many people are simply overwhelmed by the calls, ads, the sheer number of choices, and this ‘choice overload’ contributes to decision-making paralysis,” said Upchurch. Seniors in Durham have as many as 74 Advantage plans and 20 drug-only plans to choose from, she said.

Upchurch said the big insurance companies like the way the system works now, with few customers inclined to explore other plans. “They call it ‘stickiness,’” she said. “If we had fewer and clear choices — an apple, orange, grape, or banana — most people would review options.”

In Washington state, one woman switched from a plan she had had for more than a decade to one that will cover all her drugs and next year will save an estimated $7,240, according to Tim Smolen, director of the state’s SHIP, Statewide Health Insurance Benefits Advisors.

In Northern California, another woman changed drug plans for the first time since 2012, and her current premium of $86 will plummet to 40 cents a month next year, an annual savings of about $1,000, said Pam Smith, a local director for California’s SHIP, called the Health Insurance Counseling & Advocacy Program.

And in Ohio, a woman sought help after learning that her monthly copayment for the blood thinner Eliquis would rise from $102 to $2,173 next year. A counselor with Ohio’s SHIP found another plan that will cover all her medications for the year and cost her just $1,760. If she stuck with her current plan, she would be paying an additional $24,852 for all her drugs next year, said Chris Reeg, who directs that state’s program.

In some cases, CMS tries to persuade beneficiaries to switch. Since 2012, it has sent letters every year to thousands of beneficiaries in poorly performing Advantage and drug plans, encouraging them to consider other options. These are plans that have received less than three out of five stars for three years from CMS.

“You may want to compare your plan to other plans available in your area and decide if it’s still right for you,” the letter says.

CMS allows low-scoring plans to continue to operate. In an unusual move, officials recently found that one plan had such a terrible track record that they will terminate its contract with government health programs next December.

CMS also contacts people about changing plans during open enrollment if they get a subsidy — called “extra help” — that pays for their drug plan’s monthly premium and some out-of-pocket expenses. Because some premiums will be more expensive next year, CMS is warning beneficiaries that they could be in for a surprise: a monthly bill to cover cost increases the subsidy doesn’t cover.

But many beneficiaries receive no such nudge from the government to find out if there is a better, less expensive plan that meets their needs and includes their health care providers or drugs.

That leaves many people with Medicare drug or Advantage plans on their own to decipher any changes to their plans while there is still time to enroll in another. Insurers are required to alert members with an “annual notice of change,” a booklet often more than two dozen pages long. Unless they plow through it, they may discover in January that their premiums have increased, the provider network has changed, or some drugs are no longer covered. If a drug plan isn’t offered the next year and the beneficiary doesn’t pick a new one, the insurer will select a plan of its choosing, without considering costs or needed drug coverage.

“Every year, our call volume skyrockets in January when folks get invoices for that new premium,” said Reeg, the Ohio program director. At that point, Medicare Advantage members have until March 30 to switch to another plan or enroll in government-run Medicare. There’s no similar grace period for people with stand-alone drug plans. “They are locked into that plan for the calendar year.”

One cost-saving option is the government’s Medicare Savings Program, which helps low-income beneficiaries pay their monthly premium for Medicare Part B, which covers doctor visits and other outpatient services. The Biden administration’s changes in eligibility for subsidies announced in September will extend financial assistance to an estimated 860,000 people — if they apply. In the past, only about half of those eligible applied.

Fixing a mistake after the open enrollment period ends Dec. 7 is easy for some people. Individuals who receive “extra help” to pay for drug plan premiums and those who have a subsidy to pay for Medicare’s Part B can change drug plans every three months.

At any time, beneficiaries can switch to a Medicare Advantage plan that earns the top five-star rating from CMS, if one is available. “We’ve been able to use those five-star plans as a safety net,” said Reeg, the Ohio SHIP director.

Other beneficiaries may be able to get a “special enrollment period” to switch plans after the open enrollment ends if they meet certain conditions. Local SHIP offices can help people make any of these changes when possible.

Reeg spends a lot of time trying to ensure that unwelcome surprises — like a drug that isn’t covered — don’t happen in the first place. “What we want to do is proactively educate Medicare patients so they know that they can go to the doctors and hospitals they want to go to in the upcoming year,” she said.

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The Dec. 1 report, prepared for the state legislature by Colorado’s Department of Health Care Policy & Financing, says that state officials approached 23 drugmakers in the last year about an importation program. Only four agreed even to discuss the proposal; none expressed interest in participating.

“Generally, the challenges that remain are outside state authority and rely on action by FDA and/or drug manufacturers,” the report reads.

Lawmakers in both parties, at the state and national level, have sought for decades to legalize importing drugs from Canada. Since 2020, when President Donald Trump’s administration opened the door to Canadian drug imports with regulations issued just weeks before he lost reelection, only a few states have filed applications with the Food and Drug Administration to create importation programs.

The FDA hasn’t yet ruled on any of them. Colorado filed its application in December 2022. Florida, which applied in 2020, has been waiting nearly three years for a decision from the Biden administration on its importation plan, pushed by Gov. Ron DeSantis, now a Republican presidential candidate.

FDA spokesperson Cherie Duvall-Jones said the FDA has not acted on states’ importation applications because it has not determined whether they would save significant money for consumers without posing risks to public health.

U.S. consumers pay some of the highest prices in the world for brand-name pharmaceuticals. Drugs are generally less expensive in Canada, where the government controls prices.

Under Trump, the federal government declared that importing drugs from Canada could be done safely — satisfying for the first time a condition spelled out in a 2003 law.

But Colorado officials cited another catch: The rule didn’t take into account that states would have to negotiate directly with drug manufacturers, which oppose selling their brand-name drugs in the United States at Canadian prices.

“As the federal Final Rule did not contemplate the need for this negotiation step, we have urged FDA to release further guidance regarding how states can operationalize the program with this in mind, but to date, no guidance has been released,” the Colorado report said.

Unlike many other Trump administration health policies, Biden hasn’t revoked or revised the importation rule. But his administration hasn’t shown much support for the idea, either. Health and Human Services Secretary Xavier Becerra told KFF Health News last December that he wouldn’t commit to the FDA ruling on any state application in 2023.

The president has repeatedly suggested that under his watch Americans would be able to import drugs from Canada.

During his 2020 campaign, Biden said he’d allow for the importation of drugs the government certified as safe. In 2021, he ordered the FDA to work with states to import prescription drugs from Canada. In a 2022 speech about how he planned to reduce drug prices, he cited Colorado estimates of how much people in the state could save through importation.

FDA officials responded to Colorado’s application in March by asking for more information and a smaller list of drugs to target, to prove that importation could save money. Colorado’s initial application listed 112 high-cost drugs. The state estimates residents and employers could save an average of 65% on the costs of those medicines, including drugs for diabetes, asthma, and cancer.

Colorado said it plans to submit an updated application early next year. By then, it’s possible the FDA will have ruled on Florida’s application.

The Colorado and Florida importation proposals differ. Colorado’s program is intended to directly help consumers obtain cheaper medicines. Florida’s plan aims to cut spending on drugs in government programs such as Medicaid, the prison system, and facilities run by the state Department of Children and Families.

The drug industry has argued the Trump administration didn’t properly certify that drugs imported from Canada would be safe, jeopardizing Americans’ health. Canada’s government, too, has expressed concern that U.S. imports would lead to shortages and higher prices in its country.

Drug manufacturers “will do anything to protect their golden goose that is United States consumers and patients who pay the largest amount for drugs in the world,” said Colorado state Sen. Sonya Jaquez Lewis, a Democrat, pharmacist, and leading advocate for drug importation.

The White House and Congress, she said, should force drugmakers to negotiate with states to start importation programs.

In its initial response to Colorado’s application, the FDA listed several types of information it still needed, including plans on labeling and drug eligibility, according to a March letter from the FDA to the state. Another problem, the FDA said: The state planned to import medicines across the U.S. border in Buffalo, New York. The FDA said the only port of entry it allows for medicines is in Detroit.

Colorado officials told the FDA in March that without federal approval of its application, it was having difficulty securing commitments from drug manufacturers to obtain medicines.

“It has been made clear that potential partners will be more interested in committing to participate once our program has been approved by the FDA,” Kim Bimestefer, executive director of the Colorado Department of Health Care Policy & Financing, wrote to the FDA.

“While we understand the regulatory framework does not permit for a provisional approval, we know that showing progress towards an approved program will aid in our negotiations with drug manufacturers,” she added.

Another complication is that the FDA’s rule doesn’t allow states to buy drugs directly from secondary drug wholesalers. Instead, they must purchase medicines directly from manufacturers, said Marc Williams, a spokesperson for the Colorado agency.

That’s proven challenging because drug manufacturers have prohibited the export of products intended for sale in Canada to the U.S., Williams said.

“Without their permission and a supply agreement directly with a manufacturer, Colorado is unable to buy and import these lower-priced drugs that would save people money,” he said.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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That’s according to a document KFF Health News and Cox Media Group obtained through a Freedom of Information Act request.

Acting Commissioner of the Social Security Administration Kilolo Kijakazi read aloud from the document during the hearing but repeatedly left out an entire category of beneficiaries displayed on the paper as well.

The document indicates the fallout from Social Security overpayments and clawbacks is much wider than Kijakazi acknowledged under direct questioning from a House Ways and Means subcommittee that oversees the federal agency.

In a statement for this article, SSA spokesperson Nicole Tiggemann described the numbers of people Kijakazi provided in her testimony and those she left out as “unverified.”

“We cannot confirm the accuracy of the information, and we have informed the committee,” Tiggemann said.

The numbers “were gathered quickly,” the spokesperson said. Social Security systems “were not designed to easily determine this information,” she said.

After the October hearing, KFF Health News and Cox Media Group sent Tiggemann several emails asking her to clarify whether the annual numbers Kijakazi gave to Congress included all Social Security programs or just a subset. She would not say.

For answers, the news organizations several weeks ago filed a FOIA request.

Rep. Greg Steube (R-Fla.), a member of the subcommittee, said in an interview that he wondered if the agency “intentionally deflated the numbers to not make it look as bad as it is.”

“Maybe we should have her come back in for another hearing, put her under oath,” and ask her “why she wasn’t being completely upfront about the numbers,” Steube said.

Steube said that, when he heard Kijakazi’s testimony, he thought she was giving the subcommittee the complete numbers.

At issue is the scope of a problem that has terrified many Social Security beneficiaries and plunged them into financial distress.

As KFF Health News and Cox Media Group television stations jointly reported in September, the government has been trying to recover billions of dollars from beneficiaries it says it overpaid. In many cases, the overpayments were the government’s fault.

But, even in cases where the beneficiary failed to comply with requirements, years can pass before the government catches the mistake and sends a notice demanding repayment, often within 30 days. In the meantime, the amount the beneficiary owes the government can grow to tens of thousands of dollars or more — far more than people living month to month could likely repay.

The people affected may be retired, disabled, or struggling to get by on only minimal income.

The number of people experiencing overpayments is important to know because overpayments can cause a lot of harm, said Kathleen Romig of the Center on Budget and Policy Priorities, who worked in research at the Social Security Administration and has since spent 20 years in the field of Social Security policy.

“It should be a very high priority at the agency to produce more reliable numbers,” Romig said.

The Social Security Administration has long quantified overpayments in dollars rather than numbers of people affected. For example, the agency’s latest annual financial report says it recovered more than $4.9 billion in overpayments in the fiscal year that ended Sept. 30 and ended that period with a cumulative uncollected overpayment balance of $23 billion.

In September, SSA’s Tiggemann said, “We do not report on the number of debtors.”

In subsequent interviews with the news organizations, some lawmakers said the agency owed the public that information. “If they’re not telling you, I can assure you that’s a question that I’m going to ask in a hearing,” said Rep. Mike Carey of Ohio, the No. 2 Republican on the subcommittee.

At an Oct. 18 hearing, Carey brought up the number of debtors and told Kijakazi, “I think it’s something that we really need to get to the bottom of.”

Then he asked, “Do we have a number of how many people have been impacted by these overpayments?”

“We do,” Kijakazi replied. “And I’m, I looked at that before I came. I’m, I’m sorry. I’m not thinking of the number right now. But I can provide that.”

Carey pressed further.

“How many people are receiving overpayment notices in a year?” he asked.

At that point, Tom Klouda, a deputy SSA commissioner, got up from his seat behind Kijakazi and handed her a piece of paper.

Reading from the page, she gave two precise numbers: 1,028,389 for the 2022 fiscal year and 986,912 for the 2023 fiscal year.

When Carey asked if 986,912 “individuals were getting these letters in the mail saying that there was an overpayment and that they needed to contact you guys and set up a payment plan,” Kijakazi said, “That’s right.”

“Seems like an awful lot,” Carey said.

Under further questioning from Carey, Kijakazi repeated the numbers. She said they were “under Social Security” and “for Social Security.”

Subsequently, the agency declined to clarify what Kijakazi meant by that. Replying to a series of emails, Tiggemann would not say whether the numbers included all the Social Security programs.

Instead, she implied the agency didn’t know.

(WFTV, Orlando)

(KIRO-TV, Seattle)

“Again, our overpayment systems were not designed to easily determine the information you’re requesting,” she wrote on Nov. 29.

The document obtained via FOIA shows that the numbers Kijakazi gave at the hearing covered only two of the three Social Security benefit programs. They did not cover Supplemental Security Income, or SSI, which provides financial support for people who have little or no income or assets and are blind, otherwise disabled, or at least 65 years old.

On the paper that the deputy commissioner handed Kijakazi, overpayment counts for SSI appeared directly below the numbers she read aloud, and they were bigger: 1,118,648 people in fiscal 2022 and 1,189,642 in fiscal 2023.

The document is titled in part, “Overpayment Basic Facts.”

In the document, the numbers Kijakazi read at the hearing, which round to about 1 million people a year, are labeled “T2.” Title II of the Social Security Act covers two programs: Disability Insurance, or DI, and Old-Age and Survivors Insurance, or OASI.

The numbers Kijakazi omitted are labeled “T16.” Title XVI of the Social Security Act covers SSI.

Within the Social Security Administration, personnel use the term T16 when referring to SSI and T2 when referring to OASI and DI combined, said Romig, the former agency researcher.

It’s possible that some people who received overpayment notices through SSI also received notices through the other programs, leading to overlap between the numbers Kijakazi read at the hearing and those she didn’t provide, Romig said.

In the 2023 fiscal year, the agency paid SSI benefits to an average of 7.5 million recipients a month. Measured in dollars, the overpayment rate in SSI has been running about 8%, according to the agency’s latest annual financial report. That’s much higher than the half a percent overpayment rate for OASI and DI combined.

A written statement Kijakazi submitted to the House subcommittee included a clue that the numbers of people she gave the committee didn’t provide a complete picture. In the statement, dated Oct. 18, Kijakazi used the term “the Social Security program itself” to describe Disability Insurance and Old-Age and Survivors Insurance — but not SSI.

A press release the Ways and Means Committee issued after the hearing made no such distinction. “One Million Americans a Year Affected by Social Security’s Improper Payment Highlights Need for Reform,” it said.

(WPXI-TV, Pittsburgh)

(WHIO-TV, Dayton)

The document obtained via FOIA included other new information. It showed that relatively few beneficiaries contest overpayment notices and that many appeals or requests for waivers fail.

Weeks after KFF Health News and CMG television stations published and broadcast the first stories in their series, the Social Security chief ordered a review of overpayments.

In her statement Dec. 5, the agency spokesperson said that, as part of the review, the Social Security Administration is “looking at how best to inform the Agency, the public, and Congress about this workload.”

Do you have an experience with Social Security overpayments you’d like to share? Click here to contact our reporting team.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Jordan Rau, KFF Health News senior correspondent, moderated a Zoom event Dec. 5 about “Dying Broke,” an investigative project undertaken with The New York Times and Times reporter Reed Abelson about America’s long-term care crisis. Panelists shared their lived experiences of caregiving.

The event was hosted by KFF Health News and the John A. Hartford Foundation.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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This story can be republished for free (details).