Christian Bartulovich

Big hospital systems, insurers, and drug companies have consolidated to the point where patients have almost no leverage left.

The one I’d put first is scope of practice. Pennsylvania still requires nurse practitioners to hold a signed collaborative agreement with two physicians. In practice that often means paying a doctor hundreds of miles away a cut of monthly revenue for a signature that gets used once or twice a year. That requirement isn’t protecting anybody. It’s a paper tether, and about thirty states have already moved past it. Bills to change it here have had Republican and Democratic sponsors, passed one chamber, died in the other, and come back again. I worked as a paramedic before this, and in a lot of Carbon County the emergency room is primary care because there’s nothing else within a reasonable drive of where people live or no appointments available if there were.

Second is hospital consolidation. Mergers and ownership changes came before more than 90 percent of Pennsylvania’s hospital closures. Right now the Attorney General usually finds out a hospital has been sold or gone bankrupt after it’s too late to do anything. That’s the piece I’d fix first: notice and disclosure before a deal closes, with the criteria written into statute so everyone knows the standard going in. What I don’t want is a vague public interest test that gets litigated case by case, because that’s how you end up with the outcome depending on who’s in the office rather than what the law says. And whatever standard we set should apply the same way regardless of whether the buyer is for-profit or nonprofit. A hospital that closes is closed either way.

On drug costs, Act 77 of 2024 gave the Insurance Department real authority over pharmacy benefit managers and banned spread pricing. Congress went further this February with rebate pass-through requirements. That’s progress. The open question is enforcement and whether independent pharmacies in places like ours actually have somewhere to go when a PBM terminates their contract or drags a dispute out of state. I’d want to see how Act 77 is working in practice before deciding what still needs fixing.

Insurers get less attention in all this than hospitals do. Act 146 gave Pennsylvanians the right to an independent outside review when a claim gets denied, and about half of the appeals that get filed end up overturned. But roughly one in seven claims filed by Pennsylvanians gets denied, and the state saw around 500 appeals in the program’s first year. Almost nobody knows the option is there. Fixing that costs almost nothing and would help a lot of people.

The last one is simple. Hospitals have been required to post their prices since 2021, compliance is still spotty, and Pennsylvania puts nothing behind the federal rule. If we’re going to have the requirement, it should mean something.

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