The rates Medicare pays hospitals are carefully calculated to cover the actual cost of care in an efficient health care facility. But Anthem, Cigna, United and other commercial health insurers in Colorado are paying significantly more than Medicare, according to a new Center for Improving Value in Health Care report.

KristIn Paulson, president and CEO of the Center for Improving Value in Health Care, said it would make sense for hospitals to charge commercial insurers a little more than Medicare, to help expand services and shore up hospital bottom lines

"But the data that we've just released demonstrates that hospitals are getting four, five, or sometimes even six times what Medicare pays. And that's well beyond what we'd expect simply to strengthen a business' bottom line or expand care," she explained.

Using a new health care payment comparison tool, the Center found that while commercial insurers are paying more, overall payments compared to Medicare dropped by 4% between 2019 and 2022 across all facility types statewide. Paulson noted programs -- including the new Colorado Option plans, which are held to a percentage of Medicare rates -- can help keep costs down.

Commercial plans operating through 'ConnectForHealthCO.com' must spend 80% of consumer premium dollars on patient care, only 20% can go to administration costs and profits. But there are no incentives to challenge high prices. Paulson noted if insurers collect $1 million in premiums, they can only take in $200,000 in profits. If costs double, insurers can increase premiums, and profits.

"If they are covering the same people for the same services, they would have to charge $2 million in premiums, and they would be able to keep up to $400,000," she continued. "So, the payers make money when prices go up as well."

Paulson said Coloradans can do their part to lower health costs by using the Center's Shop for Care tool at 'civhc.org/shop-for-care,' which compares procedure prices at different facilities.

"The more we're paying for health care out of our own pocket, and through our health insurance companies, the more premiums will continue to rise. So as consumers, we need to be aware that these prices differences exist, and we need to look for opportunities to get lower-cost high-quality care," she said.

Gov. Mike Parson recently announced Senate Bill 751 would become law, allowing Missourians to access essential medications within their communities through the federal government's 340B program, which requires drugmakers participating in Medicaid to sell outpatient drugs at discounted prices to health care organizations caring for uninsured and low-income patients.

This law counters what advocates called "restrictive measures" imposed by large pharmaceutical manufacturers and ensures patients no longer need to travel long distances for treatment.

Karen White, CEO of Missouri Highlands Health Center, said the legislation is critical for women's health care, especially for those in rural parts of the state.

"Without the 340B program, access to crucial women's health services not just in the seven counties we serve, but throughout underserved areas in the state could be severely compromised," White contended.

Drew Duncan, a lobbyist for pharmaceutical manufacturer Pfizer, said while his company supports the 340B program, it does not provide substantial savings to patients and added the discounts given by manufacturers are often not passed on to patients.

Despite some opposition, the bill received strong bipartisan support in the Senate and House.

Joe Perle, CEO of the Missouri Primary Care Association, believes the effects will reverberate across the state.

"Missourians will now be able to access affordable prescriptions closer to home," Perle pointed out. "Before this, Big Pharma put a lot of restrictions on the number of pharmacies we could contract. It's a big win for all Missourians, especially those who are uninsured or underinsured."

While supporters celebrate the bill as a victory for health care access, critics may raise concerns about its long-term implications for pharmaceutical regulation. The measure is expected to especially benefit rural and underserved areas, where local pharmacies will play a crucial role in sustaining health care services.

An Alabama group is sounding the alarm about the need for Medicaid expansion, in part to keep rural hospitals in business.

Many hospitals in Alabama are becoming what's known as Emergency Rural Hospitals, reducing their services to emergency-only operations and eliminating inpatient care.

Debbie Smith, Cover Alabama campaign director for the group Alabama Arise, said it is largely due to financing, noting Medicaid reimbursement rates are too low to cover the cost of care.

She is particularly concerned without inpatient services, maternity care may be limited, sending women to other areas, even for routine care.

"A lot of women just can't afford to do that," Smith pointed out. "They don't have the transportation, or a lot of people would have to take off the full day of work just to go see the doctor. So, it's really concerning, and I think that's a real deterrent for people to even go see the OB/GYN and get their regular checkups, which can lead to a lot of issues down the line."

She emphasized the service cutbacks could also limit critical mental health and specialty care access across the state. Grove Hill Memorial Hospital in Clarke County is one of the latest to announce its move to Emergency Rural Hospital status. Hospitals in Bullock, Chambers and Monroe counties have done the same.

The Emergency Rural Hospital designation was created by Congress under the 2021 Consolidated Appropriations Act. It provides hospitals with higher reimbursement rates and financial assistance to help keep them afloat.

Smith believes one way to improve health outcomes is through Medicaid expansion.

"We have seen from other states that there's a much less likely chance of our rural hospitals closing in expansion states; it's proven," Smith asserted. "Medicaid expansion can really help with helping out on those costs and helping with uncompensated care costs."

Smith added Gov. Kay Ivey could use her executive authority to expand Medicaid. Alabama is one of only 10 states to have not done so, leaving nearly 300,000 people in the "coverage gap," who work but make too much money to qualify for Medicaid and not enough to afford traditional health insurance.

Nursing home workers in Washington state have come back from the White House with renewed resolve to fight for their union contract. A delegation of SEIU members was in Washington, D.C., last week to meet with the Biden-Harris administration.

Gurnesh Chetty, medications manager for Aegis Ravenna in Seattle and is a member of SEIU 775, said members of the administration encouraged him to file a complaint with the National Labor Relations Board over contract negotiations with his employer.

"Even we were told that a lot of big corporations like Aegis, what they do is, they intentionally start letting go of employees that do support the union or want a union," Chetty said.

Chetty and his coworkers voted to form a union in March 2023, but the union has yet to secure its first contract. A spokesperson for Aegis Living says its objective is to "foster a strong and unified team environment," and that it's proud of its 2,700 employees serving 2,500 residents.

Chetty said working at Aegis can be stressful, which is why workers formed a union.

"We've been understaffed," he said. "We've been asking for more staffing, better pay, better retention of employees. People work there about three to six months and they end up leaving, because the employees aren't taken care of."

Chetty added retention is especially important in a nursing home setting.

"Once you form a relationship with the resident and then, you know exactly what they want, you know exactly what time they prefer things, it makes it better and easier and convenient for them, where they're happier," he continued.