Health care affects us all, but understanding the cost of care and how to access it can be challenging.

From insurance coverage and medical bills to preventative care and provider networks, today's health care system is complex and constantly evolving.

Tonight on this community conversation the cost of staying healthy.

We'll explore what's driving health care costs, how access to care is changing, and what it all means for patients and families in our community.

Here's your host, Brittany Sweeney.

Good evening and welcome to this community conversation.

The Cost of Staying Healthy, brought to you by Lehigh Valley Public Media.

Thank you all for joining us.

Nearly everyone has experienced it.

Higher insurance premiums, rising prescription costs, bigger deductibles and medical bills that seem impossible to understand sometimes while inflation has cooled in many areas.

Surveys show health care costs continue to rise, leaving families wondering how their will afford their care that they need.

Tonight, we're asking an important question why does staying healthy cost so much and what can we do about it?

We'll discuss everything from health insurance and employer sponsored coverage to preventive care, reproductive health, and community programs that can improve health while reducing costs.

Affordable Care Act policy premiums have spiked across Pennsylvania this year, and residents in the greater Lehigh Valley are getting the brunt of it.

Lehigh Valley Public Media Politics reporter Tom Shortall breaks down what that means for those living here.

On average, ACA policy premiums for Lehigh County residents jumped $330 a month.

That's more than triple the local average from last year, according to Penny, Pennsylvania's health insurance marketplace.

Meanwhile, Northampton County residents saw their policy premiums cost an extra $317 a month, a jump of 163%, according to Penny.

Those are some of the steepest increases in Pennsylvania.

The hike came after Congress allowed ACA tax credits to expire entering 2026.

Lehigh Valley Congressman Ryan McKenzie, a Republican, joined Democratic efforts to pass an extension in the US House, but the measure never advanced in the Senate.

The result?

Penny enrollment fell by more than 10,000 people.

It's the first time the program has shrunk in its history.

More Pennsylvanians also opted for cheaper, riskier plans.

Those customers will pay less upfront for the privilege of health insurance, will be exposed to greater expenses if they face medical emergencies.

Thank you Tom.

Most people know health care is expensive, but fewer understand why insurance premiums continue to increase.

Employers struggle to provide affordable benefits, and consumers are left trying to make sense of deductibles, co-pays and out-of-pocket costs.

Let's begin by looking at the bigger picture.

Joining us now are Amanda Marie green, the vice president of programs and initiatives for Lehigh Valley Business Coalition on Health Care, BSI Corporate Benefits CEO Tony Ray, and the executive director for Penny, the state's health insurance marketplace, Devin Trolley.

Thank you all so much for joining us.

It's great to have you.

Devin, we'll start with you.

We just heard some of the changes and the impacts of those changes from the ACA changes.

And so what are you seeing firsthand at Penny?

Yeah.

What we're seeing is a lot of what you are seeing here, right here in Lehigh in the numbers that were in the video are even higher.

They drop every day where more and more people are dropping coverage.

And what we've seen, especially even in just Lehigh and Northampton counties, is that half the people who had coverage in 2025 no longer do.

And we are seeing those same stories play out across Pennsylvania.

And so we are really monitoring the cost, the impacts and trying to help people through these changes.

But as it was mentioned, a lot of them are due to federal changes that we are not able to impact.

And for those who don't know how Penny can help people across Pennsylvania, how does that work?

Well, Penny is the official health insurance marketplace, and what that means is it's for anyone who doesn't get coverage elsewhere.

So if you don't have coverage through your job or from Medicare or Medicaid, it's a great place to go.

Many enrollees over 430,000 across Pennsylvania are farmers, gig workers, independent business owners.

And the two benefits about Penny is that it's the only place to get premium tax credits that instantly lower the cost of coverage.

And it's also a place where you know you are getting high quality plans.

Every health plan available through Penny, which are available for many different insurance companies, have comprehensive benefits, cover things like preexisting conditions and much more.

So it's really a place to go for high quality and affordable coverage if you don't get it from anywhere else.

Amanda, I want to bring you into this conversation.

How does your side of things, the Lehigh Valley Business Coalition on health care, what are you watching from day to day when it comes to health care and premiums?

Sure.

So we're representing groups of purchasers who pool their purchasing power to be able to purchase things like medical insurance at a cheaper rate than they could get on their own.

Really important as health care is changing, it's getting bigger.

Hospitals are consolidating.

Everyone else has more and more scale, so it's important for the employers to have similar.

We see a lot of trends.

I mean, just in general, prices have been going up related to premiums related to health care costs.

They've been going up.

They continue to go up.

Kaiser Family Foundation estimated the average was about 5 to 6% last year, but that's just the average.

Some groups are seeing much more than that.

We commonly think of health care costs, and we think of the medical side, and we see something staying the same.

So still a lot of musculoskeletal.

So things like orthopedic surgeries remain a large driver of cost.

There's also increasing costs related to oncology and mental health.

We can debate whether that's a good or a bad thing.

It's good that more people are seeking access to coverage for mental health than what we're finding is that it is more on the outpatient side, so it's not the critical thing.

So hopefully it's more that we've addressed the stigma and that people are accessing it.

But those are increased costs.

But more importantly, and where we're seeing more of a shift is on the pharmacy side.

The pharmacy side is very complicated.

Worked in health care for 15, 20 years and I'm still just learning the pharmacy language.

It has its own lingo, but the employer side really a lot of it relies on things like rebates.

And we've seen legislation that's changing the way that that works.

And it doesn't mean much to the average person, to you or me, but it is really changing how things are being priced.

So everything on the medical side is rolling down to that shift in what's happening on the pharmacy side.

Amanda, I think that really says something about the medical and the health care field and navigating insurance and medical bills.

When you say you've been working within this field and you're still just grasping it, then the average person is coming and trying to navigate.

Tony, I want to bring you into this as a provider of corporate benefits, BSI.

And so is it getting harder for businesses to offer quality health care and insurance at this point?

Well, I think for a long time that what we've tried to be able to say to business leaders is it has long since shifted from an HR benefits and HR problem to a C-suite challenge.

It's it's absolutely one of the top three expenses for most organizations.

But the surprise is that most of the C-suite leaders and most companies typically are not in the room.

And 95% of our business across the country is self-funded.

So the misconception may be that the carrier, the Capital Blue Cross, the Highmark Blue Shield is the insurance carrier.

They're really not for the majority of employees that work for the majority of companies.

Their employer is actually the insurance company.

So the idea of making sure that those companies understand that they're the ones paying the bill, so be in the room.

And that's a really important concept that companies need to understand in this change in health care with respect to premiums and cites the Kaiser Foundation and people talk about 5 to 6%, I guarantee and the penny and the individual world or in the business world, any company, if I gave them an opportunity to take 5% and lock it in for the next five years in their health care, they would push the button right away.

So that's a reality of the entire country.

When you bring in organizations like Boeing, right?

That's not the reality of the Lehigh Valley.

The individuals on the ground, 5% is not a reality on what health care what is happening with health care right now.

Sure.

That's from the the business level.

Let's go down to the employee level.

What are some of the common misconceptions that employees have about their health benefits?

I think there's a tremendous amount of misconception because it's about education.

So if you understand how it whispered down the alley, when people play that telephone game, in order for an employer to procure health care from an insurance company, and then it goes through HR and then it goes through a meeting, the average person takes 28 days to decide to buy a car.

Open enrollment meetings typically take 15 minutes, and they're usually in the popcorn room in the basement, right.

The reality is education.

So the employees don't get access to the education to be able to make the decisions as consumers that they need to make in a huge expense for them and their families.

So education is the most important thing.

And there are a ton of misconceptions because of that.

Sure.

So education is key here.

Know what your health plan is offering is what I'm hearing from you, Devin, when it comes to plans like that Penny offers, what are some of the resources people can use to pick their plan if they are shopping on the state's health care network?

Yeah, we have a lot of resources.

We know that health insurance is often not people's favorite thing to shop for, so we spend a lot of time at Penny trying to think about how to make that process more simple.

And we have a lot of resources available for people who are trying to navigate it.

We have a call center.

We also have a lot of local help.

We partner with community organizations who get trained up on Penny, and how to get premium tax credits and how to shop for plans.

And also, many agents and brokers within the community are also trained on the On Pennies program and can help pick and decide between many different health insurance companies and plan options available through Penny.

So we have all of that available on our website where you can find resources right here in the Lehigh Valley area to help walk through that process, because we know it's it's not everyone's favorite thing.

Sure.

It's confusing.

It's hard to navigate.

I know I like to just push it off if I can because it's so hard to navigate.

Right.

But it's something we need to do.

Health care is something we need.

Tony, on the business side, what's the one thing that you make sure you tell every small business who's looking for a plan for their employees?

I think every single year in this health care environment, you have to be in the full market, you know, certainly understand the rate of business and organizations and the idea that companies have been in this long cycle of, hey, if we got a 3% increase in our health care and they hit the easy button, let's just let's go on and do what we do for a business.

But the reality is, because it's become such a key expense to organizations, you got to be in the room.

And it's an every year process, not a just set it and forget it until you get the 40% increase.

So I think making sure that it's a top priority on a year over year basis and holding every single stakeholder in the pipeline for health care, and there are a lot of human beings taking money from employers before it's delivered in health care, holding every single one of those stakeholders accountable along the way.

Sure.

So you have to be involved revisiting this every year.

Amanda, I wanted to talk to you about some of the increases that are happening.

What are we seeing where the areas that we're seeing these increases grow the fastest?

Yeah, we're seeing a lot.

So there's a bucket called High Cost Claims.

And those are your people that cost their health plan 50 to $100,000 a year at a minimum.

We're seeing increases in those.

So it's a very small number of people, usually less than 10%.

Some it's even 3%.

And they're driving more than 30% of the cost.

So it's a huge bucket of costs coming from a really small number of people that continues to grow in that.

A lot of that's on the medical side, but we're also seeing more and more impact from the pharmacy side again.

So, you know, in about 2019, I think the highest cost drug on the market was under $1 million for a dose.

Now we're at 4.25 million or exceeding that.

So drugs are just becoming more and more expensive.

That's a major driver of what's causing the medical premiums to go up, causing employers to have to pay more money.

We also have a whole bucket of drugs that maybe aren't our generic or our brand name ones, these specialty ones that are still thousands of dollars a dose, and they're being prescribed in more and more people for more and more prescriptions.

So probably everyone's familiar with GLP one drugs.

They started out for diabetes.

Now we've seen a major influx of use for weight management and obesity.

That's really been driving a lot of the increases that we're hearing from employers.

It's one of the top three things they're being told is driving their increases.

And now they're being approved for even more conditions.

So they're going to be looked into for things like liver disease.

There's studies for addiction.

There's just so many different places they can be used and it's just increasing costs.

Sure.

So we talk about picking a plan, right.

Whether that be on the business side or the individual side.

But then when it comes to deciphering our health care and how we're getting charged for our health care, is there one line item that people find most confusing?

Is there one section that people just or I know, I see you're like everything, but is there one that that people really kind of have a hard time comprehending the most?

Oh, I don't know if there's one thing that people have trouble comprehending the most.

It's just I think the impact is shifting.

What we think of as medical has just changed.

You know, I remember when I started in healthcare and the Da Vinci robot was just this big and it's $1 million investment, and now we're talking about drugs to treat one person or four times the cost.

Things just don't make sense.

And there's a lot of things that are counterintuitive.

So things that we thought would drive down costs aren't necessarily.

So it's not really one thing.

There's a whole lot of things that are confusing.

Sure.

Absolutely.

So navigating that is tough.

Tony, are there there are other things that have changed or what has changed in terms of employers and what they're willing to cut so that they can can control costs, you know, are they still offering everything that they once were, or are we starting to see these kind of curated plans to make them fit into what their costs need to be?

Well, I think that we like to say that every single organization, your same industry, same geography, they're all fingerprints.

Every company is unique with their culture.

So you have to decide as an organization, the companies that we represent.

Where do you want your employee benefit spend?

I mean, it's called play benefits for a reason.

So organizations that are that want to just cut everything.

Well, you reap what you sow, right?

So I think that that is a solution that is not you can't just double a deductible.

I mean, I'm not very good at math, but you can't double a deductible every year for five years and still win.

Right.

So there is a there is a real problem if that is a strategy for an organization.

So I think that every organization has to take into account where do they want to fit in with from an employee benefit perspective?

Because all of the organizations are living in the same environment and from a positive perspective, and there's not a lot of positive and in health care that way.

But we're all on the same field and all these organizations on the same field.

So we try to talk to organizations about you have competitors, and that means you could be a nonprofit, you could be a for profit.

But if you're going to be in the room, understand that line item and understand that winning at that line item doesn't necessarily mean nobody's going to walk in your office, not Washington or anybody else, and lower your health care by 30%.

It's just not going to happen.

So you have to take accountability for that and then make the decision on how are we going to navigate health care in our space, to be able to control that line item and deliver value to our employees better than the company down the street who could hire them away from us?

So I think it's a balance between those two things.

An organization that is just going to chop their benefits and raise the amount of money coming out of someone's paycheck.

The answer seems to the employees will speak with their with their movement.

Yeah.

Is the price and the cost of these plans, is that what's driving companies to choose one plan over the other or or what do they what are they looking at here?

What are some of the the best way to navigate this and make those informed decisions?

When we talk to employers, any type of change in strategy has to come with the other side of what is the effect on your employees, the individuals and their families who drive your company.

So if it is a ivory tower not to pick on CFOs and they're like, well, that looks great.

Plan to that's 30% less.

Let's go with that.

If you also don't realize what the impact is to your employees and the families, and you're not looking at that side of it, that is a recipe for disaster.

So there has to be a marriage between those two considerations before an organization is going to move forward with a bottom line type of decision.

Sure makes sense.

And Devin, when people are shopping around for their health care and what fits their needs, is it cost that's necessarily driving them?

Or what's the best way for families and individuals who need health care to kind of navigate what's right for them?

Yeah.

What we hear time and time again is it's cost.

It's always cost.

And, you know, one thing that we also find though, is a lot of people don't have awareness of Penny and that there are premium tax credits available to lower the cost of coverage.

And so through Penny, a normal full price plan maybe cost 5 or $600.

But we have people paying $10 or $50 a month because what you pay is based on what you make.

But one of the issues is that only half the uninsured know that the premium tax credits are available to lower those costs.

Just in Lehigh and Northampton counties, there are 35,000 people who are uninsured who probably qualify for premium tax credits and could potentially find affordable, high quality health coverage through Penny.

So I think one thing that we always encourage people to do is on our website, there's a tool that you can use.

It's very quick.

It only takes a couple of minutes to see if you qualify and what types of plans you could be looking at.

I think that's a good resource.

I want to reiterate that people can go on, they can see, they may think, you know, they hear these changes, the ACA changes.

They think, you know what, I'm not qualified.

You're saying you can go on the Penny website and check out and just takes a couple of minutes, right.

That's right.

Yeah.

You know, it really does depend on the individual.

There are fewer tax credits available, but there are a lot of people who still do qualify for out of five people still qualify for tax credits who are enrolled through Penny in, the best way to know is just to go in and check.

And so we really encourage people to do that because on average, people say 500, $500 a month with the premium tax credits.

Great.

That's a great resource.

Tony and Amanda, I want to talk a little bit about transparency.

Do you think we need more in the health care space, and would that change some of the habits that we're seeing right now.

Amanda I'll let you start on that one.

Yeah.

We absolutely need more transparency.

I don't think we can keep going with the transparency we have.

It hasn't really accomplished a lot.

There's been requirements for transparency from hospitals and health systems since the early 2020s.

So we've had five years to kind of see and we're not seeing a lot of improvements.

A lot of focus is on the cost.

And I think cost data is great, but it's great when you can use it with things like quality, safety outcomes to really have a better picture of what it is that you're paying for, what it is you're utilizing through the health care system.

You know, hospital A may be less expensive, but you don't want to go there if there infection rates are high, if they don't have good outcomes for their surgery, if their mortality rates are high, it's not the better value.

And that's really what we need to look for with transparency is more information on that.

And also we're talking a lot about insurance.

We're not really talking a lot about health care costs themselves.

And that is confusing to people.

And we don't have a lot of transparency into that because we're insurance based system.

People don't really know what they're paying for.

Specific services, specific doctors.

Absolutely.

And we're going to we're going to talk about that more as this is this conversation goes on.

Tony, what do you think about transparency?

Do you think there needs to be more?

Do you think that that the plans right now that are offered and the choices that are out there for health care are pretty transparent?

You just need to find the information.

It takes about three minutes for all of us to order an Uber, and we know exactly what it costs.

If if the industry wanted everybody to know what everything cost, we would know.

There are mountains of individuals and hands in the middle that don't want us to know what everything costs.

We don't live in the 1800s.

It's not it's not hard to figure out.

There are lots of organizations in the middle of health care between the provider and the individual, who actually gets the care, who have no interest in those individuals finding out how much health care costs.

So from an employer perspective, and what 95% employers across the country are self-funded, it's their data.

I think if that would be a message that anybody's listening as a company and boy, will everybody rage against the machine against them for that.

But the reality is the employers need to understand they are the payer and it is their data.

So if a hospital system or a provider or a PBM or a pharmacy says, well, we can't give you that, oh yes, they can and they have to.

And it's understanding the where they sit as employers as giving health insurance to their employees.

It's their data, which means they have a right to it.

So it's a common misconception that companies have that.

Well, I guess I can't have that information.

Oh yes, you can.

You know, it just it's just not going to come on the first ask.

Yeah.

That's a great point to make.

Where do you direct your clients to get more information to get, you know, where are the resources?

Where are we finding them?

Best place, you would say from a from a company perspective, from a best resource perspective, that data can flow now on a monthly basis.

Meaning there's there's wonderful, you know, AI tools in the world that could set up here comes the claims, de-identified without the individual's names.

But we have a really good ground level at this point of how much everything costs in our area between competing health systems.

We have all that information on an employee level, you need to be an advocate or you need to have an advocate for yourself, because any individual that's ever been through the health system, myself included, it doesn't just set you up to be easy.

You know, when you go in and you ask an additional follow up question because you don't understand an EOB, an explanation of benefits, right?

Right.

And it's hard for people to push back against people that are supposed to be there to take care of them.

When they tell them that they can't have access to their own information.

You're trusting them, right?

Amanda?

What's the best resource you would offer?

I would say the best resource.

I would just add on to what Tony saying the best thing to do is to then use the data.

So we're talking about all of this not having the data or not having enough data.

But then when we get it, we don't always have them making decisions based on the data.

The employers aren't always making changes, so we can tell them how A is better and it's cheaper and it'll be better for you in the long run.

And they might not want to risk recruitment and retention.

They might not want to risk alienating an employee who's always gone to the other health care system.

So if they're not willing to steer or tier based on that, it's not a very valuable resource, no matter where they're getting it from.

The same thing for the employees.

We have the whole system kind of based on developing these plans that are meant to promote consumerism, give you information and help you choose.

Some people just don't make informed choices even though they have the information.

Sure.

And we heard that Penny has some resources right on the Penny website.

Devon.

Tony, Amanda, thank you so much for this insightful information.

Really great resources that you're sharing with our folks about the health care industry.

Thank you.

Thank you.

All right.

Now we turn to a story about an eastern woman who hasn't had health insurance in three years.

She says when premiums soared, she was forced to drop her coverage entirely.

Our Megan Frank has that story.

Jackie Coughlin is a licensed professional counselor and the owner of Center Square Counseling in Easton.

Navigating the health care system is something she learned at an early age.

My journey to understand health care really started as young as 18 for me, because back in the early 90s, not to date myself, you know, they didn't offer health insurance past, I think it was 18 or 19.

I wound up being a teen mom and had to navigate how to get on Medicaid.

Through years of hard work, Coughlin worked her way up to running her own private practice, but her independence came with a heavy financial cost when health insurance rates priced her out of the market.

And I was originally able to get on a health care plan through Penny, and with that, my costs were not too high, was manageable.

I was doing okay with it.

It felt good.

Unfortunately, when the talk about the subsidies started, the companies raised all these rates to the point where it was just not sustainable for me to have this health coverage anymore, and I had to let it go.

My rate was I was about $359, I believe a month that I was paying the same plan right now as over $1,800.

It's it doesn't really make any sense to me how those numbers make sense, but it's not sustainable.

It would be like having a second rent payment or, you know, three cars.

It's really the decision between, you know, can I pay for my car payment?

Can I pay my rent?

Can I buy groceries?

Because of the cost of those also went up.

I'm fortunate that my health is is pretty good, but I do have some chronic back stuff, some some things that are going on for me.

I'm of that menopausal age, so I have some things going on there.

But really the scary thing is, I don't know.

It's been three years now without health coverage.

I had a recent hospital stay they called me from, I guess, the front office or something, and said they wanted to confirm that I had no health insurance and I said yes, that's correct.

Within 30 minutes, a doctor that I had not seen before came into my room.

The nurses started on hooking my IV, and they told me they didn't believe I needed inpatient treatment, that they were going to send me home on oral antibiotics for a it was a cellulitis infection in my eye.

It was pretty jarring the way it happened, and it's very hard for me to believe that there was no connection between the fact that I had no health insurance, and the fact that I did not need to stay for the 24 hours that doctors had told me I needed to, to keep her dream of owning a business alive, she's considering taking on a second job with benefits, and as a counselor, she stays committed to helping others in the same boat.

I believe we have a right to have health care.

It's not just for me, it's also for my clients.

I have people that I see pro bono that also lost their coverage, and I couldn't turn them away because I knew they needed the care.

This is about people taking care of each other, and I think that's what we need to do.

We thank her for sharing her story, and thank you to Megan for telling that story.

It really highlights such a difficult reality for so many small business owners.

Having to choose between keeping their doors open and getting basic health care needs.

One of the biggest ways to reduce health care costs is surprisingly simple.

Keep people healthy before they become sick.

Right.

But preventive care isn't always easy to access.

And so joining us now are Planned Parenthood's associate medical director Kathy Scully, the chief medical officer for Star Community Health, doctor Alicia Waltz, and the chief physician, executive and executive vice president of Jefferson Health, Doctor Edmond.

Thank you all so much for joining us.

So we just heard this patient who did not have health insurance.

She told this story about how she felt.

She kind of got rushed out of the hospital that she was at.

How often are we hearing stories like this or something similar?

How often are we seeing people come in choosing between keeping their business doors open and or getting health insurance?

What are we seeing firsthand?

Cassie, we'll start with you.

Sure.

I mean, I think Planned Parenthood is known for seeing patients that don't have insurance.

I think people are often actually surprised on the other side of things, of not realizing that we also do take insurance, Medicaid and commercial insurance.

So a majority of our patients are on that kind of sliding scale fee, which is we base that off of household income.

And so we are able to take patients without insurance.

Great.

Doctor Walter, you're shaking your head.

Star community health set up to help those uninsured and underinsured.

So are you hearing stories like this of people, even if they know they can come in, are they hesitant to come in because they still think they're going to have to pay?

Absolutely.

We noticed during Covid that there was a pretty big spike of patients that were coming in that had previously had either employer benefits or could afford ACA type plans, and then found themselves without that job or on unemployment temporarily.

And really, they didn't even know what resources were available.

Unfortunately, you don't tend to know what is available to you, and till actually you're kind of thrown into the deep end.

We traditionally, as a federally qualified health center, have had a decent portion of patients that were uninsured.

Most of those patients were because they were ineligible for different coverage.

What we've noticed in the last few years is that we are seeing a lot more patients who are coming in that, in theory, would are eligible and would it be able to purchase insurance but just cannot anymore.

Unfortunately, they make just a little bit too much.

In the state of Pennsylvania, it's about 45,000 ish for a family of four.

If you make more than that, you're not going to be eligible for Medicaid.

That's not a high salary for a family of four.

It's certainly not sustainable or a salary in which a family could thrive in the Lehigh Valley.

So we're seeing a lot more people that are filling into that gap.

Yeah.

And Doctor Purbeck and I welcome you into this conversation a little bit different than the community health aspect.

What's the aspect from Jefferson Health?

Are you seeing people come in who may not have coverage but seeking services?

You know, this happens every single day.

But even more tragic are all the people that actually don't seek services because, you know, they're working two jobs, as this lady was, to just get by and they just can't find time to come in.

They are scared to come in because of these huge bills that can result.

You know, we're committed to bringing some of that health care to the community, just like PFCs do, just like Planned Parenthood.

We have tried to do events with church groups.

We have an inspired group that will come out to go to these areas to bring health care to the folks that are underinsured or uninsured, to say, hey, it's okay, come in.

Getting the preventive care you need is much more important than the embarrassment that you may feel.

It's much more important for your family to get the care.

Let us try to provide it.

Mobile screening bands for cancer.

Hypertension.

All of these things are things that we need to bring to people because quite honestly, they're scared to come in and that's really a tragedy.

We need to try to address that.

And doctor, and it's not just the folks who are uninsured, underinsured.

It sounds like there are people across the board, even if they have health insurance, that they're skipping some of that preventative care because of the cost.

What are some of the screenings you're seeing people skip?

What are the most common ones that they're skipping?

I mean, some of the ones that are hard to do, it's not easy to get a mammography.

It's not easy to get a colonoscopy.

These are ones that are skipped.

The hypertension is one that is frequently overlooked that we see.

These are chronic conditions that, you know, if you go for years without getting your blood pressure checked and your blood pressure is high, you will likely develop a stroke.

You know, and then that's a greater tragedy.

The diabetes.

Diabetes is a really a tremendous problem because the problems accumulate over time.

And then before you know it, you have diabetic foot ulcers.

You have issues with sensation in different parts of the body.

These are the things that people overlook because they're sort of quiet killers, so to speak.

And and we need to get that information out there.

Again, I think you need to go to where the people are.

You need to go to churches.

You need to go to barbershops.

You need to go to beauty salons.

You need to bring it to the community.

We're we're committed to doing that.

At Jefferson and Lehigh Valley, I mean, we we really think that that's where we need to democratize health care, so to speak, to bring it to the people that really need it.

Yeah.

Alicia, I see you shaking your head there.

What are some of the the the tests or preventive measures that people should be taking that you see them skipping right now that really that could be paying the price down the line.

It seems so simple, right?

Get the care you need before something happens.

But it's not that easy.

So the average family, if they are actually doing all of the preventative health measures that we recommend, and there are several different organizations that will say for women's health, make sure you're getting, for example, your cervical cancer screening or mammography.

And heart associations want you to be screened for hypertension, things like that.

You'll save 34% on your health care costs overall lifetime.

That's a really big chunk that's very easy to dictate to someone.

But if you are example, if you're working under the table, if you are trying to get a colonoscopy and we can't do the colonoscopy unless you have someone to drive you home that day, that's someone to watch your kids, that's taking a day off, that's asking someone for transportation.

There are barriers in place of that that most people wouldn't even necessarily think of.

I have been focusing a lot on medical care, but I think dental care is probably the number one item that's skipped.

Many people that have commercial or government insurance don't have access to dental care, so if you're going every six months, there's significant reduction in your overall cost is a lot cheaper to be able to go in for your dentist appointment in hygiene than it is later to have those extractions, oral surgery, dentures made.

None of those things are covered by the majority of those plans, and that those issues can lead to other issues within the body.

Correct.

Yeah.

So in addition to that, Planned Parenthood, you know, a lot of times we think of reproductive services at Planned Parenthood, but there's other there's other services there as well.

Cassie.

So I want to touch upon them, but I also want to talk about a big group.

That age group that you serve is the younger population, too.

And why is it so important that we make sure that that age group is starting that early?

Sure.

I think I mean, we've already touched on kind of like the cancer screening prevention, but when you're looking at sort of the services that plan Parenthood could offer, things like birth control and sexually transmitted infection screening, those can also be considered a preventive right.

We saw with the Medicaid defund that we went through last year, we're now able to accept Medicaid again, but we went through a full year where we were not able to.

We saw a 25% decrease in people accessing their birth control and birth control.

It prevents pregnancy, but it also helps manage things like heavy crampy periods, you know, different things like that.

It allows our patients to be able to continue the education that they want to work on, provide for the family that they have right now with sexually transmitted infections.

We saw like a 10% decrease in that as well.

You know, sexually transmitted infections are very curable when, you know, caught early.

But if left untreated, it can lead to complications.

Things like pelvic inflammatory disease lead to hospital stays, lead to infertility.

So being able to kind of intervene in that early easy way is a is a is very important for that population.

Absolutely.

And Doctor Waltz I know you see children as well.

Is it important for us to be setting that example as adults.

Do the kids see that, you know, and do they feel more comfortable, or are they more open to care when they've seen their parents go through it 100%?

So most studies that have been put out about something, for example, like weight loss, if you're isolating a child and you're saying this one can't eat this, can't eat this food shouldn't do this, this one needs to exercise more than the siblings.

It's going to fail.

It's not sustainable.

It's going to have long term traumatic effects on the child.

Every study that we've seen have shown that when the entire family undergoes these lifestyle lifestyle changes, with healthier diets or healthier exercise, there's more of an impact and it's sustained for a long time.

Most of the most impactful community organizations that we see really work on that prevention, and a lot of them do work on children.

It's obviously, to your point, a lot more cost effective to work on the prevention of chronic disease before it even occurs.

You want people to stay as healthy as they can for as long as possible.

Doctor bacon, we talk about cost, health care cost.

But then on the other side there's health care.

The value of that care.

Right.

And so how do we balance that?

How do we balance the cost of care with making sure that we're giving these folks the value of care that they need at the cost that they can afford?

Is that something you have to think about in way in the office?

I think you do.

You know, I'm still a practicing physician.

Many of us are, and that are executives across Jefferson.

It's important that we stay in contact and we understand the the real questions that the patients are asking.

They they need to know what is the best, most affordable route for them to receive the care that they they need.

We need to make sure that the quality of care that we deliver is paramount for them.

You know, the truth is that there are lots of different measures.

There are leapfrog measures for the hospitals.

Were continually striving to get our hospitals to leapfrog.

There are different measures that you can look up online that can tell you the quality of the care that you're going to receive in a given institution.

I think those are important.

It's important to be transparent about what you are able to accomplish and what you're not.

And you know, the more we talk about the quality that's delivered, the more we measure it, the better it's going to become.

And so we're very open to being measured.

We have to do that.

If we don't, then we're really failing the public.

So I think the most important thing with quality is to continue this view.

It's important to measure.

It's you have to know what you're delivering.

And then ultimately you have to do the cost benefit ratio and figure out what we can deliver for the money that we have.

And I want to stay with you and talk a little bit about a situation that played out with Lehigh Valley Health Network, part of Jefferson Health and UnitedHealthCare.

There was a dispute between the two that that affected a lot of the patients in the area.

Many of the patients then in where they could receive care.

And so is that going on?

Is that dispute resolved?

And what was kind of the outcome of that?

What are patients seeing now here in the Lehigh Valley?

So sadly, the dispute is not resolved.

We've been working for two years to get a fair agreement so that we can continue to provide care for an entire population, about 50,000 folks.

We know it's critical to us to be able to deliver care to that community.

However, the real challenge is that if you are providing care for an entire community and then all of a sudden an entire group in that community is no longer paying its fair share, is no longer coming to an agreement that allows you to continue giving service to everybody.

That puts everybody's care at risk, and not just that group.

And so you have this really challenging situation where a person has to decide, do I continue going to the people that I've trusted for so many years, but pay higher co-pays and higher deductibles, or do I switch to a completely new provider that doesn't know me as well?

This is a horrible situation to be in.

It's not a situation that we want to be in, but in a sense, we have to protect the resources that we need to provide care to the entire community.

And so you're going to see this from time to time.

I can tell you that we will continue to work with United Health Care to find an agreement that allows us to be paid fairly for the service we provide, because we do think that service is valuable and we want to give it to the entire community.

Sure, health care is deeply personal, right?

As someone who's seen the same doctor for the past 30 years and has driven out of state to see her, I connect with that completely.

People want to want to see the people they trust.

And when you put a barrier like that, are we seeing people kind of fall through the cracks and not go anywhere then and then they're not receiving the care.

That sounds like that could be the outcome.

Then they're not receiving the care.

Have either of you seen people coming through the doors because of situations similar?

Maybe their health insurance changed and they're not really sure where to go.

Their doctor retired.

Do you see this from time to time?

We definitely see a fair number of those patients.

I think what we tend to see more is that to your point, they're not coming in at all.

They know that they can't afford the co-pay.

They're trying to avoid paying anything, or they've lost insurance and they don't know how to navigate not having any insurance at all, or charity care programs, or coming to an FCS or Planned Parenthood where there are sliding scale fees.

It seems counterintuitive, but to back to your point about preventive care.

So community health centers, we see everybody.

We see whether you have insurance or not.

It seems like that would be really unsustainable.

And it seems like how could you possibly have these good outcomes and sustain it, because we focus so much on preventive care and we're able to really encourage and support people.

It's estimated that in the last several years, community health centers in Pennsylvania have saved about $1.5 billion in health care.

So it shows you kind of that value.

The other issue is that trust.

So we are addressing those social drivers of health.

We're checking to make sure you have transportation and providing it.

If you don't we're making sure you can afford not only just food but the medication.

I can prescribe you any medication I want.

If you're choosing between getting rent, paying rent, paying groceries or getting the medication, no one's picking the medication.

So until a lot of those really grassroots items are addressed, people's health care will always come secondary.

They value it, but they're not able to make it their priority.

Sure.

In the same breath, once we're addressing those different areas, if you address those areas, could you lower the cost of health care overall in the area once you get to those disparities?

Absolutely.

And that's been proven time and time again.

All of our health networks that have had any kind of ACA involvement have been required to do something called the Community Health Needs Assessment.

Every few years.

That breaks down zip code by zip code, almost street by street level with the needs of those areas are in terms of housing, are there is there free places to play for children that are outdoors that are safe?

Is there anywhere to get the free food or healthy food things that we don't necessarily associate with health care, rent costs, things like that.

Once we can actually address those items, most of the time the health care is going to follow because you're able to focus more on your actual primary health care needs.

Patients that have a safe place to stay, that are not food insecure, that do have a roof over their head.

In general, they're going to be able to go to the doctor.

They're going to be able to make those appointments.

They're going to be able to get those preventive health screenings done and accomplished.

That drives down those long term costs for everybody in the entire health care system.

Sure, everybody is looking for lower cost of health care.

We're going to get to some resources in just a couple of minutes.

But before we do that, doctor, I want to ask about mergers and hospital systems coming together and, you know, addressing that because recently Lehigh Valley Health Network and Jefferson Health have come together and they're one entity.

Now, some critics say that that mergers sometimes drive up health care prices.

What has been the case?

The mergers.

It's been what, about two years now?

If I'm if I'm remembering correctly since since the merger happened.

And so what's the case in your case.

Our patients seeing different prices one way or the other.

Well I think that the the pricing really is making the, the health care system much more viable and able to provide the care that it can do in different ways that it wasn't able to do before.

We have learned so much about providing care to the folks in the Lehigh Valley.

We have learned and brought that to Jefferson and the other way around.

You know, it is almost impossible for a small hospital system to be able to provide the care that's necessary.

They don't have the technology.

Now, we offer 340 different languages at Jefferson.

Almost anybody that comes in can immediately have a translator available to be able to care for them.

We offer what we call ambient listening, where when you go in to see the doctor, they're not working on a computer.

They're looking at you, they're talking to you.

And at every center now, we now are able to do that so that the computer disappears and you are talking face to face with your doctor, who's spending more time with you and improving the care that's delivered.

These are costs that require scale.

You need to be able to do these things.

You need to be able to keep your records safe.

Every week goes by, there's another hospital that's been hacked.

There's a beautiful group of private practice doctors in the Lehigh Valley that just got hacked.

They're going to have to shut down if you're part of a larger group, if you're part of a health care system, if you have scale, you can protect against those things.

You can provide services, mobile vans, etc.

you can afford.

We gave $2.7 billion of community care last year.

Community benefit.

You can't do that by yourself anymore.

In today's world, you need to have scale to be able to do that.

The costs are going to be still there, but they're going to be managed over a larger population, and they're going to be managed in such a way with scale that you can deliver services that you otherwise would have no hope of delivering.

And so I want to ask and touch upon more on the resources before we wrap up this section of the community conversation.

What are the resources at hand for the folks?

And Cassie, I'll let you start with that one.

What resources are available right now through Planned Parenthood?

If somebody comes in uninsured or underinsured and needs health care.

So again, we operate on that sliding sliding scale based on household income.

So we would talk to the patient about kind of what their household income is and then put them on that scale for self-pay.

We often will refer to places like Penny or, you know, in order for them to sign up for Medicaid, if we know that they're eligible.

I think and the other piece that you were mentioning about how having to think about where to send medication and things along those lines, we've been doing that for years.

We are very good at this, and we've been doing it for a long time.

And so, you know, whenever I'm training a new clinician, I'm always like, you have to think about the three different things.

You have to think about how much this is going to cost.

Where can we send patients for medication?

You know, there's some great online pharmacies that are going to be a lot less expensive.

And so we already kind of know a lot of that because we've been doing it for a long time.

Sure.

Doctor Walter, where can folks find community health, uninsured underinsured patients?

Where can they find community health care in the area?

So absolutely, our organization specifically is Stark Community Health.

So if you go to our website, we have links for any kind of an appointment that you may need primary care, women's health, dental, things like that.

To your point, available in every language in multiple different written languages and spoken languages.

We also have financial counselors.

So who really are just kind of I don't know what to do.

I'm not sure what my next step is.

Please just go to our website, take a look.

We'll be able to guide you through the penny process, things like that.

Wonderful.

Thank you all so much for these great resources and great information.

I really appreciate your your voices in this conversation.

Thank you.

Well, now we head to Nazareth, where one woman had to navigate a shocking medication price hike while managing uterine fibroids.

Our Megan Frank spoke with her about how she managed the surge in costs.

Mary Grube is a veteran who has spent most of her career working in the pharmaceutical industry, but even with her background, nothing prepared her for the complexities of her own health care journey.

About five years ago, I was having some abdominal pain, went to my doctor and he told me that I had a hernia, an umbilical hernia.

So he referred me to a surgeon.

I went to the surgeon to find out what we needed to do to correct that, and subsequently had a Cat scan during that Cat scan.

She immediately sent me back to my gynecologist because she said, not only do you have a hernia, but you also have multiple uterine fibroids.

Her doctor recommended a hysterectomy but offered a wait and see approach first.

Mary wasn't ready for major surgery, but over time her symptoms escalated with fibroids.

There is a lot of heavy bleeding involved, a lot of cramping over the years.

Like I said, symptoms started to get worse and with me getting older than you are, perimenopause on top of that.

So it started wreaking havoc.

After a procedure to remove the fibroids was cut short due to blood loss.

May return to a medication recommended by her doctor.

They told me that they were going to charge me close to $5,000 for a three month prescription, so it was you have a $6,300 deductible that you have to pay out of pocket before we'll cover it, and then even after that will only cover it at 30%, which still would still be a $500 copay every month.

So out of pocket, I think this medication, it's like $1,633 a month retail, which breaks down at $55 a pill.

I was angry, and then I started to worry a little bit.

What kind of world do we live in?

That my insurer is like, it's cheaper for you to have a hysterectomy than for us to let you have access to this medication.

Megan, thank you.

And Mary, thank you for sharing your story.

When you break it down to $55 a pill, it really puts into perspective the impossible choice too many people face between their health and their savings.

We also want to add that Mary was able to find a manufacturer co-pay card that dropped her out of pocket costs.

Well, even after someone receives care, another challenge often begins, which is paying for it, as we just heard.

Medical bills can be confusing and overwhelming.

So tonight we're joined by someone whose company works to help patients better navigate those costs.

Joining us now is John Fisher, the founder and CEO of Able Pay Health.

John, thank you so much for joining this conversation.

Absolutely.

So we just heard Mary talk about some of the shocking bills that she faced, right.

She was had this diagnosis.

Then all of a sudden she has to go through these different procedures.

And then she's faced with these bills and so able pay.

What you do is help people almost navigate those bills and help negotiate and bring down those bills.

So so I'll let you tell how does Apple pay work?

Yeah, sure.

I think starting this ten years ago, we're on our 10th year.

The whole idea from the beginning was to try to help hospitals change patient payment behavior, but ultimately lower the cost of health care for patients.

So how it works.

You sign up for able pay.

It's very much like a secondary insurance.

So you're going to use your primary insurance.

You're able to pay card for a secondary.

That bill is going to come to us.

We have a second discount on top of your insurance discount just for the patient out of pocket portion.

Why would hospitals do that?

It's because they really struggle to collect that money.

So they're typically averaging between 30 and $0.40 on a dollar for that collection.

So we're paying somewhere around $0.70 on a dollar.

They're getting that money in two weeks with no recourse.

But we share savings with the member based on how quickly they pay.

So if they have the money and they can pay in full, they can get 13% off all their bills for free.

Or if they don't and they need more time, they can pay over time with less of a discount or no discount at all.

But never any interest, never any interest costs or any other cost to join.

John, you're the founder and CEO.

What was the driving force behind this?

How did you come about this idea and what was what was that?

Moment.

We need this in our health care system.

Yeah.

So I was actually the CFO chief operating officer for local health system previously.

So I had a firsthand view into how this was changing over time with deductibles, co-pays, co-insurance rising over a period of time.

And I thought there was a better way to approach this problem.

So what we saw was banks entered that problem and said, well, you can't afford the bill, so we're going to give you a credit card.

Well, that adds cost to the system, right?

Or you have these engagement companies that say we'll make it easier to pay, but it doesn't really fit and solve the solution overall, which is changing how people pay their bills.

And to change how people pay their bills, they have to trust the bill.

We've heard a lot of that conversation today.

It's extremely complicated, right?

What's an EOB?

What's a deductible?

50% of people don't know what a copay is.

So it's a complicated inherent process.

So in the end, you want someone to be there for you as an advocate to step in.

We thought that we could be that advocate for people, but also negotiate lower costs for them as well, and combine both of those things together.

Sure.

We heard Tony from BSI earlier say businesses need to know what their health care is offering.

They need to know the ins and outs.

I feel like it's the same for patients.

We don't always know what we're looking at.

Okay, I have this medical bill.

What's this line item right here?

Does your company go through that information or do you do you look for errors in that kind of thing as well?

You do.

We do.

Yes.

So we're you know, it's going to get processed and adjudicated by the primary insurance first for the most part.

Then that bill would flow to able pay.

So we have checks in place to make sure that bill was properly adjudicated overall.

If someone does ultimately pay a bill and it did change because there was an update and it got reprocessed, we will correct those claims as well.

Whether you're an uninsured patient and you just have a full charge, bill will help you negotiate that.

Or if you have a balance after insurance payment, we'll work through that, that bill for you and help you find a way to pay that bill.

What's the most common misconception when people receive a hospital bill, a medical bill?

What's the most common misconception that they are coming across or don't know?

Well, I'd say that they assume that it's automatically right or it's automatically wrong.

And it's the truth is probably in the middle.

Fortunately, only 20% of people trust the bill that comes from the provider, so they should review it themselves.

They could educate themselves on how their benefit plan works.

They can go to their insurance broker and call them like Tony's group, and ask them questions about the bill, or sign up for a free program like Able Pay.

And we can walk them through those details so they have a good feeling of of the truth of that bill.

And ultimately, when they're comfortable, pay that bill.

So able pay is a resource, right, to help people pay their bill.

A lot of people just get it.

Don't even look at it and just pay the bill, not even knowing they have resources so able pay as a resource.

Are there are there different resources that people have when it comes to paying their medical bills?

Yeah, I think online there's a lot of information that they can review.

There's obviously price information out there.

We talked about this a little convoluted in the space, and it's not really up to par as you to help you understand your bill.

And ultimately you can go back to your broker as well.

There's advocacy services you can pay for to help you negotiate bills, or there's free services like us.

Wonderful, John, what's the best way for folks to get more information about either able pay or navigating health care bills that maybe they don't understand or can't pay right now?

Yeah, sure.

I would go on to.

Com you could sign up.

It's free to enroll.

I know that we get a lot of questions like it's too good to be true, right?

A lot of people are probably thinking that today, but the reality is it's just because we have in a position to go to another discount with the provider and then share that savings with them over time.

So it can be a free service or a for profit company that really has a nonprofit heart.

Wonderful.

John Pfitzner, founder of and CEO of Able Pay Health.

Thank you so much for offering your voice to this conversation.

Thank you.

Absolutely.

Tonight we've heard that while health care costs are complex, there are also resources available to help, whether it's understanding your insurance, taking advantage of preventative care.

Asking questions about medical bills, or connecting with community resources.

Being an informed patient can make a real difference.

We want to thank all of our guests for joining us tonight, and you for watching from all of us here at Lehigh Valley Public Media.

I'm Brittany Sweeney.

Have a great night.