Hi, reddit! I’m Sarah Kliff, Senior Policy Correspondent at Vox, host of the Impact podcast, co-author of the VoxCare newsletter, and co-host of The Weeds podcast. I’ve spent a decade chronicling Washington’s battle over the Affordable Care Act. In the past few years, my reporting has taken me to the White House for a wide-ranging interview with President Obama on the health law — and to rural Kentucky, for a widely-read story about why Obamacare enrollees voted for Donald Trump.

For the past 15 months, I’ve asked Vox readers to submit emergency room bills to our database. I’ve read emergency room bills from all 50 states and the District of Columbia. I’ve looked at bills from big cities and from rural areas, from patients who are babies and patients who are elderly. I’ve even submitted one of my own emergency room bills for an unexpected visit this past summer.

Proof: https://twitter.com/sarahkliff/status/1086385645440913410

Update: Thanks so much for all the great questions! I have to sign off for now, but keep posting your questions and I'll try to answer more tomorrow!

Comments: 1541 • Responses: 17  • Date: 

Kai_Daigoji539 karma

Hi Sarah! I'm a big fan of your work, and this project specifically.

One major question I've had about healthcare policy in the US, is why insurer's ability to negotiate for lower prices doesn't seem to exert much downward pressure on healthcare costs. Do you have any thoughts or insight into this? Is it just that hospitals can pass along the full cost to the patients regardless, or is something else at play?

vox507 karma

I do have thoughts on this! I think the key thing here is that insurers don’t actually have much leverage in negotiations with hospitals. It’s really hard for insurers to exclude a hospital from their network. This is especially true in rural areas where there might be just one hospital, for well-known hospitals (like Cleveland Clinic or Mayo Clinic) or speciality hospitals (like children’s hospitals). It would be really hard for insurers to sell plans without those type of providers, which gives hospitals a lot of leverage. Meanwhile, hospitals tend to have access to a decent number of revenue streams — multiple private insurers as well as Medicare and Medicaid. I think this lopsided dynamic leads to a situation where insurers don’t exert downward pressure on prices. It’s easier to pass along a rate hike to customers rather than explain why the hospital that patients want to go to won’t be included in the network.

tunaonrye472 karma

What information do hospital admins have that insurance providers and policy-makers don't have?

vox660 karma

The key information that hospitals have is the prices they get paid. Policymakers don’t have access to that information. Insurance plans have partial access because they know the prices that their plan pays for medical services — but they don’t know the prices that other insurance plans are paying. This data is really crucial to understanding how much health care costs — it’s also important for patients in terms of understanding how much their doctor visit or ER trip will cost them. Without it, its a lot harder for policymakers to come up with good solutions because we don’t know everything we’d like to about the problem.

Slap_a_Chicken238 karma

Hello Sarah!

The surprise- and balance-billing issues seem like such obvious public policy issues yet there doesn't seem to be any rush to pass legislation to fix them. Why do you think policymakers aren't treating this problem with more urgency?

vox220 karma

Definitely agree that this seems like the type of health policy issue that should move relatively quickly. You have Democrats and Republicans who want to fix this, are coming up with policy proposals that have already been tested in the states, and patients complaining about the issue. That being said, it seems to me that balance billing legislation could end up stuck in the general gridlock of Washington. There are some powerful interests who would likely oppose these bills (hospitals, for example), and that could also slow things down. From what I can tell, there seems to be more momentum right now behind plans to reduce prescription drug pricing (likely an issue that affects more patients), than there is around balance-billing.

I think if this does move forward though, it will be part of some larger package of legislation rather than a stand alone bill. Bills like this often have better odds when they get tacked on as a smaller part of a bigger bill.


Aidtor148 karma

Hi Sarah!

Are there any plans to anonymize and release this data to academics for analysis?

Edit: Or just data nerds like myself?

vox129 karma

This is definitely something we're exploring, but no firm plans right now. Stay tuned!

lebek183 karma

Over the past year, what have you learned about the best practices for the average person to keep their ER bill down? Anything they should request? Any info they should be sure to give (or not give)?

vox118 karma

This is probably the question I get the most ever since I started working on ER bills. It's a really hard space to give advice on though, because people going to the emergency room often have little say over the care being provided to them — especially if they're dealing with a life-threatening, traumatic situation.

That being said, I think patients are well within their right to ask their doctors why a certain procedure is being done, whether its necessary, and how much it will cost. Sometimes, doctors won't have the information available. But sometimes they will, and it will at least kick start a conversation about whether this is the right treatment path for you. If possible, I'd also recommend asking the emergency room providers — or the person at the front desk — about whether they and other doctors in the ER are in-network with your health insurance. Some of the biggest bills I see are from patients who went to in-network ERs, but were seen there by an out-of-network doctor.

This isn't always possible but, when it is, it could be a good way to get a better grasp on what your health care costs might be.


PotentiallySarcastic67 karma

Are there any trends to healthcare costs from state to state? Like are some states better set from price standpoints than others?


vox87 karma

There definitely are huge differences from city to city and state to state when it comes to health care prices. I'd recommend the Healthy Marketplace Index from HCCI, a non-profit that maintains a large claims database, as a good place to explore this question. They have some really great city-level data that shows wide variation in health spending, and big differences in how much prices are going up in different areas.

You can find that here: https://www.healthcostinstitute.org/research/hmi/price-index


crazyeyedmcgee60 karma

Hi Sarah! I've been following you since Wonkblog and have really enjoyed your reporting - you're my go-to resource.

From your perspective, what is the most complicated, but super important, health care policy issue to cover insofar as it is super wonky and difficult to relay to the non-wonkish?

vox82 karma

For me, this is probably payment reform — changes to how we pay for health care, whether they save money, and how they affect patients. These are questions that are really important to answer, but ones that can be difficult to write about because they're dealing with some really complex topics.

I'll give you one specific example: the Affordable Care Act included a penalty for when Medicare patients get re-admitted to the hospital. The idea was to incentivize better health care, and not reward hospitals when they screwed up and a patient landed back in the hospital because of a complication.

There's now a big debate in the academic literature about whether this program worked — or whether it, somewhat perversely, created an incentive not to readmit patients who actually needed care, leading to harm or possibly death.

This is a hard topic to write about because the data is quite dense and the answers aren't clear. But it's one that is vitally important to understand as we try and figure out the best ways to provide health care, and pay for it in a way that helps patients.


MarriedMSTP55 karma

Hi Sarah,

Why do you think all payer rate setting hasn't gotten as much attention as other potential HC reforms? Especially since it can be done at the state level.

Second question: As a med student, I've been surprised at how cost of treatment to my patients simply is not a factor in treatment decisions. Physicians will often insist that a drug or test is absolutely necessary, when in fact it would be very harmful to take that drug if it meant you had to take on a 2nd job. My hospital told me that it is possible to display treatment costs in our EHR, but that studies have shown that such displays don't change what care is provided. What is the state of the literature on this question? My impression is that the work that has been done has mostly examined ER docs, but I would think the biggest impact would be made in clinic settings.

Thank you for all your work on these questions!

vox32 karma

I think this first question is an excellent one — all-payer rate setting gets you prettttty far towards Medicare for All, but you don't hear nearly as much chatter about it. Part of it, I think, has to do with the wonky name, which doesn't do great for campaign slogans! But part of it also has to do with the fact a lot of states tried all-payer rate setting in the 1990s and ultimately gave it up. So I think the history of the program definitely plays a role here.


Helpful_Junket1239 karma

Thank you for your great work and effort about ER bills. Question: Do you think the recent regulation regarding price transparency will help with this in any way?

vox58 karma

I generally think it’s a really good idea to move to a system with more transparent prices, so am in favor of this regulation. At the same time, I think it has a lot of shortcomings that will prevent it from moving the needle much in terms of improving patient experience. The price lists that many hospitals are releasing to comply with this regulation are often incredibly difficult to read. I tried to look up the prices at one of my local hospital, and found a 4,000-line Excel document that was nearly impossible to read. I wrote a little bit more about that here: https://www.vox.com/policy-and-politics/2019/1/14/18182450/hospital-prices-transparency-health-care

At the same time, there are some reasons to think this could, on the margins, be helpful. I liked Elisabeth Rosenthal’s piece in the New York Times recently which suggested that patients might be able to use these type of lists to look up the price of something such as an arm sling. “With access to list prices on your phone, you could reject the $300 sling in the emergency room and instead order one for one-tenth of the price on Amazon,” she writes.



identicallyzero32 karma

Big fan of The Weeds (not to mention your phenomenal work). It's the only podcast that I never skip an episode.

Are there any legislators at the national level (or even state level) that you think are taking up the cause of balance billing? We've heard murmurs about it here and there (and some states already taking action), but we know nothing big will happen until someone champions it.

vox26 karma

The two Senators I've seen working on this issue are Sen. Maggie Hassan and Sen. Bill Cassidy.

I've written about Cassidy's plan here: https://www.vox.com/policy-and-politics/2018/9/21/17887692/voxcare-surprise-er-bills-senate

And Hassan's plan here: https://www.vox.com/2018/10/29/18018098/hassan-emergency-room-bill

Hope that helps!

barelyanonymous15 karma

Hi Sarah! What made you choose health care as the thing you wanted to focus on in your reporting? Did you see a gap where people weren't reporting, or is it something that you just really enjoy? Something else?

vox24 karma

I was actually assigned the health care beat in my first internship out of college - and it turns out, I really loved it!

The reason I've stuck with it for a decade now, is that I really love stories where you see how policy plays out in real life. And this happens in some many interesting, exciting, and frustrating ways in health care. I really enjoy being on this beat because there are so many human stories to tell.


CannonGibsonator7 karma

Hi Sarah, I sent in two ER bills last year from Idaho and am wondering if you plan to collect ER physician fees? Mine were $1,100 each visit, in addition to the facility fee. thanks

vox8 karma

Hi, yes - you should submit those to erbills.vox.com. Thanks in advance!


emmafred244 karma

Hi Sarah!

As a new mother, what is one or two policies that haven't been implemented yet in the US (or not in most states) that you think would help new parents and their young children the most?

vox8 karma

The two policies that I think would be most beneficial would be paid parental leave and subsidized daycare. I say this both from my work in policy, and a new mom myself!


MarriedMSTP2 karma

Besides Medicaid expansion, what kinds of health care reforms can be done at the state/local level to reduce prices for patients? Are there any state legislators who are doing anything particularly exciting (besides the medicaid expansion/buy in plans that have sprouted up)?

vox4 karma

I'm pretty interested in the state-level laws that are trying to protect patients from balance billing. The Commonwealth Fund had a nice summary of those recently: https://www.commonwealthfund.org/blog/2019/state-efforts-protect-consumers-balance-billing

There's also some pretty interesting work being done by Louisiana's Department of Health to try and make expensive Hepatitis C drugs more expensive that I think is worth keeping an eye on. https://www.npr.org/2018/07/19/630378124/louisianas-new-approach-to-treating-hepatitis-c


zellius2 karma

Hey Sarah! How do we keep your work going after Vox's project is over? It would be a shame to lose all that emergency room visit data. Is there any chance of releasing that data back to the public in some safe/secure way so that people visiting ERs in the future have better negotiating leverage? (and as a data engineer, how can I get involved?)

vox4 karma

We're currently wrestling with this exact question and I don't have an answer for you quite yet. We'd like the data to live on in some form, we just need to make sure we're protecting the privacy of those who have submitted information to us. Stay tuned!


ctsneak1 karma

Sarah, you are my favorite healthcare reporter! I am the social worker for a private nonprofit free clinic. Your work has greatly helped me understand healthcare and helped me develop as a social worker, helping low low-income, uninsured people.

I was wondering if you have any future predictions about Medicare expanding to include dental care? I know the chances are slim to none, but wanted to hear your thoughts :)

Thanks for keeping me informed in this crazy landscape of healthcare!

vox4 karma

Hi, thank you! I think if this were to happen, it would happen as part of a larger Medicare for All overhaul. Most the Congressional plans for Medicare for All would expand the program to cover vision and dental, which are not (as you mention) currently included in the benefit package. Whether we'll get a Medicare for All program, THAT is an even bigger question :-D