But, today, he isn’t working in rural America and he doesn’t do primary care. In fact, he no longer practices medicine at all.

As CEO of CardioOne, which provides back-office support to cardiologists, Gundersen is part of a growing trend: physicians and medical school students earning advanced business degrees to work the business side of the booming health care industry.

Just over 60% of medical schools now offer dual MD-MBA programs, more than twice the number two decades ago, a recent study shows. And researchers estimate the number of dual-degree graduates has nearly tripled. Still, it’s difficult to know exactly how many physicians now have business degrees. While the medical school students who simultaneously earned both a medical and business degree represent almost 1% of the roughly 28,000 medical school students who graduate each year, that doesn’t include physicians, like Gundersen, who later go back to school to pursue an executive MBA.

For years, some doctors have sought auxiliary degrees, including master’s degrees in public health and law degrees. But more and more, doctors want to pair their clinical expertise with management skills and financial literacy as the American health system focuses on maximizing profits. Often that’s so they can become business executives, especially as lucrative health tech startups proliferate and hospital systems, pharmacy benefit managers, and insurers have swelled into formidable companies.

However, this pursuit of advanced business degrees begs the question: Whom will these doctors end up serving more, patients or shareholders?

Long gone are the days when nuns ran many local hospitals. Now, many hospitals are part of multibillion-dollar systems, some of which, such as HCA Healthcare Inc. and Tenet Healthcare Corp., outrank some of America’s most recognizable brands on the Fortune 500 list.

Still, it’s one of the few sectors of the economy where the people who know the most about what’s going on in their companies aren’t the ones running them, said J.B. Silvers, a management professor at Case Western Reserve University who has been teaching business fundamentals to medical students and physicians for decades.

In the past, doctors rarely left medicine to join the ranks of management because they tended to earn more as practicing physicians. But that’s changing, Silvers said, especially as new career paths emerge. The MBA can serve as the doorway to those new opportunities — and the potentially lucrative ownership stakes that can come from leading successful medical technology companies.

Physicians earn, on average, $350,000 a year, making them among the highest-paid workers in the U.S. Doctors in primary care tend to make less than that, while the top 1% of physicians can make more than $1.7 million annually.

“There’s a lot of other ways to make more money now,” said Rich Joseph, who, as an MD-MBA graduate from Stanford, is an example of the trend. Joseph, an outspoken critic of how U.S. doctors are trained, is chief medical officer for Restore Hyper Wellness, which offers cryotherapy and IV drips at locations across the country.

Doctors are considered the face of the health care system, but a lot of big decisions are made in the boardroom, said Folawiyo Laditi, a recent graduate of Yale’s MD-MBA program and a urology resident at the University of Pittsburgh.

Laditi wants to leverage his business degree to tackle systemic issues in health care that sometimes don’t always feel “fixable” as a doctor treating a single patient at a time. He hopes “to make changes that can affect a lot of patients and a lot of people at once.”

Medical schools are selling the power that comes from the dual degree. “Ready to pair your clinical expertise with business best practices to transform your organization? Hone your business acumen to assume a greater scope of leadership,” touts the website of the University of Tennessee’s physician executive MBA program.

Harvard University says on its website that its dual-degree program is intended to “develop outstanding physician leaders, skilled in both medicine and management, to take positions of influence through which they will contribute substantially to the health and well-being of individuals and society.”

Gundersen, the CardioOne CEO, who attended the University of Tennessee program and now lives outside of Denver, found it useful to practice medicine for years after he got his business degree, juggling executive and clinical work. He stopped treating patients nearly four years ago.

It helps to speak the language of physicians, Gundersen said while in Florida during a summer business trip to sell cardiologists on using his company’s platform. He pitches alleviating a pain point for most doctors — the nondoctoring work — so they can focus on patient care. It’s something he felt as a practicing physician.

Gundersen said the nation needs more doctors, especially ones who remain independent from sprawling health care companies. As he promotes that message to prospective cardiac doctors, Gundersen recognizes the irony. “We need more doctors, and here I am the doctor who doesn’t doctor anymore,” he said.

This article was produced by KFF Health News, formerly known as Kaiser Health News (KHN), a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

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Twice, she’d tried to use Montana’s public assistance help line to complete an interview required to recertify her Supplemental Nutrition Assistance Program, or SNAP, benefits. Each time, the call dropped after more than an hour on hold.

“I was ready to cry,” Brost said as she stood in line with about a dozen other people waiting for the office to open on a recent November morning. “I’ve got a hungry 13-year-old kid.”

Low-income families that need safety-net services, such as food and cash assistance, have become collateral damage in the bureaucratic scramble to determine whether tens of millions of people still qualify for Medicaid after a pandemic-era freeze on disenrollment ended this spring. These are people whose applications and renewal forms have been delayed or lost, or who, like Brost, can’t reach overwhelmed government call center workers.

The impact on services for low-income families is an overlooked consequence of the Medicaid “unwinding,” which has led to coverage being terminated for millions of people since April, with millions more expected to lose coverage in the coming months.

“The Medicaid unwinding has created huge problems for administrative staff,” said Leighton Ku, director of the Center for Health Policy Research at George Washington University’s Milken Institute School of Public Health.

Most states rely on the same workers and computer systems to sort eligibility for Medicaid and SNAP, according to the Center on Budget and Policy Priorities, a left-leaning think tank in Washington, D.C. The difficulty of signing up for other public assistance benefits varies, depending on how each state sets up its programs and how well agencies are staffed to handle extra work caused by Medicaid redeterminations.

People seeking public aid have historically encountered long call center wait times and limited options for in-person help. Those long-standing problems have worsened as record numbers of Medicaid recipients seek help with enrollment.

Attorneys and organizations assisting applicants for food benefits in Montana, Missouri, and Virginia, for example, said applications have vanished without a response and phone calls to workers determining eligibility frequently go unanswered.

“Our clients are already living on a razor’s edge, and this can just knock them off,” said Megan Dishong, deputy director of the Montana Legal Services Association.

SNAP enrollment is about half that of Medicaid. In April, nearly 42 million Americans received food assistance, compared with 87.4 million enrolled in the health coverage program.  

SNAP itself has undergone major changes this year — a policy that increased benefits during the pandemic expired, and work requirements have been reinstated. According to the most recent federal data, SNAP enrollment dropped by 1 million from January to August, much less than the decline in Medicaid enrollment that started in April.

Still, official data sources don’t capture delays and other difficulties people face in getting benefits.

In Virginia, where local offices of the state Department of Social Services handle Medicaid and SNAP applications, “I’ve had several clients who have submitted applications and they’ve just gone into the ether,” said Majesta-Doré Legnini, an Equal Justice Works fellow at the Legal Aid Justice Center who works on SNAP issues.

A client applying for assistance for the first time didn’t hear anything for three months and had to refile. Another got benefits after 2½ months, after having endured application processing delays, a denial letter, and an appeal. A family with mixed immigration status — the children qualified for benefits — didn’t have benefits for eight months after being erroneously cut off and then experienced delays after reapplying.

Virginia is supposed to process each application within 30 days. “Most of my clients have kids that are under 15,” Legnini said, and many tell her “they’re having trouble getting enough food to feed their kids.” The Virginia Department of Social Services did not answer questions from California Healthline.

In Missouri, a federal lawsuit filed before the unwinding began alleges that a dysfunctional system prevents low-income residents from getting food aid. More than half of Missouri applicants were denied aid in July because they couldn’t complete an interview — not because they were ineligible, according to a document filed in the case.

The application of Mary Holmes, a 57-year-old St. Louis woman with throat cancer and other chronic conditions, was denied in February 2022 because she couldn’t reach a call center to complete her interview. Holmes repeatedly phoned the call center but waited for hours on hold, often with hundreds of people ahead of her. Her benefits were reinstated after the judge admonished the state for the long waits during a March 2022 hearing. The lawsuit remains open.

Now, with Missouri reassessing the Medicaid enrollment of more than 1 million recipients, advocates said those systemic flaws have escalated into a crisis for the most vulnerable.

“It’s a major firestorm with both these things going on at once,” said Joel Ferber, director of advocacy for Legal Services of Eastern Missouri, which represents Holmes and the other plaintiffs.

State officials said they had “made significant strides to make interviews more widely available,” according to a recent case filing, such as by hiring “outside vendors to handle Medicaid calls to free up more state employees to handle SNAP interviews.”

Montana officials said the Medicaid redetermination process similarly collided with an already troubled system in that state.

In September, Charlie Brereton, director of the Montana Department of Public Health and Human Services, told lawmakers the state was working to improve its public assistance help line, “which, frankly, has been plagued with some challenges and issues for many, many years.”

Brereton said the agency increased the wages of client coordinators to fill in-person jobs. The state contracted about 50 workers from national agencies to supplement the call center’s staff and created a separate queue on its help line for people applying for food or temporary cash assistance.

Jon Ebelt, a Montana health department spokesperson, didn’t directly answer how long SNAP and cash assistance callers are waiting on hold on average, but said applications “are being processed in a timely fashion.”

People trying to use the state’s system said the long waits persisted in November.

Since April, nearly 5,000 fewer Montanans are receiving SNAP benefits. But that doesn’t necessarily mean fewer people qualify, said Lorianne Burhop, chief policy officer for the Montana Food Bank Network. Clients without internet access, unlimited cellphone minutes, or the ability to travel to a public assistance office may not be able to jump through the hoops to keep their benefits.

“We’ve seen consistently high numbers at food banks, whereas SNAP, we’ve seen trickling down,” Burhop said. “I think you have to consider access as a factor that’s driving that decline.”

In Missoula, DeAnna Marchand waited on hold on Montana’s help line as a November deadline approached. She fell into a category of people facing multiple cutoffs: one to recertify food assistance for her and her grandson, another to prove she still qualifies for the Medicaid program that pays for her in-home caregiver, and a third to keep her grandson’s Medicaid.

“I don’t know what they want,” Marchand said. “How am I supposed to get that if I can’t talk with somebody?”

After half an hour, she followed prompts to schedule a callback. But an automated voice announced slots were full and instructed her to wait on hold again. An hour later, the call dropped.

This article was produced by KFF Health News, formerly known as Kaiser Health News (KHN), a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

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

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En dos ocasiones, intentó usar la línea de ayuda de Montana para completar una entrevista requerida para recertificar sus beneficios del Programa de Asistencia Nutricional Suplementaria (SNAP, conocido antes como Food Stamps o estampillas de alimentos). Cada vez, la llamada se cortó después de más de una hora en espera.

“Estaba lista para llorar”, dijo Brost, parada en la larga fila, esperando que la oficina abriera en una mañana reciente de noviembre. “Tengo a un niño de 13 años que está hambriento”.

Las familias de bajos ingresos que necesitan servicios como ayuda alimentaria y dinero en efectivo, se han convertido en daños colaterales en la carrera burocrática para determinar si decenas de millones de personas aún califican para Medicaid. Esto después que finalizara en la primavera el período de gracia durante la pandemia, en el que se prohibió anular inscripciones.

Estas son personas cuyas solicitudes y formularios de renovación se han retrasado o perdido, o que, como Brost, no pueden comunicarse con los abrumados trabajadores del centro de llamadas del gobierno.

El impacto para las familias de bajos ingresos es una consecuencia que el proceso para expulsar a beneficiarios de Medicaid pasó por alto. Desde abril, millones han perdido la cobertura, y millones más están en camino de perderla.

“Este desmantelamiento de Medicaid ha creado enormes problemas para el personal administrativo”, dijo Leighton Ku, director del Centro de Investigación de Políticas de Salud en la Escuela de Salud Pública Milken de la Universidad George Washington.

La mayoría de los estados dependen de los mismos trabajadores y sistemas informáticos para analizar la elegibilidad para Medicaid y SNAP, según el Centro de Prioridades y Políticas Presupuestarias.

La dificultad para inscribirse en otros beneficios de asistencia públicos varía, dependiendo de cómo cada estado configure sus programas y cuán bien estén dotadas las agencias para manejar el trabajo adicional causado por las recalificaciones de Medicaid.

Históricamente, las personas que buscan ayuda pública han enfrentado largos períodos de espera en los centros de llamadas y opciones limitadas de apoyo en persona. Estos problemas de larga data se han agravado a medida que un número récord de beneficiarios de Medicaid buscan asistencia con la inscripción.

Por ejemplo, abogados y organizaciones que ayudan a los que solicitan beneficios de alimentos en Montana, Missouri y Virginia, dijeron que las solicitudes han desaparecido sin respuesta, y a menudo los trabajadores que determinan la elegibilidad no responden.

“Nuestros clientes ya están viviendo al límite, y esto simplemente los puede terminar de demoler”, dijo Megan Dishong, directora adjunta de la Asociación de Servicios Legales de Montana.

La inscripción en el programa SNAP es aproximadamente la mitad que la de Medicaid. En abril, casi 42 millones de estadounidenses recibieron asistencia alimentaria, en comparación con los 87.4 millones inscritos en el programa de salud.

SNAP en sí ha experimentado cambios importantes este año; una norma que aumentó los beneficios durante la pandemia expiró y se reinstauraron los requisitos de trabajo. Según los datos federales más recientes, la inscripción disminuyó en 1 millón de enero a agosto, mucho menos que la disminución en la inscripción de Medicaid que comenzó en abril.

Sin embargo, las fuentes oficiales de datos no capturan los retrasos y otras dificultades que enfrentan las personas para obtener beneficios.

En Virginia, donde las oficinas locales del Departamento de Servicios Sociales del estado manejan las solicitudes de Medicaid y SNAP, “he tenido varios clientes que han presentado solicitudes y simplemente se han perdido”, dijo Majesta-Doré Legnini, de Equal Justice Works en el Legal Aid Justice Center que trabaja en temas de SNAP.

Un cliente que solicitó ayuda por primera vez no recibió noticias durante tres meses y tuvo que volver a presentar la solicitud. Otro obtuvo beneficios después de dos meses y medio, luego de haber sufrido retrasos en el procesamiento de la solicitud, una carta de denegación y una apelación.

Una familia con estatus migratorio mixto, donde los niños calificaban para recibir beneficios, no los obtuvo por ocho meses, después que fueran expulsados erróneamente del programa y experimentaran retrasos después de volver a presentar la solicitud.

Virginia debería procesar cada solicitud en un plazo de 30 días. “La mayoría de mis clientes tienen niños menores de 15 años”, dijo Legnini, “y muchos dicen que tienen problemas para conseguir suficiente comida para alimentar a sus hijos”.

En Missouri, una demanda federal presentada antes que comenzara el proceso de expulsiones de Medicaid alega que un sistema disfuncional impide que los residentes de bajos ingresos obtengan ayuda alimentaria. A más de la mitad de los solicitantes del estado se les denegó ayuda en julio porque no pudieron completar una entrevista, no porque no fueran elegibles, según un documento presentado en el caso.

Ahora, con Missouri reevaluando la inscripción de Medicaid de más de 1 millón de beneficiarios, defensores dicen que esas fallas sistémicas se han convertido en una grave crisis para los más vulnerables.

Por su parte, oficiales de Montana han dicho que el proceso de revisar la elegibilidad se suma a un sistema ya problemático.

En septiembre, Charlie Brereton, director del Departamento de Salud Pública y Servicios Humanos de Montana, informó a los legisladores que el estado estaba trabajando para mejorar su línea de ayuda de asistencia pública, “que, francamente, ha estado plagada de algunos desafíos y problemas durante muchos, muchos años”.

Brereton dijo que se aumentaron los salarios de los coordinadores de clientes para cubrir trabajos en persona. El estado contrató a unos 50 trabajadores de agencias nacionales para fortalecer el personal del centro de llamadas, y creó una espera separada en su línea para las personas que solicitan ayuda temporal para alimentos o dinero en efectivo.

Jon Ebelt, vocero del Departamento de Salud de Montana, no respondió directamente sobre cuánto es la espera en línea para SNAP y asistencia de dinero en efectivo, pero dijo que las solicitudes “se están procesando de manera oportuna”.

Las personas que intentan utilizar el sistema del estado dijeron que las esperas largas persistían en noviembre.

Desde abril, casi 5,000 habitantes de Montana están recibiendo menos beneficios de SNAP. Pero eso no necesariamente significa que menos personas califiquen, dijo Lorianne Burhop, directora de política del Montana Food Bank Network.

Los clientes sin acceso a Internet, con minutos de teléfono limitados o sin la capacidad de viajar a una oficina de asistencia pública pueden no poder sortear los obstáculos para mantener sus beneficios.

“Hemos visto números consistentemente altos en los bancos de alimentos, mientras que con SNAP, hemos visto una disminución gradual”, dijo Burhop. “Creo que hay que considerar el acceso como un factor que impulsa esa baja”.

En Missoula, DeAnna Marchand estaba en espera en la línea de ayuda de Montana cuando se acercaba una fecha límite en noviembre. Enfrentaba múltiples cortes: uno para recertificar la asistencia alimentaria para ella y su nieto, otro para demostrar que aún calificaba para el programa de Medicaid que paga por su cuidador en el hogar, y un tercero para mantener el Medicaid de su nieto.

“No sé lo que quieren”, dijo Marchand. “¿Cómo se supone que debo obtener todo eso si no puedo hablar con alguien?”.

Después de media hora, siguió las indicaciones para programar una devolución de llamada. Pero una voz automatizada dijo que los espacios estaban llenos y transfirió la llamada de nuevo a espera. Una hora después, la llamada se cortó.

Esta historia fue producida por KFF Health News, conocido antes como Kaiser Health News (KHN), una redacción nacional que produce periodismo en profundidad sobre temas de salud y es uno de los principales programas operativos de KFF, la fuente independiente de investigación de políticas de salud, encuestas y periodismo. 

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

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In Missouri and Florida, callers waited on hold for more than two hours on hotlines to renew their Medicaid coverage.

In Tennessee, the parents of a disabled man who had been on Medicaid for three decades fought with the state this summer to keep him enrolled as he lay dying from pneumonia in a hospital.

Seven months into what was predicted to be the biggest upheaval in the 58-year history of the government health insurance program for people with low incomes and disabilities, states have reviewed the eligibility of more than 28 million people and terminated coverage for over 10 million of them. Millions more are expected to lose Medicaid in the coming months.

The unprecedented enrollment drop comes after federal protections ended this spring that had prohibited states from removing people from Medicaid during the three pandemic years. Since March 2020, enrollment in Medicaid and the related Children’s Health Insurance Program had surged by more than 22 million to reach 94 million people.

The process of reviewing all recipients’ eligibility has been anything but smooth for many Medicaid enrollees. Some are losing coverage without understanding why. Some are struggling to prove they’re still eligible. Recipients and patient advocates say Medicaid officials sent mandatory renewal forms to outdated addresses, miscalculated income levels, and offered clumsy translations of the documents. Attempting to process the cases of tens of millions of people at the same time also has exacerbated long-standing weaknesses in the bureaucratic system. Some suspect particular states have used the confusing system to discourage enrollment.

“It’s not just bad, but worse than people can imagine,” said Camille Richoux, health policy director for the nonprofit Arkansas Advocates for Children and Families. “This unwinding has not been about determining who is eligible by all possible means, but how we can kick people off by all possible means.”

To be sure, some of the Medicaid recipients who signed on to the program when the U.S. unemployment rate soared amid covid-19 lockdowns have since gotten health insurance through new jobs as unemployment dropped back to pre-pandemic lows.

And some of the disenrolled are signing up for Affordable Care Act marketplace plans. Centene CEO Sarah London, for example, told investors on Oct. 24 that the health care giant expected as many as 2.4 million of its 15 million Medicaid managed care members to lose coverage from the unwinding, but more than 1 million customers had joined its exchange plans since the same time last year.

Still, it’s anyone’s guess how many former Medicaid beneficiaries remain uninsured. States don’t track what happens to everyone after they’re disenrolled. And the final tallies likely won’t be known until 2025, after the unwinding finishes by next summer and federal officials survey Americans’ insurance status.

Without Medicaid, Patients Miss Appointments

Trish Chastain, 35, of Springfield, Missouri, said her Medicaid coverage is scheduled to expire at the end of the year. Though her children are still covered, she no longer qualifies because her $22-an-hour income is too high. Chastain’s employer, a rehab center, offers health insurance, but her share of the premium would be $260 a month. “I can’t afford that with my monthly budget,” Chastain said.

Gaps in coverage can jeopardize people’s access to health services or their financial security if they get medical bills for care they cannot postpone.

Doctors and representatives of community health centers around the country said they have seen an uptick in cancellations and no-shows among patients without coverage — including children. Nationwide, states have already disenrolled at least 1.8 million children in the 20 states that provide the data by age. Children typically qualify more easily than adults, so child advocates believe many kids are being wrongly terminated based on their parents’ being deemed no longer eligible. Meanwhile, enrollment in CHIP, which has higher income eligibility levels than Medicaid, has shown only a tiny increase.

Kids accounted for varying shares of those disenrolled in each state, ranging from 68% in Texas to 16% in Massachusetts, according to KFF. In September, President Joe Biden’s administration said most states were conducting eligibility checks incorrectly and inappropriately disenrolling eligible children or household members. It ordered states to reinstate coverage for some 500,000 people.

Varying Timetables, Varying Rates of Disenrollment

Idaho, one of a few states that completed the unwind in six months, said it disenrolled 121,000 of the 153,000 recipients it reviewed as of September because it suspected they were no longer eligible following the end of the public health emergency. Of those kicked off, about 13,600 signed up for private coverage on the state’s ACA marketplace, said Pat Kelly, executive director of Your Health Idaho, the state’s exchange. State officials said they don’t know what happened to the rest.

California, by contrast, started terminating recipients only this summer and is automatically transferring coverage from Medi-Cal to marketplace plans for those eligible. Medi-Cal, by far the nation’s largest Medicaid program, with over 15 million enrollees, has cut just over 500,000 people in the first three months, according to the most current data available.

The Medicaid disenrollment rates of people reviewed so far vary dramatically by state, largely along a blue-red political divide, from a low of 10% in Illinois to a high of 65% in Texas.

“I feel like Illinois is doing everything in their power to ensure that as few people lose coverage as possible,” said Paula Campbell of the Illinois Primary Health Care Association, which represents dozens of community health centers.

Nationwide, about 71% of Medicaid enrollees terminated during the unwinding have been cut because of procedural issues, such as not responding to requests for information to verify their eligibility. It’s unclear how many are actually still eligible. In California, that number is 88%, the fifth highest among states, according to data tracked by KFF.

“It’s terrible. Eighty-seven percent of people with Medi-Cal don’t get to keep their coverage based on whether they actually qualify,” said David Kane, an attorney at the Western Center on Law and Poverty. “Instead, they see their health coverage cut off automatically for procedural and paperwork reasons largely outside of their control.”

But Yingjia Huang, assistant deputy director of health care benefits and eligibility at California’s Department of Health Care Services, which oversees Medi-Cal, said the main reason for paperwork-related terminations is that people don’t return their packets, which was a problem even before the pandemic. “Now, I think there is a group of people who most likely have obtained other forms of health insurance,” Huang said. “That’s probably one of the biggest reasons they don’t return their packets.”

State and local Medicaid officials across the country say they have tried contacting enrollees in multiple ways — including through letters, phone calls, emails, and texts — to check their eligibility. Yet some Medicaid recipients lack consistent addresses or internet service, do not speak English, or are juggling more pressing needs.

In California, officials acknowledge that staffing shortages are a problem but say they are working hard to fix it. Eileen Cubanski, interim executive director of the County Welfare Directors Association of California, said the counties are “hiring as fast as they can, and they are all training as fast as they can.”

‘People Are Not Getting Through’

In many states, enrollees have faced long waits to get help with renewals. The longest phone waits were in Missouri, according to a KFF Health News review of letters the Centers for Medicare & Medicaid Services sent to states in August. In the letter to Missouri’s Medicaid program, CMS said it was concerned that the average wait time of 48 minutes and the 44% rate of Missourians abandoning those calls in May was “impeding equitable access” to assistance and patients’ ability to maintain coverage.

In Florida, which has removed over 730,000 people from the program since April, enrollees earlier this year were waiting almost 2½ hours on a Spanish-language call center, according to a report from UnidosUS, a civil rights advocacy group. “They can barely get the Spanish translations right” on the Medicaid application, on the renewal website, and in other communications, said Jared Nordlund, the Florida director for UnidosUS.

Miguel Nevarez, press secretary for Florida’s Department of Children and Families, which is managing the state’s Medicaid redetermination process, criticized complaints about poor translations and long waits for the Spanish-language call center as a “false narrative.” He said, “The data clearly shows Florida has executed a fair and effective plan for redeterminations.”

In California, similarly jammed phone lines, crowded and understaffed county offices, and trouble downloading renewal applications electronically are all “compounding people’s difficulty to renew” their Medicaid, said Skyler Rosellini, a senior attorney in the Los Angeles office of the National Health Law Program. “We do know, based on the cases we’re getting, that people are not getting through.”

Jasmine McClain, a 31-year-old medical assistant, said she tried everything before Montana ended Medicaid coverage for her kids, ages 3 and 5, in early October. She tried submitting paperwork online and over fax to prove they still qualified. She spent hours on hold with the state hotline. After her kids’ coverage ended, she went to a state public assistance office in Missoula but couldn’t get an appointment. One day in mid-October, roughly 30 people lined up outside the office starting as early as 6:40 a.m., before its doors opened.

After three weeks of her pleading for help while her kids were uninsured, the state restored her kids’ coverage. A supervisor told her the family’s paperwork submitted online had not been processed initially.

Spokespeople for the Montana, Florida, and Missouri Medicaid programs all said their states had reduced call wait times.

Some Medicaid recipients are seeking help through the courts. In a 2020 class-action lawsuit against Tennessee that seeks to pause the Medicaid eligibility review, parents of recipients describe spending hours on the phone or online with the state Medicaid program, trying to ensure their children’s insurance coverage is not lost.

One of those parents, Donna Guyton, said in a court filing that Tennessee’s Medicaid program, called TennCare, sent a June letter revoking the coverage of her 37-year-old son, Patrick, who had been eligible for Medicaid because of disabilities since he was 6. As Guyton made calls and filed appeals to protect her son’s insurance, he was hospitalized with pneumonia, then spent weeks there before dying in late July.

“While Patrick was fighting for his life, TennCare was threatening to take away his health insurance coverage and the services he relied on,” she said in a court filing. “Though we should have been able to focus on Patrick’s care, our family was required to navigate a system that kept denying his eligibility and putting his health coverage at risk.”

TennCare said in a court filing Patrick Guyton’s Medicaid coverage was never actually revoked — the termination letter was sent to his family because of an “error.”

Phil Galewitz in Washington, D.C., wrote this article. Daniel Chang in Hollywood, Florida; Katheryn Houghton in Missoula, Montana; Brett Kelman in Nashville, Tennessee; Samantha Liss and Bram Sable-Smith in St. Louis; and Bernard J. Wolfson in Los Angeles contributed to this report.

This article was produced by KFF Health News, formerly known as Kaiser Health News (KHN), a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

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

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En Missouri y Florida, beneficiarios que llamaron por teléfono esperaron más de dos horas en las líneas directas para realizar la renovación.

El verano pasado, en Tennessee, los padres de un hombre discapacitado, beneficiario de Medicaid durante tres décadas, lucharon contra el estado para mantenerlo inscrito mientras agonizaba en un hospital a causa de una neumonía.

Siete meses después de lo que se predijo sería el mayor terremoto en los 58 años de historia del programa gubernamental de seguro médico para personas con bajos ingresos y con ciertas discapacidades, los estados han revisado la elegibilidad de más de 28 millones de personas y han cancelado la cobertura de más de 10 millones de ellas.

Y se espera que millones más pierdan Medicaid en los próximos meses.

La caída sin precedentes en la inscripción se produce después que esta primavera terminaran las protecciones federales que habían prohibido a los estados sacar a las personas de Medicaid durante los tres años de la pandemia.

Desde marzo de 2020, la inscripción en Medicaid y el Programa de Seguro de Salud Infantil (CHIP) había aumentado en más de 22 millones hasta alcanzar la cifra récord de 94 millones de beneficiarios.

El proceso de revisión de la elegibilidad de todos los inscriptos en Medicaid no ha sido nada sencillo para muchos afiliados. Algunos están perdiendo cobertura sin entender por qué. Otros están luchando por demostrar que todavía son elegibles.

Tanto beneficiarios como defensores de pacientes dicen que los funcionarios de Medicaid enviaron formularios de renovación obligatoria a direcciones viejas, calcularon mal los niveles de ingresos e hicieron malas traducciones de los documentos.

Intentar procesar los casos de decenas de millones de personas al mismo tiempo también ha exacerbado las fragilidades de larga data en el sistema burocrático. Algunos hasta sospechan que ciertos estados han aprovechado el confuso sistema para desalentar la inscripción.

"No sólo es malo, es peor de lo que la gente puede imaginar", dijo Camille Richoux, directora de políticas de salud de la organización sin fines de lucro Arkansas Advocates for Children and Families. "Esta reducción no se ha tratado de determinar quién es elegible por todos los medios posibles, sino de cómo podemos expulsar a la gente por todos los medios posibles".

Sin duda, algunos de los beneficiarios de Medicaid que se inscribieron en el programa cuando la tasa de desempleo en Estados Unidos se disparó, en medio de los aislamientos por covid-19, han obtenido desde entonces seguro médico a través de nuevos empleos, a medida que el desempleo volvió a caer a los mínimos previos a la pandemia.

Y algunos de los que se dieron de baja se están inscribiendo en planes de los mercados de seguros establecidos por la Ley de Cuidado de Salud a Bajo Precio (ACA).

Por ejemplo, Sarah London, directora ejecutiva de Centene, dijo a los inversionistas el 24 de octubre que el gigante de la atención médica esperaba que hasta 2,4 millones de sus 15 millones de miembros de atención administrada de Medicaid perderían la cobertura debido a cancelaciones, pero más de 1 millón habían adquirido sus planes del mercado desde octubre la misma época el año pasado.

Aún así, nadie sabe cuántos ex beneficiarios de Medicaid siguen sin seguro. Los estados no hacen un seguimiento de lo que les sucede a todos luego que son expulsados del programa. Y las cifras finales probablemente no se conocerán hasta 2025, después que el proceso finalice el próximo verano y los funcionarios federales investiguen el estatus de seguro de los estadounidenses.

Sin Medicaid, los pacientes no van a sus citas

Trish Chastain, de 35 años, de Springfield, Missouri, dijo que su cobertura de Medicaid expirará a fines de año. Aunque sus hijos todavía están cubiertos, ella ya no califica porque sus ingresos son demasiado altos: $22 la hora. El empleador de Chastain, un centro de rehabilitación, ofrece seguro médico, pero su parte de la prima sería de $260 al mes. "No puedo permitirme eso con mi presupuesto mensual", dijo.

Dijo que no sabía que podría ser elegible para un plan de más bajo costo en los mercados de seguros de ACA. Sin embargo, eso todavía significaría nuevos costos.

Las brechas en la cobertura pueden poner en peligro el acceso de las personas a los servicios de salud o su seguridad financiera si reciben facturas médicas por atención que no pueden posponer.

"Cualquier tipo de atención que se posponga —ya sea asma, autismo o algo tan simple como un dolor de oído— puede empeorar si se espera", dijo Pam Shaw, pediatra de Kansas City, Kansas, que preside el Comité de asuntos gubernamentales estatales de la Academia Americana de Pediatría.

Médicos y representantes de centros de salud comunitarios de todo el país dijeron que han visto un aumento en las cancelaciones y faltas entre los pacientes sin cobertura, incluidos los niños. A nivel nacional, los estados ya han dado de baja a cerca de 1,8 millones de niños en los 20 estados que proporcionan datos por edad.

Los niños suelen calificar más fácilmente que los adultos, por lo que sus defensores creen que a muchos se los expulsa injustamente porque se considera que sus padres ya no son elegibles. Mientras tanto, la inscripción en CHIP, que tiene niveles de elegibilidad de ingresos más altos que Medicaid, ha mostrado sólo un pequeño aumento.

Los niños representaron porcentajes variables de las personas dadas de baja en cada estado, desde el 68% en Texas hasta el 16% en Massachusetts, según KFF.

En septiembre, la administración Biden dijo que la mayoría de los estados estaban realizando controles de elegibilidad de manera incorrecta y cancelando de manera inapropiada la inscripción de niños o miembros del hogar elegibles. Ordenó a los estados restablecer la cobertura para unas 500,000 personas.

Horarios variables, tasas de bajas variables

Idaho, uno de los pocos estados que completó la reducción en seis meses, dijo que canceló de la inscripción de 121,000 personas, de las 153,000 que revisó en septiembre porque sospechaba que ya no eran elegibles con el fin de la emergencia de salud pública. De los expulsados, alrededor de 13,600 se inscribieron para cobertura privada de ACA, dijo Pat Kelly, director ejecutivo de Your Health Idaho, el mercado de seguros de salud estatal. Los funcionarios estatales dicen que no saben qué pasó con el resto.

California, por el contrario, comenzó a remover beneficiarios recién este verano y está transfiriendo automáticamente la cobertura de Medicaid a los planes del mercado para aquellos elegibles. Medi-Cal, por lejos el programa de Medicaid más grande del país, con más de 15 millones de afiliados, ha eliminado a poco más de 500,000 personas en los primeros tres meses, según los datos más recientes disponibles.

Hasta ahora, las tasas de bajas de Medicaid de las personas analizadas varían dramáticamente según el estado, en gran medida a lo largo de una división política azul-roja, desde un mínimo del 10% en Illinois hasta un máximo del 65% en Texas.

“Siento que Illinois está haciendo todo lo que está a su alcance para garantizar que la menor cantidad posible de personas pierdan la cobertura”, dijo Paula Campbell de la Asociación de Atención Primaria de Salud de Illinois, que representa a docenas de centros de salud comunitarios.

A nivel nacional, alrededor del 71% de los afiliados a Medicaid que perdieron la cobertura fue debido a problemas de procedimiento, como no responder a las solicitudes de información para verificar su elegibilidad. No está claro cuántos siguen siendo elegibles. En California, esa cifra es del 88%, la quinta más alta entre los estados, según datos de KFF.

"Es terrible. El 87% de las personas con Medi-Cal no pueden mantener su cobertura en función de si realmente califican”, dijo David Kane, abogado del Western Center on Law and Poverty. "En cambio, ven que su cobertura de salud se corta automáticamente por razones de procedimiento y papeleo que en gran medida escapan a su control".

Pero Yingjia Huang, subdirectora adjunta de elegibilidad y beneficios de atención médica del Departamento de Servicios de Atención Médica de California, que supervisa Medi-Cal, dijo que la razón principal de las bajas relacionadas con el papeleo es porque las personas no devuelven sus paquetes, lo cual fue un problema incluso antes de la pandemia. "Ahora creo que hay un grupo de personas que probablemente hayan obtenido otros seguros médicos", dijo Huang. "Esa es probablemente una de las principales razones por las que no devuelven sus paquetes".

Funcionarios estatales y locales de Medicaid dicen que han intentado comunicarse con los beneficiarios de muchas maneras, a través de cartas, llamadas telefónicas, correos electrónicos y mensajes de texto, para verificar la elegibilidad. Sin embargo, algunos beneficiarios no tienen un correo electrónico o servicios de Internet consistentes, no hablan inglés o están haciendo malabarismos con necesidades más urgentes.

"El esfuerzo de desmantelamiento sigue siendo un gran desafío y un impulso significativo para todos los estados", dijo Kate McEvoy, directora ejecutiva de la Asociación Nacional de Directores de Medicaid.

La gente no entiende lo que está pasando

En muchos estados, eso ha significado que los afiliados hayan tenido que enfrentar largas esperas para obtener ayuda con las renovaciones.

Las peores esperas telefónicas se produjeron en Missouri, según una revisión de KFF Health News de las cartas que los Centros de Servicios de Medicare y Medicaid (CMS) enviaron a los estados en agosto. En la carta al programa de Medicaid de Missouri, los CMS dijeron que preocupaba que el tiempo de espera promedio de 48 minutos y la tasa del 44% de habitantes de Missouri que abandonaron esas llamadas en mayo estuvieran "impidiendo el acceso equitativo" a la asistencia y la capacidad de los pacientes para mantener la cobertura.

Algunas personas quedan en espera más de tres horas, dijo Sunni Johnson, trabajadora de inscripción en Affinia Healthcare, que administra centros de salud comunitarios en el área de St. Louis. Se trata de un obstáculo importante para una población en la que muchos tienen minutos limitados en sus celulares.

En Florida, que ha eliminado a más de 730,000 personas del programa desde abril, los inscritos a principios de este año estuvieron esperando casi dos horas y media en un centro de llamadas en español, según un informe de UnidosUS, un grupo de defensa de los derechos civiles. Las versiones en español de la solicitud de Medicaid, el sitio web de renovación y otras comunicaciones también son confusas, aseguró Jared Nordlund, director de UnidosUS en Florida.

“Apenas pueden hacer bien las traducciones al español”, dijo.

Miguel Nevarez, secretario de prensa del Departamento de Niños y Familias de Florida, que gestiona el proceso de redeterminación de Medicaid, criticó las quejas sobre malas traducciones y largas esperas para acceder al centro de llamadas en español como una “narrativa falsa”. Dijo: "Los datos muestran claramente que Florida ha ejecutado un plan justo y eficaz para las redeterminaciones".

En California, líneas telefónicas congestionadas, oficinas de los condados abarrotadas y con poco personal, y problemas para descargar las solicitudes de renovación electrónicamente están "agravando la dificultad de las personas para renovar su Medicaid”, dijo Skyler Rosellini, abogado principal de la oficina de Los Ángeles del National Health Law Program. "Sabemos, según los casos que recibimos, que la gente no logra salir adelante".

Jasmine McClain, asistente médica de 31 años, dijo que intentó todo antes de que Montana terminara la cobertura de Medicaid para sus hijos, de 3 y 5 años, a principios de octubre. Envió la documentación en línea y por fax para demostrar que aún calificaban. Pasó horas en espera en la línea directa estatal. Después que terminó la cobertura de sus hijos, fue a una oficina estatal de asistencia pública en Missoula pero no pudo conseguir una cita. Un día a mediados de octubre, aproximadamente 30 personas hicieron fila afuera de la oficina desde las 6:40 am, antes de que abriera.

Después de tres semanas de pedir ayuda mientras sus hijos no tenían seguro, el estado restableció la cobertura de sus hijos. Dijo que un supervisor le dijo que la documentación de la familia presentada en línea no había sido procesada inicialmente.

“El sistema de llamadas telefónicas era un desastre. Las devoluciones de llamada tardaron una semana”, dijo McClain. “Tuve que superar muchos obstáculos”.

Los voceros de los programas de Medicaid de Montana, Florida y Missouri dijeron que sus estados habían reducido los tiempos de espera de las llamadas.

Algunos beneficiarios de Medicaid buscan ayuda a través de los tribunales. En una demanda colectiva de 2020 contra Tennessee que busca ponerle una pausa a la revisión de elegibilidad para Medicaid, los padres de los beneficiarios describen pasar horas al teléfono o en línea con el programa, tratando de garantizar que no se pierda la cobertura de sus hijos.

Uno de esos padres, Donna Guyton, dijo en un expediente judicial que el programa Medicaid de Tennessee, llamado TennCare, envió una carta en junio revocando la cobertura de su hijo Patrick, de 37 años, quien había sido elegible para Medicaid debido a discapacidades desde que tenía 6 años. Mientras Guyton hacía llamadas y presentaba apelaciones para proteger el seguro de su hijo, fue hospitalizado con neumonía, y estuvo internado semanas hasta que murió a finales de julio.

“Mientras Patrick luchaba por su vida, TennCare amenazaba con quitarle la cobertura de su seguro médico y los servicios en los que dependía”, dijo en un expediente judicial. “Aunque deberíamos haber podido centrarnos en la atención de Patrick, nuestra familia tuvo que navegar por un sistema que seguía negando su elegibilidad y poniendo en riesgo su cobertura médica”.

TennCare dijo en un expediente judicial que la cobertura de Medicaid de Patrick Guyton nunca fue revocada: la carta de terminación fue enviada a su familia debido a un “error”.

Phil Galewitz en Washington, D.C., escribió este artículo. Daniel Chang en Hollywood, Florida; Katheryn Houghton en Missoula, Montana; Brett Kelman en Nashville, Tennessee; Samantha Liss y Bram Sable-Smith en St. Louis; y Bernard J. Wolfson en Los Ángeles contribuyeron con la historia.

Esta historia fue producida por KFF Health News, conocido antes como Kaiser Health News (KHN), una redacción nacional que produce periodismo en profundidad sobre temas de salud y es uno de los principales programas operativos de KFF, la fuente independiente de investigación de políticas de salud, encuestas y periodismo. 

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

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The merger, which would span markets 250 miles apart and include facilities in neighboring Kansas and Illinois, is just one of the latest in a quickly consolidating hospital industry. Cross-market deals accounted for more than half of all hospital mergers and acquisitions during the last decade, according to a paper from experts on antitrust law. Today, nearly 60% of health systems operate multiple hospitals in different geographic markets.

Not only are such deals more common, they can increase costs for patients. Merged hospitals in the same state but in different markets raised prices as much as 10% compared with other hospitals, researchers found after analyzing past deals. A separate study found stand-alone hospitals raised prices 17% after they were acquired by a hospital company in another market.

But for some 50 years, federal regulators have not stepped in to prevent hospitals from merging with systems in other markets, according to antitrust law experts. Without federal intervention, states that have seen such megamergers, such as Michigan and California, are often left to wrestle with the complex question of how to respond, given the likelihood of higher prices for their residents.

The Federal Trade Commission and the Justice Department are reviewing public comments on draft merger guidelines designed to crack down on mergers in multiple sectors, including health care. It’s not yet clear if or how cross-market hospital mergers within a state could be affected. Still, the draft says consolidation should not “entrench or extend a dominant position” by extending into “new markets.”

But such cross-market mergers aren’t quite a textbook case of a monopoly. When hospitals have bought up local rivals, knocking out their competition, federal regulators have intervened to block these traditional mergers to protect patients from the resulting loss of competition. In recent years, they helped stop proposed mergers in New Jersey, Utah, and Rhode Island. The thinking is that without local competition, prices increase and the quality of care decreases.

It’s harder to prove how cross-market mergers, like the one planned in Missouri, reduce competition if the hospitals do not operate within a single market, said Chris Garmon, an assistant professor at the University of Missouri-Kansas City, who researches hospital mergers. Regulators would have to prove the mergers don’t just raise prices but also run afoul of the law by suppressing competition.

“That’s why we haven’t seen a cross-market merger challenge yet. It’s because it’s hard to tell the story of why this would be a problem,” he said.

The Federal Trade Commission did not answer questions from California Healthline on its broader strategy around such deals or the BJC-Saint Luke’s merger. Whether an investigation is underway is not public information, said Mitchell Katz, an agency spokesperson.

After the FTC didn’t stop cross-market hospital mergers in California and Michigan, those states landed poles apart in handling the deals. California won concessions after challenging a deal, while Michigan did not intervene.

The FTC did closely examine the 2020 deal in Michigan between Spectrum Health, based in Grand Rapids, and the Detroit area’s Beaumont Health. Still, it ultimately didn’t oppose the marriage that created the state’s largest hospital chain, Corewell Health, with 22 hospitals in regions more than 150 miles apart.

The lack of intervention frustrated some, including Bret Jackson, CEO of the Economic Alliance for Michigan, a nonprofit that helps employers wrangle health costs. Spectrum was already the more expensive operator, said Jackson. He worries Beaumont prices will rise to match Spectrum’s once the insurance contracts with the individual hospital systems expire.

“They’re not going to want to take a pay cut,” Jackson said of Spectrum. “We’re really concerned about it.”

Jackson said that he was already fed up with rising hospital prices and that so are the automotive companies and laborers he represents. Health costs consume about 10% of a typical U.S. family’s income.

Ellen Bristol, a Corewell Health spokesperson, did not address California Healthline’s questions about patient costs but said that the collaboration is improving quality statewide and creating efficiencies that help the company navigate economic headwinds.

Even though regulators did not step in, FTC staffers and Michigan’s Department of the Attorney General volleyed emails back and forth for months, according to communications obtained by California Healthline through a public records request from the state.

The FTC asked the attorney general’s office to connect its staffers to employers and state officials, plus provide information and data on the health care landscape in the state, the emails show. The FTC interviewed executives from BorgWarner, an automotive supplier, and CMS Energy, a utility company.

Jackson said he, too, was interviewed by the FTC, which he said was less interested in his thoughts on the deal than in Michigan’s market dynamics.

It’s hard to glean much from the FTC’s assessment of the merger because many of the emails the state supplied to California Healthline are redacted. But they do illustrate what information and which people the FTC consulted to reach a decision.

The emails also suggest state officials were made aware of the FTC’s findings. On the evening of Jan. 13, 2022, an assistant AG sent a lengthy email to Michigan Attorney General Dana Nessel about the FTC’s review of possible antitrust implications, according to the subject line. In the version provided to California Healthline, though, the entire email — except for the greeting and the signature — was blacked out.

The next day, other emails show, hospital officials began discussing final language with the AG’s office for a press release announcing the deal would soon close.

Michigan did not move to block the deal or investigate further. Danny Wimmer, a spokesperson for Nessel, a Democrat, said the deal fell outside the authority of her office, further frustrating Jackson, of the Economic Alliance for Michigan.

“We need to give state regulators the tools to at least assess mergers in the health care system,” Jackson said.

Nessel’s position is not the attitude taken in all states. A 2020 merger agreement in California between Huntington Hospital in Pasadena and Cedars-Sinai Health System, with its flagship hospital in Los Angeles, attracted the attention of then-state Attorney General Xavier Becerra, who imposed conditions, such as price caps to protect consumers.

Becerra, a Democrat who is now Health and Human Services secretary, had argued the cross-market merger would lead to higher prices.

Employers relied on having both Cedars-Sinai and Huntington Hospital in their networks to ensure adequate access to all employees scattered across the massive Los Angeles region — with a population larger than that of most states — which California officials said has several distinct markets serving patients. If the two were to combine, employers would have to accept price hikes to maintain access to both entities, according to an analysis the AG’s office commissioned. Health systems can “threaten to create important holes in a health plan’s provider network,” the analysis said, by refusing to include all hospitals, giving the system greater leverage to extract higher prices from the health plan.

Cedars-Sinai and Huntington sued the AG over the conditions imposed on the merger.

Ultimately, the parties settled on revised conditions, which included a 10-year ban on all-or-nothing contracting with insurers and a cap on price increases for five years.

The settlement allowed Cedars-Sinai to expand access while reflecting a shared goal of “keeping healthcare affordable,” said Duke Helfand, a spokesperson for Cedars-Sinai. Still, it was considered a win for antitrust enforcers, with implications that could reverberate across the country, some health economists said.

In Missouri, the key question is whether state officials will intervene. Attorney General Andrew Bailey, a Republican, is reviewing the merger, which requires his office’s approval before it can close, said Madeline Sieren, a spokesperson for the AG.

Neither BJC nor Saint Luke’s answered questions from California Healthline about potential price increases or plans to improve quality. The hospitals have estimated the merged system will generate annual revenue topping $10 billion.

The Missouri systems ought to explain how this merger will benefit patients by lowering costs and improving quality, Garmon said.

“Whether they actually do them or not depends on whether they actually have the incentive to do them,” Garmon said.

This article was produced by KFF Health News, formerly known as Kaiser Health News (KHN), a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

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

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In February 2022, doctors said that Kent, her husband of 33 years, was too weak for the routine chemotherapy that had kept his colon cancer at bay since 2018. He was admitted to Barnes-Jewish Hospital in St. Louis, not far from their home in Olivette, Missouri.

Doctors discovered a partial blockage of his bowel, Reynolds said, but she remained hopeful that his treatment would soon resume.

“I remember calling our kids and saying, ‘OK, this is all really good news. We just need to get him kind of bolstered back up and feeling well,’” she said.

But years of chemotherapy had taken a toll on his body, and he told his wife that he couldn’t go on any longer.

Kent was discharged and began hospice care at home. He died the next month at age 62.

When Reynolds received the bill for the hospital stay, she paid the $823.15 it said her husband owed. She scribbled “paid” on the bill, memorializing the date, June 30, 2022 — the financial endpoint, she thought, of Kent’s years of treatment.

Then the bill came (again).

The Patient: Kent Reynolds, deceased, had been covered by Blue Cross and Blue Shield of Illinois through his Illinois-based employer.

Medical Service: A 14-day hospital stay related to complications from colon cancer, including a partially blocked bowel.

Service Provider: BJC HealthCare, a tax-exempt health system that operates 14 hospitals, mostly in the St. Louis area, including Barnes-Jewish Hospital.

Total Bill: The hospital charged $110,666.46 for the stay before any payments or adjustments. The insurer negotiated that price down to $60,348.77, and Reynolds paid the $823.15 the hospital said the patient owed. Then, a year after her husband’s death, she received a new version of the bill from the hospital, charging her an additional $1,093.16.

What Gives: Reynolds encountered a perplexing reality in medical billing: Providers can — and do — come after patients to collect more money for services months or years after a bill has been paid.

The new bill said Kent Reynolds had been enrolled in a payment plan and that the first “monthly installment” on the nearly $1,100 balance was soon due.

She said she called both the hospital and Blue Cross and Blue Shield of Illinois in search of answers but didn’t get an explanation that made sense to her.

According to Reynolds, a BJC HealthCare representative told her that the insurer had paid more than it owed, meaning the health system had to reimburse the insurer and charge the patient more.

Reynolds said she grabbed a yardstick to use as a straight edge and went line by line, comparing both bills, to see what had changed, a task that evoked painful memories of her husband’s last days. The amount for each individual charge — medications, lab tests, supplies, and more — was the same on both bills. The total had not changed.

Only three aspects of the bill had changed: the adjustments; the amount paid by the insurance company; and what the patient owed.

Adjustments, or discounts, are amounts that may be subtracted from a medical bill, typically under the provider’s pre-negotiated contract with an insurer. Insurers and providers agree to lower, in-network rates for services provided to patients covered by the insurer.

Reynolds also received an EOB, or “explanation of benefits,” notice showing the insurer reviewed the bill again in February, a year after the hospital stay. The document said the hospital’s charges for her husband’s private room — amounting to nearly $77,000 — were more than his health plan’s negotiated room rates, which did not cover the full cost.

The EOB noted that the patient could still owe the hospital $50,216.31 for the room charges — a startling amount — although Reynolds ultimately received no bill indicating she owed that much.

Reynolds said she spent hours trying to understand the items on the hospital and insurance paperwork, since they used medical abbreviations and were grouped differently on the documents.

“It shouldn’t be this hard for a widow to figure out what the medical bills were,” said Erin Duffy, a research scientist at the University of Southern California’s Schaeffer Center for Health Policy and Economics.

Blue Cross and Blue Shield of Illinois declined to comment despite receiving a signed release from Reynolds waiving federal privacy protections.

The Resolution: Unclear about what had changed and how much she owed, Reynolds held off on paying the second bill. After KFF Health News contacted BJC HealthCare, Laura High, a media relations manager for the system, said the charges were the result of a “clerical error.” Reynolds no longer has a balance, High said in an email in May.

“I was shocked by it,” Reynolds said. “I’m convinced most of the people I know would have paid this.”

High did not answer questions about the cause of the billing error or how often such errors occur.

However, Duffy provided a different explanation for the charges. “This doesn’t seem like an error,” she said. “It seems consistent with their insurance plan design.”

She said it appeared the additional $1,100 charge — assessed a year later — represented Kent’s coinsurance share of the private room charges, which she found as a recurring line item on each page of the bill under the heading “Oncology/PVT.”

While his coinsurance responsibility could have amounted to 10% of what the insurer paid in room charges — potentially a huge amount — Kent had met his out-of-pocket payment maximum for the year, so the charges did not reach the full 10% of the room costs, Reynolds said.

The Takeaway: In the United States, medical bills and insurance statements create a burdensome puzzle for patients to sort through to determine what is actually owed. The first rule of thumb is: “Don’t pay the bill before you’ve gotten the EOB,” which is the insurer’s accounting of what you owe and what the insurer will pay, said Kaye Pestaina, co-director of KFF’s Program on Patient and Consumer Protections.

In addition, ask for an itemized breakdown of charges and compare it against the EOB.

Medical billing experts said standardizing terms and other details on medical bills and EOBs would help patients enormously in this undertaking.

A few states have taken steps toward giving patients more information about health care charges, including by simplifying medical bills. In 2019, New York state lawmakers proposed requiring hospitals to provide patients with bills in plain language, including an itemized list of services labeled as paid by the insurer or owed by the patient. The proposal, which did not advance, required hospitals to send patients a single bill within seven days of leaving the hospital.

Reynolds’ experience highlights the lack of laws and standards around how long providers have to bill — and review bills — for medical services. Insurers may dictate in their contracts how long providers have to submit claims; the Medicare program has a 12-month limit to file claims, for instance. However, Dave Dillon, a spokesperson for the Missouri Hospital Association, said no laws restrict how long providers have to send a bill to patients.

Creditors may seek payment from a deceased person’s estate to collect whatever they can, said Berneta Haynes, a senior attorney at the National Consumer Law Center. In Missouri, a living spouse can be held responsible for a deceased spouse’s medical bills in certain instances, said Terry Lawson, a managing attorney for Legal Services of Eastern Missouri.

Experts said they did not pinpoint anything Reynolds could have done differently, noting that it is the system that needs to change.

“When can she move on from these hospital bills?” Duffy asked.

Stephanie O’Neill Patison reported the audio story.

Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

This article was produced by KFF Health News, formerly known as Kaiser Health News (KHN), a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

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

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That’s leaving many patients confused about how to get new medical insurance.

“It’s an overwhelming task,” said Taffy Morrison, who is working to connect Louisiana residents to new coverage through the nonprofit Southwest Louisiana Area Health Education Center. But Morrison reminds people: “Don’t panic. There is help.”

For many of those kicked off Medicaid, a state-federal health insurance program that covers people with low incomes and disabilities, new insurance will come from their employers. Others may need to turn to the Affordable Care Act online marketplaces to replace their coverage.

Elevance insurance officials told investors in mid-July they were seeing signs of movement from Medicaid to exchange plans as states ramp up reviews of who still qualifies for the public insurance program. The company, formerly called Anthem, reported 18.2% growth in its exchange plans from the year before, with its marketplace plans now covering at least 949,000 people.

To prevent gaps in insurance coverage, some states, such as California and Rhode Island, will automatically enroll people who lose Medicaid in such marketplace plans. But elsewhere, Morrison and workers at similar nonprofit health groups nationwide are helping people navigate the difficult administrative process of finding the right plan. Known as “navigators” or “assisters” and publicly funded, they work with patients free of charge.

Consumers should be wary of anyone charging to assist them in finding coverage — or pushing a particular plan. Misleading marketing has led some people to plans that aren’t actually insurance, such as health care sharing ministries, which don’t necessarily cover members’ medical bills.

The dramatic reshuffling of insurance coverage comes with the end of federal covid-19 pandemic protections. States were barred from kicking enrollees off Medicaid during the pandemic to ensure people had access to health care. As a result, the program swelled by 30% from February 2020 to December 2022 to cover about 92 million people, including children who receive coverage under CHIP, the Children’s Health Insurance Program. Now, for the first time since 2020, states have resumed checking whether enrollees remain eligible.

The first batch of numbers are rolling in. So far, more than 4 million people have lost coverage in 42 states and the District of Columbia. And in June alone, more than 50,000 of them lived in Louisiana, according to state data. Of the more than 151,000 beneficiaries’ files the state reviewed in a single month, nearly 13,000 people no longer qualified for Medicaid but roughly 38,000 additional people lost coverage because they did not submit a renewal packet for the state to determine whether they still qualified.

Morrison’s group of 50 navigators across the state will now try to make a dent in those numbers as coverage losses are expected to grow.

Patient advocates in Louisiana and elsewhere agree on one crucial first step Medicaid enrollees must take regardless of eligibility status: They must fill out and return their Medicaid renewal packets.

“That Medicaid paperwork, it’s beneficial for everybody to finish it up,” said Geoffrey Oliver, who leads Connecting Kids to Coverage, a program of Legal Services of Eastern Missouri that helps families navigate the enrollment process.

If people return the forms and are found to be ineligible, states pass along their information to online insurance exchanges such as healthcare.gov. The exchanges will follow up with people and share health plan options, functioning as another tap on the shoulder to prevent people from becoming uninsured.

People shouldn’t assume they can’t afford marketplace plans, insurance experts say. Many can enroll in low- to no-cost coverage. Roughly 2.7 million people are likely to be eligible for discounted plans, federal estimates show, representing about one-third of all those expected to be ineligible for Medicaid. Of those, about 1.7 million will qualify for zero-premium plans.

Another reason to fill out the packet: Even if adults in a household no longer qualify for Medicaid coverage, or now have employer coverage, children may still be eligible for public plans.

A message plastered on a billboard in Randolph County, Missouri, reminds people about Medicaid renewal in big, bold letters: “Don’t miss this letter.” About 34% of people living in the central Missouri county are covered by Medicaid, according to a tracker maintained by Washington University in St. Louis.

If people throughout the country fail to turn in the renewal packet, they run the risk of falling through the cracks, said Adrianna McIntyre, an assistant professor of health policy at Harvard. Being uninsured can lead people to postpone preventive care — and cause them to end up in debilitating medical debt if emergencies happen.

Most of the millions cut from Medicaid so far lost their benefits because they didn’t complete the paperwork, not that they were deemed ineligible, according to KFF. And patient advocates worry enrollees may never have received the packet. Many recipients have likely moved and changed addresses but have not updated their contact information with states. Advocates fear those issues may be felt harder in places such as Louisiana, where many people have been displaced by floods and hurricanes in the past three years.

In some states, Medicaid recipients can check their eligibility status online. Elsewhere, they can ask free navigators, such as Morrison, for help checking on their packets.

What to Know About Navigating the Path to Insurance Coverage

The most important step: Fill out, sign, and return your Medicaid renewal packet.

If you no longer qualify for Medicaid, that denial triggers a special enrollment period for you to find another source of coverage. You typically have 60 days before the loss of your Medicaid coverage to enroll in a new plan; the packets should arrive ahead of losing any coverage, so that should serve as a warning that a change in your benefits may be coming.

You also have 60 days from when you report the loss of coverage, not the date when you actually lost it, to enroll in a new plan. That clock starts when you submit a new application via healthcare.gov, according to federal guidelines.

To avoid gaps in coverage, plan ahead. Most marketplace coverage begins the first day of the following month.

Here are potential coverage options for you and your family:

Enroll in insurance through your job. Losing Medicaid triggers a special sign-up window for you to enroll in your employer’s insurance, if available.

Enroll in an Affordable Care Act plan. If employer-based coverage is not available or affordable, you and your family may be eligible for a discounted plan on the exchange. If your portion of the monthly premium for the lowest-cost family plan exceeds 9.12% of your household income, your family members would qualify for an exchange plan that offers financial assistance.

Workplace insurance may be affordable for a father, for example, but not for the rest of the family. “In that situation, Dad should enroll in the employer-sponsored insurance plan and then they should go to the marketplace for the rest of the family,” said Geoffrey Oliver, a navigator who leads Connecting Kids to Coverage, a program of Legal Services of Eastern Missouri.

Your kids may still be eligible for Medicaid even if you no longer qualify:

Even if parents or guardians no longer qualify for Medicaid coverage, their children might. In some places, kids can qualify for the Children’s Health Insurance Program, known as CHIP, with an annual household income of up to 400% of the federal poverty level, which equates to an income of $120,000 for a family of four.

What to do before you turn 19 and lose CHIP coverage:

Some young adults will age out of CHIP coverage at age 19. For them, especially those with chronic health conditions, it’s important to take advantage of the special enrollment period for an Affordable Care Act plan before losing public coverage.

If you turn 19 in the middle of the month — say, September — you should choose an exchange plan in August because most marketplace coverage begins the first day of the following month. This ensures you will not experience a gap in coverage when CHIP coverage expires.

This article was produced by KFF Health News, formerly known as Kaiser Health News (KHN), a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

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

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The issue is that some insurers are bypassing hospital pharmacies and physician offices and instead sending more complex drugs through third-party pharmacies. Those pharmacies then send the medications directly to the medical provider or facility for outpatient infusing, which is called “white bagging,” or, more rarely, to patients, in what is called “brown bagging.” That shifts who gets to buy and bill for these complex medications, including pricey chemotherapy drugs.

Insurers say the policies are needed because hospital markups are too high. But hospitals argue that adding an intermediary results in unnecessary risks and delays, and they say some insurers have their own or affiliated pharmacy companies, creating financial motives for controlling the source of the medications. The patients, meanwhile, are left to deal with the red tape.

Paula Bruton Shepard in Bolivar, Missouri, is among those caught in the middle. Flares of lupus, an autoimmune disease, rob Shepard of her mobility by attacking her joints. She relies on monthly infusions to treat her symptoms. But at times, she said, her treatments were delayed due to UnitedHealthcare’s white bagging infusion policy. And interruptions to her treatments exacerbated her symptoms.

“I once had to use a toilet lift and it was kind of demoralizing to say, ‘I’m a 50-year-old woman and I have to use a toilet lift,’” Shepard said of the medication delays.

This is a tug of war over profits between insurers and medical providers, said Ge Bai, a professor of accounting and health policy at Johns Hopkins University. While insurers claim the arrangement reduces costs, she said, that doesn’t mean insurers pass along savings to patients.

“I don’t think we should have more sympathy toward one party or the other,” Bai said. “Nobody is better than the other. They’re all trying to make money.”

The savings from white bagging can be significant for expensive infusion drugs, according to a report from the Massachusetts Health Policy Commission. For example, Remicade, used to treat a variety of inflammatory diseases, including Crohn’s, cost on average $1,106 per unit in 2015 under hospitals’ traditional buy-and-bill system, the commission found in its review of state claims data. That same drug cost an average of $975 per unit under white bagging, a 12% savings.

Siteman Cancer Center, led by physicians from Washington University School of Medicine in St. Louis, has confronted the same issue. But the cancer center’s size has helped it largely avoid such insurer policies.

John DiPersio, a Siteman oncologist and researcher who led the university’s oncology division for more than two decades, said Siteman reluctantly allows white bagging for simple injectables but refuses to accept it for complicated chemotherapies. It does not accept brown bagging. Occasionally, he said, that means turning patients away.

“You’re talking about cancer patients that are getting life-threatening treatments,” DiPersio said, referring to the dangers of chemo drugs, which he said can be fatal if used improperly. “It doesn’t make any sense to me. It’s all stupid. It’s all lunacy.”

At least 21 states, including Missouri, introduced some form of white or brown bagging legislation during the most recent legislative session, according to the American Society of Health-System Pharmacists. And in the past two years, the trade group said, at least 13 states have already enacted restrictions on white bagging, including Arkansas, Louisiana, and Virginia.

ASHP has created model legislation to limit insurers from requiring the practices as a condition of coverage.

“This is a major issue,” said Tom Kraus, a vice president at the trade group. “We see this as central to our ability to coordinate patient care.”

At the heart of the tension is an often-litigated federal program that allows certain hospitals and the clinics they own to purchase drugs at deep discounts. The 340B program, named for a section of the law that created it, allows hospitals to buy certain drugs for much less — sometimes for a total cost of a single penny — than what they are later paid for those drugs. Hospitals are not required to pass along 340B savings to patients.

The program was intended to help hospitals spread scarce resources further to treat patients in poor and vulnerable communities, but it has morphed into a means of enriching hospitals and their affiliated clinics, researchers said in a 2014 Health Affairs report. Hollabaugh said many rural facilities such as Citizens rely on the revenue generated from the 340B drugs to subsidize infusions that have no profit margin.

The number of participating hospitals and their affiliated outpatient clinics has increased significantly since the 340B program was created in 1992. More than 2,600 of the nation’s roughly 6,100 hospitals were participating in the 340B program as of January 2023. That gives them access to discounts that can knock off as much as 50% of a drug’s cost, according to the Health Resources & Services Administration, which oversees the program.

The insurance industry argues that hospital markups, especially when made on top of those discounts, have gotten out of control.

“The fact is, people got greedy,” Shannon Cooper, a lobbyist for Blue Cross and Blue Shield of Kansas City, said during a Missouri state Senate hearing in March.

Markups are not unique to 340B hospitals, said Sean Dickson, who helps lead pharmaceutical policy for AHIP, a trade group formerly known as America’s Health Insurance Plans. The markups thrusted on commercial plans are “widely out of line” with what Medicare will pay, he said, and that is driving up costs without providing additional value.

Legislation that targets white bagging hinders an insurer’s ability to rein in such costs, Dickson said, especially when an area lacks competition.

“What we're really trying to focus on here is putting pressure on those markups that are not related to cost or safety,” Dickson said.

Anthem Blue Cross and Blue Shield lobbyist David Smith testified during the March hearing in Missouri that even the idea of white bagging elicited a quick response and that almost every major hospital system in the state said they would drop their prices and come back to the negotiation table.

For now, Citizens Memorial Hospital and other Missouri medical facilities will have to continue to tango with the insurers: Legislation to limit white and brown bagging did not pass during the Missouri General Assembly’s recent session.

Shepard, though, won’t need such legislation.

UnitedHealthcare had been sending her lupus infusion through other pharmacies on and off since 2021, unwilling to cover the drugs if they came from Citizens’ in-house pharmacy. Shepard had to authorize each shipment before it was sent. If she missed the monthly call, she said, it was a “bureaucratic mess” trying to get the medication shipped.

“We are driving unnecessary costs out of the health care system to help make care more affordable, while also maintaining drug safety, effectiveness and quality of care,” UnitedHealthcare spokesperson Tony Marusic wrote.

But after KFF Health News inquired about Shepard’s case, Marusic said UnitedHealthcare stopped white bagging Shepard’s medication to “prevent potential delays in shipping.” And during her latest infusion in June, her hospital was again able to supply Shepard’s medication directly.

“I'm just so relieved,” Shepard said. “I don't have to take phone calls. I don't have to reply to emails. I just show up.”

This article was produced by KFF Health News, formerly known as Kaiser Health News (KHN), a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

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

USE OUR CONTENT

This story can be republished for free (details).