Emily Gebel was diagnosed with breast cancer in early 2022. After Gebel moved her treatment from Seattle to Alaska, where she lived, she discovered it was priced much higher in her home state.

Ash Adams/KFF Health News

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Emily Gebel was diagnosed with breast cancer in early 2022. After Gebel moved her treatment from Seattle to Alaska, where she lived, she discovered it was priced much higher in her home state.

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Ash Adams/KFF Health News

Emily Gebel was trying to figure out why she was having trouble breastfeeding. That’s when she felt a lump.

Gebel, a mother of two children, went to her primary care doctor in Juneau, Alaska, who referred her for testing, she said.

Her 9-month-old was asleep in her arms when she got the results.

“I got the call from my primary care nurse telling me it was cancer. And I remember I just sat there for probably at least another half an hour or so and cried,” Gebel said.

Juneau, the state capital, has about 31,700 residents, who are served by the city-owned Bartlett Regional Hospital. But Gebel said she has several friends who have also had cancer, all of whom recommended she seek treatment out of town because they felt bigger cities would have better care.

She opted for treatment in Seattle, the closest major American city to Alaska. She underwent surgery at Virginia Mason Medical Center in September 2022. In January, she began chemotherapy at Lifespring Cancer Treatment Center, a stand-alone clinic that she said she selected because it offers a lower-dose chemotherapy.

During chemo, she learned she had stage 4 breast cancer, she said.

Commuting to Seattle for chemo every week — nonstop flights last as long as two hours and 45 minutes — became tiring. So Gebel began treatment at Bartlett Regional Hospital after her Seattle doctor taught hospital staffers there how to administer her chemo regimen.

Then the bill came.

The patient: Emily Gebel, 37, insured through her husband’s employer by Premera Blue Cross. She was previously covered by Moda Health.

Medical service: One round of metronomic chemotherapy, which involves regular infusions at lower but more frequent doses and over a longer period than traditional chemotherapy.

Service provider: Bartlett Regional Hospital and Lifespring Cancer Treatment Center. The hospital is a tax-exempt facility owned by the city and borough of Juneau, though most of its revenue comes from the services it provides, according to hospital officials. Lifespring is a stand-alone, doctor-owned cancer clinic in Seattle.

Total bill: The prices for Emily’s chemo infusions at Bartlett Regional Hospital varied week to week. A hospital bill showed one infusion in July was listed at $5,077.28 — more than three times the price for a similar mix of drugs at the Seattle clinic, $1,611.24.

What gives: In the United States, the price for the same medical service can vary based on where it is received. And for those living in remote areas like Alaska, the price difference can put care further out of reach.

Emily’s firsthand experience with this disparity began after her husband, Jered, requested a cost estimate from Bartlett Regional Hospital. It said Emily’s chemo would cost around $7,500 per weekly infusion, more than 4½ times what she had been charged in Seattle.

“The email came through with the bill estimate, and it’s like, ‘Oh my goodness, this has to be wrong,’” Jered said.

Jered said Emily had met her annual out-of-pocket maximum, meaning her insurance would cover the costs of her treatment, but from the start, the disparity just bothered him.

When Emily received a bill for a few rounds of her weekly chemo treatments, it showed that the hospital charged more than triple what the Seattle clinic did for a round of chemo, asking higher prices for every related service and medication she received that week.

The hospital charged about $1,000 for the first hour of chemo infusion, which is more than twice the rate at the Seattle clinic. One of Emily’s drugs cost $714, more than three times the price at the clinic.

It was even the tiniest things: The hospital charged $19.15 for Benadryl, about 22 times the clinic’s price of 87 cents.

Staff at Lifespring Cancer Treatment Center, the Seattle clinic, did not reply to requests for comment.

Sam Muse, the hospital’s former chief financial officer who no longer works there, said Bartlett Regional Hospital officials determined prices by looking at average wholesale prices and what other facilities in the region charge. Muse said the hospital had to account for high operating costs.

“Anything that we charge certainly has to take into consideration … the cost of just supplying healthcare in a rural setting like Juneau,” Muse said. “We’re not accessible by road at all, only ferry or plane.”

Juneau’s isolated geography makes reaching many resources a challenge. The city is part of the Alaska Panhandle, a narrow, island-speckled sliver of the state wedged between Canada, the Pacific Ocean, and Glacier Bay National Park & Preserve. Neither Anchorage nor Vancouver, its nearest major cities, is close by.

The hospital — the only one in the city and largest in the panhandle — treats a small number of cancer patients, at least a few hundred last year, Muse said. Its two oncologists live outside the city and fly into Juneau six times a month, said Erin Hardin, a hospital spokesperson.

Bartlett spent nearly $11 million last year to pay and fly in nurses, doctors, and other staffers who live outside the city, Muse said.

We’re “trying to find that happy medium between keeping care here and keeping costs down and how do we do that in a sustainable way for the long term,” Muse said.

Even though research shows Alaskans seek emergency care and are admitted to the hospital less often than many Americans, they had the third-highest health care expenditures per capita in 2020.

“Alaska is special in that it’s small, it’s remote, therefore it’s more expensive,” said Mouhcine Guettabi, an associate professor of economics at the University of North Carolina-Wilmington who studied health care costs in Alaska when he taught there.

Guettabi said hospitals often need to offer higher wages to recruit doctors and nurses willing to live in Alaska, which has a higher cost of living than most states.

Towns or entire regions may have few specialists and only one hospital, creating a dearth of competition that may drive up costs, Guettabi said. It’s also more expensive to ship items there, including medical supplies.

But Alaska’s costs are higher even when taking all those factors into account, Guettabi said. In Anchorage, for instance, prices for medical items increased nearly three times faster from 1991 through 2017 than prices overall.

Alaska also has a unique policy that may be increasing prices. Its “80th percentile rule” was enacted in 2004 to limit the amount of money patients pay when treated by providers outside their health insurers’ network. But like many experiments meant to rein in costs, the rule has instead been increasing health care spending, according to a study by Guettabi.

“Critics think the rule may be adding to that soaring spending, partly because over time providers could increase their charges — and insurance payments would have to keep pace,” the study noted.

The resolution: Emily received a bill from the hospital in September, more than five months after beginning treatment there.

It said Emily owed about $3,100 even though a previous explanation of benefits said she’d met her out-of-pocket limit.

Jered said he contacted hospital billing officials, who discovered that a medicine had been incorrectly coded and told Jered that Emily’s charge was zero.

“We know how hard it is to pay these ridiculous medical bills,” Jered said. “If I’m able to push back a little bit against this massive system, well, hey, maybe other people can, too. And who knows, maybe eventually health care prices can come down.”

Emily said she’s glad Jered knows how to handle the financial aspects of her care. Like many Americans, she could have just paid or ignored the incorrect bills, risking being sent to collections.

“I can’t imagine the amount of time I would have to spend on it while juggling parenting and also dealing with completing treatment, going through the sickness that goes along with that, and just generally feeling very run down,” she said.

The takeaway: Alaska government officials, nonprofits, and experts have suggested methods to lower the cost of health care. The state is considering repealing the 80^th percentile rule and implementing value-based care, which emphasizes paying providers based on health outcomes.

But what should Alaskans and other patients do in the meantime? If you live in a high-cost state, you might check out prices at a health care system in a state next door.

In any case, get ready to advocate for yourself.

Jered learned about medical billing by following the Bill of the Month series and reading “Never Pay the First Bill,” a book by Marshall Allen, a former ProPublica reporter.

Request itemized bills and make sure the codes match the services you received, Jered said. Note any prices that seem outrageous. If you have concerns, arrange an in-person meeting with an official in the provider’s finance department. If that’s not possible, a phone call is better than email. Make sure to document all conversations, so you have a record.

Come prepared with your documents and evidence, including the rate paid by Medicare, the federal insurance system for those 65 and older. Ask the official to explain the reasons for the codes and pricing before contesting anything. You can sometimes negotiate high-priced services down. And remember that the person you’re speaking with isn’t to blame for your health care costs.

“Don’t come at them angry, don’t come at them as viewing them as the enemy — because they’re not,” Jered said. “They are working within the same broken system.”

Emmarie Huetteman of KFF Health News edited the digital story, and Taunya English of KFF Health News edited the audio story. NPR’s Will Stone edited the audio and digital story.

KFF Health News, formerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.

As Congress barrels toward a government shutdown starting Sunday, a lapse in federal funding is poised to pause pay for thousands of federal workers in Alaska, while many government services could be hobbled.

If a shutdown happens, how long it will last and exactly how it will play out in Alaska is unclear.

Some federal agencies in Alaska, including those operating under the sprawling Interior Department, had not released specific plans as of Thursday.

But with just two days until government funding runs out, a fix appears less and less likely to arrive.

How will a shutdown affect Alaska’s federal employees?

Federally paid workers have a huge presence in Alaska, with its vast land ownership, 200-plus federally recognized tribes, and several military bases.

Alaska is home to 16,000 federal employees, state data shows. There are also 20,000 active-duty service members counted separately. Together, those workers represent a large portion of workers in the state

Many of those workers aren’t expected to be paid during a shutdown, though a 2019 law passed by Congress ensures they receive back pay when it’s over. Also, Alaska Republican Sen. Dan Sullivan is leading a bill to pay military personnel during the shutdown, but it was blocked Wednesday.

Oct. 13 will be the first day many federal workers miss paychecks, should the shutdown extend to that point.

Furloughed federal workers can sign up for unemployment compensation through the state, but they’re required to repay that money when they receive back pay, according to the Alaska Department of Labor and Workforce Development.

[Federal government starts notifying employees a shutdown may be imminent]

Federal employees who must continue working during the shutdown are not eligible for unemployment compensation, even if they’re not paid while working, since they’re not unemployed, the agency says.

A statement from Gov. Mike Dunleavy’s office said that 4,700 state executive branch positions are at least partially federally funded, but will see no disruption in pay and will report to work. The federal government will determine the status of federal employees who work in state of Alaska departments, the statement said.

What services will continue?

Despite the shutdown, several federal programs like Social Security, Medicare and veterans benefits should continue as usual.

Medicare is funded permanently, so benefits will not be affected by a shutdown. Medicaid would also operate for the time being since the program is funded for the next three months.

The Centers for Medicare and Medicaid Services could experience some administrative disruptions. According to the agency’s contingency plan, more than half of its staff will be furloughed, which could cause processing lags.

Like Medicare, Social Security is not subject to annual appropriations, so in the event of a shutdown the Social Security Administration would continue to send checks.

Veterans benefits like pensions and health care would also continue, and most of the Department of Veterans Affairs will keep working through a shutdown.

For food assistance, the Supplemental Nutrition Assistance Program will maintain operations through October, according to Shirley Sakaye with the Alaska Department of Health.

“If the shutdown goes beyond October, the feds have stated they will provide guidance to states,” Sakaye said by email.

Benefits for the Women, Infants and Children program “will be funded through December” using unspent funds, she said.

The U.S. Postal Service will still deliver mail uninterrupted during a shutdown, and all post offices will remain open. USPS is not funded through tax dollars, so it won’t be impacted by a shutdown.

[How a government shutdown would affect Medicare and Medicaid benefits]

Alaskans will be able to apply for passports from the U.S. Passport Agency, but with the agency facing furloughs and an already extensive backlog, securing a passport could take longer than usual.

The National Weather Service will continue operating its regular schedule, keeping up forecasts, warnings and observations, spokeswoman Maureen O’Leary said in an email. Also, critical functions such as radar repair will continue, she said.

But routine equipment maintenance, upgrades to forecast models and other longer-term improvements to service delivery will be delayed, she said.

As far as state services go, the statement on Tuesday from the governor’s office said Alaska is prepared to continue state-administered federally funded programs for 34 days — the length of the most recent shutdown that ended in 2019.

If a shutdown lasts longer than that, the state “will reevaluate the situation if necessary, and prioritize programs that most directly impact the life, health, and safety of Alaskans,” the governor’s office said.

Active-duty military operations, including search and rescue, will also continue through a shutdown even as service members miss paychecks.

What services might be paused?

A shutdown will likely lead to wide-ranging impacts, both big and small. Applications for social service programs could be stalled, permitting efforts could be put on hold, small-business loans could be delayed, and many federal contractors aren’t paid.

The White House this week said a shutdown will leave disaster relief programs underfunded, delaying 14 long-term recovery projects in Alaska, and many more in the U.S. The White House did not say which projects in Alaska would be affected. The Federal Emergency Management Agency did not respond to an email seeking comment.

[FEMA delays $2.8 billion in disaster aid to keep from running out of money]

The White House also said travel could be delayed during a shutdown as air traffic controllers and Transportation Security Administration agents work without pay, including about 730 such workers in Alaska.

Transportation Secretary Pete Buttigieg has also raised concerns that air traffic controllers in training will be furloughed, hamstringing the department’s efforts to fill a controller shortage.

During the 2019 partial shutdown that lasted five weeks, 10% of TSA agents nationally, who were not getting paid, called in sick, exacerbating delays.

Public meetings scheduled in Alaska while the government is shut down would also likely be canceled until it ends, federal officials say.

That includes two public meetings on the Biden administration’s environmental review of the oil and gas lease program in the Arctic National Wildlife Refuge. The first is set for Fairbanks on Monday.

Other federal meetings that could be canceled next week include subsistence regional advisory council meetings in Kenai and Arctic Village to discuss hunting and trapping regulations.

In Alaska, past shutdowns have also delayed permitting for commercial fishing boats, hobbled planning and preparation for wilderness firefighting efforts in Alaska, and led to closures or limited services at national parks, including those in Alaska.

What is Alaska’s congressional delegation doing?

The Alaska congressional delegation has said Congress should try to avoid a shutdown, though at this point, averting or blunting a lapse in appropriations appears unlikely.

Sen. Sullivan introduced the “Pay Our Military Act” to ensure members of the military will receive paychecks during a shutdown. His fellow Alaska Republican, Sen. Lisa Murkowski, and 14 other GOP senators have signed on.

Sullivan attempted to fast-track the bill on the Senate floor Wednesday.

“It’s pretty simple, in the event of a shutdown — and right now we are all working hard to make sure we avoid it — we need to make sure that the men and women who protect us get paid. That’s it,” Sullivan said on the Senate floor.

Sullivan made a similar attempt last week to pass a bipartisan bill treating Coast Guard pay like the rest of the military in the case of the shutdown. Due to the Coast Guard’s funding mechanism, during the shutdown ending in 2019, Coast Guard members were not paid alongside the rest of the military.

Both Sullivan-led bills have hit roadblocks from Democratic leadership.

Alaska Democratic Rep. Mary Peltola signed onto similar Coast Guard legislation in the House.

This week, the Senate also began work on a 45-day short-term funding measure. Murkowski and Sullivan have supported two procedural Senate votes this week to advance a spending plan.

But if the Senate bill passed in its current form, it’s likely dead on arrival in the House. House Republican leadership has floundered while trying to pass their own short-term spending legislation to avoid a shutdown.

Peltola is in Alaska taking time to grieve the loss of her late husband, Eugene “Buzzy” Peltola Jr., who died in a plane crash earlier this month.

Peltola spokesman Sam Erickson said Peltola is receiving updates from the House floor and she will be prepared to return to D.C. if her vote is necessary to avert a shutdown.

What are the potential economic impacts for Alaska?

Neal Fried, a recently retired state economist, said the federal workforce in Alaska is large and well-compensated.

Delayed payment of their wages won’t damage the economy if the shutdown lasts a short period, as they typically have in the past, he said.

“But if it drags on for months, it will obviously be felt in the economy,” he said.

Federal civilian employees averaged about $90,000 in pay last year, compared to about $65,000 for the average Alaskan, he said.

Jonathan King, an economist who owns Halcyon Consulting in Anchorage, said a prolonged shutdown will be stressful for people who don’t collect paychecks.

He said a shutdown could temporarily lead to less spending in the economy, but it shouldn’t cause long-term economic impacts in part because workers will receive back pay.

“The bigger economic effects are the lost productivity,” he said. “Environmental impact statements won’t get reviewed. Permits won’t get issued. So that’s sort of the hidden effect, the work that doesn’t get done in those periods.”

Non-essential federal employees reached for this article said that if a shutdown begins on Sunday, they expected to receive an email Monday explaining that they would not be permitted to work during the shutdown.

Daily News reporter Annie Berman contributed to this report.

A Peruvian national has been arrested for sending more than 150 fake bomb threats to schools across the United States, including several in Alaska.

Peruvian authorities arrested Eddie Manuel Nunez Santos, 33, in Lima, Peru, on Tuesday.

Nunez Santos is charged in the Southern District of New York with sending threatening communications, as well as soliciting a 15-year-old child for nude and sexual photographs. After she and other children refused to comply with his requests – made in an online game, while Nunez Santos posed as a teenager named “Lucas” –  he emailed bomb threats to school districts, synagogues, airports, hospitals, and a shopping mall in retaliation, according to the federal charges.

The threats were sent out between Sept. 15 and 21 to communities in Alaska, New York, Pennsylvania, Connecticut and Arizona.

“I placed multiple bombs in all of the schools from your School Districts,” Nunez Santos is alleged to have written in one of the emails. “The bombs will blow up in a few hours.”

The charges say an FBI agent was able to track down a phone number associated with Nunez Santos through the email domain names and providers.

Schools across Alaska had varying responses to the threats. Dillingham closed its schools, while districts in the Annette Island and Southeast Island districts evacuated their schools in response. The Anchorage School District also received threats but opted not to close schools.

“The threat is broad in nature and lacks specific information,” Corey Young, an Anchorage School District spokesman, wrote in an email to parents at the time. “Regardless, we are taking this threat seriously.”

In total, federal authorities say thousands of schoolchildren were evacuated across the country.

“Not only did Santos allegedly email hundreds of hoax bomb threats terrorizing schools, hospitals, and houses of worship, he also perversely tried to sextort innocent teenage girls,” said James Smith, Assistant Director in Charge of the New York FBI Field Office. “His actions wasted limited law enforcement resources, put first responders in unnecessary danger, and victimized children.”

According to the charges, Nunez Santos is a web developer in Peru and used a virtual private network to communicate with the underage victims. VPNs are often used to mask a person’s online activity.

The charges against Nunez Santos carry a possible sentence ranging from 30 years to life in prison.