Republicans' Proposed Medicaid Cuts Would Hit Rural Patients Hard

Pemiscot Memorial, the public hospital in Missouri’s poorest county, depends on Medicaid funding to survive, its CEO says.

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For the hundreds of rural U.S. hospitals struggling to stay in business, health policy decisions made in Washington, D.C., this summer could make survival a lot tougher.

Since 2010, at least 79 rural hospitals have closed across the country, and nearly 700 more are at risk of closing. These hospitals serve a largely older, poorer and sicker population than most hospitals, and that makes them particularly vulnerable to changes made to Medicaid funding.

“A lot of hospitals like [ours] could get hurt,” says Kerry Noble, CEO of Pemiscot Memorial Health Systems, the public hospital in the poorest county in Missouri.

The GOP’s American Health Care Act would cut Medicaid — the public insurance program for many low-income families, children and elderly Americans, as well as people with disabilities — by as much as $834 billion. The Congressional Budget Office has said that would result in 23 million more people being uninsured in the next 10 years. Even more could lose coverage under the budget proposed by President Donald Trump, which suggests an additional $610 billion in cuts to the program.

That’s a problem for small rural hospitals like Pemiscot Memorial, which depend on Medicaid. The hospital serves an agricultural county that ranks worst in Missouri for most health indicators, including premature deaths, quality of life and even adult smoking rates. Closing the county’s hospital could make those much worse.

And a rural hospital closure goes beyond people losing health care. Jobs, property values, even schools can suffer. Pemiscot County already has the state’s highest unemployment rate. Losing the hospital would mean losing the county’s largest employer.

“It would be devastating economically,” Noble says. “Our annual payrolls are around $20 million a year.”

All of that weighs on Noble’s mind when he ponders the hospital’s future. Pemiscot’s story is a lesson in how decisions made by state and federal lawmakers have put these small hospitals on the edge of collapse.

Kerry Noble, Pemiscot Memorial’s CEO, points to plans for expansion and improvements the county hospital was ready to make –and pay for — in 2005, before the state legislature slashed Medicaid rolls.

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Back in 2005, things were very different. The hospital was doing well, and Noble commissioned a $16 million plan to completely overhaul the facility, which was built back in 1951.

“We were going to pay for the first phase of that in cash. We didn’t even need to borrow any money for it,” Noble says while thumbing through the old blueprints in his office at the hospital.

But those renovations never happened. In 2005 the Missouri legislature passed sweeping cuts to Medicaid. More than 100,000 Missourians lost their health coverage and this had an immediate impact on Pemiscot Memorial’s bottom line. About 40 percent of their patients were enrolled in Medicaid at the time, and nearly half of them lost their insurance in the cuts.

Those now-uninsured patients still needed care, though, and as a public hospital, Pemiscot Memorial had to take them in.

“So we’re still providing care, but we’re no longer being compensated,” Noble says.

And as the cost of treating the uninsured went up, the hospital’s already slim margins shrunk. The hospital went into survival mode.

The Affordable Care Act was supposed to help with the problem of uncompensated care. It offered rural hospitals a potential lifeline by giving states the option to expand Medicaid to a larger segment of their populations. In Missouri that would have covered about 300,000 people.

“It was the fundamental building block [of the ACA] that was supposed to cover low-income Americans,” says Sidney Watson, a St. Louis University health law professor.

In Missouri, Kerry Noble and Pemiscot Memorial became the poster children for Medicaid expansion. In 2013 Noble went to the state capital to make the case for expansion on behalf of the hospital.

“Our facility will no longer be in existence if this expansion does not occur,” Noble told a crowd at a press conference. “Medicaid cuts are always hard to rural hospitals,” Watson says. “People have less employer-sponsored coverage in rural areas and people are relying more on Medicaid and on Medicare.”

But the Missouri legislature voted against expansion.

For now, the doors of Pemiscot Memorial are still open. The hospital has cut some costly programs — like obstetrics — outsourced its ambulance service and has skipped upgrades.

“People might look at us and say, ‘See, you didn’t need Medicaid expansion. You’re still there,’ ” Noble says. “But how long are we going to be here if we don’t get some relief?”

Relief for rural hospitals is not what’s being debated in Washington right now. Under the GOP House plan, even states like Missouri that did not expand Medicaid could see tens of thousands of residents losing their Medicaid coverage.

This story is part of NPR’s reporting partnership with KBIA, Side Effects Public Media and Kaiser Health News. The local version also got support from the Association of Health Care Journalists and The Commonwealth Fund.

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Fans Of Pakistan's Cricket Team Arrested For Sedition In India

Pakistan’s captain, Sarfraz Ahmed, gives a teammate a leaping hug defeating India in the ICC Champions Trophy final in London on Sunday.

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When Pakistan clobbered India in the ICC Champions Trophy final on Sunday — pulling off an upset so shocking, ESPN called it “some diamond-studded, galactic-scale nonsense” — flabbergasted fans took to the streets in several countries to celebrate the national cricket team’s big win.

In India, those celebrations got some fans in deep legal trouble.

Police have arrested at least 19 people across the country on charges of sedition, according to the Times of India.

“While the entire country was saddened by the defeat, these people were raising slogans in favour of Pakistan and burst crackers on Sunday night, threatening peace in the area,” Sanjay Pathak, a police inspector in Madhya Pradesh, a state where 15 men were arrested, told the newspaper.

“They celebrated with firecrackers, distributing sweets and raising slogans of ‘Long live Pakistan,’ ” another Madhya Pradesh police officer, Ramasray Yadav, told The New York Times. “They expressed hatred toward India and friendship toward Pakistan. They are charged for sedition and criminal conspiracy.”

The Times reports that all the people arrested are Muslims:

“The arrests come as some Muslims in India say they feel a sense of rising alienation. There have been episodes of violence, including by vigilante groups that have staged attacks on Muslims and low-caste Hindus suspected of slaughtering cows, which are considered sacred in Hinduism, the dominant religion in India.”

“These arrests are patently absurd, and the 19 men should be released immediately,” Asmita Basu, program director of Amnesty International India, said in a statement.

“Even if the arrested men had supported Pakistan, as the police claim, that is not a crime,” Basu continued. “Supporting a sporting team is a matter of individual choice, and arresting someone for cheering a rival team clearly violates their right to freedom of expression.”

But Pathak maintains similar situations have caused unrest in the past.

“This has been happening for several years, whenever there is an India-Pakistan match,” he told CNN. “We don’t have any previous cases or official complaints on record but those residing in Mohad have told us that this has happened before.”

As NPR’s Michel Martin reported, the two countries rarely play each other in cricket, partly because of political tensions between them — which made Sunday’s match all the more heavy with consequence.

Osman Samiuddin, senior editor of ESPNCricinfo, told Michel that “450 to 500 million people watched it around the world on TV. … It’s not just a sport. It’s not just a religion. I think it’s become a compulsion.”

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Intel Signs On As An Olympic Sponsor, Promising Virtual Reality And 360-Degree Video

Intel says it will bring virtual reality, drones and 360-degree to future Olympics, after signing a deal to become a worldwide Olympic partner through 2024. The company says it will bring its technical prowess to the upcoming Winter Games in Pyeongchang, South Korea.

Intel “will accelerate the adoption of technology for the future of sports on the world’s largest athletic stage,” CEO Brian Krzanich said in a statement about the company’s plan.

The International Olympic Committee and Intel announced the new sponsorship deal Wednesday. If the plans live up to high expectations, Intel’s participation could change the way we watch the Olympics.

Some highlights:

  • Intel will offer “the first live virtual reality broadcast of the Olympic Winter Games” to immerse fans in the action.
  • 360-degree replay technology will let viewers isolate moments and watch them “from every angle at the Olympic venues.”
  • Drones will put on a light show that “will create never-seen-before images in the sky.”

In a sign that the recent trend of letting Olympics viewers to choose their own content will continue, Intel and the IOC say they will give fans “the power to choose what they want to see” and how they experience it.

The technological changes aren’t the only thing that will be different about the Pyeongchang Games. In March, NBC said that it would end its longtime practice of broadcasting time-delayed coverage of events.

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CEOs Say They'll Sell Health Insurance Next Year, But Are Flying Blind

Mario Schlosser, CEO of the startup Oscar Health, says he’s optimistic that Congress will come up with a humane health care bill.

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The Senate vote on a bill to repeal and replace the Affordable Care Act is, according to conventional wisdom, one week away.

And we still don’t know what’s in the bill.

Not having concrete information is deeply uncomfortable for a journalist like me.

But for lots of people, like those who work in the insurance industry, not knowing what’s in that bill is a bigger deal. Wednesday is a deadline of sorts for these companies. If they want to sell policies next year in states that use the federal health exchange on, they have to let Health and Human Services know their intentions.

How are they dealing?

I reached out to a couple of insurance executives and asked.

Mario Schlosser is CEO of Oscar, the insurance startup that’s betting hard on the Affordable Care Act, also known as Obamacare.

Wednesday morning, Oscar announced it’s going to keep selling individual insurance in New York in 2018, and expanding its offerings in five states – New Jersey, Ohio, California, Florida and Tennessee.

It’s a bold move, considering Congress is right now considering dismantling the Affordable Care Act markets and changing the rules governing health insurance.

“When the dust settles, the individual market will be stable, and we want to be part of getting it there,” Schlosser told me.

He agreed with President Trump that the American Health Care Act, passed by the House in May, is “mean.”

“I think that bill was mean and I think that bill would lead to loss of coverage that would be bad for pretty much everybody in the system,” he said.

Schlosser said it’s crucial for the Trump administration to stabilize the current system in preparation for any changes. That includes enforcing the individual mandate, which penalizes people who don’t buy insurance, and promising to make cost-sharing payments required under the ACA that reimburse insurers for giving extra discounts to the lowest-income customers.

If they don’t, “it would kill the market overnight.” Schlosser said.

“That would be terrible for society, it would be terrible for the whole health care system, and everybody would be worse off,” he said.

I pointed out to Schlosser that his company has a direct line to the White House. His partner and co-founder is Joshua Kushner, the brother of Jared Kushner, Trump’s son-in-law and senior adviser.

Schlosser avoided talking about that relationship and suggested he didn’t know what Trump will do.

Later, I sat down for a cup of coffee at the National Press Club with Dan Hilferty, who runs Independence Blue Cross in Philadelphia and is chairman of the board of the Blue Cross Blue Shield Association. His company sells ACA health plans in the Philadelphia area and southern New Jersey.

“I’m here in DC because of what’s happening in health care,” he said. But acknowledged he doesn’t know what’s in the Senate bill, even though the Blue plans he represents as chairman of the association insure one-third of all Americans.

Hilferty said the ACA has problems, but it did manage to bring insurance coverage to about 20 million people who didn’t have it before. That’s what he’s focused on in meetings with members of Congress.

The Congressional Budget Office says the bill passed by the House would result in 23 million fewer people having insurance coverage in 10 years, compared to current law.

“So I would say let’s build a system that doesn’t that doesn’t push those 20 million people back to uninsured, “Hilferty said.

He says his company is focused on ensuring that whatever lawmakers do, they don’t make it harder for low-income people to get insurance.

“Frankly, we don’t care if it’s the ACA or the AHCA as long as it gives us the ability to cover more people, get them access to care and not lose money,” Hilferty said.

Like Schlosser, Hilferty is worried about what’s going to happen next year. His company has filed to sell ACA plans in the Philadelphia area. But if the Trump administration doesn’t commit to making cost-sharing payments or to enforcing the individual mandate that requires people to have insurance, his rates could go up a lot.

Either way, both companies are operating as if the ACA markets will be alive and functioning in 2018.

“I do think that in the end, reason and compassion will prevail in DC,” Schlosser said.

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Survivors Of Childhood Diseases Struggle To Find Care As Adults

As a child, Rachael Goldring had multiple open-heart surgeries to treat her congenital heart disease. At 24, she still sees pediatricians because she’s had difficulty finding the right care in adult medicine.

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Rachael Goldring was born with congenital heart disease. Had she been born a few decades earlier, she probably would have died as a baby. Goldring is now 24, and among a population of patients who present new challenges to a health care system unaccustomed to dealing with survivors of once-fatal conditions.

Today there are more adults than kids living with some of these diseases, and medical training lags behind. Young adults who can’t find suitable doctors may drop out of care, and their conditions may worsen.

Goldring’s condition was pulmonary atresia with Tetralogy of Fallot. She was born without a pulmonary valve directing blood from her heart to her lungs. It’s the condition that talk show host Jimmy Kimmel’s baby was born with this spring.

“I had my first surgery when I was 9 months,” Goldring says. “Now, they do it from birth.”

Her condition has also meant three more surgeries, a heart valve from a cadaver, complicated secondary diseases, and a lifetime in and out of doctors’ offices.

“I just celebrated my one-year anniversary of staying out of the hospital for the first time since birth,” Goldring says. “So, this year, knock on wood, it’s been amazing.”

But she fears it might not last. Right now, she’s in limbo between pediatric and adult medical care. For Goldring, finding a good doctor could be a matter of life and death.

Today, survivors of congenital heart disease can live well past childhood. Dr. Patrick Burke, a pediatrician at Valley Children’s Hospital in Madera, Calif., says other once-fatal ailments like sickle cell disease and spina bifida have undergone similar advances.

“This is the so-called medical miracle promised to our parents and grandparents,” Burke says, adding that miracle kids like Goldring grow up to be complicated adults. “The job’s not done after the surgery or the initial treatment. Many if not most of these conditions require ongoing medical care — lifelong medical care.”

Burke is in charge of a new program at his hospital in the new field of “transitional care.” He says many conditions worsen around the age of 18, right as children age out of pediatric care. For instance, he says, that’s when patients with congenital heart disease suffer complications with their blood and organs. The trend is particularly stark for cystic fibrosis.

“We’re seeing this spike of deaths that are happening in the early 20s. And it’s bizarre,” he says.

Dr. Megumi Okumura, a pediatrician with the University of California, San Francisco, became interested in this transition during her residency in the early 2000s. She would see 40- and 50-year-olds in pediatric wards. The reason, she says, partly lies with our fragmented health care system.

“They are transferring from differing systems of care,” she says, noting the silos that separate pediatric care from adult care. “We have different funding streams and programs.”

Now, Okumura and other researchers are looking for ways to remove what she considers artificial barriers. Clinics around the world are trying out new strategies like giving non-pediatric doctors more training, or bringing in transitional specialists to connect young adults who are chronically ill with new providers.

Goldring is fortunate in that she can remain with her pediatrician until she finds the right adult provider. She’s working on it, but at the moment, she’s much more focused on another transition: She’ll be getting married in October.

This story is part of a reporting partnership with NPR, local member stations and Kaiser Health News.

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Here's What We Know About The Senate GOP Health Care Bill

Senate Majority Leader Mitch McConnell, R-K.Y., seen speaking to reporters on Tuesday, is set to release a draft of the Senate’s version of the Republican health care bill on Thursday.

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Senate Majority Leader Mitch McConnell says Republicans will release a discussion draft of their version of the health care bill on Thursday, with a vote likely next week.

Private health care talks have been underway in the Senate for weeks. McConnell tapped a 13-member working group last month to hash out senators’ differences over the House-passed American Health Care Act. McConnell’s office has since taken the lead drafting the Senate version of the party’s long-promised legislation to dismantle the Affordable Care Act.

Senate Republicans have been coy — or simply out of the loop — on the specifics in the Senate plan, but here is what we know about what might be in the bill and where it could be headed:

It Sounds A Lot Like The House Bill

After the House passed AHCA in early May, leading senators asserted that the Senate would go their own way. “We’re writing a Senate bill and not passing the House bill,” Sen. Lamar Alexander, R-Tenn., said then. “We’ll take whatever good ideas we find there that meet our goals.”

In the end, those goals appear to be aligned.

The structure of the Senate bill, as described by GOP senators and aides, appears fundamentally the same as the House-passed plan.

The Senate bill is also expected to repeal the individual mandate and all or most of the ACA’s taxes, phase out the Medicaid expansion as well as change how the Medicaid program is funded, establish a system of tax credits to help people buy insurance if they choose, and make it easier for states to opt-out of the ACA’s mandates for preexisting conditions and minimum insurance coverage mandates.

There will be changes. For instance, the Senate version is expected to include more generous tax credits to make sure older, poorer Americans don’t get hit with higher costs. Republicans are also battling over how best to remake the Medicaid program, with key vote senators like Shelley Moore Capito of West Virginia sounding skittish about Medicaid reductions.

Other Republicans are excited by the bill. Sen. John Barrasso, R-Wyo., has been one of the most vocal advocates for Obamacare repeal. “People didn’t want to have to buy this product. This is a sinking ship, people are ready to jump off,” he said Tuesday. Republicans like Barrasso see the bill as a win for the GOP and for the promises they made on the campaign trail.

“We eliminate the individual mandate. You’ll see more people as free citizens making a decision to not have Obamacare insurance, but certainly have more freedom,” Barrasso said.

The Process Stinks

“Can you say it was done openly? With transparency and accountability? Without backroom deals and struck behind closed doors? Hidden from the people? Hell no you can’t! Have you read the bill? Have you read the reconciliation bill? Have you read the manager’s amendment? Hell no you haven’t!”

That’s not Senate Minority Leader Chuck Schumer in 2017, that was former Minority Leader John Boehner in 2010 before House Democrats passed the Affordable Care Act.

Republicans vilified Democrats seven years ago for negotiating the final details of Obamacare behind closed doors. Today Senate Republicans’ response could be: We learned it from watching you.

The Senate has not held any public hearings on their health care bill (the House did), senators involved in the talks have been tight-lipped on the substance, and the public will only have a few days to see it before it gets a vote.

McConnell brushed off questions about transparency. “They’ll have plenty of time,” he told reporters Tuesday. “We’ve been discussing all the elements of this endlessly for seven years. Everybody pretty well understands it. Everybody will have adequate time to take a look at it.”

That argument rings hollow with some of his fellow Republicans. “We used to complain like hell when the Democrats ran the Affordable Care Act. Now, we’re doing the same thing,” Sen. John McCain, R-Ariz., told CNN.

“If you’re frustrated in the lack of transparency in this process, I share your frustration,” Sen. Mike Lee, R-Utah, said in a Facebook video for his constituents. Lee is a part of the 13-member working group, but he said he hasn’t seen the draft bill. “I just haven’t been able to see it yet and as far as I know the overwhelming majority of my colleagues haven’t been able to see it either.”

Failure Is An Option

McConnell has been quietly leading Republicans’ to a vote next week but that doesn’t mean it’s going to pass.

“We’re going to make every effort to pass a bill that dramatically changes the current health care law,” McConnell said when asked if he has the votes.

“I think the leader has made it pretty clear we’re going to vote, one way or another, and hopefully we’ll have 50 votes when that time comes,” Senate Republican Conference Chairman John Thune said when asked if he believed McConnell would bring a bill to the floor that didn’t have the votes to pass.

While no Republican senator has yet come out opposed the bill, McConnell has only a two-vote margin of error with many senators voicing problems with the legislation.

“If our bill comes in with greater subsidies than Obamacare, it makes it hard for conservatives to support a bill that actually has greater subsidies than Obamacare,” Sen. Rand Paul, R-Ky., told reporters in regards to the tax credits in the GOP plan. “That for me is a nonstarter.”

Conservatives like Ted Cruz of Texas and Mike Lee have Utah have been skeptical about the bill’s ability to ultimately lower premium costs for Americans. Both are seen as potential ‘no’ votes on the bill.

More moderate senators like Susan Collins of Maine and Lisa Murkowski of Alaska are also seen as potential ‘no’ votes on the other end of the spectrum.

Defeat of the House-passed bill wouldn’t necessarily end the health care debate in Congress, but it would redefine it.

Wisconsin GOP Sen. Ron Johnson hinted at what that would look like at a constituent event last Friday. “I’m not sure if we’re going to come up with 50 votes with a Republican solution. Let’s stabilize the markets and then, long-term, work with the Democrats colleagues to actually fix the healthcare system,” Johnson said.

The White House Doesn’t Love It — Yet

The White House has maintained a light tough when it comes to shaping the policies in the health care bill, but President Trump reportedly told a group of senators last week that the bill passed in the House was “mean” and he wanted the final bill to do more to help needier Americans.

On Tuesday, White House Spokesman Sean Spicer told reporters the president “wants a bill that has heart in it” but did not offer any specific policies Trump wants in the bill. Spicer also said he didn’t know if the president had seen a draft of the Senate bill.

If the Senate approves a bill next week, it still has more hurdles to go. The House either needs to pass the Senate bill as-is and send it to Trump’s desk, or the House and Senate have to go into a third round of negotiations in which both chambers would have to vote again on a final, compromise bill.

Either way, the health care debate is likely to continue into July if the Senate can pass a bill next week.

Democrats Debate How Far To Take Their Fight

Senate Democrats can’t filibuster the bill because it’s protected under special budget rules and only requires a majority vote. They’re all going to oppose it, but they can’t ultimately stop it from eventually getting an up-or-down vote.

Democrats have started a series of protests this week that could intensify as the Senate approaches that vote. They held the floor Monday evening for a series of speeches in opposition to the bill. On Tuesday, they invoked a rule to block any committee hearings from taking place that afternoon to draw attention to their opposition to the health care bill.

Outside Democratic activists associated with Indivisible are calling for Democrats to use every procedural tactic available to slow down debate. Since amendments are unlimited on a bill like this, one activist has even called on Democrats to introduce 40,000 amendments to keep the Senate on the bill through the 2018 midterms.

It’s unclear how Democrats will respond next week, but Schumer said Republicans should expect a fight. “If Republicans won’t relent and debate their health care bill in the open for the American people to see, then they shouldn’t expect business as usual in the Senate,” Schumer said in a statement.

NPR congressional reporters Scott Detrow and Geoff Bennett contributed to this report.

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A Pioneer In 'Flat-Fee Primary Care' Had To Close Its Clinics. What Went Wrong?

In theory, “direct primary care” should result in better health for patients and lower health care costs overall. But some analysts say that approach just encourages the worried well to get more care than they need.

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In recent years, a small but growing number of medical practices embraced a buffet approach to primary care, offering patients unlimited services for a modest flat fee — say, $50 to $150 per month — instead of billing them a la carte for every office visit and test.

But a pioneer in the field — Seattle-based Qliance — shut its public clinics as of June 15, and some health care analysts are questioning whether the approach to medical care is valid and viable.

This style of medical practice is called “direct primary care,” and many doctors and patients say they like the arrangement. Typically, these physicians don’t accept insurance — which frees the doctors from having to get preapprovals from insurers on treatment and lets them skip the paperwork involved in insurance claims. Doctors say that allows them more time and energy for their patients.

Meanwhile, patients say they like being able to consult with their doctor or a nurse practitioner as often as they need to, at a relatively low cost. (Some employers buy the service for their workers.) Patients who are signed up for the plan still need to carry a regular insurance plan (typically a high-deductible policy) to cover hospitalizations, consultations with specialists and other services.

In theory, the result should be better health for patients and lower health care costs overall.

But some who analyze the use of health care are concerned that the approach encourages the “worried well” to get more care than they need. They describe unlimited primary care as a blunt instrument that doesn’t necessarily improve the odds that patients will get evidence-based services that improve their health. Others argue it’s important to find a way to provide cost-effective primary care within the health insurance context, not outside it.

Although only a sliver of medical practices operate this way, the number is on the rise, says Shawn Martin, a senior vice president at the American Academy of Family Physicians. He puts the figure at about 3 percent.

Qliance, founded in 2007, was an early leader in this type of care. With startup funding from high-profile investors Jeff Bezos and Michael Dell, the company was serving 35,000 patients at several clinics in the Seattle area by 2015. Those patients included individuals, workers at large companies like Expedia and Comcast, and Medicaid patients through a contract with the state’s Medicaid insurer.

In a 2015 press release, Qliance said medical claims for its patients were 20 percent lower than those of other patients because, among other things, Qliance members went to the emergency room less often, were hospitalized less frequently and saw fewer specialists.

By early 2017, though, Qliance was faltering. The company had lost some of the big employers, and its patient base had shrunk to 13,000. Last week, it closed the last of its private clinics, though its CEO, Dr. Erika Bliss, will continue to operate one site that provides occupational health services for Seattle firefighters.

In general, Bliss says, the market is reluctant to pay what is required for primary care to flourish. In some cases, she says, payers were resistant to rewarding Qliance even when it exceeded its targets for quality and savings.

“The bottom line is it’s not for free,” Bliss says.

The closure took January Gens, a 45-year-old Seattle resident, by surprise. A Qliance patient for a couple of years, Gens had worked with her primary care doctor to manage crippling pain from endometriosis. The $79 monthly fee was worth every penny, she thought. She had been able to reduce the dosage of some of her medications and was awaiting a referral to start physical therapy when she learned that Qliance was shutting down. Now she’s not sure what she’ll do.

“I had felt very lucky to have found Qliance, to know I had a doctor and could always be seen when needed without causing more damage to the family budget,” Gens says. “Now it’s just gone.”

Patients who have chronic conditions that need ongoing management may benefit from this sort of flat-fee program, says Dr. A. Mark Fendrick, an internist who directs the University of Michigan’s Center for Value-Based Insurance Design.

But for people who are generally healthy and without symptoms that need to be diagnosed, “unlimited primary care is no guarantee that the services that are provided will improve the health of those people,” he says.

As an example, Fendrick notes that the annual checkup — one of the most popular primary care services — isn’t clinically helpful for most people, according to the Choosing Wisely initiative, a program of the American Board of Internal Medicine Foundation that identifies overused and unnecessary medical services.

An examination of research related to direct primary care practices, published in the November-December 2015 issue of the Journal of the American Board of Family Medicine, found that they charged patients an average $77.38 per month. In contrast, “concierge” or “boutique” medical practices — which are similar to “direct primary care” programs, but charge more — typically have higher fees for patients — averaging $182.76, the study found — and they generally also bill insurers for their services.

However, there was a paucity of data related to the quality of care provided by these practices, the study found.

Some analysts say that while they’re sympathetic to doctors’ frustration with insurance companies’ intrusion into patient care and the billing hassles that go along with that, the answer isn’t to turn their backs on insurance.

“I think, absolutely, this type of care could be done inside insurance,” says Robert Berenson, a fellow at the Urban Institute who specializes in health care delivery. “But it means we have to learn how to pay within the system for the things that doctors should be doing — and are doing — in direct primary care.”

As things stand now, the direct-care model can create difficulties for some patients. Take the situation in which someone in this sort of practice goes to his primary care provider for an earache, but antibiotics don’t work and he needs to be referred to an ear, nose and throat specialist. That patient, who likely has a high-deductible insurance policy to cover care that goes beyond the primary practitioner’s purview, will probably be on the hook financially for the entire cost of medical services provided by the specialist — rather than insurance paying a share.

Qliance’s Bliss scoffs at the idea that patients may get stuck paying more out of pocket if they have direct primary care. Most people these days have high-deductible health plans, she says. “The reality is that, unless you have Medicaid, you are on the hook no matter what.”

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Follow Michelle Andrews on Twitter @mandrews110.

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Democrats Tie Up The Senate To Protest GOP Health Care Push

Senate Minority Leader Chuck Schumer of N.Y. speaks to reporters on Capitol Hill.

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The Republican effort to overhaul the Affordable Care Act, or Obamacare, has led to a standoff in the Senate.

Senate Democrats on Monday night began using parliamentary maneuvers to slow Senate business as part of a coordinated protest against the GOP push to pass an Obamacare replacement bill. A small group of Republican senators has been working in private for weeks, shielding from public view the bill and the negotiations surrounding it.

In a show of frustration with what they deem the GOP’s “shameful” and “secret” legislative process, Democrats on Monday also held the Senate floor with a series of back-to-back speeches.

“If Republicans are not going to allow debate on their bill on the floor or in committee, Democrats will make opportunities to debate,” said Senate Minority Leader Chuck Schumer, speaking Monday on the Senate floor. “And these are merely the first steps we’re prepared to take in order to shine a light on the shameful Trumpcare bill and reveal to the public the GOP’s backroom deal-making.”

Liberal activists cheered on social media as Schumer forced McConnell to object to a motion to hold public hearings on the health care bill, and then pressed the Republican leader to commit to 10 hours of open debate.

WOW: @SenateMajLdr blatantly refuses to give senators more than 10 hours to read & amend Obamacare repeal bill (that we have yet to see!)

— CAP Action (@CAPAction) June 19, 2017

Senate Democrats, in taking action Monday, are inserting themselves into a process that has excluded them by design. Democratic lawmakers are also responding to growing pressure from progressive activists who have been calling for more aggressive opposition. Members of the Democratic base have expressed concern that Republicans are moving forward with their health care bill while attention has been focused elsewhere — namely on the Russia investigations.

Some Republicans are also out of the loop

It’s not just Democrats who have been left out of the health care deliberations. Many Republican senators have seen little more than an outline and a Power Point summary of the Senate health care legislation that is being drafted.

“It’s not unusual, especially for a big bill like this. It’s okay that the drafting is happening behind closed doors,” Tommy Binion, a congressional liaison at the conservative Heritage Foundation, told NPR’s Morning Edition.

While GOP senators aren’t objecting to the process as vehemently as Democrats, a number of Republicans, including Sen. Marco Rubio, R-Fla., say the health care legislation should eventually be subject to open debate.

“If it’s an effort to rush it from a small group of people straight to the floor on an up or down vote, it’ll be a problem,” Rubio said Sunday on CNN’s State of the Union.

McConnell: “Nobody is hiding the ball here”

The Republican health care bill could be voted on as early as next week – ahead of the July 4th recess — without any committee hearings or public input. For his part, Senate Majority Leader Mitch McConnell is defending the closed health care talks.

“Nobody is hiding the ball here,” McConnell, R-Ky., told reporters last week. “There have been gazillions of hearings on this subject when [Democrats] were in the majority, when we were in the majority. We understand the issue very well and we are now coming up with a solution.”

Republicans contend the secret Senate negotiations give them time and space free from scrutiny to hash out the significant and serious differences among themselves over contentious issues, such as phasing out Medicaid expansion and determining the plan’s coverage requirements.

Democrats say the closed talks are a tacit acknowledgment by Republicans that their efforts are unpopular.

“There’s only one reason why Republicans are doing this: They’re ashamed of their bill,” said Schumer on Monday. “The Republicans are writing their health care bill under the cover of darkness because they’re ashamed of it, plain and simple.”

While the Senate is crafting its own legislation, the House-passed American Health Care Act is viewed unfavorably by a majority of Americans – 55 percent – compared with 31 percent who viewed it favorably, according to a Kaiser Family Foundation poll released in May.

What’s more, the Congressional Budget Office estimated that the House health care bill would result in 23 million fewer people with insurance in a decade, and it would leave many sicker and older Americans with much higher costs.

Republicans eager to move on from health care

Still, Senate Republicans badly want to take up other priorities such as overhauling the country’s tax code.

“We’ve been debating Obamacare’s failures and what to do about them for so many years now,” McConnell said Monday on the Senate floor. “Members are very, very familiar with this issue. Thankfully, at the end of this process, the Senate will finally have a chance to turn the page on this failed law.”

Any legislation the Senate passes would head back to the House for consideration before President Trump can sign it into law.

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