Six years ago, a newly minted graduate of the School of the Art Institute of Chicago was working three part-time jobs and adjusting to life as a non-student. She stopped in for a drink one night at a restaurant in Chicago’s Bucktown neighborhood, where she got into a conversation with a guy. The next thing she remembers clearly was awakening at home the next morning, aching, covered in bruises, with a swollen lip.

She believed she had been raped and went to the local police station to file a report. The police sent her to a hospital emergency room nearby where, with her permission, a doctor did a medical forensic exam, checking her for injuries and taking evidence from her body and clothes to potentially use in a prosecution case. The exam took hours and made her even more miserable.

Police never made an arrest.

As time passed and the woman tried to move past the assault, she received regular, unwelcome reminders: bills from the hospital and emergency physicians group that treated her.

The physicians group eventually sent her bill to a collection agency, and she started receiving nagging phone calls as well. Now 28 and living near Dallas, she still gets phone calls and letters a couple of times a year ordering her to pay up.

“When I get that phone call, it’s still so raw. I’m shaking,” says the woman, whose first name is Erin. (NPR has agreed not to use Erin’s last name, to protect her privacy.)

For 25 years, the federal Violence Against Women Act has required any state that wants to be eligible for certain federal grants to certify that the state covers the cost of medical forensic exams for people who have been sexually assaulted.

Subsequent reauthorizations of the Act have clarified that these individuals also can’t be required to participate with law enforcement to get an exam; nor do they have to pay anything out-of-pocket for that exam at any point (not even if they would be reimbursed later).

And yet for some people who have been raped, the bills keep coming — despite this long-standing federal prohibition and other state laws that provide additional financial protections in many places.

“There’s often a disconnect between the emergency room personnel that take care of the person and the billing department that sends out the bills,” says Jennifer Pierce-Weeks, CEO of the International Association of Forensic Nurses, professionals who have specialized training in how to evaluate and care for victims of violent crime or abuse.

There is wide variation in how states meet their financial obligations to cover sexual assault exams — sometimes called “rape kits” — that collect evidence of the crime. Many states tap funds they receive under the federal Victims of Crime Act. Others use money from law enforcement or prosecutors’ budgets or other designated options.

What services are covered as part of the rape exam can vary by state as well. Federal rules require that the patient be interviewed and examined for physical trauma, penetration or force, and that evidence be collected and evaluated.

But many states include additional services without charging victims, including testing and treatment for pregnancy or sexually transmitted diseases. Some may cover treatment for counseling, or for injuries that survivors experience during the assault.

Having financial protections on the books for people who have been raped, however, doesn’t necessarily translate to seamless, no-cost services on the ground.

For instance, New York requires that patients treated for sexual assault receive some services at no charge beyond the federal requirements, including emergency contraception and treatment for STDs, says Christopher Bromson, executive director of the Crime Victims Treatment Center in New York.

Still, last November the New York attorney general’s office announced settlements with seven hospitals that had illegally charged more than 200 such patients for medical forensic exams, with amounts ranging from $46 to $3,000. In some cases, the hospitals referred the individuals to bill collectors who dunned them for the payments.

Afterward, the Healthcare Association of New York State, a nonprofit group that advocates for better health services, teamed up with the state Department of Health and others to present four webinars for hospital personnel to explain their legal responsibilities.

Karen Roach, the association’s senior director of regulatory affairs and rural health, says the billing problem in New York doesn’t appear widespread.

“Some of these issues arose from greater automation of the billing process,” Roach says. “Training is needed to flag these cases, to put systems in place not to automatically generate a bill.”

Working with an advocacy group, Erin eventually got the hospital to stop billing her. But the emergency physicians group that treated her no longer exists, and her $131.68 bill has been bundled with other debts and resold to different collectors several times, she says.

When Erin tells a debt collector that the bill they’re calling about is for services related to rape, “They say, ‘Oh, we’ll fix it,’ but they don’t,” she says. “They just sell it again and it just becomes someone else’s problem. But it’s always my problem.”

Despite state and federal laws, many people who were raped wind up paying for some medical services out-of-pocket, even if they have insurance. An analysis of billing records from 1,355 insured female rape survivors found that in 2013 they paid an average $948 out-of-pocket for prescription drugs and hospital inpatient or outpatient services during the first 30 days after the assault. That amount represented 14% of total costs, the study found.

“We just assumed that this was only a problem for women who fell through the cracks,” says Kit Simpson, a professor in the department of health care leadership and management at the Medical University of South Carolina in Charleston, who co-authored the study. “But this was a systematic problem.”

Some people who have been assaulted sexually don’t want to use their insurance in any case, because they are worried about privacy or safety issues if family members or others find out, advocates say.

The Violence Against Women Act, often referred to as VAWA, is up for reauthorization this year. It’s not clear if a new bill would address these payment issues. If states don’t certify that they shoulder the cost of rape exams, funds can be frozen. (States must also certify that they don’t require these patients to participate in the criminal justice system.)

The Department of Justice declined multiple requests for comment on whether and how those VAWA provisions are enforced.

Some advocates for people who have been sexually assaulted would like to see the federal definition of what must be included in a no-cost medical forensic exam broadened to include such services as testing and medication for pregnancy and sexually transmitted infections, including HIV. Such a move would level the playing field across the U.S., they say.

Janine Zweig, associate vice president of justice policy at the Urban Institute, who co-authored a study examining state payment practices for rape exams, says a federal standard should be considered. “Do we really want it to be about which state you live in?”

Kaiser Health News is a nonprofit, editorially independent program of the Kaiser Family Foundation. KHN is not affiliated with Kaiser Permanente.

Let’s block ads! (Why?)

California has become the first state in the country to offer government-subsidized health benefits to young adults living in the U.S. illegally.

The measure signed by Gov. Gavin Newsom on Tuesday extends coverage to low-income, undocumented adults age 25 and younger for the state’s Medicaid program.

Since 2016, California has allowed children under 18 to receive taxpayer-backed healthcare despite immigration status. And state officials expect that the plan will cover roughly 90,000 people.

The idea of giving health benefits to undocumented immigrants is supported by most of the Democratic candidates running for president, and California’s move comes as the Trump administration continues to ramp up its hardline crackdown on unauthorized immigrants. On Tuesday, Newsom said the state law draws a sharp contrast with Trump’s immigration policies.

“If you believe in universal health care, you believe in universal health care,” Newsom said. “We are the most un-Trump state in America when it comes to health policy.”

In California, extending health benefits to undocumented immigrants is widely popular. A March survey conducted by the nonpartisan Public Policy Institute of California found that almost two-thirds of state residents support providing coverage to young adults who are not legally authorized to live in the country.

California, the institute notes, has more immigrants than any other state. And an estimated 14% of them are living in the state without legal status.

A national poll suggests that many Americans across the country are far less accepting of the notion of giving health coverage to those who came into the U.S. illegally. A CNN poll conducted after the Democratic debates last month found that 59% of those surveyed do not think government-backed health coverage should be provided to undocumented immigrants.

In most states, people living in the country illegally are not eligible for federal health insurance programs like Medicaid and Medicare, except is some cases, like medical emergencies and pregnancies, according to the National Conference of State Legislatures.

Republican lawmakers in California criticized the law, arguing that the state should be spending health care dollars on those living in the state legally.

“We are going to be a magnet that is going to further attract people to a state of California that’s willing to write a blank check to anyone that wants to come here,” said Republican Senator Jeff Stone at a May legislative hearing. “We are doing a disservice to citizens who legally call California their home.”

The plan does not cover all unauthorized immigrants under 25, only those whose incomes are low income to qualify. State officials estimate in the first year the program will cover around 138,000 residents and cost California taxpayers $98 million.

Trump has publicly attacked Newsom’s plans.

“It’s crazy what they’re doing. It’s crazy,” Trump told reporters last week. “And it’s mean, and it’s very unfair to our citizens. And we’re going to stop it, but we may need an election to stop it.”

Let’s block ads! (Why?)

A federal judge on Monday stopped a Trump administration initiative that would have required drug makers to reveal the sticker price of their drugs in television ads.

Under the rule, if a medicine’s list price was more than $35 a month, its list price would have to be stated during the commercial. The challenge opponents say is that a drug’s list price and estimates of what people can expect to pay varies widely depending on coverage.

The rule was blocked hours before it was set to take effect, the latest setback for the White House as Trump administration officials continue to search for ways to pressure pharmaceutical companies into lowering their prices — a proposal made by the Trump administration in the run up to last November’s midterm election.

The decision from U.S. District Judge Amit Mehta in Washington, D.C. ruled that the Health and Human Services Department does not have the regulatory power to make drug manufactures include the cost of drugs in television commercials.

Mehta wrote that in halting the rule, the court was not questioning its wisdom, but rests the issue on the law set by Congress in the first place.

“That policy very well could be an effective tool in halting the rising cost of prescription drugs. But no matter how vexing the problem of spiraling drug costs may be, HHS cannot do more than what Congress has authorized,” Mehta wrote.

Critics pointed out that the rule was toothless, since there was no enforcement mechanism spelled out for when a company did not comply. Instead, the rule relied on the private sector to police itself.

The television-ad rule had the support of both the Trump administration and consumer rights advocates.

That said, patient advocate groups told NPR that while holding drugmakers accountable for prices is welcome, they remained skeptical that drug companies could be shamed, as the administration intended, into lowering their prices.

Last month, groups including drug manufacturers Merck, Eli Lilly and Amgen sued the Trump administration over the rule, arguing that it would violate the companies’ free speech rights.

AARP, which represents older Americans, expressed disappointment on Monday over the court’s ruling.

“Today’s ruling is a step backward in the battle against skyrocketing drug prices and providing more information to consumers,” the group said. “Americans should be trusted to evaluate drug price information and discuss any concerns with their health care providers.”

Let’s block ads! (Why?)