Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

Relating to Relatives of Lonely Dementia Patients

I was sent the article by Judith Graham on older adults with dementia living alone (“Going It Alone: Millions of Aging Americans Are Facing Dementia by Themselves,” Oct. 15). I appreciate this article. My mom lives alone with dementia. My son lives next door and checks on her, and my daughter comes when she is able to vacuum floors and to scrub the kitchen and bathroom. I handle the bills, clean and change her clothes, wash her clothes, search for mail, and bring in groceries. She refused to allow the home health aide in, which complicates the care schedule. Neighbors watch out for her, including police at the station across the street. It is complex and complicated for caregivers. Applying for Medicaid is a nightmare, as is searching for memory care facilities. The thought of actually moving her is heartbreaking and so stressful. Again: Thank you for sharing that others with dementia are living on their own.

— Gail Daniels, Washington, D.C.

On the social platform X, a reader drew on her own experience:

Having cared for my mom toward the end of her journey with dementia, this is terrifying.For many elders, there is no family to cushion the insults of dementia and cognitive decline.https://t.co/LTZ76Ojgwg

— Shava Nerad – @shava23@bluesky (@shava23) October 19, 2024

— Shava Nerad, Arlington, Massachusetts

Bonding — To the Letter

Thanks a million! I read your article “Going It Alone: Historic Numbers of Americans Live by Themselves as They Age” (Sept. 17) in the Las Vegas Review-Journal and related to it on a major level. As a senior living alone, I am experiencing some of the same “social isolation” expressed by your interviewees. Since I love to write, I thought it would be interesting to involve some of the persons mentioned in a nationwide pen pal association. This would place very little demand on their budget (other than postage and stationery), on their time, and with little or no travel involved.

It is breathtakingly exhilarating to receive a letter from a friend or relative, a package from anywhere, and experience the reward of sitting down and reading good news from afar.

I appreciate our advances in technology and I use it rather sparingly. However, I come from a generation that writes in cursive, knows the five elements of letter writing, and understands what a return address is and where it’s positioned on an envelope.

— Gloria Rankin, Las Vegas

A specialist in health economics and policy tweeted praise:

Historic Numbers of Americans Live by Themselves as They Agehttps://t.co/lwpfrhJauWImportant, impactful story by superb @judith_graham

— Paul Hughes-Cromwick (Pooge) (@cromwick) September 17, 2024

—  Paul Hughes-Cromwick (Pooge), Ann Arbor, Michigan

On X, a group of interdisciplinary faculty representing Johns Hopkins University shared KFF Health News’ coverage about racial bias in the development and use of pulse oximeters:

In a @KFFHealthNews article, BDP @iwashyna explains how we move forward from the racial bias of our current pulse oximeters.https://t.co/dmhqzoAfmK

— Bloomberg Distinguished Professors (@JHU_BDPs) October 23, 2024

A Slap on the Wrist for Pulse Oximeters

Between 1983 and 1988, I had four sons at Stanford Hospital. I was friends with Eben Kermit, who was a bioengineer. He was developing the original pulse oximeter on babies in the neonatal intensive care unit (“Systemic Sickness: FDA’s Promised Guidance on Pulse Oximeters Unlikely To End Decades of Racial Bias,” Oct. 7). He tested only white babies. That is because white parents could come to the NICU in the daytime, which is when Eben was at work in the NICU. Black parents could come only at night because their work wouldn’t give them time off to care for a very sick baby. Since no one was there to sign consent forms, at night, with the Black parents, no Black children were included. Discrimination against Black parents by their employers is continuing to cascade through the Black community through the exclusion of Black people from the development of medical technology.

— Zoe Joyner Danielson, a toxicology biologist, Woodland, California

This X post came from a consulting and training firm that focuses on health equity issues:

Reforms are needed ASAP—these devices have harmed so many #Black patients.FDA’s Promised Guidance on Pulse Oximeters Unlikely To End Decades of Racial Bias https://t.co/5R9LH5XyTI by @ArthurAllen202 @kffhealthnews CC: @NohaAboelataMD @mlipnick @iculung @djcantillonmd @iwashyna pic.twitter.com/yliCxMdRvG

— HealthBegins (@HealthBegins) October 10, 2024

What’s All This Fuss About Fluoride?

No one seems to address the fact that not everyone drinks water from public water systems (“Does Fluoride Cause Cancer, IQ Loss, and More? Fact-Checking Robert F. Kennedy Jr.’s Claims,” Nov. 18). I see many people buying bottled water by the trunkful, or have a water fountain at home with 5-gallon bottles of purified drinking water, or have reverse osmosis water filtration systems installed at their sink.

So even if RFK Jr. removes fluoride from public water systems, I can’t see that there would be a drastic increase in dental issues. Also, when you get your teeth cleaned at the dentist, they give you a fluoride treatment (unless you opt out). So on this issue of removing fluoride, would this be a drastic issue knowing that many now are not getting fluoridated water?

— Suzann Lebda, Sun Lakes, Arizona

Hitting the Paywall

Why does your newsletter link to articles with paywalls? As an example:

The Oct. 18 aggregation “Former Medicare Chief Warns About Medicare Advantage Pay Rates” links to Stat News, where the article cannot be read without a subscription. If you are doing this as a means to provide subscribers to them, too bad.

In any case, this practice does not represent your organization well since it supports the trend that only those who can afford it get to be informed. I hope you reconsider this practice.

The financial barriers to accessing important information are hurting us as individuals and as a society. It is expensive for most people to have access to a mainstream publication, but it gets cost-prohibitive to have access to multiple points of view, to learn, reason, and make up our own minds. In most cases, the only alternative available is to get “bites of information” from the “free” social media. The results are as one would expect: We become less aware of what is really going on as we are guided into silos of ignorance.

Thank you.

— Carl Loben, Bellevue, Washington

On X, a technology journalist in Spain shared the article about pregnant people being asked by their providers to pay out-of-pocket fees earlier than expected:

Pay first, deliver later: Some pregnant people are being asked to prepay for their baby https://t.co/NLWTeawgnk

— José María López (@gilead1984) November 16, 2024

— José María López, Badalona, Spain

A New Generation of Health Plans Overdue

The recent article “Pay First, Deliver Later: Some Women Are Being Asked To Prepay for Their Baby” (Nov. 15) effectively highlights the emotional and financial uncertainty facing providers and patients. I commend the author for capturing how this uncertainty, rooted in empathy and fairness, must be better understood and addressed.

I write to draw attention to market trends and federal legislation aimed at alleviating this issue. Until recently, health plans considered the out-of-pocket experience as definitionally out-of-scope, leaving patients, and providers, to manage this growing uncertainty on their own.

The evidence shows that it is possible to build a more pragmatic and empathic out-of-pocket experience into a health plan, improving care accessibility and affordability without removing patient responsibility. This approach has been proven, across thousands of employer health plans, to feel better and financially benefit everyone — patients, providers, and plans (employers/insurers).

On Oct. 15, 2024, the Medicare Prescription Payment Plan launched, offering nearly 54 million Americans the option to have their insurer pay their out-of-pocket expenses upfront at the point of service giving members time to review and repay the balance — without interest or fees. If the patient in the article had a health plan with this capability, her OB-GYN would have been paid, on her behalf, by her insurer. She would have received a simple monthly statement to repay in full or over time from the comfort of her home. Everyone benefits and it is a better member experience.

This new, bipartisan, commonsense improvement to one of health care’s most acute pain points is rapidly expanding as employers and insurers realize there is significant actuarial value, provider savings, and member behavior change caused by improving a person’s ability to pay for care.

Brian Whorley, Columbia, Missouri

An associate professor in the health care leadership program at Rockhurst University’s Helzberg School of Management also shared the article on X:

Pay First, Deliver Later: Some Women Are Being Asked To Prepay for Their Baby https://t.co/QEnX8GA3Ih via @kffhealthnews

— Prof. Jim Dockins (@DrDockins) November 15, 2024

— Jim Dockins, Kansas City, Missouri

On Hospital Gatekeepers and Tolls

In regards to the article “Pay First, Deliver Later: Some Women Are Being Asked To Prepay for Their Baby” (Nov. 15): Back in 1992, the hospital where my son was going to be delivered required that the projected copay be paid to them one month before the delivery date or my wife would not be admitted (a Catholic hospital, very charitable).

My wife was born at the same hospital in 1963; at that time, my father-in-law was informed by the hospital that he could not take her home until the bill was paid in full. He contacted a friend who was an attorney who told him to let the hospital know that would be considered kidnapping and that he would be calling the police if they didn’t release her.

— Andrew McGovern, Great River, New York

Taken Advantage Of?

I belong to a Blue Cross Blue Shield Medicare Advantage plan and, for the past several years, it has offered a home assessment with a reward of $25. I have participated in the program in the past but declined this year since I didn’t think there was much value to the program. I am a retired registered nurse, and I felt that the nurse who did my assessment did not do an especially thorough job, and any questions I asked of her, she could not answer. The nurse was also from out of state.

After reading your article on “The Medicare Advantage Influence Machine” (Sept. 30), the reasons for the assessment seem to be more than improving the beneficiary’s health and well-being, which is what I believed. I am relatively healthy and active, so it would not appear that BCBS found any new diagnoses that it could bill Medicare for, but I assume that that is not the case with other seniors.

— Bruce Gilman, Millis, Massachusetts

An economist in Florida had this to say on social media:

Thank you @KFFHealthNews  for pointing out the failed bureaucracy @CMS I’ve been talking about for years. You can’t read this and not conclude DC bureaucrats are “captured” and policy makers are beholden to Medicare Advantage lobby money. #WhoWillCarehttps://t.co/rDGg8juoop

— Luke Neumann (@pglukeneumann) September 30, 2024

— Luke Neumann, St. Petersburg, Florida

In Defense of Deloitte

On March 12, 2024, in good faith and with respect for KFF Health News, Deloitte’s health and human services practice leader provided a 90-minute interview with two reporters for a story they said was about “problems with Deloitte’s eligibility systems across the country.”

We agreed to the interview because we had heard from several of our state clients that they, too, had been contacted, and that the questions being raised showed a misunderstanding of integrated eligibility systems, the technology that sustains them, and the complexity of the health and human services programs they support.

The eligibility systems are owned by the states, not Deloitte; they are uniquely built for each state (in some cases, by other vendors decades ago); and we work at the direction of our clients to maintain and enhance these systems to comply with state-specific policies, rules, and processes, and evolving federal regulations.

Two stories subsequently ran: “Medicaid for Millions in America Hinges on Deloitte-Run Systems Plagued by Errors” (June 24) and “Errors in Deloitte-Run Medicaid Systems Can Cost Millions and Take Years To Fix” (Sept. 5).

Many of the issues reported as “widespread” are isolated to specific situations or involve sensitive data that cannot be refuted by Deloitte due to client confidentiality obligations. That said, there are many reasons why someone may lose coverage or no longer be eligible for a benefit they once received.

Not every “issue” a constituent faces is the result of a system “error,” and challenges with individual cases in individual systems are not due to some fundamental problem in the way Deloitte supports state Medicaid programs.

On the issue of contract changes, Deloitte rejected the claim in March that our state clients send us a “change request … when a fix is needed.” We said that was inaccurate and explained that when there are policy or rule changes — or a global pandemic — that require modifications to a state’s technology, change orders are not only necessary but appropriate.

They do not represent errors in a system that need to be fixed.

Throughout the unwinding of the covid-19 public health emergency — as technologies evolved and policies changed — Deloitte worked closely with states to minimize challenges for those going through the Medicaid redetermination process. The innovations and human-centered design processes we helped our clients implement enhanced the digital experience for their constituents and made it easier for caseworkers, staff, and community partners to support the 34 million people in their care.

Our clients understand that large system implementations are challenging due to the complexity of the programs they support, and that all IT systems require ongoing maintenance, periodic enhancements and upgrades to software and hardware, and database management.

That is why so many states continue to select Deloitte to help them maintain their mission-critical systems, and why industry analysts like Forrester and Gartner consistently rank Deloitte as a leader in system integration and business transformation.

— Karen L. Walsh, Government & Public Services, Deloitte Consulting LLP, Harrisburg, Pennsylvania

[Editor’s note: KFF Health News stands by its reporting on Deloitte and the state eligibility determination systems that Deloitte supports.]

An assistant professor at Harvard voiced her opinion on X:

This is such a grim summary of the state of Medicaid eligibility and enrollment systems https://t.co/3hpVnJdPOm pic.twitter.com/Gdi2AF1pyr

— Adrianna McIntyre (@adrianna.bsky.social) (@onceuponA) September 5, 2024

— Adrianna McIntyre, Boston

Far Less Than Meets the Eye

I read your article about the new $2,000 limit for out-of-pocket payments for Medicare Part D (“Medicare Drug Plans Are Getting Better Next Year. Some Will Also Cost More,” Oct. 21). As someone with very high drug costs, I was very excited about this change. However, once I researched the different drug plans available for me and my husband, I realized that the money we spend on drugs that are prescribed by a doctor but not covered by our plan will not count toward the $2,000 limit. Therefore, our cost for necessary drugs will continue to be exorbitant.

I think that there are many seniors who will be very disappointed once they realize this.

— Pia Stampe, Eureka, California

In sharing the article on X, a Florida attorney simply shared their contact information:

“Medicare Drug Plans Are Getting Better Next Year. Some Will Also Cost More:”https://t.co/9uEjVxTSGb Grady H. Williams, Jr., LL.M., Attorneys at Law P.A. 1543 Kingsley Avenue, Building 5 Orange Park, FL 32073 Tel: 904-264-8800 • Fax: 904-264-0155

— Grady H. Williams (@floridaelder) November 9, 2024

— Grady H. Williams, Orange Park, Florida

Shedding Light on Fluorescence in Dental Care

Congratulations on a highly impactful publication (“Dentists Are Pulling ‘Healthy’ and Treatable Teeth To Profit From Implants, Experts Warn,” Nov. 1). The facts presented are harrowing for a retired practitioner with multiple specialties who tried a lifetime to preserve teeth and promote human health.

As you might know, oral biofilm is the biggest enemy of oral health and even general health. Dental clinicians have not been able to visualize and identify the presence of pathogenic oral microbiome until recently. Pathogenic oral bacteria are among the significant generators of hard and soft tissue deterioration, such as tooth decay, gum diseases, and even infection of dental implants. The most trusted and used diagnosis procedure is still the X-ray.

X-rays can identify only established diseases. Unfortunately, radiologic diagnosis is still the most trusted diagnostic tool used and taught in dental education.

Microbiology, the microbiome science, utilizes fluorescence as its major identification procedure. Some of the most aggressive oral bacteria, generators of caries, gum diseases, etc., generate so-called porphyrins, which, once excited by a specific wavelength, emit light at a different wavelength. Highly reliable and simple-to-use technologies have been created recently to support direct visualization and point-of-care identification of this pathogenic bacteria through the above-described procedure. These devices support the diagnostic process and help the dental clinician by guiding the treatment execution and identifying when the treatment goal has been achieved. Dental treatment protocols utilizing “Fluorescence-Enhanced Theragnosis” have become reliable and less invasive.

The high loss of human lives in the ICUs during the pandemic due to ventilator-associated pneumonia could have been dramatically reduced using the above protocol.

Wound-care science has already implemented fluorescence and is undergoing a tremendous protocol change. Tumor surgery celebrates fluorescence-guided surgery as a milestone in its development.

Academic dental education is due for an urgent renewal. We must open the doors and facilitate science translation to benefit humankind!

— Liviu Steier, Needham, Massachusetts

A reader who manages a website predicting the collapse of the American health care system commented on X:

https://t.co/JTFn1h12rc Technically, American dentistry was once ranked as the best in the world. Unfortunately, It has a history of mismanagement and negligence. It’s a “reputational good” that’s been flooded with scams. Now it’s payback time. It’s demonstrating the…

— Francis Anthony Toto (@francisatoto) November 2, 2024

— Francis Anthony Toto, San Diego

Unauthorized switching of Affordable Care Act plans appears to have tapered off in recent weeks based on an almost one-third drop in casework associated with consumer complaints, say federal regulators. The Centers for Medicare & Medicaid Services, which oversees the ACA, credits steps taken to thwart enrollment and switching problems that triggered more than 274,000 complaints this year through August.

Now, the annual ACA open enrollment period that began Nov. 1 poses a real-world test: Will the changes curb fraud by rogue agents or brokerages without unduly slowing the process of enrolling or reducing the total number of sign-ups for 2025 coverage?

“They really have this tightrope to walk,” said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University. “The more you tighten it up to prevent fraud, the more barriers there are that could inhibit enrollment among those who need the coverage.”

CMS said in July that some types of policy changes — those in which the agent is not “affiliated” with the existing plan — will face more requirements, such as a three-way call with the consumer, broker, and a healthcare.gov call center representative.

In August, the agency barred two of about a dozen private sector online-enrollment platforms from connecting with healthcare.gov over concerns related to improper switching.

And CMS has suspended 850 agents suspected of being involved in unauthorized plan-switching from accessing the ACA marketplace.

Still, the clampdown could add complexity to enrollment and slow the process. For example, a consumer might have to wait in a queue for a three-way call, or scramble to find a new agent because the one they previously worked with had been suspended.

Given that phone lines with healthcare.gov staff already get busy — especially during mid-December — agents and policy analysts advise consumers not to dally this year.

“Hit the ground running,” said Ronnell Nolan, president and CEO of Health Agents for America, a professional organization for brokers.

Meanwhile, reports are emerging that some rogue entities are already figuring out workarounds that could undermine some of the anti-fraud protections CMS put in place, Nolan said.

“Bottom line is: Fraud and abuse is still happening,” Nolan said.

Brokers assist the majority of people actively enrolling in ACA plans and are paid a monthly commission by insurers for their efforts. Consumers can compare plans or enroll themselves online through federal or state marketplace websites. They can also seek help from people called assisters or navigators — certified helpers who are not paid commissions. Under a “find local help” button on the federal and state ACA websites, consumers can search for nearby brokers or navigators.

CMS says it has “ramped up support operations” at its healthcare.gov marketplace call centers, which are open 24/7, in anticipation of increased demand for three-way calls, and it expects “minimal wait times,” said Jeff Wu, deputy director for policy of the CMS Center for Consumer Information and Insurance Oversight.

Wu said those three-way calls are necessary only when an agent or a broker not already associated with a consumer’s enrollment wants to change that consumer’s enrollment or end that consumer’s coverage. It does not apply to people seeking coverage for the first time.

Organizations paid by the government to offer navigator services have a dedicated phone line to the federal marketplace, and callers are not currently experiencing long waits, said Xonjenese Jacobs, director of Florida Covering Kids & Families, a program based at the University of South Florida that coordinates enrollment across the state through its Covering Florida navigator program.

Navigators can assist with the three-way calls if a consumer’s situation requires it.

“Because we have our quick line in, there’s no increased wait time,” Jacobs said.

The problem of unauthorized switches has been around for a while but took off during last year’s open enrollment season.

Brokers generally blamed much of the problem on the ease with which rogue agents can access ACA information in the federal marketplace, needing only a person’s name, date of birth, and state of residence. Though federal regulators have worked to tighten that access with the three-way call requirement, they stopped short of instituting what some agent groups say is needed: two-factor authentication, which could involve a code accessed by a consumer through a smartphone.

Unauthorized switches can lead to a host of problems for consumers, from higher deductibles to landing in new networks that do not include their preferred physicians or hospitals. Some people have received tax bills when unauthorized policies came with premium credits for which they did not qualify.

Unauthorized switches posed a political liability for the Biden administration, a blemish on two years of record ACA enrollment. The practice drew criticism from lawmakers on both sides of the aisle; Democrats demanded more oversight and punishment of rogue agents, while Republicans said fraud attempts were fueled by Biden administration moves that allowed for more generous premium subsidies and special enrollment periods. The fate of those enhanced subsidies, which are set to expire, will be decided by Congress next year as the Trump administration takes power. But the premiums and subsidies that come with 2025 plans that people are enrolling in now will remain in effect for the entire year.

The actions taken this year to thwart the unauthorized enrollments apply to the federal marketplace, used by 31 states. The remaining states and the District of Columbia run their own websites, with many having in place additional layers of security.

For its part, CMS says its efforts are working, pointing to the 30% drop in complaint casework. The agency also noted a 90% drop in the number of times an agent’s name was replaced by another’s, which it says indicates that it is tougher for rival agents to steal clients to gain the monthly commissions that insurers pay.

Still, the move to suspend 850 agents has drawn pushback from agent groups that initially brought the problem to federal regulators’ attention. They say some of those accused were suspended before getting a chance to respond to the allegations.

“There will be a certain number of agents and brokers who are going to be suspended without due process,” said Nolan, with the health agents’ group. She said that it has called for increased protections against unauthorized switching and that two-factor authentication, like that used in some state marketplaces or in the financial sector, would be more effective than what’s been done.

“We now have to jump through so many hoops that I’m not sure we’re going to survive,” she said of agents in general. “They are just throwing things against the wall to see what sticks when they could just do two-factor.”

The agency did not respond to questions asking for details about how the 850 agents suspended since July were selected, the states where they were located, or how many had their suspensions reversed after supplying additional information.

Julie Appleby:
jappleby@kff.org,
@Julie_appleby

If confirmed by the Senate, Jackson will be the first Black woman to serve on the Supreme Court. She would replace Justice Stephen Breyer, who is retiring this summer. CNN first reported that Biden will announce her nomination at the White House. 

Jackson, a top contender from the start, currently serves on the U.S. Court of Appeals for the D.C. Circuit. She was previously on President Barack Obama’s short list for a Supreme Court pick in 2016 after Justice Antonin Scalia died in February of that year.

Jackson, who was born in Washington, D.C., but grew up in Miami, has worked as a public defender and was confirmed by Congress in 2009 to serve as vice chair of the U.S. Sentencing Commission from 2010 to 2014. During her tenure, the commission reduced sentences for many crack cocaine offenses, where research has consistently shown disproportionate sentencing rates between Black and white offenders.