Collection agencies held $140 billion in unpaid medical debt in 2020, according to a study published July 20 in JAMA.
Researchers examined a nationally representative panel of consumer credit reports between January 2009 and June 2020. Below are four other notable findings from their report.
An estimated 17.8 percent of Americans owed medical debt in June 2020. The average amount owed was $429.
Over the time period studied, the amount of medical debt became progressively more concentrated in states that don’t participate in the Affordable Care Act’s Medicaid expansion program.
Between 2013 and 2020, states that expanded Medicaid in 2014 experienced a decline in the average flow of medical debt that was 34 percentage points greater than the average medical debt flow in states that didn’t expand Medicaid.
In the states that expanded Medicaid, the gap in the average medical debt flow between the lowest and highest ZIP code income levels decreased by $145, while the gap increased by $218 in states that did not expand Medicaid.
Health Partners, one of the largest home healthcare providers in Michigan, laid off 560 employees at the beginning of July, including nurses, nursing assistants, therapists and direct care workers, according to Crain’s Detroit Business.
The layoffs occurred July 1 and happened as the Bingham Farms-based company is winding down business. The job losses are attributed to a 2019 state law capping Health Partners’ payment rates at 55 percent of what it bills insurance companies to care for injured motorists, said Chad Livengood, a senior editor at Crain’s Detroit Business.
Health Partners owner John G. Prosser II, who has been in the home health business for decades, said the company couldn’t absorb the losses from the new fee schedule, which cuts payments by 45 percent, according to Crain’s.
Other home healthcare companies in Michigan haven’t met the same fate as Health Partners because they rely more heavily on Medicaid, workers’ compensation insurance or private payers, according to the report.
Here are 18 health systems with strong operational metrics and solid financial positions, according to reports from Fitch Ratings, Moody’s Investors Service and S&P Global Ratings.
1. Altamonte Springs, Fla.-based AdventHealth has an “Aa2” rating and stable outlook with Moody’s and an “AA” rating and a stable outlook with Fitch. The system has strong profitability, solid liquidity and presence in several high growth markets, Fitch said.
2. St. Louis-based BJC HealthCare has an “AA” rating and stable outlook with S&P and an “Aa2” rating and stable outlook with Moody’s. The health system has a leading market share and a highly regarded reputation, particularly for its flagship hospitals that are affiliated with Washington University School of Medicine in St. Louis, S&P said. The health system has consistently produced stable earnings and cash flow, even during the COVID-19 pandemic, according to the credit rating agency.
3. Dallas-based Children’s Health System of Texas has an “AA” rating and stable outlook with Fitch. The system has robust operating profitability, good expense management and strong EBITDA margins, according to Fitch.
4. Cleveland Clinic has an “Aa2” rating and stable outlook with Moody’s. The system’s international brand will allow it to grow revenue outside of the northeast Ohio market and offset the effects of the pandemic on patient volume, Moody’s said. The credit rating agency expects the system to maintain good cash flow margins.
5. Evansville, Ind.-based Deaconess Health System has an “AA” rating and stable outlook with Fitch. The health system has strong operating performance and an expanding footprint in a stable and economically diverse service area, Fitch said. Investments in core service lines should help support patient volume growth, according to the credit rating agency.
6. Durham, N.C.-based Duke Health has an “AA” rating and stable outlook with Fitch. The system has a strong clinical reputation and a solid balance sheet with substantial liquidity reserves, Fitch said.
7. Pinehurst, N.C.-based FirstHealth of the Carolinas has an “AA” rating and stable outlook with Fitch. The health system has a strong financial profile and stable operating performance, despite disruption from the COVID-19 pandemic, Fitch said. The health system’s revenue in the first quarter of fiscal 2021 rebounded to levels close to historical trends, according to the credit rating agency.
8. Milwaukee-based Froedtert Health has an “AA” rating and stable outlook with Fitch. The system has a solid market position and a robust liquidity position, Fitch said. The credit rating agency expects Froedtert to maintain robust operating cash flow levels.
9. Indianapolis-based Indiana University Health has an “Aa2” rating and stable outlook with Moody’s and an “AA” rating and positive outlook with Fitch. Cost controls and patient volume will help the system sustain strong margins and liquidity, Moody’s said.
10. IHC Health Services, the borrowing group of Salt Lake City-based Intermountain Healthcare, has an “Aa1” rating and stable outlook with Moody’s. Intermountain has a leading statewide market position, low debt levels and strong cash levels, Moody’s said. The credit rating agency expects Intermountain will sustain strong margins and cash levels.
11. Falls Church, Va.-based Inova Health System has an “Aa2” rating and stable outlook with Moody’s. The system has a strong financial profile, and Moody’s expects Inova’s balance sheet to remain exceptionally strong.
12. Rochester, Minn.-based Mayo Clinic has an “Aa2” rating and stable outlook with Moody’s. The health system has strong balance sheet measures, an excellent market position and strong patient demand at its three academic campuses in Minnesota, Arizona and Florida, Moody’s said. The credit rating agency expects strong patient demand and steps taken by management to allow Mayo to maintain adequate cash flow and strengthen balance sheet measures.
13. Traverse City, Mich.-based Munson Healthcare has an “AA” rating and stable outlook with Fitch. The system has strong leverage and liquidity, Fitch said. The credit rating agency expects Munson to maintain solid operating cash flow margins.
14. Tupelo-based North Mississippi Health Services has an “AA” rating and stable outlook with Fitch. The system has a leading market share in a large 20-county service area and strong adjusted leverage metrics, Fitch said.
15. Chicago-based Northwestern Memorial HealthCare has an “Aa2” rating and stable outlook with Moody’s and an “AA+” rating and stable outlook with S&P. The health system had strong pre-COVID margins and liquidity, Moody’s said. The credit rating agency expects the system to maintain strong operating cash flow margins.
16. Columbus-based OhioHealth has an “Aa2” rating and stable outlook with Moody’s and an “AA+” rating and stable outlook with S&P. The system has a leading market position and opportunities for service line expansion, Moody’s said. The credit rating agency expects the system’s strong liquidity to provide ample cushion for volatility in investment returns.
17. Stanford (Calif.) Health Care has an “AA” rating and stable outlook with Fitch. The system has broad reach and is a clinical destination for high acuity services, Fitch said. The credit rating agency expects the system to sustain strong EBITDA margins.
18. Iowa City-based University of Iowa Hospitals & Clinics has an “Aa2” rating and stable outlook with Moody’s. The credit rating agency expects the system to maintain strong operating performance and cash flow. The system benefits as the only academic medical center in Iowa, according to Moody’s.
With every passing day, the United States appears more likely to be on the cusp of a dreaded fourth wave of COVID-19 infections, even as the percentage of fully vaccinated Americans inches toward 50%. In the past two weeks, the number of average new daily cases has more than doubled, from 13,200 on July 4 to more than 32,300 on July 18, a surge that harbors grim reminders of the fronts of the second and third waves in the summer and fall of 2020.
But on closer inspection, this surge looks significantly different than those we have seen in the past—and may very well be worse than it looks on the page.
The coronavirus pandemic has never, even in its worst heights last winter, struck the U.S. uniformly. Instead, it has wandered from eruptions in specific urban areas to suburban and rural counties and then back again, like a persistent hurricane. Now, as the gap between states’ completed vaccination rates widens—Alabama has vaccinated just 33.7% of residents, compared to nearly 70% in Vermont—the per capita rate of new cases has clustered in a handful of regions where a majority of adults remain unvaccinated even as reopening continues apace.
To draw on my amateur oceanography, the current crest resembles less a wave than a rip tide, with surges of current inundating several hotspots while the remainder of the country remains blissfully unaware (or unwilling to admit) that the pandemic is not remotely over. The upshot is that local data, rather than state- or nationwide-level figures, now paint the most accurate picture of the current state of the outbreak.
“State-wide cases don’t tell the entire story. We need a finer-toothed comb,” says Jennifer Nuzzo, the lead epidemiologist for the Johns Hopkins University Testing Insights Initiative.
As Nuzzo notes, the most recent documented outbreaks are more concentrated in rural areas than those of the worst spikes over the past 16 months (though the virus didn’t spare any corner of the country). What appears to be different now, even within more rural regions, is a blossoming of outbreaks that are at the moment highly clustered, particularly along the border between Arkansas and Missouri as well as northeast Florida and southeast Georgia.
But any such observation comes with the same caveat that we on the Numbers Beat have been striving to communicate since the beginning: The number of cases is contingent on the number of people being tested for the virus, a figure that can only underestimate the true picture, not exaggerate it.
Let’s recall: A year ago, COVID-19 skeptics, including then-Vice President Mike Pence, were attributing a spike in cases at the time to an increase in testing, a claim that was easily debunked. Now we face the opposite question: As the number of weekly tests has plummeted, taking a back seat to vaccination, and with the sense of urgency abating (for now), is the situation in fact worse than it appears?
“I don’t worry that we are missing the severe cases,” including when a patient is hospitalized, Nuzzo says. “It’s everybody else I worry about. We have turned our telescope to a different part of the sky.”
Murray Côté, an associate professor of health policy and management at Texas A&M University, agrees. “I still think we’re missing a chunk” of positive cases, he says. “It’s a confluence of things. We don’t have the testing facilities we used to have [earlier in the pandemic].” That chunk, both Côté and Nuzzo say, is likely made up of people who are experiencing mild or no symptoms, but can still be part of a transmission chain.
I last spoke with Côté in June 2020 when unwinding Pence’s claim that the summer surge was a product of more testing. Our conversation this time felt both reversed, as we were discussing a possible under-calculation of reality, as well as strangely familiar, because a year ago, we were seeing a new surge amid a widespread relaxation of safety measures—not unlike the freedom from safety measures like maskless dining we currently enjoy.
“We’re behaving exactly the same way as we did last year,” Côté says. To refresh your memory: Around this time in 2020, the U.S. had a brief moment where cases began to drop. Some Americans started to ease their social distancing and mask wearing, and it led to both a summer surge and, after another lull, the massive winter spike that turned out to be the worst stretch of the global outbreak to hit any country in the world. What’s different now is that this time we have highly effective vaccines—but, while inoculation can protect individuals, vaccination rates in many communities across the U.S. remain too low to prevent fresh outbreaks.
In the heady days of spring, 2021, many states began reducing the frequency of their reports on new cases to every few days or once a week. That was a foolish mistake when, even with a massive reduction in testing, the seven-day rolling average of new cases never dipped below 10,000 at the national level. Given that the best-case scenario—even before the emergence of the Delta variant—was a reduction of cases and deaths to endemic levels for years to come, states must pair their desperate attempts to vaccinate more individuals with a renewed focus on surveillance and contact tracing.
For now, the best way to prevent the current spikes from becoming a proper fourth wave is vaccination (which, even if cases continue to rise, can help prevent hospitalizations and deaths), increased surveillance, and a return to mitigation measures. Indeed, Los Angeles County on Sunday reinstituted mandatory mask-wearing in businesses and public areas, a major rollback after the U.S. Centers for Disease Control and Prevention said on May 13 that fully vaccinated individuals could shed their masks in many scenarios. Unless states can rapidly revive widespread and easily available testing, L.A. will be far from the last county to ask residents to mask up once again.
While CFOs, on the whole, remain optimistic about an economic rebound this year, they’re concerned about labor availability and accompanying cost pressures,according to a quarterly survey by Duke University’s Fuqua School of Business and the Federal Reserve Banks of Richmond and Atlanta.
Over 75% of CFOs included in the survey said their companies faced challenges in finding workers. More than half of that group also said worker shortage reduced their revenue—especially for small businesses. The survey panel includes 969 CFOs across the U.S.
“CFOs expect revenue and employment to rise notably through the rest of 2021,” Sonya Ravindranath Waddell, VP and economist at the Federal Reserve Bank of Richmond said. “[But] over a third of firms anticipated worker shortages to reduce revenue potential in the year.”
Dive Insight:
As many companies struggle to find employees and meet renewed product demand, it’s unsurprising CFOs anticipate both cost and price increases, Waddell said.
About four out of five CFO respondents reported larger-than-normal cost increases at their firms, which they expect will last for several more months. They anticipate the bulk of these cost increases will be passed along to the consumer, translating into higher-priced services.
Despite labor concerns, CFOs are reporting higher optimism than last quarter, ranking their optimism at 74.9 on a scale of zero to 100, a 1.7 jump. They rated their optimism towards the overall U.S. economy at an average of 69 out of 100, a 1.3 increase over last quarter.
For many CFOs, revenue has dipped below 2019 levels due to worker shortage, and in some cases, material shortages, Waddell told Fortune last week. Even so, spending is on the rise, which respondents chalked up to a reopening economy.
“Our calculations indicate that, if we extrapolate from the CFO survey results, the labor shortage has reduced revenues across the country by 2.1%,” Waddell added. “In 2019, we didn’t face [the] conundrum of nine million vacancies combined with nine million unemployed workers.”
Consumer prices have jumped 5.4% over the past year, a U.S. Department of Labor report from last week found; a Fortune report found that to be the largest 12-month inflation spike since the Great Recession in 2008.
To reduce the need for labor amid the shortage, many companies will be “surviving with just some compressed margins for a while, or turning to automation,” Waddell said.
The delta variant of the coronavirus is sweeping through the United States, raising the average number of cases to 30,000-per-day, crowding hospitals in areas with large number of unvaccinated people and spurring questions about the nation’s recovery from the pandemic.
Stocks tanked on Monday, with the Dow Jones Industrial average dropping 725 points after being down more than 900 points at one time.
It was the worst one-day performance in the Dow since last October, and followed losses in markets around the world as investor fears about how the delta virus might slow both the health and economic recovery took hold.
Health officials have described the latest stage of the coronavirus as a pandemic of the unvaccinated while emphasizing that those who have had their shots are relatively safe.
Yet Los Angeles County on Saturday reinstated a mask mandate for indoor public settings, a sign that local communities may decide to reimpose restrictions as a safety measure.
An Olympic gymnast and an Olympic women’s basketball player both announced they had tested positive as they prepared for the Games, which is being held in a state of emergency in Tokyo where the rate of vaccinations is behind the United States.
Canada had also been well behind the U.S. in its vaccination rate but surpassed its southern neighbor on Monday, a sign of how much more slowly the vaccination rate now is in the United States. A big reason is that many people who are unvaccinated do not want to get the vaccine, something the Biden administration has increasingly blamed on social media and some conservative media outlets.
While the 30,000 cases per day on average is more than double the 13,000 average at the end of June, that rate is still well below highs from last fall and earlier this year.
Still, deaths are also ticking back up, at around 240 per day.
Because vaccinated people are still overwhelmingly protected, especially from severe outcomes, case and death numbers are likely to stay well below the worst of last winter’s surges, before vaccines were widely available.
But unvaccinated people are at increasing risk, especially given the rise of the highly transmissible delta variant, and the vaccination campaign is hitting a wall, leaving more than 30 percent of adults without any shots and exposed to the full dangers of the virus.
States with lower vaccination rates are seeing the worst outbreaks. Arkansas, Missouri, Florida and Louisiana are the four states with the highest per capita new cases per day, according to data from the Covid Act Now tracking site. The percentage of the population with at least one shot in those states is 44 percent, 47 percent, 56 percent, and 40 percent, respectively.
In contrast, Vermont and Massachusetts, where the vaccination rate is over 70 percent, are faring much better.
Vaccine resistance among some leading conservative commentators and lawmakers is raising fears that many of the remaining unvaccinated may never get the shots.
Sten Vermund, a professor at the Yale School of Public Health, said he is “not particularly worried” about COVID-19 for himself, because he is fully vaccinated.
“What worries me is my fellow Americans who for a variety of reasons choose not to get vaccinated; they continue to be in harm’s way,” Vermund said.
In the rare instances where vaccinated people do get COVID-19 cases, symptoms are likely to be much milder.
CDC Director Rochelle Walensky said Friday that 97 percent of people entering the hospital with COVID-19 are unvaccinated, part of why she said it “is becoming a pandemic of the unvaccinated.”
Conservative resistance to vaccination is stiffening. A Washington Post-ABC News poll released earlier this month found that 47 percent of Republicans said they were unlikely to get vaccinated, compared to just six percent of Democrats. Among Republicans, 38 percent said they definitely would not get the shots.
Former President Trump has previously encouraged people to get vaccinated, though he has not made a forceful push, for example by recording a public service announcement or getting his own shots in public.
On Sunday, though, Trump appeared to justify people not taking the vaccine, blaming President Biden.
“He’s way behind schedule, and people are refusing to take the Vaccine because they don’t trust his Administration, they don’t trust the Election results, and they certainly don’t trust the Fake News, which is refusing to tell the Truth,” Trump said in a statement.
Asked if Biden would request Trump film a public service announcement on vaccination, White House press secretary Jen Psaki said “we don’t believe that requires an embroidered invitation to be a part of.”
“Certainly any role of anyone who has a platform where they can provide information to the public that the vaccine is safe, it is effective, we don’t see this as a political issue,” Psaki said. “We’d certainly welcome that engagement.”
She also emphasized, though, that the administration is focusing on local doctors and community leaders to try to boost vaccination rates, not national officials.
The effort is hitting its limits, though. The pace of vaccinations has fallen to around 500,000 per day, down from over 3 million at the peak in April, according to Our World in Data.
“I’m not that hopeful that we’re going to get to people who have refused to be vaccinated,” said Preeti Malani, an infectious disease expert at the University of Michigan.
Experts increasingly say the best remaining hopes of reaching the remaining unvaccinated are school and employer mandates for their workers or students to get vaccinated.
France is experiencing a surge in vaccinations after President Emmanuel Macron announced this month that proof of vaccination, or a negative test, would be required for everyday activities like going to restaurants. The Biden administration has repeatedly ruled out a national vaccine passport in the U.S., though, and Republicans have rebelled against the idea.
Full approval of the vaccines from the Food and Drug Administration, as opposed to the current emergency authorization, could also help assuage some people’s fears, and some experts have called on the FDA to move faster on issuing a full approval.
The Biden administration has stepped up its calls for Facebook and other technology companies to do more to fight vaccine misinformation on their platforms.
Biden on Friday said social media companies are “killing people” with misinformation. On Monday, though, he dialed the criticism back down, instead pointing to 12 people responsible for much of the disinformation.
“Facebook isn’t killing people, these 12 people are out there giving misinformation,” Biden said.
“My hope is that Facebook, instead of taking it personally, that somehow I’m saying Facebook is killing people, that they would do something about the misinformation, the outrageous misinformation about the vaccine,” Biden added. “That’s what I meant.”
For its part, Facebook said over the weekend, before Biden’s walk-back, that the administration was “finger pointing” and the company was not the reason the president’s goal of getting 70 percent of adults at least one shot by July 4 was missed.
Los Angeles County’s move to return to an an indoor mask mandate, even for vaccinated people,
got mixed reviews from experts, but either way, it is unlikely to be replicated in places that are the hardest hit, given that places that are resistant to vaccines tend to also be resistant to masks.
“Vaccines are really the only way out,” Malani said. “We can’t live in masks forever.”
Trinity Health is the latest—and now the largest—U.S. provider organization to roll out a COVID-19 vaccination requirement for all of its employees.
Announced Thursday and effective immediately, the nonprofit, Catholic healthcare system said the policy will extend across its entire workforce of more than 117,000 employees, including clinical staff, remote employees, contractors and “those conducting business in its healthcare facilities.”
Trinity said it will approve exemptions for religious or health reasons that are formally requested and documented. Others who don’t meet the criteria for exemption and fail to provide proof of vaccination “will face termination of employment,” according to the announcement.
Trinity said an estimated 75% of its employees have already received at least one dose of a COVID-19 vaccine, and it hopes the new policy will bring that number closer to 100%.
“Safety is one of our core values. We feel it is important that we take every step available to us to stop the spread and protect those around us—especially the most vulnerable in our communities who cannot be vaccinated including young children and the more than 10 million people who are immunocompromised,” Trinity Health President and CEO Mike Slubowski said in a statement.
“Over the last year, Trinity Health has counted our own colleagues and patients in the too-high coronavirus death toll. Now that we have a proven way to prevent COVID-19 deaths, we are not hesitating to do our part,” he said.
Livonia, Michigan-based Trinity operates 91 hospitals and 113 continuing care locations serving more than 30 million people across 22 states. The system reports $19.4 billion in annual operating revenues and is on track to top that number having recently reported $15.1 billion in operating revenues for the nine-month period between July 2020 and March 2021.
Trinity said that most of its locations will be requiring employees to submit their proof of vaccination by Sept. 21. Should it be determined that COVID-19 vaccine boosters will be necessary down the line, the hospital said that it would similarly require employees to submit proof of their receipt “as needed.”
“The science has shown us that the COVID-19 vaccine is the single most effective tool in slowing, and even stopping, the spread of the virus,” Dan Roth, M.D., Trinity Health executive vice president and chief clinical officer, said in a statement. “As a Catholic Health Ministry—even if we work remotely or do not regularly encounter patients—we view ourselves as caregivers, and it’s important that we do everything we can to end the pandemic and save lives.”
But perhaps the best known of the bunch has been Houston Methodist, which drew a line in the sand on June 8 and has since cut loose 153 employees who did not comply with the vaccine mandate.
That policy led to protests from the dissenting employees as well as a lawsuit that argued the system was “forcing its employees to be human ‘guinea pigs’ as a condition for continued employment.” The case was dismissed by a U.S. district judge and quickly appealed by the employees.
Other organizations such as Mass General Brigham have signaled support for a mandatory COVID-19 vaccination policy but said that they would not enforce the requirement until a COVID-19 vaccine receives formal approval from the FDA.
Earlier this year, the U.S. Equal Employment Opportunity Commission paved the way for employer-mandated COVID-19 vaccine policies with guidance permitting the requirements “so long as employers comply with the reasonable accommodation provisions of the [Americans with Disabilities Act] and Title VII of the Civil Rights Act of 1964 and other [Equal Employment Opportunity] considerations.”
COVID-19 cases are up by nearly 70% over the past seven days due to huge spikes of cases in low vaccinated areas, Biden administration officials said Friday.
“This is becoming a pandemicof the unvaccinated,” said Rochelle Walensky, M.D., director of the Centers for Disease Control and Prevention, during a briefing Friday. “We are seeing outbreaks of cases in parts of the country that have low vaccination coverage because unvaccinated people are at risk. Communities that are fully vaccinated are generally faring well.”
The seven-day average of cases was 26,300 per day, an increase of nearly 70% from the last seven-day average, Walensky said.
Hospitalizations are also up to 2,790 per day, an increase of 36% from the previous seven-day period.
Deaths, a metric that has declined since prior surges earlier in the year, have also started to increase. The seven-day average increased by 26% to 211 per day, Walensky said.
“Our biggest concern is we are going to see preventable cases, hospitalizations and, sadly, deaths among the unvaccinated,” she said.
A major driver of the increases has been the highly transmissible Delta variant of COVID-19, but Walensky said that 97% of the patients hospitalized right now with the virus are unvaccinated.
The Biden administration is ramping up efforts to increase vaccinations in areas that have stubbornly low rates. The administration is sending more than 100 people to states to help enhance vaccine access and boost outreach efforts, said Jeff Zients, the White House coronavirus response coordinator, during the briefing.
States with the highest cases are starting to see their vaccination rates go up, Zients said.
“In the past week, the five states with the highest case rates had a higher rate of people getting newly vaccinated compared to the national average,” he added.
He added that so far the CDC and the Food and Drug Administration have not recommended a booster shot for the fully vaccinated.
Infectious disease expert Anthony Fauci, MD, said Friday that the federal government is looking into evidence accumulated on a daily basis on the need for a booster.
“At this particular time right now, we don’t recommend that there be boosters for people,” Fauci said.
HENRY KOTULA 