The National Education Association, the nation’s largest union, reversed course Friday on its threat to cut off health insurance to about 300 Washington, D.C.-based workers in an effort to end a bitter contract dispute.

“The NEA is not discontinuing its unionized staff’s health insurance and will continue to pay insurance premiums as we bargain a new contract,” Kim Anderson, NEA’s executive director, said in a statement to ºÚÁϳԹÏÍø News. “Both parties have mutually agreed to mediation and we are making every effort to reach an agreement as quickly as possible.”

The NEA’s decision came just hours after ºÚÁϳԹÏÍø News reported on the union’s warning that it would cancel health benefits on Aug. 1 for striking workers, including some with ongoing medical issues. Reached Friday, officials at the NEA staff union confirmed they had been notified by the NEA.

Some private employers have used the threat of cutting off health benefits as leverage against unionized workers, a tactic that has drawn scrutiny from congressional Democrats and is prohibited for state employers in California. Experts on labor law say they’ve never seen a union make the move against its own workers.

“This is like a man-bites-dog situation where the union is now in a position as the employer,” said Paul Clark, a professor of labor and employment relations at Penn State University. “It’s not a good look for a union.”

NEA workers with pressing health needs were worried but said they wouldn’t fold. Joye Mercer Barksdale, a writer on the NEA’s government relations team, said she needs coverage for a medical procedure to address atrial fibrillation, a cardiac disorder. “This is insane for the NEA to use our health benefits as a bargaining chip,” she said.

But Barksdale had said she was “not ready to give in.” Reached Friday morning, she said she was thrilled by the reversal: “Oh my God, I am so thankful.”

The NEA Staff Organization, the union representing workers at the NEA’s headquarters, launched a strike on July 5 in Philadelphia, during the union’s annual delegate assembly. It was its second walkout this summer as the two parties negotiate a new contract, navigating sticking points such as wages and remote work.

In response, the NEA ended the conference early. President Joe Biden was supposed to speak at the event but withdrew, refusing to cross the picket line. The NEA on July 24 endorsed Kamala Harris for president.

On July 8, the day after the conference had been scheduled to end, the NEA locked out workers. In a letter the day before, the NEA informed its unionized workers that they would not be paid, effective immediately, and their health benefits would expire at the end of July unless a new deal were reached.

“NEA cannot allow NEASO to act again in a way that will bring such lasting harm to our members and our organization,” Anderson, the NEA’s executive director, wrote in the letter, obtained by ºÚÁϳԹÏÍø News. “We are, and have always been, committed both to our union values and to the importance of conducting ourselves as a model employer.”

Democrats in Congress, including Sens. Sherrod Brown of Ohio and Bob Casey of Pennsylvania, introduced legislation last year to protect striking workers from losing their health benefits, after several large companies, including General Motors, John Deere, RTX (formerly Raytheon Technologies), and the maker of Kellogg’s cereals, threatened to or did cut off coverage during labor disputes.

“Workers shouldn’t have to choose between their family’s health and a fair contract,” Brown said in a statement to ºÚÁϳԹÏÍø News.

The legislation was endorsed by large labor unions including the Service Employees International Union and United Steelworkers, according to a press release from Brown’s office. The NEA wasn’t among them.

“This tactic is immoral, and it should be illegal,” United Steelworkers’ president at the time, Thomas Conway, said in the release.

Officials at the NEA, which represents teachers and other administrators, declined an interview request. In a statement Wednesday, the organization’s president, Becky Pringle, said “we are making every effort to reach an agreement as quickly as possible” with its staff union.

“As union leaders who have been on strike, we recognize the significance and impact of these important decisions on a personal and family level. We truly value our employees and look forward to continued collaboration with NEASO to develop a new contract that benefits us all,” she said.

Kate Hilts, a digital strategist who works for the NEA, said she feared losing her coverage would leave her unable to afford treatment for a rare autoimmune disease that attacks her kidneys. Her next treatment was slated for August.

“I wake up every day and can’t believe this is happening,” she said. “You would expect this from an employer that is antiworker or has a terrible labor record, but I am totally flabbergasted that a labor union would do this that bills itself as pro-worker, pro-family, pro-education, and pro-children.”

The NEA staff union has with the National Labor Relations Board this year, including allegations that the NEA withheld holiday overtime pay and failed to provide information on the outsourcing of millions of dollars in bargaining unit work.

California is one of the only states that protect striking workers from losing health coverage. The state legislature passed a law in 2021 that blocks the tactic from being used against public employees and another law in 2022 that allows any striking workers who lose their insurance to immediately get heavily discounted coverage through the state’s Affordable Care Act marketplace.

If they had remained locked out, the NEA workers would have been eligible for coverage under COBRA, a federal program that allows people who are fired or laid off to maintain their employer-sponsored insurance for 18 months.

But the coverage can be a financial hardship, as individuals often must pay the entire cost of their insurance premiums, plus a 2% administrative fee.

Another option for workers would have been coverage through the Affordable Care Act marketplace, though that also can be costly. And it may have been unclear how soon that coverage would begin or whether insurers would cover their existing doctors.

“I’m hoping the NEA will be so ashamed of what they are doing that, at the very least, they will not take away our health benefits,” Barksdale said before the NEA’s decision.

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

U.S. Health Care Is Harmful to One’s Health

Thank you for publishing this research (“Hundreds of Hospitals Sue Patients or Threaten Their Credit, a KHN Investigation Finds. Does Yours?” Dec. 21). I am a psychotherapist and have written about this problem in my blog. The mercenary American health care system is hypocritical in the stressful financial demands and threats it imposes on so many patients. Stress due to health care-related bankruptcy, or the threat of bankruptcy, is harmful to one’s health. A health care system that is supposed to treat illness and restore health can, in fact, cause serious illness and/or exacerbate existing medical problems. The higher levels of stress and the threat of bankruptcy that all too frequently follow needed medical care can be harmful to individuals with cardiovascular issues such as high blood pressure and heart arrhythmia, and can trigger panic attacks in those who suffer from anxiety disorders. There may be digestive issues associated with higher levels of stress, and the patient’s sleep may be adversely affected. The individual may have to cut back on essentials such as food and medications because of unpaid medical bills, aggressive calls from collection agencies, and the threat of bankruptcy.

All of this in the name of “health care” delivered by professions and organizations that proclaim the importance of beneficence, justice, and non-malfeasance within their respective codes of ethics. Curative stress? Therapeutic bankruptcy? The hypocrisy is palpable.

American history is replete with examples of discrimination against certain groups, including racial discrimination, the disenfranchisement of women, child labor, and others. Eventually, political measures were enacted to correct these injustices. It’s only a matter of time until the American health care system, including the pharmaceutical industry, is forced to reform itself for the sake of the men, women, and children in need of essential health care. It’s not a question of if, but when.

— Fred Medinger, Parkton, Maryland

I find this infuriating! Especially the nonprofit organizations. Hundreds of US Hospitals Sue Patients or Threaten Their Credit, a KHN Investigation Finds | Kaiser Health News

— Jan Oldenburg ☮️ (@janoldenburg)

— Jan Oldenburg, Richmond, Virginia

Thanks for the article about hospitals suing patients. I just switched health plans in New York state. Reasons: My previous insurer raised my premium over 90% last year, paid very little of my claims (leaving Medicare to pay most of the claims), and sent me to collections. This, even though I worked two full-time jobs for most of my 46 years of teaching. How do insurance companies and hospitals get away with this unethical and outrageous behavior?

— George Deshaies, Buffalo, New York

Great story by ‘ , which found that at least 297 hospitals in MN, 56%, sue patients for unpaid medical bills. 90, or 17%, can deny patients nonemergency medical care if they have past-due bills.

Mayo is one of those hospitals. See🧵

— Molly Castle Work (@mollycastlework)

— Molly Work, Rochester, Minnesota

Unhappy New Year of Deductibles and Copays

Listened to between Noam N. Levey and NPR’s Ari Shapiro, regarding Levey’s article on Germany’s lack of medical debt (“What Germany’s Coal Miners Can Teach America About Medical Debt,” Dec. 14). Levey passed along the tidbit that Affordable Care Act plans purchased through state exchanges would pay a maximum out-of-pocket amount of $9,000 a year. Likely Mr. Levey knows the actual details of the ACA at least as well as I, but I had well over $20,000 in out-of-pocket expenses for my own care last year (in addition to annual premiums of over $15,000). The deductible/copay aspect of health insurance is rigged against folks who actually use their insurance. The in-network and out-of-network provider scheme is likewise designed to benefit providers as opposed to patients.

I’ve had health insurance for about 40 years, since I graduated from college. Always a plan paid for by myself, never through an employer. I’ve had my first year of using a lot of heath care services (colon cancer surgery and chemo follow-up), and the bills are quite astronomical. Still awaiting the final negotiations between Stanford Hospital and Blue Shield of California for the $97,000 bill for services for the surgery and stay in the hospital. Though my surgery was in September, the two had not resolved the bill by year-end. Now all my copays and deductibles have reset, and I’ll be back at the starting gate, dollar-wise.

We need health care payment reform.

— George McCann, Half Moon Bay, California

Tx for this important comparative piece on how Germany’s private healthcare system does not create . We need to do better.

— Allison Sesso (@AllisonSesso)

— Allison Sesso, president and CEO of RIP Medical Debt, Long Island City, New York

Greedy to the Bone?

In orthopedics, surgery is where the money is (“More Orthopedic Physicians Sell Out to Private Equity Firms, Raising Alarms About Costs and Quality,” Jan. 6). Just as a private equity-controlled ophthalmology group tried to persuade me to have unnecessary cataract surgery (three other eye doctors agreed it wasn’t necessary), too many orthopedic patients can expect to be pushed to unnecessary surgeries.

— Gloria Kohut, Grand Rapids, Michigan

As firms acquire practices, the issue of non-competes and covenants become even more relevant in @linakhanFTC

— Amit Jain, MD, MBA (@AmitJainSpine)

— Dr. Amit Jain, Baltimore

The Painful Truth of the Opioid Epidemic

In a recent article, Aneri Pattani and Rae Ellen Bichell discussed disparities in the distribution of settlement funds from lawsuits against major pharmaceutical companies, especially in rural areas (“In Rural America, Deadly Costs of Opioids Outweigh the Dollars Tagged to Address Them,” Dec. 12).

We suggest that the merit of many of the lawsuits that led to these large settlements remains unproven. While Purdue Pharma clearly of prescription opioids in treating chronic pain, judges in two high-profile cases ruled in favor of the pharmaceutical companies stating that prosecutors and noted that opioids used per FDA guidelines are safe and effective, remaining a vital means to treat chronic pain. Also, many cases involving Purdue Pharma, Johnson & Johnson, and others were settled based on expediency, rather than merit. This may have been due to the reasoning that continuing their defense against prosecutors having access to limitless public funds would lead to bankruptcy.

The primary cause of America’s overdose crisis is not physicians’ “overprescribing” opioids. Dr. Thomas Frieden, former head of the Centers for Disease Control and Prevention, noted that the rise in prescription opioids in opioid deaths up to 2010, leading the CDC to create guidelines in 2016 limiting opioid use to treat chronic pain. However, cause-and-effect relationships between the legitimate use of prescription opioids and opioid deaths remain unclear. For example, the National Institute on Drug Abuse noted in 2015 that since 2000, misuse of prescription drugs preceded the use of heroin in most cases. But legitimate prescriptions by physicians to patients with chronic pain constituted only 20% of the cases leading to heroin addiction. Prescription drugs used by heroin addicts were from family members or friends in leading to heroin use.

Since at least 2010, the volume of prescription opioids dropped by over 60% — yet overdose deaths have skyrocketed to over 100,000 cases in 2021. The opioid overdose death crisis is now driven mainly by illegally imported fentanyl and in part by a of the Drug Enforcement Administration against physicians who legitimately prescribe opioids to chronic pain patients, forcing them to seek out street drugs.

Statistics from Michigan indicate that nearly will no longer see new patients for pain management. The CDC, in its 2022 updated guidelines, attempted to clarify misunderstandings, including inappropriate rapid tapering and individualizing care. However, the public health crisis of undertreated pain remains. Some states have passed to restore access to opioids to chronic pain patients with a legitimate need, indicating the shortfalls of the CDC guidelines to treat pain.

— Richard A. Lawhern, Fort Mill, South Carolina, and Dr. Keith Shulman, Skokie, Illinois

Important reporting from and in : National settlements are being paid out by manufacturers, but communities are often getting less funds to address the than their urban and suburban counterparts.

— Joanne Conroy (@JoanneConroyMD)

— Dr. Joanne Conroy, Lebanon, New Hampshire

We’re fighting to hold accountable the companies that helped create and fuel the opioid crisis so we can help people struggling with opioid use disorder across North Carolina and the country get resources for treatment and recovery. We need this money now to save lives.

To that end, I wanted to flag one concern about the article on rural counties and opioid funding. It looks as if the comparison and the maps about North Carolina funding by county and overdose deaths may not correlate. The reporting seems to reflect overdose deaths on a per capita basis, but funding is indicated by total dollars received.

might be helpful. It ranks each North Carolina county by the amount of funds they will receive from the distributor and Johnson & Johnson settlements (as posted on ) per capita, using 2019 population figures. In per capita rankings, rural and/or less populous counties are typically receiving more funding per capita than larger counties. For example, the 10 counties receiving the most per capita funding are all rural and/or less populous counties (Wilkes, Cherokee, Burke, Columbus, Graham, Yancey, Mitchell, Clay, Swain, and Surry). Wake County, our most populous county, is ranked 80th.

It’s also important to note that the formula was developed by experts for counsel to local governments in the national opioid litigation, who represent and have duties of loyalty to both large urban and small rural local governments. It takes into account opioid use disorder in the county (the number of people with opioid use disorder divided by the total number of people nationwide with opioid use disorder), overdose deaths as a percentage of the nation’s opioid overdose deaths, and the number of opioids in the county. Click for more information.

Indeed, one of the special masters appointed by U.S. District Judge Dan Polster in the national opioid litigation found that the national allocation model “reflects a serious effort on the part of the litigating entities that devised it to distribute the class’s recovery according to the driving force at the heart of the lawsuit — the devastation caused by this horrific epidemic.” (See Page 5 of of Special Master Yanni.)

You’re absolutely right that rural counties were often the earliest and hardest hit by the opioid epidemic, and it’s critical that they receive funds to help get residents the treatment and recovery resources they need. We’re hopeful that these funds, whose allocation was determined in partnership by local government counsel, will help deliver those resources.

— Nazneen Ahmed, North Carolina Attorney General’s Office, Raleigh, North Carolina

— Kate Roberts, Durham, North Carolina

A Holistic Approach to Strengthening the Nursing Workforce Pipeline

As we face the nation’s worst nursing shortage in decades, some regions are adopting creative solutions to fill in the gaps (“Rural Colorado Tries to Fill Health Worker Gaps With Apprenticeships,” Nov. 29). To truly solve the root of this crisis, we must look earlier in the workforce pipeline.

The entire nation currently sits in a dire situation when it comes to having an adequate number of nurses — especially rural communities. With the tripledemic of covid-19, influenza, and RSV tearing through hospitals, it’s never been more evident how vital nurses are to the functioning of our health care system. A found that we need to double the number of nurses entering the workforce every year for the next three years to meet anticipated demand. Without support from policymakers and health care leaders, we cannot meet that.

As a health care executive myself, I’ve seen firsthand how impactful apprenticeships can be because they help sustain the health care workforce pipeline. From high school students to working adults, these “earn while you learn” apprenticeships allow students to make a living while working toward their degree, and my system’s apprenticeship program has even reduced our turnover by up to 50%. It provides a framework to support a competency-based education rooted in real-life skills and hands-on training for key nursing support roles, all while team members earn an income.

Education is key to developing competent, practice-ready nurses. Not just through apprenticeships but early on in students’ educational journey, too. According to the newest data from the , students in most states and most demographic groups experienced the steepest declines in math and reading ever recorded. As we continue to see the devastating impact the pandemic had on young learners, it’s crucial we invest more in remediation and support, so students graduate from secondary school with a deep understanding of these core competencies and are ready to pursue nursing. A of nearly 4,000 prospective nursing students from ATI Nursing Education found that a lack of academic preparedness was the top reason for delaying or forgoing nursing school.

Without intervention now, our nursing workforce shortage will only worsen in the future. We need our leaders to face these challenges head-on and invest in a holistic approach to strengthen our nursing pipeline. There’s no time to waste.

— Natalie Jones, executive director of workforce development at WellStar Health System, Atlanta

1 solution to the staffing crisis: Apprenticeship programs put students directly into long-term care professions. Rural areas benefit the most since they have more residents who are 65 or older & fewer direct care workers to help people w/ disabilities.

— OK Health Action (@ok_action)

— Oklahoma Health Action Network, Oklahoma City

Planning Major Surgery? Plan Ahead

I read Judith Graham’s good article “Weighing Risks of a Major Surgery: 7 Questions Older Americans Should Ask Their Surgeon” (Jan. 3) . Thought I should add some personal experience. At age 78, my mother had back surgery in 2016. When she was getting prepped, she was given multiple documents to sign. Once signed, she was immediately taken to surgery. There was not enough time to read any of them. In hindsight, we are certain the documents were mostly for release of liability if something goes wrong. After surgery, she had “drop foot” — total loss of use of her left foot. Never heard of it. She was told she would regain use in about six months. Never happened. She had to use a walker and still had numerous falls in which her head had hit the ground multiple times. She slowly slid into long-term “confusion” that was attributed to her falls and passed away at age 84.

My story is about my abdominal aorta aneurysm surgery in 2022 at age 62. I did not have an overnight recovery — tube taken out of my throat, catheter removed, and was immediately transferred to a room. An IV pump of saline was left on and my arm swelled up — I thought my arm was going to burst. Five days later, I was discharged. Everything seemed rushed. The only postsurgical “instructions” I received were to keep the incision clean and not to play golf, and I don’t even play golf. I recuperated at home, and after five months I still have abdominal pain that I’ll always have.

Both of our surgeries were done on a Friday. I’m certain our experiences were due to hospital staff wanting to leave early on Friday, and weekend staffers are mostly the “B” team. So, my advice is to suggest to the elderly not to have surgery scheduled on a Friday unless there is absolute urgency in choosing the date.

— Paul Lyon, Chesapeake, Virginia

Reality bites, doesn’t it.

— suzette sommer (@suzette_sommer)

— Suzette Sommer, Seattle

I am writing to express my concerns over the significant misinformation in the article about what older Americans should ask their surgeon before major surgery.

Most abdominal aortic aneurysms are treated with endovascular methods. These minimally invasive procedures still require general anesthesia (with a breathing tube), but most patients have the tube removed before leaving the operating room, and many patients leave the hospital the next day with minimal functional limitations due to surgery being performed through half-inch incisions in each groin.

The “best case” surgical scenario described in your article describes open abdominal aortic aneurysm repair, which is recommended for fewer than 20% of patients requiring aortic aneurysm repairs.

In essence, you’re threatening everyone who comes in for a tuneup with an engine rebuild.

Abdominal aortic aneurysms are still undertreated in the U.S., with many patients not receiving screening recommended by Medicare since 2006. Your article misrepresents the “best case” scenario and may dissuade patients from receiving lifesaving care.

— Dr. David Nabi, Newport Beach, California

I read, with interest, Judith Graham’s article about older Americans preparing for major surgery. But you failed to mention the life-altering effects of anesthesia. My independent 82-year-old mother had a minor fall in July and broke her hip. After undergoing anesthesia, she is required to have 24/7 care as her short-term memory has been forever altered. Was there a choice not to have hip surgery? I didn’t hear one. Did anyone explain the issues that could (and often do) occur with an elderly brain due to anesthesia? No. And now we are dealing with this consequence. And what happens when you don’t have money (like most people in the U.S.) for 24/7 care? I hope you’ll consider writing about this.

— Nancy Simpson, Scottsdale, Arizona

Shouldn’t more people wonder why MA plans are profitable while our own gov’t MC is losing money. Only 5% of MA plans are audited yearly. Yet they are getting 8.5% increase in payment & docs (the folks taking care of the pts) are getting cut. via

— Madelaine Feldman (@MattieRheumMD)

— Dr. Madelaine Feldman, New Orleans

The High Bar of Medicare Advantage Transparency

Unfortunately, KHN’s article “How Medicare Advantage Plans Dodged Auditors and Overcharged Taxpayers by Millions” (Dec. 13) provided a misleading, incomplete depiction of Medicare Advantage payment.

This story focuses largely on audits that, in some cases, are more than a decade old. While KHN’s focus is on alleged “overpayment,” the same audits show that many plans were underpaid by as much as $773 per patient.

More recent research demonstrates Medicare Advantage’s affordability and responsible stewardship of Medicare dollars. For example, an October 2021 Milliman report concludes “the federal government pays less and gets more for its dollar in MA than in FFS,” while the Department of Health and Human Services’ fiscal year 2021 report shows that the net improper payment rate in Medicare Advantage was roughly half that of fee-for-service Medicare.

KHN’s article is right about one thing: Only a small fraction of Medicare Advantage plans are audited each year — denying policymakers and the public a fuller understanding of the program’s exceptional value to seniors and the health care system. That is why has called for regulators to conduct Risk Adjustment Data Validation (RADV) audits of every Medicare Advantage plan every year.

There are opportunities, as outlined in our recent policy recommendations, to further strengthen and improve Medicare Advantage’s high bar of transparency and accountability, but that effort is not well served by this misleading article.

— Mary Beth Donahue, president and CEO of the , Chevy Chase, Maryland

Targeting Gun Violence

I’m curious why KHN neglected to actually get into all the “meat and potatoes” regarding its report on Colorado’s red flag law (“Colorado Considers Changing Its Red Flag Law After Mass Shooting at Nightclub,” Dec. 23). Specifically, it failed to report that the suspect in this case used a “ghost gun” to execute the crime in Colorado Springs, and more importantly what impact any red flag law is going to have on a person who manufactures their own illegal firearm. Lastly, why is it the national conversation regarding the illegal use and possession of firearms curiously avoids any in-depth, substantive conversation of access to firearms by mentally ill people? Quite frankly, this is the underlying cause of illegal firearms use and no one wants to step up to the plate and address the issue at any in-depth level. It’s categorically embarrassing for American journalism.

— Steve Smith, Carbondale, Colorado

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

A Centene subsidiary, Operose Health, took over nearly three dozen medical practices in London — gateways for NHS care — in a deal worth tens of millions of dollars. The subsidiary became the largest private supplier of general practice services in the United Kingdom, with 67 practices accounting for 570,000 patients.

A local health commission, records show, signed off after a nine-minute review in a virtual hearing held the week before Christmas. Centene was not mentioned. Not a question was asked. It was the time of year — amid pandemic restraints — when official business in London gave way to fizzy cocktails and quiet glad tidings.

Within weeks, the acquisition set off alarms for Louise Irvine, an NHS doctor, who called it “privatization of the NHS by stealth.” Irvine, other practitioners, and residents supported a crowdfunded legal challenge to the takeover of AT Medics Holdings, the U.K. primary care company under contract to the NHS.

Centene is the largest privately managed care provider in the U.S. that offers government-sponsored insurance, such as Medicaid and Affordable Care Act plans, as well as health care to seniors, prisoners, military members, and veterans. Britons who protested its expansion saw a for-profit outsider with ambitions that could weaken the NHS. They worried Centene would decide on staffing to suit its bottom line. NHS contracts with doctors at set rates, and assistants are paid less; critics questioned whether the Centene deal would reduce more highly trained staff.

Then there was this: The corporation since 2013, over noncompliance with state or federal Medicaid contracts or rules. By mid-2021, as its legal battle intensified in London, Centene was grappling with allegations of overbilling Medicaid for pharmacy services. It has since paid about $657 million . It faces investor lawsuits as well as overbilling allegations from several more states. Centene, based in Missouri, has denied wrongdoing.

Centene’s “suitability” for doing business with the NHS was not discussed in the virtual hearing. And because of technical limitations, members of the public could review the decision only through an audio recording, released online a day later.

“It was covid time,” Irvine, now retired, said with some frustration about the public meeting. “We believe NHS should be a public service, and it is being gradually eroded.”

Centene did not respond to requests to discuss its U.K. strategy. By July 2021, Centene’s interests also acquired Circle Health Group, a private health care group based in London with 50 hospitals.

Earlier this year, a judge ruled that the 2020 public meeting was conducted lawfully. The judge questioned the relevance of raising Centene’s liabilities; she noted the American company’s counsel had documented that its “financial position was strong” and that the insurer “continues to operate successfully in the U.S. health care market.”

Advocates for market-based efficiencies, including former NHS chiefs who were hired by Centene-related businesses, portray the managed-care titan as a change agent that can innovate and trim costs.

In October, an NHS care commission declined to renew a Centene contract for Hanley Primary Care Center in north London, which . The clinic was left with too few doctors, , and patient appointments had dropped by 270 a week, representing a “huge hole” in care since the acquisition. The NHS’ decision , in which clinic employees said the practice was short eight doctors and that less qualified workers, called physician associates, filled the gaps.

Operose spokesperson Stephen Webb, in an email, said the Hanley practice “is currently rated as ‘Good’ by the national regulator” and the contract would be reviewed next year. On its website, Operose calls the BBC report “sensational.” It adds that “we have a strong track record of performance, recruitment and investment in our staff and services.”

The Hanley decision is a small validation for Irvine and others who warned that efficiencies would degrade the quality of care.

“The whole ethos of the American system, well, it is fundamentally different than how we view care in the U.K.,” Irvine said. “Our values are free and accessible health care for all.”

Cultivating Ties in Government

Centene was eyeing the British health system in winter 2011, when it hosted health advisers from across Europe to tour its facilities in Spain’s seaside region of Valencia.

In March 2011, and again in 2015, representatives from Centene’s subsidiary Ribera Salud promoted its “pioneering approach” to caregiving at hospitals and treatment centers through a public-private partnership, according to.

Like Britain, Spain faces an aging population. The subsidiary promised a model for “efficient and effective healthcare” for patients who are government-supported or pay out-of-pocket. The government paid the provider a flat rate per patient each year, and Ribera Salud operated the sites and managed staff.

The approach intrigued British politicians and advisers, conservatives as well as liberals, eager to manage health care costs by encouraging competition.

Centene cultivated its image and relationships, launching the subsidiary Centene UK in 2016. Within months, it was hiring NHS administrators for its executive ranks. Among the highest-profile recruits: Samantha Jones, a nurse and the NHS England director of “new care models,” who had championed Centene’s work in Spain.

By 2019, Jones was named CEO of Centene UK. In 2021, she left to work for Prime Minister Boris Johnson as “an expert adviser for NHS transformation and social care.”

As Johnson’s premiership came under pressure, Jones was named chief of operations at No. 10 Downing St. She left when he resigned in July.

By then, Centene had a substantial U.K. foothold and other former NHS administrators had joined its top ranks. Contacted through LinkedIn, Jones said she was “not available to do any interviews.”

For consumers intent on preserving Britain’s national health care — or just understanding who owns what and where — Centene is difficult to track. It’s the same in the U.S., where the company has more than 300 subsidiaries. Names there typically lean into local iconography such as Peach State Health Plan of Georgia and Buckeye Community Health Plan of Ohio — with no mention of Centene.

In England, Jenny Shepherd, 72, has written about Centene and its subsidiaries for years. She set up a hyperlocal news site in 2012 to track public services amid government budget restraints. She soon focused on NHS. When Centene’s operations in Spain were being floated as a model for reform, Shepherd saw little coverage of it. “Journalism was lacking,” she said.

Shepherd scours regulatory filings for her posts, published under “.” Over years, she has documented a flowchart of sorts of Centene’s businesses. She said the company routinely recasts its corporate profile. From 2016 to 2018 alone, subsidiary names, addresses, and company directors changed often, she noted.

In 2018, Centene UK was listed as controlled by a Centene subsidiary, MH Services International Holdings. In November 2019, according to regulatory filings, Centene UK formally changed its name to Operose Health.

The practices acquired in 2020, however, were still identified in March 2021 as part of AT Medics Holdings. That filing, in U.K. government records, lists Operose Health as a board member.

Centene’s stake in Circle Health was laid out in December 2021 regulatory filings. Circle Health’s parent company in the U.K. is MH Services International (UK) Ltd., “with the ultimate parent being Centene Corporation,” records show.

Centene aims to wring profit from government-guaranteed payments, Shepherd said: “The English NHS is as big as the Chinese army, and it was clear that the Americans wanted to get their hands on it.”

Such guarantees have diminished, however, as health care costs have increased. The pandemic has propelled a two-year backlog for some treatments. For the first time in history, NHS nurses in England, Wales, and Northern Ireland went on strike in December, largely over pay. Ambulance drivers and paramedics in England and Wales followed suit. Military personnel were readied to take over some services.

‘Closer to the American Model’

The rise of for-profit providers within the British NHS has sparked incendiary debates, with brute questions about costs and motives. How much is spent on patients? How much is spent on services? And could market forces plow the national health landscape into a tiered system of care?

“We are seeing a shift in care access and waiting times, and a big rise in the number of people moving toward a private system,” said Chris Thomas, principal health fellow at the Institute for Public Policy Research think tank in London. “Britain already has the largest number of private patients in the G-7, and that brings us closer to the American model.”

Centene has been welcomed by some as a way “to ease burdens within a chronically overworked NHS,” Thomas said. “But it doesn’t seem optimal to have a corporation — a for-profit organization — coming in.”

Centene has seen limits to government guarantees, particularly in Spain.

Even as British health advisers visited Ribera Salud in 2011, the Spanish press was documenting financial missteps in the venture. Fees per patient, meant to cover access to universal care, had to be renegotiated. Directors and administrators moved between public-sector jobs and Ribera through what appeared to be an unchecked .

Anne Stafford, a finance professor at University of Manchester, behind the Ribera model. The rhetoric of savings never matched reality, she said, with no clear comparison offered of labor costs, financing, wage demand, and patient ratios between Spain and Britain.

Debates over how best to deliver care often lack rigor and consistency, she added. “People say they love their NHS, but they have no concept of how it is funded or how it operates,” she said. “That allows people with an agenda to get into the market.”

British politicians have seen health care as ripe for privatization since the late 1990s, she said, but “there is very little proper accountability” for whether “the private sector, in fact, is delivering value for money.”

NHS advisers also have questioned whether the two systems could be effectively compared: Invented after World War II, the NHS was so celebrated that in 2012 doctors and nurses marched in the opening ceremony of the London Olympics. Spain’s national health care emerged in the 1980s, after the death of dictator Gen. Francisco Franco, and it struggled with costs within its first decade. The Centene model in Valencia, reliant on bank financing, was implemented in 1999.

The report found differences in size and staffing of facilities as well as how care systems were integrated. Measuring possible cost savings was difficult and, the report said,

By December 2021, it was clear that Centene no longer regarded its Ribera operations as a moneymaker. It announced it would divest “non-core assets” to improve its profit margin.

Centene executives to two international assets: Circle Health and Ribera.

Within months, the Spanish subsidiary was sold for an undisclosed figure, bundled with other health and diagnostic groups, to Vivalto Santé, the third-largest private hospital company in France. The acquisition was completed in November.

Centene, in a statement, described its excising of Ribera, with 10 hospitals, 1,650 beds, and 71 primary care and outpatient clinics, as a “significant milestone in our value creation plan.”

For now, with its Circle Health venture. Its 1,900 beds delivered two-thirds of more than $2 billion in annual revenue, according to investor guidance in December 2021. It’s now the largest private hospital care provider in England.

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The $10,563.49 in initial ER charges from a Froedtert South hospital in Pleasant Prairie, Wisconsin, seemed high considering he basically got only an exam, X-rays, pain relief, and an arm splint. His insurer negotiated the cost down to $7,922.62 — but, with Shah owing $250 for his deductible and 40% of the remaining charges, his bill of $3,319.05 still felt like too much. However, he thought, who was he to question the hospital’s billing department?

Shah’s wife, on the other hand, is highly qualified to question such charges. Sunita Kalsariya, 45, is the office manager of her husband’s medical practice, a job that includes overseeing billing. She took one look at the hospital charges and decided to investigate further.

Kalsariya had no way of knowing then that she was embarking on a crusade that would take over a year, send their bill to debt collections, lead her to complain to the Illinois attorney general, and discover that the hospital charged nearly $7,000 for a procedure that was never performed.

Froedtert South did not respond to multiple requests for comment on the case.

Here’s how Kalsariya reduced her family’s bill:

Tip 1: Start Early

Even before you know you’ll be challenging a bill, Kalsariya said, you should ask the hospital both for more information and to pause the billing process. The sooner you do that, the more time you’ll have to track down the details you need to contest a bill — and possibly reset the clock before it is sent to collections.

“Even in our case, we waited until the second bill,” Kalsariya said. “Start acting with the first bill.”

Tip 2: Get an Itemized Bill

Hospitals often have their own internal billing codes, so it’s important to ask for an itemized bill that lists “current procedural terminology” billing codes (CPT codes, for short), which are standardized across the country.

Depending on the medical procedure, Kalsariya said, a bill could contain an overwhelming number of line items that are hard to understand. She suggested focusing on the items that stand out, such as those with the highest price tag.

Kalsariya said it took months to get a bill that included CPT codes for her husband’s ER trip. Once she did, one item jumped out: $6,961.75 for CPT code 24505 — treating a fractured humerus without making an incision.

Shah didn’t remember having that treatment at Froedtert South. What he did recall was having his arm splinted in a comfortable position and making plans to have surgery the next day at a hospital in the Chicagoland area unaffiliated with Froedtert South. He returned home that night, caught maybe a couple of hours of sleep while propped up by pillows in an almost-seated position, then had a successful surgery.

Tip 3: Compare Your Charges With Those at Other Hospitals

Since January 2021, all hospitals to make their prices publicly available, although some do so in a way that is difficult to find. Still, Kalsariya was able to find the prices that other hospitals in Wisconsin and beyond charged for the same procedure. They ranged from $201 in Boise, Idaho, to $1,300 in Madison, Wisconsin, she said, but all were fractions of the nearly $7,000 that Froedtert South charged.

The website has a tool that allows consumers to search for typical patient expenses for procedures in their area. The website estimates that the out-of-network cost for the procedure Shah underwent, within the hospital’s ZIP code, would be $3,863; in network, it would be $1,707. Medicare also to find national average patient expenses searchable by CPT code. The total cost for that procedure is listed at $1,892, with Medicare paying $1,514 and the patient on the hook for $378.

Tip 4: Challenge Your Charges

Armed with the information that Froedtert South was seemingly charging more than others for the bone realignment, the couple tried appealing directly to the hospital with no luck.

“The charges incurred on your date of service were both reasonable and within the range usually charged by similar healthcare providers in the area,” the hospital’s response letter read. “Moreover, your insurance company, United Healthcare Choice-Golden Rule, entered into a long-term agreement with Froedtert South knowing the charges for its various services.”

The couple sent two complaints to their insurer asking how it could allow itself to be charged such a high amount, but response letters said the claim was processed correctly.

“We expect our in-network providers to bill appropriately for their services,” UnitedHealthcare spokesperson Maria Gordon Shydlo wrote in an email to KHN. “We paid the claim under the terms of Mr. Shah’s benefit plan based on the information we received from the provider.”

Fed up, Kalsariya filed a complaint with the Illinois attorney general’s office. After going back and forth, she eventually was told her husband could apply for the hospital’s financial assistance program to reduce his bill. But Kalsariya said they didn’t need financial assistance. They could afford $3,319.05. This, she said, was about the principle of the thing — she felt they were being egregiously overcharged.

Tip 5: Request Your Medical Records

Getting Shah’s medical records proved to be another challenge. Kalsariya said her attempt to access the records on the hospital’s website didn’t work, so instead the couple was required to send hospital officials a form to release the records.

“They wouldn’t even accept fax or email,” Kalsariya said. “They needed it mailed, specifically, and it had to be notarized.”

It almost didn’t seem worth the hassle to them. But when a KHN reporter responded to the family’s request for help investigating Shah’s hospital bill, the couple decided to send in the form to accurately document their saga.

When the records arrived, they showed the splinting that Shah remembered but not the treatment that was driving up his bill. They appealed the bill to Froedtert South once more in May 2022, this time noting the discrepancy between the charges and the medical records.

Tip 6: Tell Collections You Are Disputing the Bill

Shah had received a letter from a debt collector, which Kalsariya said came in November 2021, over his unpaid medical bill. She asked the hospital to pull the bill from collections because the dispute was unresolved, which she said it did.

Informing a collections agency that a bill is in dispute can help protect a patient’s credit score. That wasn’t an issue with Shah’s bill from the hospital because the hospital pulled it back after Kalsariya’s call.

How It All Ended

After the couple asked the hospital about the discrepancy with the procedure, Shah received a letter from the hospital dated May 27 of this year, saying it had reviewed the records and discovered the bill was inappropriately coded: The hospital should have used the code for a splint, not a treatment. A month later, Shah got a new bill with a patient balance of $1,214.91 — $2,100 less than the original balance.

Kalsariya still thought the bill seemed high and that the hospital seemed unapologetic about charging for a procedure that was never performed.

But the couple paid the new, smaller bill, and their saga was finally over. Her advice to other patients? When you get a bill, look into it before paying.

“I know it’s time-consuming. It is really taxing on our minds to do this,” Kalsariya said. “But if everybody makes that effort, then they have to be transparent.”

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Plus, Sebastian was developing well in other ways: When he was just 18 months old, for example, he could identify the magnetized letters of the alphabet on the refrigerator at their home in Bronxville, a short train ride north of New York City.

But by the time Sebastian was a little over 2 years old, his skills weren’t keeping up with those of other kids his age: He spoke only simple words, like “mama” and “dada,” and had problems interacting with people, Amparo Rios said. He didn’t know how to play with other kids and didn’t care about showing people his toys or sharing them. He made eye contact less and less.

The Rioses worried their son might have autism but didn’t know how to get a definitive diagnosis for his lagging skills or how to get him help.

with autism spectrum disorder by age 8, according to federal estimates. It is a developmental disability that affects people’s social and communication skills and their behavior to varying degrees. About a third of children with autism have intellectual disabilities as well, according to the federal Centers for Disease Control and Prevention.

As awareness of the autism spectrum has grown, new diagnostic criteria that cover milder forms of the disability have helped draw attention to the needs of children, like Sebastian, who may benefit from ongoing treatment and need significant support to go to school and participate in activities like sports.

Autism can’t be diagnosed with a blood test or scan. Instead, professionals generally rely on in-depth interviews with parents or caregivers about a child’s development, as well as evaluations of a child’s behavior during one-on-one sessions. Those may require out-of-pocket payments as insurance companies impose stricter coverage standards. Parents can wait months for appointments with a developmental pediatrician or other specialists.

“There are significant provider shortages, especially with the number of children who are diagnosed or suspected to have autism these days,” said Kelly Headrick, senior director of state government affairs and grassroots advocacy at Autism Speaks, a research and advocacy organization.

As a result, the Rioses discovered, getting a diagnosis and any subsequent help can be a long, winding, nerve-wracking, and sometimes costly road.

Although parents may notice developmental problems during a child’s first 18 to 24 months, children aren’t diagnosed with autism, on average, until they are more than 4 years old, studies show. That means missed opportunities for intervention: Research shows that early treatment of autism leads to better outcomes.

Eager to get help for Sebastian, the Rioses asked their pediatrician for help when their son was 2. The doctor referred them to their school district, so Sebastian could be assessed for special education services. But he was too young for the district to help.

The Rioses learned that children under age 3 need to connect with services through the federally mandated early intervention program that requires states to provide services to children with developmental delays or disabilities.

The family waited more than three months for the battery of tests and appointments to be completed, and the gap between Sebastian’s development and that of other kids his age continued to widen. In addition to his language and social developmental delays, he struggled with imaginative play and was intensely self-directed, focused completely on what he wanted to do when he wanted to do it.

Although the staff members of the early intervention program didn’t have the specialized skills necessary to provide a medical diagnosis, they recommended Sebastian begin occupational therapy, speech therapy, and , a widely used technique in which therapists work intensively with children who have autism using positive reinforcement to achieve goals related to communication, learning, motor, and other skills. For example, a therapist might encourage a child to play a game the therapist has chosen before playing the game the child prefers. If the child does that, he might be praised by the therapist or get something else he values, like a toy or playground time.

The early intervention program paid for someone to go to the Rioses’ home six hours a week to do ABA therapy. But Amparo Rios said the therapist didn’t focus on Sebastian’s problem areas, such as transitioning from one activity to another without having a meltdown, so she wanted a different ABA therapist.

The Rioses had health coverage through a plan administered by Trustmark, which set coverage policies in consultation with Amparo Rios’ employer, a local college. But Sebastian needed a medical diagnosis of autism from a provider the plan considered a qualified clinician before it would pay for ABA therapy — a diagnosis Sebastian still didn’t have at age 3. At about this time, the Rioses noticed their son was “stimming,” shorthand for self-stimulating behavior, often repetitive movements or sounds that help calm or comfort people with autism. In Sebastian’s case, he made grunting noises.

Since there is no single standardized test required to diagnose the condition, providers use different tools — some of which specific insurers will not accept.

The family took Sebastian to a neurologist for an exam, but she said she wasn’t sure he had autism. “We felt so rudderless,” Amparo said. “We didn’t know who to turn to to diagnose him or figure out what was wrong with him.”

Six months later, in September 2020, the family found a clinical psychologist who specialized in autism spectrum disorders and was in their provider network. She tested Sebastian over three months, evaluating his cognitive abilities and his capacity to attend to tasks, follow directions, and pay attention, among other things. The pandemic slowed medical care to a crawl, and in May 2021 she finally diagnosed Sebastian, then 4, with Level 1 autism spectrum disorder, the least limiting form, and recommended he again begin ABA therapy.

The delay cost Sebastian. His stimming behaviors got worse, and he made eye contact with others less frequently. “We had very mixed feelings about the diagnosis,” said Amparo. “It was a relief that we had a diagnosis we could rely on for medical care. But it was mixed because as parents we didn’t know what he would grow up to be.”

Two years after the Rioses noticed their son’s atypical behaviors, they enrolled him in individual ABA therapy for 15 hours a week at a center near their home. It felt like the pieces were finally falling into place. Sebastian’s language skills were getting better because of speech therapy, but he was very self-directed and still not good at making eye contact. He sometimes wandered off on his own, a terrible safety risk, and couldn’t use the bathroom by himself.

Amparo’s health plan administrator, Trustmark, confirmed that ABA therapy was covered, with a copayment of $25 per session.

It was tough for Sebastian at first, Amparo said, as he worked with a therapist to learn how to be less rigid and less focused on doing only what he wanted to do. But he gradually got better at skills like making eye contact and using the bathroom on his own.

The relief was short-lived.

In September, the Rioses started getting notices from the health plan administrator saying it wouldn’t pay for the therapy because it wasn’t medically necessary. Unfortunately, the therapist who had provided the diagnosis hadn’t screened Sebastian using the (ADOS-2), a highly regarded test.

Sebastian’s developmental pediatrician sent a letter to the health plan explaining the need, and the ABA therapy provider sent clinical notes from Sebastian’s sessions.

It didn’t work. Trustmark refused to pay for the ABA therapy, and in February the Rioses discontinued it. Now they’re facing more than $11,000 in bills for the sessions. Without the therapy, their son’s progress is slipping, Amparo said. He’s stimming more and has been distracted and disruptive in his kindergarten class, needing constant reminders to stay focused.

Trustmark declined to comment for this article.

“It’s just really frustrating” for parents, Amparo said, “but ultimately it’s very sad for my son.”

The Rioses appealed the denial but lost. An independent reviewer found in May that the ABA services weren’t medically necessary and questioned whether Sebastian had autism. He noted that Sebastian hadn’t been screened using the ADOS-2 test and said he needed it.

It was the last straw. Amparo quit her job, and the family switched their health coverage to her husband’s plan. They began a new assessment process for Sebastian, now 5. They paid $500 to a provider to administer the ADOS-2 test, which confirmed his autism diagnosis in June. Now, three years after starting the search for help, they’re trying to enroll Sebastian in ABA therapy again using the new health plan’s coverage.

“You want your child to be assessed as early as possible to get as much help as possible,” Amparo said. “This is a critical time in his development, and I just feel beaten down.”

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She picked a Humana drug plan for its low prices, with help from her longtime insurance agent and Medicare’s Plan Finder, an online pricing tool for comparing a dizzying array of options. But instead of the $70.09 she expected to pay for her dextroamphetamine, used to treat attention-deficit/hyperactivity disorder, her pharmacist told her she owed $275.90.

“I didn’t pick it up because I thought something was wrong,” said Griffith, 73, a retired construction company accountant who lives in the Northern California town of Weaverville.

“To me, when you purchase a plan, you have an implied contract,” she said. “I say I will pay the premium on time for this plan. And they’re going to make sure I get the drug for a certain amount.”

But it often doesn’t work that way. As early as three weeks after Medicare’s drug plan enrollment period ends on Dec. 7, insurance plans can change what they charge members for drugs — and they can do it repeatedly. Griffith’s prescription out-of-pocket cost has varied each month, and through March, she has already paid $433 more than she expected to.

A by AARP, which is lobbying Congress to pass legislation to control drug prices, compared drugmakers’ list prices between the end of December 2021 — shortly after the Dec. 7 sign-up deadline — and the end of January 2022, just a month after new Medicare drug plans began. Researchers found that the list prices for the 75 brand-name drugs most frequently prescribed to Medicare beneficiaries had risen as much as 8%.

Medicare officials acknowledge that manufacturers’ prices and the out-of-pocket costs charged by an insurer can fluctuate. “Your plan may raise the copayment or coinsurance you pay for a particular drug when the manufacturer raises their price, or when a plan starts to offer a generic form of a drug,” the warns.

But no matter how high the prices go, most plan members can’t switch to cheaper plans after Jan. 1, said Fred Riccardi, president of the , which helps seniors access Medicare benefits.

Drug manufacturers usually change the list price for drugs in January and occasionally again in July, “but they can increase prices more often,” said , an associate professor of health policy at Vanderbilt University and a member of the Medicare Payment Advisory Commission. That’s true for any health insurance policy, not just Medicare drug plans.

Like a car’s sticker price, a drug’s list price is the starting point for negotiating discounts — in this case, between insurers or their pharmacy benefit managers and drug manufacturers. If the list price goes up, the amount the plan member pays may go up, too, she said.

The discounts that insurers or their pharmacy benefit managers receive “don’t typically translate into lower prices at the pharmacy counter,” she said. “Instead, these savings are used to reduce premiums or slow premium growth for all beneficiaries.”

Medicare’s prescription drug benefit, which began in 2006, was supposed to take the surprise out of filling a prescription. But even when seniors have insurance coverage for drugs, advocates said, many still can’t afford them.

“We hear consistently from people who just have absolute sticker shock when they see not only the full cost of the drug, but their cost sharing,” said Riccardi.

The potential for surprises is growing. More insurers have eliminated copayments — a set dollar amount for a prescription — and instead charge members a percentage of the drug price, or coinsurance, , the top official at the Centers for Medicare & Medicaid Services, said in a recent interview with KHN. The drug benefit is designed to give insurers the “flexibility” to make such changes. “And that is one of the reasons why we’re asking Congress to give us authority to negotiate drug prices,” she said.

CMS also is looking at ways to make drugs more affordable without waiting for Congress to act. “We are always trying to consider where it makes sense to be able to allow people to change plans,” said , CMS deputy administrator and director of the Center for Medicare, who joined Brooks-LaSure during the interview.

On April 22, CMS unveiled a proposal to streamline access to the Medicare Savings Program, which helps 10 million low-income enrollees pay Medicare premiums and reduce cost sharing. Enrollees also receive drug coverage with reduced premiums and out-of-pocket costs.

The subsidies make a difference. Low-income beneficiaries who have separate drug coverage plans and receive subsidies are nearly twice as likely to take their medications as those without financial assistance, according to a for Health Affairs in April.

When CMS approves plans to be sold to beneficiaries, the only part of drug pricing it approves is the cost-sharing amount — or tier — applied to each drug. Some plans have as many as six drug tiers.

In addition to the drug tier, what patients pay can also depend on the pharmacy, their deductible, their copayment or coinsurance — and whether they opt to abandon their insurance and pay cash.

After Linda Griffith left the pharmacy without her medication, she spent a week making phone calls to her drug plan, pharmacy, Social Security, and Medicare but still couldn’t find out why the cost was so high. “I finally just had to give in and pay it because I need the meds — I can’t function without them,” she said.

But she didn’t give up. She appealed to her insurance company for a tier reduction, which was denied. The plan denied two more requests for price adjustments, despite assistance from Pam Smith, program manager for five California counties served by the . They are now appealing directly to CMS.

“It’s important to us to work with our members who have questions about any out-of-pocket costs that are higher than the member would expect,” said Lisa Dimond, a Humana spokesperson. She could not comment about Griffith’s situation because of privacy rules.

However, Griffith said she received a call from a Humana executive who said the company had received an inquiry from the media. After they discussed the problem, Griffith said, the woman told her, “The [Medicare] Plan Finder is an outside source and therefore not reliable information,” but assured Griffith that she would find out where the Plan Finder information had come from.

She won’t have to look far: CMS requires insurers to update their prices every .

“I want my money back, and I want to be charged the amount I agreed to pay for the drug,” said Griffith. “I think this needs to be fixed because other people are going to be cheated.”

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The company’s February note said its health plan sign-ups saw “extraordinary growth” — passing the “one-million-member mark” in the previous year — and tied that success to the good relationships it has with brokers. But, the note continued, the insurer wanted to “suspend growth during this special enrollment season” and thus would stop paying commissions to brokers who enroll new people in coverage starting April 1.

“Why sell something I don’t get paid for?” the Georgia-based Holtzman recalled thinking.

Bright Health is not the only company cutting commissions. Several other insurers, including Oscar, Molina Healthcare, and some Blue Cross Blue Shield plans, have taken similar steps recently — just as the Biden administration rolls out a new aimed at signing up low-income Americans into ACA coverage outside of the usual annual open period. The new sign-up program became available in mid-March for coverage starting at the beginning of April.

The insurance industry’s trade group, however, opposed the plan, saying that people who sign up outside of the end-of-the-year enrollment window tend to be sicker, drive up the price of insurance, and cost insurers more.

“We have significant concerns it would create instability in the individual market and result in higher premiums for all enrollees,” AHIP wrote in a July to federal agencies.

Consumers could, insurers warn, wait until they get sick to enroll or switch plans to one with more generous benefits. The Centers for Medicare & Medicaid Services estimates that the low-income special enrollment program could by 0.5% to 2% annually because of sicker enrollees.

periods have always been allowed under the ACA when triggered by certain life events. Everyone else signs up during the annual open enrollment, typically from November to January. That restriction is designed to reduce the incentive for people to wait until they fall ill to buy insurance, which likely would drive up premium costs for everyone.

Last year, the Biden administration added a six-month covid-related special enrollment, which resulted in a .

Still, “there is limited data on whether folks come in sicker” during the special enrollment periods that have occurred since the ACA began, said Katie Keith, a researcher at the Center on Health Insurance Reforms at Georgetown University, adding that some of the verification rules supported by the industry around previous special enrollment exceptions are onerous enough that they may discourage the healthy more than the ill. Brokers note that low-income customers do turn to brokers when considering insurance coverage.

“Those are people who often need help the most,” said Marcy Buckner, senior vice president for government affairs at the National Association of Health Underwriters, an industry trade and lobbying group. “Agents and brokers want to help consumers, but they also have to keep their doors open. If they’re not earning commissions, they may not be able to help those consumers.”

The move by some insurers to cut commissions as of April 1 has caught the attention not only of brokers but of federal regulators.

“We are concerned about the impact on consumers, particularly those consumers whose circumstances lead them to enroll mid-year, and are actively investigating this matter,” Ellen Montz, director of the Center for Consumer Information and Insurance Oversight at CMS, said in a statement.

The Biden administration program allows people who earn less than 150% of the federal poverty level — about $19,320 for a single person or $32,940 for a family of three — to sign up anytime during the year. Other special enrollment offers, such as those for people who lose job-based insurance, get married or divorced, or want to add a baby to their plans, are generally time-limited. Among those currently uninsured, an could be eligible for the new low-income enrollment option.

Many more might need help enrolling soon for another reason, said policy experts. Some estimate that millions of people once the official pandemic emergency ends because states will no longer be held to an agreement they made with the federal government not to drop enrollees during the pandemic.

Although many of those health consumers might enroll on their own through federal or state marketplaces, or seek help from federal grant-funded assisters, experts say some may turn to private brokers, who may not want to take on new customers if they’re not going to get paid for their time.

“If insurers are not paying commissions for the special enrollment period, that will diminish sign-ups,” said Sarah Lueck, vice president for health policy at the Center on Budget and Policy Priorities, a left-leaning think tank in Washington, D.C.

Agents and brokers also argue that changing commissions midyear might run afoul of federal or state rules barring discrimination.

They point to issued in 2016, when some insurers were changing commission structures, warning the industry against practices that had the effect of “discouraging the enrollment of individuals with significant health needs in health insurance coverage.”

Neither Oscar nor Molina would comment for this story. In a written statement, Bright HealthCare said the industry is trying “to ensure continued access to care at affordable prices,” and is “working closely with its brokers to implement the [special enrollment period] commissions change as part of the solution.”

The Biden administration’s new policy for low-income special enrollment automatically applies to using the federal health exchange; the remainder that run their own marketplaces have the choice of whether to offer it. Excluded are people eligible for Medicaid or who have job-based coverage that meets the ACA’s criteria as affordable.

While the new special enrollment period is considered permanent, made available through the American Rescue Plan Act to help people buy coverage, which expire at the end of 2022 unless Congress extends them.

Insurers recently have expressed concerns about costlier customers enrolling during special periods, with some toward the end of last year on new enrollment.

Some of those cutting commissions, however, , still posted profits last year.

But not all. posted a 49% jump in membership during 2021, but a net loss of $571 million. , Bright HealthCare’s parent company, also showed membership growth last year, but with a net loss of more than a billion dollars.

Brokers say federal statistics recently shared with them found that close to half of all sign-ups during special enrollment periods were aided by brokers.

Insurers should not credit brokers on one hand for their tremendous growth and then cut their pay, said Ronnell Nolan, president and CEO of Health Agents for America, a professional and advocacy group for brokers.

“They can always point to how they are losing money. I always say, ‘Let’s check top management’s income’ and, guess what, it’s not zero,” Nolan said. “If they are not doing a good job in their financials, that’s not my job. We are doing our jobs.”

Commissions are paid by the insurers, so consumers who use a broker don’t pay more than those who do not. Still, commissions are baked into premiums overall, potentially raising prices across the board, and some policy experts question whether commissions lead agents to push certain plans over others.

Unlike brokers, government-funded navigators do not earn a commission, and they cannot suggest a specific plan for clients.

“We help them filter through the plans, which can be overwhelming,” said Jodi Ray, director of the nonprofit Florida Covering Kids & Families, one of about 60 Navigator programs operating in 30 states.

Navigator programs this year when the Biden administration significantly increased funding above the levels paid during the Trump administration.

So, Ray is not worried about having enough staffers to help people with the new low-income enrollment or the expected wave of former Medicaid patients who may lose their Medicaid eligibility once the pandemic emergency ends.

Instead, she’s concerned “about whether the state is willing to let people know where they can get that free help.”

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Testing, as well as mask-wearing, is an important measure if the country ever hopes to beat covid, restore normal routines and get the economy running efficiently. To get Americans cheaper tests, the federal government now plans to have insurance companies pay for them.

The Biden administration that every person with private insurance can get full coverage for . You can either get one without any out-of-pocket expense from retail pharmacies that are part of an insurance company’s network or buy it at any store and get reimbursed by the insurer.

Congress said private insurers must cover all covid testing and any associated medical services when it passed the and . The have-insurance-pay-for-it solution has been used frequently through the pandemic. Insurance companies have been told to pay for PCR tests, covid treatments and the administration of vaccines. (Taxpayers are paying for the cost of the vaccines themselves.) It appears to be an elegant solution for a politician because it looks free and isn’t using taxpayer money.

1. Are the tests really free?

Well, no. As many an economist will tell you, there ain’t no such thing as a free lunch. Someone has to pick up the tab. Initially, the insurance companies bear the cost. , a vice president at KFF who studies the Affordable Care Act and private insurers, said the total bill could amount to billions of dollars. Exactly how much depends on “how easy it is to get them, and how many will be reimbursed,” she said.

2. Will the insurance company just swallow those imposed costs?

If companies draw from the time-tested insurance giants’ playbook, they’ll pass along those costs to customers. “This will put upward pressure on premiums,” said , vice president and coordinator for health policy at the Center for American Progress.

Major insurance companies like Cigna, Anthem, UnitedHealthcare and Aetna did not respond to requests to discuss this issue.

3. If that’s the case, why haven’t I been hit with higher premiums already?

Insurance companies had the chance last year to raise premiums but, mostly, they did not.

Why? Perhaps because insurers have so far made so much money during the pandemic they didn’t need to. For example, the industry’s profits in 2020 increased 41% to $31 billion from $22 billion, according to the National Association of Insurance Commissioners. The NAIC said the industry has continued its “tremendous growth trend” that started before covid emerged. Companies will be reporting 2021 results soon.

The reason behind these profits is clear. You were paying premiums based on projections your insurance company made about how much health care consumers would use that year. Because people stayed home, had fewer accidents, postponed surgeries and, often, avoided going to visit the doctor or the hospital, insurers paid out less. They rebated some of their earnings back to customers, but they pocketed a lot more.

As the companies’ actuaries work on predicting 2023 expenditures, premiums could go up if they foresee more claims and expenses. Paying for millions of rapid tests is something they would include in their calculations.

4. Regardless of my premiums, will the tests cost me money directly?

It’s quite possible. If your insurance company doesn’t have an arrangement with a retailer where you can simply pick up your allotted tests, you’ll have to pay for them — at whatever price the store sets. If that’s the case, you’ll need to fill out a form to request a reimbursement from the insurance company. How many times have you lost receipts or just plain neglected to mail in for rebates on something you bought? A lot, right?

Here’s another thing: The reimbursement is set at $12 per test. If you pay $30 for a test — and that is not unheard of — your insurer is only on the hook for $12. You eat the $18.

And by the way, people on Medicare will have to pay for their tests themselves. People who get their health care covered by Medicaid can obtain free test kits at community centers.

A few free tests are supposed to arrive at every American home via the U.S. Postal Service. And the Biden administration has where Americans can order free tests from a cache of a billion the federal government ordered.

5. Will this help bring down the costs of at-home tests and make them easier to find?

The free covid tests are unlikely to have much immediate impact on general cost and availability. You will still need to search for them. The federal measures likely will stimulate the demand for tests, which in the short term may make them harder to find.

But the demand, and some government guarantees to manufacturers, may induce test makers to make more of them faster. The increased competition and supply theoretically could bring down the price. There is certainly room for prices to decline since the wholesale cost of the test is between $5 and $7, analysts estimate. “It’s a big step in the right direction,” Gee said.

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Doctors said she had a case of appendicitis. But she also tested positive at the hospital in Marietta, Georgia, for covid-19. Physicians decided not to do surgery and treated her with antibiotics and painkillers. Azzopardi, 47, went home after a couple of days in the hospital, feeling better.

But in October, the appendix pain again flared. Her husband took her to the same hospital, where surgery was performed successfully. This time, though, she ran into a snag with her insurance.

Azzopardi has UnitedHealthcare coverage, and as of Oct. 3, Wellstar Health System was no longer in the giant insurer’s network, after the two sides did not agree on a new contract.

Wellstar dominates the Cobb County area where Azzopardi and her husband live. She has applied to UnitedHealthcare for a “continuity of care” waiver, which would extend her previous in-network coverage for the treatment of an ongoing condition for the October hospital visit and surgery. If it doesn’t work out, she could owe thousands of dollars. “I don’t know where it stands,” Azzopardi said.

On a larger level, the severed contract between a hospital system and health insurer reflects tensions that have been growing nationally this year. In the past, even when contract negotiations became publicly antagonistic, they typically would be resolved before the deadline for termination.

Now health care consultants and industry officials say an increasing number of contracts end without a deal. Even if they are eventually resolved, those terminations throw tens of thousands of patients into the difficult position of choosing between much higher out-of-pocket costs or leaving a trusted physician and hospital.

The Wellstar vs. UnitedHealthcare situation — and an even bigger dispute looming in metro Atlanta involving Anthem Blue Cross and Blue Shield — come at a tricky time, during open enrollment season when many employers have already picked their insurance offerings and many consumers must choose their health plan.

“We are seeing more insurers terminate contracts without a deal, and this is both a national and local trend,” said Beth Spoto, a Georgia-based health care consultant with Spoto & Associates. From the insurers’ point of view, she said, it’s a hardball tactic to lower payment rates to medical providers for services.

“Health systems are getting quite large, so you are dealing with hundreds of millions of dollars,” she said. “The fighting is getting pretty tough.”

Recent contract terminations involving big insurers include UnitedHealthcare vs. Montefiore Health System in New York, and Anthem vs. Dignity Health in California. Each conflict was eventually resolved, though Montefiore took several months to settle.

Hospitals are reporting higher tensions in negotiations with health insurers, said Molly Smith, an vice president. She said contract talks often are not conducted by local executives of the insurer, which might allow for more collaboration, but are directed instead by company headquarters.

Just in the Atlanta area, other out-of-network situations involving insurance heavyweights UnitedHealthcare and Anthem have occurred in the past couple of years. Northside Hospital’s Gwinnett County facilities were out of network for UnitedHealthcare members for five months, while Northeast Georgia Health System in Gainesville left Anthem’s lineup for three months.

In the most recent dispute, Wellstar said it wants UHC to pay reimbursements similar to those it gets from other insurers. UnitedHealthcare, based in Minnesota, counters that Wellstar wants “egregious” rate hikes that the insurer said would amount to 37% over three years.

“Both sides said the other is just out for money,” Azzopardi said. The impasse, she said, “is cruel to the patients who have done nothing wrong.”

The open enrollment quandary has Emilie Cousineau of Smyrna, Georgia, wondering whether to stay with UnitedHealthcare or switch to Anthem, which she said would cost her more for the upcoming benefits year in her employer plan.

Cousineau canceled a Wellstar well-check appointment recently because suddenly it was out of network. “Right now, it’s an inconvenience.” But her doctor as well as her kids’ pediatrician are Wellstar physicians. “I’m picky about my health care,” she said.

Uncertainty over covid and rising hospital labor costs are fueling the disruptions, consultants said.

Health insurers recorded sky-high profits last year as people avoided medical care because of fears about covid. This year, profits have been lower but still healthy. For hospitals, the pandemic brought mixed results. Some richer, bigger health systems racked up huge surpluses, helped by covid relief funds, while many safety-net and rural hospitals fought hard to break even.

Cole Manbeck, a spokesperson for UnitedHealthcare, said affordability of health care is of prime importance to consumers and employers. They expect the insurer to help contain costs, which requires maintaining fair and competitive agreements with hospitals and doctors in its network, he said.

Insurers also point out that health care systems have enhanced their bargaining clout by acquiring additional hospitals and doctor practices. The tough negotiations extend to physician group contracts, said Dave Smith with the health care consulting firm . Insurers, he said, “are trying to drive health care costs down, and are doing it on the backs of physicians and hospitals.”

Factoring into the fray are payment delays involving insurers Anthem and UnitedHealthcare. Hospitals are dealing with a spike in retroactive claim denials by UnitedHealthcare for emergency department care, the AHA’s Smith said.

KHN also recently reported that Anthem Blue Cross is behind on billions of dollars in payments owed to hospitals and doctors because of onerous new reimbursement rules, computer problems and mishandled claims, according to hospital officials in multiple states.

Tom Mee, CEO of in New Hampshire, said the outstanding claims owed to his system by Anthem rose $250,000 in one quarter to reach $1 million.

Indianapolis-based Anthem said the contract rifts and the claims issue are not related. Both it and UnitedHealthcare noted that the large majority of contracts are renewed without public attention.

Employers, meanwhile, don’t like these network disruptions, said , a health care consultant with KPMG. But, he added, employers also don’t want to subsidize the rate increases.

“When times are good, and everybody is doing well, generally you don’t see these negotiation issues,” he said. “As long as the environment remains unpredictable, we’ll see some unpredictable negotiations.”

Contract terminations harm hospitals more than insurers, said Nathan Kaufman of . For example, UnitedHealthcare and Anthem, which operate in several states, “can take a hit in one state,” he said, because they’re diversified and insurers still receive premium payments for members after a contract with a hospital lapses.

“On day one, the hospitals start feeling increased financial stress,” Kaufman said. “They experience this financial jolt.”

The Atlanta market is facing another such contract disruption. Anthem has alerted consumers that Northside Hospital and its facilities may not be part of its network come Jan. 1. While the Wellstar vs. UnitedHealthcare tug-of-war involves an estimated 80,000 consumers, the Northside contract could affect four or five times that many, according to Northside officials.

“Anthem’s timing is very unfavorable to our patients,” said Lee Echols, a Northside spokesperson. “It’s hard to understand. We’re still in a pandemic, and this is the open enrollment period for health care policyholders. Many people are returning to their physicians and hospitals for deferred care, and Anthem’s threats make that process really challenging.”

But Anthem spokesperson Christina Gaines said that the company is fighting to curb health care costs, and that Northside is one of the most expensive systems in Georgia.

The showdown has consumers such as Carol Lander of Sandy Springs, Georgia, concerned and confused.

She has been an Anthem member for years and has used nearby Northside facilities and doctors. She’s now shopping for other plans to see if they include Northside in their networks. One insurance plan has her doctor but not her sons’ physician.

“It’s so frustrating,” said Lander. “This is a huge deal in this area.”

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Click here for a transcript of the episode.

Congress appears to be making progress on its huge social spending bill, but even if it passes the House as planned the week of Nov. 15, it’s unlikely it can get through the Senate before the Thanksgiving deadline that Democrats set for themselves.

Meanwhile, the cost of employer-provided health insurance continues to rise, even with so many people forgoing care during the pandemic. The annual KFF survey of employers reported that the average cost of a job-based family plan has risen to more than $22,000. To provide what their workers most need, however, this year many employers added additional coverage of mental health care and telehealth.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Anna Edney of Bloomberg News and Rebecca Adams of CQ Roll Call.

Among the takeaways from this week’s episode:

• Moderate Democrats who were worried about the price tag of the social spending bill said during negotiations last week that they wanted to see the full analysis of spending and costs from the Congressional Budget Office. But members of the House probably won’t get that score before voting on the bill. CBO instead is releasing its assessments piecemeal as analysts go through specific sections of the huge bill.
• If the House passes the bill next week, which leadership is pledging, the legislation could still undergo major revisions in the Senate. Some provisions will be subject to the “Byrd Rule,” which says items in this type of bill must be related to the budget. Republicans are expected to challenge parts of the bill, and the parliamentarian will have to rule on whether their objections are valid.
• Among the provisions that some moderate Democratic senators might object to are the paid family leave and the mechanism for lowering Medicare drug prices.
• Congress is looking at a very busy end of the year, which could complicate passage of the social spending bill. Leaders already postponed a bill to raise the debt ceiling and the annual federal spending bills until early December.
• A federal judge has blocked Texas Republican Gov. Greg Abbott’s order prohibiting mask mandates in schools. But a final resolution is likely some time away as the case is appealed. Disability rights groups, which had sued to stop the governor’s order, argued that the ban was keeping children with health problems who are at high risk from covid from coming to school.
• Despite opposition from conservative leaders to vaccine mandates, the vast majority of workers have had their shots, either because they wanted them or their employer mandated it. Lawsuits brought against those workplace requirements may not signal a broad opposition among the population.
• In its survey of employers’ health plans, KFF found that premiums are still increasing faster than wages as health costs continue to rise. Leaders of both political parties say they would like to reduce the cost of care, but no magic pill appears likely. Instead, lawmakers generally are more inclined to have the government pick up a bigger portion of the country’s health care costs when not finding a way to cut that spending.
• One key challenge in addressing rising health care spending in Congress is the power of the health care industry. With the close political party margins on Capitol Hill, it is fairly easy for the industries to use their contributions to pick off a couple of members and keep major reform from passing.
• The KFF survey also documented the wide expansion of telehealth coverage during the pandemic. Although employers and the government have been concerned that telehealth adds to spending because it duplicates services or allows doctors to charge for services they once performed over the phone without billing, it will be hard to put this genie back in the bottle. Consumers like the convenience. And some services, such as mental health therapy or medical consultations for rural residents, are much easier.

Also this week, Rovner interviews Rebecca Love, a nurse, academic and entrepreneur who has thought a lot about the future of the nursing profession and where it fits into the U.S. health care system

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: Washington Monthly’s “,” by Merrill Goozner.

Alice Miranda Ollstein: NPR’s “,” by Joseph Shapiro and Allison Mollenkamp.

Rebecca Adams: KHN’s “Patients Went Into the Hospital for Care. After Testing Positive There for Covid, Some Never Came Out,” by Christina Jewett.

Anna Edney: Bloomberg News’ “,” by Kristen V Brown.

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