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Teledoc Medication Abortions Under Attack

By MIKE MAGEE

For those prepared to take a deep breath and relax in the aftermath of the MAGA induced assault on the First Amendment that whipsawed Disney leadership last week as they abandoned and then rescued Jimmy Kimmel, be advised reproductive health access is at the top of the list when it comes to MAGA campaigns to “restrict liberties.”

Consider the ongoing campaign to federally restrict telemedicine enabled medication abortion.

A few facts:

  1. Medication abortion is a process that involves taking two medications (mifepristone and misoprostol) at specific intervals over one to three days. It is approved for use up to the first 70 days of a pregnancy and costs on average about $500.
  2. As defined by Yale Medicine, “Mifepristone is a medication that blocks progesterone activity in a female’s body. Progesterone is a critical hormone for supporting an early pregnancy. The second medication, misoprostol, causes contractions and expels the pregnancy tissue. It typically takes 12 to 24 hours to pass the tissue.”
  3. The overall number of abortions have risen since the Dobbs decision overturned Roe v. Wade. There were 1.1 million US abortions in 2023, that is 88,000 per month compared to 80,000 the year before.
  4. Medication abortions account for 2/3 of all abortions in the US. At least 1 in 4 of these last year involved telemedicine provision by mail order including to citizens from states with highly restrictive abortion laws.
  5. Success rate in terminating pregnancy is 99.6%. Major complications occur in .4% of cases and mortality is nearly non-existent.
  6. Anti-abortion advocates are currently focused on obstructing legal access to abortion pills.

Immediately following the Dobbs decision, 12 states banned abortion and 4 states imposed a 6-week gestational limit on access to abortion. Nine of these states now explicitly ban telehealth enabled medication abortion. Countering these measures, eight states where abortion remains legal have passed “shield laws” that protect health professionals from prosecution by other states for engaging in telehealth support of patients seeking self-care within states where abortion is illegal. By latest count, 1 in 7 telehealth assisted medication abortions involved practitioners from shield states.

President Trump’s campaign pledge to reinstate the dormant 1873 Comstock Act to cripple telehealth efforts in support of medication abortion has gone nowhere. In a similar vein, flawed science studies engineered by anti-abortion advocates attempting to challenge FDA clearances for safety and self management of the drugs involved have been exposed as unscientific, deceptive and biased. Multiple state suits, for and against imposing additional FDA hurdles to access in the absence of demonstrable medical benefit or risk mitigation are piling up in the courts. And Louisiana recently took a different tact, reclassifying misoprostol a “controlled substance” and inviting provider countersuits.

As Cornell legal experts remind us, the freedom of expression and the right to freedom of speech may be exercised “in direct (words) or a symbolic (actions) way.” When first written, and adopted as the first of the original 10 entries in the Bill of Rights in 1791, the First Amendment said: “Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble, and to petition the Government for a redress of grievances.”

Nowadays, the provision applies to the entire federal government and is reinforced by the Due Process Claus of the 14th Amendment which protects citizens from state government interference as well.

For better or worse, the actions leading up to the Dobbs decision were led, funded, organized and executed primarily by religious groups, primarily Roman Catholics and Evangelical Christians, joining ranks on the issue five decades ago. Those very religions legitimacy and independence has long been protected by the First Amendment.

A simple listing of the opening salvo of our Bill of Rights reveals a complex tangle of protections that define not only our primary rights as citizens, but also our power and legitimacy as a healthy representative democracy.

What’s included? According to legal experts, our 1st Amendment “protects the right to freedom of religion and freedom of expression from government interference. It prohibits any laws that establish a national religion, impede the free exercise of religion, abridge the freedom of speech, infringe upon the freedom of the press, interfere with the right to peaceably assemble, or prohibit people from petitioning for a governmental redress of grievances.”

Religious leaders remain deeply divided. Opposing reproductive choice while protecting the religious freedom assured by the very same 1st Amendment is a difficult needle to thread. Consider the comment of Baltimore Archbishop William Lori, Chairman of the U.S. Conference of Catholic Bishops’ Committee on Pro-Life Activities, on June 24, 2022, the day of the Dobbs decision: “I recognize there are people on both sides of the question in the Catholic Church. What we are finding though is that when people become more aware of what the church is doing to assist women in difficult pregnancies … hearts and minds begin to change.”

Well, not exactly. A March, 2025 Pew Survey of Catholics nationwide revealed that 6 in 10 Catholics believe that abortion should be legal in all or most cases.

It is ironic that, in attempting to usurp women’s rights to their own reproductive freedoms, that some religious leaders continue to attack the country’s foundational 1st Amendment that has assured the continued existence of their sponsoring organizations.

Mike Magee MD is a Medical Historian and regular contributor to THCB. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex.

Boulder Care: Stephanie Strong & Marianna Zaslavsky

Stephanie Strong, CEO & Marianna Zaslavsky, the (relatively new) Head of Growth at Boulder Care came on THCB to tell Matthew Holt about their service which delivers medication assisted treatment for those suffering from substance used disorder, via telehealth. Stephanie has been one of the leading advocates for getting patients, especially those on Medicaid, access to treatment. She led a campaign to get the DEA to continue to allow substance abuse treatment using medication via telehealth. Marianna joined this summer with the goal of helping patients get access via managed care plans. We discussed a lot about the potential for Boulder to continue its harm reduction strategy for patients, and also the potential limits that might be coming via Medicaid reductions as part of the BBB. Stephanie & Boulder are supporting a campaign called Majority for Medicaid which is raising awareness about the impact of Medicaid cuts on these patients. Some of those stories are here

You can also text MAJORITY to 50409 to urge your representative to protect the promise of Medicaid.

HHS’s Independence: If Not Now, When?

By DAVID INTROCASO

After having worked in DC for sixteen years, in 2013 I created The Healthcare Policy Podcast.  The title was in part intended to be sarcastic because healthcare policymaking in DC is very narrowly drawn.  Consequently, healthcare delivery is excessively commodified, reductionistic and financialized or in sum anachronistic and ironically lacking purchase.  If the policy objective was health, we’d be healthier.  We’re not.  For example, though anthropogenic warming poses the greatest threat to human health, we’ve no related healthcare policy. 

Among more conventional issues, there is no serious policy discussion regarding HHS’s mission “to enhance . . . the well-being of all Americans.  That we treat the disease not the person means we define health as simply the absence thereof.  The same for excess deaths, comparatively declining life expectancy and compressing morbidity among Medicare beneficiaries who will soon exceed 20% of the population.  As for children, HHS’s recent “Make Our Children Healthy Again” report expressed concern about children’s aerobic fitness but was silent about the prevalence of childhood sexual abuse despite Jeffrey Epstein and the Congress’s own serial child molester former House Speaker Dennis Hastert.  Bizarrely, the AMA has yet to rescind Speaker Hastert’s 2006 Nathan Davis award for “outstanding contributions to the betterment of public health.”  The HHS report was also silent about Medicaid reform even though the program provides healthcare for roughly half of US children.  It is similarly remarkable how seldom if ever names like Arrow, Canguilhem, Farmer, Foucault, Illich, Marmot, Starfield and Virchow are discussed in healthcare policy circles.  

Now after OBBBA cuts to the Medicaid and Medicare programs, 500 rounds fired into six CDC buildings, one killing a police officer, and seven months of HHS moral obliquity we are confronted with the reality that healthcare policymaking is now unambiguously on the road to nowhere.  This may be because, having failed to appreciate Richard Hofstadter, Humphrey Building leadership is busy fomenting a new chapter in anti-intellectualism.  We’re left to ask if healthcare enshittification has now been achieved possibly because healthcare policymakers have adopted Mark Manson’s “The Subtle Art of Not Giving a F*ck.”

The good news is the storm and stress about HHS no longer being fit for purpose could be effectively cured if the Congress, along with support from MedPAC, MACPAC and others, would work to free the department from politicization or partisan influence by redefining it as an independent agency.  If policymakers exercised more imagination such a simple and obvious reform would have already received serious attention.          

The idea of an independent HHS has at least been recognized.  Roughly twenty years ago Dr. Arnold Relman, the esteemed former editor of The New England Journal of Medicine, argued healthcare be managed by a “National Health Care Agency” defined as a hybrid public-private entity like, he said, the Federal Reserve.  Similarly, HHS would be governed by an independent board whose members would be nominated by the president and confirmed by the Senate for 14-year terms. 

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Lessons From The Medical Error That Orphaned A Cabinet Secretary

By MICHAEL MILLENSON

It was a small anecdote, buried in a lengthy profile in The New Yorker of Commerce Secretary Howard Lutnick, “Donald Trump’s Tariff Dealmaker-in-Chief.” But as a patient safety activist, the stark depiction of the effect of medical error felt like a sudden shock.

Lutnick, the article related, knew tragedy early in life: “his mother died of lymphoma while he was in high school; in his first week of [Haverford] college, his father was accidentally administered a fatal dose of chemotherapy. Other relatives receded into the background, leaving Lutnick and his two siblings on their own.”

A medical error and, suddenly, three kids are abruptly orphaned and effectively abandoned. With World Patient Safety Day just past us on Sept. 17, I wanted to put that devastating event into the broader patient safety context.

As is frequently the case, The New York Times obituary of Sept. 15, 1979, for Solomon Lutnick gave no cause of death. There were a handful of personal and professional details (he was a history professor at Queens College) and that he died at age 51 at Syosset (Long Island) Hospital.

Invisible Harm

Unfortunately, treatment-caused harm has often been invisible, even where it occurred. The year before Solomon Lutnick died, the first study to examine adverse events at multiple hospitals concluded that given the benefits of modern medicine, the incidence was “remarkably low.” The 1978 study, commissioned by California hospital and medical associations worried about rising malpractice premiums, was overseen by physician-attorney Don Harper Mills, who assured the worried sponsors there were few “potentially compensable events.”

There’s no indication Solomon Lutnick’s death prompted a lawsuit; he was being treated for metastatic colon cancer when a nurse accidentally administered 100 times the recommended chemotherapy dose, according to accounts Howard Lutnick has shared elsewhere. It’s unclear how Syosset Hospital reacted, but the Mills study, reflecting the attitude of many at the time, didn’t count deaths of individuals who the research team assessed would have died anyway within a year.

Even with that methodology, when in my 1997 book I extrapolated Mills’ results nationally, his “remarkably low” incidence of harm amounted to 120,000 people killed each year by medical care. I wonder whether anyone told the three Lutnick children, “Your dad was going to die soon, anyway,” and whether they found that any sort of comfort.

In 2025, addressing patient harm was long ago supposed to have become part of hospital culture, but invisibility nonetheless continues. The Office of the Inspector General of the Department of Health and Human Services Hospitals has repeatedly found that millions of Medicare patients every year are harmed by their medical care. Yet hospitals still fail to capture even half of harm events, while also failing to report two-thirds of events for which reporting is required, according to the most recent OIG report. Worse, few incidents of harm are even investigated “and even fewer led to hospitals making improvements for patient safety,” the OIG concluded.

Echoing Another Error

But it wasn’t only the way Solomon Lutnick’s avoidable death would have been minimized during that era that struck me. It also stood out for its eerie echo of a later death that became a patient safety milestone. On Dec. 3, 1994, an obituary in the Boston Globe for its personal health columnist, Betsy Lehman, related that the 39-year-old married mother of two young daughters had died at Dana-Farber Cancer Institute due to complications of breast cancer. However, it wasn’t until after a routine record review by Dana-Farber clerks found the error, which was relayed to her family and then to her Globe colleagues, that a page one story appeared on March 23, 1995, detailing how an accidental overdose of a powerful chemotherapy drug had actually caused Lehman’s death.

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And Yet It Moves

By KIM BELLARD

Science buffs will recognize the title as the (possibly apocryphal) quote Galileo muttered after he was forced by the Catholic Church to recant his assertion that the earth moved around the sun, contrary to church dogma. We’re in an era where it is the Trump Administration, not the church, forcing people and organizations to accede to things they don’t really believe in, whether they are law firms, universities, media companies, or big corporations, to name a few.  

That’s why I was so pleased when last week the National Academies of Sciences, Engineering, and Medicine (NAS) not only didn’t take a knee about the Trump Administration’s dogma about climate change being a hoax, they also didn’t just mutter their objections. They issued a lengthy report outlining how climate change is very real, is largely due to human contributions, and is extremely bad for us and the planet.  

And yet it moves indeed.

The NAS was spurred into action by an EPA announcement proposing to rescind an Endangerment Finding issued in 2009 by the Obama EPA. “With this proposal, the Trump EPA is proposing to end sixteen years of uncertainty for automakers and American consumers,” EPA Administrator Zeldin said.“In our work so far, many stakeholders have told me that the Obama and Biden EPAs twisted the law, ignored precedent, and warped science to achieve their preferred ends and stick American families with hundreds of billions of dollars in hidden taxes every single year.” He was practically giddy.

Not so fast, the NAS report says. Its overarching conclusion: “EPA’s 2009 finding that the human-caused emissions of greenhouse gases threaten human health and welfare was accurate, has stood the test of time, and is now reinforced by even stronger evidence.”

The report lists five key conclusions:

  • Emissions of greenhouse gases (GHGs) from human activities are increasing the concentration of these gases in the atmosphere.
  • Improved observations confirm unequivocally that greenhouse gas emissions are warming Earth’s surface and changing Earth’s climate.
  • Human-caused emissions of greenhouse gases and resulting climate change harm the health of people in the United States.
  • Changes in climate resulting from human-caused emissions of greenhouse gases harm the welfare of people in the United States.
  • Continued emissions of greenhouse gases from human activities will lead to more climate changes in the United States, with the severity of expected change increasing with every ton of greenhouse gases emitted.

Pulling no punches, it says:

In summary, the committee concludes that the evidence for current and future harm to human health and welfare created by human-caused GHGs is beyond scientific dispute. Much of the understanding of climate change that was uncertain or tentative in 2009 is now resolved and new threats have been identified. These new threats and the areas of remaining uncertainty are under intensive investigation by the scientific community. The United States faces a future in which climate-induced harm continues to worsen and today’s extremes become tomorrow’s norms.

i.e., “And yet we are endangering ourselves, and the planet.”

Shirley Tilghman, professor of molecular biology and public affairs, emeritus, and former president, Princeton University, and chair of the committee that wrote the report, was more diplomatic: “This study was undertaken with the ultimate aim of informing the EPA, following its call for public comments, as it considers the status of the endangerment finding. We are hopeful that the evidence summarized here shows the strong base of scientific evidence available to inform sound decision-making.”

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New Bereavement Cost Calculator shows that grief is expensive

by EMMA PAYNE

Grief is expensive. In addition to the significant human impacts, research shows that bereavement leads to a 20%-30% increase in health care utilization.

Grief is also common. While we may not like to talk about it, 37% of Americans are grieving a recent death. The U.S. averaged 3.26 million deaths per year over the last five years and data suggests that an average of nine people grieve a single death. The CDC started measuring bereavement for the first time in 2021, but most health plans aren’t yet measuring the incidence or cost of grief.

So we decided to take a look. Here’s just some of what we found.

When a member is bereaved, health plans — especially those serving older adults — see significant jumps in utilization and costs across multiple claims categories. Examples include:

● 51% increase in Emergency Department visits and 43% increase in hospitalizations for bereaved spouses whose partners died in hospital
● 67% higher risk level for psychiatric hospitalization in the first year of bereavement for parents who have lost a child
● 74% of husbands and 67% of wives are hospitalized at least once in the nine years following the death of their spouse
● 463% higher odds of antidepressant use for people who have a prolonged grief disorder diagnosis

These increases lead to escalating claims costs that add up quickly, especially in populations 65+. But what are these costs? And what can insurers do to mitigate them?

To make these hidden costs visible, my team at Help Texts created a tool that health plans can use to model bereavement’s financial impacts. With just member numbers, the Bereavement Cost Calculator from Help Texts will estimate a health plan’s:

● Projected Per Member Per Month (PMPM) cost increase after bereavement
● Total cost impact of grief when no intervention is provided
● Estimated savings when plans provide Help Texts’ clinically sound, scalable, grief support for bereaved members

Consider a Medicare Advantage Plan with 250K members ages 65+. It should expect:
● Potential year one cost reduction (with intervention): $22.8M
● 11,500 members to be grieving the death of a partner or child
● 81,500 members to be grieving other losses (eg. parent, sibling, friend)
● Average PMPM increase (without intervention): $120
● Total estimated year one cost impact (without intervention): $134M *

What can a health plan do to save money and improve care and outcomes for its members? The numbers are powerful, showing that grief is expensive, but also that bereavement presents a clear opportunity to provide an impactful upstream intervention that can save millions, while also caring for people during what is often the loneliest time in their lives.

Help Texts is a clinically sound, scalable, bereavement intervention. With subscribers in 59 countries and all 50 states, Help Texts delivers affordable, multilingual grief support via text message. With extraordinary acceptability (95%) and 6-month retention (90%) rates, Help Texts’ light-weight solution makes it easy for health plans and others to improve health and community outcomes, while also realizing significant cost savings for those in their care.

Health Plans, particularly Medicare Advantage plans, can use the new bereavement cost calculator from Help Texts to estimate the true cost of bereavement and their cost savings when grief support is provided. The Bereavement Cost Calculator from Help Texts uncovers the savings potential when caring for grieving members. In less than a minute, you can start to see how much bereavement is costing, and how much could be saved by supporting members grieving the loss of a loved one.

Because the true cost of bereavement isn’t only emotional, it’s also financial. And for health plans, addressing both is the smartest investment you can make.

Emma Payne is the CEO of Help Texts

Does American Health Care Violate the ICJ’s Recent Climate Advisory Opinion?

By DAVID INTROCASO

In late July the UN International Court of Justice (ICJ) announced its long-awaited and highly-anticipated climate advisory opinion.  The ICJ ruling represents an historic moment in climate accountability.

“Obligations of States in Respect of Climate Change”

In a rare unanimous decision, the ICJ opinion concluded “a clean, healthy and sustainable environment” is in part a precondition for the enjoyment of human rights including the right to life and the right to health.  Consequently, the ICJ ruled states including their private actors are obligated to ensure the climate is protected from anthropogenic greenhouse gas emissions (GHGs) and can be held legally culpable by other harmed or unharmed states, groups and individuals for failing to protect the climate.

The 140-page opinion is the result of a 2023 UN resolution that requested the ICJ produce an advisory opinion answering two questions: what are states’ obligations under international law to ensure protecting the climate and what are the legal consequences for causing significant climate harm?  In a failed attempt the US State Department opposed the resolution arguing the ICJ can only consider applicable climate treaties such as the 2015 Paris Agreement and to the exclusion of other rules of international law.

In sum, the ICJ found states have substantive, urgent and enforceable obligations under UN climate treaties and international laws to prevent significant harm to the environment from GHG emissions that includes those resulting from fossil fuel use.  The court broadly defined fossil fuel use as the adoption of laws, regulatory policies and programs that promote fossil fuel production and consumption via leases, licenses and subsidies. 

States must act using “all means at their disposal” that includes adopting appropriate legal and regulatory measures, acquiring and analyzing scientific and technological information and risk and impact assessments, meeting a duty of cessation and acting in good faith that includes a duty to cooperate and collaborate internationally.  The ruling also allows for legal action to protect future generations.  The court rejected the argument attributing harm on a case-by-case basis is unachievable stating it is “scientifically possible” to determine each state’s current and historical emissions.  Without naming the US, the ICJ affirmed states not party to UN treaties must still meet their equivalent responsibilities under international law.  (Columbia’s Sabin Center Climate Change Law Blog has examined at length the ICJ opinion.)

US Healthcare’s Contribution to Anthropogenic Warming

Because the ICJ recognizes an inherent link between anthropogenic warming and human rights, the opinion implies the right to health cannot be secured without addressing US health care’s own climate obligations.  Meeting these pose a substantial challenge for the industry for several reasons.

US health care significantly contributes to anthropogenic warming.  Per Northeastern Professor Matthew Eckelman, the industry accounts for a growing amount GHG emissions currently at over 600 million metric tons of carbon dioxide equivalents (CO2e), or 9-10% of total US emissions and 25% of global healthcare emissions.  If US healthcare was its own country it would likely rank 9th, less than Saudi Arabia but more than Germany.      

Two reasons largely explain US healthcare’s carbon footprint.  The industry is immense.  Despite providing care for 4% of the world’s population, last year it constituted a $5.3 trillion market or roughly half of total global healthcare spending.  The industry wastes an enormous amount of energy.  Despite spending over $5 billion annually on energy, equivalent to at least 15% of profits, hospitals are significantly energy inefficient because they continue to consume fossil fuels to first generate heat to produce electricity that is dramatically less efficient than using renewable resources that directly generate electricity or work demand.  End-use energy inefficiency compounds the problem.  For example, only a trivial number of hospitals are EPA Energy Star certified for energy efficiency.  For the ten-year period ending in 2024, 85 or 1.4% of over 6,000 hospitals were on average certified. 

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That’s More Like It

By KIM BELLARD

I’m always on the lookout for advances in healthcare that seem more like 22st century medicine than what we still experience in 2025. Way too much of it seems less advanced than we should be expecting in a world of AI, genetic engineering, nanobots, and the like. I often think of the scene in Star Trek IV where Dr. McCoy finds himself in a 20th century hospital and is appalled:

So I’m pleased to report on a couple of developments that seem like the future.

Transcranial ultrasound stimulation (aka “ultrasound helmet): You may not have ever heard of deep brain stimulation, unless you know someone who has advanced Parkinson’s, dystonia, essential tremors, or epilepsy. It turns out that electrical impulses to certain parts of the brain can help reduce the involuntary motions these conditions can result in.

The drawback is that deep brain stimulation is delivered by electrodes implanted deep in the brain. While this may not be quite as daunting as it sounds, people are still, you know, drilling holes in your head and pushing electrodes into your brain. You can imagine Dr. McCloy’s reaction.

Enter transcranial ultrasound stimulation. A new paper in Nature from researchers at University College London (UCL) and Oxford describes using a 256 element helmet to precisely aim ultrasound waves to accomplish the same results.

Our findings reveal this system’s potential to non-invasively modulate deep brain circuits with unprecedented precision and specificity, offering new avenues for studying brain function and developing targeted therapies for neurological and psychiatric disorders, with transformative potential for both research and clinical applications.

Professor Bradley Treeby, senior author of the study from UCL Medical Physics and Biomedical Engineering, said:

Clinically, this new technology could transform treatment of neurological and psychiatric disorders like Parkinson’s disease, depression, and essential tremor, offering unprecedented precision in targeting specific brain circuits that play key roles in these conditions.

The ability to precisely modulate deep brain structures without surgery represents a paradigm shift in neuroscience, offering a safe, reversible, and repeatable method for both understanding brain function and developing targeted therapies.

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Telehealth safe harbor: a call to action for health plans

By AMI PAREKH

A little-noticed telehealth safe harbor provision tucked inside the One Big Beautiful Bill was a significant milestone in virtual care. Though it specifically addresses pre-deductible telehealth services in high-deductible health plans, the legislation has far wider implications for both care delivery and insurance design, especially in the commercial insurance market. In fact the permanent extension of a pandemic-era policy is a clear signal to health insurers that a new era of virtual care is under way.

The provision, which permanently extended an expired pandemic-era policy, is a win for employers and workers. After five years of uncertainty, employers are now empowered to provide telehealth services to their entire workforce at little or no cost, which has been shown to reduce access barriers and close gaps in care. For self-funded employers in particular, this flexibility in cost-sharing — combined with an increasingly sophisticated ecosystem of virtual care providers — will further accelerate innovation in benefits strategy and workforce well-being.

Less obviously, this employer-led innovation is also changing the virtual care landscape for a key partner: health plans. Though 20% of employers contract directly with specialized telehealth vendors, 78% rely on their health plan partners — and their vendors — to provide telehealth services for employees. As employers revisit their long-term virtual care strategy with new assurance in the wake of the safe harbor provision, health plans have an important seat at the table.

That seat is heating up, however. In a year when employer healthcare costs are projected to increase by more than 9%, employers are scrutinizing their partnerships and plan design to ensure that virtual care solutions are delivering meaningful value to their employees and their bottom line.

In a new annual survey from the Business Group on Health (BGH), more than three-quarters of employers said they are actively eliminating underutilized programs and underperforming vendors, or are considering doing so. Employers are also stepping up expectations in RFPs, evaluating potential healthcare partners on a growing list of factors and capabilities including performance guarantees, product and network design, reporting and analytics, and member experience.

In this light, the safe harbor provision is a call to action for health plans to evaluate their own virtual care strategy and partnerships through an employer’s lens. Three areas are especially important:

1. Quality

In the BGH survey, employers cited navigation to higher-quality providers and better quality transparency as top priorities — and virtual care is no exception. In last year’s survey, half of all employers expressed concerns about the quality of virtual care.

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Labcorp, Blue Shield and my $34.95 co pay (part 5)

By MATTHEW HOLT

I have been on a quest to try to understand why I am being charged $34.95 by Labcorp for some lab tests that I think should be free under the ACA preventative care statutes, and for which my insurer Blue Shield of Californian has issued me an EOB with a $0 co-pay.

It’s been a microcosm of the chaos of American health care so far, If you want to catch up here’s part 1, part 2, part 3 and part 4

You may recall that I had paid a $50 co pay for the lab tests connected to my preventative annual wellness visit in 2024 (and I didn’t pay attention) but that when I got a $34.94 charge from Labcorp in 2025 and found that Blue Shield said my copay was $0, I decided to investigate.

I have had a lot of help from Rhea, a senior customer service rep at Labcorp who I think is having nearly as much fun with this as I am. She told me that the co-pay Labcorp tries to collect is the lower of $50 or whatever the total bill is. For the 5 tests I had, Labcorp’s agreed rate with Brown and Toland Physicians (the Blue Shield-owned IPA that contracts with their HMO, of which I am a member) was $34.94. So that is the answer as to that charge.

But it still doesnt answer a couple more questions.

  1. Why was a subsequent lab test I had as a follow up also shown by Blue Shield as a $0 copay on the EOB?
  2. Why weren’t the lab tests I had considered preventative under the ACA and therefore also free?

Rhea’s guess for the first answer is that Labcorp receives a capitated amount for lab tests from Blue Shield or Brown and Toland, and that the second test was somehow covered under that. Maybe, but then why wasn’t the first one?

The second question takes me further down a rabbit hole. Rhea dug out the order from One Medical to Labcorp. You can see below that the CPT codes are on it (what the tests actually are) and also what the related diagnosis codes are.

I of course asked chatGPT what those diagnosis codes were and the answer is
E78.5 = Hyperlipidemia (i.e. high cholesterol)
R73.03 = PreDiabetes
E66.811 = Obesity class 1
M10.9 = Gout

As you might suspect as a pretty typical 60+ year old American, I fit the bill for all those diagnoses. The CPT codes for the tests I had are complete blood count, Metabolic Panel, Hemoglobin (A1C), Lipid Panel, and Uric Acid (which causes gout).

Presumably all of those, with the possible exception of the Gout/Uric Acid, could be seen to be preventative. After all the CMS web site explains that preventative screening is free for “Annual Wellness Visits and Physical Exams, for instance with a primary care doctor and Health Screenings for blood pressure, cholesterol, blood sugar for diabetes, and various cancer screenings such as colonoscopies and mammograms”.

So why is this not free to me? Rhea from Labcorp suggests that Blue Shield initially issued me a $0 copay EOB but later should have reprocessed that when it got the bill from Labcorp, and told me to pay the $39.94. She also found that in addition to CMS suggesting what should be called preventative, Blue Shield of CA has a very long document with what it thinks is preventative care. You can see and download it here.

I asked ChatGPT to read it for me and after a bit of looking around we (that’s me and ChatGPT) concluded that E78.5 is in the list of applicable ICD-10 diagnoses codes for Annual health appraisal visits, which are a (free) covered service. So my high cholesterol should be screened for free.

On the other hand there’s a whole section on Page 28 of the document discussing pre-diabetes education but it doesn’t explicitly say that an A1C test is covered under the annual wellness visit. And if you go way down, to page 116, there’s a table that suggests that last year a Blue Shield review removed several of the diabetes codes, including R73.03.

Now I am not going to pretend that I understand what the hell is going on in this document, and why (or whether) Blue Shield is able to change what CMS says it should do–if that is what in fact is happening. But it does seem weird.

And again, because there are no actual costs per test from Labcorp (there are charges per test but they are bundled and discounted on the bill), it’s impossible to tell what the contracted cost for each test was, and therefore whether I got some for free (as I think I should have) and what I was actually charged for.

Finally, I got very excited as Blue Shield sent me a message tonight which had an attachment which I think is a response to the grievance that was somehow filed for me by someone from their executive offices in part 2. But the attachment wasn’t properly formatted. So I don’t know what it says!

No less than I’d expect on this adventure.

But hopefully we are close to finding out who is charging whom for what and why!

UPDATE. I called Blue Shield’s grievance line and a nice customer service rep read me the letter that I couldn’t see online. Essentially Blue Shield has asked Brown and Toland to explain what happened. That grievance will take another 30 days! The rep wasn’t able to send it to me in my portal, but she could send me an email (It will be one of those secured ones that are super annoying to open). She told me it was sent while she was on the phone but 30 mins later, it’s not here!

Matthew Holt is the founder and publisher of THCB

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