Trump Team’s Rhetoric Doesn’t Match Actions

The recent ºÚÁϳԹÏÍø News article “Beyond Ivy League, RFK Jr.’s NIH Slashed Science Funding Across States That Backed Trump” (April 17) struck a nerve. The rapid succession of suspended National Institutes of Health grants that swept the country shortly after President Donald Trump’s election have left us struggling to understand why such vital research — the bedrock of our ability to support the public’s health — would be treated as unnecessary or, worse, harmful.

People often think research, per se, doesn’t directly affect them. But research forms the basis for what we know will best work to treat, prevent, and manage illness, from chronic diseases such as diabetes, hypertension, and HIV, to mental health disorders. In addition to basic and applied research, NIH grants provide services directly to individuals and families, and they build community-based systems of care for its residents. We all benefit.

One area where federally funded research and programs have been especially impactful is in addressing the substance use crisis in America. With relatively modest investments, addiction science has led to enormous personal, societal, and economic benefits. Accomplishments include the treatments we use to break the cycle of addiction for millions of people, strategies for communities to support families with substance-related problems, prevention programs that divert youth away from substance use, and policies that reduce crime, suicide, overdose, and substance-related conditions like hepatitis and liver disease. Although we’re not done yet by any measure, these accomplishments have produced considerable returns on investment in personal and economic terms that are now at risk.

Out of a high level of concern, a group of career scientists formed the to protect addiction research and evidence-based practice from actions by this administration. The number of researchers, practitioners, people with lived experience, and national organizations expressing their support for ASDN’s mission is growing into the hundreds. The Trump administration touts its commitment to reducing addiction, but its action don’t match the rhetoric. By curtailing research and funding for science-based solutions, we are practically assuring that the problem will continue to worsen over time. And, as underscored in Rae Ellen Bichell and Rachana Pradhan’s article, given that rates of drug overdose are highest in red states, predictions are that Trump supporters may suffer most of all.

— Diana Fishbein, Nova Institute for Health scholar, ASDN Coordinating Committee member, and University of North Carolina senior scientist, Chapel Hill, North Carolina

Staying Afloat Amid Federal Funding Cuts

Your article “Moms in Crisis, Jobs Lost: The Human Cost of Trump’s Addiction Funding Cuts” (April 25) mentioned that the Niyyah Recovery Initiative may be affected by losing federal funding. But it has been provided not associated with federal money in the sum of $200,000 a year through 2027. Presumptive speculation on how its services would be affected should have been disclosed.

— John Smythe, Fort Lauderdale, Florida

[Editor’s note: A bill to provide Niyyah Recovery Initiative a one-time $200,000 appropriation was  in April 2025. As of May 12, it had not received a hearing or vote, meaning the payment had not been made.]

Count the Blessings of Direct Primary Care

While I am almost always a fan of the work that ºÚÁϳԹÏÍø News and NPR publish, particularly together, the article “In Rural Massachusetts, Patients and Physicians Weigh Trade-Offs of Concierge Medicine” (April 16) contained a mischaracterization that was pretty disappointing.

The author suggests, and a photo caption states, that “direct primary care is similar to concierge medicine but does not accept insurance.” While it’s true DPC patients and concierge patients both pay membership fees, they couldn’t be more different. The membership fee for concierge practices just gets you in the door — patients still pay copays/coinsurance or, in some cases, full out-of-network price, for every service. With direct primary care, your monthly cost — typically (I’ll hedge, though I haven’t seen any exceptions) — includes unlimited visits, in-house procedures and tests, and telemedicine appointments. Many even offer the ability to text-message your doctor when you need medical advice on a more urgent basis.

I’m not affiliated with the DPC industry in any way, I’m just a former patient. DPC changed my life. I felt for the first time as an adult (I am 33) as if I had actual, genuine health care. Not worrying about the drudgery of fee-for-service meant I didn’t hesitate to get, say, tested for flu and covid-19 when I had a respiratory illness, have skin issues looked at, or finally get care for long-standing issues. The fact that I had a high-deductible health plan only rarely mattered. For $100 a month, it was an absolute steal, and I was a cheerleader for everyone in my area who could afford it. At least a few folks who were uninsured or severely underinsured got health care thanks to that practice, which unfortunately is no longer serving primary care.

DPC has its thorns. Certainly, not everyone can afford a monthly fee. Access can be limited by capped patient loads. But, on the whole, DPC is a blessing for many people, and it’s simply unfair to paint it with the same brush as concierge medicine. I hope to see better from ºÚÁϳԹÏÍø News and its partners in the future.

— James Joyce, Opelika, Alabama

I got fed up with the feeling of being on a medical hamster wheel and switched to a concierge doctor. I feel like a patient instead of a name on a chart.

—

— Ian Carter, Hillsboro, Oregon

Some Medical Debt Is Clearly Fraud

Be aware that false unpaid medical bills are sold to collection companies in bulk along with legitimate paid charges (“Diagnosis: Debt: Blockbuster Deal Will Wipe Out $30 Billion in Medical Debt. Even Backers Say It’s Not Enough,” April 7).

I went through cancer treatment in 2023. I paid all my legitimate charges after my Medicare Advantage plan paid. I paid regularly and on time. But I made sure I received my explanation of benefits (EOB) from my insurance company before I paid any additional fees. Those EOB statements list legal charges and billing.

In February 2024, I received new statements from SSM Healthcare for the infusion center, doctors, and hospital. These statements were for charges that were a year old and listed as paid in full in 2023. The SSM system sold some of that fake debt to a collection agency. I sent that collection company proof of payment and the paid-in-full statements that were still in the MyChart billing system.

Patients who go through chemotherapy, surgeries, and treatments for severe disabling conditions often also have cognitive deficits afterward. These cognitive problems may be short-term, but they can be extreme. False medical billing and fraudulent charges are often purposely used in these situations to take advantage of patients’ cognitive deficits. The medical systems utilize the false debt scam to sell it to collection companies to make a profit on essentially nonexistent debt. This system defrauds patients and the debt collection industry.

The elderly and disabled patients end up paying the legitimate debt and the fraudulent debt. The “unpaid” medical debt is bundled in such a way as to be impossible to identify as fraudulent or legitimate. Disadvantaged individuals aren’t capable of managing the documentation to prove their debt was paid, and the collection companies frighten and bully those individuals.

How much of the debt written off by Undue Medical Debt was legitimate? No one will ever know. But there’s a much larger issue than the simple belief that people don’t pay medical bills. Organizational fraud is likely responsible for a large percentage of the debt that companies like Undue purchase and utilize for profit.

— Diana Rickles, Ballwin, Missouri

Blockbuster Deal Will Wipe Out $30 Billion in Medical Debt. Even Backers Say It’s Not Enough. — yes, it's not enough, but it's something via

— Ellen Andrews (@cthealthnotes)

— Ellen Andrews, Hamden, Connecticut

Don’t Hesitate To Sound the Alarm

I am a regular watcher of “CBS Mornings” and always appreciated Dr. Céline Gounder’s reports during the covid-19 pandemic. But I found on CBS much too meek in the face of a devastating effort on the part of Robert F. Kennedy Jr. to slash the Department of Health and Human Services workforce by 25%.

This is catastrophic for disease prevention and future medical science — as well as the flight of talent from the U.S. to other countries. Dr. Gounder mentioned people from Yale leaving for Toronto. But Dr. Gounder should have been more assertive and sounded a greater alarm than just saying the impact of these cuts “remains to be seen.” For heaven’s sake! These cuts are catastrophic — not only for America’s health, but for the 20,000 talented people who have been shown the door. Dr. Gounder: You need to be more assertive and alert Americans that this is a tragedy.

— Uldis Kruze, El Cerrito, California

Today in NIMBY Land: Neighbors are now stopping hospitals in SIX different states from opening up psychiatric centers for children amidst a psychiatric bed shortage. Ugh. Great story from :

— Lawson Mansell (@lawsonhmansell)

— Lawson Mansell, Washington, D.C.

We Must Prioritize Children’s Mental Health

As a concerned member of our mental health support community, I write to highlight an urgent issue that too often goes unnoticed: the mental health of our children (“More Psych Hospital Beds Are Needed for Kids, but Neighbors Say Not Here,” April 11). With rising rates of anxiety, depression, suicide, and behavioral challenges among youth, it is imperative that we take collective action to prioritize mental well-being just as seriously as we do physical health.

Children today face a unique set of stressors — from academic pressure and social media to family instability and global uncertainty. These factors can significantly affect their emotional development and overall well-being. Yet, despite the growing need, access to qualified mental health professionals, school counselors, and community support services remains limited or unaffordable for many families. Not all hospitals are equipped for mental health cases, and the number of psychiatric beds available is often little to none. A child in mental health crisis should not have to wait days or weeks to find treatments. Parents shouldn’t have to watch their child struggle and not have their concerns taken seriously. If a child goes into a hospital with a broken bone, it is immediately treated; the parents aren’t given numbers for places to call in hopes that they can be seen in a few days.

We must advocate for policies that ensure mental health screenings in schools, expand funding for youth-focused services, and promote training for educators to identify early signs of distress. Hospitals and mental health facilities need to be prepared and equipped to take in patients, not turn them away. Children should never be unable to receive treatment because of a lack of a bed. Our children should be our priority, not an afterthought of what a care facility will do to the neighborhood. No child should suffer in silence due to a lack of resources or awareness.

Investing in children’s mental health is not just compassionate — it’s smart. Healthy, supported children are more likely to succeed academically and socially and, ultimately, become well-adjusted adults. Let’s ensure that every child has access to the help they need.

— Jennifer Groseclose, Leeton, Missouri

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“You’d call and you’re talking about weeks to a month,” Andrews said.

That’s not surprising, as many workplace surveys show the supply of primary care doctors has fallen well below the demand, especially in rural areas such as western Massachusetts. But Andrews still wasn’t prepared for the letter that arrived last summer from her doctor, Christine Baker, at .

“We are writing to inform you of an exciting change we will be making in our Internal Medicine Practice,” the letter read. “As of September 1st, 2024, we will be switching to Concierge Membership Practice.”

Concierge medicine is a business model in which a doctor charges patients a monthly or annual membership fee — even as the patients continue paying insurance premiums, copays, and deductibles. In exchange for the membership fee, doctors limit their number of patients.

Many physicians who’ve made the change said it resolved some of the pressures they faced in primary care, such as having too many patients to see in too short a time.

Andrews was floored when she got the letter. “The second paragraph tells me the yearly fee for joining will be $1,000 per year for existing patients. It’ll be $1,500 for new patients,” she said.

Although numbers are not tracked in any one place, the trade magazine Concierge Medicine Today estimates there are concierge physicians in the U.S. Membership fees range from $1,000 to as high as $50,000 a year.

Critics say concierge medicine helps only patients who have extra money to spend on health care, while shrinking the supply of more traditional primary care practices in a community. It can particularly affect rural communities already experiencing a shortage of primary care options.

Andrews and her husband had three months to either join and pay the fee or leave the practice. They left.

“I’m insulted and I’m offended,” Andrews said. “I would never, never expect to have to pay more out of my pocket to get the kind of care that I should be getting with my insurance premiums.”

Baker, Andrews’ former physician, said fewer than half her patients opted to stay — shrinking her patient load from 1,700 to around 800, which she considers much more manageable. Baker said she had been feeling so stressed that she considered retiring.

“I knew some people would be very unhappy. I knew some would like it,” she said. “And a lot of people who didn’t sign up said, ‘I get why you’re doing it.’”

Patty Healey, another patient at Baker’s practice, said she didn’t consider leaving.

“I knew I had to pay,” Healey said. As a retired nurse, Healey knew about the shortages in primary care, and she was convinced that if she left, she’d have a very difficult time finding a new doctor. Healey was open to the idea that she might like the concierge model.

“It might be to my benefit, because maybe I’ll get earlier appointments and maybe I’ll be able to spend a longer period of time talking about my concerns,” she said.

This is the conundrum of concierge medicine, according to Michael Dill, director of workforce studies at the . The quality of care may go up for those who can and do pay the fees, Dill said. “But that means fewer people have access,” he said. “So each time any physician makes that switch, it exacerbates the shortage.”

the U.S. will face a shortage of within the next decade.

found that the percentage of residents in western Massachusetts who said they had a primary care provider was lower than in several other regions of the state.

Dill said the impact of concierge care is worse in rural areas, which often already experience physician shortages. “If even one or two make that switch, you’re going to feel it,” Dill said.

Rebecca Starr, an internist who specializes in geriatric care, recently started a concierge practice in Northampton.

For many years, she consulted for a medical group whose patients got only 15 minutes with a primary care doctor, “and that was hardly enough time to review medications, much less manage chronic conditions,” she said.

When Starr opened , she wanted to offer longer appointments — but still bring in enough revenue to make the business work.

“I did feel a little torn,” Starr said. While it was her dream to offer high-quality care in a small practice, she said, “I have to do it in a way that I have to charge people, in addition to what insurance is paying for.”

Starr said her fee is $3,600 a year, and her patient load will be capped at 200, much lower than the 1,000 or even 2,000 patients that some doctors have. But she still hasn’t hit her limit.

“Certainly there’s some people that would love to join and can’t join because they have limited income,” Starr said.

Many doctors making the switch to concierge medicine say the membership model is the only way to have the kind of personal relationships with patients that attracted them to the profession in the first place.

“It’s a way to practice self-preservation in this field that is punishing patients and doctors alike,” said internal medicine physician Shayne Taylor, who recently opened offering “direct primary care” in Northampton. The direct primary care model is similar to concierge care in that it involves charging a recurring fee to patients, but bypasses insurance companies altogether.

Taylor’s patients, capped at 300, pay her $225 a month for basic primary care visits — and they must have health insurance to cover care such as X-rays and medications, which her practice does not provide. But Taylor doesn’t accept insurance for any of her services, which saves her administrative costs.

“We get a lot of pushback because people are saying, ‘Oh, this is elitist, and this is only going to be accessible to people that have money,’” Taylor said.

But she said the traditional primary care model doesn’t work. “We cannot spend so much time seeing so many patients and documenting in such a way to get an extra $17 from the insurance company.”

While much of the pushback on the membership model comes from patients and policy experts, some of the resistance comes from physicians.

, a primary care doctor who runs in western Massachusetts, said his practice is more stretched than ever. One reason is that the group’s clinics are absorbing some of the patients who have lost their doctor to concierge medicine.

“We all contribute through our tax dollars, which fund these training programs,” Carlan said.

“And so, to some degree, the folks who practice health care in our country are a public good,” Carlan said. “We should be worried when folks are making decisions about how to practice in ways that reduce their capacity to deliver that good back to the public.”

But Taylor, who has the direct primary care practice, said it’s not fair to demand that individual doctors take on the task of fixing a dysfunctional health care system.

“It’s either we do something like this,” Taylor said, “or we quit.”

This article is from a partnership that includes , , and ºÚÁϳԹÏÍø News.

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It’s called direct primary care, modeled after “concierge” practices that have gained prominence in the past two decades. Those feature doctors generally bypassing insurance companies to provide personalized health care while charging a flat fee on a monthly or yearly basis. Patients can shell out anywhere from thousands to tens of thousands of dollars annually, getting care with an air of exclusivity.

In direct primary care, patients pay about $100 a month or less directly to the physician for comprehensive primary care, including basic medication, lab tests and follow-up visits in person, over email and by phone. The idea is that doctors, who no longer have to wade through heaps of insurance paperwork, can focus on treating patients. They spend less on overhead, driving costs down. In turn, physicians say they can give care that’s more personal and convenient than in traditional practices.

The health law’s language was “sort of [an] ‘open-for-business’ sign,” said Jay Keese, a lobbyist who heads the Direct Primary Care Coalition. Before 2010, between six and 20 direct primary care practices existed across the country. Now, there are more than 400 group practices.

The total number of physicians participating doctors may exceed 1,300. The American Academy of Family Physicians estimates 2 percent of its 68,000 members offer .

“This is a movement — I would say it’s in its early phase,” said AAFP President Wanda Filer, a doctor in Pennsylvania. “But when I go out to chapter meetings, I hear a lot more interest.”

But questions persist about feasibility. The lower fees could still be a non-starter for people earning minimum wage or on a limited budget, said Robert Berenson, a senior fellow at the Urban Institute. “Can people afford this? Or is it [still] just for well-off people?”

doctors to consider whether direct primary care can work within their practices, but also urges physicians to recognize how it could affect poorer patients and look for ways to keep care affordable.

Direct primary care doctors say they see patients across incomes. Dr. Stanford Owen, of Gulfport, Mississippi, treats “waitresses and shrimpers, as well as doctors and lawyers.” He charges $225 for initial visits, $125 for a follow-up, if needed, and then about $50 per month after.

Owen and other physicians report positive experiences, triggering other efforts to apply direct care more broadly. Although most of these doctors eschew dealing with insurance, some have been trying the model with Medicaid and Medicare patients.

If those experiments work — and save money and improve health — they could mitigate concerns about who can afford direct primary care. Berenson pointed out that partnering with insurance or public programs is key to making direct care affordable for lower-income people.

“The idea of setting up stronger primary care services for patients is very exciting and very much needed,” said Ann Hwang, director of the Center for Consumer Engagement in Health Innovation, an outpost of the consumer advocacy group Community Catalyst. But, she added, “This is so new that I think the jury is still really out on whether this will be successful.”

In Seattle, a company called Qliance, which operates a network of primary care doctors, has been testing how to blend direct primary care with the state’s Medicaid program. They started taking Medicaid patients in 2014. So far, about 15,000 have signed up. They get a Qliance doctor and the unlimited visits and virtual access that are hallmarks of the model.

“Medicaid patients are made to feel like they’re a burden on the system,” said Dr. Erika Bliss, Qliance’s CEO. “For them, it was a breath of fresh air to be able to get such personalized care — to be able to talk to doctors over phone and email.”

Qliance has a contract with Centene, an insurance company in the state’s Medicaid program. That Medicaid coverage pays for the monthly fee, which covers primary and preventive care, and for other specialty and emergency services. If patients need a specialist, they’ll get referred to one who accepts Medicaid. Advocates in other states — such as North Carolina, Idaho and Texas — are watching the outcomes and costs while considering rolling out similar programs.

There’s little data so far. Bliss estimated participants will cost Washington state between 15 and 20 percent less than traditional Medicaid. Before launching the Medicaid pilot, Qliance contracted with some companies that provide insurance to their employees — in those cases, employees who opted for Qliance cost about . Because patients get better care upfront, the theory goes, they’re less likely to develop expensive chronic illnesses.

Still, expanding this approach is tricky. The number of participating physicians is low. There’s already a nationwide shortage of primary care doctors. In this model, physicians see fewer patients, potentially exacerbating that shortage’s impact. Also, Medicaid negotiates the monthly payment rate, which could be less than what doctors might set independently.

In New Jersey, using direct primary care is launching in 2016 for state employees, like firefighters and teachers. It’s a hybrid: When consumers pick a primary doctor, they can choose a direct primary care-style practice, which gives around-the-clock access to preventive and primary care services. The monthly fee is undetermined.

Participants will get benefits such as same-day appointments for non-emergency visits. But when they pick this plan — which will be administered by Aetna and Horizon — they will have access to specialists that participate in the insurers’ plan networks.

In New Jersey, about 800,000 people will be eligible to enroll in the direct primary care program. The state’s hoping to attract and accommodate at least 10,000 in the first year.

That’s appealing, said Mark Blum, executive director of America’s Agenda, an advocacy group that helped develop the project. He cited interest in California, Texas, Pennsylvania and Nebraska. “There are a lot of eyes on New Jersey right now.”

Meanwhile, direct primary care is finding traction with Medicare Advantage, the private health plan alternatives to traditional Medicare. Iora Health, a direct primary care system that contracts with unions and employers, a year ago launched clinics in Washington and Arizona catering to Medicare Advantage patients.

Iora’s setting up similar clinics in Colorado and Massachusetts.

Despite its potential, the direct care model faces the challenges of integration into existing payment systems and attracting more participating doctors. And navigating Medicare and Medicaid rules can deter physicians.

“It’s not for the faint of heart,” said Dr. Rushika Fernandopulle, Iora’s CEO.

How it evolves from here will vary across the country, said Filer, the AAFP president.

“There are some parts of the country where it is working very well,” she said. “But there are other reasons a physician might decide, ‘This is not for my patient base.’”

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Q: I was recently advised by my primary care physician that he is transitioning to a “membership-based personalized health care program,” also known as concierge medicine. This program will cost me $1,760 a year. I currently am covered by Medicare, and my out-of-pocket expenses have never exceeded $100 per quarter. If I sign up with the program, how might it affect my Medicare coverage and costs?

A: As long as your doctor still participates in the Medicare program — and nearly all physicians do — he can’t apply the concierge practice annual fee to services that Medicare covers, says Cristina Boccuti, a senior associate at the Program on Medicare Policy at the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.) Likewise, if you sign up for the concierge program, you’ll still be responsible for normal cost sharing for covered Medicare services as well, says Boccuti.

In addition, Medicare will not pay any of the concierge fee.

Concierge practices often say the annual fee entitles patients to continue seeing a familiar doctor, get faster access or extra perks. As long those extras aren’t services covered by Medicare, that’s OK. You may get a wellness newsletter, for example, or preventive services during your annual check-up that aren’t included in the annual wellness exam that Medicare covers.

It’s up to you whether you think that access or those extra services are worth an additional fee.

Q: I’m a health insurance counselor, and I’m working with a Medicare beneficiary who hit the doughnut hole on his Medicare Part D prescription drug plan because of the . Now he’s been told that because he uses an insulin pump, both the pump and the insulin are covered under Medicare Part B as durable medical equipment, and should not have bumped him into the donut hole. Will this change save him money?

A: It’s hard to know exactly what the impact will be. There are cost sharing issues either way. In a Part D drug plan, once the patient and the drug plan together spend $2,960 on prescription drugs, the patient enters the coverage gap often called the “doughnut hole” where he’s responsible for a greater share of the cost of his drugs. Once he reaches $4,700 in spending, he leaves the and Medicare picks up nearly all remaining drug costs for the year.

But there are costs associated with Part B coverage as well. Insulin pumps and the insulin that the device uses are covered under Medicare Part B, which covers outpatient medical services and durable medical equipment. After meeting the $147 annual deductible, patients generally have to pay 20 percent of the cost of Part B care, unless they have a Medigap plan that .

Depending on how much insulin someone uses and the specific drug he’s on, 20 percent coinsurance could be significant, says Dr. Robert Gabbay, chief medical director at the Joslin Diabetes Center in Boston.

As an example, a vial of insulin might cost $250, and someone might use three vials a month in their insulin pump, Gabbay says. The annual cost of that insulin would be $9,000, and the beneficiary could be responsible for $1,800 in coinsurance charges.

Insulin pumps, which are small battery-powered devices that deliver insulin through a tube inserted under the skin, are recommended by physicians for some patients whose blood sugar control isn’t optimal. The pump may cost more than $5,000 plus $100 monthly for supplies, such as the needle, tubing and adhesive.  can maintain better insulin control and help the patient stay healthier, thereby helping patients and the Medicare program avoid hospitalizations and other pricey medical care.

“If you need an insulin pump and it’s the right therapy, for the Medicare program it easily pays for itself over time,” Gabbay says.

Q: My 85-year-old husband has been diagnosed with anxiety and depression. He had a stroke last year and now spends most of his time in bed. His mind is failing and he’s frequently confused. Taking care of him is exhausting, but I’m concerned that unless the doctor gives him a diagnosis of dementia I can’t qualify for respite care. What are the criteria?

A: Coverage for caregivers to take a breather from caring for a loved one at home is spotty.

In general, the traditional Medicare program only pays for respite care if a patient has entered hospice. , the doctor has to certify that the patient is terminally ill and expected to live for six months or less. The program pays for the Medicare beneficiary to be moved to a hospital or nursing home for up to five days at a time so the caregiver can get some rest.

It doesn’t sound as if your husband is in hospice, however, so this is probably not an option.

Some Medicare Advantage Special Needs Plans may cover respite care, but there’s no requirement that they do so, says Elaine Wong Eakin, executive director of California Health Advocates, a Medicare advocacy group.

Special needs plans are Medicare Advantage managed care plans that limit membership to certain types of beneficiaries and tailor services to their needs. Some only accept people who have certain diseases such as dementia or heart failure. Others only sign up people who are eligible for both Medicare and Medicaid, the federal/state health program for low income people. Still others .

Eakin advises checking with your state health insurance assistance program to find Medicare Advantage .

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