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Several members of Congress are calling on the Social Security Administration to answer for issuing billions of dollars of payments it says beneficiaries weren’t entitled to receive — and then demanding the money back.

Many of the recipients are elderly, poor, or disabled and have already spent the money. They have little or no way of repaying it.

“The government’s got to fix this,” said Sen. Sherrod Brown (D-Ohio), who chairs a Senate panel that oversees Social Security.

“It’s a management problem, and people there should be held accountable,” Brown added.

Rep. Mike Carey of Ohio, the No. 2 Republican on a House panel that oversees Social Security, called for a congressional hearing on the subject.

“We need to have a hearing,” he said. “The general sense from members is … we do have a problem, we’ve got to address it, we’ve got to fix it,” he added.

(WSB-TV, Atlanta)

Sen. Rick Scott (R-Fla.), a member of the Committee on Aging, questioned how the volume of overpayments was allowed to grow to more than $20 billion. “Is somebody going to be held accountable at the federal level for, you know, messing this up?”

Those lawmakers and others commented in the wake of an investigation by KFF Health News and Cox Media Group (CMG) that found many of the nation’s poorest and most vulnerable, including people receiving disability benefits, have been called on to repay the government sums that can reach tens of thousands of dollars or more.

The Social Security Administration recovered $4.7 billion of overpayments during the 2022 fiscal year but ended that year with $21.6 billion of overpayments still uncollected, according to a November 2022 report by SSA’s inspector general.

In many cases, the overpayments were the result of errors by the government rather than the person receiving the money, the agency has stated.

For example, in a disclosure covering some of the programs involved — Old-Age, Survivors, and Disability Insurance, collectively known as OASDI — the agency reported issuing about $2 billion of overpayments in the 2022 fiscal year, of which about $1.5 billion was “within agency control.”

“The beneficiary or third-party provided the information we requested, but we failed to use the data/information to validate accuracy prior to making a payment,” the agency reported.

Social Security Administration spokesperson Nicole Tiggemann declined to comment for this article or to arrange an interview with the agency’s acting commissioner, Kilolo Kijakazi.

Overwhelmed and Panic-Stricken

For some benefits, recipients are required to keep the Social Security Administration updated about changes in their circumstances — for instance, whether others are giving them food or a place to stay.

Beneficiaries can lose certain benefits if they earn or save too much. For individuals in the Supplemental Security Income program — which supports people with little or no income or other financial resources who are disabled, blind, or at least age 65 — having more than $2,000 in the bank is generally disqualifying.

By the time the government catches mistakes, years can pass, and the amounts it says people owe can balloon to staggering levels. Social Security beneficiaries struggling to make ends meet described being overwhelmed and panic-stricken by demands that they repay money they no longer have.

Those who recounted their experiences to KFF Health News and Cox Media Group included a woman with multiple sclerosis, a man with autism, and a former police officer trying to support his family after being shot in the face.

Since that coverage was published and broadcast, almost 200 people have contacted KFF Health News and CMG television stations around the country to share their experiences with Social Security overpayments. Many criticized the system.

“I think it’s disgusting, it’s vile, it’s evil,” Renee Walker told CMG’s WPXI-TV in Pittsburgh.

Walker said her mother, a nurse, was disabled by covid-19 and dying of cancer at age 64 when SSA sent her a letter in August saying it would withhold five months of benefits — $1,214 per month, her entire income — plus an additional $309 to recover an overpayment of $6,379. According to Walker, the Social Security Administration said her mother, Rita Walker, had earned too much money in 2022. Walker said that wasn’t true.

“What she needed to survive was taken away from her,” Walker said, “and she passed away penniless.”

Nicole Eberhardt, 39, told WSOC-TV in Charlotte that she has been legally blind since birth and had been receiving benefits since childhood.

Then, in July, the Social Security Administration told her she had been overpaid by $9,664.50. She wondered how that was possible because her employer monitors her wages to make sure she doesn’t earn too much.

In August, her monthly benefit check didn’t arrive. As a result, she and her family were evicted this month, and they had to split up, she said.

“Now I have to pay not only Social Security back, but I have to pay my apartment complex back for the eviction,” she said.

(WHIO-TV, Dayton)

Tammy Eichler, a 70-year-old retiree, described sleepless nights after receiving an overpayment notice from SSA demanding she repay $5,575 in retirement benefits.

The agency stopped sending her Social Security checks and told her she won’t get another until June 2024.

“It’s just devastating to us,” Eichler told WHIO-TV in Dayton, Ohio.

Eichler still doesn’t understand what went wrong.

“I’ve been trying to call Social Security and on the phone for like an hour, just on hold every time,” Eichler said.

Eichler filed an appeal and waited.

“At 60 days, I still didn’t hear,” she said. “So, I called Social Security again. And they said it could take six months to a year because of so many people being involved in this mess. And I said, ‘What are people supposed to do in the meantime?’”

Lawmakers Call for Change

In a Sept. 21 news release, Rep. Marc Molinaro (R-N.Y.) said the Social Security Administration should fix its systems and “immediately stop seeking back overpayments.”

“The Social Security Administration screwed up, and now they’re demanding that seniors pay for the administration’s mistakes,” Molinaro said.

Demanding repayment “is absolutely unfair to the Americans who unknowingly received overpayments from the SSA, and this needs to be addressed immediately,” he wrote in a letter to the agency’s acting commissioner.

In an interview Sept. 27, Brown, the chairman of a Senate subcommittee on Social Security, said he had taken action in the wake of the CMG-KFF Health News investigation.

“We’ve let the federal agency know we expect them to stop and not penalize those people,” Brown said. “They may have been overpaid over the years, but it’s not like they have a savings account now of those overpaid dollars that they can simply pay back.”

Brown said he wanted to “push the agency to do the right thing.”

“There’s a lot of ways to hold their feet to the fire,” he said.

Sen. Maggie Hassan (D-N.H.), a member of the Senate Finance subcommittee on Social Security, Pensions, and Family Policy, said in a statement that the administration “needs to keep working to prevent overpayments in the first place while also not causing undue harm on some of the most vulnerable Social Security recipients if overpayments do occur.”

In notices informing beneficiaries of overpayments, the government routinely asks people to repay the amount owed within 30 days. People receiving those letters can appeal, ask for a waiver, or request an arrangement that allows them to repay the debt in small increments. Absent such forbearance, the government can reduce or cut off people’s monthly benefit checks.

The Social Security Administration, which issues more than $1 trillion of payments annually, has said its overall payment accuracy is high. The agency is required by law to adjust benefits or recover debts when it establishes that someone has been overpaid, SSA spokesperson Tiggemann said in a Sept. 13 statement for the recent investigative report by KFF Health News and CMG.

The White House did not address questions for this article, including what if anything President Joe Biden is doing about overpayments, how many people are facing overpayment notices, and whether SSA should disclose that number.

“Would refer you to SSA,” White House spokesperson Michael Kikukawa said.

The agency has declined to say how many people are facing overpayment notices.

Lawmakers said the SSA should disclose that information.

“They’re a government agency, and they need to be transparent,” Brown said.

“They’re receiving government money, they’re government employees, and they should give the answers to the American public,” Carey said.

As for the more than $20 billion in overpayments, “it’s an outrage, and it should have been caught,” said Rep. John Larson of Connecticut, the top Democrat on a House panel that oversees Social Security.

Larson called for Congress to increase funding for the agency.

“They need personnel bad,” he said.

That echoed the views of SSA employees and advocates for beneficiaries, who said the agency is so understaffed that members of the public have trouble communicating with it — either to submit information or to sort out alleged overpayments.

“We’re like a ghost town,” said Angela Digeronimo, a claims specialist for the SSA in New Jersey and an official in a union for agency employees.

Bill Sweeney, AARP’s senior vice president of government affairs, said the overpayments and collections pose “a real crisis” for people “trying to just get by,” and Congress should take responsibility.

That includes funding the agency adequately and making sure it “has enough people in place who know what they’re doing, who can make these decisions right in the first place.”

“They need to have some committee hearings,” Sweeney said. “They need to be focused on this. They need to dig into it.”

Jessica LaPointe, an SSA claims specialist in Wisconsin and the president of a union council for agency employees, encouraged Congress to hold hearings. “It’s a moral imperative that we fix the situation, and it’s on Congress right now to do that,” she said.

Reporters contributing to this investigation: Samantha Manning, Cox Media Group, Washington D.C.; Josh Wade, Cox Media Group; John Bedell, WHIO-TV, Dayton, Ohio; Alyssa Raymond, WPXI-TV, Pittsburgh; Madison Carter, WSOC-TV, Charlotte, North Carolina; Amy Hudak, WPXI-TV, Pittsburgh; Justin Gray, WSB-TV, Atlanta; Jesse Jones, KIRO-TV, Seattle.

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JOHNSON CITY, Tenn. — Five years ago, rival hospital companies in this blue-collar corner of Appalachia made a deal. If state lawmakers let them merge, leaving no competitors, the hospitals promised not to gouge prices or cut corners. They agreed to dozens of quality-of-care conditions, spelled out with benchmarks, and to provide hundreds of millions of dollars in charity care to patients in need.

Today, Ballad Health’s 20 hospitals remain the only option for hospital care for most of about 1.1 million residents in a 29-county region at the nexus of Tennessee, Virginia, Kentucky, and North Carolina. But Ballad has not met many of the quality benchmarks nor provided much of the charity, spurring discontent among those with no choice but to rely on Ballad for their care.

Two dozen states, from Florida to Washington, have at some point passed so-called COPA laws that allow hospital systems to merge into monopolies, disregarding warnings from the Federal Trade Commission that such mergers can become difficult to control and may decrease the overall quality of care. In the case of Ballad, the nation’s largest-known COPA deal, public records suggest that is exactly what happened.

Documents released by the Tennessee Department of Health show:

• Ballad has not fulfilled the annual charity care obligation it made to Tennessee, falling short by about $148 million over a four-year span. In those same years, Ballad took thousands of patients to court to collect unpaid bills.

• Ballad failed to meet about 80% of benchmarks designed to monitor and improve its quality of care — including rates of infection and death — in the most recent year for which data is available. Federal health officials cited some of these same problems this year in issuing one-star ratings to three Ballad hospitals, including a flagship, Johnson City Medical Center.

“The state of Virginia and the state of Tennessee took a chance on [Ballad] to do the right thing,” said Michele Johnson, executive director of the Tennessee Justice Center, a nonprofit focused on health care for the poor. “And they’ve proven that they are not worthy of that chance.”

In a two-hour interview with KFF Health News, Ballad Health CEO Alan Levine defended the merger as “hugely successful” for a region rife with poverty and sickness, saying his company had planted seeds of better health that “you can’t quantify today.” More specifically, Levine said the enormous pressure of the coronavirus pandemic caused Ballad’s slumping quality of care. He attributed charity care shortfalls to Medicaid changes beyond Ballad’s control and new preventive care programs that keep patients out of the hospital so they don’t need charity.

Levine said the Ballad merger had likely prevented at least three hospital closures and kept giant corporations from swooping into Appalachia to buy up the scraps.

“Our critics say, ‘No Ballad. We don’t want Ballad.’ Well, then what?” Levine said. “Because the hospitals were on their way to being closed.”

Ballad is centered in Tennessee and Virginia’s Tri-Cities region, a cluster of hardscrabble towns and wooded foothills that is home to the famous Bristol Motor Speedway and recognized by Congress as “the birthplace of Country Music.” Census data shows the Tri-Cities poverty rate is about 30% higher than the national average, and residents’ general health is below average for the nation and their respective states, according to the BlueCross BlueShield National Health Index.

Ballad launched in 2018 after state officials approved the nation’s largest-known Certificate of Public Advantage, or COPA, agreement, which waived anti-monopoly laws so the region’s only two hospital systems — Mountain States Health Alliance and Wellmont Health System — could merge. To offset the perils of a monopoly, the COPA requires Ballad to agree to increased oversight by the state and a long list of special conditions, including limiting price increases, maintaining quality, and providing charity care. Ballad also committed to investing $308 million over 10 years to improve the health of the region, some of which it has spent on a low-to-no-cost care network for the uninsured and expanded addiction treatment services.

Even with this spending, Ballad has turned a profit. The company generated net income of more than $143 million and $63 million in fiscal years 2022 and 2021, respectively, while receiving $175 million in pandemic relief funds, according to an S&P Global Ratings independent analysis, which excludes items like gains and losses separate from hospital operations.

The merger was profitable for Levine too. His total compensation has nearly doubled to about $4.3 million since the merger, including some deferred retirement payments, according to reports filed with the IRS. Prior to Ballad, Levine worked as a high-level health official in Florida and Louisiana and was an executive at two larger hospital corporations, HCA Healthcare and Health Management Associates. Federal prosecutors accused both companies of widespread health care fraud during some of the years when Levine was one of their leaders, claims the companies denied but later paid hundreds of millions of dollars to settle.

Nationwide, the COPA model is uncommon but gaining momentum. COPAs have been used in about 10 hospital mergers over the past three decades, including two in Texas and one in Louisiana in just the past three years, and another is being proposed in Indiana. Nineteen states have laws on the books allowing for COPAs, although not all have approved a specific merger, and five other states passed COPA laws and later repealed them, according to The Source on HealthCare Price & Competition, a website by the University of California College of the Law-San Francisco.

Rahul Rao, a deputy director of the Bureau of Competition at the Federal Trade Commission, which consistently opposes COPAs, said removing hospital competition leads to predictable results — rising prices, decreasing quality, and monopolies that are very hard to break up.

Rao said the FTC has for years studied how the Ballad merger is affecting health care in the region but that it is not yet ready to publish its findings.

“States should be very wary and distrustful of COPAs in general,” Rao said. “It’s very hard to unscramble the eggs.”

Tennessee began to pave the way for Ballad in 2015 when state Sen. Rusty Crowe (R-Johnson City) co-sponsored a bill allowing for the merger, which was later mirrored in Virginia. Crowe was also working as a contractor for Mountain States Health Alliance when the bill was introduced, and since the merger he has been similarly contracted with Ballad, the lawmaker said.

Tennessee financial disclosure records confirm Crowe was paid by both hospital systems but don’t say how much or for what. Crowe, who did not agree to an interview, said in an email that he was hired to “help in the development of wound care and hyperbaric medicine” and that he “complied with all the Senate ethics code requirements regarding any potential conflict of interest.”

Tennessee and Virginia health officials have concluded annually that the merger remains beneficial to the public and, in reports and interviews, credited Ballad for weathering the pandemic and keeping hospitals open.

Dennis Barry, one of the state monitors hired to keep tabs on Ballad, said he believed Ballad had largely lived up to the agreement, or at least the “intent.” Barry dismissed the FTC’s position that hospital competition is necessarily beneficial and said no one knows how the region would have fared without the merger.

“In a sense, we’ll never be able to determine whether or not this was a good idea or a bad idea,” Barry said. “I view it as an experiment.”

As Ballad fell short of its COPA benchmarks, state officials took steps to relax the oversight of its hospitals, particularly in Tennessee. Both Tennessee and Virginia gave Ballad more time to spend tens of millions to benefit the region, and Tennessee officials have repeatedly waived Ballad’s annual charity care obligation. Tennessee in 2021 stopped publishing a “final score” for Ballad’s adherence to the COPA terms and in 2022 revised COPA rules so Ballad could oppose the opening of competing hospitals or other medical facilities in the region, according to state documents. A local COPA advisory council, created to hear complaints from residents, no longer hosts public hearings.

Ballad Cites Pandemic Amid Quality Decline

Ballad has failed to meet quality-of-care benchmarks established in the COPA agreement in recent years, according to public reports from the Tennessee government and the hospital system itself. For example, a Tennessee report shows that from July 2021 through June 2022, Ballad hospitals fell short of 61 of 75 benchmarks, including some about sepsis, surgery-related infections, emergency room speed, and rates of readmission and death from heart failure.

The Centers for Medicare & Medicaid Services this year issued one-star ratings to three Ballad hospitals, all of which had ratings of at least two stars before the merger. Because CMS calculates star ratings from data collected over several years, the ratings released this year are the first to grade the Ballad hospitals entirely on post-merger data.

Levine, citing arguments similar to those of other hospital leaders, insisted the CMS five-star rating system is broken because it judges hospitals on a sliver of patients and doesn’t account for poor health in the region. He said Ballad fell short of the COPA benchmarks because the coronavirus overwhelmed hospitals and sparked an unprecedented nursing turnover.

But Ballad’s hospitals have since rebounded, Levine said, pointing to partial data on the company website — not yet reported by the states — that appears to show improving performance as of this summer. And Levine said internal data showed Ballad was now tracking with the top 10% of U.S. hospitals on some quality-of-care metrics.

“We went way backwards during covid, no question about it. And now we’ve emerged out of covid,” Levine said. “We’re recovering faster than other people.”

Erik Bodin, a Virginia Department of Health official who oversees the agreement with Ballad, said the pandemic caused quality issues at hospitals across the state, including Ballad’s, which were “not acceptable” but “to some extent understandable.” Bodin said Virginia still has “concerns” and is “watching very closely” because not all of Ballad’s metrics are rebounding.

The Tennessee Department of Health, which has the most robust role in regulating Ballad, declined an interview request and did not answer questions submitted in writing.

Ballad has also cut back on facilities for patients with life-threatening conditions. Citing redundancy with other hospitals, it downgraded the capabilities of trauma centers at Bristol Regional Medical Center and Holston Valley Medical Center and closed the intensive care unit at Sycamore Shoals Hospital. Ballad also shuttered the Holston Valley neonatal ICU. Residents were so angry that protesters gathered outside Holston Valley for eight months.

“I packed a sleeping bag, a backpack, and my laptop bag. I made two signs in my living room,” said Dani Cook, the protest leader and grandmother of a former Holston Valley NICU patient. “And next thing you know, 50 people showed up.”

One month after Holston Valley’s trauma center was downgraded, Jeremiah Shane Fields, 37, died at the hospital from chest injuries sustained in a car crash. According to a CMS investigation report obtained by KFF Health News, Fields’ blood pressure dropped for hours before his death, but his doctor did not come to his bedside as his condition deteriorated.

Holston Valley’s chief medical officer, who is quoted in the report but not named, called the case a “fundamental failure of basic trauma care” in which Fields’ doctor was “not following essential standards,” according to the report. Holston Valley was cited for “deficiencies” that were likely to harm patients, which the hospital immediately corrected, the report states.

Fields’ family has filed an ongoing lawsuit alleging negligent care, and Ballad Health has denied all wrongdoing in court filings. Molly Luton, a spokesperson for Ballad, said that Fields’ death was “an outlier” and “not the result of a systemic issue.”

Fields’ mother, Penny Meade, 59, said she believed the hospital could have done more to save her son.

“It used to be wonderful,” Meade said. “But then everything changed. They took it all away, after that merger.”

‘Helping People’ vs. ‘Coming After Them’

Ballad has fallen short of the annual charity care commitment in the COPA agreement by about $20 million to $48 million each year, according to Tennessee Department of Health documents. The agency waived this obligation each year after it wasn’t met, the documents show.

Charity care comes in two forms: free or discounted care for low-income patients, or the amount left over when Medicaid patients are treated but their entire cost is not covered. Most of Ballad’s charity care is from the second scenario, the documents show.

Ballad said in its annual reports it is unable to meet its charity care obligation because after the COPA was negotiated both Tennessee and Virginia increased their Medicaid reimbursement and Virginia expanded Medicaid to cover more people, leaving fewer people uninsured and in need of charity. (Tennessee has not expanded Medicaid.)

Levine added that Ballad’s new Appalachian Highlands Care Network provides preventive care to uninsured residents.

“We are doing everything we can, for instance, to manage their diabetes so that they don’t end up with a spike and end up in the ER,” Levine said. “That reduces your charity care.”

Some are unconvinced. Chris Garmon, a former FTC economist and a leading expert on COPAs at the University of Missouri-Kansas City, said Ballad had put forth a “strange defense” for its lack of charity care in a state where so many are uninsured.

“Last time I checked, Tennessee had not expanded Medicaid,” Garmon said. “This sounds like Ballad is pushing the envelope, like a toddler, trying to see when their parents will actually institute some discipline.”

As it was falling short of its charity commitment, Ballad filed thousands of debt collection lawsuits against patients in its first two years of operation, according to reporting from The New York Times and Modern Healthcare.

Levine said that Ballad does not sue patients who qualify for charity care and that its lawsuits slowed significantly after it adopted a more generous charity care policy in 2020. Ballad now offers free care to those who live at or below 225% of the federal poverty level, or an income of less than $67,500 for a family of four.

But the company still takes many patients to court. For example, in Tennessee’s Sullivan County, one of the most populous areas in Ballad’s market, the company has filed about 500 lawsuits since enacting the new charity care policy, court records show.

Wendy McClanahan, 44, said Ballad started garnishing her paycheck this summer over a lingering debt from a 2017 surgery. McClanahan said she was unemployed and unable to afford the bill at the time and she believed it was written off until court papers arrived in the mail.

Ballad will take 25% of McClanahan’s paycheck until she has paid off $2,747, court records show. McClanahan said she’s working overtime at her office job to make up for the lost income.

“They’re supposed to be helping people instead of coming after them,” she said. “It’s a lot of money to me, you know, and nothing to them.”

KFF Health News correspondent Bram Sable-Smith contributed to this report.

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Emily Gebel was trying to figure out why she was having trouble breastfeeding. That’s when she felt a lump.

Gebel, a mother of two, went to her primary care doctor in Juneau, Alaska, who referred her for testing, she said.

Her 9-month-old was asleep in her arms when she got the results.

“I got the call from my primary care nurse telling me it was cancer. And I remember I just sat there for probably at least another half an hour or so and cried,” Gebel said.

Juneau, the state capital, has about 31,700 residents, who are served by the city-owned Bartlett Regional Hospital. But Gebel said she has several friends who have also had cancer, all of whom recommended she seek treatment out of town because they felt bigger cities would have better care.

She opted for treatment in Seattle, the closest major American city to Alaska. She underwent surgery at Virginia Mason Medical Center in September 2022. In January, she began chemotherapy at Lifespring Cancer Treatment Center, a stand-alone clinic that she said she selected because it offers a lower-dose chemotherapy.

During chemo, she learned she had stage 4 breast cancer, she said.

Commuting to Seattle for chemo every week — nonstop flights that lasted as long as two hours and 45 minutes — became tiring. So Gebel began treatment at Bartlett Regional Hospital after her Seattle doctor taught hospital staffers there how to administer her chemo regimen.

Then the bill came.

The Patient: Emily Gebel, 37, insured through her husband’s employer by Premera Blue Cross. She was previously covered by Moda Health.

Medical Service: One round of metronomic chemotherapy, which involves regular infusions at lower but more frequent doses and over a longer period than traditional chemotherapy.

Service Provider: Bartlett Regional Hospital and Lifespring Cancer Treatment Center. The hospital is a tax-exempt facility owned by the city and borough of Juneau, though most of its revenue comes from the services it provides, according to hospital officials. Lifespring is a stand-alone, doctor-owned cancer clinic in Seattle.

Total Bill: The prices for Gebel’s chemo infusions at Bartlett Regional Hospital varied week to week. A hospital bill showed one infusion in July was listed at $5,077.28 — more than three times the price for a similar mix of drugs at the Seattle clinic, $1,611.24.

What Gives: In the United States, the price for the same medical service can vary based on where it is received. And for those living in remote areas like Alaska, the price difference can put care further out of reach.

Gebel’s firsthand experience with this disparity began after her husband, Jered, requested a cost estimate from Bartlett Regional Hospital. It said Gebel’s chemo would cost around $7,500 per weekly infusion, more than 4½ times what she had been charged in Seattle.

“The email came through with the bill estimate, and it’s like, ‘Oh my goodness, this has to be wrong,” Jered said.

Jered said Emily had met her annual out-of-pocket maximum, meaning her insurance would cover the costs of her treatment, but from the start, the disparity just bothered him.

When Emily received a bill for a few rounds of her weekly chemo treatments, it showed the hospital charged more than triple what the Seattle clinic did for a round of chemo, asking higher prices for every related service and medication she received that week.

The hospital charged about $1,000 for the first hour of chemo infusion, which is more than twice the rate at the Seattle clinic. One of the drugs cost $714, more than three times the price at the clinic.

It was even the tiniest things: The hospital charged $19.15 for Benadryl, about 22 times the clinic’s price of 87 cents.

Staff at Lifespring Cancer Treatment Center, the Seattle clinic, did not reply to requests for comment.

Sam Muse, the hospital’s former chief financial officer, who no longer works there, said Bartlett Regional Hospital officials determined prices by looking at average wholesale prices and what other facilities in the region charge. Muse said the hospital had to account for high operating costs.

“Anything that we charge certainly has to take into consideration … the cost of just supplying health care in a rural setting like Juneau,” Muse said. “We’re not accessible by road at all, only ferry or plane.”

Juneau’s isolated geography makes reaching many resources a challenge. The city is part of the Alaska Panhandle, a narrow, island-speckled sliver of the state wedged between Canada, the Pacific Ocean, and Glacier Bay National Park & Preserve. Neither Anchorage nor Vancouver, its nearest major cities, is close by.

The hospital — the only one in the city and largest in the panhandle — treats a small number of cancer patients, at least a few hundred last year, Muse said. Its two oncologists live outside the city and fly into Juneau six times a month, said Erin Hardin, a hospital spokesperson.

Bartlett spent nearly $11 million last year to pay and fly in nurses, doctors, and other staffers who live outside the city, Muse said.

We’re “trying to find that happy medium between keeping care here and keeping costs down and how do we do that in a sustainable way for the long term,” Muse said.

Even though research shows Alaskans seek emergency care and are admitted to the hospital less often than many Americans, they had the third-highest health care expenditures per capita in 2020.

“Alaska is special in that it’s small, it’s remote, therefore it’s more expensive,” said Mouhcine Guettabi, an associate professor of economics at the University of North Carolina-Wilmington who studied health care costs in Alaska when he taught there.

Guettabi said hospitals often need to offer higher wages to recruit doctors and nurses willing to live in Alaska, which has a higher cost of living than that of most states.

Towns or entire regions may have few specialists and only one hospital, creating a dearth of competition that may drive up costs, Guettabi said. It’s also more expensive to ship items there, including medical supplies.

But Alaska’s costs are higher even when taking all those factors into account, Guettabi said. In Anchorage, for instance, prices for medical items increased nearly three times as fast from 1991 through 2017 than prices overall.

Alaska also has a unique policy that may be increasing prices. Its “80th percentile rule” was enacted in 2004 to limit the amount of money patients pay when treated by providers outside their health insurers’ network. But like many experiments meant to rein in costs, the rule has instead been increasing health care spending, according to a study by Guettabi.

“Critics think the rule may be adding to that soaring spending, partly because over time providers could increase their charges — and insurance payments would have to keep pace,” the study noted.

The Resolution: Emily received a bill from the hospital in September, more than five months after beginning treatment there.

It said Emily owed about $3,100 even though a previous explanation of benefits said she’d met her out-of-pocket limit.

Jered said he contacted hospital billing officials, who discovered that a medicine had been incorrectly coded and told Jered that Emily’s charge was zero.

“We know how hard it is to pay these ridiculous medical bills,” Jered said. “If I’m able to push back a little bit against this massive system, well, hey, maybe other people can, too. And who knows, maybe eventually health care prices can come down.”

Emily said she’s glad Jered knows how to handle the financial aspects of her care. Like many Americans, she could have just paid or ignored the incorrect bills, risking being sent to collections.

“I can’t imagine the amount of time I would have to spend on it while juggling parenting and also dealing with completing treatment, going through the sickness that goes along with that, and just generally feeling very run down,” she said.

The Takeaway: Alaska government officials, nonprofits, and experts have suggested methods to lower the cost of health care. The state is considering repealing the 80th percentile rule and implementing value-based care, which emphasizes paying providers based on health outcomes.

But what should Alaskans and other patients do in the meantime? If you live in a high-cost state, you might check out prices at a health care system in a state next door.

In any case, get ready to advocate for yourself.

Jered learned about medical billing by following the Bill of the Month series and reading “Never Pay the First Bill,” a book by Marshall Allen, a former ProPublica reporter.

Request itemized bills and make sure the codes match the services you received, Jered said. Note any prices that seem outrageous. If you have concerns, arrange an in-person meeting with an official in the provider’s finance department. If that’s not possible, a phone call is better than email. Make sure to document all conversations, so you have a record.

Come prepared with your documents and evidence, including the rate paid by Medicare, the federal insurance system for those 65 and older. Ask the official to explain the reasons for the codes and pricing before contesting anything. You can sometimes negotiate high-priced services down. And remember that the person you’re speaking with isn’t to blame for your health care costs.

“Don’t come at them angry, don’t come at them as viewing them as the enemy — because they’re not,” Jered said. “They are working within the same broken system.”

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From the start of the second Republican presidential primary debate of the 2024 campaign, the seven candidates on stage were boisterous and unruly.

Florida Gov. Ron DeSantis, former South Carolina Gov. Nikki Haley, South Carolina Sen. Tim Scott, entrepreneur Vivek Ramaswamy, former Vice President Mike Pence, former New Jersey Gov. Chris Christie, and North Dakota Gov. Doug Burgum spent most of the evening talking loudly over — and sometimes quite angrily at — one another.

The moderators — Fox News’ Dana Perino, Fox Business’ Stuart Varney, and Univision’s Ilia Calderón — sometimes struggled to referee at the Ronald Reagan Presidential Library & Museum in Simi Valley, California, as the presidential hopefuls clashed on topics ranging from the autoworkers’ strike to foreign policy. At points, health care issues crept into the discussion.

Our PolitiFact partners fact-checked the candidates in real time. You can read their full coverage here.

Candidates sparred over manufacturing and employment, inflation, and federal spending. When it came to the government shutdown threat, Haley promised to change the process, pointing out that Congress had delivered appropriations on schedule only four times in 40 years.

Asked about medical debt, which plagues tens of millions of Americans, she pledged a multipronged effort to protect people from financial ruin when they need care. She spoke of introducing more competition in the health system and putting “the patient in the driver’s seat” while increasing transparency.

“We’re going to have to make every part of the industry open up and show us where the warts are,” she said. She didn’t elaborate on how that could be accomplished.

Pence dodged a question about whether he would make good on his promise, from 2016 and the current campaign, to repeal the Affordable Care Act — also known as Obamacare — which Perino noted seemed more popular now than ever.

“It’s my intention,” the former vice president said, “to make the federal government smaller by returning to the states those resources and programs that are rightfully theirs under the 10th Amendment of the Constitution.” That would include all Obamacare and Health and Human Services funding, he said.

Pence also said he is “sick and tired” of mass shootings and promised, if elected, to advance an expedited federal death penalty “for anyone involved in a mass shooting” so they “meet their fate in months, not years.” The former vice president criticized DeSantis over the sentence handed down to a gunman who attacked Marjory Stoneman Douglas High School in Parkland, Florida, in 2018, calling it “unconscionable” that he’ll “spend the rest of his life behind bars.”

On the issue of health insurance coverage, DeSantis wore his state’s high uninsurance rate as a badge of honor.

“You can do well in the state, but we’re not going to be like California and have massive numbers of people on government programs without work requirements,” he said. Under DeSantis, Florida is one of just 10 states that have declined to take advantage of federal funding available under Obamacare to expand Medicaid, the program that covers low-income Americans.

Throughout the evening, the candidates sometimes invoked Reagan’s name and memory. He wasn’t the only former president not in attendance but often mentioned. Donald Trump, who enjoys a commanding lead in the polls, opted again to steer clear of the debate stage.

“Donald, I know you are watching — you can’t help yourself,” Christie said early on. He said Trump avoided the event because he was “afraid” of “being on the stage” and defending his record.

Trump told Fox News Digital in an interview after the debate that he hadn’t watched it.

Former Arkansas Gov. Asa Hutchinson did not meet the Republican National Committee’s donor and polling thresholds to participate. Former Texas Rep. Will Hurd also did not qualify.

Here are last night’s health-related claims checked by PolitiFact:

Ron DeSantis: 2.6 million Floridians going without health insurance “is a symptom of our overall economic decline.”

When moderator Varney pressed DeSantis on the relatively high number of Floridians without health insurance — Varney said it’s 2.6 million — DeSantis blamed politicians in Washington, D.C.

But the numbers from DeSantis’ own state health department show no correlation between economic conditions and the number of Floridians without health insurance. Despite population growth and economic changes, Florida had about 2.6 million uninsured residents from 2018 through 2021, and about 2.4 million in 2022.

In 2022, Florida’s uninsured rate was 11.2%, higher than the 8% national rate, according to the U.S. Census Bureau.

Vivek Ramaswamy: “Transgenderism, especially in kids, is a mental health disorder.” 

Medical experts disagree. Being transgender and having gender dysphoria — the distress that some people may experience when their sex assigned at birth does not align with their gender identity — is not considered a mental health disorder. Historically, the diagnosis has carried the term “disorder,” but experts no longer view it as a pathology and are working to destigmatize the diagnosis.

Previous terms such as “gender identity disorder” and “transexualism” have evolved into “gender incongruence,” a condition the World Health Organization now considers a condition related to sexual health — not mental health. The American Psychiatric Association’s “Diagnostic and Statistical Manual of Mental Disorders,” or DSM-5, contains a diagnosis for “gender dysphoria,” but experts say it remains partly to let insurance companies cover gender-affirming care and let incarcerated people access care.

Mike Pence: Linn-Mar Community School District in Iowa had a policy where “you could get a gender transition plan without notifying your parents.”

This needs more context. The Iowa school district outside Cedar Rapids in 2022 adopted a policy that allowed students to request a “gender support plan.” According to Axios, this plan would outline a student’s preferred name and pronouns as well as which locker rooms or bathroom the student would use, which is associated with a social, rather than a medical, transition.

The student could choose whether the parents were informed, but the plan was not related to medical transition, which, for minors, requires the consent of parental guardians. Schools often don’t inform parents when students signal they are socially transitioning, The Washington Post reported.

Tim Scott: The southwestern U.S. border under President Joe Biden is “unsafe, wide-open, and insecure, leading to the deaths of 70,000 Americans in the last 12 months because of fentanyl.”

Scott’s claim is misleading. Deaths from fentanyl jumped 23% in Biden’s first year in office to more than 70,000. But they have been increasing since 2014 and also rose during the Trump administration.

Although immigration encounters at the southern U.S. border have spiked under Biden’s watch, most of the fentanyl coming into the U.S. from Mexico reportedly comes through legal ports of entry. The vast majority of people sentenced for fentanyl trafficking are U.S. citizens, federal data shows.

Stephanie Stephens

As Medicare Advantage continues to gain popularity among seniors, three Southern California companies are pioneering new types of plans that target cultural and ethnic communities with special offerings and native-language practitioners.

Clever Care Health Plan, based in Huntington Beach, and Alignment Health, based in nearby Orange, both have plans aimed at Asian Americans, with extra benefits including coverage for Eastern medicines and treatments such as cupping and tui na massage. Alignment also has an offering targeting Latinos, while Long Beach-based SCAN Health Plan has a product aimed at the LGBTQ+ community. All of them have launched since 2020.

While many Medicare Advantage providers target various communities with their advertising, this trio of companies appear to be among the first in the nation to create plans with provider networks and benefits designed for specific cultural cohorts. Medicare Advantage is typically cheaper than traditional Medicare but generally requires patients to use in-network providers.

“This fits me better,” said Clever Care member Tam Pham, 78, a Vietnamese American from Westminster, California. Speaking to KFF Health News via an interpreter, she said she appreciates the dental care and herbal supplement benefits included in her plan, and especially the access to a Vietnamese-speaking doctor.

“I can always get help when I call, without an interpreter,” she said.

Proponents of these new culturally targeted plans say they can offer not only trusted providers who understand their patients’ unique context and speak their language, but also special products and services designed for their needs. Asian Americans may want coverage for traditional Eastern treatments, while LGBTQ+ patients might be especially concerned with HIV prevention or management, for example.

Health policy researchers note that Medicare Advantage tends to be lucrative for insurers but can be a mixed bag for patients, who often have a limited choice of providers — and that targeted plans would not necessarily solve that problem. Some also worry that the approach could end up being a new vector for discrimination.

“It’s strange to think about commodifying and profiting off people’s racial and ethnic identities,” said Naomi Zewde, an assistant professor at the UCLA Fielding School of Public Health. “We should do so with care and proceed carefully, so as not to be exploitive.”

Still, there’s plenty of evidence that patients can benefit from care that is targeted to their race, ethnicity, or sexual orientation.

A November 2020 study of almost 118,000 patient surveys, published in JAMA Network Open, underscored the need for a connection between physician and patient, finding that patients with the same racial or ethnic background as their physicians are more likely to rate the latter highly. A 2022 survey of 11,500 people around the world by the pharmaceutical company Sanofi showed a legacy of distrust in health care systems among marginalized groups, such as ethnic minorities, LGBTQ+ people, and people with disabilities.

Clever Care, founded by Korean American health care executive Myong Lee, aimed from the start to create Medicare Advantage plans for underserved Asian communities, said Peter Winston, the senior vice president and general manager of community and provider development at the company. “When we started enrollments, we realized there is no one ‘Asian,’ but there is Korean, Chinese, Vietnamese, Filipino, and Japanese,” Winston added.

The company has separate customer service lines by language and gives members flexibility on how and where to spend their allowances for benefits like fitness programs.

Winston said the plan began with 500 members in January 2021 and is now up to 14,000 (still very small compared with mainstream plans). Herbal supplement benefit dollars vary by plan, but more than 200 products traditionally used by Asian clients are on offer, with coverage of up to several hundred dollars per quarter.

Sachin Jain, a physician and the CEO of SCAN Group, said its LGBTQ+ plan serves 600 members.

“This is a group of people who, for much of their lives, lived in the shadows,” Jain added. “There is an opportunity for us as a company to help affirm them, to provide them with a special set of benefits that address unmet needs.”

SCAN has run into bias issues itself, with some of its employees posting hate speech and one longtime provider refusing to participate in the plan, Jain recounted.

Alignment Health offers a plan targeting Asian Americans in six California counties, with benefits such as traditional wellness services, a grocery allowance for Asian stores, nonemergency medical transportation, and even pet care in the event a member has a hospital procedure or emergency and needs to be away from home.

Alignment also has an offering aimed at Latinos, dubbed el Único, in parts of Arizona, Nevada, Texas, Florida, and California. The California product, an HMO co-branded with Rite Aid, is available in six counties, while in Florida and Nevada, it’s a so-called special needs plan for Medicare beneficiaries who also qualify for Medicaid. All offer a Spanish-speaking provider network.

Todd Macaluso, the chief growth officer for Alignment, declined to share specific numbers but said California membership in Harmony — its plan tailored to Asian Americans — and el Único together has grown 80% year over year since 2021.

Alignment’s marketing efforts, which include visiting places where prospective members may shop or socialize, are about more than just signing up customers, Macaluso said.

“Being present there means we can see what works, what’s needed, and build it out. The Medicare-eligible population in Fresno looks very different from one in Ventura.”

“Just having materials in the same language is important, as is identifying the caller and routing them properly,” Macaluso added.

Blacks, Latinos, and Asians overall are significantly more likely than white beneficiaries to choose Medicare Advantage plans, according to recent research conducted for Better Medicare Alliance, a nonprofit funded by health insurers. (Latino people can be of any race or combination of races.) But it’s not clear to what extent that will translate into the growth of targeted networks: Big insurers’ Medicare Advantage marketing efforts often target specific racial or ethnic cohorts, but the plans don’t usually include any special features for those groups.

Utibe Essien, an assistant professor of medicine at UCLA, noted the historical underserving of the Black community, and that the shortage of Black physicians could make it hard to build a targeted offering for that population. Similarly, many parts of the country don’t have a high enough concentration of specific groups to support a dedicated network.

Still, all three companies are optimistic about expansion among groups that haven’t always been treated well by the health care system. “If you treat them with respect, and bring care to them the way they expect it, they will come,” Winston said.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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

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A registered nurse who works in New Jersey’s Matawan-Aberdeen Regional School District reacted on X, formerly known as Twitter, to KFF Health News’ investigative collaboration with Cox Media Group on the federal government’s attempt to claw back money it has overpaid to Social Security beneficiaries: “Social Security Overpays Billions to People, Many on Disability. Then It Demands the Money Back” (Sept. 15).

Can I just say to tell folks that they only have 30 days to pay back any overpayments that they likely were not even aware of until they received the notice, is crazy!https://t.co/CfaWrd9VVQ

— Sheila Caldwell (@SCaldwell7201) September 17, 2023

— Sheila Caldwell, Aberdeen, New Jersey

A law professor at the S.J. Quinney College of Law at the University of Utah also chimed in on X:

Important @KFF @KFFHealthNewsexposé on Social Security making errors and sending people ludicrous bills to to recover overpayments. One disabled woman got a bill for $60,175.90 out of the blue. The agency suffers from underfunding/understaffinghttps://t.co/0vNfROIVe9

— Daniel G. Aaron, MD, JD (@MedlawDan) September 18, 2023

— Daniel G. Aaron, Salt Lake City

For Shame, UnitedHealthcare

Thank you for shining a light on one of the most infuriating insurance barriers in all of medicine: prior authorization (“Doctors and Patients Try to Shame Insurers Online to Reverse Prior Authorization Denials,” Aug. 23).

During the pandemic, many people skipped or could not access routine medical care such as colonoscopies and endoscopies. Research has long shown that these services are underutilized, especially among communities of color, which is one reason for continued disparities in colorectal cancer and other gastrointestinal diseases.

As the demand for routine diagnostic and surveillance procedures grows, it is critical to ensure that patients are not caught up in bureaucratic red tape. Unfortunately, the nation’s largest and most profitable insurer, UnitedHealthcare, is slowly, quietly working to expand prior authorization to these key forms of gastrointestinal care.

While UHC publicly pledged to slash prior authorization, we must judge them by their actions, not their words. Since UHC made that promise this spring — a move welcomed by doctors and patients across the country — the insurer also announced troubling new prior authorization requirements for colonoscopies and endoscopies for its 27 million commercial beneficiaries. The insurer planned to begin implementing prior authorization for these vital procedures starting June 1 but temporarily halted the plan after major outcry from patients and gastroenterologists.

Yet, the threat lingers. Right now, UHC is asking doctors to participate in a burdensome “Advanced Notification program,” which forces physicians to submit all kinds of data that the insurer will use to inform its planned “Gold Card” prior authorization program in 2024.

Physicians see through this ruse. While UHC claims no patients are being denied the colonoscopies and endoscopies that could help save their lives, the administrative burden Advanced Notification causes is clogging already backlogged offices, especially small practices. Even worse, the gastroenterological community fears that millions of patients may face UHC’s prior authorization requirements in a matter of months — yet the insurer has failed to coordinate with specialty societies or transparently communicate how the program will operate or how UHC will ensure patient care is not disrupted.

This issue affects all of us. If UHC is allowed to deny or delay colonoscopies and endoscopies, where will it end? Diagnostic mammograms? Pap smears? Lung cancer screenings? And will other insurers follow suit with equally oppressive prior authorization policies?

UHC must immediately reverse course on its alarming policies to ensure streamlined access to care. In the meantime, gastroenterologists will continue to hold the line for our patients.

— Lawrence Kim, vice president of the American Gastroenterological Association, Lone Tree, Colorado

The branding director for Norwood, a health care staffing and consulting company in Texas, posted on X that publicly shaming insurers may prove a smart strategy.

Good; shameful practices deserve public shaming: Doctors and Patients Try to Shame Insurers Online to Reverse Prior Authorization Denials https://t.co/OvbTUXOkOR via @kffhealthnews

— Brian Murphy (@NorwoodCDI) August 23, 2023

— Brian Murphy, Austin, Texas

Reaction was also robust on Threads:

How New York Is Tackling Tobacco Use Among Youths

I just read Liz Szabo’s piece on child nicotine poisonings (“Doctors Sound Alarm About Child Nicotine Poisoning as Vapes Flood the US Market,” Aug. 3). The reporting illuminated a crucial yet lesser-known issue regarding the harms of these e-liquids. The response does call for a combined public health effort, so I wanted to share further information regarding New York state policy (mentioned in the piece) that has shown to be successful in reducing the sale and use of vapes and traditional, combustible cigarettes. This policy-level intervention’s results imply that fewer young children are being exposed to/have access to these products based on decreased rates of smoking and vaping use and initiation among older siblings or adults around them. I hope this information proves useful to your national audience who may consider these policies in the context of their state’s.

The New York State Department of Health released three new reports that indicate that the current tobacco control policies adopted in the state have helped effectively reduce tobacco use and initiation, including smoking and vaping. The evidence-based approaches bolstered ongoing decreases in youth vaping rates; between 2018 and 2022, rates declined by about 32%. Youth tobacco use (of any tobacco product) also declined by 32%, from 30.6% in 2018 to 20.8% in 2022. This significant decline brings New York closer to achieving the Prevention Agenda goal of decreasing high school youth tobacco use to 19.7% by 2024.

While this is great progress, tobacco still is the No. 1 cause of preventable disease in the United States — it is estimated that it kills 480,000 adults in the U.S. every year — and there are still issues with regulation and a lack of protective packaging on vapes.

NYC Treats Tobacco works with health care organizations in New York City to ensure they effectively screen and treat their patients for tobacco use.

— Avani B. Ansari, MPH, CHES, project coordinator for NYC Treats Tobacco, New York City

An organization that advocates for policies promoting opportunities and wellness for children posted this on X:

Thousands of kids a year are exposed to the liquid nicotine in e-cigarettes, also known as vapes. For a toddler, even a few drops can be fatal. Doctors sound alarm about child nicotine poisoning as vapes flood the US market: https://t.co/3IHV8L1UKX

— KY Youth Advocates (@KYYouth) August 14, 2023

— Kentucky Youth Advocates, Jeffersontown, Kentucky

And a Georgia state representative shared her two cents on X regarding Liz Szabo’s previous coverage on youth vaping:

Youth vaping is on the rise, with the industry marketing products blatantly targeted to kids + teens.The unregulated nicotine in e-cigs ( 76% over 5y) can addict kids in just days.My bills #HR43 and #HB192 aim to study + disincentivize youth vaping.https://t.co/p5NGJd8gAw

— Dr. Michelle Au (@AuforGA) June 27, 2023

— Michelle Au, Johns Creek, Georgia

Recuerdo vívidamente ese viernes por la tarde cuando mi presión ocular se disparó y tuve que ir tambaleando hasta el consultorio de mi oftalmólogo. Mi visión se volvía cada vez más borrosa y veía nublados los autos y los semáforos.

El consultorio ya había cerrado, pero todo el equipo estaba allí esperándome. Uno de ellos me pinchó los globos oculares con un instrumento punzante para drenar el líquido que se había acumulado. Eso alivió la presión y me devolvió la visión.

Pero era el cuarto pico de presión ocular que amenazaba mi visión en nueve días, y los doctores temían que volviera a suceder durante el fin de semana. Así que me fui a la sala de emergencias, donde pasé la noche conectado a un tubo intravenoso que suministraba un poderoso agente antiinflamatorio.

Más tarde, cuando le contaba esta historia a mis amigos y colegas, algunos de ellos no entendían la importancia de la presión ocular o ni siquiera lo que era. “No sabía que se podía medir la presión sanguínea en los ojos”, me dijeron.

La mayoría de las personas consideran que su visión es de suma importancia. Sin embargo, muchas de ellas saben muy poco sobre las enfermedades oculares más graves.

En un estudio de 2016 publicado en JAMA Ophthalmology, basado en una encuesta nacional en línea, casi la mitad de los encuestados dijeron que temían perder la vista más que la memoria, el habla, el oído o sus extremidades. Sin embargo, muchos “no tenían conciencia de enfermedades oculares importantes”, según el estudio.

Un estudio publicado este mes, realizado por Wakefield Research para las organizaciones sin fines de lucro Prevent Blindness y Regeneron Pharmaceuticals, reveló que una cuarta parte de los adultos con mayor riesgo de desarrollar enfermedades de la retina, como degeneración macular y retinopatía diabética, atrasaron la búsqueda de atención médica para sus problemas de visión.

“Se hace mucho menos énfasis en la salud ocular que en la salud general”, afirma Rohit Varma, director fundador del Southern California Eye Institute de Hollywood Presbyterian Medical Center.

Varma dice que, debido a que muchas veces las enfermedades de los ojos no causan dolor y avanzan lentamente, “la gente se acostumbra, y a medida que envejece empieza a pensar, ‘esto es una parte normal del envejecimiento’”. Pero si sintiera un dolor intenso, agrega, la misma persona buscaría atención médica.

Pero para muchos no es fácil tener un examen de la vista o recibir tratamiento. Millones no tienen seguro de salud, otros no pueden pagar su parte del costo, o viven en comunidades donde no hay muchos oftalmólogos.

“El hecho de que la gente sepa que necesita atención médica no significa que pueda pagarla o que tenga acceso a ella”, dice Jeff Todd, director y presidente de Prevent Blindness.

Otro reto que refleja la brecha entre la atención oftalmológica y la atención de salud general es que el seguro médico suele cubrir solo el cuidado de ojos para diagnosticar o tratar enfermedades, excepto en el caso de los niños.

Muchos planes de salud cubren los exámenes de visión de rutina, pero estos generalmente no incluyen el tipo de examen que se utiliza para recetar anteojos y lentes de contacto. Tampoco suelen cubrir el costo de los lentes. En algunos casos se necesita un seguro de visión aparte para estos servicios; consulta con tu plan de salud para saber qué cubre.

Desde que me diagnosticaron glaucoma hace 15 años, he tenido más controles de presión ocular, exámenes de visión, recetas de gotas para los ojos y cirugías láser de los que puedo recordar. Yo no debería subestimar la importancia de mi vista. Y sin embargo, cuando mis ojos se llenaron de esa niebla que empañaba mi visión en marzo pasado, me sentí extrañamente optimista.

Resultó que esos picos de presión en serie habían sido provocados por una reacción adversa a las gotas a base de esteroides que me recetaron tras una operación de cataratas. Mi oftalmólogo me dijo más tarde que había estado “a pocas horas” de perder la vista.

Espero que mi experiencia de estar cerca de la ceguera inspire a la gente a ser más consciente de sus ojos.

Los anteojos o los lentes de contacto pueden marcar una gran diferencia en la calidad de vida de una persona al corregir los errores de refracción, que afectan a 150 millones de estadounidenses. Pero no hay que ignorar el riesgo de los trastornos oculares mucho más graves, que pueden sorprendernos. En muchos casos se pueden controlar, si se detectan a tiempo.

El glaucoma, que afecta a unas 3 millones de personas en Estados Unidos, ataca primero la visión periférica y puede causar daños irreversibles en el nervio óptico. Es hereditario y es cinco veces más prevalente en las personas afroamericanas que en la población general.

Casi 10 millones de personas en este país tienen retinopatía diabética, una complicación de la diabetes que ocurre cuando se dañan los vasos sanguíneos de la retina. Y unas 20 millones de personas de 40 años o más tienen degeneración macular, una enfermedad de la retina asociada con el envejecimiento que, con el tiempo, disminuye la visión central.

Las cataratas causan opacidad en el cristalino, la lente natural del ojo. A medida que las personas envejecen, es muy común que las desarrollen: la mitad de las personas de 75 años o más las tienen. Las cataratas pueden causar ceguera, pero se tratan con cirugía.

Si tienes más de 40 años y no te has realizado un examen ocular completo en un tiempo, o nunca, pónlo en tu lista de tareas pendientes. Y hazlo antes de esa edad si tienes diabetes, antecedentes familiares de glaucoma o si eres una persona afroamericana o parte de otro grupo racial o étnico con alto riesgo de ciertas enfermedades oculares.

Y no te olvides de los más jóvenes. Múltiples afecciones oculares pueden afectar a los niños. Los errores de refracción, tratables con lentes correctivas, pueden causar problemas más adelante en la vida si no se tratan lo suficientemente temprano.

Los estilos de vida saludables también benefician a tus ojos. “Todo lo que ayuda a tu salud general ayuda a tu visión”, dice Andrew Iwach, vocero clínico de la Academia Americana de Oftalmología y director ejecutivo del Glaucoma Center of San Francisco.

Reduce el estrés, haz ejercicio regularmente y sigue una dieta saludable. También deja de fumar. Aumenta el riesgo de enfermedades oculares graves.

Y considera adoptar hábitos que protejan tus ojos de lesiones: usa lentes de sol cuando estés al aire libre, descansa de la pantalla de tu computadora y teléfono celular regularmente, y usa anteojos protectores cuando trabajes en la casa o practiques deportes.

El sitio web de Prevent Blindness ofrece información sobre prácticamente todo lo relacionado con la salud ocular, incluyendo el seguro. Otras buenas fuentes son el sitio EyeSmart de la Academia Americana de Oftalmología y el Instituto Nacional del Ojo.

Así que lee y comparte lo que has aprendido. “Cuando te reúnas con tu familia para las fiestas”, dice Iwach, “si no sabes de qué hablar, habla de tus ojos”.

Esta historia fue producida por KFF Health News, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation.

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Jordan Rau, KFF Health News and Tony Leys

DALLAS CENTER, Iowa — “Covid is not pretty in a nursing home,” said Deb Wityk, a 70-year-old retired massage therapist who lives in one called Spurgeon Manor, in rural Iowa. She twice contracted the disease and is eager to get the newly approved vaccine because she has chronic lymphocytic leukemia, which weakens her immune system.

The Centers for Disease Control and Prevention approved the latest vaccine on Sept. 12, and the new shots became available to the general public within the past week or so. But many nursing homes will not begin inoculations until well into October or even November, though infections among this vulnerable population are rising steeply, to nearly 1%, or 9.7 per 1,000 residents, as of mid-September from a low of 2.2per 1,000 residents in mid-June.

“The distribution of the new covid-19 vaccine is not going well,” said Chad Worz, CEO of the American Society of Consultant Pharmacists. “Older adults in those settings are certainly the most vulnerable and should have been prioritized.”

With the end of the formal public health emergency in May, the federal government stopped purchasing and distributing covid vaccines. That has added complications for operators of nursing homes who have encountered resistance throughout the pandemic in persuading employees and residents to get the shots.

The coronavirus decimated nursing homes during the first two years of the pandemic, killing more than 200,000 residents and staffers. Elizabeth Sobczyk, project director of Moving Needles, a CDC-funded initiative to improve adult immunization rates in long-term care facilities, said without a government agreement to purchase the shots, vaccine manufacturers will make large quantities only once CDC experts have recommended approval.

“Then they need to be FDA inspected — we want safe vaccines — then there is contracting and rollout,” Sobczyk said. “So I completely understand the frustration, but also why the availability wasn’t immediate.”

Even once the shots are available, nursing homes face continuing resistance to the vaccine among nurses and aides. Without state mandates for workers to be vaccinated, most nursing homes are relying on persuasion, and that is often proving difficult.

“People want covid-19 to be in the rearview mirror,” said Leslie Eber, medical director of Orchard Park Health Care Center in Centennial, Colorado. “We’re going to have to remind people more this year that covid-19 is not benign. Maybe it’s a cold for some people, but it’s not going to be a cold for the folks I care for.”

Sixty-two percent of nursing home residents are up to date on their vaccines, meaning they received the second booster available before this month’s new shot. That’s an improvement over the 38% rate at the start of October 2022, according to the most recent federal data as of mid-September.

But only 25% of nursing home employees are up to date, which is close to last October’s rate.

In a written statement, the Department of Health and Human Services said that it will be identifying long-term care facilities with low vaccination rates and reaching out to ensure “proven infection prevention and control measures are being implemented to protect seniors.”This year, more nurses and aides will have to obtain shots at drugstores or health centers, on their personal time rather than at work. Many homes run clinics, with their long-term care pharmacies supplying the vaccine as they did before, but face extra bureaucratic hassles in billing insurers for the vaccine for both residents and employees.

On top of that, homes are rolling out a new vaccine for a dangerous respiratory virus, RSV, which will be a third shot for many residents along with vaccines for covid and the flu.

The trio of vaccines will create more administrative complexity for nursing homes since this year they must bill Medicare to be reimbursed for the shots. The covid vaccine should be charged to Medicare Part B, which covers outpatient and physicians’ services, but the RSV vaccine must be billed to Medicare Part D, the prescription drug benefit.

“The United States has been phenomenal in screwing up vaccinations,” said David Nace, chief medical officer of UPMC Senior Communities in Pittsburgh. “This idea that some are under Part B and some are under Part D and some can be billed by a pharmacy — who in God’s name came up with this?”

While Medicare will pay for vaccines for most nursing home residents, employees may face private insurance red tape and, for a small group, potential out-of-pocket costs.

Leslie Frane, an executive vice president of the Service Employees International Union, which represents more than 134,000 workers in 1,465 nursing homes, said that many homes had stopped running clinics in their facilities and told workers to go to the drugstore to get vaccinated. She said this would lead to more workers skipping their shots.

“There’s very little time, given how many nursing home workers work multiple jobs,” she said.

The CDC has arranged for 25 million to 30 million people lacking health insurance or whose insurance doesn’t cover the complete cost of the vaccine to get free covid shots at select pharmacies, health centers, and medical offices listed at vaccines.gov. Frane said that program is not well known among workers, and Worz said distribution is favoring the large pharmacy chains, slowing access in rural communities. Of the nation’s 19,400 independent pharmacies, federal officials said 627, many in rural areas, are enrolled in the program and 100 are being added.

A big obstacle, though, continues to be resistance to the vaccination among nurses and aides. Like many facility owners, Avalon Health Care Group, which owns or operates more than a dozen nursing homes in Western states, is not mandating staff be vaccinated. Sabine von Preyss-Friedman, Avalon’s chief medical officer, said she tries to address the reasons with each worker and won’t abandon the push.

“We’re not going to just say, ‘OK, everyone get vaccinated’ and then forget about it,” she said.

Avalon’s homes have used modest financial incentives, such as organizing contests between different units, with the winner getting prizes like a pizza party or a drawing for a gift certificate from a department store, and those efforts will resume this year.

Jim Wright, medical director of Our Lady of Hope Health Center and two other nursing homes in Richmond, Virginia, said that rewards and respectful persuasion were not enough to sway his homes’ employees. They tend to be in their 20s and 30s and are not worried about catching covid, which many of them have already weathered.

“They most likely will not do it to protect the residents or protect themselves,” he said. “I don’t know what the answer is.”

Sheena Bumpas, a certified nursing assistant in Duncan, Oklahoma, and vice chair of the National Association of Health Care Assistants, plans on getting this season’s shot but said some of her colleagues won’t.

“Now that the public health emergency has ended, I think people are done with it,” she said.

Edenwald Senior Living, a nursing home within a retirement community in Towson, Maryland, is requiring its workers to be vaccinated unless they can justify an exemption for medical or religious reasons.

As of Sept. 10, about three-fourths of the home’s workers were up to date with their previous covid vaccines, which is triple the national rate for nursing home employees, according to federal records.

Edenwald is relying on the Giant supermarket pharmacy to administer the shots in the auditorium of its independent living section. Sign-up sheets have already been distributed for clinics later this month. The home is billing workers’ insurance for the shots, but facility managers said it will pay for employers without health coverage.

“This is our seventh clinic for covid,” said Meghan Curtis, Edenwald’s director of care management. “We’ve kind of got it down pat.”

Swati Gaur, medical director of three nursing homes affiliated with Northeast Georgia Health System, said leaders may offer recalcitrant employees the option to take the Novavax vaccine. It relies on more traditional virus-blocking technology than the Moderna or Pfizer shots that use messenger RNA.

“We are basically saying, ‘Why are you not taking the vaccine? Have you thought about Novavax? It’s manufactured like the flu vaccine,’” Gaur said.

For the first time, nursing home residents will be offered a vaccine for respiratory syncytial virus, or RSV. The virus causes the hospitalizations of as many as 160,000 people 65 and older each year, killing up to 10,000. Most nursing homes are coupling the flu vaccine with either the covid vaccine or the RSV vaccine, but not attempting to give all three simultaneously.

Gaur said because of the novelty of the vaccine and the relative unfamiliarity with RSV, clinicians will need to spend more time explaining the reason for the shots.

In Dallas Center, Iowa, Spurgeon Manor, an independent nonprofit home, is partnering with the pharmacy from a nearby Hy-Vee grocery store to provide the covid shot, most likely in early October, to 85 residents of the nursing home and an adjoining assisted living center as well as employees.

Alana Marean, Spurgeon’s assistant director of nursing, said workers will be encouraged to receive the shots, but she guessed that not even half would do so. “There’s a lot of stigma out there about it,” she said.

Resident Lee Giese, 95, a retired truck driver, said he’s looking forward to the latest shot after coming down with covid last winter. He suspects his earlier vaccinations helped protect him from more serious symptoms.

He expects most residents of his facility will get the shots, but a few will refuse. “Some people have a death wish,” he said.

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

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For the first time since 2019, congressional gridlock is poised to at least temporarily shut down big parts of the federal government — including many health programs.

If it happens, some government functions would stop completely and some in part, while others wouldn’t be immediately affected — including Medicare, Medicaid, and health plans sold under the Affordable Care Act. But a shutdown could complicate the lives of everyone who interacts with any federal health program, as well as the people who work at the agencies administering them.

Here are five things to know about the potential impact to health programs:

1. Not all federal health spending is the same.

“Mandatory” spending programs, like Medicare, have permanent funding and don’t need Congress to act periodically to keep them running. But the Department of Health and Human Services is full of “discretionary” programs — including at the National Institutes of Health, Centers for Disease Control and Prevention, community health centers, and HIV/AIDS initiatives — that must be specifically funded by Congress through annual appropriations bills.

The appropriations bills (there are 12 of them, each covering various departments and agencies) are supposed to be passed by both chambers of Congress and signed by the president before the start of the federal fiscal year, Oct. 1. This almost never happens. In fact, according to the Pew Research Center, Congress has passed all the appropriations bills in time for the start of the fiscal year only four times since the modern budget process was adopted in the 1970s; the last time was in 1997.

Congress usually keeps the lights on for the government by passing short-term funding bills, known as “continuing resolutions,” or CRs, until lawmakers can resolve their differences on longer-term spending.

This year, however, a handful of conservative Republicans in the House have said they won’t vote for any CR, in an attempt to force deeper spending cuts than those agreed to this spring in a bipartisan bill to raise the nation’s borrowing authority. House Speaker Kevin McCarthy and his allies could join with Democrats to keep the government running, but that would almost certainly cost McCarthy his speakership. Several of the rebellious conservatives are already threatening to force a vote to oust him.

2. The Biden administration decides what stays open.

The White House Office of Management and Budget is responsible for drawing up contingency plans in case of a government shutdown and publishes one for each federal department. The plan for Health and Human Services estimates that 42% of its staff would be furloughed in a shutdown and 58% retained.

The general rule is that two types of activities may continue absent annual spending authority from Congress. One is activities needed “for safety of human life or the protection of property.” At HHS, that would include caring for patients at the hospital on the campus of the National Institutes of Health — though new patients generally would not be admitted — as well as the agency’s laboratory animals, and CDC investigations of disease outbreaks.

Other activities that may continue are those with funding sources that aren’t dependent on annual appropriations. Medicare and Social Security, for example, are entitlements funded by taxes and premiums. Drug approvals at the FDA are largely funded by user fees paid by drugmakers, so approvals in process could continue, but questions remain about whether new approval processes could start.

Also unaffected are programs that have been funded in advance by Congress. For example, the Indian Health Service is already funded through the 2024 fiscal year.

3. What happens to enrollment in Medicare and Affordable Care Act plans?

It depends on how long the shutdown lasts. In the short term, mandatory spending programs would be mostly, but not completely, unaffected by a government shutdown. Benefits would continue under programs like Medicare, Medicaid, and the Affordable Care Act, and doctors and hospitals could continue to submit bills and get paid. But federal staffers not considered “essential” would be furloughed.

That means initial Medicare enrollment could be temporarily stopped. According to the Committee for a Responsible Federal Budget, an independent group that tracks federal spending, during the 1995-96 federal shutdown, “more than 10,000 Medicare applicants were temporarily turned away every day of the shutdown.”

A shutdown shouldn’t much affect Medicare’s annual open enrollment period, which starts Oct. 15 and allows current beneficiaries to join or change private Medicare Advantage or prescription drug plans. That’s because much of the funding to help seniors and other beneficiaries choose or change Medicare health plans has already been allocated.

Rebecca Kinney, who runs the HHS office that oversees the federal program that counsels Medicare beneficiaries about their myriad choices, said Sept. 22 that funding for both the 1-800-MEDICARE hotline and federally funded state counseling agencies has already been distributed for this year, so neither would be affected, at least in the short run.

The same is true for Affordable Care Act plans, which open for enrollment Nov. 1. The HHS contingency documents say the Centers for Medicare & Medicaid Services, which oversees the federal health exchange, healthcare.gov, “will continue Federal Exchange activities, such as eligibility verification,” using fees paid by insurers left over from the previous year.

Still, about half of CMS staffers would be furloughed in a shutdown. That could complicate a lot of other activities there, starting with drug price negotiations set to begin Oct. 1. HHS Secretary Xavier Becerra told reporters at the White House last week that a shutdown would likely push back the timeline for negotiations.

A shutdown would also threaten HHS oversight of the Medicaid “unwinding” process, as states reevaluate the eligibility of those enrolled in the program for low-income people. State workers would be unaffected, according to the Georgetown University Center for Children and Families, so eligibility reviews would continue regardless. But because of federal furloughs, “technical assistance to help states address unwinding problems and adopt mitigation strategies could cease,” wrote the center’s Kelly Whitener and Edwin Park. “Efforts to determine if there are further renewal processes that are out of compliance with federal requirements could be limited or ended.”

4. What if the shutdown is prolonged?

More programs could be affected. For example, the HHS shutdown contingency document says that “CMS will have sufficient funding for Medicaid to fund the first quarter” of fiscal year 2024. The government has never been shut down long enough to know what would happen after that. The 2013 shutdown, which included HHS, lasted just over two weeks. Most of the agency wasn’t affected by the 2018-19 shutdown because its annual appropriations bill had already been signed into law. (The FDA is funded under the appropriations bill that covers the Agriculture Department rather than the one that funds HHS.)

5. Do federal employees get paid during a shutdown?

It depends. Employees whose programs are funded continue to work and be paid. Those considered “essential” but whose programs are not funded would continue to work, but they wouldn’t get paid until after the shutdown ends. A 2019 law now requires federal workers to get back pay when funding resumes, which was not always the case. However, federal contractors, including those who work in food service or maintenance jobs, have no such guarantee.

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