Kaiser Health News
An Arm and a Leg: To Get Health Insurance, This Couple Made a Movie
Dan Weissmann
Thu, 30 Nov 2023 10:00:00 +0000
Last fall, Ellen Haun and Dru Johnston were hustling to get their health insurance sorted out for 2023. The Hollywood couple are members of SAG-AFTRA, the union representing actors and writers. Members have to earn about $26,000 a year on union projects to be eligible for union insurance.
And Haun was about $800 short.
When she couldn’t book the gigs she needed, Haun, with husband Johnston’s help, came up with a plan: to crowdfund enough money to make their own movie starring Haun, called “Ellen Needs Insurance.”
In this episode of “An Arm and a Leg,” host Dan Weissmann speaks with Haun and Johnston about their short film, how they were affected by the 2023 SAG-AFTRA strike, and their ongoing quest to stay insured.
Dan Weissmann
Host and producer of “An Arm and a Leg.” Previously, Dan was a staff reporter for Marketplace and Chicago’s WBEZ. His work also appears on All Things Considered, Marketplace, the BBC, 99 Percent Invisible, and Reveal, from the Center for Investigative Reporting.
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Emily Pisacreta
Producer
Adam Raymonda
Audio wizard
Ellen Weiss
Editor
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Transcript: To Get Health Insurance, This Couple Made a Movie
Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.
Dan: Hey there. OK, here’s something I never expected to say — I’ve got a funny, kind of sweet story about health insurance. OK, maybe sweet and sour. Here it is …
As we record this, it’s November, which means it’s open enrollment for lots of people — time to get next year’s health insurance figured out, both on the Obamacare exchanges and at lots of workplaces. A year ago, Ellen Haun and her husband Dru Johnston were HUSTLING to get their health insurance set up for 2023. In the most creative possible way … by crowdfunding a creative project. They posted a video of course.
Ellen: Hi, I’m Ellen, and I need health insurance.
Dru: And I’m Dru, and I also need health insurance.
Dan: Ellen and Dru work in Hollywood — acting and writing — and folks in that industry get their insurance through the unions. But only if they’ve racked up enough wages for union work over a 12-month period. They’d been on Ellen’s insurance through the actors’ union, SAG. But last fall, as they explained in their crowdfunding video, that union insurance wasn’t looking like a sure thing for the coming year.
Dru: Right now, Ellen is $804 short. So we’re making a short film.
Ellen: And that short film is called “Ellen Needs Insurance.”
Dan: The video outlined their plan: to employ not just Ellen but other actors who also needed a little help getting over the finish line to qualify.
Dru: Also, which brings up the next point, are you an actor that’s close to hitting your health insurance? Then please get in touch.
Ellen: Yes, we want to cast you. We want you to have insurance.
Dru: And if we raise more money than our goal, we will use all of that only
towards casting more actors and getting them insurance.
Ellen: We’ll add parts. We don’t care.
Dru: Yeah, this isn’t Shakespeare. This is a script we wrote. We’ll add parts.
Ellen: We can … We’ll make them up.
Dan: That was a year ago. And spoiler: They did make the film. Of course now they need insurance for 2024. And Ellen’s union spent a lot of 2023 on strike, which has narrowed down the opportunities to earn that insurance again. So… I wanted to talk with them!
[“An Arm and a Leg” theme music plays.]
This is “An Arm and a Leg” — a show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann. I’m a reporter, and I like a challenge.
So the job we’ve picked here is to take one of the most enraging, terrifying, depressing parts of American life, and bring you something entertaining, empowering and useful.
[“An Arm and a Leg” theme music ends.]
Ellen and Dru met at a wedding.
Ellen: I was friends with the bride and Drew was friends with the groom. And at the bachelorette party, Emily had been, like, talking about all the single guys that were going to be at the wedding, but she had forgot to include Dru on that list. So I was like, just, I was like, why is this guy talking to me so much? He’s probably got a girlfriend somewhere.
Dru: Turns out I didn’t. And then, uh, we ended up, uh, starting to date almost immediately after that wedding.
Dan: By then, Ellen was earning enough as an actor to qualify for health insurance, starting with an ad for Xfinity Internet and a recurring role as a law student on “How to Get Away with Murder.”
Viola Davis: Ms. Chapin, can you tell us what the Fifth Amendment is?
Ellen: The Fifth Amendment? Um, right.
It, um, assures your right to protection from self incrimination.
Viola Davis: Are you asking me?
Ellen: No, that’s my answer.
Viola Davis: And it’s a correct one.
Dan: Getting that insurance was a big professional milestone. More than 85 percent of SAG members do not book enough union work to qualify– it takes about 26 thousand dollars across a one-year period. (And, you know, of course most actors, Ellen included, pick up other work on the side, or even hold down a day job.) For most of the last few years, Ellen had no worries about making enough money to qualify for insurance. She’d been getting paid for a commercial that ran and ran, because it was so terrific. You may have seen it. Even I have seen it … and I kinda never watch TV. Ellen plays BOTH parts in it. She’s call center employee
Claire in Phoenix: This is Claire in Phoenix, can I help you?
Dan: And she’s a woman who’s dialed in for customer support.
Ellen as customer: Yes.
Claire in Phoenix: Great.
Ellen as customer: Correct.
Claire in Phoenix: Ma’am. This isn’t an automated computer.
Ellen as customer: Operator?
Claire in Phoenix: Ma’am? I’m here. I’m live.
Ellen as customer: Wait, you’re real?
Claire in Phoenix: Yeah! With Discover Card, you can talk to a real person.
Dan: Ellen had been getting a “holding fee” — to keep her from auditioning for commercials for competitors.
Ellen: And I kind of knew in the back of my mind that like, okay, eventually this holding fee is going to go away because this commercial isn’t running anymore.
Dan: And then last June, she got the call.
Ellen: My agent was like, Hey, they’re releasing you from the holds. Uh, you’re not getting that payment. You, um, you’re free to audition for other commercials.
And I was like, okay, but what about that health insurance?
Dan: This was in June. She needed to make another 6 thousand dollars, by the end of December, to keep her insurance.
Ellen: And I thought, okay, I’ve got half the year. Like that’s just booking like one other commercial.
Dan: But that wasn’t a sure thing. She’d done it for years and years, but she wanted to hedge her bets. She experimented with working as an extra.
Ellen: And I was getting like, pretty consistent work, but also background work does not pay very well.
Dan: $187 a day. More if there’s overtime, but still. It’s not that it’s not that much, especially if you’re trying to chip away at like a 6,000 balance.
I was like, I don’t know if I’m going to make this, um, I knew that it was definitely going to be down to the wire. So that’s when I was like, you know what, maybe we should think about making a movie about this.
Dan: Actually, this was an idea that had kind of been on Dru’s shelf for a few years. As a comedy writer for a TV talk show, Dru had gotten his insurance from the screenwriter’s union, the WGA. And then in 2018 the show got canceled. Lucky for Drew, he was married to Ellen by then, so they put him on her SAG insurance. And then after that saga had ended, he had a fun idea.
Dru: I was like, oh, you know what I should have done is I should have just made a web series called, “Dru Needs Insurance.” And then I was like, well, it’s too late. I guess that’s an idea that I’m never going to have to do. And then flash forward.
Dan: They’re in the same boat! all over again.
Except now, it’s Ellen who’s short, and nothing to fall back on. I asked if they remembered the day when they decided to try making the film. Dru was like, …
Dru: It was in the OBGYN’s office.
Dan: Yeah. They were pregnant! This was the first doctor visit.
Dru: We had gone to the ultrasound. We saw the baby. We heard the heartbeat. We were like, well, that we were having the baby. It’s coming.
Dan: Now they were gonna see the doctor, talk about next steps.
Dru: And we had about 20 minutes in that waiting room, just sitting there kind of going like, okay, our life’s gonna change.
We got to make some, some choices, or we got to, like, figure out, like, what room are we going to use? All that stuff. But also in the middle of that, we were like, oh, also our health insurance is going … is set to run out.
Dan: Actually, it was going to run out exactly one month before the baby’s due date.
Dru: And I was like, well, shit, we need that health insurance. Um, and, and that’s when Ellen said, I think I need to make a movie and we need to do that.
Dan: So they did! They banged out a script — and brought a friend’s production company on board. (The union doesn’t let you just pay yourself directly.) Which brings us to the point in the story when they made that crowdfunding video
[Bouncy music plays in the background.]
Dru: It’s a comedy about an actress named Ellen, and the things she does to get insurance.
Ellen: Things like begging my agent for a job, praying to the gods for a surprise residual check, and even background work.
Also, the movie’s just about how hard it is to navigate insurance in this country.
[Bouncy music ends.
Dan: How’d it come out? That’s next.
This episode of “An Arm and a Leg” is produced in partnership with KFF Health News. That’s a nonprofit newsroom covering health care in America. Their journalism is terrific– wins all kinds of awards every year– and I’m honored to work with them.
Dan: So, Ellen and Dru did raise the money: more than 33 thousand dollars. They actually did beat their goal. The movie is delightfully meta. It starts with Ellen-the-character in her kitchen in the middle of a conversation with her best friend …
Best Friend: Why can’t you just pay the difference?
Ellen: Oh yeah, I tried. But I called and they told me that’s not allowed.
Best Friend: I thought that was the whole thing about health insurance in this country. You have to pay for it.
Ellen: Apparently, not when you want to. If I want to keep my health insurance, I have to book another SAG job by the end of the year.
Best Friend: Couldn’t you cast yourself in something?
Ellen: Like in what, my own movie? Yeah. I mean, I’d have to get funding,
write a script, hire a production team, get a payroll company, …
Dan: So just like the real Ellen did, movie-Ellen decides to go all out to book another commercial. And if you ever thought it might be fun to take a crack at a career in acting, the audition scene — with Ellen and a casting director — that might dissuade you.
Casting director: Alright, we’ll start on action and, uh, remember, this determines whether or not you can see a doctor in the next year.
Dan: Soon, we see Ellen looking up COBRA — which you may have looked up yourself, like if you ever left a job without your next gig — and your next insurance — lined up.
COBRA pitch: Losing your health insurance?
Don’t worry. It happens all the time. Cobra is here for you. …
Dan: And if you’ve looked at it, you know: COBRA is EXPENSIVE. Like, average employer coverage for a family costs more than 20 thousand dollars a year. So that’s the price range for COBRA.
COBRA pitch: The fact that it’s named after a deadly and venomous snake is just part of the fun, and has nothing to do with the fact that it feels like death. You made less money, and now you have to pay more.
Dan: On her agent’s advice, Ellen tries background work, another case of art imitating life. And, in a scene that really highlights some of the peculiarities about how all of this works, she debriefs with her friend, over drinks at a bar.
Best Friend: How is it?
Ellen: It’s not as bad as I thought, but it does not pay very well. You get a
lot more if you have a line.
Dan: And suddenly, another patron in the bar leans into the conversation… Bar patron: Excuse me, did you say you get more money if you have a line?
Ellen: Yeah.
Bar patron: Got it.
Dan: And another patron. Bar patron: Just one line?
Ellen: Yeah.
You get more if you have more than five lines, too.
Bar patron: Wow. Wow.
Dan:Now it’s everybody in the bar.
Bar patrons: Wow. Wow. Wow. Wow. Wow. Wow. Wow. Wow. Wow. Wow.
Dan: The bit about a pay bump is real, of course. Including the bump for more-than-five-lines. And just to expand on that for a minute here – Dru experienced the downside of that rule — ridiculously, painfully — when he did a one-shot appearance on Orange Is the New Black. It was a big meaty scene, but somehow wasn’t more than five lines.
Dru: I was a lawyer and every line was about a half of a page of just legalese
Dru as Lawyer: based on copious witness testimony, the U. S. attorney has charged you and four others
[DUCKS UNDER: with inciting the riot. They allege that you created and maintained a secret riot bunker, and there’s also evidence that directly implicates you in the kidnapping and false imprisonment of Officer Desmond Piscatella…]
Dan: But that’s how a “line” gets defined in this situation: As long as nobody interrupts you, a monologue is just one line. A role with five lines or less gets called an “under-five”
Dru: And I was like, this is an under five? I was like, okay, well, there we go. I’ll just lecture for two pages.
Dru as Lawyer: I’ve negotiated a plea deal for you. If you admit to the riot charges, they’re willing to drop everything else. This is very good.
Dan: We have still not gotten to the end of Dru’s first line in this scene Dru as Lawyer: It’ll garner you the shortest possible sentence.
Dru as Lawyer: Do you understand?
Dan: Back in the film, the Ellen character is still freaking out when she shows up for a doctor’s appointment.
Dr Receptionist: Has your insurance changed?
Ellen: No, but it might soon, so I wanted to make sure that you all would still take it.
Dr. Receptionist: Well, we take most insurances, so I’m sure we’ll be fine.
Ellen: Great. Um, I was looking on the California Insurance Exchange. Dr Receptionist: Uh, no.
Ellen: Excuse me?
Dr. Receptionist: No, we, we don’t take that.
Dan: And in the doctor’s office– in another echo of Ellen and Dru’s story– Ellen-the-character gets an ultrasound.
Ellen: Congratulations.
Dan: And she flashes back to the first scene, with her friend…
Best Friend: Couldn’t you cast yourself in something?
Ellen: Like in what? My own movie? (echos) My own movie?
Dan: And of course, that’s where she decides. She’s gonna do this. On her way out, she tells the receptionist…
Ellen: My insurance is not going to change. You can count on it.
Dr. Receptionist: Um, okay.
Dan: When I saw the movie, I did not know that Ellen Haun had been pregnant when they made it.
Dru: We never brought it up in crowdfunding. But then when we were making the movie, we were like, let’s just use real life. Not only was it real, it felt like the easiest way to explain it.
Dan: They shot the movie over three days in December 2022. Making this film on $33,000 and change was a feat on its own. They paid 15 actors, and a crew. There was a location to rent, and equipment…
Ellen: You’ve got to pay for food to feed your cast and crew. And especially, you know, everyone is kind of working a little bit under their rate so you want to buy them good food.
Dan: You’ve heard some of the results. I won’t spoil the rest. It’s a very-enjoyable 13 minutes. We’ll have a link wherever you’re listening to this. With the movie wrapped by New Years, Ellen qualified for her insurance, so she was on it when their baby Bruce was born a few weeks early.
Ellen: We spent three weeks in the NICU and the entire time that we were in the hospital with him, we just kept saying, I’m so glad we have insurance. I’m so glad we have insurance. I’m so glad we have insurance.
Dan: Just a few weeks after Bruce was born, Dru’s union– the Writer’s Guild– went on strike. Then Ellen’s union went on strike too.
Ellen: We took Bruce to his very first picket when he was like two months old. And I’ve been going, like, about, once a week to, to picket with him. So everybody knows him at
the Disney Picket location. He’s a little union baby.
Dru: We say the joke, he went straight from labor to labor action.
Dan: No joke, though: the SAG strike meant there was less work for actors in 2023– fewer chances to earn money and qualify for insurance. The health plan extended a grace period to keep folks from getting cut off, and a new law in California lets workers who are on strike get subsidized insurance from the state’s Obamacare exchange. Meanwhile, Ellen managed to book another commercial — only TV shows and movies were targeted by the strike, not ads — so their family is set for next year too.
It’s a happy ending … for now.
But this seems like an exhausting merry-go-round to stay on for the rest of your life. I asked Ellen and Dru how they felt about it.
Ellen: So something that has been nice about the strike has been talking to a bunch of our friends about how hard it’s gotten over the last several years to make a living doing this.
I was like in my late twenties when I got the SAG health insurance for the first time. I thought, like, “Great.” Like, “this is it.”
Dan: That was almost ten years ago. But somehow getting consistent work actually got harder over time. And that felt personal.
Ellen: It was like feeling, like, emotionally, like there’s something wrong with me that I am not making the amount of money that I made earlier in my career. And so, honestly, that has been a nice part of the strike has been realizing that, hey, this is happening to all of us. It’s not just happening to me. It’s really hard.
Dan: But it’s not just hard for actors and writers.
Dru: My brother works in tech. Right. And like, I think the nature of employment, across many industries has changed. And like, there isn’t really that same job security that there used to be when, like, my parents were coming up.
Dan: Dru thinks back to the time, years ago, when he first quit his day job, to write and perform full-time. It was touch and go at first. Like, week to week, it could feel precarious.
Dru: I had a kind of a down week and I was like, maybe it’s time to get a real day job like my brother. And right that week, he got laid off. He’s found another job, he’s figured it out, but it was that moment where I was like, oh, there’s no job that you can just get and be like, now I’m set with health insurance. So that’s a long answer to say, I don’t think we’re leaving the entertainment industry anytime soon.
Ellen: Yeah, we’ve kind of put all of our chips on the table.
Dan: And like Dru said: Fewer of us these days have jobs where we don’t have to worry about where our health insurance is coming from, or if it’s gonna be any good. I mean, if more of us had that kind of security, I would literally never have started making this show. There would be no reason to make it. But of course, five years in, I do not expect to run out of material.
As we publish this episode, we’ve also just put out an installment of our First Aid Kit newsletter, this one sums up and updates all our best advice about how to pick the least-crappy health insurance for you.
I’ve learned a lot in five years. And we’re able to share what we’ve learned because you’ve been supporting us. And if you can, this is the absolute best moment to pitch in, because right now, every dollar you give — up to a thousand dollars per person! — get matched. Thanks to NewsMatch from the Institute for Nonprofit News, every dollar you give us counts for double. The place to go is arm and a leg show, dot com, slash support. That’s https://armandalegshow.com/support/.
We’ll be back in three weeks with part one of a big investigative story we’ve been working on … pretty much all year. Talk about learning a ton. It’s been a wild ride. We’ve been able to do that — and we’ll be able to share the results with you– because of your support, and I am super-thankful. I’ll leave you with that address one more time: arm and a leg show dot com, slash, support. Thanks! I’ll catch you in three weeks. Till then, take care of yourself.
This episode of “An Arm and a Leg” was produced by Emily Pisacreta and me, Dan Weissman and edited by Ellen Weiss.
Daisy Rosario is our consulting managing producer.
Adam Raymonda is our audio wizard.
Our music is by Dave Winer and Blue Dot Sessions.
Gabrielle Healy is our managing editor for audience. She edits the First Aid Kit Newsletter.
Bea Bosco is our consulting director of operations.
Sarah Ballema is our operations manager.
“An Arm and a Leg” is produced in partnership with KFF Health News — formerly known as Kaiser Health News. That’s a national newsroom producing in-depth journalism about healthcare in America, and a core program at KFF — an independent source of health policy research, polling, and journalism. You can learn more about KFF Health News at: https://armandalegshow.com/about-x/partners-and-supporters/kaiserhealthnews/
Zach Dyer is senior audio producer at KFF Health News. He is editorial liaison to this show.
Big thanks to the Institute for Nonprofit News for serving as our fiscal sponsor, allowing us to accept tax-exempt donations. You can learn more about INN at INN.org
And now for one of my favorite parts of the gig … giving a shout out to some of the people who’ve come aboard to support this show in the last few weeks. Thanks at this time to our supporters (Dan lists donors.) Thank you so much!
“An Arm and a Leg” is a co-production of KFF Health News and Public Road Productions.
To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and X, formerly known as Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.
To hear all KFF Health News podcasts, click here.
And subscribe to “An Arm and a Leg” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.
——————————
By: Dan Weissmann
Title: An Arm and a Leg: To Get Health Insurance, This Couple Made a Movie
Sourced From: kffhealthnews.org/news/podcast/health-insurance-actors-union-couple-movie/
Published Date: Thu, 30 Nov 2023 10:00:00 +0000
Did you miss our previous article…
https://www.biloxinewsevents.com/medicare-advantage-increasingly-popular-with-seniors-but-not-hospitals-and-doctors/
Kaiser Health News
Years Later, Centene Settlements With States Still Unfinished
More than three years ago, health insurance giant Centene Corp. settled allegations that it overcharged Medicaid programs in Ohio and Mississippi related to prescription drug billing.
Now at least 20 states have settled with Centene over its pharmacy benefit manager operation that coordinated the medications for Medicaid patients. Arizona was among the most recent to join the ranks, settling for an undisclosed payout, Richie Taylor, a spokesperson for the state’s attorney general, told KFF Health News in December.
All told, Centene has agreed to pay more than $1 billion in settlements, according to Cohen Milstein, one of the law firms representing states in the agreements. Meanwhile, St. Louis-based Centene reported $163 billion in revenue in 2024, largely proceeds from government health programs for Medicaid, Medicare, and the Affordable Care Act. The health care company has admitted no wrongdoing in the settlements.
Two state holdouts appear to remain: Georgia has yet to settle with Centene, even though the administration of Gov. Brian Kemp hired law firm Liston & Deas in 2019 to investigate state pharmacy benefit operations.
Florida hired the same law firm in 2021 to pursue overbilling allegations involving Centene, but state officials declined to answer a reporter’s questions about whether Florida has dropped the case, reached an undisclosed settlement, or is still discussing the issue.
Neither state has publicly disclosed what’s standing in the way of potentially tens of millions of dollars in Centene payouts, or whether negotiations are taking place. Because the deals are largely occurring outside the court system, the process between the private law firms hired by states and Centene remains generally out of public view.
Centene spokespeople did not return multiple phone calls and emails asking for updates. In 2022, the company said it was working on settlements with Georgia and eight other states, having reached deals with 13 others. And in a Securities and Exchange Commission filing in October, Centene said it had reached settlements with “the vast majority of states impacted” over the operations of its former pharmacy benefits manager.
Georgia has “taken disproportionately long compared to other states,” said Greg Reybold, a vice president of the American Pharmacy Cooperative, which represents independent pharmacies.
Meanwhile, Centene’s Georgia Medicaid plan, the Peach State Health Plan, lost its bid last year to continue its longtime participation in a Georgia Medicaid program in which companies cover the care for Medicaid recipients for a set fee from the government rather than for each medical service provided. The company, which has been part of the contract since the managed-care program began in 2006, filed a protest over the contract awards, saying that the process was “mismanaged, rife with errors and reckless practices.”
Nationally, pharmacy benefit managers, or PBMs, have come under increased scrutiny over accusations of pocketing discounts on medications or inflating costs in the years since Centene started settling its Medicaid-related allegations. Members of Congress have proposed major policy constraints on PBMs. Centene has since overhauled its PBM operation.
Still, a possible settlement in Georgia could bring in significant money to the state. California had the largest publicly disclosed settlement at $215 million, split with the federal government, but a settlement with Georgia could be in the range of the $88 million that Centene agreed to pay in the Ohio dispute, Reybold said.
The state should aggressively pursue a settlement with Centene, said Roland Behm, co-founder of the Georgia Mental Health Policy Partnership, who is a critic of Centene and its Georgia Medicaid plan. Behm said state Attorney General Chris Carr should take “the same tenacious prosecutorial action” against Centene that Carr’s agency takes against individuals involved in fraud against Medicaid, the federal-state program that provides health insurance coverage for those with low incomes or disabilities.
Carr’s office said in 2022 that it stood ready to represent Georgia in settlement negotiations with Centene. Carr, a Republican who has announced he’s running for governor in 2026, received tens of thousands of dollars in campaign contributions from Centene, its subsidiaries, and its executives, as did Kemp, a fellow Republican, KFF Health News reported in 2022. Contributions to the Kemp and Carr campaigns were part of more than $26.9 million that Centene, its subsidiaries, its top executives, and their spouses donated to state politicians in 33 states, to their political parties, and to nonprofit fundraising groups from 2015 through 2022.
Since 2022, the company and its political action committee have contributed, combined, at least $2 million more to the campaigns of Florida and Georgia candidates of both political parties, along with state party organizations and political committees, according to state campaign finance records.
When asked about a possible settlement, a spokesperson for Carr, Kara Murray, directed a reporter to the Georgia Department of Community Health, which administers Medicaid.
Fiona Roberts, a spokesperson for that agency, then told KFF Health News that the department “is actively pursuing options to ensure regulatory compliance with the state’s contract.” She declined to comment further.
Florida’s attorney general’s office directed a reporter to the state agency that oversees Medicaid, the Florida Agency for Health Care Administration. But that agency did not respond to multiple phone calls and emails requesting comment.
Rebecca Grapevine of Healthbeat contributed to this article.
The post Years Later, Centene Settlements With States Still Unfinished appeared first on kffhealthnews.org
Kaiser Health News
Home Improvements Can Help People Age Independently. But Medicare Seldom Picks Up the Bill.
Chikao Tsubaki had been having a terrible time.
In his mid-80s, he had a stroke. Then lymphoma. Then prostate cancer. He was fatigued, isolated, not all that steady on his feet.
Then Tsubaki took part in an innovative care initiative that, over four months, sent an occupational therapist, a nurse, and a handy worker to his home to help figure out what he needed to stay safe. In addition to grab bars and rails, the handy worker built a bookshelf so neither Tsubaki nor the books he cherished would topple over when he reached for them.
Reading “is kind of the back door for my cognitive health — my brain exercise,” said Tsubaki, a longtime community college teacher. Now 87, he lives independently and walks a mile and a half almost every day.
The program that helped Tsubaki remain independent, called Community Aging in Place: Advancing Better Living for Elders, or CAPABLE, has been around for 15 years and is offered in about 65 places across 26 states. It helps people 60 and up, and some younger people with disabilities or limitations, who want to remain at home but have trouble with activities like bathing, dressing, or moving around safely. Several published studies have found the program saves money and prevents falls, which the Centers for Disease Control and Prevention says contribute to the deaths of 41,000 older Americans and cost Medicare about $50 billion each year.
Despite evidence and accolades, CAPABLE remains small, serving roughly 4,600 people to date. Insurance seldom covers it (although the typical cost of $3,500 to $4,000 per client is less than many health care interventions). Traditional Medicare and most Medicare Advantage private insurance plans don’t cover it. Only four states use funds from Medicaid,the federal-state program for low-income and disabled people. CAPABLE gets by on a patchwork of grants from places like state agencies for aging and philanthropies.
The payment obstacles are an object lesson in how insurers, including Medicare, are built around paying for doctors and hospitals treating people who are injured or sick — not around community services that keep people healthy. Medicare has billing codes for treating a broken hip, but not for avoiding one, let alone for something like having a handy person “tack down loose carpet near stairs.”
And while keeping someone alive longer may be a desirable outcome, it’s not necessarily counted as savings under federal budget rules. A 2017 Centers for Medicare & Medicaid Services evaluation found that CAPABLE had high satisfaction rates and some savings. But its limited size made it hard to assess the long-term economic impact.
It’s unclear how the Trump administration will approach senior care.
The barriers to broader state or federal financing are frustrating, said Sarah Szanton, who helped create CAPABLE while working as a nurse practitioner doing home visits in west Baltimore. Some patients struggled to reach the door to open it for her. One tossed keys to her out of a second-story window, she recalled.
Seeking a solution, Szanton discovered a program called ABLE, which brought an occupational therapist and a handy worker to the home. Inspired by its success, Szanton developed CAPABLE, which added a nurse to check on medications, pain, and mental well-being, and do things like help participants communicate with doctors. It began in 2008. Szanton since 2021 has been the dean of Johns Hopkins University School of Nursing, which coordinates research on CAPABLE. The model is participatory, with the client and care team “problem-solving and brainstorming together,” said Amanda Goodenow, an occupational therapist who worked in hospitals and traditional home health before joining CAPABLE in Denver, where she also works for the CAPABLE National Center, the nonprofit that runs the program.
CAPABLE doesn’t profess to fix all the gaps in U.S. long-term care, and it doesn’t work with all older people. Those with dementia, for example, don’t qualify. But studies show it does help participants live more safely at home with greater mobility. And one study that Szanton co-authored estimated Medicare savings of around $20,000 per person would continue for two years after a CAPABLE intervention.
“To us, it’s so obvious the impact that can be made just in a short amount of time and with a small budget,” said Amy Eschbach, a nurse who has worked with CAPABLE clients in the St. Louis area, where a Medicare Advantage plan covers CAPABLE. That St. Louis program caps spending on home modifications at $1,300 a person.
Both Hill staff and CMS experts who have looked at CAPABLE do see potential routes to broader coverage. One senior Democratic House aide, who asked not to be identified because they were not allowed to speak publicly, said Medicare would have to establish careful parameters. For instance, CMS would have to decide which beneficiaries would be eligible. Everyone in Medicare? Or only those with low incomes? Could Medicare somehow ensure that only necessary home modifications are made — and that unscrupulous contractors don’t try to extract the equivalent of a “copay” or “deductible” from clients?
Szanton said there are safeguards and more could be built in. For instance, it’s the therapists like Goodenow, not the handy workers, who put in the work orders to stay on budget.
For Tsubaki, whose books are not only shelved but organized by topic, the benefits have endured.
“I became more independent. I’m able to handle most of my activities. I go shopping, to the library, and so forth,” he said. His pace is slow, he acknowledged. But he gets there.
Kenen is the journalist-in-residence and a faculty member at Johns Hopkins University School of Public Health. She is not affiliated with the CAPABLE program.
The post Home Improvements Can Help People Age Independently. But Medicare Seldom Picks Up the Bill. appeared first on kffhealthnews.org
Kaiser Health News
A Runner Was Hit by a Car, Then by a Surprise Ambulance Bill
Jagdish Whitten was on a run in July 2023 when a car hit him as he crossed a busy San Francisco street. Whitten, then 25, described doing “a little flip” over the vehicle and landing in the street before getting himself to the curb.
Concerned onlookers called an ambulance. But Whitten instead had friends pick him up and take him to a nearby hospital, the Helen Diller Medical Center, operated by the University of California-San Francisco.
“I knew that ambulances were expensive, and I didn’t think I was going to die,” he said.
Whitten said doctors treated him for a mild concussion, a broken toe, and bruises.As he sat in a hospital bed, attached to an IV and wearing a neck brace, Whitten said, doctors told him that because he had suffered a traumatic injury, they had to send him by ambulance to the city’s only trauma center, Zuckerberg San Francisco General Hospital.
After a short ambulance ride, Whitten said, emergency room doctors checked him out, told him he had already received appropriate treatment, and released him.
Then the bill came.
The Medical Procedure
Traumatic injuries are those that threaten life or limb, and some facilities specialize in providing care for them. For someone hit by a car, that can include stabilizing vital signs, screening for internal injuries, and treating broken bones and concussions. Zuckerberg Hospital is a Level 1 trauma center, meaning it can provide any care needed for severely injured patients.
In emergency medicine, it is standard to transfer patients to centers best equipped to provide care. Ambulances are typically used for transfers because they are able to handle trauma patients, with tools to aid in resuscitation, immobilization, and life support.
At the first hospital, Whitten said, doctors performed a thorough workup, including a CT scan and X-rays, and advised him to follow up with his primary care physician and an orthopedic doctor. He was evaluated at the second hospital and released without additional treatment, he said.
The Final Bill
$12,872.99 for a 6-mile ambulance ride between hospitals: a $11,670.11 base rate, $737.16 for mileage, $314.45 for EKG monitoring, and $151.27 for “infection control.”
The Billing Problem: Surprise Bills Are Common With Ground Ambulances
Ground ambulance services are operated by a hodgepodge of private and public entities — with no uniform structure, or regulatory oversight, for billing — and most function outside insurance networks. Patients don’t typically have a choice of ambulance provider.
There are state and federal laws shielding patients from out-of-network ambulance bills, but none of those protections applied in Whitten’s case.
Whitten was insured under his father’s employer-sponsored health plan from Anthem Blue Cross. So when he received a nearly $13,000 bill months after his short transfer ride, he sent a photo of it to his dad.
Brian Whitten said the bills from the two hospitals — and the family’s out-of-pocket responsibility — were in line with what he had anticipated. But he was stunned by his son’s ambulance bill from AMR, one of the nation’s largest ambulance providers. Anthem Blue Cross denied the claim, saying the ambulance was out-of-network and required pre-authorization.
“It didn’t make a whole lot of sense to me, because the doctor is the one who put him in the ambulance,” Brian Whitten said. “It’s not like somehow he just decided, ‘Hey, can I take an ambulance ride?’”
Kristen Bole, a UCSF spokesperson, said in a statement that the health system’s standard of care is to stabilize patients and, when appropriate, transfer them to other medical facilities that are most appropriate to care for patients’ needs, adding that ambulance transfers between hospitals are standard practice.
While the medical system at large relies on negotiated prices for services, ambulance services operate largely outside of the competitive marketplace, said Patricia Kelmar, senior director of health care campaigns for PIRG, a nonpartisan consumer protection and good-government advocacy organization.
Ambulance transfers between hospitals to ensure the highest quality of care available are fairly common, Kelmar said. And with many hospitals being purchased and consolidated, it would follow that the number of ambulance transfers between facilities could increase as specialized medical units at any given hospital are downsized or eliminated, she said.
According to a study of private insurance claims data conducted in 2023, about 80% of ground ambulance rides resulted in out-of-network billing.
Generally, out-of-network providers may charge patients for the remainder of their bill after insurance pays. In some cases, patients can be on the hook even when they did not knowingly choose the out-of-network provider. These bills are known as “surprise” bills.
“It’s a financial burden, a significant financial burden,” said Kelmar, who is a member of the committee created to advise federal lawmakers on surprise bills and emergency ambulance transportation.
Eighteen states have implemented laws regulating surprise ambulance billing. A California law cracking down on surprise ambulance billing took effect on Jan. 1, 2024 — months after Jagdish Whitten’s ambulance ride.But Kelmar said those state laws don’t really help people with employer-sponsored insurance, because those plans are beyond state control — which is why federal legislation is so important, she said.
As of 2022, federal law protects patients from receiving some surprise bills, especially for emergency services. But while lawmakers included protections against air ambulance bills in the law, known as the No Surprises Act, they excluded ground ambulance transports.
The Resolution
Whitten’s father filed an insurance appeal on his son’s behalf, which Anthem granted. The insurer paid AMR $9,966.60.
Michael Bowman, a spokesperson for Anthem, said AMR had not submitted all the information it required to process the claim, leading to the initial denial. After consulting with AMR, Anthem paid its coverage amount, Bowman said.
But the insurer’s payment still left Whitten with a $2,906.39 bill for his out-of-network ambulance ride. Brian Whitten said he called an AMR customer service number several times to contest the remaining charges but was unable to bypass its automated system and speak with a human.
“I couldn’t find a way to talk to somebody about this bill other than how to pay it, and I didn’t want to pay it,” he said.
Unsuccessful and frustrated, Brian Whitten paid the remaining bill in January 2024, he said, concerned it would be turned over to a collection agency and hurt his son’s credit — and his well-being.
There was one more twist: He was shocked when he later reviewed his credit card statements and discovered that AMR had quietly but fully refunded his payment in October.
“It’s amazing that he got his money back,” Kelmar said. “That’s what’s shocking.”
In a statement, Suzie Robinson, vice president of revenue cycle management with AMR, said the company’s third-party billing agency regularly performs audits to ensure accuracy. An audit of Jagdish Whitten’s bill “revealed that the care provided did not meet the criteria for critical care,” Robinson said, which prompted the full refund.
Robinson said audits indicated fewer than 1% of its 4 million medical encounters annually are billed incorrectly.
The Takeaway
Robinson said patients who feel that AMR has billed them incorrectly should contact the company via email.
For patients in need of an ambulance in an emergency, there are few protections — and usually few options: Sometimes you don’t have a better choice than to get in.
Federal protections require that health plans cover certain surprise bills, with patients paying only what they would if they had received in-network care. Expanding those protections to ground ambulance bills would require Congress to act.
Ambulance providers deserve to be appropriately compensated for their vital role in our medical system, Kelmar said. But the system as it stands almost incentivizes providers to charge a higher rate, which can lead to surprise billing and financial hardship for patients and their families, she said.
Kelmar said she worries not just about the debt those bills create for consumers but also that people may decline vital ambulance transportation in an emergency, for fear of getting hit with an exorbitant bill.
“We just need to bring some sense back to the system,” she said.
Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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The post A Runner Was Hit by a Car, Then by a Surprise Ambulance Bill appeared first on kffhealthnews.org
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