Tag: health policy

The Patients Over Profits Act: What It Could Mean for Patients and Providers

The Patients Over Profits Act (“POP Act”) was introduced in both Houses of Congress this fall. The proposed Act addresses vertical integration in the healthcare system, specifically covering various stages of insurance coverage. Vertical integration, as opposed to horizontal integration, is when multiple stages of a certain industry are all controlled by the same company. For example, vertical integration in the healthcare industry happens in various situations, but in this context happens when a certain company owns or controls both the insurer and the physician. 

Multiple industries have been trending towards vertical integration, and the healthcare industry is no exception. The Supreme Court has stated that any sort of integration is “highly relevant” in deciding whether anticompetitive effects exist. The Patients Over Profits Act seeks to address the effects of vertical integration in the healthcare industry on patients. 

Specifically, the supporters of the POP Act argue that insurers can now control physician practices, and then set their own policies regarding insurance. Supporting documents explain that these financial incentives surrounding insurance companies can in turn affect the care and treatment patients receive from providers who are owned by companies who control both the physicians and the insurance payouts. Proponents of the Patients Over Profits Act not only argue that the financial incentives can influence clinical decision-making, but they also have the ability and desire to increase costs and drive up profits for their company.  Recently, many insurance conglomerates have purchased clinics and other physician-groups, resulting in vertical integration. For example, UnitedHealthcare purchased a large physician-owned clinic in Oregon, after they had already purchased other similar medical groups in Oregon. This type of integration is not unique to Oregon, it is happening throughout the United States.  

Specifically, the Patients Over Profits Act addresses physicians and insurers participating in Medicare and Medicaid. Medicare and Medicaid protect our most vulnerable citizens. Medicare provides healthcare assistance through a federally funded insurance program to people who are sixty-five or older, and others who qualify or have certain disabilities. Medicaid similarly provides insurance assistance through federal and state funding for low income citizens. The POP Act addresses these concerns in many ways. First, it seeks to prohibit ownership of both a health insurance company and a medical provider who participates in Medicare and Medicaid. Further, it seeks to control Management Services Organizations  (MSOs) through their Management Service Agreements (MSAs). MSOs provide non-clinical services to medical providers, and they use their MSAs, which are contractual agreements, to govern these services. The POP Act seeks to restrict the mechanisms these entities can use to control the medical services the MSOs provide. Further, the Act seeks to enable federal enforcement through the Department of Justice, Federal Trade Commission, and the Department of Health and Human Services regarding those insurance companies engaging in vertical integration, especially those participating in Medicare and Medicaid. 

In short, the Patients over Providers Act seeks to protect patients, rather than providers of healthcare services and insurance companies receiving all of the benefits. By requiring these entities to disclose their information and subject them to strict enforcement through federal agencies, the Act hopes to ensure patients receive care with fair payment. If the POP Act passes, health insurers will need to disclose interests they have in medical practices, or they will be subject to high financial penalties or suspension from federal health programs, such as Medicare and Medicaid. 

The ‘Elder’ Medical-Legal Partnership and Caregiving from an Interdisciplinary Lens

New frameworks, interdisciplinary collaborations, and models of health care may need to emerge to address the impending “caregiving crisis,” or growing strain on the elder caregiving workforce with our aging population. The medical-legal partnership (MLP) model is one potential approach in addressing elder well-being, health, and the caregiving crisis. Medical legal partnerships are an established interdisciplinary framework, combining the legal and medical worlds to holistically serve a population’s needs. Within MLP clinical sites, attorneys are placed directly onsite to work with healthcare providers in identifying and remedying health-harming legal needs.

The model is based on the understanding that health issues are seldom solvable by addressing medical needs. For instance, an elder patient and their caregiver may need assistance in accessing incapacity plans or safe housing for an elder at risk for falls at home. By utilizing the MLP model, clinics can assist older adults and caregivers in navigating the multidimensional, overlapping legal and health issues that elders face, potentially reducing some of the burden on the caregiving population. Addressing common elder issues in one clinic with the expertise of two professions can help streamline access to other resources like public benefits, support the dignity and autonomy of elders, and address a variety of unmet financial, housing and legal needs. The MLP can also assist with the fact that elders have specific barriers to legal and healthcare related to mobility, transportation, and isolation by acting as a “one stop shop” for holistic support. Contributors to elder law also point out that medical providers and attorneys are well-positioned to collaborate so that providers can identify elder abuse.

While MLPs have become increasingly popular, they have scarcely been tailored to elder populations. The Medical-Legal Partnership for Seniors (MLPS) in San-Francisco, a law school clinic that trains medical providers on the legal needs of elders, is one example of an MLP tailored to the elder populations. But for the most part, MLPs have been utilized at the pediatric level where pediatricians are trained to identify the causes of their patient’s health conditions, which often stem from social determinants of health (SDOH) like poor housing conditions. Research has suggested that SDOHs are more important to individual health than genetic predisposition, where SDOHs such as socioeconomic resources, working conditions, housing, environment, race, and gender may be “fundamental causes” of health outcomes. These same SDOHs shape elder health, independence, and overall wellbeing, where intersecting factors and elder social identities may compound poor legal and health outcomes for elders. For example, a low income, older woman of color experiencing housing instability may face intersecting barriers that healthcare nor legal interventions alone can adequately address. Recognizing this, MLP interventions should be multi-pronged to address underlying social factors like structural racism and critically assess their own role in reinforcing systemic inequities. Elders are not a monolithic group, and ‘non-essentializing’ this population is critical in delivering equitable care.

Overall, the MLP framework could be more widely utilized to benefit the elder population and promote their health and justice. Having stronger societal supports like numerous MLPs tailored to elder needs may furthermore assist incrementally in the caregiving crisis, given that elder issues are only becoming increasingly relevant as our population continues to age. The MLP model thus may be a promising method to expand on caregiver and elder supports in the United States.

A Foot in the Door: Virginia’s New Doula Law, S.B. 1384, Guarantees Their Presence, but not Their Access

Virginia has taken a critical step to address its maternal health crisis with a new law guaranteeing a birthing person’s right to have both a doula and a partner (or other support person) present during labor and childbirth. This legislation is a direct response to the state’s alarming maternal mortality rates, which disproportionately affect Black mothers who are nearly three times more likely to die from pregnancy-related causes than their White counterparts. A doula is a trained, often community-based professional who provides physical, emotional, and informational guidance to an individual before, during, and after childbirth.  Research indicates that continuous doula support improves birth outcomes, reduces the need for C-sections, and enhances patient satisfaction. For Black and other minority women, doulas serve as important advocates, familiar with their communities and bodies, and able to communicate their needs and birth preferences to doctors who may lack the same understanding. Previously, and especially during the COVID-19 pandemic, many hospitals limited patients to a single support person, forcing birthing individuals to choose between their visitors. The new law rectifies this by legally defining a doula as a member of the essential care team—a foundational step that grants legal protection to a patient’s right to their full support system. However, while this law codifies a crucial right, its promise is diluted by significant systemic barriers that prevent equitable access.

A major implementation gap exists between the law’s text and lived reality in Virginia hospitals. The legislation grants “discretion to the treating physician” to override the patient’s right to a doula. This clause is used to enforce restrictive institutional polices, most notably banning doulas from operating rooms during C-sections, even though the law explicitly includes cesarean births in its definition of “birth.” Many hospitals lack clear, updated protocols, creating a confusing and inconsistent environment where a birthing person’s rights depend on their location and provider. This institutional gatekeeping maintains the status quo, leaving families without vital support during vulnerable moments and undermining the law’s core intent.

For many Virginians, a primary obstacle to hiring a doula is financial. Private doulas can range from $800 to $2,500, placing this essential support out of reach for low and middle income families. While Virginia’s Medicaid program now covers doula services, its design creates a new set of challenges. The reimbursement rate of approximately $859 is significantly below market rate and fails to provide a living wage, especially considering the on-call nature of the work. Furthermore, doulas face a costly process to become certified and enrolled with multiple managed care organizations. These financial disincentives limit the number of participating doulas, particularly in rural maternity care deserts, where support is already scarce, perpetuating a two-tiered system of access.

Senate Bill 1384 is a legislative victory for maternal health in Virginia. Yet, a right on paper is not a right in practice. To truly realize the law’s life-saving potential, policymakers, hospitals, and state agencies must work to dismantle the deep-seated institutional and economic barriers that continue to deny so many families the support they deserve and are now legally guaranteed.

The Beginning of the End for Vaccine Mandates?: What Happens When Ideological Opposition to Vaccination Invades Public Health Policy

“We did it everybody!” exclaimed Leslie Manookian, “We passed the first true medical freedom bill in the nation!” Ms. Manookian and other members of the anti-vaccine group Health Freedom Idaho were celebrating the Idaho Medical Freedom Act being signed into Idaho state law on April 4, 2025, which protects those who refuse to take medical interventions like vaccines from being excluded from activities of daily life such as obtaining a service from a business or attending school.

Idaho is the first state in the country to enact a law protecting personal medical freedom which includes these types of protections for people who are against getting vaccinated, but other states may attempt to implement similar laws and public health policy changes due to vaccine skepticism present throughout the nation. For example, Florida’s current Surgeon General Joseph Ladapo has expressed a desire to eliminate vaccine mandates throughout the state of Florida despite broad medical and religious exemptions. Mr. Ladapo’s rhetoric regarding eliminating vaccine mandates seems less based on science and more based on morals and principle. When describing vaccine mandates Mr. Ladapo stated, “every last one of them is wrong and drips with disdain and slavery,” he added that forcing vaccine mandates “immoral” and “wrong”, and he proclaimed “Your body is a gift from God.” Similarly, when asked about her motivations to help codify the Idaho Medical Freedom Act, Ms. Manookian stated that she and others pushing for freedom from vaccine mandates believe that “our immune systems, given to us by God, are perfect as long as they’re well nourished.” Ms. Manookian also insisted that it was “not accurate” that the implementation of the measles vaccine was what led to the eradication of measles, instead citing improvements in clean drinking water and waste management which helped quell spread of the disease. These types of moral statements regarding vaccine use reflect a growing population of people who see public health interventions such as vaccines more as an issue of personal freedom rather than an issue of safety. These statements made by Mr. Ladapo and Ms. Manookian highlight a crucial ideological issue that public health officials must learn to address more effectively to reduce vaccine skepticism. Global health organizations are beginning to provide targeted guidance to assist healthcare professionals in combating vaccine skepticism not just by providing accurate information but by building trust and a deeper understanding of community perceptions, social norms, and potential logistical barriers to vaccination.

So far in 2025 the United States had had over 1,600 measles infections, which is the most measles infections in the country since 1992, and in 92% of cases the patients are either unvaccinated people or their vaccine status is unknown. Prior case law on the issue of vaccine mandates in the United States, such as the landmark Supreme Court case Jacobson v. Massachusetts, have allowed state public health departments to compel their citizens to be vaccinated despite ideological opposition to the vaccine, but if the legislatures and health departments themselves buy into ideological opposition to vaccines then a key safeguard against disease transmission will be dismantled. It may not be enough to simply combat vaccine misinformation with accurate science, as surveys have shown that false or unproven claims about vaccines are more widely accepted today than two to three years ago despite concerted efforts to combat misinformation with accurate science. The American College of Allergy, Asthma, and Immunology has urged policymakers to weigh the unintended public health implications if vaccine mandates were to be eliminated, but public health officials and medical professionals should be prepared going forward to find new ways to address skepticism to vaccines once a major legal enforcement tool is eroded.

Mental Health Parity: A Question of Agency Authority

A recent legal challenge to a key mental health parity law sparks conversations about federal agencies’ power to interpret and enforce statutes. Earlier this year, the Employee Retirement Income Security Act Industry Committee (ERIC) filed a lawsuit against the Department of Health and Human Services (HHS), the Department of Labor (DOL), and the Treasury, regarding the enforcement of the updated 2024 Mental Health Parity and Addiction Equity Act (MHPAEA).

MHPAEA was enacted in 2008 to address disparities in benefits between mental health or substance use disorder (MH/SUD) treatment and medical/surgical (M/S) services. Under MHPAEA, MH/SUD treatment and financial limits must not be more restrictive than those for M/S services, and MH/SUD benefits cannot have separate limits that are not also applied to M/S benefits. In practice, the law required health plans and healthcare facilities to cover MH/SUD services in the same way as M/S services. 

A 2013 Rule updated MHPAEA, clarifying ambiguity about parity for non-quantitative treatment limits (NQTLs), such as prior authorizations, network adequacy, medical necessity standards, and step therapies. This Rule also confirms that parity applies across all care levels, including outpatient, inpatient, and “intermediate” behavioral health settings. 

Enforcing compliance with insurance plans under MHPAEA was difficult because the Act did not require strong proof of adherence. The 2021 Consolidated Appropriations Act (CAA) addressed this issue by requiring a comparative analysis of health plans to demonstrate parity between MH/SUD and M/S services, specifically NQTLs, and by allowing federal agency audits and on-demand submissions from health plans. 

The 2024 Final Rule aimed to improve enforceability further and reduce ambiguity across employer plans (ERISA), ACA marketplace plans, and Managed Care plans through several new standards: requirements to report NQTL comparative analysis data to federal agencies and beneficiaries with clear explanations, fiduciary certification for ERISA plans, a more detailed NQTL collection and reporting process, and a standard that ensures plans offering any MH/SUD benefits provide meaningful material benefits in every classification that the plan also offers M/S benefits. 

ERIC filed a lawsuit on January 17, 2025, with several allegations against the implementation of the 2024 Final Rule. First, ERIC argued that the Final Rule is too vague in guiding the collection and reporting of NQTL outcome measures and in addressing and fixing material differences in MH/SUD and M/S benefits. ERIC also claimed that many of these measures, now required for collection, could be affected by external factors that might hinder payers’ ability to remain compliant.

Additionally, ERIC questioned the scope of the Final Rule, arguing that the 1:1 requirement for MH/SUD and M/S benefits across all classifications exceeds the Act’s scope and intent. Finally, ERIC challenged the applicability date of January 1, 2025, claiming that it offers too little time for employers/agencies to make the necessary adjustments to comply. Throughout their complaint, ERIC argued that HHS, DOL, and the Treasury violated the Administrative Procedure Act by creating and enforcing what they describe as a vague and overbroad regulation. 

On May 12, 2025, the U.S. District Court for the District of Columbia agreed to stay ERIC’s lawsuit after the Tri-Agencies made a motion for abeyance to consider rescinding or modifying the 2024 Rule. The agencies also issued a non-enforcement policy for the components of the Rule that took effect in January 2025 or were set to take effect in 2026.

Several advocacy organizations and provider-focused trade associations have criticized the decision not to enforce, claiming that it harms agencies’ ability to implement and enforce aspects of the 2021 additions to MHPAEA, while also inhibiting critical steps to ensure more detailed analysis of parity and leaving room for health insurers to take advantage of potential loopholes.

Following the Supreme Court’s decision in Loper Bright v. Raimando, debates over federal agency authority and explicit statutory authorization requirements have become more common. ERIC’s complaint, in large part, focuses on concerns regarding agency overreach in interpreting and enforcing statutes. Lawsuits like this are likely to play a part in setting a precedent for what constitutes an acceptable scope for federal agency interpretation and enforcement of statutes governing their authority.

The Role of Local Government in Dealing with Food Deserts and Food Insecurity

Zohran Mamdani’s recent victory in the New York City mayoral democratic primary has brought national attention to his proposal for city-run grocery stores and how to address the issues posed by food deserts and food insecurity. According to the US Department of Agriculture (USDA), approximately 2.3 million, or 2.2%, of households in the continental US live more than a mile from a supermarket and do not have access to a vehicle. The USDA’s Food Access Research Atlas notes that 18.8 million Americans, or 6.1%, live more than 1 mile (in urban areas) or more than 10 miles (in rural areas) from a supermarket. This lack of access to supermarkets and healthy food poses health risks to these Americans. 

Mamdani’s pilot plan to address food deserts and food insecurity in New York City is to build five city-owned grocery stores, one per borough, focused on keeping prices low rather than making a profit. This grocery store plan is not only about addressing the lack of access to healthy food, but also about affordability. The pilot program has a $60 million estimated cost and the stores would be exempt from rent and property taxes. According to polling done by Data for Progress, 66% of likely voters support Mamdani’s plan. A 2023 report by the New York State Department of Health found rates of food insecurity in New York City vary from 39% of adults living in food insecurity in the Bronx to 22.1% in Staten Island. Food deserts can presently be found in more than 2 dozen neighborhoods in New York City.  

City-run grocery stores are not a novel idea. Many cities across the country have implemented plans similar to Mamdani’s with varying levels of success and city involvement. In the town of St. Paul, Kansas, where there had not been a grocery store for almost two decades, a city-run grocery store was opened in 2008 and continues to provide the town with healthy, affordable food. Madison, Wisconsin, and Atlanta, Georgia, have both implemented successful public-private grocery store partnerships where the cities have helped finance construction and provided tax incentives. Those plans both featured less city-government involvement than Mamdani’s, but still show that city government can play a role in combating food deserts and food insecurity.

There are differing opinions on whether Mamdani’s plan will be successful. Mamdani has famously drawn criticism from New York grocery chain CEO John Casimatidis, who sees the prospect of city-run grocery stores as a threat to private grocers that already operate on very small margins. Mamdani’s detractors also point to examples of city-run efforts gone awry. Not far from St. Paul, Kansas, a city-run grocery store, Erie Market, in Erie, Kansas, struggled to compete with the prices of other grocers that were at least a 15-20 minute drive away. Erie Market had been the only market in town, and after significant investment in the store by the town, its management and operation were transferred to a private company, and it subsequently ceased operations entirely.  

While the fact that there is a need to increase the access and affordability of healthy food in the US is clearly evident, there is still debate on what role city-run grocery stores and local governments at large have to play in solving the ongoing food insecurity and food desert crises.