States. They’re just as perplexed as the rest of us over the ever-rising cost of health care premiums.

Now some states –including Montana, North Carolina and Oregon — are moving to control costs of state employee health plans. Their strategy: Use Medicare reimbursement rates to recalibrate how they pay hospitals. If the gamble pays off, more private-sector employers could start doing the same thing.

“Government workers will get it first, then everyone else will see the savings and demand it,” says Glenn Melnick, a hospital finance expert and professor at the University of Southern California. “This is the camel’s nose. It will just grow and grow.”

In North Carolina, for instance, state Treasurer Dale Folwell next year plans to start paying most hospitals Medicare rates plus 82 percent — a figure he says would provide for a modest profit margin while saving the state more than $258 million annually.

“State workers can’t afford the family premium [and other costs],” he says. That’s what I’m trying to fix.” The estimated $60 million in savings to health plan members, he says, would mainly come from savings in out-of-pocket costs.

That approach differs from the traditional method of behind-the-scenes negotiating, in which employers or insurers ask for discounts off hospital-set charges that rise every year and generally are many times the actual cost of a service. Payments from private-insurers, even with those discounts, can be double or triple what Medicare would pay.

This state-level activity could be a game changer, fueling a broad movement toward lower payments to hospitals. Montana’s state employee program made the adjustment two years ago; Oregon will start this fall. Delaware’s state employee program is also considering such “Medicare-based contracting” as one of several options to lower spending.

The bold move comes as other factors — notably marketplace competition among hospitals, and high-deductible insurance plans aimed at getting consumers to “shop” for lower prices — have largely failed to slow rising health care premiums.

For hospitals, though, it can be viewed as “an existential threat,” says USC’s Melnick.

Indeed, the treasurer’s plan in North Carolina has drawn heated opposition, with a hospital industry-associated group running television ads that warn of dire financial consequences, especially for rural hospitals. When the plan first came out, the state’s hospital association complained it would reduce hospital revenue statewide by an estimated $460 million.

Hospitals in areas with large concentrations of state workers “would be getting reimbursed less than the cost of care,” says Cody Hand, the association’s senior vice president and deputy general counsel.

“Our biggest concern is this is not something that we were at the table for in discussion,” he says.

Rural hospitals are particularly at risk, Hand says, because many were already teetering on the brink financially and the payment change would be an additional problem.

After months of acrimony, the North Carolina treasurer in mid-March agreed to grant a 20 percent boost in payment to rural hospitals that would give those hospitals an additional $52 million a year. On average, rural hospitals would be paid 218 percent of the Medicare rate.

Nationwide, hospitals have long complained that Medicare underpays them, and some hospital and business groups have warned employers that tying payments from state workers’ plans more closely to Medicare could result in higher charges to private-sector businesses.

“The result will be a cost shift of tens of millions of dollars to other Oregonians,” wrote the Oregon Association of Hospitals and Health Systems as lawmakers there debated a plan (that eventually became law) paying hospitals 200 percent of Medicare rates.

But policy experts are skeptical.

“Even if Medicare pays a bit below cost, 177 percent of Medicare should be at least 50 percent above cost,” says Mark Hall, director of the health law and policy program at Wake Forest University. “Is that a reasonable margin? I guess that’s up for debate, but to most people a 50 percent margin might sound reasonable.”

Another concern some people have raised is that hospitals might refuse to join networks that employ these states’ Medicare-based strategy.

Indeed, Montana officials worked hard to get all hospitals in the state to agree to accept for the state worker program an average of 234 percent of Medicare’s reimbursement rates. A few hospitals held out, right up to the deadline, backing down only after pressure from employee unions.

The risk if hospitals opt to remain out-of-network is that workers could be balance billed for the difference between those Medicare-plus rates and their generally much higher charges — amounts that could be hundreds or even thousands of dollars.

To prevent that, Oregon lawmakers set the law’s in-network reimbursement for hospitals at 200 percent of Medicare’s reimbursement rates. But, those that opt out would receive only 185 percent.

The measure also bars hospitals from billing state workers for the difference between those amounts and the higher rates they might like to charge.

“Oregon thought it through,” says Gerard Anderson, a professor at Johns Hopkins who researches health care costs.

“Hospitals need to go on a diet,” adds Anderson. “The private sector has not put them on a diet, but maybe the state employee plans will.”

Meanwhile, in the private sector …

For decades, health insurance costs for employers and workers have risen faster than inflation, despite various efforts to rein them in.

Currently, a typical family plan offered by employers tops $19,000 a year in premiums, while the price tag for a single employee is close to $7,000.

To be sure, hospital costs make up just one part of what premiums cover, along with doctor costs, drug payments and other services. Spending on hospital care accounts for about one-third of the nation’s $3.5 trillion health care tab.

“Health care is just becoming unaffordable,” says Cheryl DeMars, president and CEO of The Alliance, a group of 240 self-insured employers in the private sector that directly contract with hospitals in Wisconsin, northern Illinois and eastern Iowa.

In January, The Alliance began what it calls “Medicare-plus” contracting. As new hospitals join and existing contracts come up for renewal, the group is negotiating rates, basing them on what Medicare pays, DeMars says.

And it will likely save money: Under its old method of paying, the group was forking out between 200 percent and 350 percent of Medicare for inpatient and outpatient hospital services in its network. Two new contracts have been signed so far, averaging 200 percent of Medicare across inpatient, outpatient and physician payments, according to The Alliance.

“We want to pay a fair price and we’re in the process of determining what that should be,” says Kyle Monroe, vice president of network development for The Alliance. “Is it 200 percent? Is it something less?”

Under traditional payment methods, the negotiated prices insurers for public- and private-sector employers pay for hospital care vary widely — by facility, treatment and insurer. But they’re generally above Medicare rates by a substantial margin.

A group of self-insured employers recently commissioned Rand to study what private insurers pay hospitals in 22 states, compared with Medicare rates.

Initial results found private employers were paying, on average, 229 percent of Medicare rates to hospitals across the states in 2017, according to Chapin White, an adjunct senior policy researcher at Rand who conducted the study.

Economists like Melnick say they would prefer that market competition — consumers voting with their feet, so to speak — would drive business to the highest-quality, lowest-cost providers.

But, so far, hospitals have held the line against this scenario and that’s not likely to change. “They’re going to fight like crazy,” Melnick says.

Kaiser Health News is a nonprofit news service and editorially independent program of the Kaiser Family Foundation. It’s not affiliated with Kaiser Permanente.

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A decade ago, the U.S. government claimed that ditching paper medical charts for electronic records would make health care better, safer and cheaper.

Ten years and $36 billion later, the digital revolution has gone awry, an investigation by Kaiser Health News and Fortune magazine has found.

Veteran reporters Fred Schulte of KHN and Erika Fry of Fortune spent months digging into what has happened as a result. (You can read the cover story here.)

Here are five takeaways from the investigation.

Patient harm: Electronic health records have created a host of risks to patient safety. Alarming reports of deaths, serious injuries and near misses — thousands of them — tied to software glitches, user errors or other system flaws have piled up for years in government and private repositories. Yet no central database exists to compile and study these incidents to improve safety.

Signs of fraud: Federal officials say the software can be misused to overcharge, a practice known as “upcoding.” And some doctors and health systems are alleged to have overstated their use of the new technology, a potentially enormous fraud against Medicare and Medicaid likely to take years to unravel. Two software-makers have paid a total of more than $200 million to settle fraud allegations.

Gaps in interoperability: Proponents of electronic health records expected a seamless system so patients could share computerized medical histories in a flash with doctors and hospitals anywhere in the United States. That has yet to materialize, largely because officials allowed hundreds of competing firms to sell medical-records software unable to exchange information among one another.

Doctor burnout: Many doctors say they spend half their day or more clicking pull-down menus and typing rather than interacting with patients. An emergency room doctor can be saddled with making up to 4,000 mouse clicks per shift. This has fueled concerns about doctor burnout, which a January report by the Harvard T.H. Chan School of Public Health, the Massachusetts Medical Society and two other organizations called a “public health crisis.”

Web of secrets: Entrenched policies continue to keep software failures out of public view. Vendors of electronic health records have imposed contractual “gag clauses” that discourage buyers from speaking out about safety issues and disastrous software installations — and some hospitals fight to withhold records from injured patients or their families.

Kaiser Health News is an editorially independent news service supported by the nonpartisan Kaiser Family Foundation. KHN is not affiliated with Kaiser Permanente.

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As head of New York City’s correctional health services, Dr. Homer Venters spent nine years overseeing the care of thousands of inmates in the jails on Rikers Island. Though he left Rikers in 2017, what he witnessed on the job has stayed with him.

“What’s important to consider about jail settings is that they are incredibly dehumanizing, and they dehumanize the individuals who pass through them,” Venters says. “There is not really a true respect for the rights of the detained.”

Venters is now a senior health and justice fellow at Community Oriented Correctional Health Services. In his new book, Life and Death in Rikers Island, he describes a number of traumatic outcomes related to what he says was subpar medical care at the jail complex, including the death of Carlos Mercado, a man with diabetes who was denied insulin during the intake process.

“This type of death really shows, in a very stark way, how jails confer health risk to people,” Venters says. “For a person to know that they are insulin-dependent — to report that and then for any state institution to fail to act on that, really puts the onus and responsibility for this man’s death directly on the jail system.”

During his tenure at Rikers, Venters pushed to improve the electronic medical records system, allowing health data from the jail to be shared with outside agencies, including the Department of Justice. He sees it as a first step in a larger effort to address abusive conditions and improve inmate care.

Working at Rikers, Venters says, “left me with a zeal to continue this work all over the country. … The problems of Rikers are in many cases the problems of jails and prisons everywhere in the United States.”

Interview highlights

On his first time at Rikers Island

I happened to go there for the first time on a day where there was a very strong snowstorm. As someone was showing me around some of the facilities, the snow was coming down so quickly it really did seem like a scene from a sci-fi movie. I couldn’t believe that the structures looming up one after the other were real. [And] the yelling coming out — the two biggest and most well-constructed facilities at the time on the island were these big buildings that look like hotels. But they were built for solitary confinement, so people [were] screaming and yelling out of those big structures, through this very thick snowfall. It left an indelible impression on me.

On not being able to find patients who need medical care because of delays in paperwork and an antiquated paper logging system

Patients would be moved from one housing area to another, and sometimes their move would be updated a couple of days later. Somebody would have to type it into a computer system. But it would mostly be updated on a paper-based log. Since I left they’ve started implementing some wristbands that could be scanned, but it’s the same problem — an officer has to do something, [and] you have to affirmatively track it.

So for us with a big health service — thousands of patients on medications every single day — we had pharmacy technicians, psychologists [and] nurses who were working hard just to find the patients who had missed medicines — who could be facing a life-threatening event if they miss that medicine. It was so routine that we couldn’t find our patients that there was no thought that we could find everybody who didn’t get their medicine today. But we would make short lists of the people who missed medicines that were what we would call “life-sustaining medicines,” or who could face a very dire health outcome, and that expenditure of energy for that purpose would become revealed when patients had very bad outcomes.

On tracking data about inmates sustaining injuries from correctional officers

One data point that’s really incredible to consider is that there was a time when, if an adolescent was in a violent conflict with someone in Rikers Island, if the conflict was with a correctional officer they were more likely to sustain a blow to the head than if the conflict was with another inmate. It’s stunning, because obviously correctional officers have enormous amounts of training about avoiding blows to the head. … And also you would think that most inmate fights start with a shot to the head. But that data point alone … we could only do because we had developed this injury surveillance system. But it was one of many that we pushed to the D.O.J.

On what data revealed about solitary confinement

The other big data set that we found very, very helpful is we did a large-scale analysis — I think the first-ever large scale analysis — of exposure to solitary confinement. We looked at 225,000 jail admissions and we found that the people … exposed to solitary confinement had about seven times higher risk of being a self-harm cohort. That is to say, to physically harm themselves. That data set … helped us really push the Department of Corrections to move from wanting more solitary confinement for mentally ill people, to actually eliminate the practice of solitary confinement for persons with serious mental illness.

On the conditions of solitary confinement units, where raw sewage often overflows because of clogged toilets

It is horrific but also dehumanizing. It really reflects quite well the end result of the practice of solitary confinement. That is to say, you have officers trying to act as if they are conducting normal business. You have patients with mental health problems who are decompensating [– functionally deteriorating under the stress –] or simply doing extreme things to try and get out of there. You have health staff coming on and off those units as quickly as they can, because while they want to protect their patients, they also are seeing this day after day after day. …

I’ve been inside these cells to talk to patients multiple times when they’ve smeared feces all over the inside of the cell. Or they’re working to light a fire inside their cell. It’s just very, very extreme behaviors and any one of these observations should be enough to reaffirm that this is a horrible practice– that we should have never built this unit and we need to back away from its use everywhere.

On if he believes Rikers Island should close

The closing of Rikers is absolutely necessary. It’s not sufficient to transform the criminal justice system in New York City to become more humane, but it’s necessary. The jails that are in operation are crumbling. If you’re a correctional officer, almost anywhere you work, any housing area, any hallway, any intake pen is so dilapidated and falling apart that inmates easily can arm themselves — and do for their own protection — with bits of hardened material that are broken off from walls; from pipes; from ceilings.

I think the other important element to this is that we have much more work to do to lower the jail population. We’ve made great strides in New York City, more than most big cities have. There were probably [22,000 to] 23,000 people in the jails when [Rudolph] Giuliani was mayor. It’s now under 8,000, so really incredible progress. But there is much more work that can be done to create alternatives that involve treatment for people with serious mental illness, and also to really develop supportive housing, which is an important element to why people cycle in and out of jail. [There’s] a lack of stable housing. [Housing] can also involve treatment for addiction and for mental health problems.

Roberta Shorrock and Seth Kelley produced and edited the audio of this interview. Bridget Bentz and Molly Seavy-Nesper adapted it for Shots.

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Ending HIV transmission in America within the next decade — a stated goal of the Trump Administration — isn’t a question of coming up with new medication. The medicines to prevent and treat HIV infections already exist.

But the road to eliminating HIV and AIDS runs through the deep South, where racism, poverty, and homophobia can be formidable obstacles to testing and treatment, particularly for black gay men. According to a Centers for Disease Control and Prevention report in 2017, more than half the new HIV diagnoses in the U.S. were in Southern states, where gay and bisexual black men make up a disproportionate share of people with HIV.

Shawn Esco lives and works in Jackson, Miss. — a city with one of the highest HIV rates in the country.

Esco remembers the moment he realized he was HIV positive. Eleven years ago, he went to a clinic to get a routine HIV test. Workers there invited him into a private room for the results, and he says he knew — before they even said a word.

“When they opened the door,” Esco says, “there was all this new literature that said ‘HIV this,’ ‘AIDS that.’ And you could tell it was there for me.”

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The Supreme Court of Mississippi in Jackson, Miss. The city has one of the highest HIV rates in the United States.

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Esco is now 37, and lives in an apartment with an affectionate pit bull named Nibbler. He’s stayed healthy in the time since his diagnosis, but the same can’t be said of many of the other HIV-positive people in his life.

In 2011, after good HIV treatments were available, Esco’s best friend from high school died of AIDS-related causes.

“I was extremely pissed off at him,” Esco says,” Because it could have been avoided. All he had to do was want to live.”

Esco says the death of that friend was the hardest to endure, but not his only loss. One of Esco’s exes also died of an AIDS-related condition. And another friend took his own life after he got his diagnosis — out of fear his family would find out.

A few years ago CDC researchers estimated that, at current infection rates, about half of all black men who have sex with men (and 25 percent of Latino gay and bisexual men) in the U.S. will be diagnosed with HIV in their lifetime.

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In 2011, Esco’s best friend from high school died of AIDS-related causes. One of Esco’s exes also died of an AIDS-related condition. And another friend took his own life after he got his diagnosis — out of fear his family would find out.

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When Esco considers the possibility of ending the epidemic in the next 10 years, he takes into account issues like homophobia, racism, lack of education and stigma, and is blunt: “Given the way things are now, that’s not going to happen.”

In the South, many gay and bisexual black men don’t know the extent of the HIV problem, he says. And, if they do, they may not have access to the tools to prevent and treat the disease.

These are problems that Dr. Leandro Mena tries to solve. He’s an HIV researcher and clinician, and a professor of population health science at the University of Mississippi. Mena also works with My Brother’s Keeper, a community-based nonprofit working to eliminate health disparities in underserved populations.

“Science has given us the tools to end the HIV epidemic,” Mena points out. “The challenge that we have is that we need to make sure those tools can reach those who actually need it most.”

HIV seems easy to keep in check, he says: There’s a daily pill that can keep someone who is infected with the virus healthy.

But things can get complicated fast if you’re poor.

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The memorial grove behind Grace House, in Jackson, Miss., where the ashes of more than 45 former residents now rest. Grace House was once a hospice for people dying of AIDS. Today the organization offers hundreds of people in Jackson financial assistance for housing.

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“What are the chances that you may remember to take a medicine that you have to take every day,” he says, “if, this morning, you wake up and you don’t have electricity or you don’t have any money to feed your family?”

Getting access to good health care of any kind — let alone lifesaving medicine — can be especially difficult for people living in rural parts of the south, Mena says. And Mississippi is the poorest state in the country.

Some people in Mississippi who are living with HIV wind up on the doorstep of Grace House, which was once a hospice for people dying of AIDS. Today the organization offers hundreds of people in Jackson financial assistance for housing, and also provides rooms for a few dozen people facing particularly severe challenges, such as addiction or mental health issues.

The Grace House compound in Jackson consists of a cluster of several homes, with a shared backyard and a garden.

It also includes a memorial grove, where statues of angels stand around the base of a tree, memorializing people whose deaths were AIDS-related.

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Catherine Sullivan is executive director of Grace House, a Jackson nonprofit that offers transitional and semi-permanent housing and support services for homeless men and women living with HIV/AIDS and women recovering from substance abuse.

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Catherine Sullivan, executive director of the organization, says the ashes of more than 45 people have been spread in the grove — “some of whom were with us at Grace House when they died; some of whose families wouldn’t pick them up from the morgue. And so we buried them.”

Just four months ago, a Grace House resident named Donna died of an AIDS-related illness. She had spent her life struggling to live openly as a transgender woman.

Sullivan keeps photos from Donna’s funeral on her phone: Donna lying peacefully in a coffin, impeccably made up, in a long white gown.

“It makes me really sad,” Sullivan says, looking at the photos. “Because, in death, who she was is honored in a way that got lost in life most of the time.”

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Jeremy Williams got HIV before there was a daily pill to prevent infection in people who are at high risk. That pill is known as PrEP — pre-exposure prophylaxis. A lot of gay and bisexual men in the South are not on PrEP, doctors say, either because they don’t know it exists, or because they can’t afford it.

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Those sorts of stories are familiar to many at Grace House, where residents now are able to live openly and get access to care.

Jeremy Williams, 32, got HIV from his college boyfriend. Williams grew up in rural Mississippi, where HIV treatment was hard to come by.

“You have to drive like an hour or two or three for quality care,” he says.

Williams got HIV before there was a daily pill to prevent infection in people who are at high risk. That pill is known as PrEP — pre-exposure prophylaxis. A lot of gay and bisexual men in the South are not on PrEP — either because they don’t know it exists, or because they can’t afford it. It can cost up to $1,600 a month without insurance. Mississippi has fought against expanding Medicaid, which could have given more people access to HIV prevention and treatment.

Williams says the cost of treatment was kept in check when he was first diagnosed, because he was on his father’s insurance. “But once I got over a certain age, I couldn’t be on his insurance no more, and I couldn’t afford the treatment,” he says.

Today, a daily HIV treatment pill, paid for by the state-administered AIDS Drug Assistance Program, has made his viral load undetectable. So it’s extremely unlikely that he could infect anyone else.

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Dating back to the early 1900s, Farish Street was once an epicenter of black life and commerce in Jackson, Miss.

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Williams says there’s another issue that makes it hard for him and many other young gay or bisexual black men to protect their sexual health: He was raised in a church that tried to convert gay people to heterosexuality. Shame was part of his daily life.

“The words that people say, they linger,” Williams says. “They linger on for years. And you just — it was like a repeated broken record over and over again. You know: ‘You’re not good enough.’ ‘You’re never going to have anybody.’ ‘No one is going to love you because you have this disease.’ I was just carrying it, you know, like it’s a garment — like all of my shame and stuff.”

There’s also a lack of specialized HIV/AIDS knowledge among too many doctors in the South, says Sandra Melvin, the chief operating officer at Jackson’s Open Arms Health Clinic, where HIV-positive patients can receive care. She says many physicians in the region don’t know about PrEP. And that goes to a broader issue.

“In some cases, I think the training has something to do with it,” Melvin says. “Medical schools don’t focus on certain things — cultural competence, how to deliver health care in rural areas. Those are all things that I think in medical school need to be a focus for young and upcoming physicians or health care providers.”

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Tiffany West, a medical assistant with the Open Arms Mobile Health Clinic, prepares to administer HIV tests to students at Tougaloo College, north of Jackson.

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Attitudes among Mississippi’s elected leaders are also part of the problem, Melvin believes.

“I think that part of what has to happen in this state is that we have to start electing people who reflect the demographics of our society,” she says.

People working to fight the HIV epidemic in Mississippi point to one recent example of a law that they believe promoted homophobic values that could increase the stigma around HIV. In 2016, the state passed a bill into law that allows doctors to refuse to serve certain patients, based on the doctor’s religious beliefs — even if those beliefs seem to be anti-gay.

While there’s no public evidence yet of a doctor refusing to treat a gay patient, critics of the law fear it could deter many people from seeking health care.

One of the Republican sponsors of the bill, Rep. Dan Eubanks, says those fears are misguided.

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Hip-hop plays inside the Open Arms Mobile Health Clinic, as a way to help the students at Tougaloo College feel more comfortable while they await testing for HIV or other STDs.

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“I think it’s reaching to try and say that this bill is going to make it worse for people with AIDS, because that was never the intention of the bill,” Eubanks says. “The intention of the bill was to protect people’s First Amendment right to adhere to the tenets of the faith — which is guaranteed in our Constitution.”

Eubanks believes that ending HIV requires education, including education about abstinence and about personal responsibility.

“If you know that participating in unprotected sex is dangerous, but yet you do nothing to try and alleviate that, you greatly increased your odds and chances of contracting a disease,” Eubanks says. “So there’s a certain amount of personal responsibility — and that has nothing to do with sexual preference.”

The Open Arms Health Care clinic operates a mobile clinic that visits college campuses so students can get tested for HIV and other sexually transmitted diseases.

DeAndré Steward, 20, showed up for the clinic when it came to Tougaloo University, outside of Jackson. Steward is black and gay, and he’s aware of the soaring infection rates in his demographic.

“It is honestly very scary,” Steward says. “We’re all sexual creatures, so we’re going to have sex.”

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Gerald Gibson (left), manager of the Open Arms Mobile Health Clinic talks with Javier Heniquez, a student at Tougaloo College, as he leaves the clinic.

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Condoms are cheaper than PrEP, and also effective at preventing HIV transmission. Steward knows this but he also knows another reality.

“You need to always use protection,” he says. “But people don’t, which is why they’re scared half to death when they’re going to get tested.”

Steward faces many of the same challenges that Esco and Williams do, but he’s from a younger generation. When asked whether he thinks the HIV epidemic can become a thing of the past, he’s optimistic.

“Absolutely,” he says. “The older generations, they still weren’t as educated on AIDS as they should have been. You know, their minds aren’t that open — our generation’s minds are.”

Steward tested negative for HIV at the clinic, and he plans to stay that way. But one of the best ways to do so would be to get on PrEP. He’d like to do so, he says, but it costs too much.

Editor’s note: In the audio version of this story, which first aired Feb. 14, Jeremy Williams’ last name was not used at his request. He has since decided he is comfortable having NPR using his full name and photograph for this digital version.

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The Trump administration’s decision to alter the way it punishes nursing homes has resulted in lower fines against many facilities found to have endangered or injured residents.

Federal records show that the average fine dropped to $28,405 under the current administration, down from $41,260 in 2016, President Obama’s final year in office.

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The decrease in fines is one of the starkest examples of how, in response to industry prodding, the Trump administration is rolling back Obama’s aggressive regulation of health care services.

Encouraged by the nursing home industry, the Trump administration switched from fining nursing homes for each day they were out of compliance — as the Obama administration typically did — to issuing a single fine for two-thirds of infractions, the records show.

That reduces the impact of the penalty, critics say, giving nursing homes less incentive to fix faulty and dangerous practices before someone gets hurt.

“It’s not changing behavior [at nursing homes] in the way that we want,” says Dr. Ashish Jha, a professor at the Harvard T.H. Chan School of Public Health. “For a small nursing home, it could be real money, but for bigger ones, it’s more likely a rounding error.”

Since President Trump took office, the administration has heeded complaints from the nursing home industry about zealous oversight. It granted facilities an 18-month moratorium from being penalized for violating eight new health and safety rules. It also revoked an Obama-era rule barring the facilities from pre-emptively requiring residents to submit to arbitration to settle disputes rather than go to court.

The reduction in total fines occurred even as the Centers for Medicare & Medicaid Services issued financial penalties 28 percent more frequently than it did under Obama. That increase in the frequency of citations with financial consequences arose because of a policy begun near the end of Obama’s term that required regulators to punish a facility every time a resident was harmed, instead of leaving it to their discretion.

While that policy increased the number of smaller fines, larger fines became less common. The total amount collected under Trump fell by 10 percent compared with the total in Obama’s final year — from $127 million under Obama to $114 million under Trump. (We compared penalties during 2016, Obama’s last year in office, with penalties under Trump from April 2017 through March 2018, the most recent month for which federal officials say data is reliably complete.)

CMS says it has revised multiple rules governing fines under both administrations to make its punishments fairer, more consistent and better tailored to prod nursing homes to improve care. “We are continuing to analyze the impact of these combined events to determine if other actions are necessary,” CMS said in a written statement.

The move toward smaller financial penalties is broadly consistent with the Trump administration’s other industry-friendly policies in the health care sector. For instance, the administration has expanded the role of short-term health insurance policies that don’t cover all types of services, has given states more leeway to change their Medicaid programs and has urged Congress to allow physicians to open their own hospitals.

Beth Martino, a spokeswoman for the American Health Care Association, a trade group for nursing homes, says the federal government has “returned to a method of applying fines in a way that incentivizes solving problems” rather than penalizing “facilities that are trying to do the right thing.”

Penalty guidelines were toughened in 2014 when the Obama administration instructed officials to favor daily fines. By 2016, that approach was applied in two-thirds of cases. Those fines averaged $61,000.

When Trump took over, the nursing home industry complained that fines had spun “out of control” and had become disproportionate to the deficiencies. “We have seen a dramatic increase in [fines] being retroactively issued and used as a punishment,” Mark Parkinson, president and CEO of the American Health Care Association, wrote in March 2017.

CMS agreed that daily fines sometimes resulted in punishments that were determined by the random timing of an inspection rather than the severity of the infraction. If inspectors visited a home in April, for instance, and discovered that an improper practice had started in February, the accumulated daily fines would be twice as much as if the inspectors had come in March.

But switching to a preference for per-instance fines means much smaller penalties, since fines are capped at $21,393 whether they are levied per instance or per day. Nursing homes that pay without contesting the fine receive a 35 percent discount, meaning they currently pay at most $13,905.

Those maximums apply even to facilities found to have committed the most serious level of violations, which are known as immediate jeopardy because the nursing home’s practices place residents at imminent risk of harm. For instance, a Mississippi nursing home was fined $13,627 after it ran out of medications because it had been relying on a pharmacy 373 miles away, in Atlanta. CMS also reduced $54,600 in daily fines to a single fine of $20,965 for a New Mexico home where workers hadn’t been properly disinfecting equipment to prevent infectious diseases from spreading.

On average, per-instance fines under Trump were below $9,000, records show.

“These are multimillion-dollar businesses — $9,000 is nothing,” says Toby Edelman, a senior policy attorney at the Center for Medicare Advocacy, a nonprofit in Washington.

Big daily fines, averaging $68,080, are still issued when a home hasn’t corrected a violation after being cited. But even in those cases, CMS officials are allowed to make exceptions and issue a single fine if the home has no history of substantial violations.

The agency cautioned that comparing average fines is misleading because the overall number of inspections resulting in fines increased under Trump, from 3.5 percent in 2016 to 4.7 percent. The circumstances now warranting fines that weren’t issued before tend to draw penalties on the lower side.

However, Kaiser Health News found that financial penalties for immediate jeopardies were issued in fewer cases under Trump. And when they were issued, the fines averaged 18 percent less than they did in 2016.

The frequency of immediate-jeopardy fines may decrease even more. CMS told inspectors in June that they were no longer required to fine facilities unless immediate-jeopardy violations resulted in “serious injury, harm, impairment or death.” Regulators still must take some action, but that could be ordering the nursing home to arrange training from an outside group or mandating specific changes to the way the home operates.

Barbara Gay, vice president of public policy communications at LeadingAge — an association of nonprofit organizations that provide elder services, including nursing homes — says that nursing homes “don’t feel they’ve been given a reprieve” under Trump.

But consumer advocates say penalties have reverted to levels too low to be effective.

“Fines need to be large enough to change facility behavior,” says Robyn Grant, director of public policy and advocacy at the National Consumer Voice for Quality Long-Term Care, a nonprofit based in Washington, D.C. “When that’s not the case and the fine is inconsequential, care generally doesn’t improve.”

Kaiser Health News is an editorially independent news service supported by the nonpartisan Kaiser Family Foundation. KHN is not affiliated with Kaiser Permanente. You can follow Jordan Rau on Twitter: @jordanrau.

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America’s big drugmakers and pharmacy chains are scrambling to respond to hundreds of lawsuits tied to the deadly opioid epidemic. Billions of dollars are at stake if the companies are found liable for fueling the crisis.

Even before judgments are rendered, companies like Purdue Pharma, Johnson & Johnson and CVS are already suffering damage to their reputations as evidence in civil suits reveals more about their internal workings.

“The narrative is clearly shifting on this story,” said David Armstrong, a senior reporter with ProPublica, who has covered the drug industry for years. “People want some sort of reckoning, some sort of accounting.”

One reason for the shift is that cities and states filing these suits are moving more aggressively to pull back the curtain on the drug industry’s practices, urging courts to make internal memos, marketing strategies and reams of other documents public.

“Our next battle is to get the depositions and the documents that are being produced made available to the public, instead of everything being filed under confidentiality agreements,” said Joe Rice, one of the lead attorneys bringing lawsuits against drug companies on behalf of local governments in Ohio.

A growing number of documents have already been released, or been leaked to the press, and many of the revelations they contain have been troubling. In internal memos, Purdue executives acknowledged that their prescription opioids are far more addictive and dangerous than the company was telling doctors. At the same time company directives pushed sales representatives to get even more opioids into the hands of vulnerable people, including seniors and military veterans.

Memos also show that Purdue executives developed a secret plan, never implemented, called Project Tango in which they acknowledged the escalating risk of the opioid epidemic. The program was allegedly designed to help Purdue profit from the growing wave of opioid dependency, by selling the company’s addiction treatment services to people hooked on products like their own OxyContin.

This increased transparency represents a big shift in the way opioid lawsuits are being handled. “We’ve done something that hasn’t been done before,” said Massachusetts Attorney General Maura Healey, who appeared in February on NPR and WBUR’s program On Point.

Massachusetts is suing Purdue, like dozens of other states, and Healey fought successfully to make all the documents her office had uncovered public, without redactions. “What Purdue’s own documents show is the extent of deception and deceit. What’s important to me is that the facts come to light and we get justice and accountability,” Healey said.

Purdue Pharma declined to speak with NPR, but the drug industry has fought these disclosures at every turn. They describe the information in these documents as proprietary, asserting that it should be viewed by the courts as corporate property. For years governments pursuing these cases mostly went along with those arguments.

In past opioid settlements, companies paid fines but insisted on gag orders. “The way it usually works is the language in the settlement requires either that the records be destroyed very quickly after the settlement or that they physically actually return the records to the drug company,” said ProPublica’s Armstrong.

That happened in 2007 when the Justice Department ended a criminal case against Purdue Pharma. It happened again a few years ago when the state of Kentucky settled a civil case with the company and that state’s attorney general destroyed thousands of pages of documents. As a result, few people in the wider public knew how serious the allegations were.

As more information has been revealed, it’s sparking fury. At a February hearing on Capitol Hill, Sen. Maggie Hassan, D-N.H., blasted industry executives. “Companies like Janssen and Purdue Pharma fueled this epidemic, employing deceptive and truly unconscionable marketing tactics despite the known risk, so you could sell more drugs to maximize your profits,” she said.

Jennifer Taubert heads the Janssen Pharmaceuticals unit of Johnson & Johnson, which makes and sells opioids. The company faces escalating lawsuits over its products, but Taubert denied any wrongdoing at the hearing. “Everything that we have done with our products when we’ve promoted opioid products, which we stopped marketing a long time ago, was appropriate and responsible,” she told lawmakers.

Yet according to the drug companies’ internal documents, firms including Johnson & Johnson pushed unscientific theories about drug addiction. They allegedly did so as part of an effort to convince doctors to prescribe even more opioids after patients showed signs of dependency.

This kind of industry backlash has happened before, such as when tobacco companies faced lawsuits in the 1990s. As those trials unfolded, the public learned for the first time about widespread corporate wrongdoing.

The difference here is that drug companies and their researchers have been seen by many in the public as healers and innovators, part of a trusted health care system.

There could be more revelations. With another big opioid trial set to begin in May in Oklahoma state court, attorneys are still fighting over millions of pages of documents, most of which the public has still never seen.

One possibility is that companies could agree to what’s known as a global settlement of these opioid cases, paying billions of dollars in compensation in hopes of winning new secrecy agreements.

If that happens, says ProPublica’s Armstrong, documents that help tell the full story of this drug epidemic could be destroyed or locked away for years. “I worry that we’re going to lose all this valuable information about how we got to this point with this crisis, who knew what when,” he said.

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