trumpcare – R&R – Reachout and Rebuild

Is the healthcare “free market” working for you?

David Posnett — Thu, 14 May 2020 03:01:02 +0000

Journalist Jon Walker published a new piece for The American Prospect titled, “A Guide to the Nightmare of Getting Health Insurance in a Pandemic,” which detailed the absurdity of the U.S. system.

Walker paints a picture of a healthcare system that is perhaps “not working” for those who need it most:

No Surprise

David Posnett — Sat, 18 Apr 2020 17:49:31 +0000

From Southampton Press: No Surprise

For those of us inclined to pay close attention to the Trump administration, this aspect in particular stands out: the undoing of all varieties of federal regulation. Environmental, banking, consumer and health regulations have been targeted for extinction or reduction. In the words of former Trump advisor Steve Bannon, “Our job is the deconstruction of the administrative state.”

Deconstructing important parts of the “administrative state” increases the threats to our health and safety, with loss of life an all-too-common outcome.

Shortly after President Trump was inaugurated, he issued an executive order directing federal agencies to use their administrative powers to begin dismantling the Affordable Care Act “to the maximum extent permitted by law.”

Last July, the federal Centers for Medicare and Medicaid Services, or CMS, proposed a reversal of Obama-era rules that aimed to protect nursing home patients by requiring all nursing home facilities to hire at least one full-time specialist in infection control. Seema Verma, the CMS administrator and a presence at President Trump’s daily coronavirus briefings, expressed concern about not “micromanaging the process.”

It should come as no surprise to learn that a nursing home lobbying group has contributed to the Trump campaign (New York Times, “Regulator Intends to Relax Oversight In Nursing Homes,” March 16, 2020).

The first novel coronavirus hotspot in the United States occurred at the Kirkland Life Care Center for the elderly in Washington State. In neighboring New Jersey, COVID-19 is running through St. Joseph’s Senior Home in Woodbridge Township. And, closer to home, Peconic Landing, an elderly community on the North Fork, is experiencing a heartbreaking toll of infected COVID-19 patients.

Is there a direct cause-effect relationship between regulatory rollback and any one positive COVID-19 case? No, but having a full-time infection control specialist knowledgeable about the science of infectious disease and vector control would have established policy and protocol ready to take the most efficacious approach to life-saving measures.

Mike Anthony

Westhampton

Mr. Anthony is a former Southampton Town Democratic Committee chairman — Ed.

COVID-19 is here!

David Posnett — Mon, 09 Mar 2020 20:21:29 +0000

We now have a confirmed case admitted at Southampton Hospital. It is time to reassess. Although there is but a single patient confirmed on the South Fork of Long Island, suspicion is running high. (update 3/11: 6 cases in Suffolk county including one in the retirement home PECONIC LANDING). A local physician tells me that patients with potential COVID-19 symptoms are examined in the parking lot, in their cars, by the physician (wearing protective gear). This is in order to avoid transmission to critical medical staff in the office. Healthcare professionals are a known risk group for contacting COVID-19. But physicians on the South Fork are still struggling to get testing for their patients.

Delays in testing

A few days ago I called the Suffolk County Department of Health to inquire about getting COVID-19 tests done on people that had recently returned from international travel to countries with now well-documented outbreaks. These persons also had flu-like symptoms. The county officials thought this did not meet CDC criteria for testing (no high fever and no acute respiratory distress) and they recommended self-isolation. I know first hand how unreliable self-isolation can be! A recent news report confirmed my suspicions when a Missouri patient’s family broke quarantine to attend a school dance!

The problems seem to have been threefold — the Centers for Disease Control did not move quickly enough to manufacture test kits at scale (either because of lack of funding or political will) nor did it open up testing options to other institutions that could have worked to develop tests — and because of the limited availability of tests, the CDC rationed how many tests were performed. Those issues were compounded by the initial release of faulty tests by the CDC in early February.

As former U.S. Food and Drug Administration official Scott Gottlieb wrote on Twitter in early February, “Since CDC and FDA haven’t authorized public health or hospital labs to run the tests, right now #CDC is the only place that can.

Also, the CDC has somewhat arbitrary criteria (?) for placing countries on the list of places that will increase your risk of having contracted COVID-19. Here is a list of countries with documented cases as a percentage of the population size. Level 3 Travel Health Advisory (CDC) applies only to the top 4 on the list. Note that Bahrain with 5.42 documented cases/100,000 inhabitants does not make the list while China with 5.79 does! Neither does Switzerland with 3.96 cases, where many cases have been tourists from its southern neighbor, Italy.

The above graph comes from a local Swiss Newspaper (NZZ) – test your German skills!

By January there was a test available. It was offered worldwide by Roche, Inc. FOR FREE and to any country in the world! The US declined the offer. Read more about these early missteps here.

The above report is from a Zurich Newspaper: note the date on the sample is Jan 29th 2020.

Note also, patients that took the test were billed about $200 (SFR 180) for labor of administering the test. That was their entire cost.

At the time an astute observer commented: “It’s very difficult to understand that countries like the US didn’t seize the opportunity to get the test for free. Perhaps some US companies wanted to make money by developing their own tests?”

Thermo Fisher Scientific corporation provides the COVID-19 test in the US currently. According to the Associated Press, Donald Trump, has listed investments in Thermo Fisher Scientific Corporation (TMO), which moved jobs out of the U.S. in high profile outsourcing deals. Apparently, Donald Trump stands to profit from medical testing of coronavirus that will now take place in the United States.

The response by the administration

The reason that COVID-19 cases are low in the USA is most likely because it has been difficult to get patients tested.

For instance, a recent CDC conference gave us a glimpse into Trump’s view of the coronavirus as a political rather than health issue. Trump said he would rather have the passengers of the Grand Princess, a cruise ship docked in San Francisco with 21 confirmed cases on board, stay on the ship than move to land — all because doing so would raise the number of total Covid-19 cases in the US:

“I would rather because I like the numbers being where they are,” Trump said. “I don’t need to have the numbers double because of one ship that wasn’t our fault.”

It is unclear how many people have been infected by the virus due simply to a delay in testing, but it has become increasingly clear in recent days that there are Americans infected with the virus across the country. It is naive to think that one can suppress the numbers.

Trump fears the fall out on the economy and indirectly on his political chances in November. But his actions are likely to make things worse for himself.

The coronavirus outbreak has U.S. companies starting to shutter offices and send workers home through layoffs, furloughs or directives to telecommute until health risks from the spreading virus recede. Even if that’s helpful to guard against further spread of the disease, it’s triggering widespread uncertainty and the biggest threat to the labor market since the financial crisis almost a dozen years ago.

The evidence is expected to show up through lost consumer spending.
“If workers can’t work … production and income go down,” Georgetown University economist Harry Holzer said. “That becomes a demand problem if workers lose income and stop spending.” When that happens, “odds of recession can go way up.”

Eleven states, including California, Massachusetts and New York, require employers to offer workers paid leave, as does the District of Columbia. But none of these jurisdictions explicitly guarantee the benefit to healthy workers on leave because a virus outbreak sent everybody home.

Fourteen Democratic senators last week wrote to leaders of the Business Roundtable, the Chamber of Commerce and the National Association of Manufacturers to urge their member companies not to penalize workers for going home during the outbreak.
Paid sick days are particularly rare for low-income workers. Ninety-three percent of workers in the top tenth of the income distribution get paid sick leave, compared with only 30 percent of those in the bottom tenth, according to the Economic Policy Institute, a left-leaning think tank.

Our Healthcare system can not handle a pandemic efficiently

Finally, let’s consider our health care system and how it is ill-suited to handle a pandemic: America’s Health System Will Likely Make the Coronavirus Outbreak Worse
Out-of-network costs, high deductibles, and confusing coverage options may keep people from getting tested or receiving care (Abigail Abrams)

Deductibles, networks, and a complicated insurance bureaucracy—that already make it tough for many Americans to afford medical care under normal conditions will likely make the outbreak worse.

First, people must actually choose to get tested—a potentially expensive prospect for millions of Americans. While the government will cover the cost of testing for Medicaid and Medicare patients, and for tests administered at federal, state and local public health labs, it’s unclear how much patients will be charged for testing at academic or commercial facilities, or whether those facilities must be in patients’ insurance networks. Just recently, a Miami man received a $3,270.75 bill after going to the hospital feeling sick following a work trip to China. (He tested positive for the seasonal flu, so did not have the new coronavirus, and was sent home to recover.)

Those who test positive for COVID-19 possibly face an even more financially harrowing path forward. Seeking out appropriate medical care or submitting to quarantines—critical in preventing the virus from spreading further—both come with potentially astronomical price tags in the U.S. Last month, a Pennsylvania man received $3,918 in bills after being released from a mandatory U.S. government quarantine after he and his daughter were evacuated from China. (Both the Miami and Pennsylvania patients saw their bills decrease after journalists reported on them, but they still owe thousands.)

In 2019, 82% of workers with health insurance through their employer had an annual deductible, up from 63% a decade ago, according to a report from the Kaiser Family Foundation. The average deductible for a single person with employer insurance has increased from $533 in 2009 to $1,396 last year. The timing of the new coronavirus at the beginning of the year makes the outlook even worse: because most deductibles reset each January, millions of Americans will be paying thousands out of pocket before their insurance companies pay a cent.

Many patients may simply decide not to go to the doctor, which is “exactly the opposite of what we want to happen in this type of situation.”

Public health experts and Democrats have also criticized the Trump administration’s decision to allow people to sidestep the Affordable Care Act’s rules and buy limited, short-term health insurance coverage. Such “junk plans,” are not required to cover diagnostic tests or vaccines.

A large group of health, law and other experts released a letter this week urging policymakers to “ensure comprehensive and affordable access to testing, including for the uninsured.”

The Trump Administration is considering using a national disaster recovery program to reimburse hospitals and doctors for treating uninsured COVID-19 patients. And even Republicans, who have traditionally opposed health care paid for by the government, are warming to the idea. “You can look at it as socialized medicine,” Florida Rep. Ted Yoho, who has vocally opposed the Affordable Care Act, told HuffPost this week. “But in the face of an outbreak, a pandemic, what’s your options?”

Medical Debt Collectors Decide Who Gets Arrested

David Posnett — Thu, 24 Oct 2019 01:54:45 +0000

From ProPublica comes a shocking story. While things aren’t quite as bad where I live, I think the story is telling about what to expect in the future unless we somehow reform our healthcare system. (D. Posnett)

Ambulance > Judge > Jail

Welcome to Coffeyville, Kansas, where the judge has no law degree, debt collectors get a cut of the bail and Americans are watching their lives — and liberty — disappear in the pursuit of medical debt collection.

On the last Tuesday of July, Tres Biggs stepped into the courthouse in Coffeyville, Kansas, for medical debt collection day, a monthly ritual in this quiet city of 9,000, just over the Oklahoma border. He was one of 90 people who had been summoned, sued by the local hospital, or doctors, or an ambulance service over unpaid bills. Some wore eye patches and bandages; others limped to their seats by the wood-paneled walls. Biggs, who is 41, had to take a day off from work to be there. He knew from experience that if he didn’t show up, he could be put in jail.

…

Biggs, who is tall and broad-shouldered, with sun-scorched skin and bright hazel eyes, looked up as defendants talked, but he was embarrassed to say much. His court dates had begun after his son developed leukemia, and they’d picked up when his wife started having seizures. He, too, had been arrested because of medical debt. It had happened more than once.

Judge David Casement entered the courtroom, a black robe swaying over his cowboy boots and silversmithed belt buckle. He is a cattle rancher who was appointed a magistrate judge, though he’d never taken a course in law. Judges don’t need a law degree in Kansas, or many other states, to preside over cases like these. Casement asked the defendants to take an oath and confirmed that the newcomers confessed to their debt. A key purpose of the hearing, though, was for patients to face debt collectors. “They want to talk to you about trying to set up a payment plan, and after you talk with them, you are free to go,” he told the debtors. Then, he left the room.

The first collector of the day was also the most notorious: Michael Hassenplug, a private attorney representing doctors and ambulance services. Every three months, Hassenplug called the same nonpaying defendants to court to list what they earned and what they owned — to testify, quite often, to their poverty. It gave him a sense of his options: to set up a payment plan, to garnish wages or bank accounts, to put a lien on a property. It was called a “debtor’s exam.”

If a debtor missed an exam, the judge typically issued a citation of contempt, a charge for disobeying an order of the court, which in this case was to appear. If the debtor missed a hearing on contempt, Hassenplug would ask the judge for a bench warrant. As long as the defendant had been properly served, the judge’s answer was always yes. In practice, this system has made Hassenplug and other collectors the real arbiters of who gets arrested and who is shown mercy. If debtors can post bail, the judge almost always applies the money to the debt. Hassenplug, like any collector working on commission, gets a cut of the cash he brings in.

Across the country, thousands of people are jailed each year for failing to appear in court for unpaid bills, in arrangements set up much like this one. The practice spread in the wake of the recession as collectors found judges willing to use their broad powers of contempt to wield the threat of arrest. Judges have issued warrants for people who owe money to landlords and payday lenders, who never paid off furniture, or day care fees, or federal student loans. Some debtors who have been arrested owed as little as $28.

More than half of the debt in collections stems from medical care, which, unlike most other debt, is often taken on without a choice or an understanding of the costs. Since the Affordable Care Act of 2010, prices for medical services have ballooned; insurers have nearly tripled deductibles — the amount a person pays before their coverage kicks in — and raised premiums and copays, as well. As a result, tens of millions of people without adequate coverage are expected to pay larger portions of their rising bills.

The sickest patients are often the most indebted, and they’re not exempt from arrest. In Indiana, a cancer patient was hauled away from home in her pajamas in front of her three children; too weak to climb the stairs to the women’s area of the jail, she spent the night in a men’s mental health unit where an inmate smeared feces on the wall. In Utah, a man who had ignored orders to appear over an unpaid ambulance bill told friends he would rather die than go to jail; the day he was arrested, he snuck poison into the cell and ended his life.

In jurisdictions with lax laws and willing judges, jail is the logical endpoint of a system that has automated the steps from high bills to debt to court, and that has given collectors power that is often unchecked. I spent several weeks this summer in Coffeyville, reviewing court files, talking to dozens of patients and interviewing those who had sued them. Though the district does not track how many of these cases end in arrest, I found more than 30 warrants issued against medical debt defendants. At least 11 people were jailed in the past year alone.

With hardly any oversight, even by the presiding judge, collection attorneys have turned this courtroom into a government-sanctioned shakedown of the uninsured and underinsured, where the leverage is the debtors’ liberty.

Seated at the front of the courtroom, Hassenplug zipped open his leather binder and uncapped his fountain pen. He is stout, with a pinkish nose and a helmet of salt and pepper hair. His opening case this Tuesday involved 28-year-old Kenneth Maggard, who owed more than $2,000, including interest and court fees, for a 40-mile ambulance ride last year. Maggard had downed most of a bottle of Purple Power Industrial Strength Cleaner, along with some 3M Super Duty Rubbing Compound, “to end it all.” His sister had called 911.

Maggard took his seat. He had cropped red hair, pouchy cheeks and mud-caked sneakers. “The welfare patients are the most demanding, difficult patients on God’s earth,” Hassenplug told me, with Maggard listening, before launching into his interrogation: Are you working? No. Are you on disability? He was diagnosed with schizoaffective disorder, bipolar type, and anxiety. Do you have a car? No. Anyone owe you money you can collect? I wish.

They had been here before, and they both knew Maggard’s disability checks were protected from collections. Hassenplug set down his pen. “Between you and me,” he asked, “you’re never going to pay this bill, are you?”

“No, never,” Maggard said. “If I had the money, I’d pay it.”

Hassenplug replied, “Well, this will end when one of us dies.”

Though debt collection filings are soaring in parts of America, Hassenplug speaks with pride about how he discovered their full potential in Coffeyville long before. A transplant from Kansas City, he was a self-dubbed “four-star fuck-up” who worked his way through law school. He moved to Coffeyville to practice in 1980 and soon earned a reputation as a hard ass. He saw that his firm, Becker, Hildreth, Eastman & Gossard, hadn’t capitalized on its collections cases. The lawyers didn’t demand sufficient payments, and they rarely followed up on litigation, he said. Where other attorneys saw petty work, Hassenplug saw opportunity.

Hassenplug started collecting for doctors, dentists and veterinarians, but also banks and lumber yards and cities. He recognized that medical providers weren’t being compensated for their services, and he was maddened by a “welfare mentality,” as he called it, that allowed patients to dodge bills. “Their attitude a lot of times is, ‘I’m a single mom and … I’m disabled and,’ and the ‘and’ means ‘the rules don’t apply to me.’ I think the rules apply to everybody,” he told me.

He logged his cases in a computer to track them. First with the firm and later in his own practice, he took debtors to court, and he won nearly every time; in about 90% of cases nationally, collectors automatically win when defendants don’t appear or contest the case. Hassenplug didn’t need to accept $10 monthly payments; he could ask for more, or, in some cases, even garnish a quarter of a debtor’s wages. His fee was, and often still is, one-third of what he collects. He asked the court to summon defendants, over and over again. It was the judge’s contempt authority that backed him, he said. “It’s the only way you can get them into court.”

The power of contempt was originally the power of kings. Under early English rule, monarchs were considered vicars of God, and disobeying them was equivalent to committing a sin. Over time, that contempt authority spread to English courts, and ultimately to American courts, which use it to encourage compliance with the judicial system. There is no law requiring that a court use civil contempt when an order isn’t followed, but judges in the U.S. can choose to, whether it’s to force a defendant to pay child support, for example, or show up at a hearing. A person jailed for defying a court order is generally released when they comply.

When Casement took the bench in 1987, after passing a self-study exam, he didn’t know much legalese — he had never been in a courtroom. But attorneys taught him early on that the power of contempt was available to him to punish people who ignored his orders. At first, Casement could see himself in the defendants. “I was a much more pro-debtor aligned judge, much more sympathetic, much less inclined to do anything that I thought would burden them,” he told me. “And over the years, I’ve gradually moved to the other side of the fulcrum. I still consider myself very much in the middle, and I don’t know if I am or not.”

Once a bustling industrial hub, Coffeyville has a poverty rate that is double the national average, and its county ranks among the least healthy in Kansas. Its red-bricked downtown is lined with empty storefronts — former department stores, restaurants and shops. Its signature hotel is now used for low-income housing. “The two growth industries in Coffeyville,” Hassenplug likes to say, “are health care and funerals.”

Coffeyville Regional Medical Center is the only hospital within a 40-mile radius, and it reported $1.5 million in uncollectible patient debt in 2017. A nonprofit run in a city-owned building, the hospital accounts for the vast majority of medical debt lawsuits in the county — about 2,000 in the past five years. It also accounts for the majority of related warrants. Account Recovery Specialists Inc. handles its collections, and it does so for hospitals in most Kansas counties. Though the hospitals can direct ARSI and its contracted attorneys to tell judges not to issue warrants, hardly any have. The Coffeyville hospital’s attorney, Doug Bell, said that its only motivation is to continue to serve the area, and that Kansas’ decision to not expand Medicaid under the Affordable Care Act has had a “dramatic effect on the economic liability of small rural hospitals.”

Three nearby hospitals in this rural region have closed in the past several years, meaning ambulances make more trips. A half-hour from Coffeyville, Independence runs its ambulance service at about a $300,000 annual loss. Its bills were at the root of four arrests this year alone. Derek Dustman, who is 36 and works odd jobs, had been driving a four-wheeler when he was hit by a car and rushed to the hospital. Though he was sued for not paying his $818 ambulance bill, he didn’t have a license to drive to the courthouse. This spring, he spent two nights in jail. “I never in a million years thought that this would end with jail time,” he told me.

For years, Hassenplug has requested that the judge issue warrants on the ambulance service’s behalf. When I asked Lacey Lies, the city’s director of finance, if she ever considered telling him not to resort to bench warrants, she was puzzled. “You’re saying an attorney with no teeth?”

The first time Tres Biggs was arrested, in 2008, he was dove hunting in a grove outside Coffeyville. It had been just a year since his 6-year-old son Lane was diagnosed with leukemia, and Biggs watched him breathe in the fresh air, seated on a haybale under an orange sky. When a game warden came through to check hunting permits, Biggs’ friends scattered and hid. He wasn’t the running type, and he took Lane by the hand. The warden ran Biggs’ license. There was a warrant out for his arrest. Biggs asked a friend to take Lane home and crouched into the warden’s truck, scouring his memory for some misstep.

The last few years had been a blur. His wife, Heather, had quit her job as a babysitter to care for their son. Then, she got sick. Some days, she passed out or felt so dizzy she couldn’t leave her bed. Her doctors didn’t know if the attacks were linked to her heart condition, in which blood flowed backward through a valve. To provide for his wife, son and two other kids, Biggs worked two jobs, at a lumber yard and on construction sites. He didn’t know when he would have had time to commit a crime. He’d never been to jail. As he stared out the window at the rolling hills, his face began to sweat. He felt his skin tighten around him and wondered if he would be sick.

The warrant, he learned at the jailhouse, was for failure to appear in court for an unpaid hospital bill. Coffeyville Regional Medical Center had sued him in 2006 for $2,146, after one of Heather’s emergency visits; neither of his jobs offered health insurance. In the shuffle of 70-hour workweeks and Lane’s chemotherapy, he had missed two consecutive court dates. He was fingerprinted, photographed, made to strip and told to brace himself for a tub of delousing liquid. His bail was set at $500 cash; he had about $50 to his name.

His friend bailed him out the next morning, but at the bond hearing, the judge granted the $500, minus court fees, to the hospital. Biggs compensated his friend with a motorboat that a client had given him in exchange for a hunting dog. But it wasn’t long before the family received a new summons. In 2009, a radiologist represented by Hassenplug sued them for $380.

Some court hearings fell on days when Lane had treatment, at a hospital in Tulsa, an hour south. Heather refused to postpone his care. Lane’s condition was improving — in a year, he would be cancer-free — and his dirty blond hair was sprouting again. Her health, though, had taken a turn. She began having weekly seizures, waking up on the floor, confused about where their Christmas tree had gone or why a red Catahoula puppy was skidding around their ranch house. Her doctors concluded she had Lyme disease, which was affecting her nervous system and wiping her short-term memory. Each time she woke up, she repeated: “Don’t take me to the hospital.”

Biggs was still on the hook for the bill that had landed him in jail; bail had covered only part of it, and the rest was growing with 12% annual interest. The hospital had garnished his wages, and the radiologist had garnished his bank account, seizing contributions that his family had raised for Lane’s care. Living on $25,000 a year, Biggs couldn’t afford to buy insurance. His family was on food stamps but didn’t qualify for Medicaid, a federal insurance program for people in poverty. Other states were about to expand it to cover the working poor, but not Kansas, which limited it, for families of his size, to those who earned under $12,000. Like millions of others across America, he and Heather fell into a coverage gap.

By 2012, the Biggs family had accrued more than $70,000 in medical debt, which it owed to Coffeyville Regional Medical Center and other hospitals, pediatricians and neurologists. Some forgave it; others set up lenient payment plans. Coffeyville’s was the only hospital that sued. The doctors who took them to court were represented by Hassenplug.

Biggs began to panic around police, haunted by the fear that at any moment, he might be locked up. That spring, outside the Woodshed gas station, he spotted a sheriff’s deputy who was also an old friend. To shake off his dread, he asked the friend to run his license. The deputy found another warrant, signed by Casement, involving the $380 radiologist’s bill. “You’re not really going to take me in, right?” Biggs remembers asking. The deputy said he had no choice. Bail, as usual, was set at $500.

The family filed for bankruptcy, a short-term fix that erased their debt but burdened them with legal fees. They lost their home and started renting. Biggs ultimately got a job that offered insurance, as a rancher, covered by Blue Cross Blue Shield. But it required Biggs to pay the first $5,000 before it covered medical expenses. When chest pain hit him as he worked cattle in the heat, and he began vomiting, the only nearby hospital was Coffeyville’s. In 2017, the hospital sued again. It was the family’s sixth lawsuit for medical debt.

Sitting in Casement’s courtroom this July, Biggs calculated that he was losing about $120 by taking time off from work to attend this hearing. “I haven’t received a bill,” he told me, slouched over his turquoise shorts. “The only thing I received was this summons.” Around noon, he finally sat down with an ARSI representative, who explained that the underlying bill had been garnished from his wages, but he still owed $328 in interest and court fees. He had another couple thousand dollars in collections for separate bills he hadn’t paid, for which he hadn’t yet been sued. He said the most he could afford to pay, every two weeks, was $12.50.

Before the end of the Tuesday docket, Casement returned to the courtroom to read off the names of the hospital’s defendants. Five had failed to show up for contempt citations, to give their reasons for missing their debtor’s exams. Casement saw that two of the no-shows hadn’t been properly notified of the hearing, so attorneys would need to try to reach them again. The judge read the names of the other three defendants and told the hospital’s collections lawyer, “That would be a bench warrant if you want it.”

The following morning, I was reading court files in the clerks’ office when Christa Strickland arrived at 10:20 in flip-flops and black leggings, her caramel hair wrapped in a bun atop her head. She ran her finger down a docket on the bulletin board and asked why her case wasn’t listed. When the clerk pulled up her file, she told Strickland that her contempt hearing had been on Tuesday and she was one day late. “You need to call the law office of Amber Brehm,” the clerk insisted, referring to ARSI’s contracted lawyer, who represents the hospital. She handed over the phone number.

Strickland sat on a hard bench and took out her cellphone. She had saved the hearing in the wrong day on her calendar, but she had taken the day off from work and wanted to clear up the misunderstanding. “I had a court date,” she said when a man answered at the law office. “I thought it was today but apparently it was yesterday. I’m just needing to see if I can set something up?”

“By not appearing at that, the court would be in the process of issuing a bench warrant,” he said.

“What does that mean?” Strickland asked, shaking her head.

“You don’t know what a bench warrant means?” he asked. “That means you will be arrested and taken to jail and ordered to post bond.”

“Oh my God.” Strickland squeezed her eyes shut, wetness smudging her mascara. She poked at her cheek with her index finger. Her father was a preacher. She’d never been in trouble with the law. She had made a mistake, she tried to explain. She wanted to make an arrangement to pay.

The man on the phone told her that it might take a couple weeks before the court processed her warrant paperwork, which the law office had not yet submitted. Once the judge issued the warrant, she could turn herself in. Strickland wanted to scream, I’ll pay the bill, don’t make me go to jail! but she didn’t have the money. Instead, she looked at the ceiling and asked: “Turn myself into the court? The police station?”

“The Sheriff’s Department,” he responded.

“They’re here in the same building,” she said. “I won’t leave here until I get this figured out. Thank you!”

She hung up. Prick, she muttered to herself. You’re going to talk to me like I’m a freaking idiot? That’s not okay. Educate me. The court has to process it? Her mind kept moving in circles. She herself worked in debt collection, for an auto title lending company. She understood that everyone was doing their job. Still, she couldn’t grasp how this bill had gotten this far.

Before she had taken this position, during her second pregnancy, her right breast had developed a chronic infection. In 2008, she was uninsured, needed surgery to remove the swollen abscess and ran up a $2,514 bill. More than a decade later, she was still chipping away at a balance that, because of interest and court fees, had more than doubled to $5,736. She had fallen behind on her monthly payment plan and now worried that her booking photo would be on Mugshot Monday, a Facebook album run by the Police Department. She imagined what she would tell her boss: I went to jail … because I missed a court date … for medical bills. It sounded absurd.

She spotted a sheriff’s deputy in a bulletproof vest with a name tag that said Bishop and a pistol on his hip. “Hey!” she called out, explaining her phone call and how the man said something about a warrant and turning herself in. Bishop radioed into dispatch and smiled with an update: “There’s no warrant in the system yet,” he told her.

“Yet!” Strickland replied, deflating his look of reassurance. “That’s what I’m worrying about.”

“You better give Amber a call back,” Bishop said.

When I asked ARSI about how attorneys decide to request warrants, Joshua Shea, who is general counsel, told me that they don’t. The judge can choose to issue one if court orders are not followed, he said. But Casement said the opposite, telling me that he gave the choice to the attorneys. “I’m not ordering a bench warrant. My decision is to give them that option,” Casement told me. “Whether they exercise it is up to them, but they have my blessing if that’s what they want to do.”

Shea sent me an eight-page email to make clear, in large part, that ARSI, as a collection agency, has no involvement in the courts, and that Brehm is a lawyer whom the agency contractually employs and who represents the hospital directly. Her email address, though, has an ARSI domain, and her resume lists her as ARSI’s director of legal. Brehm said that court hearings aren’t the only option for debtors, who can call her instead and answer questions under oath. Shea said nobody — not the hospital, ARSI, Brehm or the court — uses the threat of jail to “extract payment.”

Strickland reached Brehm after several days, and the attorney agreed to a new hearing. On Aug. 13, when they met in court, Brehm sat at the front of the room.

“We’re giving you a second chance on that citation; just to try to take care of this without there having to be any sort of bench warrant,” the lawyer said. “I want to make sure that we’re all on the same page about the consequences of not coming into court when the order has been issued.”

Strickland nodded.

“Again, if you set a payment plan and keep it,” Brehm said, “we won’t have to worry about that.”

In some courthouses, like Coffeyville’s, collection attorneys are not only invited to decide when warrants are issued, but they can also shape how law is applied. Recently, Hassenplug came to believe that debtors were only attending every other hearing in a scheme to avoid jail, and he raised his concern with the judge. He suggested that the judge could fix this by charging extra legal fees; Casement wrote a new policy explaining that anyone who missed two debtor’s exam hearings without a good reason would be ordered to pay an extra $50 to cover the plaintiff’s attorney fees. If they didn’t pay, they would be given a two-day jail sentence; for each additional hearing that they missed, they would be charged a higher attorney fee and get a longer sentence.

Most states don’t allow contempt charges to be used for nonpayment, and some, like Indiana and Florida, have concluded that it is unconstitutional. Michael Crowell, a retired law professor at the University of North Carolina and an expert in judicial authority, reviewed Casement’s policy. “You can’t lock people up for contempt for failing to pay unless you have gone to the trouble to determine that they really have the ability to pay,” he said. Casement told me he hadn’t made findings on ability to pay before ordering defendants to foot attorney’s fees, “but I know that’s something the court should consider,” he said. He also made plain why he wrote the policy: “Mr. Hassenplug and Brehm’s outfit have asked me to.” (Brehm denied she requested this.)

Casement has not done everything the debt collection lawyers have suggested. At first, he agreed to their requests to set bail at the amount of the debt, but he eventually settled on $500. “Most people can come up with $500,” he said. “It may not be their money, but they know someone who will pay.” He made sure no one was arrested unless they’d been reached by personal service or certified mail.

Kansas law allows courts to order debtors in “from time to time,” leaving discretion to judges. Casement limited the frequency of Hassenplug’s debtor’s exams to once every three months. He came to the decision by his own logic around what seemed like a reasonable burden for defendants, and it remains his personal policy today. The law also states that anyone found to be disabled and unable to pay can only be ordered to appear once a year. Without an attorney, debtors like Kenneth Maggard don’t know to assert this right.

Allowing bail money to count toward collections raises some of the most critical legal questions. Hassenplug told me that he thinks it’s great that cash bail is applied to the debt. “A lot of times, that’s the only time we get paid, is if they go to jail,” he said. Peter Holland, the former director of the Consumer Protection Clinic at the University of Maryland Law School, explained that this practice reveals that the jailing is not about contempt, but about collection. “Most judges will tell you, ‘I’m working for the rule of law, and if you don’t show up and you were summoned, there have to be consequences,’” he explained. “But the proof is in the pudding: If the judge is upholding the rule of law, he would give the bail money back to you when you appear in court. Instead, he is using his power to take money from you and hand it to the debt collector. It raises constitutional questions.”

Congress has not acted on advocates’ calls to amend the Fair Debt Collection Practices Act to prohibit collectors from requesting warrants. There are also no current efforts to bar nonprofit hospitals or medical providers that receive funds through Medicare or Medicaid from seeking warrants. Some states have reformed their laws, to make sure defendants are properly served or to prohibit wage garnishments for debt. But legal experts on collections say that more remains to be done, like taking jail out of the equation and instead requiring debtors to sign a financial affidavit or a promise to appear.

Shea, from ARSI, said that using the legal process is time-consuming and costly — a last resort; arrests are “the least desirable stage for any case to reach for all involved.” Even after lawsuits are filed, they try to connect eligible debtors with the Coffeyville hospital to apply for financial assistance, he said. Last year, the hospital wrote off $1.7 million in charity care, said Bell, the hospital lawyer. “That is evidence of a hospital that cares.”

Casement said he did not consider the legality of his policies a problem. He placed some blame on the health care system. “What we have isn’t working,” he said. “As a lifelong Republican, I would probably be hung, but I think we need health care for everybody with some limits on what it’s going to cost us.”

The way he saw it, he had wide latitude to enforce compliance with a court order, though he acknowledged that creditors used bail money to their advantage. “I don’t know whether the Legislature intended it to be used that way or not,” he told me. “I have not had enough pushback from the defendants’ side to give me the impression that I’m really abusing this badly.”

Before I left Coffeyville, I sat down with Hassenplug in the low-ceilinged courtroom. I asked him whether he thought that the system in Coffeyville was effectively imprisonment for debt, in a country that has outlawed debtors’ prisons. “The only thing they’re in jail for is not appearing,” he replied. “I do my job, I follow the law. You just have to show up in court.”

Debt collection is an $11 billion industry, involving nearly 8,000 firms across the country. Medical debt makes up almost half of what’s collected each year. Today, millions of debt collection suits are overwhelming state courts. The practice is considered a “race of the diligent,” where every creditor is rushing to the courthouse, hustling to get the first judgment, in order to be the first to collect on a debtor’s assets. In Hassenplug’s view, though, this work is not the rich taking from the poor. He laughed at how locals spread rumors, saying that he seized wheelchairs or Christmas trees. Once, he confessed, he took a man’s Rolex, only to find out it was a fake. Some months, he said, even his law office could not make ends meet.

After a couple of hours, a clerk poked her head into the courtroom and told us it was time to leave. Hassenplug and I began to walk out, and on the terrazzo steps, he asked if I wanted to see his buildings. He owned five of them on a shuttered stretch of town. He wondered out loud if he was making a mistake by inviting me, but he was pleased when I accepted. “There ain’t any place on earth quieter than downtown Coffeyville,” he said, leading me into the silent streets.

He walked me through the alleys under a cloudless sky, and when he arrived at one of his buildings, he tapped a code to his garage. The door lifted, and inside, five perfectly maintained motorcycles, Yamahas and Suzukis, were propped in a line. To their left, nine pristine, candy-colored cars were arranged – a Camaro SS with orange stripes, a Pontiac Trans Am, a vintage Silverado pickup with velvet seats. He toured me around the show cars, peering into their windows, and mused about what his hard work had gotten him.

By Lizzie Presser, Photography by Edmund D. Fountain October 16, 2019. Doris Burke contributed research.

Correction, Oct. 16, 2019: This story originally misstated the type of cancer Tres Biggs’ son, Lane, had. It was leukemia, not lymphoma.

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for ProPublica’s Big Story newsletter to receive stories like this one in your inbox as soon as they are published.

The emphases are mine (D. Posnett)

Medical Billing Obfuscation versus Vaccines

David Posnett — Mon, 07 May 2018 19:30:23 +0000

I am one of those guys who never goes to see a doctor! But in 2016 I became a grandfather. The pediatrician of the newborn child warned the parents that everyone in contact with the child needed to have received a flu shot. Dutifully I got my flu shot at a local clinic staffed by GPs. The bill was $435. As an MD myself, I tried to understand the billing which has dragged on for nearly 1.5 years and wondered whether I could draw some lessons for healthcare consumers in general.

$435: Provider bill for flu shot, Tetanus booster (which I apparently agreed to), and the visit per se (consisting of vital signs and a few questions about allergies and whether I had had adverse reactions to prior immunizations, etc.).

$128: Medicare determines this amount is admissible and the doctors office can’t charge more

$48: Medicare pays this amount.

$80: The remaining amount that Medicare passes on to myself because of a yearly deductible

$45: collected by doctors office from my secondary insurance (Aetna)

Total collected by provider: $173 (37.5% of the bill). Total outstanding that provider will forgo: $262 (62.5%)

Republicans currently in power would have a free-market style healthcare system. Most people, including myself, have no idea how much their medical care or procedure might cost. Therefore we can not make educated decisions on what to buy, as you might do if you were buying a TV or a car. I had heard that flu shots cost about $25 (as advertised in a local CVS store) and I assumed that would be my bill, roughly speaking.

In addition, Obamacare and Medicare/Medicaid are supposed to cover immunizations. The thinking here is sound: if I have the flu and I have to travel to work using the New York subway or a bus, I will likely spread the virus to others. So this becomes a public health problem. This is how epidemics start. The problem has been around since the early days of small pox and polio vaccinations. Remember the massive programs of the 1950s when all school kids received free polio vaccines. Have we simply forgotten?

Just out of curiosity I searched the web. Here are the prices for flu shots at Costco:

Here are the prices for flu shots at CVS:

But there is a HUGE caveat. Prices really differ from store to store! And some people who are unwilling to pay extra fees, charged at some stores, are simply turned away.

You should really read the blog entries and comments on the various sites, like this one for example! Some people report having been charged up to $1000 for a vaccine. Here is one comment from a patient who received a tetanus shot while in the hospital:

Charge for tetanus booster was $820. $215 for vaccine, $165 for administration of vaccine by the nurse, & $440 for the hospital pharmacy to take the vaccine out of their cupboard.

Containing an infectious epidemic is VERY expensive for the government (and for us as a society). Just think of the Ebola outbreak in West Africa (2013-2016).

In addition to the loss of life, the outbreak had a number of significant economic impacts. In March 2015, the United Nations Development Group reported that due to a decrease in trade, closing of borders, flight cancellations, and drop in foreign investment and tourism activity fueled by stigma, the epidemic resulted in vast economic consequences both in the affected areas and throughout Africa. A September 2014 report in the Financial Times suggested that the economic impact of the Ebola outbreak could kill more people than the disease itself.

Here is a visual of the cost of aid from outside the affected countries. There was good reason for spending money: Ebola cases made it on to the US mainland! Containing the virus in West Africa was paramount. Infectious diseases don’t need passports and they don’t care about immigration policies such as those of Donald Trump.

Perhaps it is now clear that prevention of epidemics, including the flu, by vaccine programs is a lot cheaper than trying to contain an epidemic when it is in full swing.

Vaccine programs are the ultimate public health measure and have saved more lives historically than any other medical intervention. Vaccines should be totally free – it is a good investment.

ACA in Reverse!

David Posnett — Thu, 03 May 2018 16:40:24 +0000

About 4 million working-age people have lost insurance coverage since 2016
The uninsured rates among lower-income adults rose from 20.9 percent in 2016 to 25.7 percent in March 2018

Check out the story here!

This is also interesting: Survey shows reversal in ACA coverage gains.

Gains in health insurance coverage made under the Affordable Care Act are beginning to reverse, according to the seventh iteration of The Commonwealth Fund’s ACA Tracking Survey.
According to the survey, the rate of uninsured people between ages 19 to 64 has increased to 15.5% from 12.7% in 2016, with higher rates in states that have not expanded Medicaid. Uninsured rates are higher in southern states.
Commonwealth attributes its findings to the repeal of the individual mandate, the rise of non-ACA-compliant insurance policies and support for Medicaid work requirements.

Continued drops are expected. Commonwealth estimates that 5% of currently-insured adults plan on dropping their insurance coverage because of the individual mandate penalty repeal.
The Trump administration is promoting expanding short-term health plans and association health plans, which supporters say will allow more affordable options for currently uninsured Americans. Several industry organizations and associations have criticized the move, arguing the expansion of short-term plans would undermine consumer protections, lead to higher premiums in the ACA-compliant individual market and jeopardize market stability.
Additionally, the Trump administration’s plans for short-term expansion would primarily impact the middle class, as lower-income people are protected from premium increases through the use of federal subsidies, according to a recent Kaiser Family Foundation report.
Gallup found that the uninsured rate increased in all demographic groups last year except for senior citizens, who are eligible for Medicare.

If you are worried about your healthcare, it is time to vote and boot out Lee Zeldin in Nov. 2018

Out-of-pocket healthcare spending could rise thanks to Lee Zeldin

David Posnett — Wed, 24 Jan 2018 18:02:17 +0000

Implementation of the Affordable Care Act (ACA, Obamacare) was associated with reduced out-of-pocket spending for US medical care, particularly among those with lower incomes, but not with reduced premiums.

That is the conclusion of a new study published in the medical journal JAMA Internal Medicine.

As summed up by Les Masterson on the HealthCare Dive

the ACA led to reduced out-of-pocket spending, especially for low-income Americans. That said, many people still feel the burden of high out-of-pocket costs and premium spending.
medical expenses continue to “consume a large share of many families’ incomes and compound income inequities.”
repealing or reversing gains made by the ACA will “especially harm poor and low-income Americans.” Premiums will likely increase for people in the exchanges if healthier people leave the exchanges.

This affects residents in our Congressional district: NY-01. Rep. Lee Zeldin has consistently voted to undermine the ACA and has supported very unpopular Trumpcare. Republicans also putting Medicare and Medicaid in jeopardy via the recently passed tax bill. Thanks for stealing our money!

Read more about the LZ track record on healthcare:

https://resistancesuffolk.blog/2017/03/18/zeldins-deception-on-health-care/

https://resistancesuffolk.blog/2017/06/30/zeldins-approval-of-senate-healthcare-bill-reveals-his-lack-of-concern-for-veterans/

http://www.1clickdaily.com/1429473

https://resistancesuffolk.blog/2017/09/25/zeldin-must-stand-up-and-protect-long-islands-health-care/

https://resistancesuffolk.blog/2017/05/21/is-zeldin-untruthful-about-healthcare/

and Zeldin complicit in CHIP used as bargaining chip:

Why are Drug Prices Going Through the Roof?

David Posnett — Fri, 01 Dec 2017 01:51:41 +0000

By Francesca Rheannon, Journalist

Writer’s Voice with Francesca Rheannon, Producer and Host

Twitter Accounts: @WritersVoice

On Facebook & LinkedIn

http://www.writersvoice.net/2017/11/wendell-potter-gerald-friedman/

Why are drug prices going through the roof? We talk with Wendell Potter about Big Pharma and what his new investigative journalism site, Tarbell, is finding out about it.

Critics say single payer health insurance would be too expensive. We talk with economist Gerald Friedman, who developed Bernie Sanders’ Medicare for All plan. He answers his critics point by point.

Wendell Potter

Are Americans getting swindled at the pharmacy? We pay an average of 300% more for medications than people in other major countries. And the costs just keep going up.

And of course, it’s not just drugs. We pay far more for all aspects of health care — insurance, doctors and hospital fees, tests and drugs — than other nations. But we aren’t getting our money’s worth.

Wendell Potter is a former health insurance industry executive turned whistleblower. We spoke with him several years ago about his book DEADLY SPIN, about how the health insurance industry skews the playing field in its favor, making sure to kill efforts at reform while getting laws passed that fatten its bottom line. His book NATION ON THE TAKE showed how corporate America in general does the same thing.

Now Potter has started a nonprofit investigative journalism site, Tarbell, to expose the inner workings of the healthcare industry. Tarbell went online in November with a series of investigative articles by different journalists about the influence of Big Pharma over our political process. We called up Wendell Potter to learn about the results of those investigations and to find out more about Tarbell itself.

How Big Pharma Keeps Drug Prices High

Gerald Friedman

During the presidential primary season last spring, we spoke with University of Massachusetts economist Gerald Friedman about Bernie Sanders’ Medicare for All plan. Friedman was the architect of that plan.

At the time, some mainstream economists published an op-ed in the New York Times saying the plan was too expensive. Then the Urban Institute came out with a study claiming that the Sanders’ plan would cost an extra $32 trillion. And candidate Hillary Clinton declared that single payer health care would “never, ever happen.”

Since then, Sanders has come out with a Medicare for All Senate bill that has actually garnered the support of sixteen Democratic senators, including some potential presidential hopefuls. Among them are Elizabeth Warren and Cory Booker.

With the GOP continuing its assault on health insurance coverage — the latest being the so-called Tax Reform bill that would collapse Obamacare and take billions out of Medicare — a push for single payer by an outraged electorate might actually gain steam.

So, would single payer really break the bank? We called up Gerald Friedman to ask him to address criticisms of his plan so we could make up our own minds. To listen to the interview on a podcast click on this link http://www.writersvoice.net/2017/11/wendell-potter-gerald-friedman/ and then click on the player to hear both interviews.

Zombie Health Care Repeal Part 5: What the GOP’s Sneaky Health Repeal Means for You

David Posnett — Wed, 15 Nov 2017 17:07:02 +0000

Yet another attempt to sabotage healthcare! They just don’t get it. David

View at Medium.com

The GOP is sneaking in a partisan health care repeal to pay for their tax cuts for the wealthy and big corporations. Here’s what you need to know:

GOP is sneaking in health repeal after failing four times. The American people rejected Republican repeal efforts four times over the course of the year. Now, they’re sneaking health repeal into their big tax cut bill for the wealthy and big corporations.
Sneaky repeal would rip coverage away from 13 million people and raise premiums by double digits. The nonpartisan Congressional Budget Office estimated that 13 million people would lose health coverage and premiums would increase double digits as a result of the health repeal provision Republicans are sneaking into their tax bill.
Key patient groups oppose sneaky repeal. Sixteen patient groups have announced their opposition: March of Dimes; the American Heart Association; the Cystic Fibrosis Foundation; the American Cancer Society Cancer Action Network; the Multiple Sclerosis Society; Lutheran Services in America; the American Lung Association; the American Diabetes Association; the National Health Council; the Epilepsy Foundation; the National Organization for Rare Disorders; the American Liver Foundation; Family Voices; Consumers Union; Little Mended Hearts; and Futures Without Violence.
Key industry stakeholders oppose sneaky repeal. Six health care industry groups have announced their opposition: America’s Health Insurance Plans; the American Academy of Family Physicians; the American Hospital Association; the American Medical Association; the Blue Cross Blue Shield Association; and the Federation of American Hospitals. In the words of CNBC: “Insurers, doctors and hospitals oppose repeal.”
The tax bill would trigger $25 billion in Medicare cuts. The nonpartisan Congressional Budget Office estimates that huge tax cuts for the wealthy and big corporations would trigger $25 billion in cuts to Medicare.
The tax bill raises health costs for middle class families and seniors with high medical expenses. The House Republican tax plan eliminates the medical expense deduction, which helps nearly 9 million people with high medical expenses, such seniors with long-term care, people with chronic health conditions and parents of children with disabilities. Nearly 70 percent of people who claimed this deduction earned $75,000 or less.
All of this is to pay for huge tax cuts for the wealthy and big corporations. Let’s be clear: Republicans are sneaking health repeal into their tax bill so they can pay for their huge tax cuts to the wealthy and big corporations. The Tax Policy Center found nearly half of the tax cuts would benefit the top 1 percent.
Republicans are not listening to the American people. Time and time again the American people have rejected health repeal. First, the GOP health care repeal is the most unpopular legislation in three decades. In last week’s elections, health care was the dominant issue. In the Virginia gubernatorial race, health care was the #1 issue to 39% of voters – more than double any other issue, and among those voters, Ralph Northam beat Ed Gillespie by 54 points (77-23). In New Jersey, 19% of voters ranked health care their top issue, and chose Phil Murphy over Kim Guadagno, who opposed the ACA, by 74 points (86–12). In Maine, voters “easily approved” an expansion of Medicaid by a nearly 60-40 margin. And in the Virginia House of Delegates races, Democrats ran on health care and achieved a historic victory, flipping fifteen seats.

Individual Mandate Repeal in Latest Tax Bill Draft

David Posnett — Wed, 15 Nov 2017 16:30:36 +0000

Author Shannon Muchmore @stmuchmore

Published Nov. 15, 2017

Dive Brief:

Republican leaders said Tuesday the latest version of their bill to overhaul the tax system would repeal the individual mandate in the Affordable Care Act (ACA).
Sen. Orrin Hatch (R-Utah) said he estimates the repeal would save $338 billion that could be used to offset tax cuts elsewhere in the legislation, Politico reported.
The Congressional Budget Office and Joint Taxation Committee earlier issued an analysis that concluded eliminating the individual mandate would result in 14 million people losing coverage by 2025 and premium increases of about 20%.

Dive Insight:

As anyone who has watched Congress debate ACA legislation this year knows, a proposed bill can change frequently during negotiations. The individual mandate repeal could still be tossed before a vote, but several Republicans are still looking for any way to deal a blow to the ACA.

The mandate is an essential part of the law, although it’s an unpopular one. Requiring most people to have insurance helps more young and healthy people to enter the risk pool. This helps payers offset the costs of covering people with pre-existing conditions. A repeal of the mandate would likely lead to more insurance companies choosing to pull out of the ACA exchanges.

Repealing the mandate would add to a string of actions weakening the law. President Donald Trump’s administration has taken a number of steps to undermine the ACA, including putting an end to cost-sharing reduction payments to insurers and paving the way for more catastrophic health plans. HHS has also drastically scaled back efforts to promote the open enrollment period.

Call Lee Zeldin to voice your opinion! (202) 225-3826

There is a Phone-in “townhall” tonight on the topic of taxes!

https://zeldin.house.gov/contact/opt-request-telephone-town-halls