Author: bkellaway

When Joshua Martz tested positive for COVID-19 this summer in a Montana jail, guards moved him and nine other inmates with the disease into a pod so cramped that some slept on mattresses on the floor.

Martz, 44, said he suffered through symptoms that included achy joints, a sore throat, fever and an unbearable headache. Jail officials largely avoided interacting with the COVID patients other than by handing out over-the-counter painkillers and cough syrup, he said. Inmates sanitized their hands with a spray bottle containing a blue liquid that Martz suspected was also used to mop the floors. A shivering inmate was denied a request for an extra blanket, so Martz gave him his own.

“None of us expected to be treated like we were in a hospital, like we’re a paying customer. That’s just not how it’s going to be,” said Martz, who has since been released on bail while his case is pending in court. “But we also thought we should have been treated with respect.”

The overcrowded Cascade County Detention Center in Great Falls, where Martz was held, is one of three Montana jails experiencing COVID outbreaks. In the Great Falls jail alone, 140 cases have been confirmed among inmates and guards since spring, with 60 active cases as of mid-September.

When inmate Joshua Martz tested positive for COVID-19 this summer at the Cascade County Detention Center in Great Falls, Montana, guards moved him and nine other inmates with the disease into a pod so cramped that some slept on mattresses on the floor. (Matt Volz/KHN)

By contrast, the Montana state prison system has the second-lowest infection rate in the nation, according to the COVID Prison Project. No confirmed coronavirus cases have been reported at the men’s prison out of 595 inmates tested. The women’s prison had just one confirmed case out of 305 inmates tested, according to Montana Department of Corrections data.

One reason for the high COVID count in jails and the low count in prisons is that Montana for months halted “county intakes,” or the transfer of people from county jails to the state prison system after conviction. Sheriffs in charge of the county jails blame their outbreaks on overcrowding partly caused by that state policy.

Restricting transfers into state prisons is a practice that’s also been instituted elsewhere in the U.S. as a measure to prevent the spread of the coronavirus. Colorado, California, Texas and New Jersey are among the states that suspended inmate intakes from county jails in the spring.

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But it’s also shifted the problem. Space was already a rare commodity in these local jails, and some sheriffs see the halting of transfers as giving the prisons room to improve the health and safety of their inmates at the expense of those in jail, who often haven’t been convicted.

The Cascade County jail was built to hold a maximum of 372 inmates, but the population has regularly exceeded that since the pandemic began, including dozens of Montana Department of Corrections inmates awaiting transfer.

“I’m getting criticized from various judges and citizens saying, ‘Why aren’t you quarantining everybody appropriately and why aren’t you social-distancing them?’” Cascade County Sheriff Jesse Slaughter said. “The truth is, if I didn’t have 40 DOC inmates in my facility I could better do that.”

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Unlike convicted offenders in state prisons, most jail inmates are only accused of a crime. They include a disproportionately high number of poor people who cannot afford to post bail to secure their release before trial or the resolution of their cases. If they do post bail or are released after spending time in a jail with a COVID outbreak, they risk bringing the disease home with them.

Andrew Harris, a professor of criminology and justice studies at the University of Massachusetts Lowell, said he finds it troubling that more attention is not paid to the conditions that lead to COVID outbreaks in jails.

“Jails are part of our communities,” Harris said. “We have people who work in these jails who go back to their families every night, we have people who go in and out of these jails on very short notice, and we have to think about jail populations as community members first and foremost.”

Some states have tried other ways to ensure county inmates don’t bring COVID-19 into prisons. In Colorado, for example, officials lifted their suspension on county intakes and are transferring inmates first to a single prison in Canon City, Department of Corrections spokesperson Annie Skinner said. There, inmates are tested and quarantined in single cells for 14 days before being relocated to other state facilities.

Outbreaks are also occurring in county jails in states that never stopped transferring inmates to state prison. Several jails in Missouri have experienced significant outbreaks, with Greene County reporting in mid-August that 83 inmates and 29 staffers had tested positive. Missouri Department of Corrections spokesperson Karen Pojmann said the state never opted to stop transfers from county jails, likely because of a robust screening and quarantine procedure implemented early in the pandemic.

At least 1,590 inmates and 440 staff members have tested positive for COVID-19 in Missouri’s 22 prison facilities since March, according to state data. The COVID Prison Project ranks Missouri’s case rate 25th among the states — better than some states that halted inmate transfers, including Colorado, Texas and California.

The halting of transfers was a critical part of the response by officials in California, whose prisons have been among the hardest hit by COVID-19. An outbreak at San Quentin State Prison this summer helped spur Democratic Gov. Gavin Newsom to order the early release of 10,000 inmates from prisons statewide.

Stefano Bertozzi, dean emeritus at the University of California-Berkeley School of Public Health, visited San Quentin before the outbreak, and afterward helped pen an urgent memo outlining immediate actions needed to avert disaster. He recommended halting all intakes at the prison and slashing its population of 3,547 inmates in half. At that point, the California Department of Corrections and Rehabilitation was already more than two months into an intake freeze.

Overcrowding has long been an issue for criminal justice reform advocates. But for Bertozzi, the term “overcrowding” needs to be redefined in the context of COVID-19, with an emphasis on exposure risk. Three inmates sharing a cell designed for two is a bad way to live, he said, “especially for the guy who’s on the floor.” But if those cells are enclosed, they offer far better protection from COVID-19 than 20 inmates sharing a congregate dorm designed for 20.

“It’s how many people are breathing the same air,” Bertozzi said.

Some California county jails struggled. In July, inmates in Tulare County’s facility, where 22 cases had been reported, filed a class action suit against Sheriff Mike Boudreaux alleging he’d failed to provide face masks and other safeguards. U.S. District Court Judge Dale Drozd ruled in favor of the inmates in early September, directing Boudreaux to implement official policies requiring face coverings and social distancing.

California resumed county intakes on Aug. 24 following the development of guidelines designed to control transmission risk and prioritize counties with the greatest need for space. But a huge backlog remains: 6,552 state inmates were still being held in county jails as of mid-September, according to corrections officials.

In Montana, the number of inmates at county jails awaiting transfer to prisons and other state corrections facilities was 238 at the beginning of September, according to state data obtained through a public records request.

Montana and county officials butted heads over delays in inmate transfers before the coronavirus, but the pandemic has increased the stakes.

“Once we had the issue with the pandemic and we had to maintain space for quarantining and isolating inmates, then it became even more critical because the space wasn’t really available,” Yellowstone County Sheriff Mike Linder said.

Montana Department of Corrections Director Reginald Michael acknowledged to state lawmakers in August that halting county intakes places a strain on counties but said it was “the right thing to do.”

“This is one of the reasons why I think our prisons are not inundated with the virus spread,” he told the Law and Justice Interim Committee.

Committee Chairman Rep. Barry Usher, a Republican, gave Michael his endorsement: “Sounds like you guys are doing a good job keeping it controlled and out of our prison systems, and everybody in Montana appreciates that.”

Since then, Montana officials have transferred up to 25 inmates a week, but they continue to block transfers from the three counties with outbreaks: Cascade, Yellowstone and Big Horn.

Martz dreaded the thought of COVID-19 following him out of jail. So much so that, after his release in early September, he walked to an RV park, where his wife met him with a tent.

Despite having tested negative for the virus prior to his release, he self-quarantined for a week before going home. The hardest part, he said, was not being able to immediately hug his 5-year-old stepdaughter. It “sucked,” but it’s what he felt he had to do.

“If somebody’s grandpa or grandmother had gotten it because I was careless and they ended up dying because of it, I’d feel horrible,” said Martz, who has returned home. “That’d be a horrible thing to do.”

When it comes to health care, President Donald Trump has promised far more than he has delivered. But that doesn’t mean his administration has had no impact on health issues — including the operation of the Affordable Care Act, prescription drug prices and women’s access to reproductive health services.

In a last-ditch effort to raise his approval rating on an issue on which he trails Democrat Joe Biden in most polls, Trump on Thursday unveiled his “America First Healthcare Plan,” which includes a number of promises with no details and pumps some minor achievements into what the administration calls “monumental steps to improve the efficiency and quality of healthcare in the United States.”

As the election nears, here is a brief breakdown of what Trump has done — and has not done — on some key health issues.

Affordable Care Act

Trump has not managed to repeal and replace the Affordable Care Act, despite his claims that the law is dead.

But his administration, and Republicans in Congress, have made changes to weaken the law while not dramatically affecting enrollment in marketplace plans.

Congress failed to rewrite the law in summer 2017, but Republicans who controlled both the House and Senate at the time included in their year-end tax cut bill a provision that reduced the penalty for failing to have health insurance to zero. That change eliminated what was by far the most unpopular provision of the law.

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It also sparked a lawsuit by Republican state attorneys general and governors arguing that the tax change undercuts the law and thus should invalidate it. The case is set to be heard by the Supreme Court the week after the Nov. 3 election. The Trump administration is formally supporting the GOP plaintiffs in that suit.

The administration also used executive and regulatory action to chip away at the law’s efficacy. Trump ended disputed cost-sharing subsidies to help insurers lower out-of-pocket costs for policyholders with low incomes. And the administration shortened the open enrollment period by half and slashed the budget for promoting the plans and paying people to help others navigate the often-confusing process of signing up.

Administration officials have complained that plans sold on the ACA marketplaces are not affordable, so they set new rules that allowed companies to sell competing “short-term” policies that were less expensive than ACA-sanctioned plans. But those plans are not required to provide comprehensive benefits or cover preexisting conditions.

Now, weeks before the election, federal officials are taking credit for premiums coming down, slightly, on ACA plans. “Premiums have gone down across all of our programs, including in healthcare.gov, which had been previously seeing double-digit rate increases,” Seema Verma, who runs Medicare, Medicaid and the ACA exchanges, told reporters in a Sept. 24 conference call.

Premiums have come down this past year, confirmed Sabrina Corlette, who tracks the ACA as co-director of the Center on Health Insurance Reforms at Georgetown University, but only after many of the Trump administration’s changes had driven them even higher. Insurers were spooked by the uncertainty — particularly in 2017, about whether the law would be repealed — and Trump’s cutoff of federal funding for subsidies.

“The bottom line is, rates have gone up under Trump,” Corlette said.

Women’s Reproductive Health

Before he was elected, Trump pledged his allegiance to anti-abortion activists, who in turn urged their supporters to vote for him. But unlike many previous GOP presidents who called themselves “pro-life” but pushed the issue to the back burner, Trump has delivered on many of his promises to abortion foes.

Foremost, Trump has nominated two justices to the Supreme Court who were supported by anti-abortion advocates. With the help of the GOP Senate, Trump has also placed 200 conservative judges on federal district and appeals courts.

While many of the policy proposals advanced by the Trump administration are tied up in court, the sheer volume of activity has been notable, outstripping in less than four years efforts by Presidents Ronald Reagan and George W. Bush over each of their two-term presidencies.

Among those actions is a re-implementation and broadening of the “Mexico City Policy” that restricts foreign aid funding to organizations that “perform or promote” abortion. The administration has also moved to push Planned Parenthood out of the federal family planning program and Medicaid program. In addition, it has moved to make private insurance that covers abortion harder to purchase under the Affordable Care Act.

Trump’s efforts on women’s reproductive health reach beyond abortion to birth control. New rules would make it easier for employers with a “moral or religious objection” to decline to offer birth control as a health insurance benefit. Other rules would make it easier for health workers to decline to participate in any procedure to which they personally object.

COVID-19

Trump often claims that his decision in February to stop most travel from China was a critical factor in keeping the coronavirus pandemic in the U.S. from being worse than it has been. But the “travel ban” not only failed to stop many people from entering the U.S. from China anyway, scientists would later determine that the virus that spread widely in New York and other cities on the East Coast most likely came from Europe.

Although the White House has a coronavirus task force, the administration primarily has allowed states and localities to determine their own restrictions and timetables for closing and opening. The administration also had difficulty distributing medical supplies from a stockpile established for exactly this purpose. The president’s son-in-law and White House adviser, Jared Kushner, said at one point that the purpose of the stockpile was to supplement state supplies, not provide them.

Testing was also a problem. An early test developed by the Centers for Disease Control and Prevention turned out to be faulty, and despite continued promises by administration officials, testing remains less available six months into the pandemic than most experts recommend. Meanwhile, Trump has claimed repeatedly — and falsely — that if the U.S. did less testing there would be fewer cases of the virus.

But many public health observers say the administration’s biggest failing during the pandemic has been the lack of a single national message about the coronavirus and the best ways to prevent its spread.

More than 200,000 people in this country have died. Although the United States has only 4% of the world’s population, it has recorded 21% of the fatalities around the globe.

Prescription Drug Costs

Trump pledged to attack high drug costs as one of his main campaign themes in 2016 and again this year. But he has not had the success he hoped for.

In one of the administration’s biggest moves, the Department of Health and Human Services approved a rule last week that allows states to set up programs to import drugs from Canada, where they are cheaper because the Canadian government limits prices. Yet, it’s unclear if the program will get off the ground, given drug industry opposition and resistance from the Canadian government.

In his health care policy speech Thursday, Trump promised to send each Medicare beneficiary a $200 discount card over the next several months to help them buy prescription drugs. The initiative is being done under a specific innovation program and must not add to the deficit. Administration officials Friday could not answer where they will get the nearly $7 billion to pay for what is perceived by many observers as a last-ditch stunt to win votes from older Americans.

The president previously signed an executive order that seeks to tie the price Medicare pays for drugs to a lower international reference price. The administration, however, hasn’t released formal regulations to implement the policy, which could take years, and the policy is expected to be challenged in court by the drug industry.

In addition, Medicare will cap the price of insulin at $35 per prescription starting in 2021 for people getting coverage through some drug plans. More than 3 million Medicare beneficiaries use insulin to control their diabetes.

Trump also signed a law banning gag clauses used by health plans and pharmacy benefit managers to bar pharmacists from telling consumers about lower-priced drug options.

The administration’s plan to require drug companies to provide prices in pharmaceutical advertising has been beaten back in court.

The administration points to the increased number of generic drugs that have been approved since Trump was elected, but many of those drugs are not on the market. That’s because generic companies sometimes make deals with brand-name manufacturers to delay introducing lower-cost versions of their medicines.

At the same time, several bills the president supported to lower prices have stalled in Congress because of partisan differences and industry opposition.

“I don’t think there has been any meaningful action that has had meaningful effect on drug prices,” said Katie Gudiksen, a senior health policy researcher at The Source on Healthcare Price and Competition, a project of UC Hastings College of the Law in San Francisco.

Yet, she said, it’s possible Trump’s harsh criticism of the industry has had a chilling effect that led to lower prices.

Still, out-of-pocket costs for many individuals continue to climb as private and government insurance shifts more responsibility to the patient via higher cost sharing. Good Rx, an online site that tracks drug prices, noted this month that prescription drug prices have increased by 33% since 2014, faster than any other medical service or product.

Medicaid

The Trump administration has tried — but largely failed — to make many major changes to the state-federal health insurance program that covers more than 70 million low-income Americans.

Efforts by Republicans to repeal the Affordable Care Act would have ended the federal funding for the District of Columbia and the 38 states that expanded their programs for everyone with incomes under 138% of the federal poverty level, or about $17,609 for an individual. About 15 million people have gained coverage through the expansion.

Trump administration officials have argued that Medicaid should be reserved for the most vulnerable Americans, including traditional enrollees such as children, pregnant women and the disabled, and not used for non-disabled adults who gained coverage under the ACA’s expansion. Since Trump took office, seven states have expanded Medicaid — Idaho, Maine, Missouri, Oklahoma, Nebraska, Utah and Virginia.

In 2018, federal officials allowed states for the first time to require some enrollees to work as a condition for Medicaid coverage. The effort resulted in more than 18,000 Medicaid enrollees losing coverage in Arkansas before a federal judge halted implementation in that state and several others. The case has been appealed to the Supreme Court.

The administration also backed a move in Congress to change the way the federal government funds Medicaid. Since Medicaid’s inception in 1966, federal funding has increased with enrollment and health costs. Republicans would like to instead offer states annual block grants that critics say would dramatically reduce state funding but that proponents say would give states more flexibility to meet their needs.

When the congressional attempt to establish block grants failed, the administration tried through executive action to implement a process allowing states to opt into a block grant. Yet only one state — Oklahoma — applied for a waiver to move to block-grant funding, and it withdrew its request in August, two weeks after voters there narrowly passed a ballot initiative to expand Medicaid to 200,000 residents.

Medicaid enrollment fell from 75 million in January 2017 to about 71 million in March 2018. Then the pandemic took hold and caused millions of people to lose jobs and their health coverage. As of May, Medicaid enrollment nationally was 73.5 million.

The administration’s decision to expand the “public charge” rule, which would allow federal immigration officials to more easily deny permanent residency status to those who depend on certain public benefits, such as Medicaid, has discouraged many people from applying for Medicaid, said Judith Solomon, senior fellow with the Center on Budget and Policy Priorities, a research group based in Washington, D.C. 

Medicare

Seniors were among Trump’s most loyal voters in 2016, and he has promised repeatedly to protect the popular Medicare program. But not all his proposals would help the seniors who depend on it.

For example, invalidating the Affordable Care Act would eliminate new preventive benefits for Medicare enrollees and reopen the notorious “doughnut hole” that subjects many seniors to large out-of-pocket costs for prescription drugs, even if they have insurance.

Trump also signed several pieces of legislation that accelerate the depletion of the Medicare trust fund by cutting taxes that support the program. And his budget for fiscal 2021 proposed Medicare cuts totaling $450 billion.

At the same time, however, the administration implemented policies dramatically expanding payment for telehealth services as well as a kidney care initiative for the millions of patients who qualify for Medicare as a result of advanced kidney disease.

Surprise Billing

Trump in May 2019 promised to end surprise billing, which leaves patients on the hook for often-exorbitant bills from hospitals, doctors and other professionals who provide service not covered by insurance.

The problem typically occurs when patients receive care at health facilities that are part of their insurance network but are treated by practitioners who are not. Other sources of surprise billing include ambulance companies and emergency room physicians and anesthesiologists, among other specialties.

An effort to end the practice stalled in Congress as some industry groups pushed back against legislative proposals.

“The administration was supportive of the pretty consumer-friendly approaches, but obviously it doesn’t have any results to speak of,” said Loren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy in Los Angeles.

“At the end of the day, plenty of people in Congress did not really want to get something done,” he said.

Taking a different route, the administration finalized a rule last November that requires hospitals to provide price information to consumers. The rule will take effect Jan. 1. A federal judge shot down an attempt by hospitals to block the rule, although appeals are expected.

Brian Blase, a former Trump adviser, said this effort could soon help consumers. “Arguably, the No. 1 problem with surprise bills is that people have no idea what prices are before they receive care,” he said.

But Adler said the rule would have a “very minor effect” because most consumers don’t look at prices before deciding where to seek care — especially during emergencies.

Public Health/Opioids

Obesity and the opioid addiction epidemic were two of the nation’s biggest public health threats until the coronavirus pandemic hit this year.

The number of opioid deaths has shown a modest decline after a dramatic increase over the past decade. Overall, overdose death rates fell by 4% from 2017 to 2018 in the United States. New CDC data shows that, over the same period, death rates involving heroin also decreased by 4% and overdose death rates involving prescription drugs decreased by 13.5%.

The administration increased funding to expand treatment programs for people using heroin and expanded access to naloxone, a medication that can reverse an overdose, said Dr. Georges Benjamin, executive director of the American Public Health Association.

Meanwhile, the nation’s obesity epidemic is worsening. Obesity, a risk factor for severe effects of COVID-19, continues to become more common, according to the CDC.

Twelve states — Alabama, Arkansas, Indiana, Kansas, Kentucky, Louisiana, Michigan, Mississippi, Oklahoma, South Carolina, Tennessee and West Virginia — have a self-reported adult obesity prevalence of 35% or more, up from nine states in 2018 and six in 2017.

Benjamin said some of the administration’s other policies, such as reducing access to food stamps and undermining clean air and water regulations, have made improving public health more difficult.

But the pandemic has been the major public health issue this administration has faced.

“We were doing a reasonable job addressing the opioid epidemic until COVID hit,” Benjamin said. “This shows the fragility of our health system, that we cannot manage these three epidemics at the same time.”

STERLING, Colo. — Tonja Jimenez is far from the only person driving an RV down Colorado’s rural highways. But unlike the other rigs, her 34-foot-long motor home is equipped as an addiction treatment clinic on wheels, bringing lifesaving treatment to the northeastern corner of the state, where patients with substance use disorders are often left to fend for themselves.

As in many states, access to addiction treatment remains a challenge in Colorado, so a new state program has transformed six RVs into mobile clinics to reach isolated farming communities and remote mountain hamlets. And, in recent months, they’ve become more crucial: During the coronavirus pandemic, even as brick-and-mortar addiction clinics have closed or stopped taking new patients, these six-wheeled clinics have kept going, except for a pit stop this summer for air conditioning repair.

Their health teams perform in-person testing and counseling. And as broadband access isn’t always a given in these rural spots, the RVs also provide a telehealth bridge to the medical providers back in the big cities. Working from afar, these providers can prescribe medicine to fight addiction and the ever-present risk of overdose, an especially looming concern amid the isolation and stress of the pandemic.

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Mobile health clinics have been around for years, bringing vision tests, asthma treatment and dentistry to places without adequate care. But using health care on wheels to treat addiction isn’t as common. Nor is equipping such motor homes with telehealth capability that expands the reach of prescribing providers to treat hard-to-reach patients in these hard-to-reach rural areas.

“We really believe we bring treatment to our patients and we meet them where they’re at,” said Donna Goldstrom, clinical director for Front Range Clinic, a Fort Collins, Colorado, practice that operates four of the RVs. “So meeting them where they’re at physically is not a long leap from meeting them where they’re at motivationally and psychologically.”

Each RV has a nurse, a counselor and a peer specialist who has personal experience with addiction — and all had to be trained to drive a vehicle that size.

“I never thought when I went to nursing school that I’d be doing this,” Christi Couron, a licensed practical nurse, said as she pumped 52 gallons of diesel fuel into the motor home she works on with Jimenez.

The crew has driven their RV more than 30,000 miles since January, much of it viewed through a cracked windshield courtesy of a summer afternoon hailstorm. Four days a week, they ply the roads from Greeley to the smaller towns near the Nebraska border, as the view goes from mile-high to miles-wide.

Don a Mask, Pee in a Cup

On a dusty lot outside a halfway house in Sterling, Jimenez, the peer specialist, activates the leveling jacks to balance the RV, and the team readies the unit for the day’s slate of patients. The passenger-side captain’s chair flips around to face a table where Jimenez will check in patients. The tabletop is crowded with a printer, a scanner, a laptop and a label-maker. Underneath lie a box of specimen cups and a gallon of windshield washer fluid. The vehicle now has plenty of masks and cleaning supplies on hand, too.

After patients check in, they go to the RV’s snug bathroom to provide a urine sample. With test strips built into the sides of the cup, results show instantly whether any of 13 categories of drugs — from opiates to antidepressants — are in the urine. The sample is later dropped off at a lab to confirm the results and determine which specific drug is involved. The results help the team understand how best to treat the patients and make sure they use the prescriptions they’re given.

Patients then head to a small exam room in the back, where they connect via video to a nurse practitioner or physician assistant in a brick-and-mortar clinic.

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If all goes well, the provider will send over a prescription for Suboxone (a combination medicine containing buprenorphine, which reduces cravings for opioids) or for Vivitrol (a monthly injectable version of naltrexone, which blocks opioid receptors). Once the staffers have the prescription in hand, the RV nurse can give those Vivitrol shots directly and distribute Narcan, a medication that will reverse an opioid overdose. Suboxone prescriptions must be called into a local pharmacy.

Patients also can drop used needles into a sharps container for disposal, but the staffers are not allowed to distribute clean needles. Some patients will talk with counselor Nicky McLean in a room just large enough to fit a table and two chairs.

Within minutes, a couple, who asked not to be identified by name because of the stigma surrounding addiction, arrive early for their appointments. They’ve brought the staff homemade chicken enchiladas. They had been spending $8,000 a month buying OxyContin on the street, and their lives and finances were a wreck. He lost his house. She needs clean urine tests to see her son. The couple started their addiction treatment only three weeks earlier, after he learned about the RV clinic from a friend.

They no longer have a car, so they walked a half-hour to get to their appointment.

“We would’ve done anything to get our drugs,” she said. “Walking 30 minutes to get better, it’s worth it.”

Even before they’ve finished, another patient is at the door. Spencer Nash, 29, has been using opioids since he was 18. Nine years ago, when his wife got pregnant, the couple decided to get clean, driving two hours each way, six days a week, to a methadone clinic in Fort Collins. Now, he walks to the RV, outside the halfway house where he lives, to get his Suboxone prescription.

Filling the Gaps

A few years ago, Robert Werthwein, director of Colorado’s Office of Behavioral Health, heard about a project using RVs for addiction treatment in rural upstate New York. He thought it would work in his state, too. The agency crunched the numbers to see which regions recorded the highest levels of opioid prescriptions and overdoses but lacked addiction treatment.

“We hear too often that in rural Colorado and the mountain regions of Colorado they don’t have the same access to services as the Denver metro and the Front Range regions,” Werthwein said. The state secured a $10 million federal grant for the program. His team brought in health care providers, such as Front Range Clinic, to staff and operate the RVs.

Once the RVs were ready, the staff had to be trained to drive them, which necessitated “a couple of repairs,” Werthwein said. The vehicles first started rolling out in December, eventually serving six regions — and in a seventh area, a place where narrow mountain roads precluded a large RV, one of Werthwein’s teams travels by SUV.

In some communities, the local doctors and others have been less than thrilled, feeling the RVs would attract drug users to their town.

“We’re hoping to address stigma, not just from a public standpoint, but we’re hoping to show providers ‘there is a demand in your community for medication-assisted treatment,’” Werthwein said.

Once the federal grant runs out in September 2022, Front Range Clinic and the other mobile unit operators will inherit and continue to operate the RVs, billing Medicaid and private insurance as they do now for the appointments.

As the RV crew’s 1 p.m. departure time in Sterling approached, one patient remained. The woman, who asked that her name not be published because she didn’t want to be publicly identified as a drug user, arrived at the mobile clinic without an appointment. But they couldn’t take her as a new patient without a urine sample. For two hours, she was in and out of the bathroom, drinking bottles of water, but unable to fill the little plastic cup. Through the bathroom door, the staffers could hear her crying and cursing at herself.

With the battery power on the RV winding down, they coaxed her out of the bathroom. Perhaps tomorrow would work better, they told her. She could continue to rehydrate through the night and then meet the mobile unit at its next stop, Fort Morgan, some 45 minutes away.

The next day, she was still unable to produce a urine sample, whether because of dehydration from her substance use or simply nerves. They asked her to come back again when the RV returned to Sterling the next week, but she never showed up.

President Donald Trump, outlining his “America First Health Plan” Thursday, announced that his administration will allow the importation of prescription drugs from Canada.

The final plan clears the way for Florida and other states to implement a program bringing medications across the border despite the strong objections of drugmakers and the Canadian government.

Florida, the biggest swing state in the presidential election, is one of six states to pass laws seeking federal approval to import drugs. Trump’s announcement came the same day counties in Florida began sending out vote-by-mail ballots.

Florida Gov. Ron DeSantis, a close ally of the president, is a strong advocate of importing drugs. His administration has already advertised for a contractor to run the state program and is expected to announce Tuesday which companies have bid for the three-year, $30 million state contract.

Congress has allowed drug importation since 2000 but only if the secretary of the Department of Health and Human Services certified it is safe. That has never occurred until Secretary Alex Azar did it Wednesday, according to a letter he wrote to congressional leaders.

Implementation under the administration’s final rule “poses no additional risk to the public’s health and safety and will result in a significant reduction in the cost of covered products to the American consumer,” Azar said in the letter KHN obtained Thursday.

Prices are cheaper north of the border because Canada limits how much drugmakers can charge for medicines. The United States lets free market dictate drug prices.

The pharmaceutical industry has long fought efforts on importation, arguing that it would disrupt the nation’s supply chain and make it easier for unsafe or counterfeit medications to enter the market.

“We are reviewing the final rule and guidance that were released; however, we continue to have grave concerns with drug importation that exposes Americans unnecessarily to the dangers of counterfeit or adulterated drugs,” said a spokesperson for the Pharmaceutical Research and Manufacturers of America, an industry trade group. “It is alarming that the administration chose to pursue a policy that threatens public health at the same time that we are fighting a global pandemic.”

Drugmakers have suggested in the past that they might try to stop such a policy through a lawsuit.

Trump has dangled his drug importation plan in campaign speeches over the past year — and again on Thursday in North Carolina during a speech that provided a litany of his promises on health care.

“We will finally allow the safe and legal importation of drugs from Canada,” Trump said. States “can go to Canada and buy your drugs for a fraction of the price” in the U.S.

“This will be a game changer for American seniors,” Trump said. “We’re doing it very, very quickly.”

The administration proposed the regulation in December. The final rule says it takes effect in 60 days.

But individuals will not be allowed to import drugs on their own, Azar said in his letter. Instead, they will have to rely on programs run by states.

For decades, Americans have been buying drugs from Canada for personal use — either by driving over the border, ordering medication on the internet or using storefronts that connect them to foreign pharmacies. Though the practice is illegal, the FDA has generally permitted purchases for individual use.

About 4 million Americans import medicines for personal use each year, and about 20 million say they or someone in their household has done so because prices are much lower in other countries, according to surveys.

The practice has been especially common in retiree-rich Florida, where more than a dozen stores help consumers make the purchases and where numerous cities, counties and school districts assist employees with the transactions.

The administration envisions a system in which a Canadian-licensed wholesaler buys from a manufacturer of drugs approved for sale in Canada and exports the drugs to a U.S. wholesaler/importer under contract to a state.

Florida’s legislation — approved in 2019 — would set up two importation programs. The first would focus on getting drugs for state programs such as Medicaid, the Department of Corrections and county health departments. State officials said they expect the program to save the state about $150 million annually.

The second program would be geared to the broader state population.

The HHS final rule said the government will “in the future” allow pharmacists to import drugs from Canada, a provision that matches the law approved by Florida in 2019.

But pharmacists in Florida and across the country oppose drug importation, saying they don’t think it will ensure that counterfeit drugs are kept out of the U.S. market.

The Canadian government told HHS last spring that the country doesn’t have enough drugs to spare and the Trump plan would only worsen shortages of medicines there.

The final rule said state importation programs will have flexibility to decide which drugs to import and in what quantities.

The rule also makes clear that drug manufacturers will have to provide to importers documentation guaranteeing the medications are the same drugs as those already sold in the United States. HHS could set up regulations that require drugmakers to comply. Importers will have to send drugs to labs to certify their authenticity.

In addition to Florida, the other states seeking federal permission to buy drugs from Canada are Colorado, Maine, New Hampshire, New Mexico and Vermont.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Matthew Fentress was just 25 when he passed out while stuffing cannolis as a cook for a senior living community six years ago. Doctors diagnosed him with viral cardiomyopathy, heart disease that developed after a bout of the flu.

Three years later, the Kentucky man’s condition had worsened, and doctors placed him in a medically induced coma and inserted a pacemaker and defibrillator. Despite having insurance, he couldn’t pay what he owed the hospital. So Baptist Health Louisville sued him and he wound up declaring bankruptcy in his 20s.

“The curse of being sick in America is a lifetime of debt, which means you live a less-than-opportune life,” said Fentress, who still works for the senior facility, providing an essential service throughout the coronavirus pandemic. “The biggest crime you can commit in America is being sick.”

Financial fears reignited this year when his cardiologist suggested he undergo an ablation procedure to restore a normal heart rhythm. He said hospital officials assured him he wouldn’t be on the hook for more than $7,000, a huge stretch on his $30,000 annual salary. But if the procedure could curb the frequent extra heartbeats that filled him with anxiety, he figured the price was worth it.

He had the outpatient procedure in late January and it went well.

Afterward, “I didn’t have the fear I’m gonna drop dead every minute,” he said. “I felt a lot better.”

Then the bill came.

Patient: Matthew Fentress is a 31-year-old cook at Atria Senior Living who lives in Taylor Mill, Kentucky. Through his job, he has UnitedHealthcare insurance with an out-of-pocket maximum of $7,900 — close to the maximum allowed by law.

Total Bill: Fentress owed a balance of $10,092.13 for cardiology, echocardiography and family medicine visits on various dates in 2019 and 2020. UnitedHealthcare had paid $28,920.52 total, including $27,561.37 for the care he received on the day of his procedure.

Service Provider: Baptist Health Louisville, part of the nonprofit system Baptist Health.

Medical Service: Fentress underwent cardiac ablation this year on Jan. 23. The outpatient procedure involved inserting catheters into an artery in his groin that were threaded into his heart. He also had related cardiology services, testing and visits to a primary care doctor and a cardiologist before and after the procedure.

What Gives: Fentress said he always made sure to take jobs with health insurance, “so I thought I’d be all right.”

But like nearly half of privately insured Americans under age 65, he has a high-deductible health plan, a type of insurance that experts say often leaves patients in the lurch. When he uses health providers within his insurer’s network, his annual deductible is $1,500 plus coinsurance. His out-of-pocket maximum is $7,900, more than a quarter of his annual salary.

Fentress owed around $5,000 after his 2017 hospitalization and set up a monthly payment plan but said he was sent to collections after missing a $150 payment. He declared bankruptcy after the same hospital sued him.

He faced another bill about a year later, when a panic attack sent him to the emergency room, he said. That time, he received financial aid from the hospital.

When he got the bill for his ablation this spring, he figured he wouldn’t qualify for financial aid a second time. So instead of applying, he tried to set up a payment plan. But hospital representatives said he’d have to pay $500 a month, he said, which was far beyond his means and made him fear another spiral into bankruptcy.

This precarious situation makes him “functionally uninsured,” said author Dave Chase, who defines this as having an insurance deductible greater than your savings. “It’s a lot more frequent than a lot of people realize,” said Chase, founder of Health Rosetta, a firm that advises large employers on health costs. “We’re the undisputed leaders in medical bankruptcy. It’s a sad state of affairs.”

Jennifer Schultz, an economics professor and co-director of the Health Care Management program at the University of Minnesota-Duluth, said Fentress faces a difficult financial road ahead. “Once you declare bankruptcy, your credit rating is destroyed,” she said. “It will be hard for a young person to come back from that.”

A recent survey by the Commonwealth Fund found that just over a quarter of adults 19 to 64 who reported medical bill problems or debt were unable to pay for basic necessities like rent or food sometime in the past two years. Three percent had declared bankruptcy. In the first half of 2020, the survey found, 43% of U.S. adults ages 19 to 64 were inadequately insured. About half of them were underinsured, with deductibles accounting for 5% or more of their household income, or out-of-pocket health costs, excluding premiums, claiming 10% or more of household income over the past year.

In Fentress’ case, the $10,092 he owed the hospital was more than a third of what his insurer paid for his care. The majority of his debt — $8,271.56 — was coinsurance, about 20% of the bill, which he must pay after meeting his deductible. Because the bill covered services spanning two years, he owed more than his annual out-of-pocket maximum. If all his care had been provided during 2019, he would have owed much less and the insurer would have been responsible for more of the bill.

Dr. Kunal Gurav, an Atlanta cardiologist who wrote about medical costs for the American College of Cardiology, said ablation usually costs about $25,000-$30,000, a range also confirmed by other experts.

The insurer’s payment for Fentress’ care that January day — around $27,600 — falls into the typical cost range, Gurav said. Fentress is being asked to pay $9,296, meaning the hospital would get more than $36,000 for the care.

Schultz, a state representative from Minnesota’s Democratic-Farmer-Labor Party, said nonprofit hospitals could potentially waive or reduce costs for needy patients.

“They definitely have a moral responsibility to provide a community benefit,” she said.

Resolution: Charles Colvin, Baptist Health’s vice president for revenue strategy, said hospital officials quoted Fentress an estimated price for the ablation that was within a few dollars of the final amount, although his bill included other services such as tests and office visits on various dates. Colvin said there appeared to be some charges that UnitedHealthcare didn’t process correctly, which could lower his bill slightly.

Maria Gordon Shydlo, communications director for UnitedHealthcare, said Fentress is responsible for 100% of health costs up to his annual, in-network deductible, then pays a percentage of health costs in “coinsurance” until he reaches his out-of-pocket maximum. So he will owe around $7,900 on his bill, she said, and any new in-network care will be fully covered for the rest of the year.

A hospital representative suggested Fentress apply for financial assistance. She followed up by sending him a form, but it went to the wrong address because Fentress was in the process of moving.

In September, he said he was finally going to fill out the form and was optimistic he’d qualify.

The Takeaway: Insurance performs two functions for those lucky enough to have it. First, you get to take advantage of insurers’ negotiated rates. Second, the insurer pays the majority of your medical bills once you’ve met your deductible. It pays nothing before then. High-deductible plans have the lowest premiums, so they are attractive or are the only plans many patients can afford. But understand you will be asked to pay for everything except preventive care until you’ve hit that number. And your deductible may be only part of the picture: “Coinsurance” is the bulk of what Fentress owes.

Out-of-pocket maximums are regulated by federal law. In 2021, the maximum will be $8,550 for single coverage. Try to plan treatment and procedures with an eye on the calendar — people with chronic conditions and this kind of insurance could save a lot of money if they have an expensive surgery in December rather than January.

As always, if you face a big medical bill, ask about payment plans, financial aid and charity care. According to the Baptist Health system’s website, the uninsured and underinsured can get discounts. Those with incomes equivalent to 200%-400% of the federal poverty level — or $25,520-$51,040 for an individual — may be eligible for assistance.

If you don’t qualify for help, negotiate with the hospital anyway. Arm yourself with information about the going rate insurers pay for the care you received by consulting websites like Healthcare Bluebook or Fair Health.

As Fentress tries to move past his latest bill, he’s now worried about something else: racking up new bills if he contracts COVID-19 down the road as an essential worker with existing health problems and the same high-deductible insurance.

“I don’t have hope for a financially stable future,” he said. “It shouldn’t be such a struggle.”

Dan Weissmann, host of “An Arm and a Leg” podcast, reported the radio interview of this story. Joe Neel of NPR produced Sacha Pfeiffer’s interview with KHN Editor-in-Chief Elisabeth Rosenthal on “All Things Considered.”

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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This story can be republished for free (details).