Kaiser Health News

When the 988 Suicide & Crisis Lifeline launched last month, many mental health providers, researchers and advocates celebrated. Although a national suicide hotline had existed for years, finally there was an easy-to-remember three-digit number for people to call, they said. The shorter number would serve as an alternative to 911 for mental health emergencies.

But not everyone felt the same way. Some advocates and people who had experiences with the mental health system took to social media to voice concerns about 988 and warn people not to call it.

One Instagram post said, “988 is not friendly. Don’t call it, don’t post it, don’t share it, without knowing the risks.” The post, which had garnered nearly a quarter of a million likes as of early August, went on to list the risks as police involvement, involuntary treatment at emergency rooms or psychiatric hospitals, and the emotional and financial toll of those experiences.

Other posts on Instagram and Twitter conveyed similar concerns, saying that the hotline sends law enforcement officers to check on people at risk of suicide without their consent and that people, especially from LGBTQ+ communities and communities of color, may be forced into treatment.

So is 988 a critical mental health resource or a cause for concern? We decided to dig into these questions, figure out how 988 works, and explain what you need to know before dialing.

Why are some people saying not to call 988?

We reached out to the creators of some of the social media posts to ask them directly.

Liz Winston, who authored the Instagram post calling 988 “not friendly,” said she wanted people to understand all the potential outcomes of calling so they wouldn’t be blindsided by the “traumatizing system” that she experienced.

Last summer, Winston was having suicidal thoughts and visited a hospital in New York. She hoped to speak with a psychiatrist but instead was involuntarily detained in the psychiatric wing of the emergency room. She said that she did not receive any counseling during the 24 hours she spent there and that the experience was “extremely traumatic.”

Winston hadn’t called the hotline, but she said those who do can end up in a similar situation. It’s true that when police respond to calls about people in mental health crises, they often take them to an emergency room or psychiatric hospital.

“I realize there is an urge to rescue people in crisis, but the reality is the services that exist make the problem much, much worse,” said Winston, who works in mental health peer support and has started an online support group for people recovering from involuntary treatment.

Research shows suicide rates increase drastically in the months after people are discharged from psychiatric hospitals. Those who were sent involuntarily are more likely to attempt suicide than those who chose to go, and involuntary commitments can make young people less likely to disclose their suicidal feelings in the future. Some people also get stuck with large bills for treatment they didn’t want.

Emily Krebs, a suicide researcher and assistant professor joining Fordham University this fall, said that involuntary treatment is viewed as a necessary part of suicide prevention in the U.S., but that other countries don’t see it that way. The United Nations has called forced mental health treatment a human rights abuse and asked countries to ban it.

Like Winston, Krebs wanted people to be fully informed before deciding to call 988. That’s why she wrote on Twitter that 988 can and will “send police if they deem it necessary.”

That can be dangerous, she said, given that 1 in 5 fatal police shootings in 2019 involved a person with mental illness. Some years, the share has been even higher.

What does 988 say about how it handles crisis situations?

Officials from 988 say they recognize the risks of having law enforcement officers involved in mental health emergencies. That’s why 988 was created as an alternative to 911, said John Draper, executive director of the hotline and a vice president at Vibrant Emotional Health, the company tasked with administering it.

“We know the best way for a person to remain safe from harm is for them to be empowered and to choose to be safe from harm,” Draper said. Dispatching police is a last resort, he said.

Counselors who answer the phones or respond to texts and online chats for 988 are supposed to be trained to actively listen, discuss the callers’ concerns and wishes, and collaborate with them to find solutions. Most calls about suicide are de-escalated without law enforcement, Draper said. Instead, counselors talk through people’s reasons for dying and reasons for living; have callers connect with supportive family, friends, religious leaders or others in their community; refer callers to outpatient treatment; or set up follow-up calls with 988.

Only when the caller cannot or will not collaborate on a safety plan and the counselor feels the caller will harm themselves imminently should emergency services be called, according to the hotline’s policy.

At that point, Draper said, “we have the choice of just letting [harm] happen or doing whatever we can to keep them safe.”

In previous years, before the 988 number launched, emergency services were dispatched in 2% of the hotline’s interactions, the service reported. With about 2.4 million calls a year, that means emergency services were initiated for roughly 48,000 calls. Those services can be mobile crisis teams, consisting of people trained in mental health and de-escalation, but in many rural and suburban communities, it is often police.

Contrary to some information circulating on social media, 988 cannot geolocate callers, Draper said. When emergency services are called, 988 call centers share with 911 operators information they have about the location of the person who contacted the hotline — typically a caller’s phone number, with area code, or a chat user’s IP address — to help first responders find the individual.

Starting this fall, Draper said, 988 will update its policies to require supervisors to review all calls that result in the use of emergency services. Counselors for 988 nationwide will also receive additional training on the alternatives to involving law enforcement and the consequences callers can face when police respond.

So should I use 988 or not?

We know it’s not satisfying, but the honest answer is: It depends.

The 988 hotline is the nation’s most comprehensive mental health crisis service and can provide crucial help to those in emotional distress. If you’re thinking about suicide but not taking steps to act on it, 988 is unlikely to call law enforcement without your consent. Instead, 988 counselors can provide resources, referrals and a kind ear. However, if you’re at imminent risk and could act on a plan to kill yourself, police may be called, and you could be taken to a hospital involuntarily.

Sonyia Richardson, a licensed clinical social worker who owns a counseling agency that serves mostly Black and brown clients in Charlotte, N.C., said she didn’t immediately tell her clients about 988 when it launched. Even though she’s a member of her state’s 988 planning committee, she said she needed time to develop trust in the service herself. When she learned at a recent committee meeting that fewer than 5% of 988 calls in North Carolina led to a law enforcement response, she felt reassured.

“There are going to be issues perhaps with 988, but it might be one of the safer options for us,” Richardson said. With suicide rates increasing among Black Americans, the community needs more ways to save lives, she added.

If I don’t want to call 988, do I have other options?

Although the U.S. doesn’t have a national, government-run mental health hotline that pledges not to call police without callers’ consent, several alternatives that are smaller than 988 aim to decrease law enforcement involvement.

“Warm” lines are one option. They’re typically staffed by “peers,” people who have experienced mental health challenges. They focus less on crisis intervention and more on emotional support to prevent crises. You can find a directory of warm lines by state here.

Below are other hotlines and resources. This is not a comprehensive list, and some resources may limit their services geographically.

• Blackline is a hotline geared toward the Black, Black LGBTQ+, brown, Native, and Muslim communities
• Kiva Centers offers daily online peer support groups
• M.H. First Oakland and M.H. First Sacramento operate during select weekend hours in the California cities of Oakland and Sacramento
• Peer Support Space hosts virtual peer support groups twice a day Monday through Saturday
• Project LETS provides support by text for urgent issues that involve involuntary hospitalization
• Samaritans of New York is a hotline based in New York City
• Trans Lifeline is a hotline for trans and questioning individuals
• Wildflower Alliance has a peer support line and online support groups focused on suicide prevention

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. It is an editorially independent operating program of KFF (Kaiser Family Foundation).

Copyright 2022 Kaiser Health News. To see more, visit Kaiser Health News.

In July, a handful of people gathered in the shade of a large pine tree in Helena, Montana for a going-away party of sorts.

Their friend, Dani Marietti, was going to have her fallopian tubes removed.

It was a decision she had made after a draft of the U.S. Supreme Court’s decision to overturn the constitutional right to abortion was leaked to the press.

The small group kicked off the “sterilization shower” for the 25-year-old by laying out chalk-written signs that said “See Ya Later Ovulater” and “I got 99 problems but tubes ain’t one.” They munched on cookies that had abortion-rights slogans, such as “My Body, My Choice,” written on them in frosting.

Marietti is a full-time graduate student in Helena working toward becoming a therapist. She doesn’t want kids to get in the way of her career. She had considered permanent sterilization before, but the possibility that the Supreme Court would overturn Roe v. Wade pushed her to seek out an OB-GYN who would help her with a permanent method of contraception.

“‘I want to do this as soon as possible,'” she recalled telling the doctor.

“I always knew I didn’t want children, and of course when you say that as a younger person, everyone is like, ‘Oh, you’ll change your mind,’ or, ‘Just wait until you find the one,'” Marietti says. “I always kind of ignored that.”

Doctors see growing demand for sterilization

Abortion is still legal in Montana, but whether it will remain so is unclear.

State Attorney General Austin Knudsen, a Republican, has asked the Montana Supreme Court to overturn its 1999 decision that said the state constitution’s right to privacy includes the right to end a pregnancy.

The uncertainty around abortion access in Montana and other states where abortion is now or could become illegal, plus the fear of future legal fights over long-term contraception, has seemingly spurred a rise in the number of people seeking surgical sterilization, according to reports from doctors. That includes Marietti, who is having a salpingectomy — a procedure in which the fallopian tubes are removed instead of tied, as in tubal ligation, which can be reversible.

How many people sought permanent sterilization after the fall of Roe won’t become clear until next year, says Megan Kavanaugh, a researcher for the Guttmacher Institute, which gathers data related to reproductive health care across the U.S. and supports abortion rights.

But anecdotal reports indicate that more people have been undergoing permanent birth control procedures since the Supreme Court’s June 24 decision in Dobbs v. Jackson Women’s Health Organization, which struck down Roe.

Dr. Kavita Arora, who chairs the American College of Obstetricians and Gynecologists’ Committee on Ethics, says providers across the country are beginning to see an influx of patients into their operating rooms.

Arora, an OB-GYN in North Carolina, recounted what one of her patients said just before a recent surgery: “She wanted to have autonomous control over her body, and this was her way of ensuring she was the person who got to make the decisions.”

More adults in their 20s and 30s without children are coming to the hospital for sterilization consultations, says Dr. Marilee Simons, an OB-GYN at Bozeman Health Deaconess Hospital in Montana.

Many are women who already use long-term birth control options, but “they are still worried about an unintended pregnancy and what that might mean in the future,” she says.

Most are asking to have their tubes removed to permanently prevent pregnancy. A smaller number of people are asking for hysterectomies, which surgically remove part or all of the uterus. To meet demand, Bozeman Deaconess has dedicated at least one provider to work with these patients multiple days a week.

Planned Parenthood of Montana President and CEO Martha Fuller says clinics statewide have seen an “unprecedented” increase in patients asking to be sterilized, including requests for vasectomies.

Patients face obstacles

But some people seeking sterilization procedures across the U.S. are being turned away.

Arora says patients who don’t have children and are in their childbearing years are reporting difficulties finding physicians willing to sterilize them. Their reluctance may stem from studies that suggest patients who are sterilized at age 30 or younger are about twice as likely as those over 30 to express regret after getting the procedure. However, other studies had mixed results and found that some women feel less regret over time.

Some patients who have been denied sterilizations have turned to therapists like Barbara DeBree, who has a private practice in Helena and writes letters to providers attesting that the patients have thought through their decisions. “This is not a quick decision for them,” DeBree says.

Cost and insurance coverage can also be issues for patients seeking sterilization procedures.

Helena resident Alex Wright, 23, doesn’t plan to have children and wants to be sterilized.

She plans to schedule a consultation to see whether her provider will perform the procedure. If her regular provider won’t do it, she says she will seek out someone from online lists of providers who are willing to perform the procedure on younger people.

“That’s only helpful if I can get the financial assistance to get it taken care of through those people,” she says. Wright says her insurance company estimates she’ll pay about $4,000 out-of-pocket if she goes with an in-network provider. Using an out-of-network doctor could cost substantially more.

Some fear future “attacks on contraception”

Although some people are seeking permanent procedures in reaction to the Dobbs decision, others are doing so because they believe the U.S. Supreme Court will continue upending reproductive health norms.

Kavanaugh, the researcher at Guttmacher, says Justice Clarence Thomas opened that door by suggesting in his concurring opinion in Dobbs that other precedents should be revisited, including the 1965 Griswold v. Connecticut decision that says banning contraceptives violates a married couple’s right to privacy.

“I think we are anticipating that there’s going to be some attacks on contraception,” Kavanaugh says.

That’s what worries Shandel Buckalew, of Billings, Montana, who wants a full hysterectomy.

The 31-year-old says her doctor thinks she has endometriosis, a painful condition in which tissue that normally grows inside the uterus grows on other parts of the reproductive organs. Buckalew hasn’t undergone the full range of testing that can be required for a diagnosis because she doesn’t have health insurance and can’t afford it.

“Even though I have an IUD [intrauterine device], the amount of cramps and the pain I go through — oh, I get so sick,” she says.

Buckalew hopes a hysterectomy will alleviate that pain, in addition to providing permanent birth control because she doesn’t want kids. But her lack of health insurance makes the procedure unaffordable.

She’s trying to get health insurance before her IUD expires in two years, because she fears the reproductive health care landscape could shift dramatically.

“It feels like my life doesn’t matter,” she says.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

Copyright 2022 Kaiser Health News. To see more, visit Kaiser Health News.

Korra Elliott has tried to avoid seeing a doctor while waiting to get on Medicaid. She worries she can’t afford more bills without any insurance coverage. But in early March — five months, she said, after applying and with still no decision about her application — a suspected case of the flu sent her blood pressure soaring and landed her in the emergency room.

The 28-year-old mother of four from Salem, Missouri, is among the tens of thousands of uninsured Missourians stuck waiting as the state slogs through a flood of applications for the state-federal health insurance program. Missouri expanded the program last year after a lengthy legal and political battle, and it now covers adults who earn up to 138% of the federal poverty level — about $18,800 annually for an individual.

Missouri had nearly 72,000 pending Medicaid applications at the end of February and was averaging 119 days to process one, more than twice the maximum turnaround time of 45 days allowed by federal rules. Adding people to Medicaid is labor-intensive, and the jobs require training and expertise. The program covers many populations — children, people with disabilities, seniors, adults who are pregnant or have children, and some without children. Different rules dictate who qualifies.

Missouri simply doesn’t have the workers to keep up. Last fiscal year, 20% of its employees who handled Medicaid applications left their jobs, said Heather Dolce, a spokesperson for the Missouri Department of Social Services. And the average number of job applications received for each opening in the department’s Family Support Division — which oversees enrollment — dropped from 47 in March 2021 to 10 in February 2022.

Just about every industry is struggling to find workers now, but staffing shortages in state Medicaid agencies around the country come at a challenging time. States will soon need to review the eligibility of tens of millions of people enrolled in the program nationwide — a herculean effort that will kick off once President Joe Biden’s administration lets the COVID-19 public health emergency declaration expire. If Missouri’s lengthy application backlogs are any indication, the nation is on course for a mass-scale disruption in people’s benefits — even for those who still qualify for the insurance.

“If you don’t have people actually processing the cases and answering the phone, it doesn’t matter what policies you have in place,” said Jennifer Wagner, director of Medicaid eligibility and enrollment for the Center on Budget and Policy Priorities, a left-leaning think tank in Washington, D.C.

Federal officials have said they will give states 60 days’ notice before ending the public health emergency, so it’s unlikely to expire before summer. Once it does, enrollees won’t be kicked off immediately: States can take up to 14 months to complete renewals, although budget pressures may push many to move faster. A bump in federal Medicaid funds to states, provided by Congress through covid relief legislation in 2020, will end shortly after the emergency’s expiration.

Ultimately, workers are needed to answer questions, process information confirming someone’s Medicaid enrollment should be renewed, or see whether the person qualifies for a different health coverage program — all before the benefits lapse and they become uninsured.

State Medicaid officials have said staffing is one of the top challenges they face. In a January meeting of the Medicaid and CHIP Payment and Access Commission, an outside panel of experts that advises Congress, Jeff Nelson said 15% to 20% of the Utah Department of Health’s eligibility workers were new. “We’ve got a fifth of the workforce that potentially doesn’t know what they’re doing,” said Nelson, who oversees eligibility for Utah’s Medicaid program.

Eligibility worker vacancies at the Texas Health and Human Services Commission quadrupled over roughly two years — 1,031 open positions as of late February compared with 260 as of March 31, 2020, according to spokesperson Kelli Weldon.

Medicaid renewals are less labor-intensive than initial applications, but it takes time before an eligibility worker knows the ins and outs of the program, Wagner said.

“It’s months before you are fully functional,” said Wagner, who previously oversaw the Illinois Department of Human Services’ offices that determine applicants’ eligibility for Medicaid, the Supplemental Nutrition Assistance Program that provides food stamps, and other assistance programs.

Other social services may be gummed up in the process because many workers also handle applications for other programs. In addition to Medicaid, workers for Kentucky’s Department for Community Based Services handle SNAP and child care assistance applications.

Consumer advocates who connect people to safety-net programs worry that an overwhelmed workforce won’t be able to keep up.

“It’s going to be a lot of work for everyone,” said Miranda Brown, who helps people apply for benefits as outreach coordinator for the Kentucky Equal Justice Center, a legal aid group.

Brown said she recently called a state office on behalf of a client toward the end of the day. She waited on hold for an hour only to be told by a caseworker that the agency couldn’t process any more cases that day.

“I even have a [phone] line that I get through faster than a consumer calling for themselves,” she said. “If it’s hard for me, it’s very hard for consumers who are trying to call on their lunch break at work.”

South Carolina planned to hire “a couple hundred workers” beginning this spring to help manage renewals at the end of the public health emergency, said Nicole Mitchell Threatt, deputy director of eligibility, enrollment, and member services at the Department of Health and Human Services. The turnover rate among eligibility workers was about 25% from July 2020 to June 2021, jumping from a 15% rate in the previous 12 months.

In Missouri, Dolce said her department hopes a recently approved pay increase will help recruit more workers and improve staff morale and retention. The department is being sued over delays in enrollments for SNAP benefits, which it also oversees.

Kim Evans, director of the Missouri Department of Social Services’ Family Support Division, told the state Medicaid oversight committee in February that her division was offering overtime and she was even offering to buy pizza to speed up the processing of applications. But the department is enrolling fewer than 3,000 people per week, leaving tens of thousands waiting and delaying their care.

In the suburbs of Kansas City, Missouri, Stacey Whitford, 41, applied in December for Medicaid for herself and her 13-year-old son. Her son needs hearing aids that she said cost $2,500 apiece without insurance. She also lined up a support worker for the boy, who has autism, through the Department of Mental Health but said she was told the worker can begin only once her son is enrolled in Medicaid.

“It’s just like hanging a golden ticket right in front of your face and saying, ‘Here it is, but you can’t touch it,’” she said in early March.

Whitford spent hours on the phone trying to sort out the status of their applications, then on March 31, just shy of four months after applying, they were finally approved.

“I am so excited! We can run with scissors now,” she joked.

But Elliott, the mother of four in Salem, is still waiting. She gave up calling the state’s Medicaid helpline after growing frustrated from spending hours on hold and being disconnected because of high call volumes. Instead, she checks on her application through the enrollment specialists at the clinic where she applied.

She was sent home from the ER with ibuprofen and Tamiflu and has yet to see a bill. If her Medicaid application is approved, her coverage will be backdated to the month she applied, likely covering her ER trip. But if her application is rejected, that cost will be added to her medical debt, which Elliott estimates is already tens of thousands of dollars.

“It makes me feel like it’s a joke,” Elliott said of Missouri’s expansion of Medicaid. “Like they’re just throwing it out there to get all these people to apply for it, but they’re not going to really help anybody.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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The new year brings new protections for patients with private health insurance who will no longer be blindsided by “surprise” medical bills when they unknowingly receive out-of-network care.

The No Surprises Act, passed by Congress in 2020 as part of the coronavirus relief package, takes effect Jan. 1.

It generally forbids insurers from passing along bills from doctors and hospitals that are not covered under a patient’s plan — such bills have often left patients to pay hundreds to tens of thousands of dollars in outstanding fees. Instead, the new law requires health care providers and insurers to work out a deal between themselves.

Here’s how the law will work and how it might affect insurance premiums and the health care industry.

It may slow premium growth

Some observers have speculated that the law will have the unintended consequence of shifting costs and leading to higher insurance premiums. But many policy experts told KHN that, in fact, the opposite may happen: It may slightly slow premium growth.

The reason, said Katie Keith, a research faculty member at the Center on Health Insurance Reforms at Georgetown University, is that a new rule released Sept. 30 by the Biden administration appears to “put a thumb on the scale” to discourage settlements at amounts higher than most insurers generally pay for in-network care.

That rule, which provides more details on the way such out of network disputes will be settled under the No Surprises Act, drew immediate opposition from hospital and physician groups. The American Medical Association called it “an undeserved gift to the insurance industry,” while the American College of Radiology said it “does not reflect real-world payment rates” and warned that relying on it so heavily “will cause large imaging cuts and reduce patient access to care.”

In early December, the AMA, joined by the American Hospital Association, filed a lawsuit challenging a part of that rule that outlines the factors that arbitrators should consider in determining payment amounts for disputed out-of-network bills. The case does not seek to halt the entire law, but does want changes to that provision, which it says unfairly benefits insurers. Later in the month, groups representing emergency physicians, radiologists and anesthesiologists filed a similar lawsuit.

Such tough talk echoes comments made while Congress was hammering out the law.

Unsettled bills will go to arbitration

The No Surprises Act takes aim at a common practice: large, unexpected “balance bills” being sent to insured patients for services such as emergency treatment at out-of-network hospitals or via air ambulance companies. Some patients get bills even after using in-network facilities because they receive care from a doctor there who has not signed on with an insurer’s network.

Patients were caught in the middle and liable for the difference in what their insurer paid toward the bill and the often-exorbitant charges they received from the provider.

Once the law takes effect next year, patients will pay only what they would have if their care had been performed in network, leaving any balance to be settled between insurers and the out-of-network medical providers. The law also gives insurers and providers 30 days to sort out discrepancies.

After that, unsettled bills can enter “baseball-style” arbitration in which both sides put forth their best offer and an arbitrator picks one, with the loser paying the arbitration cost, which the rule sets for next year as $200 to $500.

Uninsured patients who are billed more than $400 over an upfront estimate of the cost of their care may also bring cases to arbitration for a $25 administrative fee.

Businesses, like government services companies or those that review coverage disputes, can start applying now for certification as arbitrators. The new rule estimates that about 50 will be selected by the three agencies overseeing the program (the departments of Health and Human Services, Labor and Treasury) after showing “expertise in arbitration, health care claims experience, managed care, billing and coding, and health care law.”

The rule also spells out that either party can object to a chosen arbitrator, and the one that is selected cannot be associated with an insurer or medical provider.

Prices may be driven to the middle

But here’s how all this could end up affecting insurance premiums. In the process of arbitration, a decision must be made about which price to pick.

The new rule specifies that the arbitrator generally should pick the amount closest to the median in-network rate negotiated by insurers for that type of care. Other factors, such as the experience of the provider, the type of hospital or the complexity of the treatment, can be considered in some circumstances, but not given equal weight.

By contrast, some of the more than a dozen state laws taking aim at surprise bills allow arbitrators to consider higher rates, such as billed charges set by hospitals or doctors, rather than negotiated rates, which potentially drive up spending.

One recent study, for example, found that in New Jersey — which has different arbitration rules than what is being set up for the federal program — cases were settled at a median of 5.7 times higher than in-network rates for the same services.

Unlike New Jersey, the federal government is specifically barring consideration of the highest amounts — the billed charges — and the lowest payment amounts, including those from Medicaid and Medicare programs.

“This seems likely to reduce premiums in addition to protecting patients from surprise bills,” said Loren Adler, associate director of the University of Southern California-Brookings Schaeffer Initiative for Health Policy, who co-authored the New Jersey study.

Still, the law’s impact on premiums is open to debate. Keith doubts they will change either way, although Adler thinks the slowdown in premium growth would be small.

Even the rule says “there is uncertainty around how premiums will be ultimately affected” with much depending on how often disputed bills go to arbitration.

It cited a Congressional Budget Office estimate that provisions in the No Surprises Act could reduce premium growth by 0.5% to 1% in most years, but also noted an estimate from the Centers for Medicare & Medicaid Services that premiums could slightly increase. Neither study isolated the effect of the arbitration guidelines from the rest of the statute.

Adler noted that relying heavily on the median in-network price likely means lower payments compared with other measures but, still, “by definition a median is what half of what doctors get paid, so this could, in theory, raise that for the other half.”

Providers pushed to join insurance networks

What’s likely, health policy experts said, is that the new law will prompt more providers to join insurer networks.

Some physicians — most often, emergency room doctors, anesthesiologists and radiologists — have avoided signing contracts with insurers. Instead, they typically have set charges above the level of insurers’ reimbursement and have sent surprise bills to patients for the difference.

The rule undercuts the incentive to use this business model.

It makes it “pretty clear” that hospitals, physicians, air ambulances and other medical professionals “should not count on staying out of network and then trying to use the federal process to capture higher reimbursement,” said Keith.

Some medical societies and advocacy groups predicted the law could have the opposite effect.

Insurers will use the disputes to “drive down payment to the point that it is no longer feasible for many providers to take that, or any insurance,” warned Katie Keysor, senior director of economic policy for the American College of Radiology, in an emailed statement.

Adler said that argument doesn’t fly when looking across the experience of states with similar laws. (Those state rules don’t apply to many types of job-based health insurance, but the federal rule will.)

“Every single surprise billing debate has done the opposite and pushed more people into the network,” he said.

Whether a group signs a contract with an insurer may matter less going forward, he said.

Once the law takes effect, “it’s completely irrelevant whether an emergency room doctor is in network or not,” he said. “For all intents and purposes, that doctor is in network. The patient will pay the in-network cost sharing and there is a price the provider has to accept, and the insurer has to pay.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. It is an independent operating program of KFF (Kaiser Family Foundation).

Many people take for granted the addition of fluoride into public drinking water systems that aims to prevent tooth decay. It’s a seven-decade-old public health effort. But it’s not nearly as universally accepted as one might think.

At least seven cities or towns across the country debated it just this summer.

For example, Wellington, Fla., decided to add fluoride back into the water in July after the city council voted two years ago to remove it. Across the country in Healdsburg, Calif., voters will revisit a ballot question in November regarding whether to stop adding the mineral to the water supply.

“There has always been periodic discussion,” said Steven Levy, a dentistry professor at the University of Iowa. Levy is involved in an Iowa-based longitudinal study that tracks fluoride intake and its effects on children’s bones. “We are seeing more challenges now because of the communication explosion with the internet.”

The debate started well before 1945 when Grand Rapids, Mich., became the first U.S. city to add fluoride to its water supply. In the decades since, opposition usually stems from studies linking fluoride intake by children with lower IQs, higher rates of attention deficit/hyperactivity disorder and potential toxicity.

Still, fluoridation has become a fairly common practice, with about 74 percent of the population receiving fluoridated water from community water systems, according to theCenters for Disease Control and Prevention. But the intervention, which is considered by the CDC to be one of the 10 top public health achievements of the 20th century and backed by the American Dental Association and the World Health Organization, also continues to raise grass roots concerns. These arguments range from casting fluoride as unnecessary and ineffective to efforts to paint the mineral as “mass medication” and a “damaging environmental pollutant.”

“Fluoridation is not safe or cost-effective,” said Bill Osmunson, director of the Fluoride Action Network, a national organization against fluoridation of water supplies, adding that people should be given the freedom of choice so they can avoid ingesting excess fluoride.

In Wellington, Mayor Anne Gerwig often fields angry emails on this issue.

“I watch the videos that they email me, I read the information they send me,” Gerwig said. Gerwig has no background in science, but she read studies and fact-checked the claims being made by the town’s residents. Gerwig said she decided to support fluoridation after she found scientific consensus about the benefits of fluoridation in preventing tooth decay.

The CDC, for instance, considers water fluoridation to be the most cost-effective method of delivering fluoride to all, reducing tooth decay by 25 percent in children and adults.Tooth decay is still one of the most common chronic conditions among children.

“A big thing about community water fluoridation is that it’s a passive intervention, you don’t really have to do anything other than drink tap water,” said Katherine Weno, oral health director at the CDC. “You don’t have to buy a product or access to a dental professional. It benefits people who don’t have money to go to a dentist or don’t have any insurance.”

But some question the need for continued fluoridation, especially as products such as toothpaste and rinses containing fluoride are available, and because the chemical’s levels vary and indications of harm are not always clear.

Philippe Grandjean, an adjunct professor at Harvard University School of Public Health, has authored a couple of studies questioning the need for the added fluoride.

“Our dental health is clearly much less dependent on fluoride in drinking water than way back when this important public health intervention was initiated,” Grandjean said.

In a 2016 Harvard Public Health article, Grandjean commented about the need for more research about populations that may be vulnerable to the mineral and the proper dose of it in drinking water. In response, the article drew multiple critical letters.

“The article misrepresents the current state of the science of community water fluoridation, and does not provide a fair and balanced perspective,” wrote Francis Kim and Scott L. Tomar from the American Association of Public Health Dentistry and Bruce Donoff, dean of the Harvard School of Dental Medicine in one of the letters.

New studies are published almost every year that bring up concerns about fluoridation in drinking water, linking the intake with various developmental issues and even thyroid problems, issues that Osmunson also brought up. Weno and Levy said those studies were performed in places where natural fluoride levels are higher and where residents may get fluoride through milk or salt rather than water. Excessive fluoride intake does have health implications — a problem commonly found in places with high concentrations of natural fluoride such as China, India and Africa. Most Americans receive water with low natural levels of fluoride.

Health officials also monitor and review what is appropriate. The Department of Health and Human Services in April 2015 released new recommendations for fluoride levels in drinking water, updating and replacing the level in place since 1962 in order to reflect the fact that Americans now have more sources of fluoride in toothpaste, mouthwashes and other products.

But other towns continue to wrestle with the issue. In July, the commissioners of Soddy-Daisy, Tenn., voted to stop adding fluoride and Houston’s city council chose to leave it in. In August, Port Angeles, Wash., stopped fluoridation until voters decide in November 2017.

And for some of the local officials involved in these debates, their take on the issue is part of even greater political questions.

“The individuals who benefit the most are poor children,” said Dick White, mayor pro tem of Durango, Colo. The town decided in June to continue adding fluoride to its water. “If we get national health care for every single person, we could probably eliminate fluoridation in the water because we can ensure that every child is getting dental care.”

In this year’s presidential campaign, health care has taken a back seat. But one issue appears to be breaking through: the rising cost of prescription drugs.

The blockbuster drugs to treat hepatitis C as well as dramatic price increases on older drugs, most recently the EpiPen allergy treatment, have combined to put the issue back on the front burner.

Democrat Hillary Clinton just issued a lengthy proposal to address what her campaign calls “unjustified price hikes for long-available drugs.” That’s in addition to a broader proposal to address high drug prices the campaign put out last fall.

Republican Donald Trump, meanwhile, has said little about health care since announcing his candidacy in 2015, but he has several times called for a change in law to allowMedicare to negotiate drug prices for the population it serves.

Here are five reasons why this issue is back — and why it is so difficult to solve.

There are multiple, often unrelated reasons that drug prices are going up.

One is the introduction of brand-name blockbuster drugs, such as Sovaldi and Harvoni. They effectively cure hepatitis C — but at a total cost of more than $80,000. Federal statisticians singled out the hepatitis C medications as a key reason prescription drug spending increased by 12.2 percent in 2014, up from 2.4 percent the year before.

That is separate from the price hikes coming from companies set up specifically to buy up older, generic drugs and reap as much profit as they can. The poster child for these efforts, which have gained attention during the past year, is Martin Shkreli. His firm Turing Pharmaceuticals purchased Daraprim, a drug used to treat toxoplasmosis, a disease caused by a parasite that can be life threatening for people with compromised immune systems, and hiked the price from $13.50 to $750 per pill. In the case of EpiPen, the treatment for life-endangering allergic reactions, the drug itself is actually inexpensive and long off-patent. But the company has almost literally created a monopoly by patenting the simple-to-use delivery mechanism.

The drug price debate is far from new.

It seems every time drug prices spike up, policymakers pay attention.

Congress first addressed the issue of rising drug prices in 1984, when it passed abipartisan bill that made it easier for generic copies of brand-name drugs to be approved. But lawmakers also gave brand-name drugmakers more time without generic competition by allowing them to keep their products on their patents longer to make up for often years-long approval process at the Food and Drug Administration.

In 1990, concern about rising medication costs to the Medicaid program, the joint federal-state insurance coverage for low-income residents, led to a law requiring drugmakers to provide significant discounts.

During the late 1990s and early 2000s, Congress repeatedly debated the idea of lowering drug prices by allowing consumers to purchase drugs that were brought in from other industrialized countries that impose price controls. A few such “reimportation” proposalswere passed into law. But the laws required certification by federal health officials and both Democratic and Republican administration officials blocked the efforts, which they said threatened the safety of the U.S. drug supply.

Advocates for seniors, who use more prescription drugs on average than younger people, raised concerns about that time also that drug prices were hurting their ability to purchase their medicine. So in 2003, Congress passed a law creating a Medicare prescription drug benefit.

A dramatic increase in use of generic drugs for the next several years helped keep the cost of the new Medicare benefit in check, and kept drug prices mostly off the political front burner.

But now, not only are prices rising again, but many people also have insurance that requires them to pay more out-of-pocket for drugs. Those patients complain, in turn, to lawmakers, who feel the need to address the issue.

It is not clear what would work to fix drug price problems, but it is pretty clear what would NOT.

Both Clinton and Trump have endorsed a change in the law to allow Medicare to negotiate drug prices, a practice that is currently banned.

But analysts agree that negotiations alone could not reduce overall costs by very much, unless Medicare was also allowed to grant preference to some drugs that offer good discounts, which is what most insurance plans do. In Medicare, however, that would be extremely controversial. And Medicare, like other insurers, would have trouble negotiating lower prices for drugs that have no competition. Thus, the Congressional Budget Office has said, repeatedly, “broad negotiating authority by itself would likely have a negligible effect on federal spending.”

Another popular proposal, included in Clinton’s drug plan and already in effect in several states, seeks to cap the amount individual consumers have to spend out-of-pocket on prescription medications.

While that would clearly help protect the individuals affected, it would do nothing to actually lower drug costs. In fact, by passing most of the cost back to insurers, the proposal would likely increase insurance premiums for everyone.

In California, meanwhile, voters this fall will face a proposal to ban state health programs from paying any more for drugs than the price at which they are sold to the Veterans Health Administration, which gets large discounts, but also covers only a limited list of drugs. The proposal is strongly opposed by the drug industry, but even some likely supporters have raised questions about whether it would work.

Addressing drug prices is very popular with the public.

The public is clearly ready for some action on the issue. Poll after poll finds large majorities of those surveyed think drug prices are too high and the government should do something to lower them. The public is also decidedly negative in its opinion on the drug industry overall. It’s no surprise politicians are feeling pressure to act.

Politics are spurring interest, but also impeding progress on addressing drug prices.

On the other hand, the pharmaceutical industry remains one of the most powerful forcesin Washington, not to mention many state capitals. Drug industry lobbying has blocked efforts to allow people to buy cheaper drugs from overseas, ensured that the Medicare prescription drug benefit did not allow the federal government to set or negotiate prices, and kept efforts to rein in drug prices out of the Affordable Care Act.

As a result, wrote three Harvard Medical School researchers in a comprehensive look at the drug price issue in the Journal of the American Medical Association, “prescription drugs are priced in the United State primarily on the basis of what the market will bear.” Attempting to set prices or otherwise constrain industry profits, they added, “would have major marketplace ramifications and is not at present politically feasible, in part because of the power to the pharmaceutical lobby in Washington, D.C.”

KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.