WASHINGTON — The Trump administration issued controversial rules Friday compelling hospitals and insurers to give consumers more information upfront about what their care will cost — requirements that the president called a historic step to give Americans tools to shop for affordable health care.
Under one rule resisted for months by a broad swath of the health-care industry, hospitals must for the first time reveal in a consumer-friendly format the discounted rates they negotiate privately with insurers for a list of 300 services patients can schedule in advance, including X-rays and cesarean deliveries. The requirement takes effect in January 2021.
In a new twist, the administration is also proposing to require most health plans that Americans get through their jobs to disclose the rates they negotiate with hospitals and doctors in their insurance networks, as well as the amounts they pay to doctors out of network.
Taken together, the pair of actions — one a final rule, the other in draft form — is part of President Donald Trump’s 2020 electoral strategy to capitalize on polls that show health care ranks among Americans’ top domestic concerns. Public opinion surveys consistently show that consumers are looking to government especially to ease the burden of escalating out-of-pocket costs.
“This is bigger than health care,” Trump said in remarks from the White House’s Roosevelt Room. “The word is transparency. I love transparency in many ways. It is going to be incredible for consumers, patients, good doctors.”
The hospital industry has vowed for months to sue to try to block the requirements affecting them, and the president and senior aides sought preemptively to tarnish such opposition.
“I don’t know if the hospitals are going to like me any more with this,” Trump said. “That’s OK. That’s OK.”
During a morning briefing, Joe Grogan, director of the White House’s domestic policy council, told reporters: “Make no mistake about it, this rule today will irritate many vested interests in Washington, D.C.”
The two biggest hospital trade groups, the American Hospital Association and the Federation of American Hospitals, confirmed Friday they plan a legal challenge.
The requirement to disclose privately negotiated rates “hurts competition, and we don’t think they have the statutory authority to do it,” said Tom Nickels, the American Hospital Association’s executive vice president for government relations and public policy.
During the news briefing, Health and Human Services Secretary Alex Azar said, “we feel we are on a very sound legal footing.”
Other moves the administration has taken to reshape the U.S. health-care system have been blocked after being challenged in court. Earlier this year, for instance, a Washington-based federal judge ruled the administration did not have the authority to force the drug industry to disclose drug prices in television advertisements.
And the administration itself withdrew a major effort to rein in drug prices by prohibiting rebates to insurance middlemen following criticism the changes could increase Medicare premiums before next year’s election.
The issue of transparency in health-care pricing has been a drumbeat for the White House and Trump’s top health advisers for much of this year. In May, administration officials made clear they were developing an executive order on the issue. In late June, the president held a signing ceremony in the White House’s grand foyer to affix his signature to that order.
The executive order directed HHS and two other federal agencies to develop far-reaching regulations, the most controversial part of which is the disclosure of negotiated rates that always have been secret. Friday’s pair of rules flow from that order.
Friday, Trump mischaracterized aspects of the rules as he talked about them surrounded by Cabinet secretaries, House Republicans and supporters. He said they would allow consumers to “I assume get résumés on doctors, see who you like.” There is no physician-rating component of either regulation.
And at one point, he said the hospital-rating rule “is kicking in immediately. It will really get going ... this coming year.”
The rule originally was proposed to take effect in January, but was postponed for a year after industry outcry. It requires disclosure of all standard charges, which include the amount a hospital is willing to accept in cash from patients, as well as the rates negotiated with insurers. All the information must be included in a computerized file organized by diagnostic codes. The 300 services that the administration is classifying as “shoppable” must also be accessible in a format easy for consumers to read.
AHA’s Nickels said the disclosure requirements are more extensive than the administration proposed this summer. They now compel hospitals to disclose the privately negotiated rate for each service for each insurer, as well as the maximum and minimum rates per insurer.
“They’ve piled on,” he said.
The health insurance industry joined hospitals in denouncing both rules Friday, although it did not talk of lawsuits.
Any attempt to improve price transparency should focus on giving patients information about out-of-pocket costs and “encourage — not undermine — competitive negotiations to lower patients’ and consumers’ costs and premiums,” Matt Eyles, president of America’s Health Insurance Plans, a trade group, said in a statement. “Neither of these rules — together or separately — satisfies these principles.”
Blue Cross Blue Shield Association President Scott Serota said in a statement that publishing negotiated rates for services “may have negative, unintended consequences — including price increases — as clinicians and medical facilities could see in the negotiated payments a road map to bidding up prices.”
During the news briefing, Azar called such predictions “a canard.”
He said the administration did not estimate the potential savings from requiring rate disclosures because “we’ve never experienced this level of transparency before.” But he gave an anecdotal example, saying MRI prices decreased by about 20 percent in New Hampshire after more public information about their costs was provided.
Seema Verma, administrator of HHS’s Centers for Medicare and Medicaid Services, minimized the cost of the requirements to hospitals. “It’s a very tiny percentage of their overall revenue, less than 1 percent,” she said in response to a question.
Nickels called the estimate “ludicrous. It certainly will cost more.”
Bags of fresh produce and a healthy serving of nutritional advice were offered to Keene residents Friday morning, as part of a statewide initiative to provide support to people who lack dependable access to healthy, high-quality food.
The Green to Go project — in its first year — is a mobile pantry provided through N.H. Healthy Families’ Gateway Services program. Gateway Services identifies social service care gaps and builds access to supports for communities across the state.
Green to Go teamed for this event with Southwestern Community Services, at 63 Community Way in Keene, and the van set up in the agency’s parking lot Friday from 10 a.m. to noon.
Fliers were given to display at Southwestern’s office and distribute, and the event was also publicized through posts on N.H. Healthy Families’ social media.
Kerry Pascetta, director of marketing for N.H. Healthy Families, said people who stop by the van are given a tote bag full of fresh fruits and vegetables, and, if eligible, the option to sign up for the state’s Medicaid program. Socks are also provided, as it’s a common need among low-income populations, she said.
Nurses were also on-site to discuss diabetes management and nutrition education.
“Instead of just selling insurance, we wanted to get out into the communities and talk to people,” Pascetta explained.
On a typical day, she said, Green to Go will see between 100 and 200 people. In Keene, this was no different, with just over 200 people seen in the two-hour period.
Each community in New Hampshire has vast differences, Pascetta noted, which changes how the organization prepares for each visit.
She said N.H. Healthy Families was told the Elm City has a wide range of people who are food insecure — meaning they don’t know where their next meal is coming from — noting they saw young mothers and senior citizens alike during Friday’s visit.
Keene was also described as a “food desert,” Pascetta added, meaning there is limited access to affordable and nutritious foods.
“Every town is different,” she said. “We try to customize to that.”
The van has traveled to “every corner of the state,” she added, and focuses on communities with high food-insecurity rates.
In Cheshire County, 7,340 people are food insecure, according to data from the N.H. Food Bank.
Statewide, one in nine people live with food insecurity, the food bank’s data state. About 12 percent of children and 6 percent of seniors fall into this category.
Sarah Burke, director of Southwestern Community Services’ Women, Infants and Children (WIC) program, said there are 770 people enrolled. The program provides supplemental food, health-care referrals and nutrition education to women and children of low income.
Burke added that there are also 45 Keene residents enrolled in Southwestern Community Services’ Commodity Supplemental Foods Program, for people of low income over the age of 60.
“The N.H. Healthy Families Green to Go van provided another way to encourage healthy food choices,” Burke said in an email Friday afternoon.
On a frigid November night, Kostas Georgiadis’ Yolo Cafe is ostensibly a colorful frozen-yogurt joint.
But as winter sets in, it can turn into Keene’s de facto bus station.
For anyone without a car, there is nowhere to wait for the Greyhound or City Express buses without having to buy a coffee or a froyo.
Some oblige, but that’s not an option for others.
“You’re supposed to buy something, but we have a lot of homeless people that come in here, and they just use the bathrooms,” Georgiadis said while helping an employee work out a kink in the waffle machine. “They don’t have any money to buy anything anyway, so if it’s too cold outside, they come inside and sit.”
With Yolo Cafe’s proximity to the Hundred Nights homeless shelter, not everyone coming inside necessarily has a bus to catch.
“It’s kind of rude to kick them out,” he continued. “They don’t have no place to go.”
Tucked across from Lindy’s Diner on Gilbo Avenue, Yolo takes up half of the building that used to house the city’s transportation center, remnants of which linger on with the rusted metal letters on the outer wall and a desolate waiting room still visible through the dirty windows.
Still, the Gilbo bus stop remains the most accessible public transportation offering in Keene and the Monadnock Region. And for the area to be economically competitive in the years to come, local leaders will have to offer more than a sign post with no seating or public restrooms, stakeholders say.
A recent study from the N.H. Department of Transportation showed the Granite State lagging far behind its neighbors in statewide transportation funding, highlighting the need to close a $90 million funding gap over the next 10 years to meet the basic requirements of the current population.
And with New Hampshire’s senior population on track to double between now and 2040, the state will face growing demand for public transit options as more and more people stop driving their own cars.
Transportation has a tentacle in just about every political issue in the region, yet Cheshire County is facing not only a shortage of viable public transit options, but a “transportation funding crisis,” according to J.B. Mack, the principal planner for the Southwest Region Planning Commission.
“... and a lot of it is political,” Mack said.
With the state gas tax merely plugging holes on an ever-growing list of road and bridge improvements, the burden to make any systemic transit improvements falls on local governments to raise their own money and try to match it with federal funds.
Already, around 20 to 22 percent of the region’s population does not drive, according to a SWRPC study Mack cited, which counts everyone from babies to seniors.
Although the community has rallied around stories such as the Serenity Center being given a car to help people in recovery from addiction get to work and receive treatment, the very nature of one-offs like that underscores the need for broader reforms.
Keene’s population of just over 20,000 anchoring the surrounding towns won’t bring a panacea better suited for a more dense population, but Mayor-elect George Hansel says transportation must be a priority for the next City Council.
“We’re gonna be looking at housing, which has been talked a lot about during the campaign, but we also need to have a serious conversation about public transportation and how people move around — not only just inside the city, but also between cities, and that connection to the Boston-Manchester area is really important,” Hansel said.
Come fly with me — if you have a car
On the macro-scale, the lack of commercial flights to the region illustrates the more tangible transportation shortcomings, with owning a car being the best way to catch a flight on time out of Manchester, Boston or Hartford.
The struggle of traveling from Keene to a major airport is one Hansel says he knows all too well. And although the city is eyeing some sort of return of commercial air to Dillant-Hopkins Airport in North Swanzey in a long-term market study, Hansel pointed to other options to make flying less of a hassle.
“I go to all three, and weirdly, Bradley [in Hartford], Boston and Manchester are all equally inconvenient at the same time,” Hansel said, chuckling, during a phone interview Wednesday.
“We need to look at really reliable bus service to one of those major airports,” he added. “And that’s something we should really be looking at and pushing for, and trying to accommodate here, because even to one of the extended train lines that have gone into Western Massachusetts now, we should be thinking of how do we create connectivity to Greenfield, and allow people to commute and work at the same time, either on a bus or a train.”
Both Hansel and Mack noted that compared to other areas of the country with a similarly light population density, the Monadnock Region has the benefit of being within two to three hours of Boston, Hartford and Albany — all of which have a host of connecting flights.
The problem, both pointed out, is that existing park-and-rides help only those who own cars.
Keene is often referred to as a hub for services and lifestyle amenities that are used by those who live in surrounding towns, but Mack questioned that notion when it comes to transit.
“Our market is really tough” when it comes to securing funding for transportation projects, Mack said of the area’s low population density. “You know, we’re sort of an island in the southwest area of the state.
“And so, although we often hear, ‘It would be great to have these services,’ ” Mack continued, “when we’ve tried to put that into action, sometimes the demand just isn’t there.”
During a recent call for federal grant proposals, Mack said the commission got only one, which was from Thomas Transportation in Swanzey.
But upon realizing federal funding would only go so far, and how minimal matching state and local funds would be, Thomas dropped its pitch for a shuttle to Boston’s airport and train station, according to company founder and President Ed Thomas.
“The [grant] funding is not really designed for a for-profit,” Thomas said, noting it takes two to three years to get any kind of business like that off the ground “because I don’t really have any funding sources other than myself.”
The future of Gilbo station
Back at the Keene bus station, two Greyhounds come into town every day, and the City Express — branded Keene’s “bus for everyone!” — rolls between grocery stores, medical providers and social service centers.
The area is the busiest around the late morning, but Georgiadis says by the time his business opens at 2 p.m., things can be pretty grim once it starts getting colder.
“The thing is that it affects my business, because these homeless people — the shelter is right across the street, so they come out all day long, and they have no place to go,” the Charlestown resident said of those who stop in with or without a bus to catch.
And the infrequent and often late buses leave those without housing little choice, Georgiadis said. He added that he lets anyone stay warm in his yogurt shop unless they start asking customers for money.
Roberta Mastrogiovanni, owner of the Corner News next door, says she feels exasperated at the lack of political action behind public transportation through the more than 20 years she has been selling Greyhound bus tickets from her store.
“We can’t be left with no public transportation,” Mastrogiovanni sighed. “I don’t really make money [as a ticket vendor], I’ll be honest, but I feel it’s my responsibility to continue to offer it.”
Hansel says a revamp of the Gilbo station will be key, and he hopes it will ride the coattails of the city’s planned arts corridor in the current expanse of parking lots flanking the street.
“I think keeping the transportation center where it is, and even building it out to be even more robust and visible in a very apparent location in the heart of downtown, is a good thing,” he said. “Because we’re gonna need [Keene State College] students to use that; we’re gonna need people living close to downtown to use that; and it seems logical to put it right in the heart of our city if we want it to naturally attract the type of activity that we need to sustain these services.”
Mack cited a study underway by the planning commission on how feasible an “intermodal transit center” would be on Gilbo Avenue. As envisioned, the facility would integrate pedestrians, bicycles and ride sharing with bus travel.
Mack said the goal would be to create “a hub, essentially, and putting Keene on the map as a place that people could visit and wouldn’t feel like they are stranded when they get here.”
Although she’s grown cynical over the years through her interactions with state and local politicians, Mastrogiovanni says maybe the recent turnover on the City Council and a new mayor is just what the doctor ordered.
“Maybe with new councilors and a new mayor, I would hope that someone would see the importance of public transportation,” she said. “Because I have ideas, I know of other modes that could potentially connect somehow ... But it’s never been a priority.”