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Julie Rovner
KHN

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Julie Rovner is chief Washington correspondent and host of KHN’s weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

The public health emergency in effect since the start of the covid-19 pandemic will end on May 11, the Biden administration announced this week. The end of the so-called PHE will bring about a raft of policy changes affecting patients, health care providers, and states. But Republicans in Congress, along with some Democrats, have been agitating for an end to the “emergency” designation for months.

Meanwhile, despite Republicans’ less-than-stellar showing in the 2022 midterm elections and broad public support for preserving abortion access, anti-abortion groups are pushing for even stronger restrictions on the procedure, arguing that Republicans did poorly because they were not strident enough on abortion issues.

This week’s panelists are Julie Rovner of KHN, Victoria Knight of Axios, Rachel Roubein of The Washington Post, and Margot Sanger-Katz of The New York Times.

Panelists

Victoria Knight
Axios

@victoriaregisk

Read Victoria's stories

Rachel Roubein
The Washington Post

@rachel_roubein

Read Rachel's stories

Margot Sanger-Katz
The New York Times

@sangerkatz

Read Margot's stories

Among the takeaways from this week’s episode:

• This week the Biden administration announced the covid public health emergency will end in May, terminating many flexibilities the government afforded health care providers during the pandemic to ease the challenges of caring for patients.
• Some of the biggest covid-era changes, like the expansion of telehealth and Medicare coverage for the antiviral medication Paxlovid, have already been extended by Congress. Lawmakers have also set a separate timetable for the end of the Medicaid coverage requirement. Meanwhile, the White House is pushing back on reports that the end of the public health emergency will also mean the end of free vaccines, testing, and treatments.
• A new KFF poll shows widespread public confusion over medication abortion, with many respondents saying they are unsure whether the abortion pill is legal in their state and how to access it. Advocates say medication abortion, which accounts for about half of abortions nationwide, is the procedure’s future, and state laws regarding its use are changing often.
• On abortion politics, the Republican National Committee passed a resolution urging candidates to “go on the offense” in 2024 and push stricter abortion laws. Abortion opponents were unhappy that Republican congressional leaders did not push through a federal gestational limit on abortion last year, and the party is signaling a desire to appeal to its conservative base in the presidential election year.
• This week, the federal government announced it will audit Medicare Advantage plans for overbilling. But according to a KHN scoop, the government will limit its clawbacks to recent years, allowing many plans to keep the money it overpaid them. Medicare Advantage is poised to enroll the majority of seniors this year.

Also this week, Rovner interviews Hannah Wesolowski of the National Alliance on Mental Illness about how the rollout of the new 988 suicide prevention hotline is going.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: Axios’ “Republicans Break With Another Historical Ally: Doctors,” by Caitlin Owens and Victoria Knight

Margot Sanger-Katz: The New York Times’ “Most Abortion Bans Include Exceptions. In Practice, Few Are Granted,” by Amy Schoenfeld Walker

Rachel Roubein: The Washington Post’s “I Wrote About High-Priced Drugs for Years. Then My Toddler Needed One,” by Carolyn Y. Johnson

Victoria Knight: The New York Times’ “Emailing Your Doctor May Carry a Fee,” by Benjamin Ryan

Also mentioned in this week’s podcast:

• KFF’s “KFF Health Tracking Poll: Early 2023 Update on Public Awareness on Abortion and Emergency Contraception,” by Grace Sparks, Shannon Schumacher, Marley Presiado, Ashley Kirzinger, and Mollyann Brodie
• USA Today’s “Biden Seeks to Bolster the Affordable Care Act’s No-Cost Contraception Rule,” by Ken Alltucker
• The National Review’s “To Reduce Abortions, Should Giving Birth Be Free?” by Wesley J. Smith
• The New York Times’ “New Medicare Rule Aims to Take Back $4.7 Billion From Insurers,” by Reed Abelson and Margot Sanger-Katz
• KHN’s “Government Lets Health Plans That Ripped Off Medicare Keep the Money,” by Fred Schulte

Click to open the transcript

Transcript: Au Revoir, Public Health Emergency

KHN’s ‘What the Health?’Episode Title: Au Revoir, Public Health EmergencyEpisode Number: 283Published: Feb. 2, 2023

Tamar Haspel: A lot of us want to eat better for the planet, but we’re not always sure how to do it. I’m Tamar Haspel.

Michael Grunwald: And I’m Michael Grunwald. And this is “Climavores,” a show about eating on a changing planet.

Haspel: We’re here to answer all kinds of questions. Questions like: Is fake meat really a good alternative to beef? Does local food actually matter?

Grunwald: You can follow us or subscribe on Stitcher, Apple Podcasts, Spotify, or wherever you listen.

Julie Rovner: Hello and welcome back to KHN’s “What the Health?” I’m Julie Rovner, chief Washington correspondent at Kaiser Health News. And I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Feb. 2, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. We are joined today via video conference by Margot Sanger-Katz of The New York Times.

Margot Sanger-Katz: Good morning, everybody.

Rovner: Rachel Roubein of The Washington Post.

Rachel Roubein: Hi, good morning.

Rovner: And Victoria Knight of Axios.

Victoria Knight: Hi! Good morning.

Rovner: Later in this episode we’ll play my interview with Hannah Wesolowski of the National Alliance on Mental Illness. She’s going to update us on the rollout of 988, the new national suicide prevention hotline. And because it’s February, we’re asking for your best health policy valentines. You can write a poem or haiku and tweet it, tagging @KHNews, and use the hashtag #healthpolicyvalentines, all one word. We’ll choose some of our favorites for that week’s podcast and the winner will be featured on Valentine’s Day on khn.org with its own illustration. But first, this week’s news. So we’re going to start with covid, which we actually haven’t talked about very much for a couple of weeks. But this week there’s some real actual news, which is that President [Joe] Biden has announced he will be ending the public health emergency, as well as the national covid emergency, which is a different thing, on May 11. Depending on who you believe, the president’s hand was forced by the Republican House this week voting on a bunch of bills that would immediately end the emergencies — or that May had always been the administration’s plan. I’m guessing it’s probably a bit of both. But let’s start with what’s going to happen in May, because it’s a bit confusing. We’ve talked at some length over the months about the Medicaid “unwinding.” So let’s start with that. How is that going to roll out, as we will?

Sanger-Katz: So that is actually not going to be affected at all by this change. When Congress passed the CARES Act, it tied a lot of these pandemic programs to the public health emergency. And I think what Congress has been doing in recent months is trying to untie some of those policies from the public health emergency, because I think it has identified that some of them are worth keeping and some of them are worth eliminating, and that it ought to make up its own mind about the right timeline and process for that — instead of just leaving it in the hands of the president to end the public health emergency when he sees fit. So what happened in the omnibus legislation, the big spending bill that passed at the end of the year, is that Congress said, OK, there has been this provision in the CARES Act that said that states need to keep everyone who is enrolled in Medicaid continuously enrolled in Medicaid until the end of the public health emergency, or they risk losing this extra Medicaid funding that they have been getting — and that, I think, has been beneficial to state budgets. And what Congress did is they said, OK, we’re going to create a date certain, starting in April, [that] this policy is going to go away, but we’re going to do it sort of incrementally. So the money’s not going to go away all at once. It’s going to go away in a couple of stages to make it a little easier on states. And they also created a lot of procedures and what they call guardrails to prevent states from just dumping everyone out of Medicaid all at once. So they’re requiring them to do various things to make sure they have the right address and that they’ve contacted people in Medicaid. They will punish them. There’s new penalties that the secretary can use to punish them if it seems like they’re doing things too arbitrarily, and there are other provisions. So as a result, the public health emergency doesn’t have any effect on this. But this policy and Medicaid is going to start unwinding right around the same time. In April and May we’re going to start seeing states probably phasing down their enrollment of some Medicaid beneficiaries as this extra funding that is tied to that goes away.

Rovner: And just a reminder, I mean, there’s now more than close to 90 million people on Medicaid, many of whom are probably no longer still eligible. So the concern is that states are going to have to basically reevaluate the eligibility of all of those people to see who’s still eligible and who’s not and who may be eligible for other government programs. And it’s just going to be a very long process. And I know health advocates are really worried about people falling through the cracks and losing their health insurance entirely.

Sanger-Katz: I think it’s still a huge risk and there still are a lot of people who are likely to lose their insurance as a result of this transition. But it was a weird situation that we were in, where you kind of went from all or nothing, just by the president deciding that the public health emergency was over. And I do understand why Congress decided, OK, look, why don’t we take some leadership over how this policy is going to phase down instead of just leaving it as this looming cliff that we don’t know exactly when it will come and where we don’t have control over the procedure for it.

Rovner: And Margot, you also mentioned things that Congress thought they might want to keep. And I guess a big one of those is telehealth, right? Because that was also in the end-of-year omnibus bill.

Sanger-Katz: Yeah, that’s proved to be really popular, because of the pandemic, because it was dangerous for people to get into doctors’ offices and hospitals early in the pandemic. Medicare loosened some rules and then Congress kind of cemented that. That allowed people to get doctors’ visits using video conferencing, telephone, other kinds of remote technologies, and Medicare paid for that. And that’s been super popular. It has a lot of bipartisan support. And now Congress has extended that benefit for longer. So I think we’re going to see telehealth become a more permanent part of how Medicare benefits are delivered.

Rovner: But not permanent yet. I think there’s still some concern that if it …

Sanger-Katz: Just for two years right now.

Rovner: Well, if it gets too popular, it could get really expensive. I think there’s a worry about …

Sanger-Katz: I do think that the two years will create some infrastructure — I think even just the temporary provision. A lot of doctors and hospitals … I was talking to folks that worked in medicine, they just weren’t set up for it at all. And they had to figure out, how are we going to do it? How are we going to build for it? What systems are we going to use? How are we going to make it secure? So some of that has already happened. But I also think two years is a long-enough runway that you start to imagine that there will be more start-ups, more health care providers that are really orienting their practice around this method of delivering care because they have some sense of permanence now.

Rovner: And I can’t imagine that this won’t become one of those, quote-unquote, “extenders” that Congress renews whenever it expires, which they do now. Rachel, you wanted to say something?

Roubein: Oh, yeah. To your point, I just think once there’s infrastructure built, it’s really hard to take things away. But I guess while we’re on the train of things that aren’t impacting, Congress also in their big government spending bill made a change to Paxlovid, allowing Medicare to continue to cover it under emergency use authorization. So that also won’t be impacted by an end to the public health emergency.

Rovner: So what are the things that will be impacted by the end of the public health emergency?

Knight: Really the biggest thing — and my colleague Maya [Goldman] has been pioneering at writing about this — is that it’s really CMS [the Centers for Medicare & Medicaid Services gave providers a lot of flexibilities that were tied to the PHE [public health emergency]. So it’s a bunch of different small things. It’s, like, reporting requirements, physical environment standards, even things like where radiologists can read X-rays. It’s small stuff like that that a lot of providers have kind of gotten used to and relied on during covid. And so those may go away. It’s possible also that HHS [the Department of Health and Human Services] could allow some of those to remain in place. When I talked to congressman Brett Guthrie, who is the one who introduced the bill to end the PHE, he said he wants to talk to HHS and figure out what are some things that he knows providers enjoy on these flexibilities. There was something about nurses’ training that he wants to keep in place. So they’re making it sound like it’s the end of the world end to this. I’m not sure that that’s actually true.

Rovner: Yeah, and I know the administration’s been pushing back on some of the stories that said that this will be an end to free vaccines and the actual covid testing. But that’s not even really true, right?

Roubein: I think one of my colleagues had talked a little bit about this to Jen Kates from the Kaiser Family Foundation, and that was a concern of hers. So I think some of it is dependent on what policies … and see what the next few months …

Rovner: My impression is that federal government has purchased all of these things. So it’s not … so much the end of the public health emergency. It’s when they run out of supply that they have now. So it’s not so much linked to a date. It’s linked to the supply, because I guess at the end of the public health emergency, they won’t be buying anymore. If nobody wants to answer this question, please don’t. But I’m confused about how this all affects the controversial Title 42, which is a public health requirement that was put in by the Trump administration that limited how many people could come across the border because of covid. I’m still confused about who’s for ending it and who’s not for ending it, and whether ending the emergency ends it or whether it’s in court. And if nobody knows, that’s fine because it’s not totally a health issue. But if anybody does, I’m dying to know.

Sanger-Katz: So my understanding on this one — which I also want to say I’m not like 1,000% sure, but this is what I’ve been told — is that it is related to public health authority and assessment that there is a health emergency, but that it is not part of that CARES framework where … when the public health emergency ends, it ends. It is a separate declaration by the CDC [and Health and Human Services] secretary. And so what I have been told is that it is not directly linked to this, but obviously it is the policy of the Biden administration that we are no longer experiencing a public health emergency. Then I do think the continued use of that policy starts to come under question because the justification for it is quite similar, even if the mechanism is different.

Knight: And I have to tell you, Julie, some of my immigration reporter friends on the Hill were also confused. I think everyone was a little confused because the Biden administration was saying this will lift Title 42 immediately, and Republicans were saying, no, it doesn’t. Brett Guthrie literally came to me and was like, “It is not ending yet.” So I think …

Rovner: I’m not the only one confused?

Knight: Yeah, you’re not the only one confused. And people were calling lawyers, being like, what does this mean when that was going on this week? So, yeah.

Roubein: I think it’s going to be a continuation of this big political fight that we’ve seen over Title 42. An administration official argued to my White House colleague Tyler Pager that essentially because Title 42 is a public health order, the CDC is determining that [there] would no longer be a need for the measure once the coronavirus no longer presents a public health emergency. So we’ll see wrangling over this.

Rovner: Yes, this will go on.

Sanger-Katz: I mean, it’s the same administration, you would think that they would be making a similar judgment about these different things. But the politics around this immigration policy are quite fraught. And it’s possible that they will be de-linked in some way. We’ll see.

Rovner: We will see.

Roubein: And the fight over this held up millions of dollars of covid aid last year. So it’s just been really political.

Rovner: That’s right. Well, moving along and speaking of the Republican-led House, they have, shall we say, refocused the special committee on covid that was set up in the last Congress. Rather than looking at how the nation flubbed preparedness in the early response to the pandemic. The Republican panel is now expected to concentrate on complaining about mask and vaccine mandates, trying to figure out the virus’s origins, and, at least so they’ve said, roasting scientists and public health leaders like the now-retired Anthony Fauci. Among the new Republican members appointed to the panel are the outspoken Marjorie Taylor Greene and former Trump White House doctor, now congressman, Ronny Jackson of Texas. I imagine, if nothing else, these hearings will be very lively to watch, right?

Knight: They definitely are going to be lively to watch. We did just find out yesterday that congressman Raul Ruiz is going to be the Democratic ranking member [of the Select Subcommittee on the Coronavirus Pandemic]. He’s also a doctor. Congressman Brad Wenstrup [R-Ohio] is the chairman of the committee. He’s also a doctor. So it is not only some members who have pushed forward misinformation about covid; there are also members that agree with vaccines and things like that. So I think it’ll be interesting to see how they play this out. I’ve been talking to a lot of them on what they’re going to focus on the committee, what the goal is. So it may not be as wild as we’re anticipating. There may be some members that want it to be, but I think that they want to look at covid origins for sure and the Biden administration’s rollout of vaccines and mandates and things like that. But there’s also Democrats on the committee. So we’ll see how it goes.

Rovner: I will point out, though, when you point out how many doctors are there that Andy Harris of Maryland, who’s also a doctor, a Johns Hopkins anesthesiologist, came under fire for prescribing ivermectin. So we’ve got doctors and we’ve got doctors in the House.

Knight: But I listened to the covid origins hearing yesterday — they did the first one, the Energy and Commerce [ Committee], and I covered it — and I was expecting it to be, like, very intense. And it actually was pretty measured and nothing too wild happened, so …

Rovner: But we shall see. All right. Well, let’s move on to abortion. This is where I get to say that if you didn’t listen to last week’s two-parter on the state of the abortion debate and you’re at all interested in this subject, you should definitely go back and do that. But, obviously, I wish more people would listen to it because a new poll this week from my colleagues over the firewall at KFF finds that a large portion of the public is still confused over whether medication abortion is legal in their state, about whether it requires a prescription (it does), and about how it works compared to emergency contraception. The first one can terminate an early pregnancy. The second one can only prevent pregnancy. Given how fast things are changing in various states, I suppose this confusion is predictable. But is there any way to make this even a little bit clearer? I mean, we have a public that honestly is getting ready to throw its hands up because they can’t figure out what’s what.

Sanger-Katz: I think there’s a good role for journalism here. The abortion pill is a very mature technology. It’s been around for a very long time. It’s become the means for more than half of abortions in America. But I still think, you know, a lot of people don’t know about it. I think when they think about abortion, a lot of Americans are thinking about a surgical procedure that happens in a clinic. Advocates on both sides of the abortion debate are very clear that medication abortion is likely the future of abortion for a lot of Americans because it is easily transportable, because it is able to be prescribed through telemedicine, because it is less expensive than clinic abortion. But I do think just a lot of Americans just don’t have a lot of familiarity with this. And so I think we just have to keep telling them about it, explaining how it works, what the safety profile of it is, how you can get it, what the laws are around it. And, you know, this is a bit of a shifting ground beneath our feet because states are actively regulating and restricting this technology. And I have a team of colleagues at The New York Times in the graphics department who are amazing, who are just like every day updating a page on our website about what is the state of laws surrounding abortion in this country? And it’s really remarkable how often the laws, particularly about abortion pills, are changing. You know, several times a week they are updating that page. So I think all of us just have to keep educating the public about this.

Rovner: And my required reminder that the “morning-after pill” is not the same as the abortion pill. The morning-after pill is now available over the counter. And we now know — thank you, FDA, for changing the label — that it cannot actually interrupt an existing pregnancy. It can only prevent pregnancy. So that’s my little PSA. Meanwhile, we have talked a lot about how anti-abortion forces are pushing harder than ever for a national abortion ban. The Republican National Committee passed a resolution last week, pushed by some of the more strident anti-abortion groups, calling for Republicans to, quote, “go on the offense” in 2024 to work for the most restrictive abortion laws possible. Given that polling still shows a majority of Americans and even a majority of swing voters still think abortion should be legal, are the Republicans driving themselves politically off a cliff here, or do they really think that revving up their base will help them win elections?

Roubein: I think that this is notable from the RNC because, as you mentioned, anti-abortion advocates were really, really mad at people like Senate Majority Leader Mitch McConnell, other Republicans who were saying that it was a state issue and had been pushing for them to paint Democrats as extreme, pushing a very different message. So this is ahead of 2024. Obviously, anti-abortion advocates are, when they’re looking at who they’re going to endorse in the presidential race, are going to be looking for candidates that support some kind of federal gestational limit on abortion.

Knight: I know Alice [Miranda Ollstein], who has been on here a lot, she was reporting that these anti-abortion groups are also pushing Republicans to put bills on the House floor to vote on restricting abortion. So there’s a six-week bill that’s already been introduced, maybe some other weeks. And so I think depending on if they actually do floor votes on this, that’s going to be something Democrats will use to attack them, I’m sure, in the upcoming election and maybe also something Republicans want to promote. So I think that it’s definitely notable, and we’re going to have to see if it’s the same as it was in the midterms when it didn’t seem to be a winning message for Republicans. But the anti-abortion groups are saying double down more. So we’ll see.

Rovner: Well, speaking of anti-abortion groups, they’ve been quietly pushing something new: a campaign to, as they call it, quote, “make birth free.” The idea is that a pregnant woman shouldn’t be swayed to have an abortion because she thinks she can’t afford to give birth. It’s been quite a few years since the anti-abortion side tried to advocate for benefits for pregnant women. I remember in the mid-1980s, congressman Henry Hyde — yes, he of the Hyde Amendment — joined with one of the most liberal members of the House, former California Democrat Henry Waxman, to sponsor a bill to reduce infant mortality. It turned out to be the beginning of Medicaid’s benefit for pregnant women, for prenatal delivery and postnatal care, something that’s now extremely popular. Do we expect to see more for this, more of this, or for this to catch on? … I’ve seen the group asking for this. I haven’t really seen any lawmakers suggesting this. It would be pretty expensive to basically pay for every birth in the country. We have a lot of shaking heads.

Knight: I had not heard any lawmakers talking about that. I don’t know if others have. I know there has been some push from some Republicans to put more safeguards in place for women who give birth, like just more supportive programs, but like, I haven’t heard like making birth completely free. And I know also that’s not maybe a widely held view within — I know there are some Republicans pushing for it. There’s a really good Washington Post article about this recently, about paid leave also. But they seem to be in the minority. And so there’s not enough movement to, like, make the party actually do anything on that.

Roubein: I think it’s sort of the beginning. Like Americans United for Life, a big anti-abortion group that’s written a lot, a lot of model laws that states have adopted. They had released a white paper about this. I think that’s sort of the beginning of the push and that’s what we tend to see with the anti-abortion movement is, you know, sometimes we see these policies come out from different groups and then they advocate and then potentially it goes to legislation and they try and find different lawmakers’ ears. So I think it’s a little bit TBD at this point.

Sanger-Katz: I also think it highlights how there’s a growing movement in the Republican Party — and I would say this is not a majority of Republicans yet — but we do see a significant minority that really are pursuing these pro-family policies, policies that we often think about as being pursued by Democrats. Family leave is an example of that, interest in day care, the child tax credit. There are a number of Republicans that were really champions of that policy in the last few years. And I think this feels like it’s a piece with that, that a lot of Republicans, they want to encourage people to have families, to have children, to be able to care for their children. And they understand that it’s hard and it’s expensive. But I do think that those ideas tend to bump up against the more libertarian elements in the Republican Party that are opposed to a lot of government spending, a lot of government intervention in people’s family lives and just concerned about the deficit and debt as well. And so this continues to be an interesting development. My colleague Claire Cain Miller at The Upshot has written a lot about this debate within the Republican Party as it relates to some of these other policies. And I wonder if this idea of making birth free could start to become part of that package of policies that you see some Republicans really interested in, even though you might think of the issue as being something that is more classically a Democratic issue.

Rovner: Although I’m wondering if the Democrats are going to pick up on this and try to hold the Republicans’ feet to the fire on it. It’s like, see, your base would like to make this free. Don’t you want to join them? I could see that happening although hard to know. All right. Well, finally this week on the reproductive health agenda, the Biden administration undid another Trump regulation, this one to eliminate employers with, quote-unquote, “moral objections to birth control” from having to offer it under the Affordable Care Act. Those with religious objections would still have a workaround to ensure that their employees get the coverage, according to the Department of Health and Human Services. Actually, only a handful of employers have used the moral exception. Actually, I think the more important part of this regulation would create a new pathway for employees of religiously objecting employers, like religious schools and colleges, to get coverage without involving the employer at all, nor making the employer pay for it. This has been a big sticking point and created a giant backlash early on in the Affordable Care Act’s rollout — and two separate Supreme Court cases — because the employers didn’t want to be seen to be facilitating people getting birth control that they didn’t believe in. Now that they’re going to totally separate this from the employer, might this put that little fight to rest? Not a little — a big fight to rest? [pause] We have no predictions?

Sanger-Katz: This feels like one of those policies that is just going to flip-flop back and forth when we have different presidents. The Trump administration, you know, went really far. This idea of a moral objection, I think doesn’t have a particularly strong basis in law or at least didn’t historically. But the Supreme Court said that they had the authority to do it. And so I think that then creates a precedent that future administrations can do it. I do think that there is a concern from the religious community that this requirement imposes too much of a moral stricture on them. And so they are always pushing for more and wider exceptions to this contraceptive coverage policy. To me, the big surprise in this is just that it took so long. The Trump administration rolled out this particular policy almost immediately upon taking office. And now we’re more than two years into the Biden administration and they have finally rolled it back.

Rovner: Yes. And I am keeping track. And I will update my little infographic about how long it’s taking the Biden administration to change some of these policies. Well, finally, this week, Medicare Advantage, as we’ve mentioned before, private Medicare plans have become very popular, particularly because they often offer extra benefits, mostly because they’re being paid extra by the federal government. But it seems some of these companies have also figured out how to game the system. Surprise. So this week, the federal government announced a crackdown by way of new audits that’s predicted to recoup nearly $5 billion. Medicare’s always … things with lots of zeros. Margot, you wrote about this this week. What are they going to do?

Sanger-Katz: So just a little bit of background. Medicare pays Medicare Advantage plans a set amount per person to take care of them. And the idea is the insurance company can try to do a better job and provide less medical care and keep people healthier and save the remainder as profits. And when Medicare Advantage started, there was this problem where the plans had this huge incentive to just pick all the healthy seniors, because if you pick all the healthy people, they don’t need a lot of medical care and then you get to keep a lot of that payment as profits. And so Congress came up with a new system where if you take care of someone who is sick, who has diabetes, who has substance abuse problems, who has COPD [chronic obstructive pulmonary disease], you get a little bonus payment so that the insurer has an incentive to cover that person. They have a little bit of extra money to take care of their health needs. And what we’ve seen over the years that the Medicare Advantage program has become mature, is that the plans have gotten extremely good at finding every single possible thing that is wrong with every single possible person that they enroll. And in some cases, they just kind of make things up that don’t seem to be justified by that person’s medical records. And so the amount that the Medicare system is paying to these plans has just gone up and up and up. And there are all kinds of estimates of how much they’ve been overpaid that are kind of eye-popping. And there are quite a lot of serious fraud lawsuits that are making their way through the federal courts. There have been some settlements, but basically every major insurer in this program is facing some kind of legal scrutiny for the way that they are diagnosing their patients to get these payments. And you know, what’s interesting to me about it is there’s been quite a lot of good journalism about this problem. Julie, your colleague Fred Schulte, I think, has been a real leader on this and had actually a big, big scoop recently. And the GAO has written about it. The HHS inspector general has done audits and written about it. There have been these lawsuits. This is not really a secret, but there has been very little action by CMS over the last decade on this problem. And I think there are a few reasons for that. One, I think it’s hard to fix. I will give them some credit. The policy levers are complicated, but I also think there is just a big political disincentive to do anything about this. Medicare Advantage has become more and more popular over the years. It is poised to enroll a majority of seniors, of Medicare beneficiaries, this year, and those people are very diffuse across the country. It’s not the case that there’s just Medicare Advantage in one or two markets where you have a couple members of Congress who care about it. They’re kind of everywhere. And they’re not just in Republican districts. Even though Republicans created this program, there are a lot of them in Democratic districts, too. And people like these plans. They have some downsides, which we could talk about another time. But they tend to have lower premiums for seniors. They tend to cover benefits like hearing, vision, and dental benefits that the traditional Medicare program does not cover. And so people really like these plans. And the more the plans are paid, the more they can afford to give all these goodies to their beneficiaries. And so I think there has been a lot of political pressure on CMS to not aggressively regulate the plans. And that’s part of why what they did this week is actually pretty striking. They did something pretty aggressive. They have been conducting these audits where they take 200 patients — which is a very, very small fraction of the total number of patients in any one plan — and they look at the diagnoses and they compare them to the medical records for those patients and they say, hey, wait a minute, I don’t think that this patient really has lung cancer. I think this patient doesn’t have that. So you shouldn’t have gotten that payment. And so that has been the system for some time where they look at a couple of records and they go back to the plans and they say, hey, pay us back this lung cancer payment. You can’t justify this based on the medical record.

Rovner: And they extrapolate from that, right? And it’s not …

Sanger-Katz: No. So what this new rule says is it says, you know, if in your 200 people that we look at, we find that you have an error rate of whatever, 5%, we are now going to ask you to pay back the money across your whole book of business, that you can’t just pay us back for the five people that we found, you have to pay back for everyone because we assume that whatever kinds of mistakes or sketchy things that you’ve done to create these errors in this small sample, probably you’ve done them to other patients, too. So that’s like the big thing that the rule does. It says “Pay back more money.” And then the other thing that it says is it says we’re going to reach back in time and you’re got to pay back all the extra money you got in 2018, in 2019, in 2020, and in 2021. So it’s not just forward-looking, but it’s also backward-looking, trying to recover some of what CMS believes are excessive payments that the plans received.

Rovner: Although, as my colleague Fred Schulte points out, they don’t go back in time as far as they could. So they’re basically leaving a fair bit of money on the table for … I guess that’s part of the balancing that they’re trying to do with being aggressive in recouping some of this money and noting that this is a very popular program that has a lot of bipartisan support.

Sanger-Katz: Yeah, it’s been interesting. The market reaction was very muted. So this suggests to me that the plans, even though it is aggressive relative to what we have seen in the past, that it was not as aggressive as what the plans and their shareholders were worried about.

Rovner: Exactly. All right. Well, that is as much time as we have for the news this week. Now, we will play my interview with Hannah Wesolowski of NAMI. Then we will come back and do our extra credits.

I am pleased to welcome back to the podcast Hannah Wesolowski of the National Alliance on Mental Illness. You may remember we spoke to Hannah last February in anticipation of the launch of the new three-digit national suicide hotline, 988. Hannah, welcome back.

Hannah Wesolowski: Thanks, Julie. It’s great to be here.

Rovner: So the 988 hotline officially launched last July. It’s been up and running now for just about seven months. How’s it going?

Wesolowski: Largely, it’s going great. We’re really excited to see that not only are more people reaching out for help — overall, there’s about a 30% to 40% increase, year over year, when we look at every month of the helpline — but they’re talking to people quickly. They’re getting that help. They’re getting connected to crisis counselors in their state. And that really displays the tremendous work that’s happened across the country to build up capacity in anticipation of the lifeline.

Rovner: Is there anything that surprised you about the rollout, something that was unexpected — or that you expected that didn’t happen?

Wesolowski: I had a few sleepless nights there, worried about: Would people be able to get through? What would demand look like? And would call centers have that capacity? This was a quick turnaround. Congress passed this in late 2020, and it went live in mid-2022. That’s not a lot of time in the real world to actually stand up call centers that have a 24/7 capacity to answer calls, texts, and chats. And yet, when we look at the numbers, they’re amazing. The number of texts alone has grown exponentially, when we look at people who were texting the lifeline previously and are now texting 988. They’re getting through. They’re talking to people quickly, and there’s tens of thousands of them that are doing it every month.

Rovner: And I imagine, particularly, younger people might well prefer to text than to actually talk to someone on the phone.

Wesolowski: Exactly. This is about making sure this resource is accessible to anyone and makes it as easy for them to get the help they need in the way that they prefer to get it. It is hard to get a young person to pick up the phone. So texting is absolutely critical to reach a population that is in crisis. There’s a youth mental health crisis in this country. And so making sure that we are responsive to the needs of youth and young adults is absolutely critical.

Rovner: So I see that mental health, in general, and the 988 program, in particular, got big funding boosts in the most recent omnibus spending bill. Republicans in the House, however, say they want to roll back funding for all of these domestic discretionary programs to fiscal 2022 levels. What would that mean for this program and for mental health in general?

Wesolowski: You’re right. 988 got [an] exponential increase in funding in the omnibus. It grew from $101.6 million in fiscal year 2022 to $501.6 million in fiscal year 2023. So nearly five times the funding. And it’s still not everything we estimated that is needed out there. Just to fund the local call centers alone, it would probably be more than $560 million. That doesn’t include the cost of operating the national network, the data integrity, the technical platforms, the backup networks, you know, all the resources that are needed to do this, plus public awareness. There still hasn’t been a widespread public awareness campaign of 988. So while $501.6 million is amazing, it’s still only a fraction of what we ultimately need. So thinking about future cuts to this … this is something that saves lives. There’s very clear data that lifelines save lives, and we’re telling people that this resource is there; to cut funding would mean that people [who need] help wouldn’t be able to connect to somebody when they need it most.

Rovner: So I know there’s been some resistance to using 988. Some folks, particularly on social media, warn that callers could be subject to police involvement or involuntary treatment or confinement. Tell us how it really works when someone calls. And are some of those concerns well placed or not?

Wesolowski: Every concern that is made about this system comes from a real place of people who have been in crisis and gotten a horrific and traumatic response. With 988, the thing that is important for people to understand is there is no way to know your location. There is no tracking of your information. This is 100% anonymous. In fact, right now we have the challenge of calls being routed based on area code and not somebody’s general geographic location. So, for example, I have a New Hampshire area code, love the great state of New Hampshire, but live in Virginia and have for many years — I would get routed to New Hampshire. I’m still talking to a crisis counselor. That’s wonderful. But we want to be connected locally. So there is no way that police can be dispatched or somebody can be taken to a hospital. Now, there are situations where the crisis counselor determines a person may be at imminent risk. They may be having thoughts of suicide, and the counselors are trained to look for that, in which case they’ll initiate emergency protocol to try to get the individual to share their location. And it’s less than 2% of contacts that an individual is at imminent risk. And many of those voluntarily share their location. So it’s a lengthy process when they don’t. And that means many minutes where we could lose a life. So it’s a challenging situation, but we know that that location is not available when somebody calls 988. And the intention is very much for this to be an anonymous resource that provides the least invasive intervention.

Rovner: So I’ve also seen concerns about just the lack of resources to back up the call centers, particularly in rural areas. What’s being done to build up the capacity?

Wesolowski: That’s one of the biggest challenges with this. 988 should be the entry point to a crisis continuum of care. When you call 911, you are connected to existing services: law enforcement, fire, EMS. 988 — we’re trying to build that system at the same time this resource is available. Many states already have robust mobile crisis response, which is a behavioral health-based response, rather than relying on law enforcement, which is unfortunately often the response that people see in their communities.

Rovner: And often doesn’t end well.

Wesolowski: Right. Often very tragic and traumatic circumstances — and it doesn’t get people the mental health care that they need. Unfortunately, [in] many communities, that’s still the main option. But more and more communities are getting mobile crisis response online, social workers, peer support specialists, nurses, EMTs, psychologists who staff those and provide a mental health-based response. But it’s much harder in rural areas. It takes longer to get to people. You’re covering a much bigger geographic area. And so that still is a challenge. You know, communities are looking at innovative ways that they can leverage existing emergency response to connect to behavioral health providers, like having law enforcement with iPads so they can leverage telehealth if somebody is in a crisis. But certainly, it’s a challenge and a solution that has to be very localized to the needs of that community.

Rovner: So what still is most needed? I know the law that created 988 also allows states to assess a fee on cellphones to help pay to boost mental health services. Are any states doing that yet?

Wesolowski: We have five states that have passed laws since 2020 to assess a monthly fee on all phone bills. That’s similar to how we fund 911. Everyone across the country already pays a 911 fee. Virginia, Colorado, Nevada, California, and Washington state all currently have legislation that has implemented a small fee on phone bills. It ranges from $0.12 to $0.40 per phone line per month. And that really is helping build out not just the 988 call centers, but that range of crisis services that can respond when somebody needs more help; it can be provided over the phone.

Rovner: Well, it sounds like it’s off to a good start. Hannah Wesolowski, thank you for coming back to update us, and I’m sure we’ll have you back again.

Wesolowski: Thank you so much, Julie. Always a pleasure.

Rovner: OK, we’re back and it’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read too. As always, don’t worry if you miss it; we will post the links on the podcast page at khn.org and in our show notes on your phone or other mobile device. Victoria, why don’t you kick us off this week?

Knight: My extra credit is “Emailing Your Doctor May Carry a Fee.” That’s the name of the article by Benjamin Ryan in The New York Times. So it basically was documenting how doctors practices are starting to charge for sending an email correspondence with a patient. I think we’ve all probably done that, especially during covid. It can be really helpful sometimes when you’re not feeling well and you don’t want to go into the office. But these doctors practices are starting to sometimes charge up to $30, $50 for this, and it’s going to become a new revenue stream for some clinics. And the example they gave in the story was the Cleveland Clinic that was doing this for some people.

Rovner: And the Cleveland Clinic, for people who don’t know, has a lot of patients. It’s a very large organization.

Knight: Yes. Yes, absolutely. So clinics are saying their doctors are spending time on this and so they need to be reimbursed for it. But the critics of this are saying it could discourage people from getting care when they need it. It also could contribute to health inequities, and also can contribute to doctor burnout, because they’re having to now really do these emails to contribute to the revenue stream. So anyway, super interesting, hasn’t happened to me yet, but I hope it doesn’t.

Rovner: The continued tension over doctors getting paid and patients having to pay and insurers having to pay. Rachel.

Roubein: My extra credit, it’s by my colleague, she’s a health and science reporter, Carolyn Y. Johnson, and it’s titled “I Wrote About High-Priced Drugs for Years. Then My Toddler Needed One.” And in her story, she describes her effort of essentially getting lost in the health care system and having to deal with a really complex system to get a pricey medication for her 3-year-old son. So her 3-year-old son was diagnosed with a rare type of childhood arthritis, which can cause young kids to suffer from daily spiking fevers, a fleeting rash, and arthritis. And doctors had recommended a really pricey drug, which required approval from her insurer. Aetna denied the request. In September, doctors wrote another test, which the insurer wanted. The denial was upheld again. She was able to get the medication through a free program offered by the drugmaker, but she was really worried because she was close to using up the last dose. She was calling it the insurer, etc., just really, really often. And, ultimately, the resolution was she was able to get a different high-cost drug that worked in a similar way approved because the request was subject to different rules. And the big-picture point that she makes is that this isn’t a unique story. It’s something that a lot of Americans deal with, a really frustrating, routine process known as prior authorization and step therapy, etc., trying to get coverage of medication that doctors think are needed.

Rovner: And boy, if it takes a professional health reporter that much time and effort to get this, just imagine what people who know less about the system have to go through. It was a really hard piece to read, but very good. Margot.

Sanger-Katz: I wanted to recommend an article from my colleague Amy Schoenfeld Walker called “Most Abortion Bans Include Exceptions. In Practice, Few Are Granted.” And I know that this connects with the abortion discussion that you guys had in the last episode, but I thought what she did was really remarkable. You know, we talk a lot in the political debate about abortion, about exceptions to protect the health of the mother, exceptions for fetuses that cannot survive outside the womb. And, of course, these very politically heated discussions about exceptions for rape and incest. And her article actually looked at the numbers of abortions that are being granted due to these exceptions and states that have them on the books and found that, you know, it’s so minimal that it’s almost not happening at all. If you are a woman who has been raped, if you are a woman who has a really serious health complication in a state where abortion has been banned, you almost always have to travel out of state, despite the existence of these exceptions. And I think this is not a huge surprise. It makes sense that medical providers are scared of getting in trouble when the sanction for being wrong is so high. And also that there aren’t a lot of abortion providers available in states that have banned abortion because there’s no place for them to practice. But I thought she did a really nice job of really putting numbers to this intuition that we all had about what was going to happen and showing how limited access is, and how meaningless in some ways these talking points are that, you know, legislators say that they are providing exceptions, but they’re not actually providing any infrastructure to provide care for the people who qualify.

Rovner: And yet we’re seeing these huge political fights in a lot of states about these exceptions, which, as we now know, don’t actually result in that much in actual practice. Well, my story this week is from Axios by former podcast panelist Caitlin Owens and Victoria here. It’s called “Republicans Break With Another Historical Ally: Doctors,” and it’s about the growing discord between the American Medical Association, long the bastion of male white Republican M.D.s, and Republicans in Congress, particularly Republican M.D.s themselves. The AMA has been moving, I won’t say left, but at least towards the center in recent years, reflecting in large part the changing demographics of the medical profession itself. And if you go back to our podcast of July 21 of last year, you can hear the “not that AMA-like” list of priorities from Jack Resnick, who’s the AMA’s current president. Well, the very conservative Republicans in Congress aren’t too thrilled and are describing the AMA as, quote, “woke” and prioritizing things that lawmakers don’t support, like the right to practice reproductive health according to their medical expertise and to treat teens with gender issues. I never thought I would say it, but it seems the Republicans in the AMA might actually be heading for a divorce. It’s a really great story. You really should read it.

OK. That is our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review — that helps other people find us, too. Special thanks, as always, to our ever-patient producer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth — all one word — @kff.org. Or you can tweet me. I’m @jrovner. Margot?

Sanger-Katz: @sangerkatz

Rovner: Victoria?

Knight: @victoriaregisk

Rovner: Rachel.

Roubein: @rachel_roubein

Rovner: We will be back in your feed next week. Until then, be healthy.

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Brill, whose family hails from Puerto Rico, knows that just discussing the term in some Spanish-speaking cultures is so frowned upon that many callers are too scared to even admit that they’re calling for themselves.

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“Honestamente, no quería pasar 10 días solo en una habitación, lo llaman el agujero”, dijo Ramírez-Cecena, quien espera que decidan si es deportado a México o puede permanecer en los Estados Unidos, en donde ha vivido por más de dos décadas.

Poco antes de que Ramírez-Cecena se enfermara, los funcionarios del Servicio de Inmigración y Control de Aduanas (ICE) de la instalación le negaron su solicitud de alta médica. Es VIH positivo, que según la lista de los Centros para el Control y la Prevención de Enfermedades es una afección que puede aumentar el riesgo de enfermar gravemente por covid.

Ahora, frente al tercer invierno pandémico, reza para no contraer covid mientras está detenido. “Todavía da miedo”, dijo.

En todo el país, la posibilidad de desarrollar una enfermedad grave o morir por covid ha bajado, por las vacunas de refuerzo actualizadas, las pruebas en el hogar y las terapias. La mayoría de las personas pueden sopesar los riesgos de asistir a reuniones o viajar.

Pero para las aproximadamente 30,000 personas que viven en espacios cerrados en la red de instalaciones de inmigración del país, covid sigue siendo una amenaza constante.

El ICE actualizó su guía de pandemia en noviembre. Pero las instalaciones han ignorado las recomendaciones anteriores de usar máscaras y equipo de protección, tener pruebas y vacunas disponibles, y evitar el uso del confinamiento solitario como cuarentena, según detenidos, grupos de defensa e informes internos del gobierno federal.

Según los protocolos de ICE, el aislamiento por covid, utilizado para evitar que otros detenidos se enfermen, debe estar separado de la segregación disciplinaria.

La agencia no abordó este punto, pero dijo en un comunicado a KHN que a los detenidos se los coloca en una “sala de alojamiento médico individual” o en un “una habitación de aislamiento médico de infecciones transmitidas por el aire”, cuando esté disponible.

La atención médica en los centros de detención de inmigrantes ya era deficiente antes de la pandemia. Y en septiembre, las personas médicamente vulnerables en los centros de detención de ICE perdieron una protección, con la expiración de una orden judicial que requería que los funcionarios federales de inmigración consideraran la liberación de los detenidos con riesgo de covid.

La agencia “ha renunciado por completo a proteger a las personas detenidas de covid”, dijo Zoe Bowman, abogada supervisora ​​de Las Américas Immigrant Advocacy Center en El Paso, Texas.

El uso de la detención de inmigrantes en el país se disparó a fines de la década de 1990 y creció después de la creación de ICE en 2003. Los centros de detención —unos 200 complejos privados, instalaciones administradas por ICE, cárceles locales y prisiones repartidas por todo el país— retienen a adultos que no son ciudadanos estadounidenses mientras disputan o esperan la deportación.

La duración promedio de la estadía en el año fiscal federal 2022 fue de aproximadamente 22 días, según la agencia. Los defensores de los inmigrantes han argumentado durante mucho tiempo que las personas no deberían ser detenidas y, en cambio, se les debería permitir vivir en comunidades.

El Centro de Detención de Stewart, un vasto complejo rodeado de cercas con alambre de púas en los bosques de Lumpkin, tiene una de las poblaciones de detenidos más grande del país. Cuatro personas bajo la custodia del centro han muerto por covid desde el comienzo de la pandemia, el mayor número de muertes por covid registradas en estos centros.

Cuando funcionarios de inmigración transfirieron a Cipriano Álvarez-Chávez al centro de Stewart en agosto de 2020, todavía confiaba en la máscara que tenía después de ser liberado de la prisión federal en julio, según su hija, Martha Chavez.

Diez días después, el sobreviviente de linfoma de 63 años fue llevado a un hospital en Columbus, a 40 millas de distancia donde dio positivo para covid, según su informe de defunción. Murió después de pasar más de un mes conectado a un ventilador.

“Fue pura negligencia”, dijo su hija.

Dos años después de la muerte de Álvarez-Chávez, grupos de defensa y detenidos dijeron que el ICE no ha hecho lo suficiente para proteger de covid a los detenidos, una situación consistente con el historial de atención médica deficiente y falta de higiene de las instalaciones.

“Es desalentador ver que no importa cuánto empeoran las cosas, nada cambia”, dijo la doctora Amy Zeidan, profesora asistente en la Facultad de Medicina de la Universidad de Emory, quien revisa los registros de salud de los detenidos y realiza evaluaciones médicas para las personas que buscan asilo.

Una investigación bipartidista del Senado reveló en noviembre que las mujeres en el Centro de Detención del Condado de Irwin en Georgia “parecen haber sido sometidas a procedimientos ginecológicos excesivos, invasivos y, a menudo, innecesarios”.

En el Centro de Procesamiento de Folkston, también en Georgia, el ICE no respondió a las solicitudes médicas de manera oportuna, tuvo una atención de salud mental inadecuada y no cumplió con los estándares básicos de higiene, incluidos baños funcionales, según un informe de junio de la Oficina del Inspector General de Seguridad del Departamento de Asuntos Internos. Y una denuncia presentada en julio por un grupo de organizaciones de defensa alegó que una enfermera del centro Stewart agredió sexualmente a cuatro mujeres.

El ICE defendió su atención médica en un comunicado enviado por correo electrónico, diciendo que gasta más de $315 millones anualmente en atención médica, y que garantiza la prestación de los servicios médicos necesarios e integrales.

Aún así, muchas instalaciones carecen de personal y están mal equipadas para manejar las necesidades médicas a largo plazo de la gran población de detenidos, dijo Zeidan. La atención tardía es común, la atención especializada es casi inexistente y el acceso a la terapia es limitado, dijo. El cuidado de covid no es diferente.

En sus protocolos para covid, el ICE recomienda el uso de anticuerpos monoclonales, que ayudan al sistema inmunológico a responder de manera más efectiva a covid, para el tratamiento. Pero no reconoce ninguno de los otros tratamientos recomendados por los CDC, incluidos los antivirales como Paxlovid, que pueden reducir las hospitalizaciones y las muertes entre los pacientes con covid.

“Durante décadas, el ICE ha demostrado ser incapaz y no estar dispuesto a garantizar la salud y la seguridad de las personas bajo su custodia”, dijo Sofia Casini, directora de monitoreo y defensa comunitaria de Freedom for Immigrants, un grupo de defensa. “Covid-19 solo ha empeorado esta horrible realidad”.

Once personas han muerto por covid bajo custodia de ICE. Pero ese número puede ser una subestimación; defensores de los detenidos han acusado a la agencia de liberar a las personas o deportarlas cuando están gravemente enfermas como una forma de evadir las estadísticas de muertes.

Antes de la pandemia, Johana Medina León fue liberada de la custodia de ICE cuatro días antes de su muerte, según un artículo de mayo en Los Angeles Times. Vio a un médico unas seis semanas después de su primera solicitud, decía el artículo, pero ICE aceleró su liberación solo unas horas después de que su condición empeorara.

Este otoño, los detenidos recluidos en instalaciones de todo el país llamaron a la línea directa de detención de Freedom for Immigrants para quejarse de las condiciones de covid, que varían de una instalación a otra, dijo Casini. “Incluso en la misma instalación, puede cambiar de semana a semana”, dijo.

Según Casini, muchas personas que habían dado positivo para covid estaban recluidas en las mismas celdas que las personas que habían dado negativo, incluidas las personas médicamente vulnerables. Este verano, el grupo encuestó a 89 personas a través de su línea directa y descubrió que alrededor del 30% de los encuestados tuvieron problemas para acceder a las vacunas mientras estuvieron detenidos.

Ramírez-Cecena dijo que le dijeron que es elegible para una segunda vacuna de refuerzo de covid, pero que, a diciembre, aún no la había recibido. Un detenido en el Centro de Procesamiento de Moshannon Valley en Pennsylvania dijo que a un guardia se le permitió interactuar con los detenidos mientras estaba visiblemente enfermo, dijo Brittney Bringuez, coordinadora del programa de asilo de Physicians for Human Rights, quien visitó las instalaciones este otoño.

La orden judicial que requería que ICE considerara la liberación de personas con alto riesgo de covid ha ayudado a los detenidos con afecciones médicas graves, dijeron los defensores. Según la orden, ICE liberó a unos 60,000 detenidos médicamente vulnerables en dos años, dijo Susan Meyers, abogada sénior del Southern Poverty Law Center, uno de los grupos de defensa que ayudó a presentar la demanda que resultó en la orden judicial.

El ICE dijo en un comunicado que aún considerará los factores de riesgo de covid como una razón para la liberación. Pero los abogados dijeron que las instalaciones de ICE a menudo no cumplían con la orden judicial cuando estaba vigente.

El año pasado, el ICE negó la solicitud de liberación de Ricardo Chambers del Centro de Detención de Stewart. Chambers, de 40 años, tiene enfermedades psiquiátricas graves, consideradas un factor de riesgo según la orden judicial. También tiene problemas para respirar y se ahoga mientras duerme, como resultado de una lesión nasal que sufrió en un ataque antes de ser detenido. A dos años de estar detenido, todavía no recibió atención para esa lesión.

Ha presentado quejas sobre los protocolos para covid de Stewart, incluidas las condiciones de hacinamiento y la falta de uso de máscaras u otro equipo de protección por parte del personal.

Al negar su liberación, el ICE dijo que Chambers era una amenaza para la seguridad pública debido a sus antecedentes penales, según su abogada Erin Argueta, abogada principal de la oficina de la Iniciativa de Libertad de Inmigrantes del Sureste del Southern Poverty Law Center en Lumpkin. Chambers ya cumplió sus condenas, dijo, y hay una familia en Nueva York que lo acogería.

A principios de este año, fue enviado a confinamiento solitario durante unos 10 días después de dar positivo para covid, dijo. Pero Chambers, quien está luchando contra una orden de deportación a Jamaica, dijo que su experiencia con covid no fue diferente de las otras veces que estuvo en aislamiento.

“Serás tratado como un animal, enjaulado y sin tener culpa de nada”, dijo Chambers.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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“Honestly, I didn’t want to go spend 10 days by myself in a room — they call it the hole,” Ramirez-Cecena said. He is being held at the center as he waits to learn whether he will be deported to Mexico or can remain in the United States, where he has lived for more than two decades.

Shortly before Ramirez-Cecena got sick, officials from U.S. Immigration and Customs Enforcement at the facility denied his request for a medical release. He is HIV-positive, which is on the Centers for Disease Control and Prevention’s list of conditions that make a person more likely to get seriously ill from covid.

Now, heading into the third pandemic winter, he’s praying he doesn’t get covid while detained. “It is still scary,” he said.

Across the country, the chance of developing severe illness or dying from covid has fallen, a result of updated booster shots, at-home tests, and therapeutics. Most people can weigh the risks of attending gatherings or traveling. But for the roughly 30,000 people living in close quarters in the country’s network of immigration facilities, covid remains an ever-present threat.

ICE updated its pandemic guidance in November. But facilities have flouted past recommendations to use masks and protective equipment, to make testing and vaccines available, and to avoid the use of solitary confinement for quarantining, according to detainees, advocacy groups, and internal federal government reports.

Under ICE’s pandemic protocols, covid isolation, used to keep other detainees from falling ill, must be separate from disciplinary segregation. The agency didn’t address claims that facilities have used solitary confinement areas to isolate detainees who have tested positive for covid but said in a statement to KHN that detainees are placed in a “single, medical housing room” or a “medical airborne infection isolation room” when available.

Medical care in immigration detention facilities was deficient even before the pandemic. Then, in September, medically vulnerable people in ICE detention facilities lost a source of protection, with the expiration of a court order that had required federal immigration officials to consider releasing detainees with covid risks.

The agency has “completely given up on protecting people in detention from covid,” said Zoe Bowman, supervising attorney at Las Americas Immigrant Advocacy Center in El Paso, Texas.

The country’s use of immigration detention exploded in the late 1990s and rose even more after the creation of ICE in 2003. Detention facilities — made up of about 200 privately run complexes, ICE-run facilities, local jails, and prisons scattered across the country — hold adults who are not U.S. citizens while they contest or await deportation. The average length of stay in the 2022 federal fiscal year was about 22 days, according to the agency. Advocates for immigrants have long argued that people shouldn’t be detained and instead should be allowed to live in communities.

Stewart Detention Center, a vast complex surrounded by rows of barbed wire in Lumpkin’s forests, has one of the largest populations of detainees in the country. Four people in the center’s custody have died from covid since the start of the pandemic — the highest number of recorded covid deaths among detention centers.

When immigration officials transferred Cipriano Alvarez-Chavez to the Stewart center in August 2020, he was still relying on the mask he had after being released from federal prison in July, according to his daughter, Martha Chavez.

Ten days later, the 63-year-old lymphoma survivor was taken to a hospital in Columbus, 40 miles away, where he tested positive for covid, according to his death report. He died after spending more than a month on a ventilator.

“It was pure neglect,” his daughter said. His death “shattered our world.”

Two years after Alvarez-Chavez’s death, advocacy groups and detainees said ICE has not done enough to protect detainees from covid, a situation consistent with the facilities’ history of poor medical care and lack of hygiene. “It’s disheartening to see that no matter how bad things get, they don’t change,” said Dr. Amy Zeidan, an assistant professor at Emory University School of Medicine, who reviews detainee health records and performs medical evaluations for people seeking asylum.

A bipartisan Senate investigation revealed in November that women at Georgia’s Irwin County Detention Center “appear to have been subjected to excessive, invasive, and often unnecessary gynecological procedures.” At the Folkston Processing Center, also in Georgia, ICE did not respond to medical requests in a timely manner, had inadequate mental health care, and failed to meet basic hygiene standards, including working toilets, according to a June report from the Department of Homeland Security’s Office of Inspector General. And a July complaint filed by a group of advocacy organizations alleged that a nurse at the Stewart center sexually assaulted four women.

ICE defended its medical care in an emailed statement, saying that it spends more than $315 million on health care annually and ensures the provision of necessary and comprehensive medical services.

Still, many facilities are understaffed and ill-equipped to handle the long-term medical needs of the large detainee population, Zeidan said. Delayed care is common, specialty care is almost nonexistent, and access to therapeutics is limited, she said. Covid care is no different.

In its covid protocols, ICE recommends the use of monoclonal antibodies, which help the immune system respond more effectively to covid, for treatment. But it recognizes none of the other CDC-recommended treatments, including antivirals such as Paxlovid, which can reduce hospitalizations and deaths among covid patients.

“For decades, ICE has proven itself incapable and unwilling to ensure the health and safety of people in its custody,” said Sofia Casini, director of monitoring and community advocacy at Freedom for Immigrants, an advocacy group. “Covid-19 has only worsened this horrifying reality.”

Eleven people have died from covid in ICE custody. But that number may be an underestimate; advocates for detainees have accused the agency of releasing people or deporting them when they are seriously ill as a way to suppress the death statistics.

Before the pandemic, Johana Medina Leon was released from ICE custody four days before her death, according to a May article in the Los Angeles Times. She saw a doctor about six weeks after her first request, the article said, but ICE expedited her release only hours after her condition grew dire.

This fall, detainees being held at facilities across the country called Freedom for Immigrants’ detention hotline to complain about covid conditions, which vary facility to facility, Casini said. “Even in the same facility, it can change week to week,” she said.

Many people who had tested positive for covid were being held in the same cells as people who had tested negative, including people who were medically vulnerable, according to Casini. The group surveyed 89 people through its hotline this summer and found that about 30% of respondents had trouble accessing vaccines in detention.

Ramirez-Cecena said he was told that he’s eligible for a second covid booster shot but had yet to receive it as of December. A detainee at Moshannon Valley Processing Center in Pennsylvania said a guard was allowed to interact with detainees while visibly sick, said Brittney Bringuez, asylum program coordinator at Physicians for Human Rights, who visited the facility this fall.

The court order that required ICE to consider releasing people with covid risks has helped detainees with serious medical conditions, advocates said. Under the order, ICE released about 60,000 medically vulnerable detainees in two years, said Susan Meyers, senior staff attorney at the Southern Poverty Law Center, one of the advocacy groups that helped bring the lawsuit that resulted in the court order.

ICE said in a statement it will still consider covid risk factors as a reason for release. But lawyers said ICE facilities often failed to comply with the court order when it was in place.

Last year, ICE denied Ricardo Chambers’ request for release from Stewart Detention Center. Chambers, who is 40, has serious psychiatric illnesses, considered a risk factor under the court order. He also has trouble breathing and chokes in his sleep — the result of a nasal injury he sustained in an attack before he was detained. It has yet to be repaired during the two years he has been at the detention facility.

He has filed complaints about Stewart’s covid protocols, including crowded conditions and failures by staffers to wear masks or other protective equipment. In its denial of his release, ICE said Chambers was a threat to public safety because of his criminal history, according to his lawyer Erin Argueta, lead attorney for the Southern Poverty Law Center’s Southeast Immigrant Freedom Initiative office in Lumpkin. Chambers has served prison time for his criminal convictions, she said, and there’s a family in New York that would take him in.

Earlier this year, he was sent to solitary confinement for about 10 days after testing positive for covid, he said. But Chambers, who is fighting a deportation order to Jamaica, said his covid experience was no different from the other times he had been in solitary.

“You’ll be treated like an animal, caged, and for no fault of your own,” Chambers said.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Medical equipment is still strewn around the house of Rick Lucas, 62, nearly two years after he came home from the hospital. He picks up a spirometer, a device that measures lung capacity, and takes a deep breath — though not as deep as he’d like.

Still, Lucas has come a long way for someone who spent more than three months on a ventilator because of covid-19.

“I’m almost normal now,” he said. “I was thrilled when I could walk to the mailbox. Now we’re walking all over town.”

Dozens of major medical centers have established specialized covid clinics around the country. A crowdsourced project counted more than 400. But there’s no standard protocol for treating long covid. And experts are casting a wide net for treatments, with few ready for formal clinical trials.

It’s not clear just how many people have suffered from symptoms of long covid. Estimates vary widely from study to study — often because the definition of long covid itself varies. But the more conservative estimates still count millions of people with this condition. For some, the lingering symptoms are worse than the initial bout of covid. Others, like Lucas, were on death’s door and experienced a roller-coaster recovery, much worse than expected, even after a long hospitalization.

Symptoms vary widely. Lucas had brain fog, fatigue, and depression. He’d start getting his energy back, then go try light yardwork and end up in the hospital with pneumonia.

It wasn’t clear which ailments stemmed from being on a ventilator so long and which signaled the mysterious condition called long covid.

“I was wanting to go to work four months after I got home,” Rick said over the laughter of his wife and primary caregiver, Cinde.

“I said, ‘You know what, just get up and go. You can’t drive. You can’t walk. But go in for an interview. Let’s see how that works,’” Cinde recalled.

Rick did start working earlier this year, taking short-term assignments in his old field as a nursing home administrator. But he’s still on partial disability.

Why has Rick mostly recovered while so many haven’t shaken the symptoms, even years later?

“There is absolutely nothing anywhere that’s clear about long covid,” said Dr. Steven Deeks, an infectious disease specialist at the University of California-San Francisco. “We have a guess at how frequently it happens. But right now, everyone’s in a data-free zone.”

Researchers like Deeks are trying to establish the condition’s underlying causes. Some of the theories include inflammation, autoimmunity, so-called microclots, and bits of the virus left in the body. Deeks said institutions need more money to create regional centers of excellence to bring together physicians from various specialties to treat patients and research therapies.

Patients say they are desperate and willing to try anything to feel normal again. And often they post personal anecdotes online.

“I’m following this stuff on social media, looking for a home run,” Deeks said.

The National Institutes of Health promises big advances soon through the RECOVER Initiative, involving thousands of patients and hundreds of researchers.

“Given the widespread and diverse impact the virus has on the human body, it is unlikely that there will be one cure, one treatment,” Dr. Gary Gibbons, director of the National Heart, Lung, and Blood Institute, told NPR. “It is important that we help find solutions for everyone. This is why there will be multiple clinical trials over the coming months.”

Meanwhile, tension is building in the medical community over what appears to be a grab-bag approach in treating long covid ahead of big clinical trials. Some clinicians hesitate to try therapies before they’re supported by research.

Dr. Kristin Englund, who oversees more than 2,000 long covid patients at the Cleveland Clinic, said a bunch of one-patient experiments could muddy the waters for research. She said she encouraged her team to stick with “evidence-based medicine.”

“I’d rather not be just kind of one-off trying things with people, because we really do need to get more data and evidence-based data,” she said. “We need to try to put things in some sort of a protocol moving forward.”

It’s not that she lacks urgency. Englund experienced her own long covid symptoms. She felt terrible for months after getting sick in 2020, “literally taking naps on the floor of my office in the afternoon,” she said.

More than anything, she said, these long covid clinics need to validate patients’ experiences with their illness and give them hope. She tries to stick with proven therapies.

For example, some patients with long covid develop POTS — a syndrome that causes them to get dizzy and their heart to race when they stand up. Englund knows how to treat those symptoms. With other patients, it’s not as straightforward. Her long covid clinic focuses on diet, sleep, meditation, and slowly increasing activity.

But other doctors are willing to throw all sorts of treatments at the wall to see what might stick.

At the Lucas house in Tennessee, the kitchen counter can barely contain the pill bottles of supplements and prescriptions. One is a drug for memory. “We discovered his memory was worse [after taking it],” Cinde said.

Other treatments, however, seemed to have helped. Cinde asked their doctor about her husband possibly taking testosterone to boost his energy, and, after doing research, the doctor agreed to give it a shot.

“People like myself are getting a little bit out over my skis, looking for things that I can try,” said Dr. Stephen Heyman, a pulmonologist who treats Rick Lucas at the long covid clinic at Ascension Saint Thomas in Nashville.

He’s trying medications seen as promising in treating addiction and combinations of drugs used for cholesterol and blood clots. And he has considered becoming a bit of a guinea pig himself.

Heyman has been up and down with his own long covid. At one point, he thought he was past the memory lapses and breathing trouble, then he caught the virus a second time and feels more fatigued than ever.

“I don’t think I can wait for somebody to tell me what I need to do,” he said. “I’m going to have to use my expertise to try and find out why I don’t feel well.”

This story is from a reporting partnership that includes WPLN, NPR, and KHN.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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This story can be republished for free (details).

His parents sued the Kool Smiles dental clinic in Yuma, Arizona, and its private equity investor, FFL Partners. They argued the procedures were done needlessly, in keeping with a corporate strategy to maximize profits by overtreating kids from lower-income families enrolled in Medicaid. Zion died after being diagnosed with “brain damage caused by a lack of oxygen,” according to the lawsuit.

Kool Smiles “overtreats, underperforms and overbills,” the family alleged in the suit, which was settled last year under confidential terms. FFL Partners and Kool Smiles had no comment but denied liability in court filings.

Private equity is rapidly moving to reshape health care in America, coming off a banner year in 2021, when the deep-pocketed firms plowed $206 billion into more than 1,400 health care acquisitions, according to industry tracker PitchBook.

Seeking quick returns, these investors are buying into eye care clinics, dental management chains, physician practices, hospices, pet care providers, and thousands of other companies that render medical care nearly from cradle to grave. Private equity-backed groups have even set up special “obstetric emergency departments” at some hospitals, which can charge expectant mothers hundreds of dollars extra for routine perinatal care.

As private equity extends its reach into health care, evidence is mounting that the penetration has led to higher prices and diminished quality of care, a KHN investigation has found. KHN found that companies owned or managed by private equity firms have agreed to pay fines of more than $500 million since 2014 to settle at least 34 lawsuits filed under the False Claims Act, a federal law that punishes false billing submissions to the federal government with fines. Most of the time, the private equity owners have avoided liability.

New research by the University of California-Berkeley has identified “hot spots” where private equity firms have quietly moved from having a small foothold to controlling more than two-thirds of the market for physician services such as anesthesiology and gastroenterology in 2021. And KHN found that in San Antonio, more than two dozen gastroenterology offices are controlled by a private equity-backed group that billed a patient $1,100 for her share of a colonoscopy charge — about three times what she paid in another state.

It’s not just prices that are drawing scrutiny.

Whistleblowers and injured patients are turning to the courts to press allegations of misconduct or other improper business dealings. The lawsuits allege that some private equity firms, or companies they invested in, have boosted the bottom line by violating federal false claims and anti-kickback laws or through other profit-boosting strategies that could harm patients.

“Their model is to deliver short-term financial goals and in order to do that you have to cut corners,” said Mary Inman, an attorney who represents whistleblowers.

Federal regulators, meanwhile, are almost blind to the incursion, since private equity typically acquires practices and hospitals below the regulatory radar. KHN found that more than 90% of private equity takeovers or investments fall below the $101 million threshold that triggers an antitrust review by the Federal Trade Commission and the U.S. Justice Department.

Spurring Growth

Private equity firms pool money from investors, ranging from wealthy people to college endowments and pension funds. They use that money to buy into businesses they hope to flip at a sizable profit, usually within three to seven years, by making them more efficient and lucrative.

Private equity has poured nearly $1 trillion into nearly 8,000 health care transactions during the past decade, according to PitchBook.

Fund managers who back the deals often say they have the expertise to reduce waste and turn around inefficient, or moribund, businesses, and they tout their role in helping to finance new drugs and technologies expected to benefit patients in years to come.

Critics see a far less rosy picture. They argue that private equity’s playbook, while it may work in some industries, is ill suited for health care, when people’s lives are on the line.

In the health care sphere, private equity has tended to find legal ways to bill more for medical services: trimming services that don’t turn a profit, cutting staff, or employing personnel with less training to perform skilled jobs — actions that may put patients at risk, critics say.

KHN, in a series of articles published this year, has examined a range of private equity forays into health care, from its marketing of America’s top-selling emergency contraception pill to buying up whole chains of ophthalmology and gastroenterology practices and investing in the booming hospice care industry and even funeral homes.

These deals happened on top of well-publicized takeovers of hospital emergency room staffing firms that led to outrageous “surprise” medical bills for some patients, as well as the buying up of entire rural hospital systems.

“Their only goal is to make outsize profits,” said Laura Olson, a political science professor at Lehigh University and a critic of the industry.

Hot Spots

When it comes to acquisitions, private equity firms have similar appetites, according to a KHN analysis of 600 deals by the 25 firms that PitchBook says have most frequently invested in health care.

Eighteen of the firms have dental companies listed in their portfolios, and 16 list centers that offer treatment of cataracts, eye surgery, or other vision care, KHN found.

Fourteen have bought stakes in animal hospitals or pet care clinics, a market in which rapid consolidation led to a recent antitrust action by the FTC. The agency reportedly also is investigating whether U.S. Anesthesia Partners, which operates anesthesia practices in nine states, has grown too dominant in some areas.

Private equity has flocked to companies that treat autism, drug addiction, and other behavioral health conditions. The firms have made inroads into ancillary services such as diagnostic and urine-testing and software for managing billing and other aspects of medical practice.

Private equity has done so much buying that it now dominates several specialized medical services, such as anesthesiology and gastroenterology, in a few metropolitan areas, according to new research made available to KHN by the Nicholas C. Petris Center at UC-Berkeley.

Although private equity plays a role in just 14% of gastroenterology practices nationwide, it controls nearly three-quarters of the market in at least five metropolitan areas across five states, including Texas and North Carolina, according to the Petris Center research.

Similarly, anesthesiology practices tied to private equity hold 12% of the market nationwide but have swallowed up more than two-thirds of it in parts of five states, including the Orlando, Florida, area, according to the data.

These expansions can lead to higher prices for patients, said Yashaswini Singh, a researcher at the Bloomberg School of Public Health at Johns Hopkins University.

In a study of 578 physician practices in dermatology, ophthalmology, and gastroenterology published in JAMA Health Forum in September, Singh and her team tied private equity takeovers to an average increase of $71 per medical claim filed and a 9% increase in lengthy, more costly, patient visits.

Singh said in an interview that private equity may develop protocols that bring patients back to see physicians more often than in the past, which can drive up costs, or order more lucrative medical services, whether needed or not, that boost profits.

“There are more questions than answers,” Singh said. “It really is a black hole.”

Jean Hemphill, a Philadelphia health care attorney, said that in some cases private equity has merely taken advantage of the realities of operating a modern medical practice amid growing administrative costs.

Physicians sometimes sell practices to private equity firms because they promise to take over things like billing, regulatory compliance, and scheduling — allowing doctors to focus on practicing medicine. (The physicians also might reap a big payout.)

“You can’t do it on a scale like Marcus Welby used to do it,” Hemphill said, referring to an early 1970s television drama about a kindly family doctor who made house calls. “That’s what leads to larger groups,” she said. “It is a more efficient way to do it.”

But Laura Alexander, a former vice president of policy at the nonprofit American Antitrust Institute, which collaborated on the Petris Center research, said she is concerned about private equity’s growing dominance in some markets.

“We’re still at the stage of understanding the scope of the problem,” Alexander said. “One thing is clear: Much more transparency and scrutiny of these deals is needed.”

‘Revenue Maximization’

Private equity firms often bring a “hands-on” approach to management, taking steps such as placing their representatives on a company’s board of directors and influencing the hiring and firing of key staffers.

“Private equity exercises immense control over the operations of health care companies it buys an interest in,” said Jeanne Markey, a Philadelphia whistleblower attorney.

Markey represented physician assistant Michelle O’Connor in a 2015 whistleblower lawsuit filed against National Spine and Pain Centers and its private equity owner, Sentinel Capital Partners.

In just a year under private equity guidance, National Spine’s patient load quadrupled as it grew into one of the nation’s largest pain management chains, treating more than 160,000 people in about 40 offices across five East Coast states, according to the suit.

O’Connor, who worked at two National Spine clinics in Virginia, said the mega-growth strategy sprang from a “corporate culture in which money trumps the provision of appropriate patient care,” according to the suit.

She cited a “revenue maximization” policy that mandated medical staffers see at least 25 patients a day, up from 16 to 18 before the takeover.

The pain clinics also overcharged Medicare by billing up to $1,100 for “unnecessary and often worthless” back braces and charging up to $1,800 each for urine drug tests that were “medically unnecessary and often worthless,” according to the suit.

In April 2019, National Spine paid the Justice Department $3.3 million to settle the whistleblower’s civil case without admitting wrongdoing.

Sentinel Capital Partners, which by that time had sold the pain management chain to another private equity firm, paid no part of National Spine’s settlement, court records show. Sentinel Capital Partners had no comment.

In another whistleblower case, a South Florida pharmacy owned by RLH Equity Partners raked in what the lawsuit called an “extraordinarily high” profit on more than $68 million in painkilling and scar creams billed to the military health insurance plan Tricare.

The suit alleges that the pharmacy paid illegal kickbacks to telemarketers who drove the business. One doctor admitted prescribing the creams to scores of patients he had never seen, examined, or even spoken to, according to the suit.

RLH, based in Los Angeles, disputed the Justice Department’s claims. In 2019, RLH and the pharmacy paid a total of $21 million to settle the case. Neither admitted liability. RLH managing director Michel Glouchevitch told KHN that his company cooperated with the investigation and that “the individuals responsible for any problems have been terminated.”

In many fraud cases, however, private equity investors walk away scot-free because the companies they own pay the fines. Eileen O’Grady, a researcher at the nonprofit Private Equity Stakeholder Project, said government should require “added scrutiny” of private equity companies whose holdings run afoul of the law.

“Nothing like that exists,” she said.

Questions About Quality

Whether private equity influences the quality of medical care is tough to discern.

Robert Homchick, a Seattle health care regulatory attorney, said private equity firms “vary tremendously” in how conscientiously they manage health care holdings, which makes generalizing about their performance difficult.

“Private equity has some bad actors, but so does the rest of the [health care] industry,” he said. “I think it’s wrong to paint them all with the same brush.”

But incipient research paints a disturbing picture, which took center stage earlier this year.

On the eve of President Joe Biden’s State of the Union speech in March, the White House released a statement that accused private equity of "buying up struggling nursing homes” and putting “profits before people.”

The covid-19 pandemic had highlighted the “tragic impact” of staffing cuts and other moneysaving tactics in nursing homes, the statement said.

More than 200,000 nursing home residents and staffers had died from covid in the previous two years, according to the White House, and research had linked private equity to inflated nursing costs and elevated patient death rates.

Some injured patients are turning to the courts in hopes of holding the firms accountable for what the patients view as lapses in care or policies that favor profits over patients.

Dozens of lawsuits link patient harm to the sale of Florida medical device maker Exactech to TPG Capital, a Texas private equity firm. TPG acquired the device company in February 2018 for about $737 million.

In August 2021, Exactech recalled its Optetrak knee replacement system, warning that a defect in packaging might cause the implant to loosen or fracture and cause “pain, bone loss or recurrent swelling.” In the lawsuits, more than three dozen patients accuse Exactech of covering up the defects for years, including, some suits say, when “full disclosure of the magnitude of the problem … might have negatively impacted” Exactech’s sale to TPG.

Linda White is suing Exactech and TPG, which she asserts is “directly involved” in the device company’s affairs.

White had Optetrak implants inserted into both her knees at a Galesburg, Illinois, hospital in June 2012. The right one failed and was replaced with a second Optetrak implant in July 2015, according to her lawsuit. That one also failed, and she had it removed and replaced with a different company’s device in January 2019.

The Exactech implant in White’s left knee had to be removed in May 2019, according to the suit, which is pending in Cook County Circuit Court in Illinois.

In a statement to KHN, Exactech said it conducted an “extensive investigation” when it received reports of “unexpected wear of our implants.”

Exactech said the problem dated to 2005 but was discovered only in July of last year. “Exactech disputes the allegations in these lawsuits and intends to vigorously defend itself,” the statement said. TPG declined to comment but has denied the allegations in court filings.

‘Invasive Procedures’

In the past, private equity business tactics have been linked to scandalously bad care at some dental clinics that treated children from low-income families.

In early 2008, a Washington, D.C., television station aired a shocking report about a local branch of the dental chain Small Smiles that included video of screaming children strapped to straightjacket-like “papoose boards” before being anesthetized to undergo needless operations like baby root canals.

Five years later, a U.S. Senate report cited the TV exposé in voicing alarm at the "corporate practice of dentistry in the Medicaid program.” The Senate report stressed that most dentists turned away kids enrolled in Medicaid because of low payments and posed the question: How could private equity make money providing that care when others could not?

“The answer is ‘volume,’” according to the report.

Small Smiles settled several whistleblower cases in 2010 by paying the government $24 million. At the time, it was providing “business management and administrative services” to 69 clinics nationwide, according to the Justice Department. It later declared bankruptcy.

But complaints that volume-driven dentistry mills have harmed disadvantaged children didn’t stop.

According to the 2018 lawsuit filed by his parents, Zion Gastelum was hooked up to an oxygen tank after questionable root canals and crowns “that was empty or not operating properly” and put under the watch of poorly trained staffers who didn’t recognize the blunder until it was too late.

Zion never regained consciousness and died four days later at Phoenix Children’s Hospital, the suit states. The cause of death was “undetermined,” according to the Maricopa County medical examiner’s office. An Arizona state dental board investigation later concluded that the toddler’s care fell below standards, according to the suit.

Less than a month after Zion’s death in December 2017, the dental management company Benevis LLC and its affiliated Kool Smiles clinics agreed to pay the Justice Department $24 million to settle False Claims Act lawsuits. The government alleged that the chain performed “medically unnecessary” dental services, including baby root canals, from January 2009 through December 2011.

In their lawsuit, Zion’s parents blamed his death on corporate billing policies that enforced “production quotas for invasive procedures such as root canals and crowns” and threatened to fire or discipline dental staff “for generating less than a set dollar amount per patient.”

Kool Smiles billed Medicaid $2,604 for Zion’s care, according to the suit. FFL Partners did not respond to requests for comment. In court filings, it denied liability, arguing it did not provide “any medical services that harmed the patient.”

Covering Tracks

Under a 1976 federal law called the Hart-Scott-Rodino Antitrust Improvements Act, deal-makers must report proposed mergers to the FTC and the Justice Department antitrust division for review. The intent is to block deals that stifle competition, which can lead to higher prices and lower-quality services.

But there’s a huge blind spot, which stymies government oversight of more than 90% of private equity investments in health care companies: The current threshold for reporting deals is $101 million.

KHN’s analysis of PitchBook data found that just 423 out of 7,839 private equity health care deals from 2012 through 2021 were known to have exceeded the current threshold.

In some deals, private equity takes a controlling interest in medical practices, and doctors work for the company. In other cases, notably in states whose laws prohibit corporate ownership of physician practices, the private equity firm handles a range of management duties.

Thomas Wollmann, a University of Chicago researcher, said antitrust authorities may not learn of consequential transactions “until long after they have been completed” and “it's very hard to break them up after the fact.”

In August, the FTC took aim at what it called “a growing trend toward consolidation” by veterinary medicine chains.

The FTC ordered JAB Consumer Partners, a private equity firm based in Luxembourg, to divest from some clinics in the San Francisco Bay and Austin, Texas, areas as part of a proposed $1.1 billion takeover of a rival.

The FTC said the deal would eliminate “head-to-head” competition, “increasing the likelihood that customers are forced to pay higher prices or experience a degradation in quality of the relevant services.”

Under the order, JAB must obtain FTC approval before buying veterinary clinics within 25 miles of the sites it owns in Texas and California.

The FTC would not say how much market consolidation is too much or whether it plans to step up scrutiny of health care mergers and acquisitions.

“Every case is fact-specific,” Betsy Lordan, an FTC spokesperson, told KHN.

Lordan, who has since left the agency, said regulators are considering updates to regulations governing mergers and are reviewing about 1,900 responses to the January 2022 request for public comment. At least 300 of the comments were from doctors or other health care workers.

Few industry observers expect the concerns to abate; they might even increase.

Investors are flush with “dry powder,” industry parlance for money waiting to stoke a deal.

The Healthcare Private Equity Association, which boasts about 100 investment companies as members, says the firms have $3 trillion in assets and are pursuing a vision for "building the future of healthcare.”

That kind of talk alarms Cornell University professor Rosemary Batt, a longtime critic of private equity. She predicts that investors chasing outsize profits will achieve their goals by “sucking the wealth” out of more and more health care providers.

“They are constantly looking for new financial tricks and strategies,” Batt said.

KHN’s Megan Kalata contributed to this article.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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