Emory University medical fellow Dr. Nicole Herbst was shocked when she saw three patients who came in with abnormal results from chest CT scans they had bought on Groupon.

Yes, Groupon — the online coupon mecca that also sells discounted fitness classes and foosball tables.

Similar deals have shown up for various lung, heart and full-body scans across Atlanta, as well as in Oklahoma and California. Groupon also offers discount coupons for expectant parents looking for ultrasounds, sold as “fetal memories.”

While Herbst declined to comment for this story, her sentiments were shared widely by the medical community on social media. The concept of patients using Groupons to get discounted medical care elicited the typical stages of Twitter grief: anger, bargaining and acceptance that this is the medical system today in the United States.

But, ultimately, the use of Groupon and other pricing tools is symptomatic of a health care market where patients desperately want a deal — or at least tools that better nail down their costs before they get care.

“Whether or not a person may philosophically agree that medicine is a business, it is a market,” says Steven Howard, who runs Saint Louis University’s health administration program.

By offering an upfront cost on a coupon site such as Groupon, medical companies are meeting people where they are, Howard argues. It helps drive prices down, he says — all the while marketing the medical businesses.

For Paul Ketchel, CEO and founder of MDsave, a site that contracts with providers to offer discount-priced vouchers on bundled medical treatments and services, the use of medical Groupons and his company’s success speak to the brokenness of the U.S. health care system.

MDsave offers deals at more than 250 hospitals around the country, selling vouchers for anything from MRIs to back surgery. It has experienced rapid growth and expansion in the several years since its launch.

Ketchel credits that growth to the general lack of price transparency in the U.S. health care industry amid rising costs to consumers. “All we are really doing is applying the e-commerce concepts and engineering concepts that have been applied to other industries to health care,” he argues.

“We are like transacting with Expedia or Kayak,” Ketchel says, “while the rest of the health care industry is working with an old-school travel agent.”

A closer look at those deals

Crown Valley Imaging, in Mission Viejo, Calif., has been selling Groupon deals for services including heart scans and full-body CT scans since February 2017 — despite what Crown Valley’s president, Sami Beydoun, called Groupon’s aggressive financial practices. According to him, Groupon dictates the price for its deals based on the competition in the area — and then takes a substantial cut.

“They take about half. It’s kind of brutal. It’s a tough place to market,” Beydoun says. “But, the way I look at it is you’re getting decent marketing.”

Groupon-type deals for health care aren’t new. They were more popular in 2011, 2012 and 2013, when Groupon and its then-competitor LivingSocial were at their height, but the industry has since lost some steam. Groupon stock and valuation have tumbled in recent years, even after buying LivingSocial in 2016.

Groupon did not respond to requests for comment on how many medical offerings it features or its pricing structure.

“Groupon is pleased any time we can save customers time and money on elective services that are important to their daily lives,” spokesman Nicholas Halliwell writes in an emailed statement. “Our marketplace of local services brings affordable dental, chiropractic and eye care, among other procedures and treatments, to our more than 46 million customers daily and helps thousands of medical professional[s] advertise and grow their practices.”

In Atlanta, two imaging centers that each offered discount coupons from Groupon say the deals have driven in new business. Bobbi Henderson, the office manager for Virtual Imaging’s Perimeter Center, says the group has been running the deal for a heart CT scan, complete with consultation, since 2012; it’s currently listed at $26 — a 96% discount. More than 5,000 of the company’s coupons have been sold, according to the Groupon site.

Brittany Swanson, who works in the front office at OutPatient Imaging in the Buckhead neighborhood of Atlanta, says she has seen hundreds of customers come through since the center posted Groupon coupons for mammograms, body scans and other screenings around six months ago. Why did the medical practice turn to Groupon discounts?

“Honestly, we saw the other competition had it,” Swanson says.

A lot of the deals offered are for preventive scans, she says, providing patients incentives to come in.

But Dr. Andrew Bierhals, a radiology safety expert at Washington University in St. Louis’ Edward Mallinckrodt Institute of Radiology, warns that such deals may be leading patients to get unnecessary initial scans — which can lead to unnecessary tests and radiation.

“If you’re going to have any type of medical testing done, I would make sure you discuss with your primary care provider or practitioner,” he cautions.

Appealing to patients who fall through an insurance gap

Because mammograms are typically covered by insurance, Swanson says, she believes OutPatient Imaging’s $99 Groupon deal is filling a gap for women who lack insurance. The cost of such breast screenings for those who don’t have insurance varies widely but can be up to several hundred dollars without a discount.

Howard says Groupon has long been used to fill insurance gaps for dental care. He often bought such deals over the years to get cheaper dental cleanings when he didn’t have insurance that covered that.

But advanced medical scans involve a higher level of scrutiny, as Chicagoan Anna Beck recently learned. In 2015, she and her husband, Miguel Centeno, were told he needed to get a chest CT after a less advanced X-ray at an urgent care center showed something suspicious.

Since her husband had just been laid off and did not have insurance, they shopped online to look for the cheapest price. They ended up driving out to the suburbs to get a CT scan at an imaging center there.

“I knew that CT scans had such a wide range of costs in a hospital setting,” Beck says. “So going in knowing that I could price check and have some idea of how much I’d be paying and a little more control” was preferable than going to the hospital.

On the drive back into the city though, the imaging center called and told them to go straight to the hospital — the CT had revealed a large mass that turned out to be a germ-cell tumor.

Fortunately, Centeno’s cancer is now in remission, his wife says. But their online shopping cost them more money than if they’d gone straight to the hospital initially. The hospital gave them charity care. And although Beck took along a CD of the scans Centeno had bought online, the hospital ended up taking its own scans as well.

“You’re trying to cut costs by getting a CT out of the hospital,” Beck says. “But they’re just going to redo it anyway.”

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

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When Jessy Rosales was a sophomore at the University of California, Riverside, she had a boyfriend and she was taking birth control pills. Then out of nowhere, she started feeling sick.

“I just thought it was the stomach flu,” she says. “It turns out I was pregnant.”

Rosales was clear that she was not ready to have a baby. She wanted a medication abortion, where she would take one pill at the clinic and a second one at home a day or two later to induce a miscarriage.

“I just wanted the intimacy of dealing with it on my own, in the privacy of my own home,” she says. “And being able to cry if I wanted to cry or just being able to curl up in my bed right away.”

Public university health centers in California do not perform abortions. But state lawmakers are expected to pass a bill in the coming weeks that would require student health centers at all 34 state campuses to provide medication abortions. If the measure becomes law, it will be the first of its kind in the U.S.

The bill’s supporters say they want to remove the obstacles women face accessing medical abortion off campus. For example, Rosales was given three off-campus referrals for abortion providers by her student health center. But the first clinic she called didn’t perform abortions after all. The second didn’t take her insurance.

By the time she could get an appointment at a third clinic, she was already into the second trimester of pregnancy — too late for a medication abortion, which can only be done up to 10 weeks. Rosales ended up having a surgical procedure.

“The doctor kept telling me to relax … and I couldn’t because it just hurt so bad,” she recalls. “I was just afraid and alone.”

Rosales graduated last year and is now advocating for the bill (SB 24) as a reproductive justice activist with the Women’s Foundation of California. She wants other students to have easier access to the abortion pill than she did.

Opponents of the bill have organized several rallies against it. In August, about 60 protesters in yellow T-shirts gathered outside a church in Sacramento, Calif., their heads bowed as a priest led them in prayer. Then they marched around the state’s Capitol, chanting, “Don’t kill babies! Don’t kill babies!”

While a consortium of women’s groups that support abortion rights has promised to pay for all the required ultrasound equipment and upfront training costs of providing the abortion pill on campus, eventually universities would likely need to dip into tax dollars or student fees for ongoing costs.

Abortion opponents such as Michele LaMonica object to that.

“Not on my dime, not on my dime,” LaMonica says. “Tax me to help the homeless. Tax me to help social services, but don’t tax me to pay for the disposal of human life.”

Insurers are already required to cover abortion under California law, and state tax dollars do go toward abortions provided through Medi-Cal, the state version of Medicaid for low-income patients. However, none of the UC campuses and only some of the CSU campuses get reimbursed for health services through Medi-Cal. University officials testified during legislative hearings on the bill last year that it could be an administrative or fiscal burden to establish billing systems to provide the abortion pill on campus. They predicted that some clinical costs, as well as security and liability costs, could fall directly to the universities and get passed on to students.

Up to 519 women at public universities seek a medication abortion every month in California, according to a study published last summer in the Journal of Adolescent Health.

The same research found that off-campus abortion providers were an average of 6 miles away from public university campuses in California.

Former Gov. Jerry Brown cited this stat when he vetoed a version of the same bill (SB 320) last year, saying the legislation was not necessary.

“Six miles away — that’s like a $5 Uber ride,” said abortion opponent Nick Reynosa, the Northern California regional coordinator for Students for Life of America.

He says the campaign is more about politics than need.

“Over the last decade, many pro-choice activists feel that in red states, there’s been a lot of momentum toward more abortion restrictions. This is a way to say, ‘No. Here, in blue California, we’re going to affirm or expand [the right to an abortion],’ ” Reynosa says.

The bill’s supporters don’t deny it. Phoebe Abramowitz was part of the student team that launched the campus campaign for medication abortions at UC Berkeley four years ago.

“Now that we’re doing statewide advocacy, we’re hoping to set a national precedent that we can, even in these really hostile times to women and queer people, move access to abortion forward,” she says. “It’s more important now than it even was a year ago.”

When Brown vetoed the bill last year, then-gubernatorial candidate Gavin Newsom said he would have supported it. He won the election about a month later, and advocates are optimistic that he will side with them this time around.

The state Legislature has until mid-September to pass the bill, and the governor has a month after that to sign or veto it.

This story is part of NPR’s reporting partnership with KQED and Kaiser Health News.

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While many Capitol Hill Republicans would like to avoid another public debate about whether to repeal the Affordable Care Act, President Donald Trump and his appointees keep bringing it up — promising their own health plan that would be “phenomenal” and make the GOP “the party of health care.”

“We’re actively engaged in conversations” on what to do, Medicare chief Seema Verma said last month. And Trump adviser Kellyanne Conway has indicated a health care announcement might come in September.

Behind the pronouncements lies a dilemma: whether or not to stray beyond efforts underway to improve the nation’s health care system — loosening insurance regulations, talking about drug prices and expanding tax-free health savings accounts — to develop an overarching plan.

For the White House, it’s a fraught decision.

A comprehensive plan could serve as a lightning rod for opponents. Conversely, not having a plan for replacing some of the most popular parts of Obamacare — such as its coverage protections for people with preexisting medical conditions — could leave the GOP flat-footed if an administration-supported lawsuit now before the 5th Circuit Court of Appeals were to invalidate the sweeping health law.

“This is a real conundrum,” says Dean Rosen, a Washington, D.C., health policy consultant who often advises Republicans. “There is a risk with action or inaction.”

No matter how the 5th Circuit rules, its decision, which could come soon, is likely to be stayed while the issue heads to the Supreme Court. Such a delay would give the Trump administration time to flesh out a proposal if the appeals judges throw out the ACA. But it would also ensure that a health care debate is front and center during the presidential campaign.

Right now, polls show the public is focused on health costs, says professor Robert Blendon, who directs the Harvard Opinion Research Program, which studies public knowledge of health care and policy issues. Consumers are concerned about what they pay at the pharmacy counter, or about the sum of their insurance premiums and deductibles.

“Most voters are not interested in another debate on a new health plan,” Blendon says.

But if the 5th Circuit upholds a Texas ruling overturning the entire ACA, “that changes the entire framework,” he adds. “The administration could not just say, ‘Oh, we’ll have something great.’ They would have to have something outlined.”

Supporters and critics say likely elements are already in plain sight, both in executive actions and proposals in the president’s budget as well as in a little-noticed interagency white paper released late last year, called Reforming American’s Health Care System Through Choice And Competition.

The president has won praise from both conservatives and liberals for initiatives such as his proposal to require hospitals to post their actual, negotiated prices, and some strategies to lower drug prices. But legal battles from industry could thwart such initiatives.

On these topics, “a lot of what they’ve proposed has been pretty smart,” says Shawn Gremminger, senior director of federal relations at the liberal Families USA advocacy group.

Still, Gremminger points to other administration actions — such as loosening rules on health insurers to allow sales of what critics call “junk” insurance, because they don’t have all the consumer protections of ACA policies, or promoting work requirements for Medicaid recipients — as strong hints to what might be in any eventual election-related plan.

“I think what we’ll see is a lot of that same sort of stuff, warmed-over and put into a new package,” Gremminger says. “We fully expect it will include a lot of really terrible ideas.”

For other policy clues, some Trump advisers, like Brian Blase, a former special assistant to the president at the National Economic Council, who is now with the Texas Public Policy Foundation, say look no further than that 2018 interagency report.

The 114-page document, a joint publication of the U.S. Departments of Labor, Treasury and Health and Human Services, includes more than two dozen recommendations that broadly focus on loosening federal and state regulations, limiting hospital and insurer market power and prompting patients to be more price-conscious shoppers.

Many are long-standing, free-market favorites of Republicans, such as increasing the use of health savings accounts — which allow consumers to set aside money, tax-free, to cover medical expenses. Other ideas are not typically associated with the GOP, such as increased federal scrutiny of mergers of hospitals and insurers; such mergers have driven up prices.

The white paper also calls for easing restrictions on Medicare Advantage plans, which offer an alternative to the traditional fee-for-service Medicare. The Trump proposal would allow the advantage program to have smaller networks of doctors and hospitals — presumably ones that agreed to charge less.

“The administration knows where it is going on health care,” Blase says.

If the court strikes down the ACA, he expects the administration to release a plan supporting “generously funded, state-based high-risk pools.”

Such pools existed in most states before the ACA. They helped provide coverage for people with preexisting conditions who were denied policies by insurers. But the pools were expensive, so they often were underfunded — capping members’ benefits and producing long waiting lists.

Not everyone thinks the white paper is a plan, but more of a “combination of policy ideas and political statements,” says Joe Antos at the conservative-leaning American Enterprise Institute.

Still, he doubts the GOP needs a comprehensive health proposal. Republicans are more likely to gain politically by merely attacking the Democrats’ ideas, Antos says, especially if the Democratic nominee backs proposals for a fully government-funded health care system, such as the Medicare for All plans some candidates support.

Republicans will “have their own one-liners, saying they are dedicated to protecting people with preexisting conditions. That might be enough for a lot of people,” Antos says.

Politically, taking on the Affordable Care Act — or not taking it on — are both risky. While many voters don’t understand all that the federal health law does, some of its rules enjoy broad support. That’s particularly true of the protections for people with medical problems — under the current law, insurers are barred from rejecting them for coverage or charging them more than people without such conditions.

The Republican effort to repeal the ACA galvanized activists during the 2018 midterm elections and is credited with boosting Democrats to victory in many House districts.

Analysts on both sides expect concerns about health costs and health law to play a large role again in 2020.

For Republicans, “the risk of doing nothing potentially leaves no port in a storm if the ACA is overturned legally,” Rosen says. “But a more limited version, which is what most Republicans are for, is likely to be met with the same concerns. No matter what the president says, it won’t be enough for the Democrats.”

Opinion poll analyst Blendon says there is an additional unknown: Which Democrat will win the nomination — and what type of coverage will she or he back?

Even as the GOP is split on how to address health care concerns, so too are the Democrats.

“If they are reading the same polling data as I am, they would have serious proposals for lowering drug and hospital costs, but not offer a national health plan,” Blendon says.

The Democrats’ most progressive wing, led by Sens. Bernie Sanders of Vermont and Elizabeth Warren of Massachusetts, wants Medicare for All, which would essentially eliminate private and job-based coverage. Recent polls have shown voters are not keen to lose private insurance.

The party’s center, led by former Vice President Joe Biden, wants to keep the ACA but apply “fixes” to make insurance purchased by individuals more affordable.

“If the Democratic nominee is running on keeping the ACA, the Republican will have to have an alternative,” Blendon says. But, if the nominee supports Medicare for All, Blendon predicts simply a GOP “anti-campaign” targeting the Democrat’s idea as unworkable, socialist or a danger to Medicare.

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

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