The Texas Department of Insurance's mediation program can intervene when Texans complain about an unexpected bill. Historically, the state program had many restrictions that left few consumers eligible for help. But the Texas Legislature expanded it in 2017.

This article was published February 13, 2019, by Kaiser Health News.

By Ashley Lopez, KUT

In Texas, a growing number of patients are turning to a little-known state mediation program to deal with unexpected hospital bills.

The bills in question often arrive in patients' mailboxes with shocking balances that run into the tens or even hundreds of thousands of dollars.

When patients, through no fault of their own, are treated outside their insurers' network of hospitals, the result can be a surprise bill. Other times, insurers won't agree to pay what the hospital charges, and the patient is on the hook for the balance.

The Texas Department of Insurance's mediation program can intervene when Texans complain about an unexpected bill — often after an emergency in which a patient is rushed for treatment at an out-of-network hospital.

Historically, the state program had many restrictions that left few consumers eligible for help. But the Texas Legislature expanded it in 2017.

Since then, more patients have been filing complaints. In 2014, the department was asked to mediate 686 medical bills. During the 2018 fiscal year, however, it received 4,445 bills, more than double the 2,063 bills received in 2017.

Even after the changes, the mediation program could be a lot more robust and is likely addressing only a fraction of these problematic bills, consumer advocates say.

The Road To A Surprise Medical Bill

Brad Buckingham had to deal with a surprise medical bill after a bicycle accident in 2016.

Buckingham sent his bill to Kaiser Health News and NPR's "Bill of the Month" portal last year.

The Austin, Texas, dentist said he was on a ride with friends in December 2016 when he crossed train tracks at an angle to avoid a pileup. His wheel slipped out from under him, and he landed hard on his left hip.

"All I could do was scream," he said. "I couldn't even make words."

His friends called an ambulance, and Buckingham was taken to the nearest hospital: St. David's South Austin Medical Center.

"I specifically remember I gave them my health insurance information in the ambulance," he said. "And they put me in the ER, and from the ER they took my insurance information again."

Buckingham had insurance through Baylor Scott & White Health, which he bought through the Affordable Care Act marketplace. St. David's was out of his plan's network, but no one told him that — at first.

Buckingham had broken his hip, and doctors took him into surgery the same day.

"They held me in the hospital for three days just for recovery and never told me I was out of network until the time of my discharge," he said.

A few weeks later, Buckingham got a bill that said he owed $71,543.

The total bill eventually came to $75,346. Baylor Scott & White, which left the ACA marketplace the following year, paid only $3,812.

Buckingham thought it was a mistake, he said. He called the hospital and the insurer to sort it out. But after weeks of inquiring about it, there was no resolution.

Both the hospital and insurer insisted payment was his responsibility.

"I'm sitting there thinking to myself that there is no way — there is no way — this is right," he said.

Baylor Scott & White said it couldn't discuss Buckingham's bill "due to confidentiality requirements."

After Buckingham gave St. David’s permission to discuss his case with the media, the hospital released a statement saying his bill was actually the amount he owed from his deductible and coinsurance — not a balance bill.

The hospital also said the bill was so large because of his "high deductible plan."

Those plans "may be attractive to some people because they cost less, though they place more financial responsibility on the patient," the statement from St. David's said.

Buckingham said his policy had a deductible of $5,000 for in-network care and $10,000 for out-of-network care. He still doesn't know how his bill got to be so high, he said.

Buckingham didn't know about the state's mediation program. But even if he had known, he wasn't eligible for the program at the time. His bike accident and the billing dispute with the hospital happened months before the Texas Legislature decided to expand the pool of eligible patients. So he hired his own lawyer to help him negotiate with the hospital.

Buckingham now owes a couple of thousand dollars to St. David's, he said, but he remains frustrated by the experience.

"You know, whenever I tell my story to anybody, they kind of agree — like, 'Oh my gosh, this is ridiculous,'" he said. "But then when you talk to the people that have any control over it, it's the exact opposite. It's: 'You owe it; we don't.'"

‘A Total Roll Of The Dice'

A surprise bill can happen to anyone who makes an urgent trip to the nearest emergency room.

"It's a total roll of the dice," said Stacey Pogue, a senior policy analyst with the Center for Public Policy Priorities in Austin. She has been looking into balance billing for years. "The medical emergency that's going to send you to the hospital where you could get a surprise bill — is that emergency room going to be in or out of network?"

Pogue said the Texas Department of Insurance's mediation process forces an insurance company and the hospital or medical provider to negotiate a fair price for services. Ninety percent of the time those negotiations happen over the phone, she said.

There are two big reasons the number of bills sent for mediation more than doubled from 2017 to 2018, Pogue said.

"One is just increased awareness," she said. "There is constant media attention now to surprise medical bills because the stories are so shocking, right? We see them covered more, so people are more aware that when they get one, they could do something about it."

The second reason is that, in 2017, the Texas Legislature opened the mediation program up to more people, including teachers.

Can’t Wish It Away

Stacey Shapiro, a first-grade teacher in Austin, also received a surprise bill from St. David's South Austin Medical Center after she landed in the emergency room last March.

The marathon runner said she woke up one Saturday for an early run and wasn’t feeling well.

"All of a sudden the whole room started spinning. … I started sweating, sweating like buckets," she said. "It was terrible, and then all I remember is that my ears started popping, my vision got blurred and then the next thing I knew, I had passed out."

Shapiro’s boyfriend heard her hit the bathroom floor. He found her passed out, with her eyes open and hardly breathing. He took her to St. David's because it was the closest hospital.

Shapiro was taken care of in a few hours, she said. Hospital staff gave her fluids and anti-nausea medication. Doctors found she had a dramatic change in her blood pressure that was likely due to a spell of hypoglycemia, or low blood sugar.

Two months later, a bill for $6,720 came in the mail.

Like many teachers in Austin, Shapiro gets her health insurance from Aetna.

In a statement, the insurer said Austin school district employees are supposed to use the Seton Accountable Care Organization network, comprising several Catholic hospitals in the area. The parent company for St. David's, the for-profit hospital chain HCA, doesn't participate in that network.

"Unfortunately, HCA is not currently accepting payments through Aetna's [contracted payment] program, which provides set payment fees for non-participating providers. This has resulted in Ms. Shapiro being balance billed for her emergency room visit," Aetna wrote in a statement.

Shapiro said she had heard of other Austin Independent School District employees dealing with high hospital bills. In fact, Shapiro reached out to radio station KUT after hearing the story of Drew Calver, an Austin high school teacher who was balance-billed for nearly $109,000 by St. David's after a heart attack. Calver's story was part of Kaiser Health News and NPR's "Bill of the Month" series last year.

In her case, Shapiro said, Aetna told her not to pay what the hospital was charging her. She was told to pay only her deductible ($1,275), which she did right away, she said. But St. David's kept sending her bills for the remaining balance, which was more than $5,000.

"I guess I just thought that it was going to go away," Shapiro said.

But it didn't. For a public school teacher, $5,000 would have been a huge blow to her budget, she said.

Shapiro applied for financial assistance, but St. David's told her she didn’t qualify. She felt out of options, she said — until a friend told her about the state's mediation program.

After she contacted the program, a state mediator set up a scheduled call with Aetna and St. David's. But before it took place, a KUT reporter asked St. David's for a comment on the situation. Shortly afterward, Shapiro said, St. David's told her she no longer owed anything.

St. David's later told KUT that Shapiro had "already satisfied her financial obligation." It also denied that she was balance-billed to begin with.

Shapiro called the whole experience exhausting. "It's just very frustrating because this has been very time-consuming," she said.

More Work To Do

Pogue, of the Center for Public Policy Priorities, has been arguing that the state needs to find more ways to get involved. The current mediation process is pretty good, she said, but not enough people know it's an option.

"Because first, the instructions for how to do it are on your medical bill and your explanation of benefits — the most indecipherable documents you are going to get," she said.

And even if people understand they have a right to mediation, they might get scared off by the concept and think they need a lawyer, Pogue added.

When people do use the program, though, it tends to work by saving patients money.

In fiscal year 2018, the initial complaints amounted to $9.7 million worth of medical bills, according to the state insurance agency. After mediation, the final charges had been negotiated down to $1.3 million.

Mediation is helpful, Pogue said, but it still puts a big burden on the patient, who may be confused. "Why didn't this happen in the first place?" she said. "How come I had to, while recovering from an emergency, decipher medical bills, fill out paperwork with the state department of insurance, jump through all these hoops, when all that needed to happen was a phone call?"

The ideal solution to surprise medical bills would remove consumers from this confusing web altogether, she said.

States like New York, California and Florida have systems that make things easier for consumers, Pogue said, and Texas should, too.

In 2015, New York became the first state to pass a law aimed at protecting patients from surprise medical bills from out-of-network hospitals. Its Emergency Medical Services and Surprise Bills Law holds consumers harmless if they are treated by an out-of-network doctor at a participating hospital, among other things.

In 2016, Florida lawmakers passed legislation protecting consumers from receiving surprise medical bills "from doctors and hospitals that don't have a contract with the patient's insurance plan," the Miami Herald reported.

And in 2017, California passed a law shielding patients from balance billing. The law kicks in if someone visits an in-network provider, including a hospital, imaging center or lab. Under the law, patients would be responsible only for their in-network share of the cost, even if they’re seen by an out-of-network provider.

In the meantime, Pogue said, more Texans should take advantage of what’s already in place in the state.

The number of people who seek mediation is "tiny compared to the number of people who get surprise bills," she said, "so there is a ton of work to be done."

This story is part of a partnership that includes KUT, NPR and Kaiser Health News.

Ashley Lopez, KUT: alopez@kut.org, @‪AshLopezRa‪dio

Sen. Mike Enzi said he knew of a foundation that would import insulin for patients, but it doesn’t appear to exist.

This article was published February 11, 2019, by Kaiser Health News.

By Jay Hancock

It sounded like an answer to prayers for millions with diabetes struggling to pay soaring prices for insulin.

At a congressional hearing last month, Sen. Mike Enzi said an adviser had found "a foundation to import insulin for a number of people at lower cost." The Wyoming Republican told the mother of a young man with Type 1 diabetes that his adviser "worked through a foundation so that it would be legal, and I will share that with you."

Such a group could link patients to safe medicines while saving them hundreds or thousands of dollars a year. But it doesn't appear to exist, leaving patients with diabetes to either pay sky-high U.S. prices or try to import cheap insulin on their own, which is technically illegal.

Enzi spokesman Max D'Onofrio said he was unable to identify the group. And neither the American Diabetes Association nor the Campaign for Personal Prescription Importation is aware of a foundation like the one Enzi described, officials at those groups said.

"I have no idea what Sen. Enzi was talking about, but I'd like to know," said Gabriel Levitt, president of PharmacyChecker.com, which helps patients compare medicine prices and connect with foreign pharmacies.

Enzi spoke at a Jan. 29 hearing on drug prices held by the Senate finance committee. He was addressing Kathy Sego, whose son had skipped insulin doses to save the family money and was profiled by Kaiser Health News in 2017.

Sego said she wants more information but never heard back from Enzi’s office. "I have not heard of ANY foundation which helps people with insulin," she said via email.

"Sen. Enzi talks to a number of informal advisers, constituents and stakeholders who are concerned about healthcare costs, including drug prices, and he was referring to an anecdotal conversation he had," D'Onofrio said. Insulin list prices have risen as much as threefold in the past decade and patients can pay hundreds of dollars per month even with insurance.

While insulin makers Sanofi, Eli Lilly and Novo Nordisk often rebate a portion of those increases back to insurance companies and pharmacy benefit managers, patients' share of the cost is often based on the list price. Uninsured patients have to pay everything themselves.

Insulin brands sold in the United States can be bought for less than half as much in Canada and Mexico, prompting unknown numbers of people to drive across the border or order insulin by mail.

Unauthorized importation of prescription medicine is technically illegal, but the Food and Drug Administration allows "entry of shipments when the quantity and purpose are clearly for personal use," according to agency rules.

Insulin needs to be refrigerated, but some Canadian pharmacies will mail it in cold packs to the United States, patients report.

Just over a year ago, FDA criminal investigation agents searched stores in Florida that help consumers order many kinds of drugs from Canada and elsewhere. That suggests that a foundation importing insulin in bulk might be subject to the same kind of scrutiny.

For Enzi's part, he "continues to have concerns that importing prescription drugs from other countries will not solve the problem of rising drug prices," said his spokesman, D’Onofrio. "He hopes Congress takes real action this year to lower healthcare costs."

Jay Hancock: jhancock@kff.org, @JayHancock1

The FDA has approved more than 1,600 generic drug applications since January 2017 — about a third more than it did in the last two years of the Obama administration. But more than 700, or about 43%, of those generics still weren't on the market as of early January.

This article was published February 7, 2019, by Kaiser Health News.

By Sydney Lupkin and Jay Hancock

The Trump administration has been trumpeting a huge increase in FDA generic drug approvals the past two years, the result of its actions to streamline a cumbersome process and combat anti-competitive practices. But nearly half of those newly approved drugs aren’t being sold in the United States, Kaiser Health News has found, meaning that many patients are deriving little practical benefit from the administration’s efforts.

The administration’s aggressive push to approve more generics is designed to spur more competition with expensive brand-name drugs, and drive prices lower, President Donald Trump noted at a White House event last month. The Food and Drug Administration has approved more than 1,600 generic drug applications since January 2017 — about a third more than it did in the last two years of the Obama administration.

But more than 700, or about 43%, of those generics still weren't on the market as of early January, a KHN data analysis of FDA and drug list price records shows. Even more noteworthy: 36% of generics that would be the first to compete against a branded drug are not yet for sale. That means thousands or even millions of patients have no option beyond buying branded drugs that can cost thousands of dollars per month.

"That’s shockingly high," said former congressman Henry Waxman, who co-sponsored the 1984 law that paved the way for the generic approval process as we know it today. He said he'd like to know more, but suspects anti-competitive behavior is at least partly to blame and that revisions to the so-called Hatch-Waxman Act might be needed.

The approved generics that haven't made it to American medicine cabinets include generic versions of expensive medicines like the blood thinner Brilinta and HIV medication Truvada. They also include six different generic versions of Nitropress, a heart failure drug, whose price spiked 310% in 2015.

Experts say a variety of factors are to blame. Generics sellers have fought for years against patent litigation and other delay tactics that protect brand-name drugs from competition. In recent years, vast industry consolidation has reduced the ranks of companies willing to purchase and distribute generics. And, in some cases, makers of generics obtain approvals and ultimately make a business decision to sit on them.

"It's a real problem because we're not getting all the expected competition," FDA Commissioner Scott Gottlieb said in an interview, adding that it will be difficult to solve because it has so many causes. It takes five generics on the market to drive prices down to 33% of the original brand-name price, according to an FDA analysis.

Without generics to lower drug costs, branded manufacturers can continue to increase their prices, at a rate of roughly 10% a year, said Scott Knoer, chief pharmacy officer at the Cleveland Clinic. "It makes healthcare costs go up across the board."

Even if hospital patients don't directly see high drug prices in their bills, the higher costs get passed to insurers, who pass them on as higher premiums, Knoer said. They also get passed to taxpayers, who pay for drugs covered by Medicare and Medicaid.

Consolidation on multiple tiers of the drug supply chain have changed the face of the generic drug market, warping supply and demand.

In some cases, key pharmaceutical ingredients are unavailable or a manufacturer doesn't have the capacity to launch a product because it's having difficulty meeting demand for existing products.

Manufacturing consolidation has dramatically reduced the production of injectable drugs, which are typically administered in a doctor's office. This may be why 157 injectable generics that were approved in the past two years haven't been brought to market.

Erin Fox, a pharmacist at the University of Utah who tracks drug shortages, said the KHN analysis of stalled generics "highlights that companies often have a lot of products 'on the books' but aren't really making them." A few generics on the list — like dextrose 10% injection, to treat patients with low blood sugar — would have been helpful to combat shortages the past few years. "This comes up with shortages a lot — it looks like there are more suppliers than there really are," Fox said.

A lot can change between the time a drugmaker files a generic application with the FDA and the time it's approved.

Some drugmakers that applied for generic approval years ago switched their attention to more profitable products. Novartis, for instance, recently sold a generics division run by Sandoz so Sandoz could focus on other drugs, including biosimilars, which compete with expensive biologic drugs made from living organisms.

"Some of these [generic] drug applications have been sitting six, seven, eight years," said Robert Pollock, a former acting deputy director of the FDA's Office of Generic Drugs who now works for Lachman Consultants. By the time it's approved, a generic can fall out of favor because patients taking the branded version reported new side effects, or because a more effective branded drug was approved.

For some generic manufacturers, there's money to be made by waiting. Brand-name drugmakers will pay them to keep their products off the market as part of a tactic sometimes called "pay for delay." The Federal Trade Commission estimates that such deals cost consumers and taxpayers $3.5 billion a year.

The number of these potentially anti-competitive settlements decreased from fiscal 2014 to fiscal 2015, according to the latest FTC report. Still, Gottlieb said he hopes to crack down on such tactics. The first generic to take on a branded drug is granted 180 days of exclusivity before the second and third generics can be approved, giving those products a clear advantage.

"We don't like that companies are able to just park [a generic for] 180 days while they cut a deal not to come to market," Gottlieb said, adding that with help from Congress he hopes to force companies to forfeit exclusivity if they don't launch on time.

In some cases, Gottlieb said, generic drugmakers wait until they've stockpiled a number of newly approved generics and have landed a contract with a purchaser before bringing their medicines to market.

These bundled contracts are secretive, so not much is known about them, but it means companies are filing generic applications just for the option of introducing generics, said health care economist Rena Conti, an associate professor at Boston University. They'll wait until the most strategic time to launch, which could be after the competition shakes out, leaving them as "the last man standing," Conti said. Then they can launch and hike the price.

To be sure, the FDA under Gottlieb's leadership has taken steps to increase generic competition, from shaming brand-name drugmakers for blocking generics to publishing documents to help manufacturers win approval more easily. But approval doesn't necessarily spur competition.

"We used to say it was all about getting in — once you got approval from the FDA, then you could go to market," said Chip Davis, CEO of the Association for Accessible Medicines, the trade group for makers of generic drugs. The biggest challenges his members face is that there aren't enough companies purchasing drugs, Davis said. Consolidation has led to three large buying groups covering 90 percent of the market, according to a Drug Channels Institute report. So, if you’re the fourth or fifth generic, you may have no one left to sell to.

Yet another barrier relates to how drug middlemen select the drugs they'll cover under industry formularies, which determine what products insurance plans will cover. In some cases, middlemen known as "pharmacy benefit managers" have made it clear they don’t have room on their formularies for another generic. Or they do, but they give branded drugs preferential treatment with lower copays, hurting the generic's market share.

Barriers to entry are lower under Gottlieb's FDA than they’ve been in years past, Conti said, and regulations can help foster competition. But, she said, "they can only do so much."

Methodology

To identify approved drugs that have not reached the market, KHN used the FDA’s Orange Book database — as of Jan. 2 — to identify drug applications approved in 2017 or 2018. We then searched the FDA’s online National Drug Code directory for billing codes for the drugs associated with each application as of the same date. To account for a possible lag, we supplemented this list with a more complete billing code directory that we obtained via a Freedom of Information Act request. It includes codes with expected future launch dates that don’t appear in the online version.

According to experts, a billing code doesn"t necessarily mean a drug is on the market. However, every drug on the market needs a list price for reimbursement. We provided a list of application numbers and billing codes to information technology firm Connecture, which then told us whether each one was active, inactive or had no list price as of Jan. 17.

If an application had at least one billing code with a list price attached, we counted it as on the market, even if other billing codes did not have list prices.

Sometimes, a single generic application can have multiple approval dates. If one of these approval dates occurred in the past two years, we included it in our analysis.

To determine whether a drug was a first generic, KHN used the FDA’s 2017 and 2018 lists of first generics as of Jan 2.

Sydney Lupkin: slupkin@kff.org, @slupkin

Jay Hancock: jhancock@kff.org, @JayHancock1

Becerra will take the national stage Tuesday when he gives the Spanish-language rebuttal to the president's State of the Union address. It will be far from his first time challenging President Trump's agenda.

This article was published February 4, 2019, by Kaiser Health News.

By Samantha Young, Kaiser Health News

When President Donald Trump demands a border wall or threatens to deport young unauthorized immigrants, one of the loudest opposition voices comes from the son of Mexican immigrants—who also happens to be California's top lawyer.

Democrat Xavier Becerra, the state's first Latino attorney general, is not only one of Trump's biggest critics, he is an unrelenting adversary in court, striking at Republican efforts to overturn federal rules not just on immigration, but on health care, birth control, climate change and more.

On Tuesday, Becerra, 61, will take the national stage when he gives the Spanish-language rebuttal to the president's State of the Union address. He has challenged the Trump agenda before.

Becerra has taken the Trump administration to court 45 times since former Gov. Jerry Brown appointed him to the job in 2017. In November, voters overwhelmingly gave him a four-year term, validating his decision to leave Congress after 24 years.

Becerra, whose wife is a doctor, is leading a coalition of 20 states and the District of Columbia in defending the Affordable Care Act against a Texas lawsuit that could determine the fate of the law—and with it, health coverage for millions of Americans. And he won a nationwide court injunction last year that blocked the Trump administration’s decision to end the Deferred Action for Childhood Arrivals (DACA) program, which allows qualified young people who were brought into the U.S. illegally as children to obtain temporary work permits.

When news reports last month revealed that Trump was considering diverting emergency disaster relief funds from California, Florida and Texas during the partial federal government shutdown, Becerra condemned the president on Twitter for poaching funds for a "reckless & lawless" border wall.

Related: California AG Blocks Sale of 2 Santa Clara Hospitals

Related: Judge Blocks Final Rule on Birth Control Coverage

The fights are ones that Becerra describes as personal. He talked to California Healthline’s Samantha Young about his role—and how his upbringing influences his legal decisions.

The following interview has been edited for length and clarity.

Q: You were a veteran member of Congress in a leadership role. Why did you take this job?

November 2016 hits. We have the election. All the things that I cared about were going to be placed in jeopardy by this new president.

I found myself thinking I probably could make a bigger difference as the attorney general for the entire state of California, defending everything I fought to erect, than as a minority member in the House of Representatives trying to make my point, but always losing.

I made a calculation. I think I made the right choice.

Q: You have sued the Trump administration 45 times on education, immigration, health care, birth control access, climate change and more. What's the one case you really wanted to win?

I'll give you two.

First, the Affordable Care Act, knowing how much it has been a game changer for families. I would never have believed that I’d be leading the effort to protect the entire Affordable Care Act as an attorney general for one of 50 states. But here I am.

The second one is the DACA litigation, because as the son of immigrants, I watched my parents struggle and saw the things they had to live through. I believe these DACA recipients are going to be some of the greatest leaders America has and it's because they had to go through so much like my parents did. So, it's very personal.

Q: Do you remember your parents' economic struggles as a child?

I thought I was middle class growing up as a kid. It really wasn't until I was driving with my mom to start my first day at Stanford University, driving through Palo Alto, that I realized I'm not middle class.

We always had decent food to eat. I never got a pair of Converse. I never had a pair of Levi's jeans. Never had that kind of stuff, but I always had clothes. It didn’t dawn on me that we were much different than other folks.

Q: How does your upbringing influence your decisions as attorney general?

Everything I do is informed by what I grew up with. I defend immigrants with a passion because I saw immigrants every day of my life. And I know how hard they work. I never saw a day where my dad didn't work.

My mom came here when she was 18 from Guadalajara, when she married my dad. Didn't know English. Learned it. She could always find a job, and when she learned English it became easier. But she could never go very high because she never went to college.

So, when someone wants to knock an immigrant, you're knocking my dad and my mom.

Q: You believe everyone should have access to health care. Was there ever a period in your life when you didn't have health insurance?

I don't ever recall a time when I didn't. That's why I'm such a big defender of unions. My dad was a construction worker. My dad got to the sixth grade. As difficult as it is for someone with a sixth-grade education to get a decent job, and while being a manual laborer and working construction doesn't make you a millionaire, if you work for a union it gets you basic benefits.

I knew what it meant to have health insurance, especially on the day my mom ended up having a miscarriage. She was hemorrhaging at home and she had to be rushed to the hospital. There was no hesitation.

We knew we could go to the doctor—and everybody should know that. For me, health care is a right. I've been a single-payer advocate all my life.

Q: Why do you think it's important to build coalitions with other states when challenging the Trump administration?

Lifting something by yourself is very difficult. When you get a team to do it, it just clicks so much easier. Maybe it's because I went through Congress more years in the minority than the majority, where you realize what it takes to actually cobble together a coalition to get something done. Or, maybe it's just that when you've been in a minority all your life, the son of immigrants with very little, you know it takes a team effort.

I got through Stanford knowing my family didn't have a lot of money, so I had to work, take out student loans and receive help from the government. It was a combination of a lot of things.

Q: What's your response to critics who say state attorneys general are "militarizing" their office to overturn policies your party can't block in Congress?

Which of the cases should we not have filed? The one to defend the Affordable Care Act, or the one to prevent women from losing access to birth control, or is it the one to allow DACA Dreamers to be deported, or is it the one to make sure that we are defending against a crazy border wall, or is it the one that should allow predatory for-profit colleges to continue to avoid having to provide relief to students who were defrauded?

We're not doing this because we're trying to attack the federal government or because we've got it out for this particular president. How would we explain to the people who would have been unprotected why we just watched, why we just spectated?

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.