NPR News

For almost a year, early childhood teachers at A Place to Grow in Oak Hill, W.Va., enjoyed a $200 bonus in every paycheck just for coming to work.

“Just be here, show up, don’t call off, be on time,” the center’s owner Melissa Colagrosso told employees.

Funded through $24 billion in pandemic relief Congress approved in 2021, the bonuses made life a lot easier for the center’s teachers and staff.

But with the expiration of the federal money on Sept. 30 came the end to those bonuses.

“All of the staff have taken a $400-a-month pay cut,” says Colagrosso.

Now, she worries about how her employees will get by. She expects some of them will soon leave her for jobs elsewhere.

A pandemic lifeline disappears

It’s no exaggeration to say government money saved child care in the pandemic.

As part of the 2021 American Rescue Plan, Congress approved a total of $39 billion for child care, an unprecedented level of spending aimed at ensuring essential workers could go to work. The majority — $24 billion — was directed toward stabilizing child care centers and home-based daycares, to guarantee they’d remain open and staffed.

Colagrosso, who opened A Place to Grow 28 years ago, poured the money into wages and bonuses, repairs and a new HVAC system, playground equipment for what had been an empty field, and even a bus to take older kids to and from school and, in the summers, on field trips.

Now that the September 30 deadline for spending the pandemic funds has passed, she and other child care providers are grappling with what they have to take back.

“We’re going to have to slow down payroll. We have to cut everywhere we can cut,” Colagrosso says.

In addition to curbing bonuses, she has ended paid sick leave for part-time staff and says she will end it for full-time staff soon. She’s eliminated a floating position, someone to help out wherever extra help was needed.

No longer will she be giving $1 an hour raises every year, as she has for the past three. She may resort to larger child-to-teacher ratios, which she says would affect quality.

Affording child care a problem up and down the wage scale

Running her center in a rural, low-income part of West Virginia has never been easy. Colagrosso says there were many months when she struggled to make payroll and found herself at the bank asking for a loan.

Close to three-quarters of the families she serves fall below 85% of West Virginia’s median income, qualifying them for state subsidies. Even those who pay full tuition can hardly afford the cost, particularly those with several young children. They worry that with pandemic relief funds gone, Colagrosso may have to raise her rates.

“We’d either have to work part-time — one of us — or one of us quit our job, which we can’t really do,” says Brittany Smith, a civil engineer. She and her husband have 1-year-old twins and a 12-year old.

Bonuses were life-changing but short-lived

Colagrosso’s immediate concerns are over her staff.

The pandemic bonuses proved life-changing for teachers including Destiny Vansickle, who saved enough money for a down payment on a two-bedroom house next to her sister — a “forever home” for her infant and her 4-year-old.

“It’s been really nice to have our own place and having my boys being able to have our own yard,” she says, adding that the low-income housing they left had no yard to play in.

Tena Gee, who’s worked at A Place to Grow for 13 years, says the bonuses allowed her to give her 9- and 12-year-old daughters Christmas for the first time — new bikes, new kayaks, a baby doll with its own bassinet.

“Just being able to do anything on my own for them — not having to lean on somebody — it’s just a feeling you can’t really describe,” she says.

She also decided to do something for herself. She was tired of driving used cars that broke down all the time, so she bought herself a brand new car.

“I took on bills that I was finally able to afford because of the extra money,” she says. “It felt like the work I was doing was finally being acknowledged. Like I feel like my pay matches the hard work I put in.”

But that satisfaction was short-lived. Without the extra $400 a month in bonuses, Gee is already behind on her car payment.

“I guess maybe it was our fault for getting used to it, thinking maybe it was going to be more than temporary,” she says.

Now, she’s considering finding a better-paying job elsewhere.

Child care not a priority

Senate Democrats have introduced a bill to extend child care stabilization funding for five years, but the measure doesn’t have support from Republicans.

West Virginia and other states are trying to help out, finding money in their budget surpluses to alleviate some of the strain.

Still, Colagrosso is facing deeper cuts.

“You do the math like any other business, and the math doesn’t add up,” she says. “This is what I need. This is what I’m bringing in. It’s not there.”

Colagrosso says she used to think there was a lack of understanding among elected leaders about the value of child care — a lack of understanding that without affordable options, people can’t go to work.

“[Then] the pandemic hit and all this money came, and I thought, ‘Oh, they did understand all along. They understood. They just didn’t prioritize it,'” she says.

And now, after an all-too-brief of recognition of child care as critical — not just for families, but for the economy — she’s afraid the same is true once again.

Copyright 2023 NPR. To see more, visit https://www.npr.org.

When JJ Apodaca was starting graduate school for biology in 2004, a first-of-its-kind study had just been released assessing the status of the world’s least understood vertebrates. The first Global Amphibian Assessment, which looked at more than 5,700 species of frogs, toads, salamanders, newts and other amphibians became “pretty much the guiding light of my career,” said Apodaca, who now heads the nonprofit group Amphibian and Reptile Conservancy.

Nineteen years later, a second global assessment of the world’s amphibians has been completed.

“It’s a gut punch,” said Apodaca, who was not involved in the study but has reviewed its findings. “Here we are 19 years later with things not only not improved but getting worse.”

The assessment, published in the journal Nature on Wednesday, looked at two decades worth of data from more than 1,000 scientists across the world. It assessed the status of nearly for nearly every known amphibian on the planet, “Ninety-four percent,” said Jennifer Luedtke, one of the lead authors on the study. Though, she noted, an average of 155 new amphibians are discovered each year.

Discovered or not, the study found that the status of amphibians globally is “deteriorating rapidly,” earning them the unenviable title of being the planet’s most threatened class of vertebrates.

Forty-one percent of the assessed amphibians are threatened with extinction in the immediate and long-term, Luedtke said. “Which is a greater percentage than threatened mammals, reptiles and birds.”

Habitat loss from agriculture, logging and human other encroachment, was the biggest driver of the deterioration. As was the case in 2004. Diseases like the infectious chytrid fungus were a major threat as well.

But the scientists were struck by how fast climate change is emerging as one of the biggest threats to amphibians globally. Between 2004 and 2022, the time surveyed in the new assessment, climate change effects were responsible for 39% of species moving closer to extinction, Luedtke said. “And that’s compared to just one percent in the two decades prior.”

As global temperatures have warmed, driven by the burning of fossil fuels, the length and frequency of droughts is increasing. Seasons are shifting. Precipitation patterns are changing. Extreme weather events like hurricanes, heatwaves and wildfires are becoming more common.

And amphibians are particularly vulnerable to changes in their environment. Many rely on water to reproduce. They’re cold-blooded and, thus, susceptible to small changes in temperature.

“They don’t have any protection in their skin,” said Patricia Burrowes, a professor of biology at the University of Puerto Rico. “They don’t have feathers, they don’t have hair, they don’t have scales.”

Scientists have documented many species moving to new places, retreating to higher ground, as temperatures have shifted. Burrowes studied the forest coqui, Eleutherodactylus portoricensis, a small, endangered yellow or tan frog, native to the mountains of Puerto Rico. It had been observed moving to higher elevations while some similar Puerto Rican frog species were not. Burrowes and a graduate student found that the specific, already endangered, forest coquis that were moving were more sensitive to small shifts in temperature.

“Patterns aren’t predictable anymore,” Burrowes said.

Salamanders and newts were found to be the most at risk, according to the new assessment. The highest concentration of salamander diversity in the world is in the southeastern U.S. — the Southern Appalachia — where Apodaca, the executive director of the Amphibian and Reptile Conservancy, works and lives.

“This isn’t just a problem of things going extinct in the Global South and Australia and Central America and places like that,” he said. “This is the story of things declining and being endangered right here in our own backyard, so it’s our responsibility, our duty to save these things.”

Copyright 2023 NPR. To see more, visit https://www.npr.org.

The House has voted to remove Kevin McCarthy as speaker, marking the first time in history that a House speaker has been removed in this way.

The final vote was 216-210 in favor of a motion to “vacate the chair.” Eight Republicans, led by Florida Rep. Matt Gaetz, joined all Democrats present in voting against McCarthy.

Congress has now entered uncharted territory: The House will be forced to hold votes on a new speaker, though McCarthy’s defectors have not named any alternative nominee. It’s not clear whether McCarthy will run for the position again, or if any other Republican could win enough votes to secure the gavel.

The vote marks what could be the end of a fraught speakership for McCarthy. It took him 15 rounds of voting to secure the position in January. And in recent weeks, hardliners within his party blocked his efforts to pass a temporary spending bill to avoid a government shutdown.

Rep. Patrick McHenry, the chair of the Financial Services Committee, has been named speaker pro tempore, or interim speaker, until a new leader is elected. House Republicans are set to meet Tuesday evening to discuss the path forward.

Republicans split into factions

Gaetz, who never supported McCarthy’s candidacy in January, has cited McCarthy’s decision to pass a short-term spending bill with Democratic support as evidence he has not “fulfilled his promises” to conservatives.

After the vote Tuesday, Gaetz told reporters that this move “represents the ripping off of the band aid, and that’s what we need to do to get back on track.”

McCarthy was defiant but resigned to the vote following a lengthy meeting of House Republicans earlier in the day.

“If you throw a speaker out that has 99 percent of their conference, that kept government open and paid the troops, I think we’re in a really bad place,” McCarthy told reporters in the Capitol Tuesday morning.

Ahead of the vote, Democrats and Republicans huddled in corners and gathered in groups on the House floor, furiously trying to calculate whether or not McCarthy would survive the challenge. It would take a majority of the members present to remove McCarthy, leaving both parties tabulating exactly how many members were in the chamber for the vote.

Counting members turned into an intense project as a group of McCarthy’s critics sat in the back corner of the House floor with Gaetz, the member who set the revolt in motion. Across the room, McCarthy’s allies huddled with the speaker’s floor staff looking at notes and their phones.

Democrats refuse to save McCarthy

Ahead of the vote, there was speculation that Democrats might step in to save McCarthy’s speakership by voting “present” rather than in favor of the motion to vacate. But McCarthy said he was not willing to offer any concessions to Democrats to help him say in power.

House Minority Leader Hakeem Jeffries, D-N.Y., said it would be up to Republicans to “break with extremists.”

“We are ready, willing and able to work together with our Republican colleagues but it is on them to join us to move the Congress and the country forward,” Jeffries told reporters in the Capitol.

His comments followed a lengthy “open mic” meeting of House Democrats in the basement of the Capitol complex Tuesday. One by one lawmakers got up and had one minute to advise on what they thought the caucus should do, and one by one Democrats railed on Speaker McCarthy’s record and his unwillingness to reach across the aisle.

“I think Kevin McCarthy is among the most unprincipled, untrustworthy people I ever have encountered in the entirely of my life, and I think he does damage to this institution and our democracy,” Virginia Rep. Abigail Spanberger, a moderate Democrats, told reporters.

Multiple Democrats told NPR that neither the speaker nor his allies had approached Democratic leaders with any proposal to support him.

Rep. Richard Neal, D-Mass., said McCarthy’s decision to change the rules on who can propose a resolution to remove the speaker, allowing just one member to do it — a concession made for McCarthy to get the speakership in the first place — “essentially puts the fringe in charge of the House of Representatives in terms of rulemaking.”

Neal said he had a “Machiavellian position” about that decision in January: “Once you seal the deal, you have to take the consequences.”

Copyright 2023 NPR. To see more, visit https://www.npr.org.

Consider yourself warned. The federal government will conduct a nationwide test of the emergency alert system on Wednesday.

The test messages will be sent to all cellphones, televisions and radios. The test will emit sound and — on phones — vibration.

The Federal Emergency Management Agency and the Federal Communications Commission are running the test in preparation for actual emergencies. The aim of the test is to ensure the emergency messaging system is running smoothly in the event Americans are threatened by natural disasters, terrorism or other dangers to public safety.

You may be familiar with the jolting sounds accompanying National Weather Service alerts and AMBER (America’s Missing: Broadcast Emergency Response) alerts. Wednesday’s cellphone alerts will be sent via the same wireless system.

When is the test happening?

The test is scheduled to begin at about 10:20 a.m. Alaska time on Wednesday, Oct. 4.

The testing window runs for 30 minutes, but you should only receive the message once. If an actual emergency happens that day, the test could be postponed — a backup test is scheduled for the following week.

What will the test message look like?

On cellphones, the alert will read:

“THIS IS A TEST of the National Wireless Emergency Alert System. No action is needed.” Phones set to Spanish will display: “ESTA ES UNA PRUEBA del Sistema Nacional de Alerta de Emergencia. No se necesita acción.”

TV and radio will announce:

“This is a nationwide test of the Emergency Alert System, issued by the Federal Emergency Management Agency, covering the United States from 14:20 to 14:50 hours ET. This is only a test. No action is required by the public.”

Why is the test happening?

FEMA is required by law to conduct national tests of the Integrated Public Alert & Warning System (IPAWS) at least once every three years. The last national test was in 2021.

Copyright 2023 NPR. To see more, visit https://www.npr.org.

The Senate voted 88 to 9 to approve a stopgap spending bill to fund the federal government through Nov. 17, narrowly averting a shutdown by a midnight deadline. The bill now heads to President Biden’s desk for his signature.

The legislation also includes $16 billion in emergency disaster assistance requested by the White House and extends authorization for the Federal Aviation Administration through the end of the year. It does not include any additional aid to Ukraine, despite widespread bipartisan support for that funding in the Senate.

Biden praised the legislation and called for Congress to move quickly to address the lack of funding for Ukraine.

“We cannot under any circumstances allow American support for Ukraine to be interrupted,” Biden said in a statement. “I fully expect the Speaker will keep his commitment to the people of Ukraine and secure passage of the support needed to help Ukraine at this critical moment.”

The sudden agreement in Congress on spending was a major reversal after House Republicans remained at an impasse for weeks. House Speaker Kevin McCarthy, R-Calif., unveiled the bill Saturday morning after a closed-door meeting with House Republicans.

The vote came after an hours-long delay led in part by Sen. Michael Bennet, D-Colo., who demanded a firm commitment from leaders in both parties on the Ukraine aid.

“I think it’s really important for us to send a message that the dysfunction that we have, in terms of this immediate question about opening or closing the government, doesn’t reflect on our bipartisan commitment to make sure that the United States stays in this battle and that we continue to support the Ukrainian people in their fight,” Bennet told reporters outside the Capitol.

The Senate vote capped a day of dramatic swings in Congress ahead of the shutdown deadline.

Earlier in the day the House voted 335 to 91 to approve the extension. McCarthy has refused for weeks to consider any spending bill that would require the support of Democrats. But facing the potential for a politically and economically harmful shutdown, McCarthy reversed course, specifically calling on Democrats for help passing the bill.

“What I am asking, Republicans and Democrats alike, put your partisanship away, focus on the American public,” McCarthy told reporters before the vote.

In the final vote, more Democrats than Republicans supported the measure, 209 to 126.

No funding for for Ukraine

The White House, congressional Democrats and many Senate Republicans have insisted on including financial support for Ukraine, because current funding is set to run out at the beginning of October. However, a bloc of House Republicans strongly oppose more funding for Ukraine, and lawmakers abandoned those plans in order to pass a deal on spending.

Senate Democrats lamented the lack of Ukraine funding but said there is a bipartisan commitment to find a path for funding. House Republicans have suggested the only way to do that is to pair the funding with money to address illegal immigration at the U.S. border with Mexico. Sen. Chris Murphy, D-Conn., rejected that idea.

“I just think it’s much better for all of us, much better for the world if we separate the question of Ukraine from any other political question,” Murphy told reporters in the Capitol.

He said lawmakers are “going back to the drawing board” to figure out what would go in a Ukraine assistance package but “that can’t happen overnight.”

Many Republicans in the House and some in the Senate oppose new funding for Ukraine without further accounting of how the previous funds have been spent.

“We’re going to have a really, really tough conversation about whether and how we’re going to fund Ukraine,” said Sen. J.D. Vance, R-Ohio. “I think this is a victory for those of us who are skeptical of indefinite funding for Ukraine. But there’s going to be another fight, whether it’s next week or three weeks from now.”

McCarthy’s reversal

The sudden rush of action came after House Republicans huddled in the basement of the Capitol to discuss strategy.

Some McCarthy allies, like Rep. Dusty Johnson, R-S.D., argued a temporary fix to funding the government was needed so House Republicans can continue to push for conservative spending policy without the threat of a shutdown. Leaders stressed that with continued resistance from a group of conservative GOP members, there was no way to move a bill with just Republicans. McCarthy holds a narrow majority and can’t lose any more than four votes.

Johnson pointed to the 21 far-right Republican members who blocked a GOP bill on Friday as the reason why the speaker moved to this new plan. Those members “put us in a position to unfortunately pass something a little less conservative. Now the good news is this is still a pathway to get the kind of conservative wins we need through the appropriations process.”

House Republican leaders canceled the planned district recess for the beginning of October and said the House will continue to move their own spending bills — they passed four of the 12 that fund federal agencies.

Conservatives pushed back against the stopgap bill. Rep. Bob Good, R-Va., told reporters he would vote no against a continuing resolution. “There’s no such thing as a clean CR.” He argued if one passed he didn’t believe the House would continue taking up the rest of the annual spending bills.

The threat to McCarthy’s leadership

McCarthy’s move opens him up to a challenge for his gavel. Florida GOP Rep. Matt Gaetz has been hinting for days he was planning to file a resolution to oust the speaker. Under rules McCarthy agreed to in January when he was elected, only one lawmaker is needed to file a “motion to vacate” — a resolution that calls for a vote of confidence in the speaker.

Asked by reporters if he was worried about his job, the speaker said, “you know what, if somebody wants to remove because I want to be the adult in the room, go ahead and try.”

Democrats join with McCarthy’s plan

There was drama early in the day as House Democrats attempted to stall progress on the House bill in order to give the Senate time to vote first on their own version of the legislation that would have provided roughly $6 billion for Ukraine.

As senators crept toward their own vote, across the Capitol, the House Appropriations Committee’s Democratic staff members released an analysis criticizing the bill for not including money for Ukraine.

But it quickly became clear that Senate Republicans were on board with McCarthy’s plan and House Democrats relented.

Rep. Jim McGovern, D-Mass., the top Democrat on the Rules Committee, said he was disappointed with the decision to remove Ukraine aid, but Congress needed to move ahead with the deal they could reach.

“There’s bipartisan consensus on [Ukraine], we’ve had overwhelming votes on this, so I think we will work that out,” McGovern told reporters. “But right now this is a bill — I mean I would have written the bill a little bit better, but this is a bill that Democrats can support and I think we won some important victories.”

NPR’s Deepa Shivaram contributed to this report.

Copyright 2023 NPR. To see more, visit https://www.npr.org.

Emily Gebel was trying to figure out why she was having trouble breastfeeding. That’s when she felt a lump.

Gebel, a mother of two children, went to her primary care doctor in Juneau, Alaska, who referred her for testing, she said.

Her 9-month-old was asleep in her arms when she got the results.

“I got the call from my primary care nurse telling me it was cancer. And I remember I just sat there for probably at least another half an hour or so and cried,” Gebel said.

Juneau, the state capital, has about 31,700 residents, who are served by the city-owned Bartlett Regional Hospital. But Gebel said she has several friends who have also had cancer, all of whom recommended she seek treatment out of town because they felt bigger cities would have better care.

She opted for treatment in Seattle, the closest major American city to Alaska. She underwent surgery at Virginia Mason Medical Center in September 2022. In January, she began chemotherapy at Lifespring Cancer Treatment Center, a stand-alone clinic that she said she selected because it offers a lower-dose chemotherapy.

During chemo, she learned she had stage 4 breast cancer, she said.

Commuting to Seattle for chemo every week — nonstop flights last as long as two hours and 45 minutes — became tiring. So Gebel began treatment at Bartlett Regional Hospital after her Seattle doctor taught hospital staffers there how to administer her chemo regimen.

Then the bill came.

The patient: Emily Gebel, 37, insured through her husband’s employer by Premera Blue Cross. She was previously covered by Moda Health.

Medical service: One round of metronomic chemotherapy, which involves regular infusions at lower but more frequent doses and over a longer period than traditional chemotherapy.

Service provider: Bartlett Regional Hospital and Lifespring Cancer Treatment Center. The hospital is a tax-exempt facility owned by the city and borough of Juneau, though most of its revenue comes from the services it provides, according to hospital officials. Lifespring is a stand-alone, doctor-owned cancer clinic in Seattle.

Total bill: The prices for Emily’s chemo infusions at Bartlett Regional Hospital varied week to week. A hospital bill showed one infusion in July was listed at $5,077.28 — more than three times the price for a similar mix of drugs at the Seattle clinic, $1,611.24.

What gives: In the United States, the price for the same medical service can vary based on where it is received. And for those living in remote areas like Alaska, the price difference can put care further out of reach.

Emily’s firsthand experience with this disparity began after her husband, Jered, requested a cost estimate from Bartlett Regional Hospital. It said Emily’s chemo would cost around $7,500 per weekly infusion, more than 4½ times what she had been charged in Seattle.

“The email came through with the bill estimate, and it’s like, ‘Oh my goodness, this has to be wrong,'” Jered said.

Jered said Emily had met her annual out-of-pocket maximum, meaning her insurance would cover the costs of her treatment, but from the start, the disparity just bothered him.

When Emily received a bill for a few rounds of her weekly chemo treatments, it showed that the hospital charged more than triple what the Seattle clinic did for a round of chemo, asking higher prices for every related service and medication she received that week.

The hospital charged about $1,000 for the first hour of chemo infusion, which is more than twice the rate at the Seattle clinic. One of Emily’s drugs cost $714, more than three times the price at the clinic.

It was even the tiniest things: The hospital charged $19.15 for Benadryl, about 22 times the clinic’s price of 87 cents.

Staff at Lifespring Cancer Treatment Center, the Seattle clinic, did not reply to requests for comment.

Sam Muse, the hospital’s former chief financial officer who no longer works there, said Bartlett Regional Hospital officials determined prices by looking at average wholesale prices and what other facilities in the region charge. Muse said the hospital had to account for high operating costs.

“Anything that we charge certainly has to take into consideration … the cost of just supplying healthcare in a rural setting like Juneau,” Muse said. “We’re not accessible by road at all, only ferry or plane.”

Juneau’s isolated geography makes reaching many resources a challenge. The city is part of the Alaska Panhandle, a narrow, island-speckled sliver of the state wedged between Canada, the Pacific Ocean, and Glacier Bay National Park & Preserve. Neither Anchorage nor Vancouver, its nearest major cities, is close by.

The hospital — the only one in the city and largest in the panhandle — treats a small number of cancer patients, at least a few hundred last year, Muse said. Its two oncologists live outside the city and fly into Juneau six times a month, said Erin Hardin, a hospital spokesperson.

Bartlett spent nearly $11 million last year to pay and fly in nurses, doctors, and other staffers who live outside the city, Muse said.

We’re “trying to find that happy medium between keeping care here and keeping costs down and how do we do that in a sustainable way for the long term,” Muse said.

Even though research shows Alaskans seek emergency care and are admitted to the hospital less often than many Americans, they had the third-highest health care expenditures per capita in 2020.

“Alaska is special in that it’s small, it’s remote, therefore it’s more expensive,” said Mouhcine Guettabi, an associate professor of economics at the University of North Carolina-Wilmington who studied health care costs in Alaska when he taught there.

Guettabi said hospitals often need to offer higher wages to recruit doctors and nurses willing to live in Alaska, which has a higher cost of living than most states.

Towns or entire regions may have few specialists and only one hospital, creating a dearth of competition that may drive up costs, Guettabi said. It’s also more expensive to ship items there, including medical supplies.

But Alaska’s costs are higher even when taking all those factors into account, Guettabi said. In Anchorage, for instance, prices for medical items increased nearly three times faster from 1991 through 2017 than prices overall.

Alaska also has a unique policy that may be increasing prices. Its “80th percentile rule” was enacted in 2004 to limit the amount of money patients pay when treated by providers outside their health insurers’ network. But like many experiments meant to rein in costs, the rule has instead been increasing health care spending, according to a study by Guettabi.

“Critics think the rule may be adding to that soaring spending, partly because over time providers could increase their charges — and insurance payments would have to keep pace,” the study noted.

The resolution: Emily received a bill from the hospital in September, more than five months after beginning treatment there.

It said Emily owed about $3,100 even though a previous explanation of benefits said she’d met her out-of-pocket limit.

Jered said he contacted hospital billing officials, who discovered that a medicine had been incorrectly coded and told Jered that Emily’s charge was zero.

“We know how hard it is to pay these ridiculous medical bills,” Jered said. “If I’m able to push back a little bit against this massive system, well, hey, maybe other people can, too. And who knows, maybe eventually health care prices can come down.”

Emily said she’s glad Jered knows how to handle the financial aspects of her care. Like many Americans, she could have just paid or ignored the incorrect bills, risking being sent to collections.

“I can’t imagine the amount of time I would have to spend on it while juggling parenting and also dealing with completing treatment, going through the sickness that goes along with that, and just generally feeling very run down,” she said.

The takeaway: Alaska government officials, nonprofits, and experts have suggested methods to lower the cost of health care. The state is considering repealing the 80^th percentile rule and implementing value-based care, which emphasizes paying providers based on health outcomes.

But what should Alaskans and other patients do in the meantime? If you live in a high-cost state, you might check out prices at a health care system in a state next door.

In any case, get ready to advocate for yourself.

Jered learned about medical billing by following the Bill of the Month series and reading “Never Pay the First Bill,” a book by Marshall Allen, a former ProPublica reporter.

Request itemized bills and make sure the codes match the services you received, Jered said. Note any prices that seem outrageous. If you have concerns, arrange an in-person meeting with an official in the provider’s finance department. If that’s not possible, a phone call is better than email. Make sure to document all conversations, so you have a record.

Come prepared with your documents and evidence, including the rate paid by Medicare, the federal insurance system for those 65 and older. Ask the official to explain the reasons for the codes and pricing before contesting anything. You can sometimes negotiate high-priced services down. And remember that the person you’re speaking with isn’t to blame for your health care costs.

“Don’t come at them angry, don’t come at them as viewing them as the enemy — because they’re not,” Jered said. “They are working within the same broken system.”

Emmarie Huetteman of KFF Health News edited the digital story, and Taunya English of KFF Health News edited the audio story. NPR’s Will Stone edited the audio and digital story.

KFF Health News, formerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.

Copyright 2023 KFF Health News. To see more, visit KFF Health News.