KFF Health News' 'What the Health?': A Not-So-Health-y GOP Debate
The Host
Julie Rovner
KFF Health News
Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
For the first time since 2004, it appears health insurance coverage will not be a central issue in the presidential campaign, at least judging from the first GOP candidate debate in Milwaukee Wednesday night. The eight candidates who shared the stage (not including absent front-runner Donald Trump) had major disagreements over how far to extend abortion restrictions, but there was not even a mention of the Affordable Care Act, which Republicans have tried unsuccessfully to repeal since it was passed in 2010.
Meanwhile, a new poll from KFF finds that health misinformation is not only rampant but that significant minorities of the public believe things that are false, such as that more people have died from the covid vaccine than from the covid-19 virus.
This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico, Victoria Knight of Axios, and Margot Sanger-Katz of The New York Times.
Panelists
Joanne Kenen
Johns Hopkins Bloomberg School of Public Health and Politico
Victoria Knight
Axios
Margot Sanger-Katz
The New York Times
Among the takeaways from this week’s episode:
- The first Republican presidential debate of the 2024 cycle included a spirited back-and-forth about abortion, but little else about health care — and that wasn’t a surprise. During the primary, Republican presidential candidates don’t really want to talk about health insurance and health care. It’s not a high priority for their base.
- The candidates were badly split on abortion between those who feel decisions should be left to the states and those who support a national ban of some sort. Former Vice President Mike Pence took a strong position favoring a national ban. The rest revealed some public disagreement over leaving the question completely to states to decide or advancing a uniform national policy.
- Earlier this summer, Stanford University’s Hoover Institute unveiled a new, conservative, free-market health care proposal. It is the latest sign that Republicans have moved past the idea of repealing and replacing Obamacare and have shifted to trying to calibrate and adjust it to make health insurance a more market-based system. The fact that such plans are more incremental makes them seem more possible. Republicans would still like to see things like association health plans and other “consumer-directed” insurance options. Focusing on health care cost transparency could also offer an opportunity for a bipartisan moment.
- In a lawsuit filed this week in U.S. District Court in Jacksonville, two Florida families allege their Medicaid coverage was terminated by the state without proper notice or opportunity to appeal. It seems to be the first such legal case to emerge since the Medicaid “unwinding” began in April. During covid, Medicaid beneficiaries did not have to go through any kind of renewal process. That protection has now ended. So far, the result is that an estimated 5 million people have lost their coverage, many because of paperwork issues, as states reassess the eligibility of everyone on their rolls. It seems likely that more pushback like this is to come.
- A new survey released by KFF this week on medical misinformation found that the pandemic seems to have accelerated the trend of people not trusting public health and other institutions. It’s not just health care. It’s a distrust of expertise. In addition, it showed that though there are people on both ends — the extremes — there is also a muddled middle.
- Legislation in Texas that was recently signed into law by Republican Gov. Greg Abbott hasn’t gotten a lot of notice. But maybe it should, because it softens some of the state’s anti-abortion restrictions. Its focus is on care for pregnant patients; it gives doctors some leeway to provide abortion when a patient’s water breaks too early and for ectopic pregnancies; and it was drafted without including the word “abortion.” It bears notice because it may offer a path for other states that have adopted strict bans and abortion limits to follow.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week they think you should read, too:
Julie Rovner: KFF Health News’ “Doctors and Patients Try to Shame Insurers Online to Reverse Prior Authorization Denials,” by Lauren Sausser.
Margot Sanger-Katz: KFF Health News’ “Life in a Rural ‘Ambulance Desert’ Means Sometimes Help Isn’t on the Way,” by Taylor Sisk.
Joanne Kenen: The Atlantic’s “A Simple Marketing Technique Could Make America Healthier,” by Lola Butcher.
Victoria Knight: The New York Times’ “The Next Frontier for Corporate Benefits: Menopause,” by Alisha Haridasani Gupta.
Also mentioned in this week’s episode:
- NPR’s “Two Families Sue Florida for Being Kicked off Medicaid in ‘Unwinding’ Process,” by Selena Simmons-Duffin
- NPR’s “Texas Has Quietly Changed Its Abortion Law,” by Selena Simmons-Duffin.
- KFF’s “Poll: Most Americans Encounter Health Misinformation, and Most Aren’t Sure Whether It’s True or False.”
Click to open the transcript
Transcript: A Not-So-Health-y GOP Debate
[Editor’s note: This transcript, generated using transcription software, has been edited for style and clarity.]
Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News. And I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Aug. 24, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So, here we go. We are joined today via video conference by Margot Sanger-Katz of The New York Times.
Margot Sanger-Katz: Good morning.
Rovner: Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico.
Joanne Kenen: Hi, everybody.
Rovner: And Victoria Knight of Axios News.
Victoria Knight: Hello, everyone.
Rovner: No interview this week, but we’ll have an entire interview episode next week. More on that later. First, we will get to this week’s news. Well, Wednesday night saw the first Republican presidential debate of the 2024 cycle, minus front-runner Donald Trump, in what could only be called a melee, on Fox News Channel. And while there was a spirited debate about abortion, which we’ll get to in a minute, I didn’t hear a single word about anything else health-related — not Medicare or Medicaid, nor any mention of the Affordable Care Act. Was anybody surprised by that? For the record, I wasn’t. I wasn’t really expecting anything except abortion.
Kenen: Well, somebody, I think it was [former New Jersey Gov. Chris] Christie actually pointed out that nobody was talking about it.
Knight: Mike Pence. It was [former Vice President] Mike Pence, actually.
Kenen: Oh, Pence. OK. “Nobody’s talking about Medicare and Social Security.” And then he didn’t talk about it, and nobody mentioned the ACA.
Rovner: Is the ACA really gone as a Republican issue, for this cycle, do we think?
Kenen: Well, I think it’s become, like, a guerrilla warfare. Like, they’re still trying to undermine it. They’re not trying to repeal it, but they’re looking at its sort of soft underbelly, so to speak, and trying to figure out where they can put more market forces on, which we can sort of come back to later. But they spent 10 years trying to repeal it, and they just figured out what they’ve got to do now is pretend it’s not there. Right now, abortion is their topic.
Rovner: Well, let us turn to that.
Sanger-Katz: Yeah, I was just going to say that we’ve been seeing this happen a little bit over the last couple of cycles. In the 2020 race — I went through the transcripts of all of the speakers during the Republican National Convention and was really staggered by how few mentions of Obamacare there were relative to the way that the issue had been discussed in the past. But I think — just a note, that this is the Republican debate. Republicans don’t really want to be talking about health insurance and health care, because they don’t really have affirmative plans to put forward and because I think that they see that there are some real political liabilities in staking out a strong position on these issues. But in a general election, I think it will be impossible for them to avoid it, because, I think, Joe Biden has a lot of things that he wants to say. I think he is very committed to, in particular, broadcasting that he wants to protect Medicare. I think he’s quite proud of the expansions that he’s made of the Affordable Care Act. And so, this is a little bit of a weird moment in the race because, you know, we really only have one party that’s having a primary, and its leading candidate is not participating in the debates. And so, I think these candidates are trying to focus elsewhere. But it is — I will say, as someone who’s covered a couple of these now — it is a weird experience to have health care and health policy feel like a second-tier issue, because it was so central — Obamacare, in particular — was just so central to so many of these election cycles and such an animating and unifying issue among Republican voters, that this kind of post-failure-of “repeal and replace” era feels very different.
Kenen: One really quick thing is, they’re going to hit Biden on inflation. Economically, it’s his most vulnerable point, and health care costs are a burden. And I was a little surprised, without going into Obamacare and repeal and all that stuff, they mentioned the price of food, the price of gas, they mentioned interest rates and housing. It would have been really easy, and I expect that at some point they will start doing it, to talk about the cost of health care, because Biden’s done a huge amount on coverage and making insurance more affordable and accessible. But the cost of health care, as we all know, is still high in America.
Rovner: And at very least, the cost of prescription drugs, which has been a bipartisan issue going back many, many years. All right. Well, the one health issue that, not surprisingly, did get a lot of attention last night was abortion. With the exception of Mike Pence, who has been an anti-abortion absolutist for his entire tenure in Congress, as governor of Indiana, and as vice president, everyone else looked pretty uncomfortable trying to walk the line between the very anti-abortion base of the party and the recognition that anti-abortion absolutism has been a losing electoral strategy since the Supreme Court overturned Roe last year. What does this portend for the rest of the presidential race and for the rest of the down-ballot next year? Rather than trying to bury the fact that they all disagree, they all just publicly disagreed?
Knight: And I think they also, like, if you listened, [former U.S. ambassador to the United Nations] Nikki Haley kind of skirted around how she would address it. She talked about some other things, like contraception and saying that there just weren’t enough votes in the Senate to pass any kind of national abortion ban. [Florida Gov.] Ron DeSantis also, similarly, said he was proud of his six-week bill but didn’t quite want to answer about a national abortion ban. There were the few that did say, like, Hey, we’re into that. And some said, You know, it needs to go back to the states. So there definitely was kind of this slew of reactions on the stage, which I think just shows that the Republican Party is figuring out what message, and they don’t have a unified one on abortion, for sure.
Rovner: I do want to talk about Nikki Haley for a second, because this is what she’s been saying for a long time that she thinks that there’s a middle ground on abortion. And, you know, bless her heart. I’ve been covering this for almost 40 years and there has never been a middle ground. And she says, well, everybody should be for contraception. Well, guess what? There’s a lot of anti-abortion stalwarts who think that many forms of contraception are abortion. So there isn’t even a consensus on contraception. Might she be able to convince people that there could be a middle ground here?
Sanger-Katz: Oh, what I found sort of interesting about her answers: I think on their face they were kind of evasive. They were like, I don’t need to answer this question because there’s not a political consensus to do these things. But I do think it was sort of revealing of where the political consensus is and isn’t that I think she’s right. Like, realistically, there aren’t the votes to totally ban abortion; there aren’t the votes to renew the Roe standard. And I think she was in some ways very honestly articulating the bind that Republicans find themselves in, where they, and I think a lot of their voters, have these very strong pro-life values. At the same time, they recognize that getting into discussions about total abortion bans gives no favors politically and also isn’t going to happen in the near future. So, I felt like, as a journalist, you know, thinking about how I would feel having asked her that question, I felt very dissatisfied by her answer, because she really didn’t answer what she would like to do. But I do think she channeled the internal debate that all these candidates are facing, which is, like, is it worth it to go all the way out there with a policy that I know will alienate a lot of American voters when I know that it cannot be achieved?
Rovner: I was actually glad that she said that because I’ve been saying the opposite is true also — everybody says, well, why didn’t, you know, Congress enshrine abortion rights when they could have? The fact is, they never could have. There have never been 60 votes in the Senate for either side of this debate. That’s why they tried early after Roe to do national bans and then a constitutional amendment. They could never get enough votes. And they tried to do the Freedom of Choice Act and other abortion rights bills, and they couldn’t get those through either. And this is where I get to remind everybody, for the 11,000th time, the family planning law, the Title X, the federal Family Planning [Services and Public Research] Act, hasn’t been reauthorized since 1984 because neither side has been able to muster the votes even to do that. Sorry, Joanne, you wanted to say something.
Kenen: No, I thought Haley’s response on abortion was actually really pretty interesting on two points, right? She didn’t technically answer the question, but she also said this question is a fantasy — you know, face it. And, you know, she said that, and then she mentioned the word contraception. She did not dwell on it. She sort of said it sort of quickly. She missed an opportunity, maybe, just for one or two more sentences. You know, she said we need to make sure that contraception … she’s the only woman on that stage. She’s a mother; she’s got two kids. And, you know, there is uncertainty. After Dobbs there were advocacy groups saying, you know, they’re going to ban contraception tomorrow, and that didn’t happen. And we still don’t know how that fight will play out and what types of contraception will be debated. But I noticed that she said that on a stage full of Republicans, and I noticed that nobody else — all men — didn’t pick up on it.
Rovner: The big divide seemed to be, do you want to leave it completely to the states or do you want to have some kind of national floor of a ban? And they seemed, yeah —
Kenen: Yeah, and the moderators didn’t pick up on that. I mean, there was such a huge brouhaha on the stage. You know, the moderators had a lot of trouble moderating last night. It wouldn’t have been easy for them to get off of abortion and follow up on contraception. But I thought it was just sort of an interesting thing that she noted it.
Sanger-Katz: I will say also, and I agree with Julie: With the possible exception of Mike Pence, even the candidates that were endorsing some kind of national abortion policy, we’re talking about a 15-week gestational limit. There really wasn’t anyone who was coming out and saying, “Let’s ban all abortions. Let’s even go to six weeks,” which many of the states, including Florida, have done. So I do think, again, like, even the candidates that were more willing to take an aggressive stand on whether the federal government should get involved in this issue were moderating the position that you might have expected for them before Dobbs.
Kenen: But even 15 weeks shows how the parameters of this conversation have changed, because what the Republicans had been doing pre-Dobbs was 20 weeks, with their so-called fetal-pain bills. So 15 weeks, which would have sounded extremely radical two years ago — compared to six weeks, 15 sounds like, oh, you know, this huge opportunity for the pro-choice people. And it is another sign of how this space has shrunk.
Sanger-Katz: Yeah, no, I don’t mean that it’s a huge opportunity for the pro-choice people, but I think it reflects that even the candidates who were willing to go the most out on the limb in wanting to enforce a national abortion restriction understand the politics do not permit them to openly advocate going all the way towards a full ban.
Rovner: While we are on the subject of Republicans and health, there actually is a new Republican plan to overhaul the health system. Sort of. It’s from the Hoover Institution at Stanford, from which a lot of conservative policy proposals emanate. And it’s premised on the concept that consumers should have better control of the money spent on their health care and a better idea of what things cost. Now, this has basically been the theme of Republican health plans for as long as I can remember. And the lead author of this plan is Lanhee Chen, who worked for Republicans in the Senate and then led presidential candidate Mitt Romney’s policy shop, and whose name has been on a lot of conservative proposals. But I find this one notable more for its timing. Republicans, as we mentioned, appear to have internalized the idea that the only thing they can agree on when it comes to health care is that they don’t like the Affordable Care Act. Is that changing or is this just sort of hope from the Republican side of the policy wonk shop?
Sanger-Katz: I think this is connected to the discussion that we had about the debate, but it feels to me like we are in a bit of a post Obamacare era where the fights about “Are we going to continue to have Obamacare or not?” have sort of faded from the mainstream of the discussion. But there’s still plenty of discussion to be had about the details. The Democrats clearly want to expand Obamacare in various ways. Some of those they have done in a temporary fashion. Others are still on the wish list. And I think this feels very much like the kind of calibration adjustment, you know, small changes, tinkers on the Republican side to try to make the health insurance market a little bit more market-based. But this is not a big overhaul kind of plan. This is not a repeal-and-replace plan. This is not a plan that is changing the basic architecture of how most Americans get their insurance and how it is paid for. This is a plan that is making small changes to the regulation of insurance and to the way that the federal government finances certain types of insurance. That said, I think the fact that it’s more incremental makes it feel like these are things that are more likely to potentially happen because they feel like there are things that you could do without having a huge disruptive effect and a big political backlash and that you could maybe develop some political consensus around.
Rovner: It does, although I do feel like, you know, this is a very 2005 plan. This is the kind of thing that we would have seen 15 years ago. But as Democrats have gotten the Affordable Care Act and discovered that the details make it difficult, Republicans have actually gotten a lot on the transparency side and, you know, helping people understand what things cost. And that hasn’t worked very well either. So there’s a long way to go, I think, on both sides to actually make some of these things work. Victoria, did you want to add something?
Knight: Yeah, I’ve been talking to Republicans a lot, trying to figure out like what is their next go-to going to be. And I think they’re pretty understanding that ACA is set in place, but they still don’t want to give up that there are alternative types of health insurance that they want to put out there. And I think that seems that’s kind of what they realize they can accomplish if they get another Republican president and they’re going to try to do association health plans again. They’re going to try to expand some of these what they call health reimbursement arrangements, things like that, to just like kind of try to add some other types of health insurance options, because I think they know that ACA is just too entrenched and that there’s not much else they can do outside of that. And then, yeah, I think focus a little more on the transparency and cost because they know that’s a winning message and that is the one thing in Congress right now on the health care end that seems to have bipartisan momentum for the most part.
Rovner: Yeah, I think you’re absolutely right. Well, another issue that could have come up in last night’s debate but didn’t was the unwinding of Medicaid coverage from the pandemic. The news this week is that the first lawsuit has been filed accusing a state of mistreating Medicaid beneficiaries. The suit filed against Florida by the National Health Law Program and other groups is on behalf of two kids, one with a disability, and a mom who recently gave birth. All would seem to still be eligible, and the mom says she was never told how to contest the eligibility determination that she was no longer eligible, and that she was cut off when she tried to call and complain. State officials say their materials have been approved by the Centers for Medicare & Medicaid Services, which they have, and that Florida, in fact, has a lower procedural disenrollment rate than the average state, which is also true. But with 5 million people already having been dropped from Medicaid, I imagine we’re going to start to see a little more pushback from advocacy groups about people who are, in all likelihood, still eligible and have been wrongly dropped. I’m actually a little surprised that it took this long.
Kenen: Many of the people who have been dropped, if they’re still eligible, they can get recertified. I mean, there’s no open enrollment season for Medicaid. If you’re Medicaid-eligible, you’re Medicaid-eligible. The issue is, obviously, she didn’t understand this. It’s not being communicated well. If you show up at the hospital, they can enroll you. But people who are afraid that they aren’t covered anymore may be afraid of going to the hospital even if they need to. So there’s all sorts of bad things that happen. In some of these cases, there are simple solutions if the person walks in the door and asks for help. But there are barriers to walking in the door and asking for help.
Rovner: I was going to say one of the plaintiffs in this lawsuit is a child with a disease …
Kenen: Cystic fibrosis.
Rovner: Right. That needs expensive drugs and had not been able to get her drugs because she had been cut off of Medicaid. So there’s clearly stuff going on here. It’s probably true that Florida is better than the average state, which means that the average state is probably not doing that well at a lot of these things. And I think we’re just starting to see, you know, it’s sort of mind-numbing to say, oh, 5 million people have been separated from their health insurance. And again, we have no idea how many of those have gotten other health insurance, how many of those don’t even know and won’t know until they show up to get health care and find out they’re no longer covered. And how many people have been told they’re no longer covered but can’t figure out how to complain and get back on?
Sanger-Katz: And it’s this very extreme thing that’s happening right now. But it is, in many ways, the normal system on steroids. You know, if you’ve been covering Medicaid for any period of time, as all of us have, like, people get disenrolled all of the time from Medicaid for these administrative reasons, because of some weird hiccup in the system, they move, their income didn’t match in some database. This is a problem that a lot of states face because they have financial incentives often to drop people off of Medicaid because they have to pay a portion of the cost of providing health care. And a lot of them have rickety systems, and they’re dealing with a population that often has unstable housing or complicated lives that make it hard for them to do a lot of paperwork and respond to letters in a timely way. And so part of the way that I’ve been thinking about this unwinding is that there’s a particular thing that’s happening now, and I think there’s a lot of scrutiny on it, appropriately. And I think that there should be to make sure that the states are not cutting any corners. But I also think in some ways it’s sort of like a way of pressure-testing the normal system and reminding us of all of the people who slip through the cracks in normal times and will continue to do so after this unwinding is over. And these stories in Florida, to me, do not feel that dissimilar from the kinds of stories that I have heard from patients and advocates in states long before this happened.
Rovner: Yeah, I think you’re right. It’s just shining a light on what happens. I mean, it was the oddity that they were … states were not allowed to redetermine eligibility during the pandemic because normally states are required to redetermine eligibility at least once a year. And I think some do it twice a year. So it’s, you know, these redeterminations happen. They just don’t happen all in a huge pile the way they’re happening now. And I think that’s the concern.
Sanger-Katz: And it also, I think, really shines a light on the way that Medicaid is structured, where the Affordable Care Act simplified it quite a lot because, [for example], you’re in an expansion state and you earn less than a certain amount of money, then you can get Medicaid. But there are all of these categories of eligibility where, you know, you have to be pregnant, you have to be the parent of a child of a certain age. You have to demonstrate that you have a certain disability. And I think [it] is a reminder that this is a pretty complicated safety net, Medicaid. You know, there’s lots of things that beneficiaries have to prove to states in order to stay eligible. And there’s lots of things, honestly, you know, if states really want to make sure that they are reserving resources for the people who need them, that they do need to be checking on. And so I think we’re all just sort of seeing that this is a messy, complicated process. And I think we’re also seeing that there are these gaps and holes in who Medicaid covers. And it’s not the case that we have a perfect and seamless system of universal coverage in this country. We have this patchwork and people do fall between the cracks.
Kenen: And this is one of the most vulnerable populations, obviously. Some of the elderly are also very vulnerable, but these are people who may not speak either English or Spanish. They don’t have access to computers necessarily. I mean, we’re giving the least assistance to the population that needs the most assistance. And, you know, I mean, I think if Biden wanted to be really savvy about fixing it, he’d come out with some slogan about “Instead of Medicare unwinding, it’s time to have Medicare rewinding,” or something like that, because they’re going to have to figure … I mean, they have taken some steps, but it’s a huge mess, and the uninsurance rate is going to go up, and hospitals are going to have patients that are no longer covered, and it’s not going to be good for either the health care system or certainly the people who rely on Medicaid.
Rovner: I think it’s noteworthy how much the administration has been trying not to politicize this, that apparently, you know, we keep hearing that they won’t even tell us which states, although you can … people can sort of start to figure it out. But, you know, states that are having a more difficult time keeping eligible people on the rolls, shall we say, when the administration could have … I mean, they could be trumpeting, you know, which states are doing badly and trying to shame them. And they are rather very purposely not doing that. So I do think that there’s at least an attempt to keep this as collegial, if you will, as possible in a presidential election year. So my colleagues here at KFF have a depressing, but I guess not all that surprising, poll out this week about medical misinformation and how much of the public believes things that simply aren’t true — like that more people died from the covid vaccine than covid itself, or that ivermectin is a useful treatment for the virus. It’s not. It’s for parasites. And the survey didn’t just ask about covid. People have been exposed to, and a significant percentage believe, things like that it’s harder to get pregnant if you’ve been on birth control and stop. It isn’t. Or that people who keep guns in their house are less likely to be killed by a gun than those who don’t. They’re not. But what’s really depressing is the fact that the pandemic seems to have accelerated an already spiraling trend in distrust of public institutions in general: government, local and national media, and social media. Are we ever going to be able to start to get that back? I mean, you know, we talk about the woes with public health, but this goes a lot deeper than that, doesn’t it?
Kenen: And it’s not just health care. When you look at historical metrics about trust — which I’ve had to for a course I teach — we were never a very trusting society, it turns out. We’ve had large sectors of the population haven’t been trusting of many institutions and sectors of society for decades. We’re just not too huggy in this country. It’s gotten way worse. And what you said is right, but it’s broad. It’s not just doctors. It’s not just vaccines, it’s expertise. This distrust is really corrosive. But of all the things in that survey, one that really blew me away was we’re like, what, 13 years since Obamacare was passed? Only 7% or 8% — “only,” I should say only in quotes, you know — only 7% or 8% still thought there were death panels, but something like 70% wasn’t sure if there were death panels. Like, has anyone known anyone who went before a death panel? Since 2010? And yet 70% — I mean, I may be a little off, I didn’t write it down — but it’s something like 70% weren’t sure. And that is a mind-blowing number. It just says, you know, they weren’t ready to come out and say, yes, there are death panels. But that meant that a lot of Democrats also weren’t sure if there were death panels There are no death panels.
Knight: I was just gonna say, I also thought it was interesting that it showed people do use social media to get a lot of their information, but then they also don’t trust the information that they get on there. So it’s kind of like, yeah …
Rovner: And they’re right not to!
Knight: Yeah, they’re absolutely right not to. But then it’s also like, well, they’re then just not getting health information at all, or if they’re getting it, they just don’t trust it. So just showcasing how difficult it is to fill that void of health information, like, people just aren’t getting it or don’t trust it.
Rovner: I feel like some of this is social literacy. I mean, you know, we talk about health literacy and things that people can understand, but, you know, people don’t understand the way journalism works, the difference between the national news and what you see on Facebook. And I think that’s, Joanne, going back to your point about people not trusting expertise, it’s also not being able to figure out what expertise is and who has expertise. I mean, that’s really sort of the bottom line of all this, isn’t it?
Kenen: Well, I mean, I was doing some research — I can’t remember the exact details, this was something I read several months ago — but there was one survey maybe a couple of years ago where the majority of people said they don’t trust the news they read, but they’re still getting their news from something that they don’t trust. So it sounds sort of funny, but it’s actually not. I mean, it’s really a crisis of people don’t know what to believe. The uncertainty is corrosive, and it’s health care and politics, this widening chasm of people with alternative sets of facts — or alternative worldviews, anyway. So it’s not good. I mean, it was a really good survey, it was a really interesting survey, but some of it wasn’t so surprising. I mean, that there’s still people who, like, the fertility issues and the vaccines. You can sort of understand why those have lingered in the environment we’re in. I had actually had a conversation the other day with a political scientist who had studied the death panel rumors 10 years ago. And I said, what about now? And, you know, he was sort of … he hadn’t looked at it and he was sort of saying, well, you know, there aren’t any. And people have probably figured that out by now. Well, no. I have to email him the study, right?
Sanger-Katz: Anytime that I read a study like this, I am also reminded — and I think it is useful for all of us to be reminded of this and probably most people who are listening to the podcast — that the average American is just not as tuned in on the news and on the Washington debate and on the minutia of public policy, as all of us are. So, you know, and I think that that is part of the reason why you see so many people not sure about these things. It’s clearly the case that they are being exposed to bad information and that is contributing to their uncertainty. And I think the rise of misinformation about both health policy and about actual, you know, health care, in the case of covid, is a bad and relatively newer phenomenon. But I also think a lot of people just aren’t paying that close attention, you know, and it’s good to be reminded of that.
Kenen: The book I just read that I referred to — it’s by an MIT political scientist named Adam Berinsky, and it’s called “Political Rumors.” And it just came out, and he was talking about exactly that, that we’re all exposed to misinformation. We can’t avoid it. It’s everywhere. And that for people who aren’t as engaged with day-to-day politics, they end up uncertain. That’s this messy middle, which they also use in the KFF survey. They came up with a very similar conclusion about the “muddled middle,” I think was the phrase they used. And what this political scientist said to me the other day was that, you know, pollsters tend to not look at the “I don’t know, I’m uncertain, no opinion.” They sort of shunt them aside and they look at the “yes” or “no” people. And he was saying, no, no, no, you know, this is the population we really need to pay attention to, the “Uncertains” because they’re probably the ones you can reach more. And in the real world, we saw that with vaccination, right? I mean, in the primary series — I mean, booster takeup was low — but in the primary when there was a lot of uncertainty about the vaccines, the people who said “no way I am ever going to get the vaccine” — I mean, KFF was surveying this every month — most of them didn’t. You know, a few on the margins did, but most of them who were really militantly against the vaccine didn’t take it. The ones who were “I don’t know” and “I’m a little scared” and “I’m waiting and seeing” … a lot of them did take it. They were reached. And that’s sort of an important lesson to shift the focus as we deal with distrust, as we deal with disinformation and we deal with messaging, which is good, and truth-building and confidence-building, it is that muddled middle that’s going to have to be more of a target than we have traditionally thought.
Rovner: Well, in the interest of actually giving good information, we have a couple of updates on the reproductive health front. For those of you keeping score, abortion bans took effect this week in South Carolina and Indiana after long drawn-out court battles. Meanwhile, in Texas, an update to our continuing discussion of women with pregnancy complications who’ve been unable to get care because doctors fear running afoul of that state’s ban, a couple of weeks ago, reports Selena Simmons-Duffin at NPR, Texas Gov. Greg Abbott very quietly signed a law that created a couple of exceptions to the ban for ectopic pregnancies and premature rupture of membranes, both of which are life-threatening to the pregnant woman, but just not necessarily immediately life-threatening. I had not heard a word about this change in the law until I saw Selena’s story. Had any of you?
Kenen: In fact, it should have come up because of this court case in Texas about, you know, a broader health exception — it’s not even “health,” it’s life-threatening. It’s like, at what point do you get sick enough that your life is in danger as opposed to, you know, should you be treating that woman before … you see what direction it’s going, and you don’t let them go to the brink of death? I mean, that was the court case and Abbott fought that. But yeah, it was interesting.
Rovner: It was a really interesting story that was also, you know, pushed by a state legislator who was trying very hard not to … never to say the word abortion and to just make sure that, you know, this was about health care and not abortion. It’s an interesting story, we will link to it.
Sanger-Katz: I wonder if other states will do this as well. It seems like, as we’ve discussed, you know, abortion bans are not as popular as I think many Republican politicians thought they would [be]. And I do think that these cases of women who face really terrible health crises and are unable to get treated are contributing to the public’s dislike of these policies. And on the one hand, I think that there is a strong dislike of exceptions among people who support abortion bans because they don’t want the loopholes to get so big that the actual policy becomes meaningless. On the other hand, it seems like there is a real incentive for them in trying to fix these obvious problems, because I think it contributes to bad outcomes for women and children. And I think it also contributes to political distaste for the abortion ban itself.
Kenen: But it’s very hard to legislate every possible medical problem … I mean, what Texas did in this case was they legislated two particular medical problems. And some states … they have the ectopic — I mean, ectopic is not … there’s no stretch of the imagination that that’s viable. Right? The only thing that happens with an ectopic pregnancy is it either disintegrates or it hemorrhages. I mean, the woman is going to have a problem, but making a list of “you get this condition, you can have a medical emergency abortion, but if you have that condition and your state legislator didn’t happen to think about it, then you can’t.” I mean, the larger issue is: How do you balance the legal restrictions and medical judgments? And that’s … I don’t think any state that has a ban has completely figured that out.
Rovner: Right. And we’re back to legislators practicing medicine, which is something that I think the public does seem to find distasteful.
Sanger-Katz: I mean, I don’t think that this solves the problem at all, but I think it does show a surprising responsiveness to the particular bad outcomes that are getting the most publicity and a sort of new flexibility among the legislators who support these abortion bans. So it’s interesting.
Rovner: All right. Meanwhile, another shocking story about pregnant women being treated badly. The Centers for Disease Control and Prevention reported this week that a survey conducted this April found that 1 in 5 women reported being mistreated by medical professionals during pregnancy or delivery. For women of color, the rate was even higher: more than 1 in 4. Mistreatment included things like getting no response to calls for help, being yelled at or scolded, and feeling coerced into accepting or rejecting certain types of treatment. We know a lot of cases where women in labor or after birth reported problems that went ignored. Among the most notable, of course, was tennis legend Serena Williams, who gave birth to her second child this week after almost not surviving the birth of her first. We’re hearing so much about the high maternal mortality rate in the U.S. What is it going to take to change this? This isn’t something that can be solved by throwing more money at it. This has got to be sort of a change in culture, doesn’t it?
Kenen: No. I mean, it’s … if someone who’s just given birth, particularly if it’s the first time and you don’t know what’s normal and what’s not and what’s dangerous and what’s not dangerous, and, you know, it’s a trauma to your body. I mean, you know, I had a very much-wanted child, but labor is tough, right? I always say that evolution should have given us a zipper. But the philosophy should be, if someone who’s just been through this physical and emotional ordeal, has discomfort or a question or a fear, that you respect it and that you calm it down, you don’t dismiss it or yell at somebody. When you’re pregnant, you read all these books and you go to Lamaze workshops and you learn all this stuff about labor and delivery. You learn nothing about what happens right after. And it’s actually quite uncomfortable. And no one had ever told me what to expect. And I didn’t know. And I always, like, when younger women are having babies, I let them know that, you know, talk to your doctor or learn about this or be prepared for this, because that is a really vulnerable point. And that this survey — and it’s more Black and poor women, and Latina women in this survey, it’s not that … it’s disproportionate like everything else in health care — they’re being disrespected and not listened to. And some of them are going to have bad medical outcomes because of that.
Rovner: As we are seeing. All right. Well, that is this week’s news now. We will take a quick break. Then we will come back and do our extra credit.
Hey, “What the Health?” listeners: You already know that few things in health care are ever simple. So if you like our show, I recommend you also listen to “Tradeoffs,” a podcast that goes even deeper into our costly, complicated, and often counterintuitive health care system. Hosted by longtime health journalist and my friend Dan Gorenstein, “Tradeoffs” digs into the evidence and research data behind health care policies and tells the stories of real people impacted by decisions made in C-suites, doctors’ offices, and even Congress. Subscribe wherever you get your podcasts.
OK, we’re back. It’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read too. As always, don’t worry, if you missed it; we will post the links on the podcast page at KFFHealthNews.org and in our show notes on your phone or other mobile device. Victoria, why don’t you go first this week?
Knight: So my extra credit is from The New York Times, and the story is called “The Next Frontier for Corporate Benefits: Menopause.” It basically details how a lot of companies are realizing that, you know, as more women get into leadership positions, high-level leadership, executive positions, they’re in their 40s, late 40s, early 50s, that’s when menopause or perimenopause starts happening. And that’s something that can last for a while. I didn’t realize the stories, that it can last almost 10 years sometimes. And so it was talking about how, you know, it affects women for a long period of time. It can also affect their productivity in the workplace and their comfort and being able to accomplish things. And so they were realizing, you know, we kind of need to do something to help these women stay in these positions. And there was actually an interesting tidbit at the very end where it was talking about some companies may even be, like, legally compelled to make accommodations. And that’s due to the new Pregnant Workers Fairness Act, which says that employers have to provide accommodations for people experiencing pregnancy but also related medical conditions. They’re saying menopause could be included in that. And just some of the benefits some of these companies were offering were access to virtual specialists, but they were talking about, like, if they need to do other things like cooling rooms and stuff like that. So I thought it was kind of interesting. And another employer benefit that maybe some employers are thinking about adding.
Kenen: I think all offices should have, like, little nap cubicles and man-woman, pregnant-not pregnant. And, you know, just like “life is rough.” [laughter]
Knight: I agree.
Kenen: Just a little corner!
Rovner: Joanne, why don’t you go next?
Kenen: Mine is from The Atlantic. It’s by Lola Butcher. And it is “A Simple Marketing Technique Could Make America Healthier.” And it’s basically talking about how some medical practices are doing what we in the news business and the tech industry knows of as “A-B testing.” You know, a tech company may try a big button or a little button and see which one consumers like. Newsrooms change headlines— headline A, headline B and see which one draws more readers — and that hospitals and medical practices have been trying to do. In some cases, it’s text messaging two different kinds of reminders to figure out, you know … one example was the message with something like 78 characters got women to book a mammogram, but a message with 155 characters did not. Two text messages were better than one for booking children’s vaccines. So some people are very excited about this. It’s getting people to do preventive care and routine care. And some people think this is just not the problem with health care, that it’s way deeper and more systemic and that this isn’t really going to move the needle. But it was an interesting piece.
Rovner: Any little thing helps.
Kenen: Right. This was an interesting piece.
Rovner: Margot.
Sanger-Katz: I wanted to talk about an article in KFF Health News from Taylor Sisk. The headline is “Life in a Rural ‘Ambulance Desert’ Means Sometimes Help Isn’t on the Way,” and it’s a really interesting exploration of some of the challenges of ambulance care in rural areas, which is a topic that is near and dear to my heart. Because when I was a reporter in New Hampshire covering rural health care delivery, I spent the better part of a year writing about ambulance services and the challenges there. And I think this story is highlighting a real challenge for people in these communities. And I think it’s also really a reminder that the ambulance system is this weird, off-to-the-side part of our health care system that I think is often not well integrated and not well thought of. It tends to be regulated as transportation, not as health care. It tends to be provided by local governments or by contractors hired by local governments as opposed to health care institutions. It tends to have a lot of difficulty with billing a very high degree of surprise billing for its patients, and also just a real lack of health services research about best practices for how fast ambulances should arrive, what level of care they should provide to people, and on and on. And I just think that it’s good that she’s highlighted this issue. And also, I think it is a reminder to me that ambulances are probably worth a little bit more attention from reporters overall.
Rovner: Well, my story is also something that’s near and dear to my heart because I’ve been covering it for a long time. It’s from my KFF Health News colleague Lauren Sausser. It’s called “Doctors and Patients Try to Shame Insurers Online to Reverse Prior Authorization Denials.” And it is a wonderful 2023 update to a fight that Joanne and I have been covering since, what, the late 1990s. It even includes comments from Dr. Linda Peeno, who testified about inappropriate insurance company care denials to Congress in 1996. I was actually at that hearing. The twist, of course, now is that while people who were wrongly denied care at the turn of the century needed to catch the attention of a journalist or picket in front of the insurance company’s headquarters. Today, an outrage post on Instagram or TikTok or X can often get things turned around much faster. On the other hand, it’s depressing that after more than a quarter of a century, patients are still being caught in the middle of appropriateness fights between doctors and insurance companies. Maybe prior authorization will be the next surprise medical bill fight in Congress. We shall see. All right. That is our show for the week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks, as always, to our amazing engineer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can tweet me or X me or whatever. I’m @jrovner, also on Bluesky and Threads. Joanne?
Kenen: I am also on Twitter, @JoanneKenen; and I’m on Threads, @joannekenen1; and Bluesky, JoanneKenen.
Rovner: Margot.
Sanger-Katz: I’m @sangerkatz.
Rovner: Victoria.
Knight: I’m @victoriaregisk on X and Threads.
Rovner: Well, we’re going to take a week off from the news next week, but watch your feed for a special episode. We will be back with our panel after Labor Day. Until then, be healthy.
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Courts, COVID-19, Elections, Medicaid, Multimedia, States, The Health Law, Abortion, KFF, KFF Health News' 'What The Health?', Misinformation, Podcasts, Polls, Pregnancy, texas, Women's Health
KFF Health News' 'What the Health?': Abortion Pill’s Legal Limbo Continues
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Julie Rovner
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
A divided three-judge federal appeals court panel has ruled that a lower court was wrong to try to reverse entirely the FDA’s approval of the abortion drug mifepristone. The panel did find, however, that the agency violated regulatory rules in making the drug more easily available and that those rules should be rolled back. In practice, nothing changes immediately, because the Supreme Court has blocked the lower court’s order that the drug effectively be removed from the U.S. market — for now.
The case is pivotal for the future of reproductive health, as the pill is part of a regimen that is now the most common way American women terminate early pregnancies and is also widely used by doctors to manage miscarriages.
Meanwhile, as President Joe Biden’s Inflation Reduction Act turns one, Medicare officials are preparing to unveil which 10 drugs will be the first to face price negotiation under the new law.
This week’s panelists are Julie Rovner of KFF Health News, Shefali Luthra of The 19th, Sarah Karlin-Smith of the Pink Sheet, and Alice Miranda Ollstein of Politico.
Panelists
Shefali Luthra
The 19th
Sarah Karlin-Smith
Pink Sheet
Alice Miranda Ollstein
Politico
Among the takeaways from this week’s episode:
- Wednesday’s federal appeals court decision siding with conservative medical groups challenging mifepristone regulations has perhaps the biggest implications for the drug’s distribution via telemedicine, which has been key to securing abortion access for people in areas where abortion is unavailable.
- The ongoing legal threat to mifepristone is reverberating through the drug industry, as drugmakers worry challenges to the FDA’s scientific authority could cause serious problems for future drug development — especially in an industry that takes big financial risks on getting products approved.
- Texas is suing Planned Parenthood over past Medicaid payments made to the program, charging that the health organization “defrauded” the state, even though the claims were made while a court had specifically allowed Planned Parenthood to remain in the program. Still, the lawsuit emphasizes just how far Texas has gone, and will go, to maintain the legal authority to not support Planned Parenthood, even in its non-abortion work.
- The federal government is expected to release the list of 10 pharmaceuticals subject to Medicare price negotiations by Sept. 1. The drugs’ identities are the subject of much educated speculation, as Congress laid out in the law how drugs qualify for consideration — though even stakeholders in the drug industry are wondering which specific drugs will be up for discussion.
- A national survey of pharmacists finds drug shortages are widespread and leading to rationing at the pharmacy level. A lack of incentives to produce generic drugs is complicating supply-chain problems, leaving fewer options when there are manufacturing or other types of issues with a particular drugmaker.
Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: Time’s “She Wasn’t Able to Get an Abortion. Now She’s a Mom. Soon She’ll Start 7th Grade,” by Charlotte Alter.
Sarah Karlin-Smith: MIT Technology Review’s “Microplastics Are Everywhere. What Does That Mean for Our Immune Systems”? by Jessica Hamzelou.
Shefali Luthra: The Atlantic’s “Right Price, Wrong Politics,” by Annie Lowrey.
Alice Miranda Ollstein: Politico’s “We’re on the Cusp of Another Psychedelic Era. But This Time Washington Is Along for the Ride,” by Erin Schumaker and Katherine Ellen Foley.
Also mentioned in this week’s episode:
- States Newsroom/The Georgia Recorder’s “Study Cited by Texas Judge in Abortion-Pill Case Under Investigation,” by Sofia Resnick.
- Stat’s “From Drug Shortages to High Prices, U.S. System’s Shortcomings Have Deep Roots,” by Matthew Herper.
Click to open the transcript
Transcript: Abortion Pill’s Legal Limbo Continues
KFF Health News’ ‘What the Health?’
Episode Title: Abortion Pill’s Legal Limbo Continues
Episode Number: 310
Published: Aug. 17, 2023
Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News. And I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Aug. 17, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So here we go. We are joined today via video conference by Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Good morning.
Rovner: Sarah Karlin-Smith of the Pink Sheet.
Sarah Karlin-Smith: Hi, everybody.
Rovner: And Shefali Luthra of The 19th.
Shefali Luthra: Hello.
Rovner: So, no interview this week but plenty of news, particularly for the middle of August, so we will get right to it. The breaking news this week is about abortion and about a Texas abortion case, because 2023. Technically, this news is out of New Orleans, where on Wednesday a three-judge panel of the 5th Circuit federal Court of Appeals upheld, in part, a lower-court decision from Texas that found that the FDA was wrong to approve the abortion pill mifepristone back in the year 2000. Before we get any further in this discussion, we should point out that this decision does not impact the immediate availability of abortion pills. The Supreme Court earlier this spring issued a stay of the lower-court ruling, meaning nothing will change until the full outcome of the case is determined, presumably by the Supreme Court at some point, probably next year. But, Alice, remind us of what this case was about and then what the decision means.
Ollstein: Yeah. So this case is: A coalition of different anti-abortion medical groups that formed last year, specifically formed in the district that a very conservative judge was in charge of down in Texas, brought the case there. And they are going after both the original FDA approval of mifepristone more than two decades ago and a bunch of decisions the agency has made since then to make the pills easier for patients to obtain, like allowing mail delivery, like allowing their use longer into pregnancy than before — 10 weeks versus seven weeks — allowing nonphysicians to prescribe the pills, a bunch of different things.
Rovner: And allowing for a lower dose of the pill actually.
Ollstein: Yes, yes.
Rovner: Which is going to get significant in a second. Go ahead.
Ollstein: Definitely. We should talk about the labeling chaos that could result from this. But so basically, the lower-court judge went all in, agreed with everything they said, essentially, and more or less ordered a national ban. That got stayed. It remains stayed for now, but the 5th Circuit has now weighed in and endorsed some but not all of those arguments. They said, look, the statute of limitations has passed us by on challenging the original FDA approval of the drugs, but they sided with the groups in ordering FDA to get rid of all of those other subsequent decisions. And so this, if upheld by the Supreme Court — we know the Biden administration is already planning to appeal — would really put the pills out of reach for a lot of people. So, it would be a sharp curtailment, but not the total ban the groups were seeking.
Rovner: Yeah, Shefali, and this was obviously what the appeals court had been leaning towards anyway. We know that because that was what they had done before the Supreme Court overruled it. And certainly we know that Justice [Samuel] Alito and I believe Justice [Clarence] Thomas would also do this. So, there’s every reason to believe that this could well be the final outcome. What would it mean? So, the pill would still be approved, but only in the form it was allowed to be distributed before 2016?
Luthra: Precisely, which would be quite significant. You mentioned, right, the need to relabel pills based on the different formulation. We would have pills technically only approved up until seven weeks of pregnancy, although doctors could prescribe them off-label, through 12 weeks in all likelihood. But the telemedicine implications are probably some of the biggest, especially in states where they’ve seen large numbers of out-of-state patients coming for abortion care, right, because they’re near states with bans. Those clinics have really relied on telemedicine because it means they can see more people, and it’s quite safe, right? It’s endorsed by the World Health Organization. You don’t need someone to come in for two, in some cases three visits to get a couple of pills and take them at home. And to lose that would really just cut capacity and make abortions, which are already very difficult to obtain, even in states where it’s legal but there just aren’t as many clinics — like a Kansas, a New Mexico, etc. — if not impossible, very nearly so, just because the math doesn’t work in terms of providers versus patients in need.
Rovner: And the piece of this that I really don’t understand, and I read through the entire decision yesterday afternoon, was they said that the plaintiffs in the case cannot challenge the approval of the generic version of the drug, which was approved in 2019. But of course, the generic version of the drug was approved under the then-rules that that are now going to be rolled back. So you would — would you have a case for the brand name and the generic would have different labeling requirements? It seems very confusing.
Luthra: I think there are a lot of questions that are still open about what this means, right, not only for mifepristone but just for the precedents of FDA approval of medications at large, especially as we’ve seen so many more FDA-approved drugs become more politicized. And, I mean, that’s one of the reasons that so many medical groups have expressed deep concern about this case. It just opens a tremendous can of worms looking well beyond abortion and puts us in pretty uncharted territory for what comes next.
Rovner: And the drug industry is kind of freaked out. Sarah, I guess you could talk to this. I mean, the reliability of FDA approval is now called into question if anybody can basically go to court and say, “Nope, FDA, you shouldn’t have done that,” and possibly win, right?
Karlin-Smith: Right. I mean, they don’t want the scientific sort of authority of the FDA questioned. And I think, you know, like a lot of hot-button political issues where there’s maybe not a good side for them to be on, the pharmaceutical companies tend to try and stay out of abortion politics as much as they can. But some executives and so forth did join amicus briefs in this case because they are concerned about the precedent of FDA approval decisions being able to be challenged in court. And if nothing else, I think drug companies really, and any business to an extent, relies on, like, certainty. And so just having the loss of that certainty that an FDA decision really means, what it means is problematic for them. But I think also these are companies that sort of are based in science and medicine and would definitely prefer to have the assurance that those are the people that approved their drugs and kind of give that seal of approval and it means what it says.
Rovner: Yeah, and the drug industry, I think more than many others, which depends on long shots a lot. I mean, there’s just a lot of dry holes in the drug industry; you spent a lot of time and a lot of money on a drug that ends up not going anywhere. So if you spend a lot of time and a lot of money on a drug that does what it’s supposed to do and gets approved, I think that that could certainly dampen the enthusiasm if then a court could come and say, “Oops, nope.”
Karlin-Smith: And the reputation we talk a lot about, like drug pricing, on this show — the reputation of the FDA and the perceived quality and trustworthiness of its decisions is kind of why the drug companies can charge, to some degree, the prices they charge for their medicines versus, say, you know, we compare it to the supplement industry, which is very loosely regulated, and their claims are not really backed up in the same way by science and medicine. And you can buy those for much cheaper at the store. So their whole business model is really threatened by this.
Rovner: Yeah.
Ollstein: And I think it’s worth noting that one of the three judges on the panel wanted to go further and fully strip FDA approval from the drug, but he was overruled by his other two colleagues. But still, he wrote that dissenting opinion. And that could come into play if and when the Supreme Court takes this up.
Rovner: And he, of course, raised the specter of the Comstock Act, that 1800s-era anti-vice law that apparently some anti-abortion groups are hoping to sort of bring back into the 21st century — Are we in the 22nd century? I’m losing track — and try to figure out if you can just make all of this illegal.
Ollstein: Yes. Judge [James] Ho, who was appointed by [then-President Donald] Trump to the 5th Circuit, and his opinion went a lot further than his colleagues’ in embracing the arguments made by the challengers. So how much influence that has on the process going forward will be really interesting. You know, the Comstock Act has to do with things sent through the mail, and the concern from a lot of legal experts and medical groups is that the interpretation that Judge Ho and these groups are making could mean that sending anything that could potentially be used for an abortion, even if it’s medical equipment that’s also used for other things, could be in jeopardy. And this would be mail delivery. Even sending something to a state where abortion is protected by law could be challenged under this federal rule. And so, we’re definitely in a “throw things at the wall and see what sticks” kind of era. And this is one of the things they’re throwing at the wall.
Rovner: Yeah, just because nothing changes for now doesn’t mean that nothing is going to change. And we will obviously keep a very close eye on this. So last week we talked about a controversy surrounding one of the scientific studies that [District] Judge [Matthew] Kacsmaryk, the lower-court judge, relied on in his ruling. The study was by the Charlotte Lozier Institute. It found that women who had medical abortions were more likely to go to a hospital emergency room within 30 days than women who had surgical procedures. And we talked about how that paper is currently under review by the publisher of the journal the paper appeared in. During the discussion, I apparently misspoke about the paper’s findings, suggesting that it was just the raw number of ER visits that rose along with increased use of medication abortion rather than the rate of the visits. But nonetheless, this study is very much an outlier in three decades of research into the safety of the drug. And I say three decades because it was available in Europe many years before it was available in the United States. And the drug has otherwise been found to have very few serious complications, right?
Luthra: Right. I think you’re absolutely correct, Julie. The study remains an outlier. There remain serious methodological questions about how it came to its findings. And we have an incredibly rich body of research that continues to grow, that shows exactly what you said, which is that the complication rate for medication abortions remains incredibly low. Most people do not require follow-up medical care, especially not in an emergency room. And the reliance on that study in particular was quite striking because of what an outlier it is in the larger medical body of research.
Rovner: And it didn’t actually come up in the appeals court ruling, although they did say, and fair point, they acknowledged that the complication, the serious complication rate, is very low. But if it’s being used by a lot of people and we now know that medication abortion is more than half of all abortions, a very small percentage of a whole lot of people is still a fair number of people. Whether that is enough people to actually create the kind of havoc in emergency rooms that’s been suggested is a different question. But I think that the appeals court justices were fairly careful in the way they worded that. So the mifepristone ruling was not the only news this week about a Texas abortion case. Another Texas abortion case in front of Judge Kacsmaryk in fact: He held a hearing earlier this week in a case brought by the state of Texas to require Planned Parenthood to pay back more than a billion dollars in Medicaid reimbursements, not for abortions, but for family planning and other medical services covered by Medicaid. This one is a weird case even by Texas standards, right?
Ollstein: Yeah, and I’ll say that they’re suing them for more than a billion dollars, but they were only paid by Medicaid in the lower millions. You know, 17-ish million is what Planned Parenthood told me. So, the 1.8 billion is for penalties and damages. They’re accusing them of defrauding the state. So, there has been a many-years’ fight over Planned Parenthood’s participation in Medicaid in Texas specifically, also in other states. Planned Parenthood says that, you know, because lower courts for years blocked the state’s attempt to kick them out of Medicaid, they were perfectly allowed to continue providing nonabortion services, like contraception, tests, whatever, and be reimbursed for that. And the state coming back later and saying that they knowingly defrauded the Medicaid program, they see it as a political attack on them and their ability to keep providing services in the state.
Rovner: There was a court stay on Texas’ desire to kick them out of the Medicaid program, right, so at least at the time it was legal for them to bill Medicaid, and Texas paid the Medicaid claims that they billed, right?
Luthra: I think it’s also helpful to situate this in just a really long history of Texas doing whatever it can to get Planned Parenthood away from government dollars, including turning down millions in federal funding, starting their own state health program for reproductive health, just so that they could have the legal authority to not include Planned Parenthood. This is not really new, but it just is so striking because of the money at stake, because of sort of the tactics, and because of the implications in a world where Planned Parenthood isn’t even providing abortions in Texas anymore.
Rovner: This goes back probably before some of you guys were born, the efforts to sort of defund Planned Parenthood from state and federal dollars, even in states where Planned Parenthood never provided abortions. And there are a number of states where they never provided abortions. But there is a line in the Medicaid statute itself about free choice of providers for patients, and that’s what has been relied on. Lower courts have relied on that for years and years. Congress tried to change it and couldn’t. Texas is actually, I think, the first state that’s ever successfully gotten a court ruling that said they can cut Planned Parenthood out of their Medicaid program. So, it was not odd for Planned Parenthood, while this litigation was going on, to say, “We’re just going to continue to provide women who come to us with family planning and other health care services that we’ve been providing under Medicaid for generations.” But now we’ll see what Judge Kacsmaryk has to say. And then I imagine this will get appealed and we will see where this one ends up, too. Well, finally this week in reproductive health, the American College of Obstetricians and Gynecologists announced the introduction of an online abortion training program, which has been a year in the making, that will give all OB-GYN residents, even in states with abortion bans, access to at least the basics in abortion care and in caring for early pregnancy loss, which is all often the same care. But I have to wonder whether this is going to make students any more willing to do their residencies in states that effectively restrict the rights to practice medicine according to evidence-based standards. I know we’ve talked about this before, but we’re looking at what could be a serious shortage of just women’s reproductive health care in general in abortion ban states, right, if the supply of students wanting to go there to do their residencies and hence stay on afterwards is going to start to dry up?
Ollstein: I mean, it’s already happening for sure. Applications are going down in these ban states. And, you know, when I saw the online curriculum, that’s better than nothing. But all the medical students and residents I’ve spoken to really stress that, in order to be trained and, for some specialties, board-certified, you need practical experience; you need to personally participate in many, many, many abortions to be fully qualified as a physician. And they really stress that the more you do, the more different complications you’re able to observe. And if you only do a few or none and just do online curriculum, you’re not going to be really prepared for a miscarriage situation or any of the many things that could come up in the future. And these could be life-or-death moments. And so to not have people trained and ready to respond in certain states where it’s already hard to recruit people because of, you know, it’s just seen as a less desirable place to be, this is yet another factor. On top of that, you have state attorneys general who have been very litigious and threatening to providers. And so, I’m hearing that that fear is making people not want to practice in particular states.
Luthra: And I think another factor that we don’t often sort of say out loud, but that’s really relevant when it comes to OB-GYNs in training, is that the majority of OB-GYNs are women. And given the age of when people finish medical school, etc., many of them are pursuing residency when they’re at a stage in their life where they might consider getting pregnant, which means that the risks are not just professional or educational; in many cases they are quite personal, and that’s a factor that many people are considering as well.
Rovner: And even the male OB-GYNs in training, many of them are married to women and, again, same age, thinking about, it’s time to start a family. Also, it’s not just the residents themselves, but the residents’ families. I’ve seen that sort of from both sides. We should point out, I mean, there are training programs now and they’re obviously — you know, it’s only been a year, so it’s hard to sort of create these things out of whole cloth — but where residents can travel to other states to get some hands-on experience and training that they want. But again, one of the things we forget sometimes about residents is they don’t earn a lot of money and it’s a disruption. I mean, it’s hard enough to move to a place to do your residency; to then have to sort of pick up and move someplace else for a couple of months to do a rotation is not terribly convenient either. So this is obviously still all being sorted out. But the education of sort of the next generation of reproductive health providers is definitely under question here, right?
Ollstein: And it’s not just the time needed; it’s often the money, because if these people are doing their residency at a public university hospital in a ban state, that public university hospital, under the state law, is afraid to give any money to support them going to another state for training. And so often people either have to apply for grants from foundations to cover that expense or even pay out of their own pockets. So, it’s a real heavy lift.
Rovner: It is. Well, in other news, and there is other news this week, President [Joe] Biden is taking a victory lap as the Inflation Reduction Act, that omnibus health-slash-energy-slash-tax bill, turns 1. But the fate of the highest-profile health policy in that law, calling for Medicare to negotiate the prices of some very expensive drugs, is still in some doubt, as drugmakers sue to try to block the program. Sarah, where is this, and when do we expect to get that list of the first 10 drugs the government wants to negotiate the price of? That’s due soon, right?
Karlin-Smith: Right. So the list is due by Sept. 1 at the latest. So that is a week, I think, from this Friday, or no, a little bit longer than that. But the expectation, I think, is we may get it before Sept. 1, because that’s the Friday before Labor Day weekend.
Rovner: Oh, I don’t know. They love to drop stuff the Friday before Labor Day.
Karlin-Smith: Sometimes they do, and sometimes they also want to take a break too. So, we’re expecting that list of 10 drugs, which would be — their negotiated prices would go into effect in 2026. There’s lots of reasonably well-educated guesses of what those drugs are, because the law sort of lays out how they select them and we have a general sense of how much money is spent on certain drugs in the U.S. and so forth. But Medicare has the most up-to-date data. So, there are still companies that kind of have a sense of, “Oh, I might be on the edge,” depending on how their sales have been in Medicare the past few years. So, people are really curious.
Rovner: Coincidentally or not so coincidentally, I’ve seen some of the speculation, and it is all of the drugs that you see all of those ads for, if you watch, if you still watch, you know, commercial television, on the news or on cable TV. I mean, there are so many ads, and it’s like, surprise, these are all the drugs that are on the likely list that Medicare is going to want to do something about the price of. I assume that is not a coincidence. I’m being snide.
Karlin-Smith: I think some of it is, right, to qualify for the list, you have to be in sort of the top spending categories. And part of that means you’re most likely to have to treat large populations of people. So when you get to drugs like that, like anticoagulants — I think there’s a few expected to be up there — blood thinners, some anti-diabetic medicines, trying to think of some of the other examples. These are kind of mass-market drugs that a lot of people, particularly in the Medicare population, need these medicines. Some cancer medicines, anti-inflammatory drugs. So, it’s not particularly surprising that you would see advertisements for them. And in a lot of cases, too, these are drugs that have some amount of brand competition for them. So, there are two newer blood thinners that might be on there. So, you know, that tends to lead to advertisement when there’s competition in a space. Same for the diabetes medicines and the anti-inflammatories; there’s a lot of expensive biologics in that space that compete.
Rovner: Well, when I’m in charge of the FDA, they’re not going to be able to use, like, songs from the ’60s and ’70s anymore, because that just makes me crazy. Well, meanwhile, in something related to this, drug shortages seem to be getting worse. There’s a new survey from the American Society of Health-System Pharmacists that found that 99% of the 1,100 hospital pharmacists that responded said they were currently managing drug shortages, and one-third said those shortages are forcing them to ration, delay, or cancel treatment. And these aren’t minor drugs. They include cancer chemotherapies, anesthesia drugs, other things that can be difficult to get but important when you need them. Sarah, is this a manufacturing problem, or a marketing problem, or both? I mean, why are drug shortages so much worse now? It’s not all supply chain, is it?
Karlin-Smith: There’s some supply chain, and I think there’s still some supply chain issues that started during covid that are still impacting people. There are manufacturing concerns, depending on the company. You know, drug shortages have gotten a lot of attention recently, but really for probably the past decade or so that I’ve been covering the drug industry and following shortages, the reasons have tended to be the same: They tend to be older, sterile, injectable drugs that are harder to make. But yet, because they have gone generic, the prices have gone down so low that players tend to leave. So only a few players stay in the market because of the pricing situation. So then if they have any manufacturing problem, it can very easily lead to a shortage. Generic companies argue that, you know, there’s just not a lot of incentive for them to invest in redundancy or certain even manufacturing capabilities that might help prevent shortages. So, for better or worse, there really hasn’t been a lot of change in the reasons for these shortages over the years; it’s just that they keep happening.
Rovner: Yeah, well, it’s funny. Matthew Herper over at Stat News has kind of a provocative piece about all of this, suggesting, as you say, that the shortages right now are, in large part, due to the incentives to find the cheapest generics, but that this new Medicare negotiation process — which includes a different clock; it will be based on time on the market rather than time under patent — could encourage drugmakers to do the opposite thing, to sit on new drugs until they can test for all possible uses because they don’t want to bring them to market until they think they can make the most money, because that’s going to determine how long before there can be competition. I mean, is this ever really going to work, being a purely capitalist market?
Karlin-Smith: I mean, there are definitely people, you know, in the shortage space that have argued that some of the current shortages make a good case for public manufacturing of drugs. And actually, it might surprise some people, but the U.S. has engaged in the past in public manufacturing. There are some efforts going on now, like in California; they’re looking into some public manufacturing. So that’s on the generic side. On some of the other situations that Matthew Herper is describing with the IRA, it’s a bit more complicated because essentially the IRA does give companies some amount of time on the market without negotiation. But a lot of drugs, they have all these multiple indications. And so companies are just trying to figure out potentially how they can game their products to make the most amount of money before they’re subject to negotiation. And I know Medicare is quite aware of some of this stuff and is thinking about how they can set up their regulations to protect against that. But not everything is within their control. So we’ll see what happens, because there is concern, you know, particularly I think in the orphan or rare disease space, that a company may delay getting a rare disease indication based on when they think they might get subject to drug negotiations.
Rovner: Every time you think, Oh, they can just lower the price of drugs, it’s super, super complicated. All right. Well, finally this week, there’s something I’ve been trying to get to for a couple of weeks: Before Congress left for the August recess, it passed, on a bipartisan vote, a bill that could finally dethrone UNOS, the United Network for Organ Sharing. UNOS has been the outside organization handling the collection and distribution of human organs for transplant since the federal government began the federal transplant program in 1984. Over the years, UNOS has been roundly criticized for its handling, or mishandling, of the system. But the legislation that originally created the federal organ transplant program had been interpreted not to allow anyone else to compete for the contract to run the network. So, this legislation changes that, for the first time letting other entities see if they can do a better job so maybe fewer people will die waiting for transplanted organs. This feels a lot more important than the attention that it got, I think because there was so much else happening as Congress was leaving town. Or does it feel important to me because I spent so many years and so many hours watching Congress fight over this?
Karlin-Smith: I think it is important. There’s certainly been a lot of big exposés of problems in the system over the years. And there’s also been a lot of, when I’ve covered this more closely in the past, like, tensions between different parts of the country in sort of figuring out how organs are allocated and which parts of regions get impacted or not. So there has always been, like, political dynamics here. I think the underlying thing to watch with this overhaul is that part of what goes on here is we just don’t have enough organs for the number of people that need it. So, you can certainly make improvements and make sure that all the organs we have get to people and get done in the fairest way possible, because there have been lots of concerns around equity issues, particularly that Black people and other people of different ethnicities have not been, you know, getting the organs they deserve. But the question becomes, you know, can anybody do anything about a shortage of organs, and how do you really handle that? I think there’s always going to be tensions on this topic if you don’t have enough organs.
Rovner: Yeah, these were the ultimate formula fights, if you will. You know, it’s usually over money. In the ’90s and early 2000s, it was literally over organs, over, you know, how far you could ship donated organs and whether the large transplant centers should keep more because they do more organ transplants and therefore are more likely to have success. And boy, this fight has been going on for a very long time, but this is at least a step, I think, towards resolving it. All right. Well, that is this week’s news. We will take a quick break and then we will come back and do our extra credit. Hey, “What the Health?” listeners, you already know that few things in health care are ever simple. So, if you like our show, I recommend you also listen to “Tradeoffs,” a podcast that goes even deeper into our costly, complicated, and often counterintuitive health care system, hosted by longtime health care journalist and friend Dan Gorenstein. “Tradeoffs” digs into the evidence and research data behind health care policies and tells the stories of real people impacted by decisions made in C-suites, doctor’s offices, and even Congress. You can subscribe to “Tradeoffs” wherever you get your podcasts. OK, we are back and it’s time for our extra credit segment. That’s when we each recommend a story we read this week we think you should read too. As always, don’t worry if you miss it; we will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Shefali, why don’t you go first this week?
Luthra: My piece is from The Atlantic, by Annie Lowrey. The headline is “Right Price, Wrong Politics.” It is incredibly smart. It is about how there is all this conversation about people wanting to move to states where they have access to health care protected, whether that is abortion or gender-affirming care, etc., etc. There is one problem, which is that those states are largely ones where it is much more expensive to live, because of housing prices. And if you want to live in a place where you can afford a home, those are often the states with restrictions on health care. I love this piece. I think there is so much conversation about, Why don’t people simply move to a place where state laws reflect what they would like? And the answer is it’s really not attainable for most people. And I think she does a great job of explaining why that is and putting it in the context of policy choices and not just sort of individual human elements.
Rovner: I was super jealous of this piece. It was like, Oh, yeah, of course. Alice.
Ollstein: I chose a piece by a couple of my colleagues, and it’s called “We’re on the Cusp of Another Psychedelic Era. But This Time Washington Is Along for the Ride.” And it’s about how much bipartisan support there is in Congress right now for making psychedelics more available as medicine to treat things like PTSD [post-traumatic stress disorder] or depression. There are just a lot more clinical trials going on right now and just support for making them available through the VA [Department of Veterans Affairs] as sort of a test of how a broader population might respond. You know, we’re talking about things like psilocybin, things like ketamine, things like ecstasy, that have shown a lot of promise in having a therapeutic benefit for mental health conditions that have resisted other forms of treatment. So, fascinating stuff.
Rovner: It is. Sarah.
Karlin-Smith: I took a look at a piece in MIT Tech Review called “Microplastics Are Everywhere. What Does That Mean for Our Immune Systems?” And it just does a good job of helping you understand what the research has shown about how these very tiny particles may impact your immune cells and then impact our ability to fight off diseases and maybe even lead to more challenges with antibiotics and antibiotic resistance. And I’ve been fascinated by all the coverage of this, because this — huge problem and, you know, they talk about them being in our air and in the deepest part of the ocean. And, you know, it’s just one of those things that we have to kind of grapple with as a society, like health, economic consequences, and so forth. So, it’s worth looking at.
Rovner: More things to keep us awake at night.
Karlin-Smith: Exactly.
Karlin-Smith: A list of more things to keep us awake at night. My story this week is one of the most talked about on social media. It’s from Time, and it’s called “She Wasn’t Able to Get an Abortion. Now She’s a Mom. Soon She’ll Start 7th Grade,” by Charlotte Alter. And as the headline indicates, it’s kind of a gutting piece about a 12-year-old in Mississippi who was raped in her own yard, was too scared to tell anyone, and ended up having a baby at age 13. It’s another story about all those things that are, quote, “made up,” or not supposed to happen. Except they did. She might have been eligible for a rape exception, except there are no abortion providers left in the state, and her mother didn’t know that rape exceptions were a possibility. In the end, the closest place for her to have gotten an abortion was Chicago, which was too far and too expensive for her family. So now she has a son while she’s going to middle school. I’m sure we will see more of these as time progresses. All right. That is our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us too. Special thanks, as always, to our amazing engineer, Francis Ying. And as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can tweet me or X me or whatever. I’m still there, @jrovner, also on Bluesky and Threads. Shefali?
Luthra: I’m @shefalil.
Rovner: Alice.
Ollstein: @AliceOllstein.
Rovner: Sarah.
Karlin-Smith: I’m @SarahKarlin or @sarahkarlin-smith.
Rovner: We will be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': On Abortion Rights, Ohio Is the New Kansas
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Julie Rovner
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
Ohio voters — in a rare August election — turned out in unexpectedly high numbers to defeat a ballot measure that would have made it harder to pass an abortion-rights constitutional amendment on the ballot in November. The election was almost a year to the day after Kansas voters also stunned observers by supporting abortion rights in a ballot measure.
Meanwhile, the percentage of Americans without health insurance dropped to an all-time low of 7.7% in early 2023, reported the Department of Health and Human Services. But that’s not likely to continue, as states boot from the Medicaid program millions of people who received coverage under special eligibility rules during the pandemic.
This week’s panelists are Julie Rovner of KFF Health News, Emmarie Huetteman of KFF Health News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico, and Rachel Roubein of The Washington Post.
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Joanne Kenen
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Rachel Roubein
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Among the takeaways from this week’s episode:
- It should not have come as much of a surprise that Ohio voters sided with abortion-rights advocates. Abortion rights so far have prevailed in every state that has considered a related ballot measure since the Supreme Court overturned Roe v. Wade, including in politically conservative states like Kentucky and Montana.
- Moderate Republicans and independents joined Democrats in defeating the Ohio ballot question. Opponents of the measure — which would have increased the threshold of votes needed to approve state constitutional amendments to 60% from a simple majority — had not only cited its ramifications for the upcoming vote on statewide abortion access, but also for other issues, like raising the minimum wage.
- A Texas case about exceptions under the state’s abortion ban awaits the input of the state’s Supreme Court. But the painful personal experiences shared by the plaintiffs — notable in part because such private stories were once scarce in public discourse — pressed abortion opponents to address the consequences for women, not fetuses.
- The uninsured rate hit a record low earlier this year, a milestone that has since been washed away by states’ efforts to strip newly ineligible Medicaid beneficiaries from their rolls as the covid-19 public health emergency ended.
- The promise of diabetes drugs to assist in weight loss has attracted plenty of attention, yet with their high price tags and coverage issues, one thorny obstacle to access remains: How could we, individually and as a society, afford this?
- Lawmakers are asking more questions about the nature of nonprofit, or tax-exempt, hospitals and the care they provide to their communities. But they still face an uphill battle in challenging the powerful hospital industry.
Also this week, Rovner interviews Kate McEvoy, executive director of the National Association of Medicaid Directors, about how the “Medicaid unwinding” is going as millions have their eligibility for coverage rechecked.
Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: KFF Health News’ “How the Texas Trial Changed the Story of Abortion Rights in America,” by Sarah Varney.
Joanne Kenen: Fox News’ “Male Health Care Leaders Complete ‘Simulated Breastfeeding Challenge’ at Texas Hospital: ‘Huge Eye-Opener’,” by Melissa Rudy.
Rachel Roubein: Stat’s “From Windows to Wall Art, Hospitals Use Virtual Reality to Design More Inclusive Rooms for Kids,” by Mohana Ravindranath.
Emmarie Huetteman: KFF Health News’ “The NIH Ices a Research Project. Is It Self-Censorship?” by Darius Tahir.
Also mentioned in this week’s episode:
- Politico’s “Abortion Rights Won Big in Ohio. Here’s Why It Wasn’t Particularly Close,” by Madison Fernandez, Alice Miranda Ollstein, and Zach Montellaro.
- KFF Health News’ “Seeking Medicare Coverage for Weight Loss Drugs, Pharma Giant Courts Black Influencers,” by Rachana Pradhan.
- Stat’s “Alarmed by Popularity of Ozempic and Wegovy, Insurers Wage Multi-Front Battle,” by Elaine Chen.
click to open the transcript
Transcript: On Abortion Rights, Ohio Is the New Kansas
KFF Health News’ ‘What the Health?’Episode Title: On Abortion Rights, Ohio Is the New KansasEpisode Number: 309Published: Aug. 10, 2023
[Editor’s note: This transcript, generated using transcription software, has been edited for style and clarity.]
Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping a day early this week, on Wednesday, Aug. 9, at 3:30 p.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. We are joined today via video conference by Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico.
Joanne Kenen: Hey, everybody.
Rovner: Rachel Roubein of The Washington Post.
Rachel Roubein: Hi, everybody.
Rovner: And my colleague and editor here at KFF Health News Emmarie Huetteman.
Emmarie Huetteman: Hey, everyone. Glad to be here.
Rovner: So later in this episode, we’ll have my interview with Kate McEvoy, executive director of the National Association of Medicaid Directors. She’s got her pulse on how that big post-public health emergency “Medicaid unwinding” is going. And she’ll share some of that with us. But first, this week’s news. I guess the biggest news of the week is out of Ohio, which, in almost a rerun of what happened in Kansas almost exactly a year ago, voters soundly defeated a ballot issue that would have made it harder for other voters this fall to reverse the legislature’s strict abortion ban. If you’re having trouble following that, so did they in Ohio. [laughs] This time, the fact that the abortion rights side won wasn’t as much of a surprise because every statewide abortion ballot question has gone for the abortion rights side since Roe v. Wade was overturned last year. What do we take away from Ohio? Other than it looked a lot like … the split looked a lot like Kansas. It was almost 60-40.
Kenen: It shows that there’s a coalition around this issue that is bigger than Democrat or Republican. Ohio was the classic swing state that has turned into a conservative Republican-voting state — not on this issue. This was clearly independents, moderate Republicans joined Democrats to … 60-40, roughly, is a pretty big win. Yes, we’ve seen it in other states. It’s still a pretty big win.
Roubein: I agree. And I think one of my colleagues, Patrick Marley, and I spent some time just driving around and traveling Ohio in July. And one of the things that we did find is that — this ballot measure to increase the threshold for constitutional amendments is 60% — it had in some, in many, ways turned into a proxy war over abortion. But, in some ways, both sides also didn’t talk about abortion when they were, you know, canvassing different voters. You know, they use different tools in the toolbox. I was following around someone from Ohio Right to Life and, you know, he very much said, “Abortion is the major issue to me.” But, you know, they tried to kind of bring together the side that supported this. Other issues like legalizing marijuana and raising the minimum wage, and, you know, the abortion rights side was very much a part of, you know, the opposition here. But when some canvassers went out — my colleague Patrick had traveled and followed some, and some, you know, kind of focused on other issues like, you know, voters having a voice in policy and keeping a simple majority rule.
Rovner: Yeah, I think it’s important — for those who have not been following this as closely as we have — what the ballot measure was was to make future ballot measures — and they said they were not going to have them in August anymore, which, this was the last one — in order to amend the constitution by referendum, you would need a 60% majority rather than a 50% majority. And just coincidentally, there is an abortion ballot measure on Ohio’s ballot for November, and it’s polling at about 58%. But, yes, this would have applied to everything, and it was defeated.
Kenen: And it’s part of a larger trend. It began before the overturning of Roe v. Wade. Over the last couple of years, you’ve seen conservative states move to tighten these rules for ballot initiatives. And that’s because more liberal positions have been winning. I mean, Medicaid, the Medicaid expansion on the ballot, has won, and won big. Only one was even close …
Rovner: In very red states!
Kenen: They often won very big in a number of very, very conservative states, places like Idaho and Nebraska. So, you know, there’s always been … the conventional wisdom is that, you know, the political parties are more extreme than many voters, that the Democratic Party is for the left and the Republican Party is for the right. And there are a lot of people who identify with one party or the other but aren’t … who are more moderate or, in this case, more liberal on Medicaid. And Medicaid … what was it, seven states? I think it’s seven. Seven really conservative states. And then the abortion has won in every single state. And there’s a little bit of conversation and it’s … very early. And I don’t know if it’s going to go anywhere, but if I’ve heard it and written a bit about it, conservative lawmakers have heard about it, too, which is there are groups interested in trying to get some gun safety initiatives on ballots. So that’s complicated. And it may not happen. But they’re seeing, I mean, that’s the classic example of both a criminal justice and a public health issue — so we can talk about it — a classic example where the country is much more in the center.
Rovner: Well, let us move to Texas, because that’s where we always end up when we talk about abortion. You may remember that lawsuit where several women who nearly died from pregnancy complications sued the state to clarify when medical personnel are able to intercede without being subjected to fines and/or jail sentences. Well, the women won, at least for a couple of days. A Texas district judge who heard the case ruled in their favor, temporarily blocking the Texas ban for women with pregnancy complications. But then the state appealed, and a Texas appeals court blocked the lower-court judge’s blocking of part of the ban. If you didn’t follow that, it just means that legally nothing has changed in Texas. And now the case goes to the Texas Supreme Court, which has a conservative majority. So we pretty much know what’s going to happen. But whether these women ultimately win or lose their case may not be the most important thing. And, to explain why I’m going to do my extra credit early this week. It’s by my KFF Health News colleague Sarah Varney. It’s called “How the Texas Trial Changed the Story of Abortion Rights in America.” She writes that this trial was particularly significant because it put abortion foes on the defensive by graphically depicting harm to women of abortion bans — rather than to fetuses. And it’s also about the power of people publicly telling their stories. I’ve done a lot of stories over the years about women whose very wanted pregnancies went very wrong, very late. And, I have to tell you, it’s been hard to find these women. And when you find them, it’s been really hard to get them to talk to a journalist. So, the fact that we’re seeing more and more people actually come out publicly, you know, may do for this issue what, you know, perhaps what gay rights, you know, what people coming out as gay did for gay marriage? I don’t know. What do you guys think?
Kenen: Well, I think these stories have been really compelling, but they’re also, they’re the most dramatic and maybe easiest to push back. But it’s, you know, there’s a whole lot of other reasons women want abortions. And the focus — and it’s life and death, so the focus, quite rightfully, has to be on these really extreme cases. But that’s not … it’s still in some ways shifting attention from the larger political discussion about choice and rights. But, clearly, some of these states, we’ve seen so many stories of women who, their lives are at stake, their doctors know it, and they just don’t think they have the legal power; they’re afraid of the consequences if they’re second-guessed. There are tremendous financial and imprisonment [risks] for a doctor who is deemed to have done an unnecessary abortion. And this idea that’s taken hold … among some conservatives is that there’s never a need for a medical abortion. And that’s just not true.
Rovner: And yet, I mean, what this trial and a lot of things in Sarah’s piece too point out is that that line between miscarriage and abortion is really kind of fuzzy in a lot of cases. You know, if you go to the hospital with a miscarriage and they’re going to say, “Well, did you initiate this miscarriage?” And we’ve seen women thrown in jail before for losing pregnancies, with them saying, “You know, you threw yourself down the stairs to end this pregnancy.” That actually happened, I think it was in Indiana. So this is —
Kenen: And miscarriage is very common.
Rovner: That was what I was saying.
Kenen: Early miscarriage is very common. Very, very common.
Huetteman: One of the things that’s so striking about the past year, since Dobbs overturned Roe v. Wade ,is that we’ve seen this kind of national education about what pregnancy is and how dangerous it can be and how care needs to really be flexible to meet those sorts of challenges. And this actually got me thinking about something that another familiar voice on this podcast, Alice Miranda Ollstein, and some colleagues wrote this morning about the Ohio outcome, which is they pointed out that the anti-abortion movement really hasn’t evolved in terms of the arguments that they’re making in the past year about why abortion should continue to be less and less available. Meanwhile, we’ve got these, like, really incredible, really emotional, moving stories from women who have experienced this firsthand. And that’s a hard message to overcome when you’re trying to reach voters in particular.
Rovner: And it’s interesting; both sides like to take — you know, they all go to the hardest cases. So, for years and years, the anti-abortion side has, you know, has gone to the hardest cases. And that’s why they talk about abortion in the ninth month up till birth, which isn’t a thing, but they talk about it. And you know, now the abortion rights side has some hard cases now that abortions are harder to get. Well, while we are on the subject of Texas lawsuits, States Newsroom — and thank you for sending this my way, Joanne — has a story reporting that the publisher of the scientific paper that both the lower court judge and the appeals court judges used to conclude that the abortion drug mifepristone causes frequent complications — it does not — is being reviewed for potential scientific misconduct. The paper comes from the Charlotte Lozier Institute, which is the research arm of the anti-abortion group the Susan B. Anthony List. Sage, which is the publisher of the journal that the paper appeared in, has posted something called an expression of concern, saying that the publisher and editor, quote, “were alerted to potential issues regarding the representation of data in the article and author conflicts of interest. SAGE has contacted the authors of this article and an investigation is underway.” This was sort of a whistleblower by a pharmacist who looked at the way the data in this paper was put together and says, “No, that’s really very misleading.” I don’t think I’ve ever seen this, though; I’ve never seen a scientific paper that’s now being questioned for its political bent, a peer-reviewed scientific paper. I mean, this could change a lot of things, couldn’t it?
Kenen: Well, not if people decide that they still think it’s true. I mean, look at — you know, the vaccine autism paper was retracted. That wasn’t initially political. It’s become more political over the years; it wasn’t political at the time. That was retracted. And people have been jumping up and down screaming, “It was retracted! It was retracted!” And, you know, millions of people still believe it. So, I mean, legally, I’m not sure how much it changes. I mean, I thought we had all heard that there were flaws in this study. This article was good because I hadn’t been aware of how deeply flawed and in all the many ways it was flawed. And also the whistleblower yarn was interesting. I’m not sure how much it changes anything.
Rovner: Well, I’m thinking not in terms of this case. And by the way, I think we didn’t say this, that the study was of emergency room visits by women who’d had either surgical or medical abortions. And the contention was that medical abortions were more dangerous than surgical abortions because more women ended up in the emergency room. But as several people have pointed out, more people ended up in the emergency room after medical abortions because there have been so many more medical abortions over the years. I mean, you don’t actually have to be a data scientist to see some of the problems.
Kenen: Right. And some of them also weren’t that — really, were nervous, and they didn’t know what was normal and they went to the ER because they were scared and they really were safe. They were not — they didn’t need — you know, they just weren’t sure how much pain and discomfort or bleeding you’re supposed to have. And they went and they were reassured and were sent home. So it’s not even that they really had a medical emergency or that they were harmed.
Rovner: Or that they had a complication.
Kenen: Right. There were many flaws pointed out with this research.
Rovner: But my broader question is, I mean, if people are going to start questioning the politics of scientific papers, I mean, I could see the other side going after this.
Kenen: Well, there’s climate science, too, that’s bad. I mean, I don’t think this is actually unique. I think it’s egregious. But there were studies minimizing the risk of smoking, which was also a political business, commercial. Climate is certainly political. I mean, I think this is sort of the most politicized and most acute example, but I don’t think it’s the only one.
Roubein: And I think, Julie, as you’d mentioned, I think when [U.S. District Judge] Matthew Kacsmaryk in Texas came down with his decision — you know, for instance, there are media outlets — that my colleagues at the Post did a story just kind of unpacking some of the kind of flaws and some of the studies that were used to make, you know, a court decision.
Rovner: Yeah, to give the judge what he assumes to be evidence that this is a dangerous drug. So it’s — yeah.
Kenen: Which he came in believing, we know, from the profiles of him and his background.
Rovner: Right. All right, well, let us move on. The official Census Bureau estimate of how many people lack health insurance won’t be out until next month. But the Department of Health and Human Services is out with a report based on that other big federal population survey that shows the uninsured rate early this year was at its lowest level since records started being kept, which I think was in the 1980s: 7.7%. Now, that’s clearly going to be the high point for the fewest number of people uninsured, at least for a while, because clearly not all of the millions of people who are losing or about to lose their Medicaid coverage are going to end up with other insurance. But I remember — Joanne, you will, too — when the rate was closer to 18% … was a huge news story, and the thing that triggered the whole health reform debate in the first place. I’m surprised that there’s been so little attention paid to this.
Kenen: Because, you know … [unintelligible] … it’s so yesterday. And also, as you alluded to, you know, we’re in the middle of the Medicaid unwinding. So the numbers are going up again now. And we don’t know. We know that it’s a couple of million people. I think 3 million might be the last —
Rovner: I think it’s 4 [million], it’s up to 4.
Kenen: Four, OK. And some of them will get covered again and some of them will find other sources of coverage. But right now, there’s an uptick, not a downtick.
Roubein: And I think when you look at just, like, estimates of what the insured and the uninsured rates would be in 2030, like, the CMS’ [Centers for Medicare & Medicaid Services] analysis, one of the other questions is, you know, whether the enhanced Obamacare subsidies continue past 2025. So there’s Medicaid and then there’s also some other kind of question marks and cliffs coming up on how and whether it will fluctuate.
Rovner: No, it’s worth watching. And remember, when the census numbers come out, those will be for 2022. Well, moving on, we have two stories this week looking at the potential cost of those breakthrough obesity drugs, but through two very different lenses. One is from my KFF Health News colleague Rachana Pradhan, details how the makers of the current “it” drug, Ozempic, which is Novo Nordisk, in an effort to get the votes to lift the Medicare payment ban on weight loss drugs, is quietly contributing large amounts of money to groups like the Congressional Black Caucus Foundation and the Congressional Hispanic Caucus Institute. It’s sort of a backdoor lobbying that’s pretty age-old, but that doesn’t mean it doesn’t work. The other story, by Elaine Chen at Stat, looks at how health insurers are pushing back hard against the off-label use of diabetes medications that also work to help people lose weight. They’re doing things like allowing the more expensive weight loss drugs only if people have tried and failed other methods or disallowing them if the other methods had been slightly successful. So, if you take a lesser drug and you lose enough weight, they won’t let you take the better drug because, look, you lost weight on the other drug. We’ve talked about this, obviously, before: These drugs, on the one hand, have the potential to make a lot of people both healthier and happier. There’s a study out this week that shows that Mounjaro, the Eli Lilly drug, actually reduces heart disease by 20%.
Kenen: In people who have heart disease.
Rovner: Right, in people who have heart disease.
Kenen: It’s not lowering everybody’s risk.
Rovner: But still, I mean, everybody’s — well, I mean, there are medical indications for using these drugs for weight loss. But if everybody who wants them could get them, it would literally break the bank. Nobody can afford to give everybody who’s eligible for these drugs these drugs. Is the winner here going to be the side with the most effective lobbying, or is that too cynical?
Huetteman: Isn’t that always the winner? Speaking of cynical.
Rovner: Yeah, in health care.
Kenen: Well, I mean, I also think there’s questions about, like, these drugs clearly are really wonderful for people who they were designed for; you don’t have to be on insulin. They’re having not just weight loss and diabetes. There are apparently cardiac and other — you know, these are probably really good drugs. But there are a lot of people who do not have diabetes or heart disease who want them because they want to lose 20 pounds. And some of them are being told you have to take it for the rest of your life. I mean, I just know this anecdotally, and I’m sure we all know it anecdotally.
Rovner: Right. It’s like statins.
Kenen: Yes.
Rovner: Or blood pressure medication. If you stop taking your blood pressure medication, your blood pressure goes back up.
Kenen: Right. So, I mean, should the goal for the weight loss be, “OK, this is going to help you take off that weight and then you’re going to have to maintain it through diet and exercise and healthy lifestyle,” blah, blah, blah, which is hard for people. We know that. Or are we putting healthy people on a really expensive drug that changes an awful lot of things about their body indefinitely? We don’t have safety data for lifelong use in otherwise healthy people. So, you know, I’m always a little worried because even the best clinical trial is small compared to the entire — it’s small and it’s time-limited. And maybe these drugs are going to turn out to be absolutely phenomenal and we’re going to all live another 20 healthy years. But maybe not, you know. Or maybe they’re going to be really great for a certain subpopulation, but, you know, we’re not going to want to put it in the water supply. So, I still think that there’s this sort of pell-mell rush. And I think it’s partly because there’s a lot of money at stake. And it’s also, like, most people who are overweight have tried to lose it, and it’s very difficult to lose and maintain weight. So, you know, people want an easier way to do it. And I think the other thing is right now it’s an injection. There are side effects for some people on discomfort. There probably will be an oral version, a pill, sometime fairly soon, which will open — you know, there are people who don’t want to take a shot who would take a pill. It also means you might be able to tell — I mean, I don’t know the science of the pills, but it would make sense to me that you could take a lower dose, you know, maybe ease into it without the side effects, or could you stay on it longer with fewer problems? I mean, we’re just the very beginning of this, but it’s a huge amount of money.
Rovner: Yeah. You could see — I mean, my big question, though, is why can’t we force the drugmakers to lower the price? That would, if not solve the problem, make it a lot better. I mean, really, we’re going to have to wait until there is generic competition?
Kenen: It’s not just this.
Rovner: Yeah.
Kenen: I mean, it’s all sorts of cancer treatments and it’s hepatitis treatments. And it’s, I mean, there’s a lot of expensive drugs out there. So, this one just has a lot of demand because it makes you skinny.
Rovner: Well, that was the thing. We went through this with the hepatitis C drugs, which were really super expensive. It’s much more like that.
Kenen: Well, they seemed super expensive at the time —
Rovner: Not so much anymore.
Kenen: — but maybe for a thousand dollars, in retrospect.
Rovner: All right. Well, let’s move on. So, speaking of powerful lobbies, let’s talk about hospitals. Iowa Republican Sen. Chuck Grassley and Massachusetts Democrat Elizabeth Warren — now, there is an unlikely couple — are among those asking the IRS to more carefully examine tax-exempt hospitals to make sure they’re actually benefiting the community in exchange for not paying taxes, which is supposed to be the deal. Now, Sen. Grassley has been on this particular hobbyhorse for many, many years, I think probably more than 20, but not much ever seems to come of this. I can’t tell you how many workshops I’ve been to on, you know, how to measure community benefits that tax-exempt hospitals are providing. Any inkling that this time is going to be any different?
Roubein: Well, hospitals don’t tend to be sort of the losers. They try and kind of frame themselves as, like, “We’re your sort of friendly neighborhood hospital,” and every — I mean, every congressman, most congressmen have, you know, hospitals in their district. So they they get lobbied a lot, though, you know — I mean, this is a different issue, but particularly on the House side, hospitals are facing site-neutral payments, which if that actually went through Congress would be a loss. So yeah, but lawmakers have found it in general hard to take on the hospital industry.
Rovner: Yeah, very much so.
Kenen: Yeah. I mean, I think that we think of nonprofits and for-profits as, they’re different, but they’re not as different as we think they are, in that, you know, nonprofits are getting a tax break and they have to reinvest their profits. But it doesn’t mean they’re not making a lot of money. Some of them are. I mean, some of them have, you know, we’ve all walked into fancy nonprofits with, you know, fancy art and marble floors and so on and so forth. And we’ve all been in nonprofits that are barely keeping their doors open. So it’s your tax status. It’s not really, you know, your ethical status or the quality of care. I mean, there’s good nonprofits, there’s good for-profits. You know, this whole thing is like, if I were a hospital, I would be getting this huge tax break, and what am I doing to deserve it? And that’s the question.
Rovner: And I think the argument is, you know, that the 7.7% uninsured we were talking about, that hospitals are supposed to be providing care as part of their community benefit that the federal government now is ending up paying for. I think that’s sort of the frustration. If nonprofit hospitals were doing what they were supposed to do, it would cost federal and state governments less money, which always surprises me because this is not gone after more. I mean, Grassley has spent his whole career working on various types of government fraud. So this is totally in line for him. But it’s never just seemed to be a big priority for any administration.
Huetteman: There’s a little bit of an X factor here. Look at the fact that Grassley and Warren are talking about this publicly now. Maybe I’m just really optimistic from all the journalism we’ve been doing about projects like “Bill of the Month.” But the reality is that a lot of people are now seeing reporting that’s showing to them what nonprofit hospitals are actually doing when it comes to pursuing patients who don’t pay bills. And what it means to have community benefit comes into question a lot when you talk about wage garnishment, suing patients who are low-income for their medical debt. These are things that journalists have uncovered over and over again, happening at — ding, ding, ding — nonprofit hospitals. It’s harder to argue that hospitals are just doing their best for people when you have these stories of poor people who are losing their homes over unpaid medical bills, for instance. And I think that right now, when we’re in this political moment where health care costs are so, so potent to people and so important, I mean, could we see that this will actually be more effective, that we’re heading towards something that’s more effective? Maybe.
Rovner: Well, repeats the journalist, as we all are, the power of storytelling. Definitely the public is primed. I imagine that’s why they’re doing it now. We’ll see what comes of it.
Kenen: think the public is primed for bad practices. I’m not sure how many patients understand if the hospital they go to is a nonprofit or a for-profit. I think the public understands that everything in health care costs too much and that there are bad actors and greed. There’s a difference between profit and greed, and I think many people would say that we’re now in an era of greed. And not everybody in the health care sector — before anybody calls us up and shouts, “Not everybody who provides care is greedy” — but we’ve seen, you know, it is clearly out there. You know, you had Zeke Emanuel on a couple of weeks ago. Remember what he said, that, you know, 10 years ago, some people still liked their health care and now nobody likes their health care, rich or poor.
Rovner: Yeah, he’s right. All right. Well, that is this week’s news. Now, we’ll play my interview with Kate McEvoy of the National Association of Medicaid Directors about how the Medicaid unwinding is going. And one note before you listen: Kate frequently refers to the federal CMCS, which is not a misspeak; it stands for the Center for Medicaid and CHIP Services, which is the branch of CMS, the Centers for Medicare & Medicaid Services, that deals with Medicaid. So, here’s the interview:
I am pleased to welcome to the podcast Kate McEvoy, executive director of the National Association of Medicaid Directors, which is pretty much exactly what the name says, a group where state Medicaid officials can share information and ideas. Kate, welcome to “What the Health?”
Kate McEvoy: Good afternoon. Thanks for having me.
Rovner: Obviously, the Medicaid unwinding, which we have talked about a lot on the podcast, is Topic A for your members right now. Remind us again which Medicaid recipients are having their coverage eligibility rechecked? It’s not just those in the expansion group from the Affordable Care Act, right?
McEvoy: It’s not, no. Each and every person served by the country nationwide has to be reevaluated from an eligibility standpoint this year.
Rovner: What do we know about how it’s going? We’re seeing lots of reports that suggest the vast majority of people losing coverage are for paperwork reasons, not because they’ve been found to be no longer eligible. I know you recently surveyed your members. What are they telling you about this?
McEvoy: So, I first want to say this is an unprecedented task and it’s obviously historically significant for everyone served by the program. The volume of the work, and also the complexity, makes it a challenging task for all states and territories. But what we are seeing to date is a few things. First, we have seen an incredible effort on the part of states and territories to saturate really every means of communicating with their membership, really getting out that message around connecting with the programs, especially if an individual has moved during the period of the pandemic, which is very typical for people served by Medicaid. So that saturation of messaging and use of new means of connecting with people, like texting, really does represent a tremendous advance for the Medicaid program that has traditionally relied on a lot of complex, formal, legal notices to people. So that seems like a very positive thing. What we are seeing, and this is not unexpected, is that, you know, for reasons related to complex life circumstances and competing considerations, many people are not responding to those notices, no matter how we are transmitting those messages. And so that is a piece that is of great interest and concern to all of us, notably Medicaid directors wanting to make sure that eligible folks do not lose coverage simply because they are not responsive to the requests for more information. So we’re at a point where we’re beyond that initial push around messaging and now are really focused on means of protecting people who remain eligible, either through automatic review of their eligibility — the ex parte process — or by restoring them through such means as reconsideration. That’s really the main focus right now.
Rovner: And there’s that 90-day reconsideration window. Is that … how does that work?
McEvoy: So the federal law gives this period of 90 days to families and children within which they can be renewed with very little effort, essentially removing the responsibility to complete a new application. We also have long-standing help to people called “presumptive eligibility.” So if someone goes to a federally qualified health center or, more unfortunately, goes to the hospital, many of those types of providers can restore someone’s eligibility. So those are important protective pieces. We also know from the survey that you mentioned of our membership that many states and territories are extending those reconsideration protections to all coverage groups — also including older adults and people with disabilities.
Rovner: So are there any states that are doing anything that’s different and innovative? I remember when CHIP [the federal Children’s Health Insurance Program] was being stood up — and boy, that was a long time ago, like 1999 — South Carolina put flyers in pizza boxes, and some other state put flyers in sneaker boxes for back-to-school stuff. Are there better ways to maybe get ahold of these people?
McEvoy: So I think the answer is: a lot of different channels. Our colleagues in Louisiana have a partnership with Family Dollar stores to essentially feature this information on receipts. There’s a lot of work at pharmacy counters. Some of the big chain pharmacies have QR codes and other means of prompting people around their Medicaid eligibility. There’s going to be a big push for the back-to-school effort. And I think CMS and states are really interested, particularly in ensuring that children do not lose coverage even if their parents have regained employment and they’re no longer eligible. Another thing that’s going on is a lot of innovation in the means of enabling access to information. So many states have put in place personal apps through which people can track their own eligibility. There’s interest and some uptake of the so-called pizza-tracker function — so you can kind of see where you’re situated in that pipeline — and also a lot of use of automation to help call people back if they’re trying to get to state call centers. So really, all of those types of strategies … we’re seeing a huge amount of effort across the country.
Rovner: How’s the cooperation going with the Department of Health and Human Services? I know that … they seem to be not happy with some states. Are they being helpful, in general?
McEvoy: They’re being extraordinarily helpful. I would say that we often talk about Medicaid representing a federal-state equity partnership, and we’ve seen that manifest from the beginning of the first notice of the certainty around the start of the unwinding. CMCS has consistently offered guidance to states. They work with states using a mitigation approach as opposed to moving rapidly to compliance. We feel mitigation is the best way of essentially working out the strategies that are going to best protect continuing eligibility for people at the state level. And we really appreciate CMS’ efforts on that. We understand they do have to ensure accountability across the country, and we’re mutually committed to that.
Rovner: You better explain mitigation strategies.
McEvoy: Yeah, so this is a year where we are calling the question on eligibility standards that help ensure that the pathway to Medicaid coverage is a smooth one, and also that there is continuity of coverage. So, for any state that wasn’t yet meeting all those standards, CMCS essentially entered into an agreement with the state or territory to say, here is how you will get there. And that could have involved some means of improving the automatic renewals for Medicaid. It could have meant relying on an integrated eligibility processes. There are a lot of different tools and strategies that were put in place, but essentially that is a path to every state and territory coming into full compliance.
Rovner: Is there anything unexpected that’s happening? I know so much of this was predicted, and it was predicted that the states that went first that, you know, were really in a hurry to get extra people off of their rolls seem to be doing just that: getting extra people off of their rolls. Are you surprised at the differences among states?
McEvoy: I think that there have definitely been differences among states in terms of the tools they have used from a system standpoint, but I don’t see any differences in terms of retention of eligible people. That remains a shared goal across the entire country. And again, this is a watershed point where we have the opportunity to bring everyone to the same standards, ongoing, so that we help to prevent some of the heartache of the eligibility process for folks ongoing.
Rovner: Anything else I didn’t ask?
McEvoy: Well, I think that piece around the reconsideration period is particularly important. We are struck by there being probably less literacy around that option, and that’s something we want to continue to promote. The other piece I’d wind up by saying is that the Medicaid program is always available for people who are eligible. So in the worst-case scenario in which an otherwise eligible person loses coverage, they can always come back and be covered. This is in contrast to private insurance that may have an annual open enrollment period. Medicaid, as you know, is available on a rolling basis, and we want to keep reinforcing that theme so that no one goes with a gap in coverage.
Rovner: Kate McEvoy, thank you very much. And I hope we can call you back in a couple of months.
McEvoy: I would be very happy to hear from you.
Rovner: OK. We are back and it’s time for our extra credit segment. That’s when we each recommend a story we read this week we think you should read too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. I did mine already. Emmarie, why don’t you go next?
Huetteman: My story this week comes from KFF Health News, my colleague Darius Tahir. He has a story called “The NIH Ices a Research Project. Is It Self-Censorship?” Now, the story talks about the fact that the former head of NIH Francis Collins, was, as he was leaving, announcing an effort to study health communications. And we’re talking about not just doctor-to-patient communications, but actually also how mass communications impact American health. But as Darius found out, the acting director quietly ended the program as NIH was preparing to open its grant applications. And officials who spoke with us said that they think political pressure over misinformation is to blame. Now, we don’t have to look too far for examples of conservative pressure over misinformation and information these days. In particular, there’s a notable one from just last month out of a Louisiana court, the federal court decision that blocked government officials from communicating with social media companies. You really don’t have to look too far to see that there’s a chilling effect on information. And we’re talking about the NIH was going to study or rather fund studies into communication and information. Not misinformation, information: how people get information about their health. So it’s a pretty interesting example and a really great story worth your read.
Rovner: And I’ve done nothing but preach about public health communication for three years now.
Kenen: It’s a very good story.
Rovner: Yeah, it was a really good story. Rachel, you’re next.
Roubein: All right. This story is called “From Windows to Wall Art, Hospitals Use Virtual Reality to Design More Inclusive Rooms for Kids,” by Stat News, by Mohana Ravindranath. And I thought this story was really interesting because she kind of dived into what Mohana called “a budding movement to make architecture more inclusive” for the people and patients who are spending a lot, a lot of time in hospital walls. And what some researchers are doing is using virtual reality to essentially gauge how comfortable children who are patients are in hospital rooms. And she talked to researchers at Berkeley who were using these, like, virtual reality headsets to kind of study and explore mocked-up hospital rooms. And, I didn’t know a ton about this field. I mean, apparently it’s not new, but it’s this kind of growing sort of movement to make patients more comfortable in the space that they’re inhabiting for perhaps long periods of time.
Rovner: I went to a conference on architecture, hospital architecture, making it more patient-centered, 10 years ago. But my favorite thing that I still remember from that is they talked about putting art on the ceiling because people are either in bed or they’re in gurneys. They’re looking up at the ceiling a lot. And ceilings are scary in hospitals. So that was one of the things that I took away from that. OK, Joanne, now it’s your turn.
Kenen: OK. This is from Fox News. And yes, you did hear that right. It’s by Melissa Rudy, and the headline is “Male Health Care Leaders Complete ‘Simulated Breastfeeding Challenge’ at Texas Hospital: ‘Huge Eye-Opener’.” So at Covenant Health, they had a bunch of high-level guys in suits pretend they were nursing and/or pumping mothers, and they had to nurse every three hours for 20 minutes at a time. And they found it was quite difficult and quite cumbersome and they didn’t have enough privacy. And as one of them said, “There was no way to multitask.” But trust me, if you have two kids, you have to figure that out, too. So it was a really good story.
Rovner: Some of these things that we feel like should be required everywhere, but it was a great read; it was a really good story. OK, that is our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us too. Special thanks this week to Zach Dyer, sitting in for the indefatigable Francis Ying. And as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can tweet me or X me or whatever; I’m @jrovner. And also on Bluesky and Threads. Rachel?
Roubein: @rachel_roubein — that’s on Twitter.
Rovner: Joanne.
Kenen: In most places I’m @JoanneKenen. On Threads, I’m @joannekenen1.
Rovner: Emmarie.
Huetteman: And I am @emmarieDC.
Rovner: We will be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': Congress Is Out. The Presidential Campaign Is In.
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Julie Rovner
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
Congress has left for its annual August recess, but lawmakers have a long to-do list waiting when they return — and only a handful of legislative days to fund the government before the Oct. 1 start of the new fiscal year.
Meanwhile, Republican presidential candidates who are not named Donald J. Trump are preparing for their first televised debate and making interesting promises about health care.
This week’s panelists are Julie Rovner of KFF Health News, Alice Miranda Ollstein of Politico, Sandhya Raman of CQ Roll Call, and Lauren Weber of The Washington Post.
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Alice Miranda Ollstein
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Sandhya Raman
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Lauren Weber
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Among the takeaways from this week’s episode:
- Work has paused on Capitol Hill. Among other items of unfinished business, lawmakers returning next month will have to pass at least a short-term spending bill — or soon face a government shutdown with implications for health programs and much, much more. Authorizations are also on the agenda, with programs like community health centers on the line. But the path to passage winds through a social issues minefield, owing to conservative House Republicans who have inserted measures targeting abortion access and gender-affirming care for transgender people.
- Access to women’s health care in the United States is worsening, with maternal health deserts popping up around the nation even in the years before the overturn of Roe v. Wade. Some states in particular have seen a huge decline in the number of maternal health providers, including the closures of obstetric wards. The fact that more people are living in counties with no maternal health providers is troubling news for a nation experiencing a maternal mortality crisis.
- State medical boards across the country have disciplined fewer than two dozen providers reported for spreading covid-19 misinformation, according to a new investigation by The Washington Post. The paucity of punishments demonstrates how ill-equipped such boards are to address the serious problem of health misinformation.
- On the 2024 presidential campaign trail, Republican candidates like Gov. Ron DeSantis of Florida are signaling that re-litigating the covid pandemic is part of their playbook — but do voters still care that strongly about vaccine mandates and business shutdowns?
- And the National Institutes of Health has moved to officially study long covid, a little-understood condition that impacts the lives of many Americans.
Also this week, Rovner interviews KFF Health News senior correspondent Phil Galewitz, who reported the latest KFF Health News-NPR “Bill of the Month” installment, about how a bill that should never have been sent created headaches for one patient. If you have an outrageous medical bill you’d like to share with us, you can do that here.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: Stat’s “Henrietta Lacks Settlement Hailed by Experts as Step Toward Correcting Medicine’s Racist History,” by Annalisa Merelli.
Alice Miranda Ollstein: The Tampa Bay Times’ “Florida Veered From Norms to Strip Transgender Care From Medicaid, Records Show,” by Emily L. Mahoney and Romy Ellenbogen.
Sandhya Raman: KFF Health News’ “Black Women Weigh Emerging Risks of ‘Creamy Crack’ Hair Straighteners,” by Ronnie Cohen.
Lauren Weber: Politico’s “CDC Investigators Find More TB Infections Linked to Bone Graft Materials,” by Alice Miranda Ollstein and Lauren Gardner.
Also mentioned in this week’s episode:
- The Washington Post’s “Doctors Who Put Lives at Risk With Covid Misinformation Rarely Punished,” by Lena H. Sun, Lauren Weber, and Hayden Godfrey.
- Roll Call’s “Health Deadlines Pile Up as Congress Adjourns for August,” by Lauren Clason, Ariel Cohen, Jessie Hellmann, and Sandhya Raman.
- Slate’s “How Meta Created a Wild West for Abortion Misinformation,” by Jennifer Neda John.
- Politico’s “‘It’s a Crisis’: Maternal Health Care Disappears for Millions,” by Alice Miranda Ollstein and Megan Messerly.
click to open the transcript
Transcript: Congress Is Out. The Presidential Campaign Is In.
KFF Health News’ ‘What the Health?’Episode Title: Congress Is Out. The Presidential Campaign Is In.Episode Number: 308Published: Aug. 3, 2023
[Editor’s note: This transcript, generated using transcription software, has been edited for style and clarity.]
Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Aug. 3, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. We are joined today via video conference by Alice Ollstein, of Politico.
Ollstein: Good morning.
Rovner: Lauren Weber, The Washington Post.
Lauren Weber: Hello, hello.
Rovner: And Sandhya Raman, of CQ Roll Call.
Sandhya Raman: Good morning.
Rovner: Later in this episode we’ll have my interview with my KFF Health News colleague Phil Galewitz, who wrote the latest “Bill of the Month” for KFF Health News and NPR. This month’s patient never should have gotten a bill for his care, but he and his family ended up with a giant mess nonetheless. But first, this week’s news. It is officially August. Congress is gone until September, which makes it a good time to take stock of what has and hasn’t been accomplished on the health agenda and what might feasibly get done this fall, which is always shorter than you think. The biggest outstanding issue, literally and figuratively, is the spending bill for the Department of Health and Human Services. When Congress comes back, members theoretically only have 11 legislative days before Oct. 1, when the new fiscal year begins. And if Congress doesn’t complete work on the spending bill, which has yet to come to the House or Senate floor or even get out of the House Appropriations Committee, a lot of Health and Human Services programs could shut down unless Congress passes a temporary bill to keep them open. Sandhya, right now everything kind of points to an Oct. 1 shutdown, or am I missing something?
Raman: Yeah, I think at this point we’re looking at either a shutdown or just, like, a continuing resolution, just kicking the can a little bit down the road and giving them some more time. So right before Congress left, the Senate did advance, in the Appropriations Committee, their spending bill for [the departments of] Labor, HHS, and Education. And that means that all 12 of theirs have gotten at least that far, through the Senate Appropriations Committee, but they would still need to come to the floor, and it doesn’t mean that the House is going to agree to any of that. And the House is a lot further behind in that the only markup they’ve had on the HHS bill is on the subcommittee level. It’s not even at the House Appropriations level. And you can kind of see the tea leaves in that they were trying to get the agriculture bill done before they left, which has all the FDA money in it, and they didn’t end up bringing it to the floor because they didn’t think they would have the votes to pass it. So I think that we’re going to need some time, given that I don’t think that, even though the Senate bills have been bipartisan so far, that they’re going to be eager to jump on those.
Rovner: Every year when there’s a change in leadership in either the House or the Senate, they vow, “This is the year we’re not going to do a big omnibus spending bill. We’re going to do all 12 appropriations separately, and we’re going to run them through the House and the Senate floors, and we’re going to have a conference.” And it hasn’t happened in more than 20 years now. And there’s clearly no reason to think it’s going to happen this year, right?
Ollstein: And one of the biggest sticking points: There are the fights that happen every single year over things like the Hyde Amendment, which prevents federal spending on abortion, but that has spread to almost every single appropriations bill. There are anti-abortion budget riders. There are anti-trans health care budget riders. There are all kinds of things tucked in there that Democrats say they will oppose and that the Senate bills don’t have. But, you know, you have this disconnect where there are plenty of House members who would be completely fine with a shutdown; they’ve said publicly that they think that would not be so bad.
Rovner: You have to say it wouldn’t be as bad as letting the debt ceiling get breached.
Ollstein: Right, right, right, right. Whereas Democrats are very much saying it would be horrible to have a shutdown. And so I was talking to some Democratic House members who say that people are really torn between the pressure to make a deal to keep the government open and the pressure to oppose all of these conservative budget riders. And that tension is going to really come into play in the fall.
Rovner: Yeah. Alice, you wrote a wonderful story on all the abortion fights in all these different bills, and I just had sort of deja vu to the ’90s. If you were following abortion, you had to keep track of obviously the ag bill with FDA in it, HHS bill, and the Department of Justice bill because of abortion in prisons, and the defense bill because of, you know, abortions for servicewomen. I mean, we basically had some kind of abortion fight in more than half of the appropriations bills. So we’re coming back to that right now. Well, there are also lots of programs whose authorizations expire Oct. 1. That’s not the same as the appropriations bills that we’ve just been talking about. Without appropriations, programs have to shut down, at least temporarily. Authorizations, though, can lapse as long as the programs are funded through the appropriations. But it’s still nice to, you know, get your work done on time. Some of the big programs Congress is working on include renewing authority for community health centers, for pandemic preparedness programs, for a big group of graduate medical education programs. What’s the fall outlook for those authorizations?
Raman: So I think part of it is tied into what we see with appropriations, because a lot of these programs — even if they come to an agreement, it’s likely to ride on whatever big spending bill we have next, whether that’s a continuing resolution, whether that’s an omnibus or anything like that. So if we end up seeing some sort of continuing resolution, which is looking likely, a lot of these are going to be short-term, maybe extended if they have an agreement there, which is what they traditionally do, and then something longer — the next vehicle that pops up, the next one, or sometimes they even get a one-year, even if there is agreement, just because this is what Congress does. So some of them, I think, are looking more promising than others. We’ve seen things kind of happen with some of the graduate medical education, the [National] Health Service Corps, like those have kind of come to some sort of agreement, but —
Rovner: And those are typically bipartisan programs.
Raman: Yeah, but then others are not as far along and will take time. I mean, the process to even do like the SUPPORT [for Patients and Communities] Act, which was a 2018 law that had a bunch of different opioid provisions in it, that was bipartisan, got through: I mean, we’ve been marked up in [the] Energy and Commerce [Committee] in the House, and the Senate has not done a markup; they just have a bill that has come out so far. And so getting that done before the Sept. 30 deadline is tricky. There are some that are a little bit more partisan that I think would be more difficult to get done. I mean, the Children’s Hospitals Graduate Medical Education has been a little bit derailed over, like, political back-and-forth over policies for transgender children. And so I think even some things that have been more easy to get across the finish line in the past are having factors that are weighing them down. So a lot of these are a question mark. Yeah.
Rovner: So that was originally a Republican program. I remember when it was created because Medicare funds most of the graduate medical education, but obviously there’s not a lot of Medicare beneficiaries who are children, so they had been left out and this is their own program. But I always get at this point to share my favorite piece of trivia about authorizations versus appropriations, which is that the federal family planning program, Title X [“ten”], has not been reauthorized since 1984. Congress has tried any number of times and has failed. It continues to get funded, but it has literally been operating without authorization for all of those years. Well, one more important authorization that’s not part of the Department of Health and Human Services but is part of health care is PEPFAR [the United States President’s Emergency Plan for AIDS Relief], the very successful international AIDS and HIV program begun under President George W. Bush 20 years ago this year. But this time around, the bipartisanly popular program is hung up over — what else? — abortion. Alice, you wrote about this. I mean, PEPFAR, this is really a Republican-backed program.
Ollstein: Yes. It was created by George W. Bush and has had bipartisan support for most of its life. It’s credited with saving the lives of tens of millions of people. Few programs can say that, of any kind. And millions of people are depending on it right now for access to medications around the world. So Republicans are saying that they won’t support reauthorizing it but they will keep it funded through appropriations, just like you were talking about, keep it sort of limping along on a one-year budget, with language restoring the Trump-era restrictions on the program. So, of course, for the entirety of the program, money has not gone to providing abortions, but this expands that and says money can’t go to any organization that, you know, uses other money to provide abortions or even an organization that gives money to another organization and that subsequent organization does abortions. And so this really has been tough for the program in the last few years. And independent experts are telling me that not reauthorizing it, yes, it wouldn’t shut down the program, but they worry it would send a signal to other countries that this is not something the U.S. is really invested in going forward and it would lead other people to cutting their contributions.
Rovner: Yeah, I mean, in addition to saving millions of lives or tens of millions of lives, this has been an important piece of international diplomacy, particularly in Africa, right?
Ollstein: Right. And that was the point Sen. [Bob] Menendez [(D-N.J.)], who had wanted a full five-year reauthorization attached to the NDAA [National Defense Authorization Act], which he said his Republican colleagues killed — he made that exact point.
Rovner: The defense authorization bill.
Ollstein: Exactly, yes. They were trying that as a workaround to get it reauthorized. And it didn’t work because of GOP opposition. But Menendez was saying, you know, this will only empower countries like China that have been trying to make inroads in Africa with philanthropic work and reduce the influence of the U.S. The geopolitics are definitely on people’s mind as well as the basic humanitarian value.
Rovner: So it’s going to be a busy fall. Well, while we are on the subject of reproductive health, the problem of getting maternal health care here in the U.S. is growing, according to a new study from the March of Dimes. We are the country that already has the worst record for maternal mortality in the developed world. Yay, us. How much worse has it gotten?
Ollstein: It’s gotten a lot worse. So in just one year, between 2019 and 2020, there was a 4% decline in the number of hospitals that have birthing services, OB [obstetrics] wards. And 4% may not sound like a lot, but it’s not evenly distributed; that’s just the national average. Some states had a nearly 25% decline. And like you said, you know, we’re already doing so much worse than other countries with maternal mortality. And this just means millions of more people than before are living in a county that has zero hospitals, zero OB-GYNs, zero maternal health care providers — and then a lot of those same places, these same states and counties, also have really high rates of chronic health conditions that are contributors to maternal mortality. And so all of this is coming as births are expected to go up because of abortion bans. This data was from before Dobbs [v. Jackson Women’s Health Organization, the 2022 Supreme Court ruling overturning the nationwide right to abortion], so we don’t know yet what’s going to happen, but the expectation is that births will go up. And at the same time, there’s just fewer care providers to meet that need.
Rovner: And we also know that in the states with bans, we’re starting to see providers either leave or not go there to train in the first place, which is just going to make the whole thing worse. This week the action is going on in a couple of Midwestern states, Indiana and Ohio, I guess both of which have bans, and one of which is in force and one of which isn’t. Where are we with Indiana and Ohio? I know it changes from hour to hour.
Ollstein: So Ohio’s ban is still enjoined, so that means abortion is still legal in Ohio. The development was about this upcoming vote, and there are two upcoming votes. This is kind of wonky, but the upcoming vote that’s happening in less than a week is whether to make ballot initiatives in general harder to pass, to raise the threshold from 50 to 60%. And that’s explicitly intended to thwart the fall vote on legalizing abortion in the state and putting something in the state constitution that supports it.
Rovner: Which, coincidentally, polls show has about like 56, 57% support, right? So 60% would make it more likely to fail.
Ollstein: Right. Right. That’s coming up. But for now, because of a court injunction, abortion remains legal and the ban is not enforced.
Rovner: And Indiana, which had a very stringent ban that was about to go into effect?
Ollstein: Sandhya, do you want to?
Raman: Oh, yeah. I was just going to add to Ohio first that, as of this morning, the voter turnout for the Ohio election next week is super high. It was, like, over 380,000 people have already cast their ballot, and that was higher than, I guess, you know, when they had, like, [a] competitive Senate primary before. And so it will definitely be something to watch. I mean, we don’t know if the voter turnout is high one way or the other, but I just thought that was really interesting. But with Indiana, their abortion ban was supposed to take effect on Tuesday and then it was halted by another lawsuit, and they were the state that was the first one to pass a post-Dobbs, new abortion ban last year. So it’s, like, another sticking point in that a lot of the bans that have gone into effect are older laws or things that have been unblocked in court.
Rovner: So, yes, it really does depend on the day. I guess I read that a bunch of clinics that had been providing abortion have stopped, even though the ban is, at least for the moment, on hold. So rather typically around the country, you literally have to go day by day to figure out what is allowed and what is not. All right. Well, let us turn now to a segment I’m calling “Myths and Disinformation” this week. Lauren, I was so glad you could join us this week because you and a couple of your colleagues at the Post have a new investigation into how doctors who were peddling bad and often dangerous information during the pandemic were called to account. Spoiler: Not a lot of them were, right?
Weber: Yeah, I was going to say spoiler alert that not a lot of them were called to account. So essentially my colleagues Lena Sun, Hayden Godfrey, and I reviewed the records from all 50 states’ various medical boards, both MD boards and osteopathic boards, to see who actually had been punished for spreading covid misinformation or for practicing in a way that is misinformation-related. And despite discovering from our various records requests over hundreds of complaints for doctors that asked patients to remove masks or told them the vaccines were full of metal or told them not to get a vaccine or a various number of the —or prescribed ivermectin or hydroxychloroquine — only 20 doctors have been disciplined, and we are three and a half years into covid. And you know, what our investigation found is something that everyone on this panel has known for quite some time. But state medical boards are historically weak, underfunded, and are very ill-equipped in the social media age, where misinformation is a deluge, to really step into that breach. And what our investigation essentially found is that they’ve really failed to stop doctors that are spreading misinformation or, you know, prescribing drugs that are not deemed the consensus around the standard of care.
Rovner: So everybody says, oh, well, this is up to medical boards in every state, and they keep doctors honest and keep them on the straight and narrow and sanction them when they do wrong things. That’s not been true for a long time. And I guess now it’s still not true, right?
Weber: Yeah, exactly. And it’s really interesting. And this came up, too, in the case in Idaho for abortion, you see a lot of misinformation folks cite free speech in their ability to practice medicine. It’s actually — you know, it makes it difficult to discipline people because it is being able to prescribe things off-label, or your medical judgment is not something people — medical boards are loath to discipline over, and for good reason. You understand why that may be, but in the case of covid, where this has continued and, you know, treatments like hydroxychloroquine or ivermectin have been deemed outside of the standard of care, it is very surprising that we’ve seen such a low number of disciplinary actions taken. It really goes to show that the boards are not equipped to kind of step into this breach as misinformation has flooded the zone.
Rovner: Well, meanwhile, abortion rights groups are getting frustrated with Meta, Facebook’s parent company, over its inconsistent moderation of information about abortion and reproductive health. It reminds me of some years ago when public libraries would try to limit internet search terms to keep people away from online porn but ended up barring people from searching about breast cancer because it had the word “breast” in it. So this isn’t something that’s new. In fact, going back decades, anti-abortion groups used to advertise their crisis pregnancy centers, which don’t offer abortion but sound like they do, in the yellow pages of the phone book. And kids, ask your parents what a Yellow Pages was. But social media algorithms have the ability to determine what information a lot more people see or don’t see. This one looks pretty hard to resolve. I know that, unlike Twitter, Facebook is trying here, but this is going to be difficult, yes?
Weber: Yeah, I would say it’s a really hard — you know, it’s interesting that the article in particular that you’re talking about, there were two different camps opposed that were saying abortion is killing the unborn child versus you’re killing people if they have an abortion. And both of those got sanctioned by Facebook because it had the word kill in it. And so what we’re going to see is how they come down on this information. But in a world where you see misinformation — in [Judge Matthew] Kacsmaryk’s circuit [district] court ruling, you know, it’s kind of hard to see how this is going to be resolved by Facebook. I do not envy them in this task. I don’t really know how you would come down on this and how you would comprehensively evaluate all of these posts in a fair manner that is respective of free speech. And like you said, Julie, you know, a lot of times it leads to unintended consequences when you try and restrict posts like this on all sides. And there are some smart people that are trying to advise in the correct way, but we’ll see what happens.
Rovner: Yeah, it is not easy. Speaking of mis- and disinformation and real information, we’re going to move to the campaign trail, because it’s only August of an odd-numbered year but the 2024 presidential campaign is in full swing, with the first Republican candidate debate later this month. And while health care, specifically the desire to repeal the Affordable Care Act, is far from the rallying cry for Republicans that it has been in the last couple of presidential campaigns, we are seeing some interesting stances and comments from candidates who are not named Donald Trump. We will start with the candidate who’s running second in the Republican primary polls. That would be Florida Gov. Ron DeSantis, whose campaign launch has been anything but smooth. DeSantis, perhaps looking for some publicity, raised some eyebrows last week when he suggested on a conservative podcast that, if elected, he might install Democratic presidential candidate and known anti-vaxxer Robert F. Kennedy Jr. at the CDC [Centers for Disease Control and Prevention] or the FDA. DeSantis has been trying to stake out kind of a middle ground on his vaccine position. He’s not outright anti-vax, but he doesn’t support mandates and he’s kind of hot and cold on supporting vaccines in general. I don’t see how this would actually win him love on either side. I mean, he actually said that they would sic RFK Jr. on the CDC or the FDA.
Weber: I got to say, I find it fascinating. I mean, look, RFK Jr. has a cult following. And I think if anything, it speaks to the fact that Republicans are very much anti-vaccine mandate, anti-government shutdown, all things that RFK says all the time. And DeSantis did walk it back and said he would put him on a committee because, you know, we wouldn’t want a Democrat actually running these things. But I think really what this episode shows is the salience that words like the CDC, and we’ll talk later about the FDA — you know, the American voting public cares about these things now. They know what these agencies are, and they have strong feelings. They blame them for pandemic policies. And I think it just goes to show that relitigating the pandemic and different people’s versions of how they believe the pandemic went is really going to be a constant in this political run-up to 2024.
Ollstein: While I agree with that, I also think it is maybe not as salient as DeSantis was hoping it would be. I mean, he really has formed his candidacy on his governorship during the pandemic, and it doesn’t seem to be breaking through. He’s still just miles and miles and miles behind Trump. And depending on the polls, some of these people with way less of a platform than the governor of Florida are doing quite well. And so I think that people do have strong feelings about vaccine mandates and mask mandates and school closures and all of that, but not nearly as strong as a year ago. So I think that he maybe isn’t getting the juice from saying a lot of these things that he was hoping he would.
Rovner: Well, speaking of candidates who have less of a platform and yet seem to be making inroads — long shot but picking-up-momentum candidate Vivek Ramaswamy, who actually does know something about health policy, as the founder of a biotech firm, has vowed to, quote, “expose and [to] ultimately gut” the FDA. Now, he is a former libertarian rapper, so it is not a shock that he opposes most federal regulatory entities. But I wonder how even Republican voters would feel about actually gutting the FDA. It’s one thing — Alice, you were talking about feelings about the pandemic, but the FDA obviously does a lot more things than just deal with masks and covid vaccines. I mean, is there really a Republican constituency for wiping out the federal regulatory mechanism?
Ollstein: I mean, there at least seems to be at the state level in some states. We’ve talked so much about how GOP lawmakers have voted to roll back public health powers in a bunch of states because of covid. But it’s set to have implications way beyond covid and limit public health workers’ ability to respond to foodborne outbreaks and other things — things in the water, things in the air. So you could see that skepticism and desire to strip the government of its public health powers at the federal level as well.
Rovner: And, Lauren, you’ve been looking at this at the state level, too, right, sort of the slow decline of trust in public health, or maybe not-so-slow decline of trust in public health.
Weber: Yeah. I mean, you know, I found this February, 30 states have passed laws that have rolled back public health powers. There’s litigation at the federal level that has really stripped a lot of executive power for the public health system. As we know, public health leaders on the ground have resigned, quit, or been fired in droves due to political pushback. There’s a lot of concern among the public health community and the folks that I talk to constantly that we have seen just a massive hollowing-out of the workforce that will be impossible to replace. And so I think you’re seeing, you know, kind of as we’ve talked about, how I think this is a talking point among Republican candidates, to kind of bash these government agencies because it’s something that is appealing to people that are irritated over these deals.
Raman: Like, if you look at his comments about this, does this really hold up to the scrutiny? I mean, FDA is not the one that would mandate vaccines, mandate mask-wearing. They don’t set prices. None of that is under their jurisdiction. And, you know, you can assume that he knows this given his background, but I think it just kind of goes with some of his other comments about, you know, defunding a lot of the other agencies that he’s made. So I think some of this also just banks on people maybe not knowing, you know, what falls under what bucket. And it just might be an easy punching bag to lump it in together if the people aren’t aware of what falls under CDC versus FDA or any other agency or state-level.
Rovner: And he’s one of those people that just seems very sure of himself, even when what he’s saying isn’t necessarily true. And the very-sure-of-himself part seems to appeal to voters. But I want to go back to DeSantis just one more time. But before we’re done, speaking of trying to have it both ways, DeSantis stepped into a bees’ nest on abortion, of all things. This is the governor who signed a six-week abortion ban bill in Florida, but he kind of hemmed and hawed about saying whether he would support a national abortion ban. So that won him a firm rebuke from the Susan B Anthony List, which is a pretty powerful political arm of conservative Republicans. Does DeSantis really think he can sustain a position like this, where you can really say, “We only want states to deal with this and we don’t really want it to be at the federal government”? I mean, that was sort of the Supreme Court’s argument. But I think that there’s a lot of grassroots Republicans who would like to not have to fight this state by state and would like to see a national ban.
Ollstein: Yes, the major anti-abortion groups have said that that, you know, “leave it to the states” is not an answer they will accept and they will continue to put the pressure on candidates. Their argument is that, you know, because of things like the appropriations process and because of things like access via Medicaid — [that] is a fight and access in prisons is a fight and access for — you know, their argument is the federal government is already involved in abortion, so you should support the federal government getting involved in banning abortion.
Rovner: Which is kind of true. I mean, the part about the federal government already being heavily involved in abortion.
Ollstein: Sure. Do with that what you will. But candidates keep falling into this same trap. I mean, you had Nikki Haley, who is not polling very well at the moment — she held a whole event with Susan B. Anthony List that they hyped, and she said she would lay out her plan for abortion and there were, like, no specifics whatsoever. And then the group said, “Oh, she assured us she supports a national ban,” but then she said she didn’t. And this is going to continue to be a fight. I think really Mike Pence is the one who is most firm in saying, “Yeah, I support a national ban.”
Rovner: Yeah, and he’s been consistent his entire career, when he was in the House and when he was governor.
Ollstein: He is also not polling very well, I will note.
Rovner: Yes, that’s true. Fair point. We will obviously continue to talk about things on the campaign trail as we move along the campaign trail. Well, finally this week, I want to talk about covid, which we haven’t done for a while. It is still around, and cases, while still low, are on the upswing at the moment. But the news this week is that after almost three years, the National Institutes of Health is finally acting on directions from Congress to get moving on efforts to study and treat so-called long covid, which as many as 10% of patients end up with after having the virus. The long covid community, which could be several million people, have been agitating for scientists to take their symptoms more seriously and do more work in the research realm. Now, NIH has finally created an Office of Long COVID [Research and Practice], albeit with only two full-time staffers to start with. It’s also started enrolling an estimated 24,000 people in several clinical trials to test things like a longer course of the drug Paxlovid. But patient groups say it’s still way too little for what’s a serious and growing more widespread ailment. Why is this all taking so long? I mean, we have a Democratic administration. One would think that they would be anxious to do this.
Weber: I mean, I think if you look at it, there was over a billion dollars allocated to this. I mean, I don’t know why it’s taking so long, Julie. I think a lot of advocates are asking the same question and really beating the drum around that — and especially if you look at things that are named Operation Warp Speed or, you know, other covid treatments, vaccine, other things that were able to move at a much quicker pace and get done in a much quicker time frame — I think there’s a lot of agitation among what could be a very large group of people that their concerns and quality of life and some of these horrible symptoms are not being addressed. And as you noted, I think it’s very fascinating there are only two full-time staffers. I’ll be curious to see if this continues to change, but historically, it hasn’t been very promising.
Rovner: This is not new that Congress will direct, particularly the NIH, to study something that NIH just doesn’t seem prepared to study. Of course, as we know, there’s no NIH director at the moment. We’ve talked about the fact that nominee is being blocked by Democrat Bernie Sanders. But still, I mean, this is something — and I think Congress wants NIH to do because so many of their constituents are coming to them and saying, “We have this problem; please go out and study it.” And yet the federal scientists don’t seem to know really what to do.
Weber: Well, and there was a congressman, I don’t remember his name, but someone on this panel probably does, who said he was retiring because he has long covid, and I think he has colleagues that also have long covid. So, I mean, I think that probably helped get them a fair amount of cash. But as you said, the delivery mechanism on getting clinical trials rolling has really not been there.
Rovner: Well, we will keep an eye on this, too. That is this week’s news. Now we will play my interview with KFF Health News’ Phil Galewitz, and then we will come back with our extra credits. We are pleased to welcome back to the podcast my colleague Phil Galewitz, who reported and wrote the latest KFF Health News-NPR “Bill of the Month” story. Phil, thanks for being here.
Phil Galewitz: Nice to be back.
Rovner: So, this month’s patient was well covered by insurance and, to cut to the chase, shouldn’t have paid anything for a surgery he had in 2021. Tell us who he is and what kind of care he got.
Galewitz: Thomas Greene had complications from diabetes, and he had to get some clogged arteries cleared out in his leg to treat something called peripheral artery disease. So he went to the hospital in 2021 for the procedure. He recovered pretty well. He had some other health issues, but he recovered fine from the procedure. The issue then came when the bills started coming in.
Rovner: And Mr. Greene has both Medicare and a supplemental Medigap policy, which should have brought his out-of-pocket cost to zero. But that’s not what happened. What did happen?
Galewitz: Yes, the Greenes, because of their good insurance, were used to whenever they got health care, that they did not have any out-of-pocket expenses. But this time, about a year later, or over a year, after the procedure, they suddenly started getting some letters from collection agencies who were looking to collect bills for about $3,000 for anesthesia.
Rovner: So, just the anesthesia part.
Galewitz: It was just the anesthesia. The hospital was fine. The surgeon who did the procedure was fine, but the anesthesiologist, who they were not even familiar with, started sending them bills through a collection agency, and they were perplexed about what was going on. And they tried to reach out and call and find out what was happening, why they were getting bills. And they said they were getting a runaround and couldn’t really get a clear answer.
Rovner: They went for help, too, and the people who were helping them had trouble getting answers.
Galewitz: Yes. They went to some organizations within Pennsylvania that specialize in helping seniors with their medical bills, and even them couldn’t get any clear answers. And then thankfully, they kept pushing and kept pushing, and they were able to get another advocacy group to work on their behalf, who talked to this organization called the North American Partners in Anesthesia, which is a large anesthesia group, to stop sending them bills, and thankfully, the bills have stopped coming. They did not pay anything, but they were worried about that this was going to affect your credit.
Rovner: So what did happen? How did they end up with these bills that they shouldn’t have had?
Galewitz: It’s still a mystery. North American would not talk to us, KFF Health News, to give us answers, and they don’t really have a clear answer. By law, providers are supposed to bill Medicare within one year to have their claims paid. In this case, the records that the Greenes have show that the bills to the claims to Medicare were sent in after a year, and that because of that, Medicare clearly marked down and said these bills are after a year, we’re not paying anything, and the patient owes zero. And when a patient gets a notice from Medicare saying, “You owe zero,” that’s supposed to be it. You don’t owe anything. No matter what letters you get from the provider, you’re not supposed to pay anything. But in this case the provider continued to bill and continued to send collection agencies after the patient. And they were perplexed.
Rovner: And just to be clear, when they billed this supplemental policy, the supplemental policy has to deny it if Medicare denied it, right?
Galewitz: Right. Humana was their supplemental provider, and that was actually the answer from Humana. If Medicare is not covering it, then we’re not going to cover it.
Rovner: So, in the meantime, even if you get one of these bills and you know that you don’t owe anything but there are collection letters coming, you do need to do something, right?
Galewitz: Yes. You should open your mail. The Greenes did say at one point they think they may have gotten some letters earlier from the anesthesia group and they may not have opened them. Because they didn’t expect any bills, they didn’t open them. The lesson is open your mail. Even if you think you shouldn’t get any bill, you should at least know ahead of time that you may be able to stave off problems down the road. So always open your mail, and then you may be able to handle the problem earlier on. So they may have stopped some of the collections. But again, they were covered. They reached out. They tried to do everything that they can within their realm, and they struggled. They’re feeling OK now. They never got a letter from North American saying, “Hey, we apologize,” or, “You’re in the clear.” They’ve just stopped getting bills. And it’s been since last year that they’ve gotten a bill, so they feel like they should be OK.
Rovner: And just the one little quirk also of this story is that it looked like the anesthesia group overbilled, right?
Galewitz: There was a question on the bills, on the claims, that it appeared that an anesthesiologist and a nurse anesthetist both billed Medicare for the exact same time, though it could be that maybe there was both, that one assisted the other. This was not a complex procedure. So there were questions about that. But it would be unusual that they would both bill for the exact same time period. And so there’s a question if they were double billing; it could not have been. North American would not answer our question.
Rovner: Well, so we have discovered another thing that, even if you don’t necessarily get answers, it appears that they got their problem solved, right?
Galewitz: Yes.
Rovner: OK. Phil, Galewitz, thank you very much.
Galewitz: Thank you.
Rovner: OK. We are back and it’s time for our extra credit segment. That’s when we each recommend a story we read this week we think you should read too. As always, don’t worry if you miss it. We’ll post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Alice, why don’t you go first this week?
Ollstein: Sure. Staying on the DeSantis train, I have a piece from the Tampa Bay Times called “Florida Veered From Norms to Strip Transgender Care From Medicaid, Records Show.” And this came out of a lawsuit that was challenging the state’s decision to strip Medicaid coverage of gender-affirming care, not just for children, but for adults as well. So what came out in discovery in the lawsuit was that the state did just all of these really unusual things. And the judge thought it showed a political motivation rather than, you know, a serious health care motivation for doing this. They paid all of these outside contractors with dubious backgrounds to be part of this effort. They came up with a slogan for the report, which is completely unusual. And the reporters found that staffers who supported defunding gender-affirming care got huge raises, and people who were not supportive of it did not. So, really good accountability reporting, and it seems to have played out in court as well.
Rovner: Yeah, quite a story. Sandhya.
Raman: My extra credit this week is called “Black Women Weigh Emerging Risks of ‘Creamy Crack’ Hair Straighteners.” And it’s from Ronnie Cohen for KFF Health News and on BET. The story takes a look at the messaging and awareness related to increasing health risks that people are worried about related to relaxers or, you know, chemically straightened hair. And it’s something that is especially popular among Black women. I think it was really interesting that only about half of states have anti-hair-discrimination laws, and so a lot of women might be more eager to get their hair chemically straightened for various reasons, workplace or things like that. And there’s not a ton of research.
Rovner: Right. It’s not just that they think it looks better.
Raman: No, no. And there’s not a ton of research on the cancer risk, but personal care products like hair relaxers don’t have the same kind of approval process through the FDA as food and drugs. So, it just takes a look at some of the different things there and what different providers are kind of considering and watching out for.
Rovner: Yeah, it’s really kind of scary. Lauren.
Weber: I actually flagged one of Alice’s stories, which is, “CDC Investigators Find More TB Infections Linked to Bone Graft Materials,” and it details how a bunch of patients have tested positive for tuberculosis after receiving bone grafts. And one of them has died. And there’s 36 more that are being treated for tuberculosis. And I find this fascinating because I find the coverage of tuberculosis in this country totally not where it should be. I mean, TB is — there are a lot of cases in the U.S. It’s a highly infectious — I mean, not a lot; there’s like 10,000 — but there’s a lot more than people realize. And it can be latent and lie in wait and, you know, to have some sort of medical procedure and then find out that whatever was implanted in you has given you a very dangerous, highly infectious disease that could result in you having to quarantine for months, depending on what it is, is really alarming. And there’s a lot of accountability follow-up questions on this for the FDA, these bone graft companies. And it gets at, do we want to gut the FDA, that is hopefully trying to stop things like this, even if it’s not preventing it here? It just leads to a lot of accountability questions that I think are quite fascinating.
Rovner: Yeah, a lot a lot of things that people have not thought about. Well, my story this week is from Stat, but it’s not so much a story as it is an event. Aug. 1 would have been the 103rd birthday of Henrietta Lacks, who longtime listeners to the podcast will remember we talked about a few years back when the book about her life, “The Immortal Life of Henrietta Lacks,” was made into a movie. For those of you without such long memories, Henrietta Lacks was an African American woman from Baltimore who was admitted to Johns Hopkins Hospital for cervical cancer in 1951. She died later that year at age 31. But the doctors who treated her also harvested cells without her knowledge or permission that turned out to be the first-ever self-perpetuating cell line. So HeLa cells, as they are called, for Henrietta Lacks, have been used in more than 75,000 different studies since then and have led to the development of such breakthroughs as the polio vaccine, treatments for cancer, and even the mapping of the human genome. While Hopkins has given the cells away for free to researchers, many of the companies that have used them have developed products that have made them, the companies, very rich. But until this week, no one in Henrietta Lacks’ family ever profited from the enormous contribution that she made to medical science. This week, the family’s lawyers reached a confidential but presumably significant settlement with one of those companies, Thermo Fisher, which makes a wide range of scientific supplies. But this is not just about justice for the family of Henrietta Lacks; it’s about starting to recognize and atone for unethical medical research over many, many years, particularly on African Americans. A good birthday present indeed. OK, that is our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us too. Special thanks, as always, to our producer, Francis Ying. Also as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can still tweet me. I’m @jrovner. Sandhya.
Raman: I’m @SandhyaWrites.
Rovner: Lauren.
Weber: @LaurenWeberHP.
Rovner: Alice.
Ollstein: @AliceOllstein.
Rovner: We will be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': Another Try for Mental Health ‘Parity’
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Julie Rovner
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
The Biden administration continued a bipartisan, decades-long effort to ensure that health insurance treats mental illnesses the same as other ailments, with a new set of regulations aimed at ensuring that services are actually available without years-long waits or excessive out-of-pocket costs.
Meanwhile, two more committees in Congress approved bills this week aimed at reining in the power of pharmacy benefit managers, who are accused of keeping prescription drug prices high to increase their bottom lines.
This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico, and Sarah Karlin-Smith of the Pink Sheet.
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Joanne Kenen
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Sarah Karlin-Smith
Pink Sheet
Among the takeaways from this week’s episode:
- The Biden administration’s new rules to enforce federal mental health parity requirements include no threat of sanctions when health plans do not comply; noncompliance with even the most minimal federal rules has been a problem dating to the 1990s. Improving access to mental health care is not a new policy priority, nor a partisan one, yet it remains difficult to achieve.
- With the anniversary of the 988 Suicide & Crisis Lifeline, more people are becoming aware of how to access help and get it. Challenges remain, however, such as the hotline service’s inability to connect callers with local care. But the program seizes on the power of an initial connection for someone in a moment of crisis and offers a lifeline for a nation experiencing high rates of depression, anxiety, and suicide.
- In news about the so-called Medicaid unwinding, 12 states have paused disenrollment efforts amid concerns they are not following renewal requirements. A major consideration is that most people who are disenrolled would qualify to obtain inexpensive or even free coverage through the Affordable Care Act. But reenrollment can be challenging, particularly for those with language barriers or housing insecurity, for instance.
- With a flurry of committee activity, Congress is revving up to pass legislation by year’s end targeting the role of pharmacy benefit managers — and, based on the advertisements blanketing Washington, PBMs are nervous. It appears legislation would increase transparency and inform policymakers as they contemplate further, more substantive changes. That could be a tough sell to a public crying out for relief from high health care costs.
- Also on Capitol Hill, far-right lawmakers are pushing to insert abortion restrictions into annual government spending bills, threatening yet another government shutdown on Oct. 1. The issue is causing heartburn for less conservative Republicans who do not want more abortion votes ahead of their reelection campaigns.
- And the damage to a Pfizer storage facility by a tornado is amplifying concerns about drug shortages. After troubling problems with a factory in India caused shortages of critical cancer drugs, decision-makers in Washington have been keeping an eye on the growing issues, and a response may be brewing.
Also this week, Rovner interviews KFF Health News’ Céline Gounder about the new season of her “Epidemic” podcast. This season chronicles the successful public health effort to eradicate smallpox.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: The Nation’s “The Anti-Abortion Movement Gets a Dose of Post-Roe Reality,” by Amy Littlefield.
Joanne Kenen: Food & Environment Reporting Network’s “Can Biden’s Climate-Smart Agriculture Program Live Up to the Hype?” by Gabriel Popkin.
Anna Edney: Bloomberg’s “Mineral Sunscreens Have Potential Hidden Dangers, Too,” by Anna Edney.
Sarah Karlin-Smith: CNN’s “They Took Blockbuster Drugs for Weight Loss and Diabetes. Now Their Stomachs Are Paralyzed,” by Brenda Goodman.
Also mentioned in this week’s episode:
- CNN’s “Medicaid Disenrollments Paused in a Dozen States After Failure to Comply With Federal Rules,” by Tami Luhby.
- Abortion, Every Day’s “Why Are OBGYNs Being Forced to Go to Texas?” by Jessica Valenti.
- Politico’s “GOP Looks to Spending Fights for Wins on Abortion, Trans Care, Contraception,” by Alice Miranda Ollstein.
- KFF Health News’ “A Year With 988: What Worked? What Challenges Lie Ahead,” by Colleen DeGuzman.
click to open the transcript
Transcript: Another Try for Mental Health ‘Parity’
KFF Health News’ ‘What the Health?’Episode Title: Another Try for Mental Health ‘Parity’Episode Number: 307Published: July 27, 2023
[Editor’s note: This transcript, generated using transcription software, has been edited for style and clarity.]
Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, July 27, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. We are joined today via video conference by Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico.
Joanne Kenen: Hi, everybody.
Rovner: Sarah Karlin-Smith, the Pink Sheet.
Sarah Karlin-Smith: Hi, Julie.
Rovner: And Anna Edney of Bloomberg News.
Edney: Hello.
Rovner: Later in this episode, we’ll have my interview with my KFF colleague Céline Gounder about the new season of her podcast “Epidemic,” which tracks one of the last great public health success stories, the eradication of smallpox. But first, this week’s news. I want to start this week with mental health, which we haven’t talked about in a while — specifically, mental health parity, which is both a law and a concept, that mental ailments should be covered and reimbursed by health insurance the same way as a broken bone or case of pneumonia or any other — air quotes — “physical ailment.” Policymakers, Republican and Democrat, and the mental health community have been fighting pretty much nonstop since the mid-1990s to require parity. And despite at least five separate acts of Congress over that time — I looked it up this week — we are still not there yet. To this day, patients with psychiatric illnesses find their care denied reimbursement, made difficult to access, or otherwise treated as lesser. This week, the Biden administration is taking another whack at the issue, putting out proposed rules it hopes will start to close the remaining parity gap, among other things by requiring health plans to analyze their networks and prior authorization rules and other potential barriers to care to ensure that members actually can get the care they need. What I didn’t see in the rules, though, was any new threat to sanction plans that don’t comply — because plans have been not complying for a couple of decades now. How much might these new rules help in the absence of a couple of multimillion-dollar fines?
Edney: I had that same question when I was considering this because I didn’t see like, OK, like, great, they’re going to do their self-policing, and then what? But I do think that there’s the possibility, and this has been used in health care before, of public shaming. If the administration gets to look over this data and in some way compile it and say, here’s the good guys, here’s the bad guys, maybe that gets us somewhere.
Rovner: You know, it strikes me, this has been going on for so very long. I mean, at first it was the employer community actually that did most of the negotiating, not the insurers. Now that it’s required, it’s the insurers who are in charge of it. But it has been just this incredible mountain to scale, and nobody has been able to do it yet.
Kenen: And it’s always been bipartisan.
Rovner: That’s right.
Kenen: And it really goes back to mostly, you know, the late Sen. [Paul] Wellstone [(D-Minn.)] and [Sen. Pete] Domenici [(R-N.M.)], both of whom had close relatives with serious mental illness. You know, Domenici was fairly conservative and traditional conservative, and Wellstone was extremely liberal. And they just said, I mean, this — the parity move began — the original parity legislation, at least the first one I’m aware of. And it was like, I think it was before I came to Washington. I think it was in the ’80s, certainly the early — by the ’90s.
Rovner: It was 1996 when when the first one actually passed. Yeah.
Kenen: I mean, they started talking about it before that because it took them seven or eight years. So this is not a new idea, and it’s not a partisan idea, and it’s still not done. It’s still not there.
Edney: I think there’s some societal shift too, possibly. I mean, we’re seeing it, and maybe we’re getting closer. I’ve seen a lot of billboards lately. I’ve done some work travel. When I’m on the road, I feel like I’m always seeing these billboards that are saying mental health care is health care. And trying to hammer that through has really taken a long time.
Rovner: So while we are on the subject of mental health, one of the good things I think the government has done in the last year is start the 988 Suicide & Crisis Lifeline, which turned 1 this month. Early data from shifting the hotline from a 10-digit number to a three-digit one that’s a lot easier to remember does suggest that more people are becoming aware of immediate help and more people are getting it. At the same time, it’s been able to keep up with the demand, even improving call answering times — I know that was a big concern — but there is still a long way to go, and this is hardly a panacea for what we know is an ongoing mental health crisis, right?
Karlin-Smith: This is a good first step to get people in crisis help without some of the risks that we’ve seen. If you go towards the 911 route, sometimes police are not well trained to handle these calls and they end in worse outcomes than necessary. But then you have to have that second part, which is what we were talking about before, which is the access to the longer-term mental health support to actually receive the treatment you need. There’s also some issues with this hotline going forward in terms of long-term funding and, you know, other tweaks they need to work out to make sure, again, that people who are not expecting to interact with law enforcement actually don’t end up indirectly getting there and things like that as well.
Kenen: Do any of you know whether there’s discussion of sort of making people who don’t remember it’s 988 and they call 911 — instead of dispatching cops, are the dispatchers being trained to just transfer it over to 988?
Rovner: That I don’t know.
Kenen: I’m not aware of that. But it just sort of seems common sense.
Rovner: One thing I know they’re working on is, right now I think there’s no geolocation. So when you call 988, you don’t necessarily get automatically referred to resources that are in your community because they don’t necessarily know where you’re calling from. And I know that’s an effort. But yeah, I’m sure there either is or is going to be some effort to interact between 988 and 911.
Kenen: It’s common sense to us. It doesn’t mean it’s actually happening. I mean, this is health care.
Rovner: As we point out, this is mental health care, too.
Kenen: Yeah, right.
Rovner: It’s a step.
Kenen: But I think that, you know, sort of the power of that initial connection is something that’s easy for people to underestimate. I mean, my son in college was doing a helpline during 2020-2021. You know, he was trained, and he was also trained, like, if you think this is beyond what a college-aged volunteer, that if you’re uncertain, you just switched immediately to a mental health professional. But sometimes it’s just, people feel really bad and just having a voice gets them through a crisis moment. And as we all know, there are a lot of people having a lot of crisis moments. I doubt any of us don’t know of a suicide in the last year, and maybe not in our immediate circle, but a friend of a friend, I mean, or, you know — I know several. You know, we are really at a moment of extreme crisis. And if a phone call can help some percentage of those people, then, you know, it needs to be publicized even more and improved so it can be more than a friendly voice, plus a connection to what, ending this repetition of crisis.
Rovner: I feel like the people who worked hard to get this implemented are pretty happy a year later at how, you know — obviously there’s further to go — but they’re happy with how far they’ve come. Well, so, probably the only thing worse than not getting care covered that should be is losing your health coverage altogether, which brings us to the Medicaid unwinding, as states redetermine who’s still eligible for Medicaid for the first time since the start of the pandemic. Our podcast colleague Tami Luhby over at CNN had a story Friday that I still haven’t seen anywhere else. Apparently 12 states have put their disenrollments on pause, says Tami. But we don’t know which 12, according to the KFF disenrollment tracker. As of Wednesday, July 26, at least 3.7 million people have been disenrolled from the 37 states that are reporting publicly, nearly three-quarters of those people for, quote, “procedural reasons,” meaning those people might still be eligible but for some reason didn’t complete the renewal process. The dozen states on pause are apparently ones that HHS [the Department of Health and Human Services] thinks are not following the renewal requirements and presumably ones whose disenrollments are out of line. The Centers for Medicare & Medicaid Services, which is overseeing this, is not naming those states, but this points up exactly what a lot of people predicted would happen when states started looking at eligibility again, that a lot of people who were quite likely still eligible were simply going to lose their insurance altogether, right?
Edney: Yeah, it seemed like there was a lot of preparation in some ways to anticipating this. And then, yeah, obviously you had the states that were just raring to go and try to get people off the rolls. And yeah, it would be very interesting to know what those 12 are. I think Tami’s reporting was stellar and she did a really good job. But that’s, like, one piece of the puzzle we’re missing. And I know CMS said that they’re not naming them because they are working well with them to try to fix it.
Rovner: The one thing we obviously do know is that there are several states that are doing this faster than is required — in fact, faster than is recommended. And what we know is that the faster they do it, the more likely they are going to have people sort of fall between the cracks. The people who are determined to be no longer eligible for Medicaid are supposed to be guided to programs for which they are eligible. And presumably most of them, unless they have, you know, gotten a really great job or hit the lottery, will still be eligible at least for subsidies under the Affordable Care Act. And they’re supposed to be guided to those programs. And it’s not clear yet whether that’s happening, although I know there are an awful lot of people who are watching this pretty closely. There were over 90 million people on Medicaid by the end of the pandemic, by the point at which states no longer had to keep people on. That’s a lot more people than Medicaid normally has. It’s usually more around 70 or even 80 million. So there’s excess people. And the question is what’s going to happen to those people and whether they’re going to have some sort of health insurance. And I guess it’s going to be more than a couple of months before we know that. Yes, Joanne.
Kenen: I think that it’s important to remember that there’s no open enrollment season for Medicaid the way there is for the ACA, so that if you’re disenrolled and you get sick and you go to a doctor or a hospital, they can requalify you and you can get it again. The problem is people who think that they’re disenrolled or are told that they’re disenrolled may not realize. They may not go to the doctor because they think they can’t afford it. They may not understand there’s a public education campaign there, too, that I haven’t seen. You know, if you get community health clinics, hospitals, they can do Medicare, Medicaid certification. But it’s dangerous, right? If you think, oh, I’m going to get a bill I can’t afford and I’m just going to see if I can tough this out, that’s not the way to take care of your health. So there’s that additional conundrum. And then, you know, I think that HHS can be flexible on special enrollment periods for those who are not Medicaid-eligible and are ACA-eligible, but most of them are still Medicaid-eligible.
Rovner: If you get kicked off of Medicaid, you get an automatic special enrollment for the ACA anyway.
Kenen: But not forever. If the issue is it’s in a language you don’t speak or at an address you don’t live in, or you just threw it out because you didn’t understand what it was — there is institutional failures in the health care system, and then there’s people have different addresses in three years, particularly poor people; they move around. There’s a communication gap. You know, I talked to a health care system a while ago in Indiana, a safety net, that was going through electronic health records and contacting people. And yet that’s Indiana and they, you know, I think it was Tami who pointed out a few weeks ago on the podcast, Indiana is not doing great, in spite of, you know, really more of a concerted effort than other states or at least other health systems, not that I talk to every single health system in the country. I was really impressed with how proactive they were being. And still people are falling, not just through the cracks. I mean, there’s just tons of cracks. It’s like, you know, this whole landscape of cracks.
Rovner: I think everybody knew this was going to be a big undertaking. And obviously the states that are trying to do it with some care are having problems because it’s a big undertaking. And the states that are doing it with a little bit less care are throwing a lot more people off of their health insurance. And we will continue to follow this. So it is the end of July. I’m still not sure how that happened.
Kenen: ’Cause after June, Julie.
Rovner: Yes. Thank you. July is often when committees in Congress rush to mark up bills that they hope to get to the floor and possibly to the president in that brief period when lawmakers return from the August recess before they go out for the year, usually around Thanksgiving. This year is obviously no exception. While Sen. Bernie Sanders [(I-Vt.)] at the Health, Education, Labor and Pensions Committee has delayed consideration of that primary care-community health center bill that we talked about last week until September, after Republicans rebelled against what was supposed to have been a bipartisan bill, committee action on pharmacy benefit managers and other Medicare issues did take place yesterday in the Senate Finance Committee and the House Ways and Means Committee. Sarah, you’re following this, right? What’s happening? And I mean, so we’ve now had basically all four of the committees that have some kind of jurisdiction over this who’ve acted. Is something going to happen on PBM regulation this year?
Karlin-Smith: Actually, five committees have acted because the House Ed[ucation] and Workforce Committee has also acted on the topic. So there’s a lot of committees with a stake in this. I think there’s certainly set up for something for the fall, end of the year, to happen in the pharmacy benefit manager space. And there’s a decent amount of bipartisanship around the issue, depending on exactly which committee you’re looking at. But even if the policies that haven’t gotten through haven’t been bipartisan, I think there’s general bipartisan interest among all the committees of tackling the issue. The question is how meaningful, I guess, the policies that we get done are. Right now it looks like what we’re going to end up with is some kind of transparency measure. It reminded me a little bit of our discussion of the mental health stuff [President Joe] Biden is doing going forward. Essentially what it’s going to end up doing is get the government a lot of detailed data about how PBMs operate, how this vertical integration of PBMs — so there’s a lot of common ownership between PBMs, health insurance plans, pharmacies and so forth — may be impacting the cost of our health care and perhaps in a negative way. And then from that point, the idea would be that later Congress could go back and actually do the sort of policy reforms that might be needed. So I know there are some people that are super excited about this transparency because it is such an opaque industry. But at the same point, you can’t kind of go to your constituents and say, “We’ve changed something,” right away or, you know, “We’re going to save you a ton of money with this kind of legislation.”
Rovner: You could tell how worried the PBMs are by how much advertising you see, if you still watch TV that has advertising, which I do, because I watch cable news. I mean, the PBMs are clearly anxious about what Congress might do. And given the fact that, as you point out and as we’ve been saying for years, drug prices are a very bipartisan issue — and it is kind of surprising, like mental health, it’s bipartisan, and they still haven’t been able to push this as far as I think both Democrats and Republicans would like for it to go. Is there anything in these bills that surprised you, that goes further than you expected or less far than expected?
Karlin-Smith: There’s been efforts to sort of delink PBM compensation from rebates. And in the past, when Congress has tried to look into doing this, it’s ended up being extremely costly to the government. And they figured out in this set of policies sort of how to do this without those costs, which is basically, they’re making sure that the PBMs don’t have this perverse incentive to make money off of higher-priced drugs. However, the health plans are still going to be able to do that. So it’s not clear how much of a benefit this will really be, because at this point, the health plans and the PBMs are essentially one and the same. They have the same ownership. But, you know, I do think there has been some kind of creativity and thoughtfulness on Congress’ part of, OK, how do we tackle this without also actually increasing how much the government spends? Because the government helps support a lot of the premiums in these health insurance programs.
Rovner: Yeah. So the government has quite a quite a financial stake in how this all turns out. All right. Well, we will definitely watch that space closely. Let us move on to abortion. In addition to it being markup season for bills like PBMs, it’s also appropriations season on Capitol Hill, with the Sept. 30 deadline looming for a completion of the 12 annual spending bills. Otherwise, large parts of the government shut down, which we have seen before in recent years. And even though Democrats and Republicans thought they had a spending detente with the approval earlier this spring of legislation to lift the nation’s debt ceiling, Republicans in the House have other ideas; they not only want to cut spending even further than the levels agreed to in the debt ceiling bill, but they want to add abortion and other social policy riders to a long list of spending bills, including not just the one for the Department of Health and Human Services but the one for the Food and Drug Administration, which is in the agriculture appropriations, for reasons I’ve never quite determined; the financial services bill, which includes funding for abortion in the federal health insurance plan for government workers; and the spending bill for Washington, D.C., which wants to use its own taxpayer money for abortion, and Congress has been making that illegal pretty much for decades. In addition to abortion bans, conservatives want riders to ban gender-affirming care and even bar the FDA from banning menthol cigarettes. So it’s not just abortion. It’s literally a long list of social issues. Now, this is nothing new. A half a dozen spending bills have carried a Hyde [Amendment] type of abortion ban language for decades, as neither Republicans nor Democrats have had the votes to either expand or take away the existing restrictions. On the other hand, these conservatives pushing all these new riders don’t seem to care if the government shuts down if these bills pass. And that’s something new, right?
Kenen: Over abortion it’s something new, but they haven’t cared. I mean, they’ve shut down the government before.
Rovner: That’s true. The last time was over Obamacare.
Kenen: Right. And, which, the great irony is the one thing they — when they shut down the government because Obamacare was mandatory, not just discretionary funding, Obamacare went ahead anyway. So, I mean, minor details, but I think this is probably going to be an annual battle from now on. It depends how hard they fight for how long. And with some of these very conservative, ultra-conservative lawmakers, we’ve seen them dig in on abortion, on other issues like the defense appointees. So I think it’s going to be a messy October.
Rovner: Yeah, I went back and pulled some of my old clips. In the early 1990s I used to literally keep a spreadsheet, and I think that’s before we had Excel, of which bill, which of the appropriations bills had abortion language and what the status was of the fights, because they were the same fights year after year after year. And as I said, they kind of reached a rapprochement at one point, or not even a rapprochement — neither side could move what was already there. At some point, they kind of stopped trying, although we have seen liberals the last few years try to make a run at the actual, the original Hyde Amendment that bans federal funding for most abortions — that’s in the HHS bill — and unsuccessfully. They have not had the votes to do that. Presumably, Republicans don’t have the votes now to get any of these — at least certainly not in the Senate — to get any of these new riders in. But as we point out, they could definitely keep the government closed for a while over it. I mean, in the Clinton administration, President [Bill] Clinton actually had to swallow a bunch of new riders because either it was that or keep the government closed. So that’s kind of how they’ve gotten in there, is that one side has sort of pushed the other to the brink. You know, everybody seems to assume at this point that we are cruising towards a shutdown on Oct. 1. Does anybody think that we’re not?
Kenen: I mean, I’m not on the Hill anymore, but I certainly expect a shutdown. I don’t know how long it lasts or how you resolve it. And I — even more certain we’ll have one next year, which, the same issues will be hot buttons five weeks before the elections. So whatever happens this year is likely to be even more intense next year, although, you know, next year’s far away and the news cycle’s about seven seconds. So, you know, I think this could be an annual fight and for some time to come, and some years will be more intense than others. And you can create a deal about something else. And, you know, the House moderates are — there are not many moderates — but they’re sort of more traditional conservatives. And there’s a split in the Republican Party in the House, and we don’t know who’s going to fold when, and we don’t — we haven’t had this kind of a showdown. So we don’t really know how long the House will hold out, because some of the more moderate lawmakers who are — they’re all up for reelection next year. I mean, some of them don’t agree. Some of are not as all or nothing on abortion as the —
Rovner: Well, there are what, a dozen and a half Republicans who are in districts that President Biden won who do not want to vote on any of these things and have made it fairly clear to their leadership that they do not want to vote on any of these things. But obviously the conservatives do.
Kenen: And they’ve been public about that. They’ve said it. I mean, we’re not guessing. Some of them spoke up and said, you know, leave it to the states. And that’s what the court decided. And they don’t want to nationalize this even further than it’s nationalized. And I think, you know, when you have the Freedom Caucus taking out Marjorie Taylor Greene, I mean, I have no idea what’s next.
Rovner: Yeah, things are odd. Well, I want to mention one more abortion story this week that I read in the newsletter “Abortion, Every Day,” by Jessica Valenti. And shoutout here: If you’re interested in this issue and you don’t subscribe, you’re missing out. I will include the link in the show notes. The story’s about Texas and the exam to become a board-certified obstetrician-gynecologist. The board that conducts the exam is based in Dallas and has been for decades, and Texas is traditionally where this test has been administered. During the pandemic, the exam was given virtually because nothing was really in person. But this year, if a doctor wants to become board-certified, he or she will have to travel to Texas this fall. And a lot of OB-GYNs don’t want to do that, for fairly obvious reasons, like they are afraid of getting arrested and sent to prison because of Texas’ extreme anti-abortion laws. And yikes, really, this does not seem to be an insignificant legal risk here for doctors who have been performing abortions in other states. This is quite the dilemma, isn’t it?
Karlin-Smith: Well, the other thing I thought was interesting about — read part of that piece — is just, she was pointing out that you might not just want to advertise in a state where a lot of people are anti-abortion that all of these people who perform abortions are all going to be at the same place at the same time. So it’s not just that they’re going to be in Texas. Like, if anybody wants to go after them, they know exactly where they are. So it can create, if nothing else, just like an opportunity for big demonstrations or interactions that might disrupt kind of the normal flow of the exam-taking.
Kenen: Or violence. Most people who are anti-abortion are obviously not violent, but we have seen political violence in this country before. And you just need one person, which, you know, we seem to have plenty of people who are willing to shoot at other people. I thought it was an excellent piece. I mean, I had not come across that before until you sent it around, and there’s a solution — you know, like, if you did it virtually before — and I wasn’t clear, or maybe I just didn’t pay attention: Was this certification or also recertification?
Rovner: No, this was just certification. Recertification’s separate. So these are these are young doctors who want to become board-certified for the first time.
Kenen: But the recertification issues will be similar. And this is a yearly — I mean, I don’t see why they just don’t give people the option of doing it virtual.
Rovner: But we’ll see if they back down. But you know, I had the same thought that Sarah did. It’s like, great, let’s advertise that everybody’s going to be in one place at one time, you know, taking this exam. Well, we’ll see how that one plays out. Well, finally this week, building on last week’s discussion on health and climate change and on drug shortages, a tornado in Rocky Mount, North Carolina, seriously damaged a giant Pfizer drug storage facility, potentially worsening several different drug shortages. Sarah, I remember when the hurricane in Puerto Rico seemed to light a fire under the FDA and the drug industry about the dangers of manufacturing being too centralized in one place. Now we have to worry about storage, too? Are we going to end up, like, burying everything underground in Fort Knox?
Karlin-Smith: I think there’s been a focus even since before [Hurricane] Maria, but that certainly brought up that there’s a lack of redundancy in U.S. medical supply chains and, really, global supply chains. It’s not so much that they need to be buried, you know, that we need bunkers. It’s just that — Pfizer had to revise the numbers, but I think the correct number was that that facility produces about 8% of the sterile kind of injectables used in the U.S. health system, 25% of all Pfizer’s — it’s more like each company or the different plants that produce these drugs, it needs to be done in more places so that if you have these severe weather events in one part of the country, there’s another facility that’s also producing these drugs or has storage. So I don’t know that these solutions need to be as extreme as you brought up. But I think the problem has been that when solutions to drug shortages have come up in Congress, they tend to focus on FDA authorities or things that kind of nibble around the edges of this issue, and no one’s ever really been able to address some of the underlying economic tensions here and the incentives that these companies have to invest in redundancy, invest in better manufacturing quality, and so forth. Because at the end of the day these are often some of the oldest and cheapest drugs we have, but they’re not necessarily actually the easiest to produce. While oftentimes we’re talking about very expensive, high-cost drugs here, this may be a case where we have to think about whether we’ve let the prices drop too low and that’s sort of keeping a market that works if everything’s going perfectly well but then leads to these shortages and other problems in health care.
Rovner: Yeah, the whole just-in-time supply chain. Well, before we leave this, Anna, since you’re our expert on this, particularly international manufacturing, I mean, has sort of what’s been happening domestically lit a fire under anybody who’s also worried about some of these, you know, overseas plants not living up to their safety requirements?
Edney: Well, I think there are these scary things happen like a tornado or hurricane and everybody is kind of suddenly paying attention. But I think that the decision-makers in the White House or on Capitol Hill have been paying attention a little bit longer. We’ve seen these cancer — I mean, for a long time not getting anything done, as Sarah mentioned — but recently, it’s sort of I think the initial spark there was these cancer drug shortages that, you know, people not being able to get their chemo. And that was from an overseas factory; that was from a factory in India that had a lot of issues, including shredding all of their quality testing documents and throwing them in a truck, trying to get it out of there before the FDA inspectors could even see it.
Kenen: That’s always very reassuring.
Edney: It is. Yeah. It makes you feel really good. And one bag did not make it out of the plant in time, so they just threw acid on it instead of letting FDA inspectors look at it. So it’s definitely building in this tornado. And what might come out of it if there are a lot of shortages, I haven’t seen huge concern yet from the FDA on that front. But I think that it’s something that just keeps happening. It’s not letting up. And, you know, my colleagues did a really good story yesterday. There’s a shortage of a certain type of penicillin you give to pregnant people who have syphilis. If you pass syphilis on to your baby, the baby can die or be born with a lot of issues — it’s not like if an adult gets syphilis — and they’re having to ration it, and adults aren’t getting treated fully for syphilis because the babies need it more so, and so this is like a steady march that just keeps going on. And there’s so many issues with the industry, sort of how it’s set up, what Sarah was talking about, that we haven’t seen anybody really be able to touch yet.
Rovner: We will continue to stay on top of it, even if nobody else does. Well, that is this week’s news. Now we will play my interview with KFF’s Céline Gounder, and then we will come back and do our extra credit. I am pleased to welcome back to the podcast Dr. Céline Gounder, KFF senior fellow and editor-at-large for public health, as well as an infectious disease specialist and epidemiologist in New York and elsewhere. Céline is here today to tell us about the second season of her podcast, “Epidemic,” which tells the story of the successful effort to eradicate smallpox and explores whether public health can accomplish such big things ever again. Céline, thank you for joining us.
Céline Gounder: It’s great to be here, Julie.
Rovner: So how did you learn about the last steps in the journey to end smallpox, and why did you think this was a story worth telling broadly now?
Gounder: Well, this is something I actually studied back when I was in college in the ’90s, and I did my senior thesis in college on polio eradication, and this was in the late ’90s, and we have yet to eradicate polio, which goes to show you how difficult it is to eradicate an infectious disease. And in the course of doing that research, I was an intern at the World Health Organization for a summer and then continued to do research on it during my senior year. I also learned a lot about smallpox eradication. I got to meet a lot of the old leaders of that effort, folks like D.A. Henderson and Ciro de Quadros. And fast-forward to the present day: I think coming out of covid we’re unfortunately not learning what at least I think are the lessons of that pandemic. And I think sometimes it’s easier to go back in time in history, and that helps to depoliticize things, when people’s emotions are not running as high about a particular topic. And my thought was to go back and look at smallpox: What are the lessons from that effort, a successful effort, and also to make sure to get that history while we still have some of those leaders with us today.
Rovner: Yes, you’re singing my song here. I noticed the first episode is called “The Goddess of Smallpox.” Is there really a goddess of smallpox?
Gounder: There is: Shitala Mata. And the point of this episode was really twofold. One was to communicate the importance of understanding local culture and beliefs, not to dismiss these as superstitions, but really as ways of adapting to what was, in this case, a very centuries-long reality of living with smallpox. And the way people thought about it was that in some ways it was a curse, but in some ways it was also a blessing. And understanding that dichotomy is also important, whether it’s with smallpox or other infectious diseases. It’s important to understand that when you’re trying to communicate about social and public health interventions.
Rovner: Yeah, because I think people don’t understand that public health is so unique to each place. I feel like in the last 50 years, even through HIV and other infectious diseases, the industrialized world still hasn’t learned very well how to deal with developing countries in terms of cultural sensitivity and the need for local trust. Why is this a lesson that governments keep having to relearn?
Gounder: Well, I would argue we don’t even do it well in our own country. And I think it’s because we think of health in terms of health care, not public health, in the United States. And that also implies a very biomedical approach to health issues. And I think the mindset here is very much, oh, well, once you have the biomedical tools — the vaccines, the diagnostics, the drugs — problem solved. And that’s not really solving the problem in a pandemic, where much of your challenge is really social and political and economic and cultural. And so if you don’t think about it in those terms, you’re really going to have a flat-footed response.
Rovner: So what should we have learned from the smallpox eradication effort that might have helped us deal with covid or might help us in the future deal with the next pandemic?
Gounder: Well, I think one side of this is really understanding what the local culture was, spending time with people in community to build trust. I think we came around to understanding it in part, in some ways, in some populations, in some geographies, but unfortunately, I think it was very much in the crisis and not necessarily a long-term concerted effort to do this. And that I think is concerning because we will face other epidemics and pandemics in the future. So, you know, how do you lose trust? How do you build trust? I think that’s a really key piece. Another big one is dreaming big. And Dr. Bill Foege — he was one of the leaders of smallpox eradication, went on to be the director of the CDC [Centers for Disease Control and Prevention] under President [Jimmy] Carter — one of the pieces of advice he’s given to me as a mentor over the years is you’ve got to be almost foolishly optimistic about getting things done, and don’t listen to the cynics and pessimists. Of course, you want to be pragmatic and understand what will or won’t work, but to take on such huge endeavors as eradicating smallpox, you do have to be very optimistic and remind yourself every day that this is something you can do if you put your mind to it.
Rovner: I noticed, at least in the first couple of episodes that I’ve listened to, the media doesn’t come out of this looking particularly good. You’re both a journalist and a medical expert. What advice do you have for journalists trying to cover big public health stories like this, like covid, like things that are really important in how you communicate this to the public?
Gounder: Well, I think one is try to be hyperlocal in at least some of your reporting. I think one mistake during the pandemic was having this very top-down perspective of “here is what the CDC says” or “here is what the FDA says” or whomever in D.C. is saying, and that doesn’t really resonate with people. They want to see their own experiences reflected in the reporting and they want to see people from their community, people they trust. And so I think that is something that we should do better at. And unfortunately, we’re also somewhat hampered in doing so because there’s been a real collapse of local journalism in most of the country. So it really does fall to places like KFF Health News, for example, to try to do some of that important reporting.
Rovner: We will all keep at it. Céline Gounder, thank you so much for joining us. You can find Season 2 of “Epidemic,” called “Eradicating Smallpox,” wherever you get your podcasts.
Gounder: Thanks, Julie.
Rovner: OK, we’re back. It’s time for our extra credit segment. That’s when we each recommend a story we read this week we think you should read too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Sarah, why don’t you go first this week?
Karlin-Smith: Sure. I took a look at a piece from Brenda Goodman at CNN called “They Took Blockbuster Drugs for Weight Loss and Diabetes. Now Their Stomachs Are Paralyzed,” and it’s a really good deep dive into — people probably have heard of Ozempic, Wegovy — these what are called GLP-1 drugs that have been used for diabetes. And we’ve realized in higher doses even for people without diabetes, they often are very helpful at losing weight, that that’s partially because they slow the passage of food through your stomach. And there are questions about whether for some people that is leading to stomach paralysis or other extreme side effects. And I think it’s a really interesting deep dive into the complicated world of figuring out, Is this caused by the drug? Is it caused by other conditions that people have? And then how should you counsel people about whether they should receive the drugs and the benefits outweighing the risks? So I think it’s like just a good thing for people to read when you sort of hear all this hype about a product and how great they must be, that it’s always a little bit more complicated than that. And it also brought up another aspect of it, which is how these drugs may impact people who are going to get surgery and anesthesia and just the importance of communicating this to your doctor so they know how to appropriately handle the drugs. Because if you still have food content in your stomach during a surgery, that can be extremely dangerous. And I thought just that aspect alone of this story is really interesting, because they talk about people maybe not wanting to even let their doctors know they’re on these drugs because of stigma surrounding weight loss. And just again, once you get a new medicine that might end up being taken by a lot of people, the complications or, you know, there’s the dynamics of how it impacts other parts of medicine, and we need to adjust.
Rovner: Yeah. And I think the other thing is, you know, we know these drugs are safe because people with diabetes have been taking them for, what, six or seven years. But inevitably, anytime you get a drug that lots more people take, then you start to see the outlier side effects, which, if it’s a lot of people, can affect a lot of people. Joanne.
Kenen: I have a piece from FERN, which is the Food & Environment Reporting Network and in partnership with Yale Environ 360, and it’s by Gabriel Popkin. And it’s called “Can Biden’s Climate-Smart Agriculture Program Live Up to the Hype?” And I knew nothing about smart agriculture, which is why I found this so interesting. So, this is an intersection of climate change and food, which is obviously also a factor in climate change. And there’s a lot of money from the Biden administration for farmers to use new techniques that are more green-friendly because as we all know, you know, beef and dairy, things that we thought were just good for us — maybe not beef so much — but, like, they’re really not so good for the planet we live on. So can you do things like, instead of using fertilizer, plant cover crops in the offseason? I mean, there’s a whole list of things that — none of us are farmers, but there’s also questions about are they going to work? Is it greenwashing? Is it stuff that will work but not in the time frame that this program is funding? How much of it’s going to go to big agribusiness, and how much of it is going to go to small farmers? So it’s one hand, it’s another. You know, there’s a lot of low-tech practices. We’re going to have to do absolutely everything we can on climate. We’re going to have to use a variety of — you know, very large toolkit. So it was interesting to me reading about these things that you can do that make agriculture, you know, still grow our food without hurting the planet, but also a lot of questions about, you know, is this really a solution or not? But, you know, I didn’t know anything about it. So it was a very interesting read.
Rovner: And boy, you think the drug companies are influential on Capitol Hill. Try going with big agriculture. Anna.
Edney: I’m going to toot my own horn for a second here —
Rovner: Please.
Edney: — and do one of my mini-investigations that I did, “Mineral Sunscreens Have Potential Hidden Dangers, Too.” So there’s been a lot of talk: Use mineral sunscreen to save the environment or, you know, for your own health potentially. But they’re white, they’re very thick. And, you know, people don’t want to look quite that ghostly. So what’s been happening lately is they’ve been getting better. But what I found out is a lot of that is due to a chemical — that is what people are trying to move away from, is chemical sunscreens — but the sunscreen-makers are using this chemical called butyloctyl salicylate. And you can read the article for kind of the issues with it. I guess the main one I would point out is, you know, I talked to the Environmental Working Group because they do these verifications of sunscreens based on their look at how good are they for your health, and a couple of their mineral ones had this ingredient in it. So when I asked them about it, they said, Oh, whoops; like, we do actually need to revisit this because it is a chemical that is not recommended for children under 4 to be using on their bodies. So there’s other issues with it, too — just the question of whether you’re really being reef-safe if it’s in there, and other things as well.
Rovner: It is hard to be safe and be good to the planet. My story this week is by Amy Littlefield of The Nation magazine, and it’s called “The Anti-Abortion Movement Gets a Dose of Post-Roe Reality.” It’s about her visit to the annual conference of the National Right to Life Committee, which for decades was the nation’s leading anti-abortion organization, although it’s been eclipsed by some others more recently. The story includes a couple of eye-opening observations, including that the anti-abortion movement is surprised that all those bans didn’t actually reduce the number of abortions by very much. As we know, women who are looking for abortions normally will find a way to get them, either in state or out of state or underground or whatever. And we also learned in this story that some in the movement are willing to allow rape and incest exceptions in abortion bills, which they have traditionally opposed, because they want to use those as sweeteners for bills that would make it easier to enforce bans, stronger bans, things like the idea in Texas of allowing individual citizens to use civil lawsuits and forbidding local prosecutors from declining to prosecute abortion cases. We’re seeing that in some sort of blue cities in red states. It’s a really interesting read and I really recommend it. OK. That is our show for this week. As always, if you enjoyed the podcast, you can subscribe where ever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks, as always, to our producer, Francis Ying. Also as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can tweet me. I’m @jrovner, and I’m on Bluesky and Threads. Joanne.
Kenen: @joannekenen1 at Threads.
Rovner: Sarah.
Karlin-Smith: I’m @SarahKarlin or @sarah.karlinsmith, depending on which of these many social media platforms you’re looking at, though.
Rovner: Anna.
Edney: @annaedney on Twitter and @anna_edneyreports on Threads.
Rovner: You can always find us here next week where we will always be in your podcast feed. Until then, be healthy.
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KFF Health News' 'What the Health?': Let’s Talk About the Weather
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
2023 will likely be remembered as the summer Arizona sizzled, Vermont got swamped, and nearly the entire Eastern Seaboard, along with huge swaths of the Midwest, choked on wildfire smoke from Canada. Still, none of that has been enough to prompt policymakers in Washington to act on climate issues.
Meanwhile, at a public court hearing, a group of women in Texas took the stand to share wrenching stories about their inability to get care for pregnancy complications, even though they should have been exempt from restrictions under the state’s strict abortion ban.
This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs of Stat, Shefali Luthra of The 19th, and Alice Miranda Ollstein of Politico.
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Rachel Cohrs
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Shefali Luthra
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Alice Miranda Ollstein
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Among the takeaways from this week’s episode:
- Tensions over abortion access between the medical and legal communities are coming to the fore in the courts, as doctors beg for clarification about bans on the procedure — and conservative state officials argue that the law is clear enough. The risk of being hauled into court and forced to defend even medically justified care could be enough to discourage a doctor from providing abortion care.
- Conservative states are targeting a Biden administration effort to update federal privacy protections, which would make it more difficult for law enforcement to obtain information about individuals who travel outside a state where abortion is restricted for the procedure. Patient privacy is also under scrutiny in Nebraska, where a case involving a terminated pregnancy is further illuminating how willing tech companies like Meta are to share user data with authorities.
- And religious freedom laws are being cited in arguments challenging abortion bans, with plaintiffs alleging the restrictions infringe on their religious rights. The argument appears to have legs, as early challenges are being permitted to move forward in the courts.
- On Capitol Hill, key Senate Democrats are holding up the confirmation process of President Joe Biden’s nominee as director of the National Institutes of Health to press for stronger drug pricing reforms and an end to the revolving-door practice of government officials going to work for private industry.
- And shortages of key cancer drugs are intensifying concerns about drug supplies and drawing attention in Congress. But Republicans are skeptical about increasing the FDA’s authority — and supply-chain issues just aren’t that politically compelling.
Also this week, Rovner interviews Meena Seshamani, director of the Center for Medicare at the Centers for Medicare & Medicaid Services at the Department of Health and Human Services.
Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: Los Angeles Times’ “Opinion: Crushing Medical Debt Is Turning Americans Against Their Doctors,” by KFF Health News’ Noam N. Levey.
Rachel Cohrs: The New York Times’ “They Lost Their Legs. Doctors and Health Care Giants Profited,” by Katie Thomas, Jessica Silver-Greenberg, and Robert Gebeloff.
Alice Miranda Ollstein: The Atlantic’s “What Happened When Oregon Decriminalized Hard Drugs,” by Jim Hinch.
Shefali Luthra: KFF Health News’ “Medical Exiles: Families Flee States Amid Crackdown on Transgender Care,” by Bram Sable-Smith, Daniel Chang, Jazmin Orozco Rodriguez, and Sandy West.
Also mentioned in this week’s episode:
- Stat’s “From Rapid Cooling Body Bags to ‘Prescriptions’ for AC, Doctors Prepare for a Future of Extreme Heat,” by Karen Pennar.
- Politico’s “The Sleeper Legal Strategy That Could Topple Abortion Bans,” by Alice Miranda Ollstein.
click to open the transcript
Transcript: Let’s Talk About the Weather
KFF Health News’ ‘What the Health?’Episode Title: Let’s Talk About the WeatherEpisode Number: 306Published: July 20, 2023
[Editor’s note: This transcript, generated using transcription software, has been edited for style and clarity.]
Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News. And I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, July 20, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So here we go. We are joined today via video conference by Alice Miranda Ollstein, of Politico.
Alice Miranda Ollstein: Hello.
Rovner: Rachel Cohrs, of Stat News.
Rachel Cohrs: Hi, everybody.
Rovner: And Shefali Luthra of The 19th.
Shefali Luthra: Hello.
Rovner: Later in this episode we’ll have my interview with Meena Seshamani, director of the Center for Medicare at the Center for Medicare & Medicaid Services at the Department of Health and Human Services. She has an update on drug price negotiations, Medicare Advantage payments, and more. But first, this week’s news. So let’s talk about the weather. Seriously, this summer of intense heat domes in the South and Southwest, flash floods in the East, and toxic air from Canadian wildfires almost everywhere below the border has advertised the dangers of climate change in a way scientists and journalists and policymakers could only dream about. The big question, though, is whether it will make any difference to the people who can actually do something about it. I hasten to point out here that in D.C., it’s normal — hot and humid for July, but nothing particularly out of the ordinary, especially compared to a lot of the rest of the country. Is anybody seeing anybody on the Hill who seems at the least alarmed by what’s going on?
Ollstein: Not other than those who normally speak out about these issues. You’re not seeing minds changed by this, even as the reports coming out, especially of the Southwest, are just devastating — I mean, especially for unhoused people, just dying. I was really interested in the story from Stat about doctors moving to start prescribing things to combat heat, like prescribing air conditioners, prescribing cooling packs and other things, really looking at heat as a medical issue and not just a feature of our lives that we have to deal with.
Rovner: Well, emergency rooms are full of patients. You can now burn yourself walking on the sidewalk in Arizona. You know, last summer was not a great summer for a lot of people, particularly in California and in western Canada. But this year, it’s like everywhere across the country, everybody’s having something that’s sort of, oh, a hundred-year something or a thousand-year something. And yet we just sort of continue on blithely.
Ollstein: And just quickly, what really hits me is how much of a vicious cycle it can create, because the more people use air conditioners, those give off heat and make the bigger situation worse. So making it better for yourself makes it worse for others. Same with driving. You know, the worse the weather is, the more people have to drive rather than bike or walk or take public transit. And so it gets into this vicious cycle that can make it worse for everyone and create these so-called heat islands in these cities.
Rovner: All right. Well, let us move on to a more familiar topic: abortion and reproductive health. In case you’re wondering why it’s hard to keep track of where abortion is legal, where it’s banned, and where it’s restricted, let’s talk about Iowa. When we last checked in, last week, state lawmakers had just passed a near-total ban after the state Supreme Court deadlocked over a previous ban and the Republican governor, Kim Reynolds, was poised to sign it. Then what happened?
Luthra: The governor signed the ban right as the hearing for the ban concluded in which Planned Parenthood and another abortion clinic in the state sued, arguing, right, that this is the exact same as the law that was just struck down and therefore should be struck down again. And this judge said that he wouldn’t rush to his ruling. He wanted to, you know, give it the time that it deserved so he wouldn’t be saying anything on Friday, which meant as soon as the law was signed, it took effect. It was in effect for maybe a little over 72 hours, essentially through the weekend. And then on Monday, the judge came and issued a ruling blocking the law. And even that is temporary, right? It only lasts as long as this case is proceeding. And one of the reasons Republicans came back and passed this ban is they are hopeful that something has changed and that this time around the state Supreme Court will let the six-week ban in Iowa stand, which really just would have quite significant implications for the Midwest, where it’s been kind of slower to restrict abortion than the South has been because of the role the courts have played in Ohio, in Iowa, blocking abortion bans, and we could very soon see restrictions in Iowa, in Indiana, potentially in Ohio, depending on how the election later this year goes. And it will look like a very different picture than it did even six months ago.
Rovner: And for the moment, abortion is legal in Iowa, right?
Luthra: Correct.
Rovner: Up to 20 weeks?
Luthra: Up to 20, 22, depending on how you count.
Rovner: But as you say, that could change any day. And it has changed from day to day as we’ve gone on. Well, if that’s not confusing enough, there are a couple of lawsuits that went to court in Texas and Missouri, and neither of them is actually challenging an abortion ban. In Texas, women who were pregnant and unable to get timely care for complications are suing to clarify the state’s abortion ban so patients don’t have to literally wait until they are dying to be treated. And in Missouri, there’s a fight between two state officials over how to describe what a proposed state ballot measure would do, honestly. So what’s the status of those two suits? Let’s start with Texas. That was quite a hearing yesterday.
Luthra: It is really devastating to watch. And the hearing continues today, Thursday. And we are hearing from these women who wanted to have their pregnancies, developed complications where they knew that the fetus would not be viable, could not get care in the state. One of them who came to the State of the Union earlier this year, she had to wait until she was septic before she could get care. Another woman traveled out of state. Another one had to give birth to a baby that died four hours after being born, and she knew that this baby wouldn’t live. And it’s really striking to watch just how obviously difficult it is for these women to relive this thing that happened to them, clearly one of the worst things in their lives, maybe the worst thing. And the state’s arguments are very interesting, too, because they appear to be trying to suggest that it is actually not that the law is unclear, but that doctors are just not doing their jobs and they should do, you know, the hard work of medicine by understanding what exceptions mean and interpreting laws that are always supposed to be a little ambiguous.
Ollstein: So when states were debating abortion bans and really Republicans were tying themselves in knots over this question of exemptions — How should the exemptions be worded? Should there be any exemptions at all? Who should they apply to? — a lot of folks on the left were yelling at the time that that’s the wrong conversation, that exemptions are unworkable; even if you say on paper that people can get an abortion in a medical emergency, it won’t work in practice. And this is really fodder for that argument. This is that argument playing out in real life, where there is a medical exemption on the books, and yet all of these women were not able to get the care they needed, and some have suffered permanent or somewhat permanent repercussions to their health and fertility going forward. As more states debate their own laws, and some states with bans have even tried to go back and clarify the exemptions and change them, I wonder how much this will impact those debates.
Rovner: Yeah, I mean, if you just say that doctors are being, you know, cowards basically by not providing this care, think of it from the doctor’s point of view, and now we see why hospital lawyers are getting involved. Even if there’s a legitimate medical reason, they could get dragged into court and have to pay tens or hundreds of thousands of dollars in legal fees just to prove that their medical judgment was correct. You can kind of see why doctors are a little bit reluctant to do that.
Ollstein: And just to stress, these laws were not written by doctors. These laws were written by politicians, and they include language that medical groups have pointed out doesn’t translate to the actual practice of medicine. Some of these bans’ exceptions’ language use terms like irreversible, and they’re like, “That’s not something we say in medicine. That doesn’t fit with our training. We don’t think in terms of that.” Also, terms like life-threatening: It’s like, OK, well, is it imminently life-threatening? And even then, what does that mean? How close does someone need to be to losing their life in order to act?
Rovner: And pregnancy itself is life-threatening.
Ollstein: Right. Or something could be life-threatening in a longer-term way, you know, down the road. Other conditions like diabetes or cancer could be life-threatening even if it won’t kill you today or tomorrow. So this is a real battle where medicine meets law.
Rovner: Well, in Missouri, it’s obviously not nearly as dramatic, but it’s also — you can see how this is playing out in a lot of these states. This is basically a fight between the state attorney general and the state auditor over how much an abortion ban might end up costing the state. They’re really sort of fighting this as hard as they can. It’s basically to make it either more or less attractive to voters, right?
Ollstein: It’s similar to some of the gambits we saw in Michigan to keep the measure off the ballot or put it on the ballot in a way that some would say would be misleading to voters. So I think you’re seeing this more and more in these states after so many states, including pretty conservative states, voted in favor of abortion rights last year. You know, the right is afraid of that continuing to happen, and so they’re looking at all of these technical ways — through the courts, through the legislatures, whatever means they can — to influence the process. And Democrats cry that this is antidemocratic, not giving people a say. Republicans claim that they’re preventing big-money outside groups from influencing the process. And I think this is going to be a huge battle. Missouri and Ohio are up next in terms of voting. And after that, you have Florida and Nevada and a bunch of other states in the queue. And so this is going to continue to be something we’re discussing for a while.
Luthra: And to flag the case in Ohio, what’s happening there, right, is the state is having voters vote onto whether to make it harder to pass constitutional amendments. There’s an election in August that would raise the threshold to two-thirds. And what we know from all of the evidence why they don’t typically have August referenda in Ohio is because the turnout is very, very low, and they are expecting that to be very low. And they’ve made it explicit that the reason they want to make it harder to pass constitutional amendments is, in fact, the concern around Ohio’s proposed abortion protection.
Rovner: Of course, that’s what they said about Kansas last year, that people wouldn’t vote because it was in the summer, so — but this is a little bit more obtuse. This is whether or not you’re going to change the standard for passing constitutional change that would enshrine abortion. So, yeah, clearly —
Luthra: It’s hard to get people excited about votes on voting.
Rovner: Yeah, exactly. An underlying theme for most of this year has been efforts by states that restrict or ban abortion to try to prevent or at least keep tabs on patients who leave the state to obtain a procedure where it is legal. Attorneys general in a dozen and a half states are now protesting a Biden administration effort to protect such information under HIPAA, the medical records privacy provisions of the Health Insurance Portability and Accountability Act. Alice, you’ve written about this. What would the HIPAA update do, and why do the red states oppose it?
Ollstein: The HIPAA update, which was proposed in April, and comment closed in June, and so we’re basically waiting for a final rule — at some point, you know, it can take a while — but it would make it harder for either law enforcement or state officials to obtain medical information about someone seeking an abortion, either out of state or in state under one of these exemptions. This would sort of beef up those protections and require a subpoena or some form of court order in order to get that data. And you have sort of an interesting pattern playing out, which you’ve seen just throughout the Biden administration, where the Biden administration hems and haws and takes an action related to abortion rights and the left says it’s not good enough and the right says it’s wild overreach and unconstitutional and they’re going to sue. And so that’s what I was documenting in my story.
Rovner: Is it 18 red states saying —
Ollstein: Nineteen, yes, yeah.
Rovner: Nineteen red states saying that this is going too far.
Ollstein: They say they want to be able to obtain that data to see if people are breaking the law.
Rovner: Well, Shefali, you wrote this week about sort of a related topic, whether states can use text or social media messages as evidence of criminal activity. That sounds kind of chilling.
Luthra: Yeah, and this is, I think, a really interesting question. We saw it in this case in Nebraska, where a sentencing for one of the defendants is happening today in fact. And I want to be careful in how I talk about this because it concerns a pregnancy that was terminated in April of 2022, before Roe was even overturned. But it sort of offered this test case, this preview for: If you do have law enforcement going after people who have broken a state’s abortion laws, how might they go about doing that? What statutes do they use to prosecute? And what information do they have access to? And the answer is potentially quite a lot. Organizations like Meta and Google are quite cooperative when it comes to government requests for user data. They are quite willing to give over history of message exchanges, history of your searches, or of, you know, where you were tracked on Google Maps. And the bigger question there is how likely are we to see individual prosecutors, individual states, going after patients and their families, their friends for breaking abortion laws? Right now, there’s been some hesitation to do that because the politics are so terrible. But if they do go in that direction, people’s internet user data is, in most states, unprotected. There is no federal law protecting, you know, your Facebook messages. And it could be quite a useful piece of information for people trying to build a case, which should raise concern for anyone trying to access care.
Rovner: Yeah, this is exactly why women were taking their period-tracking apps off of their phones, to worry about the protection of quite personal information. Well, finally this week on the abortion front, we have talked so, so much about how conservative Christians complain that various abortion and even birth control laws violate their religious beliefs. Well, now representatives of several other religions, including Judaism and even some of the more liberal branches of Christianity, say that abortion bans violate their right to practice their religion. This is going on in a bunch of different states. I think the first one we talked about was Florida, I think a year ago. Are any of these lawsuits going anywhere? Do we expect this to end up before the Supreme Court at some point?
Ollstein: So most of them are in state court, not federal. I mean, it’s always possible it could go to the Supreme Court. A couple of them are in federal court and a couple of them have already reached the appeals court level. But the experts I talked to for my story on this said this is mainly going to have an impact in state courts and how they interpret state constitutions. A lot of states have stronger language around religious protections than the federal Constitution, including some laws that pretty conservative state leaders passed in the last few years, and I doubt they expected that same language would be cited to defend abortion rights. But here we are. And yeah, a Missouri court recently ruled that the lawsuit can go forward, the religious challenge to the state’s abortion ban. It’s a coalition of a bunch of different faith leaders bringing that challenge. And in Indiana, they won a preliminary ruling on that case. And there are others pending in Kentucky, Florida, a bunch of other states. And so, yeah, I think this definitely has legs.
Rovner: Yeah, we’re all learning an awful lot about court procedure in lots of different states. Let us move to Capitol Hill, where Congress is in its annual July race to the August recess. Seriously, this is actually a month in which Congress typically does get a lot done. Maybe not so much this year. One perhaps unexpected holdup in the U.S. Senate is where the confirmation of Monica Bertagnolli, President Biden’s nominee to head the National Institutes of Health, is being held up not by a Republican but by two Democrats: health committee chair Bernie Sanders, another member of the committee, Elizabeth Warren. Rachel, what is going on with this?
Cohrs: Sen. Bernie Sanders has long wanted the Biden administration to be more aggressive on drug pricing. And there is one issue in particular that Sen. Sanders has wanted the NIH specifically to use to challenge drug companies’ patents or at least put some pricing protections in there for drugs that are developed using publicly funded research. And the laws that the NIH potentially could use to challenge these companies for high-priced medications have never been used in this way. And Sen. Sanders is using his bully pulpit and the main leverage he has, which is over nominations, to get the White House’s attention. And I think the White House’s position here is that they have done more than any administration in the past 20 years to lower drug prices.
Rovner: Which is true.
Cohrs: It is true. And — but Sen. Sanders still is not satisfied with that and wants to see commitments from the White House and from NIH to do more.
Rovner: And Sen. Elizabeth Warren.
Cohrs: Sen. Elizabeth Warren, yes, who my colleague Sarah Owermohle first reported had some concerns over the revolving door at NIH and wanted a commitment that the nominee wouldn’t go to lobby or work for a large pharmaceutical company for four years after leaving the position, and I don’t know that she’s agreed to that yet. So I don’t see where this resolves. It’s tough, because we’re looking so close to an election, and I think there are big questions about what breaks this logjam. But it certainly has slowed down what looked like a very smooth and noncontroversial nomination process.
Rovner: Yeah, I mean, obviously, you know, we’ve seen many, many times over the years nominations held up for other reasons — I mean, basically using them as leverage to get some policy aim. It’s more rare that you see it on the president’s own party but obviously, you know, not completely unprecedented. Certainly in this case we have a lot of things to be worked out there. Well, Sen. Sanders also seems to be threatening the reauthorization of one of his very pet programs, the bipartisanly popular community health centers. His staff this week put out a draft bill and announced a markup before sharing it with Republicans on the committee. Now Ranking Member Bill Cassidy, who also supports the community health centers program — almost everybody in Congress supports the community health centers program — Cassidy complains there’s no budget score, that the bill includes programs from outside the committee’s jurisdiction, and other details that can be very important. Is Sanders trying to make things partisan on purpose, or is this just sloppy staff work?
Cohrs: Honestly, I can’t answer that question for you, but I don’t think that it’s going to result in a productive outcome for the community health centers. And I think we have in recent years seen significant cooperation between the chair and ranking member, but with Lamar Alexander, with Richard Burr, with Patty Murray, you know, we have seen a lot civility on this committee in the recent past, and that appears to have ended. And I think Sen. Cassidy’s response that he hadn’t seen the legislation publicly was, I think, telling. We don’t usually see that kind of public fighting from a committee chair.
Rovner: He put out a press release.
Cohrs: Right, put out a press release. Yeah. This is not what we usually see in these committees. And it is true that Sen. Sanders’ bill is so much more money than I think is usually given to community health centers in this reauthorization process. I think it’s true that the bill that he dropped touches issues that would anger almost every other stakeholder in the health care system. And I don’t think Sen. Cassidy quite envisioned that. And he introduced his own bill that would have introduced —
Rovner: Cassidy introduced his own bill.
Cohrs: Yes, Sen. Cassidy introduced his own bill last week that would have continued on with what the House Energy and Commerce Committee had passed unanimously earlier this summer to give community health centers a more modest boost in funding for two years.
Rovner: And obviously, there’s some urgency to this because the authorization runs out at the end of September and now we’re in July and they’re going to go away for August. So this is obviously something else that we’re going to need to keep a fairly close eye on. Well, meanwhile, elsewhere, as in at the Senate Finance Committee, which oversees Medicare and Medicaid, we’re starting to see legislation to regulate PBMs — pharmacy benefit managers — or are we? Rachel, we’ve come at this several times this year. How close are we getting?
Cohrs: We’re getting closer. And I think that two key committees are really feeling the heat to get their proposals out there before the end of the year. The first, like you mentioned, was the Senate Finance Committee, which is planning a markup next week, right before senators leave for August recess. They’ve asked for feedback from CBO [the Congressional Budget Office] around the end of August recess so that they’ll be ready to go. But I think it’s no secret that their delay in marking anything up or introducing anything has slowed down this process. And in the House, I know the Ways and Means Committee is trying to put together their own proposal and find time for a markup, whereas the House Energy and Commerce Committee, which also has jurisdiction over many of these issues, is frustrated, because they got their bill introduced, they had all the full regular order of subcommittee and then full committee hearings and then markups, got this bill unanimously out of their committee, and now everyone’s kind of waiting around on these two committees with jurisdiction over the Medicare program to see what they’re going to put together before any larger package can be compiled.
Rovner: Well, you know things are heating up when you start seeing PBM ads all over cable news. So even if you don’t understand what the issue is, you know that it’s definitely in play on Capitol Hill. Well, while we’re on the subject of drug prices, we have another lawsuit trying to block Medicare’s drug price negotiation, this one filed by Johnson & Johnson. Why so many? Wouldn’t these drug companies have more clout if they got together on one big suit, or is there some strategy here to spread it out and hope somebody finds a sympathetic judge?
Ollstein: Yes, I think the latter is exactly what they’re doing, because if they were to all kind of band together, then it would be putting all their eggs in one basket. And this way we see most of the companies have filed in different jurisdictions. I think Johnson & Johnson did file in the same court as Bristol Myers Squibb did, so I think it’s not a perfect trend. But generally what we are seeing is that the trade groups like the [U.S.] Chamber of Commerce and PhRMA [the Pharmaceutical Research and Manufacturers of America] kind of have their own arguments that they’re making in different venues. The drug manufacturers themselves have their own arguments that they’re making in their own venues, and they’re spreading out across the country in some typically more liberal courts and circuits and some more conservative. But I think that it’s important to note that the Chamber of Commerce so far is the only one that’s asked for a preliminary injunction, in Ohio. That is kind of the motion that, if it’s approved, could potentially put a stop to this program even beginning to go into effect. So they’ve asked for that by Oct. 1.
Rovner: And remember, I guess we’re supposed to see the first 10 drugs from negotiation in September, right?
Cohrs: By Sept. 1, yes.
Rovner: By Sept. 1.
Cohrs: Pretty imminently here.
Rovner: Also happening soon. Well, before we stop with the news this week, I do want to talk briefly about drug shortages. This has come up from time to time, both before and during the pandemic, obviously, when we had supply chain issues. But it seems like something new is happening. Some of these shortages seem to be coming because generic makers of some drugs just don’t find them lucrative enough to continue to make them. Now we’re looking at some major shortages of key cancer drugs, literally causing doctors to have to choose who lives and who dies. Are there any proposals on Capitol Hill for addressing this? It’s kind of flying below the radar, but it’s a pretty big deal.
Cohrs: I think we’ve seen Congressman Frank Pallone make this his pet issue in the reauthorization of PAHPA [Pandemic and All-Hazards Preparedness Act], which is the pandemic preparedness bill, which also expires on Sept. 30. So, you know, they have a full plate.
Rovner: Which we will talk about next week because they’re marking it up today.
Cohrs: Exactly. Yes. So but what we have seen is that Democrats in the House Energy and Commerce Committee have made this a top priority to at least have something on drug shortages in PAHPA. And I think my colleague John Wilkerson watched a hearing this week and noted that the chair of the committee, Cathy McMorris Rodgers, seemed more open to adding something than she had been in the past. But again, I think it’s kind of uncertain what we’ll see. And Sen. Bernie Sanders did add a couple of drug shortage policies to his version of PAHPA in the HELP Committee [Senate Committee on Health, Education, Labor and Pensions]. So I think we are seeing some movement on at least some policies to address it. But the problem is that the supply chain is not sexy and Republicans are not crazy about the idea of giving the FDA more authority. I think there is just so much skepticism of these public health agencies. It’s a hard systemic issue to crack. So I think we may see something, but it’s unclear whether any of this would provide any immediate relief.
Rovner: Everybody agrees that there’s a problem and nobody agrees on how to solve it. Welcome to Capitol Hill. OK, that is this week’s news. Now we will play my interview with Medicare chief Meena Seshamani, and then we’ll come back and do our extra credit. I am pleased to welcome to the podcast Meena Seshamani, deputy administrator and director of the Center for Medicare at the Centers for Medicare & Medicaid Services at the Department of Health and Human Services. That must be a very long business card.
Meena Seshamani: [laughs]
Rovner: Translated, that means she’s basically in charge of the Medicare program for the federal government. She comes to this job with more than the requisite experience. She is a physician, a head and neck surgeon in fact, a PhD health economist, a former hospital executive, and a former top administrator there at HHS. Meena, welcome to “What the Health?” We are so happy to have you.
Seshamani: Thank you so much for having me, Julie.
Rovner: So, our podcast listeners will know, because we talk about it so much, that the biggest Medicare story of 2023 is the launch of a program to negotiate prescription drug prices and hopefully bring down the price of some of those drugs. Can you give us a quick update on how that’s going and when patients can expect to start to see results?
Seshamani: Absolutely. The new prescription drug law, the Inflation Reduction Act, really has made historic changes to the Medicare program. And to your point, people are seeing those results right now. There is now a $35 cap on what someone will pay out-of-pocket for a month’s supply of covered insulin at the pharmacy, which is huge. I’ve met with people all over the country. Sometimes people are spending up to $400 for a month’s supply of this lifesaving medication. Also, vaccines at no cost out-of-pocket. And a lot of this leads to what you’re mentioning with the drug negotiation program, a historic opportunity for Medicare to negotiate drugs. In January, we put out a timeline of the various pieces that we’re putting in place to stand up this negotiation program. Along that timeline, we have released guidance that describes the process that we will undergo to negotiate, what we’ll think about as we’re engaging in negotiation. And the first 10 drugs for negotiation that are selected will be announced on Sept. 1. And that will then lead into the negotiation process.
Rovner: And as we’ve mentioned — I think it was on last week’s podcast — there’s a lot of lawsuits that are trying to stop this. Are you confident that you’re going to be able to overcome this and keep this train on the tracks?
Seshamani: Well, we don’t generally comment on the lawsuits. I will say that we are implementing this law in the most thoughtful manner possible. From the day that the law was enacted, we have been meeting with drug manufacturers, health plans, patient groups, health care providers, you know, experts in the field, to really understand the complexity of the drug space and what we can do with this opportunity to really improve things, improve access and affordability to have innovative therapies for the cures that people need.
Rovner: Well, while we are on that subject, we — not just Medicare, but society at large — is facing down a gigantic conundrum. The good news is that we’re finally starting to see drugs that can treat or possibly cure such devastating ailments as Alzheimer’s disease and obesity. But those drugs are currently so expensive, and the population that could benefit from them is so large, they could basically bankrupt the entire health care system. How is Medicare approaching that? Obviously, in the Alzheimer’s space, that could be a very big deal.
Seshamani: Well, Julie, we are committed to helping ensure that people have timely access to innovative treatments that can lead to improved care and better outcomes. And in doing this, we take into account what the Medicare law enables coverage for and what the evidence shows. So with Alzheimer’s, CMS underwent a national coverage determination. And consistent with that, Medicare is covering the drug when a physician and clinical team participates in the collection of evidence about how these drugs work in the real world, also known as a registry. And this is very important because it will enable us to gather more information on patient outcomes as we continue to see innovations in this space. And you mentioned obesity. In the Medicare law, there is a carve-out for drugs for weight loss.
Rovner: A carve-out meaning you can’t cover them.
Seshamani: Correct. It says that the Medicare Part D prescription drug program will not cover drugs for weight loss. So we are looking at the increasing evidence. And for example, where there is a drug that is used for diabetes, for example, you know, then it can certainly be covered. And this is an area that we are continuing to partner with our colleagues in the FDA on and that we’d like to partner with the broader community to continue to build the evidence base around benefits for the Medicare population as we continue to evaluate where we want to make sure that people have access.
Rovner: But are you thinking sort of generally about what to do about these drugs that cost sometimes tens of thousands of dollars a year, hundreds of thousands of dollars a year, that half the population could benefit from? I mean, that cannot happen, right, financially?
Seshamani: Well, Julie, this is where the new provisions in the new drug law really come into play. Thinking from access for people for the high-cost drugs, I think we all know what a financial strain the high cost of drugs have created for our nation’s seniors, where now, in 2025, there will be a $2,000 out-of-pocket cap, that people will not have to pay out-of-pocket more than $2,000, which enables them to access drugs. And on the other side, as we talked about with drug negotiation, where for drugs that have been in the market for seven years or 11 years, if they are high-cost drugs, they could potentially be selected for negotiation where we can then, you know, as we laid out in the guidance that we put out, look at what is the benefit that this drug provides to a population? What are the therapeutic alternatives? And then also consider things like what’s the cost of producing that drug and distributing it? How much federal support was given for the research and development of that drug? And how much is the total R & D costs? So I think that there are several tools that we’ve been given in the Inflation Reduction Act that demonstrate how we are continuing to think about how we can ensure that Medicare is delivering for people now and in the future.
Rovner: Well, speaking of things that are popular but also expensive, let’s talk briefly about Medicare Advantage. More and more beneficiaries are opting for private plans over traditional, fee-for-service Medicare. But the health plans have figured out lots of ways to game the system to make large profits basically at taxpayers’ expense. Is there a long-term plan for Medicare Advantage or are we just going to continue to play whack-a-mole, trying to plug the loopholes that the plans keep finding?
Seshamani: You know, as now we have 50% of the population in Medicare Advantage, Medicare Advantage plays a critical role in advancing our vision for the Medicare program around advancing health equity, expanding access to care, driving innovation, and enabling us to be good stewards of the Medicare dollar. And that vision that we have is reflected in all of the policies that we have put forward to date. And I might add that those policies really have been informed by engagement with everyone who’s interested in Medicare Advantage. We did a request for comment and got more than 4,000 suggestions from people. This has now come out in recent policies like cracking down on misleading marketing practices so that people can get the plan that best suits their needs; ensuring clear rules of the road for prior authorization and utilization management so we can make sure that people are accessing the medically necessary care that they need; things like improving network adequacy, particularly in behavioral health, so people can access the health care providers in the networks of the plans; and then the work that we’re doing around payment, to make sure that we’re paying accurately, updating the years that we use for data, looking at the coding patterns of Medicare Advantage. And again, this is all work that is important to make sure that the program is really serving the people in the Medicare program.
Rovner: So, as you know, we’ve done big investigative projects here at KFF Health News about both medical debt and nonprofit hospitals not living up to their responsibilities to the community. As the largest single payer of hospitals, what is Medicare doing to try and address requirements for charity care, for example?
Seshamani: Well, the. IRS oversees the requirements for community benefit, which is how hospitals maintain or get a nonprofit status. We have certainly worked with the Consumer Financial Protection Bureau and the Department of Treasury on, for example, issuing a request for information, seeking public comment on, you know, medical credit cards. But even beyond that, I think this is an example of where we need to bring more payment accuracy and transparency in the health care system. So, for example, we have recently just proposed strengthening hospital price transparency so that people can know what is the cost of services, standard charges that hospitals provide. We also are adding quality measures to hospitals, particularly around issues around health equity, making sure that hospitals are screening patients for social needs. And we’re also tying increasingly our payment programs to making sure that those underserved populations are receiving excellent care, so again, really trying to drive transparency, quality, and access through all of the work that we’re doing with hospitals.
Rovner: But can you leverage Medicare’s power? Obviously, you know, that was what created EMTALA [the Emergency Medical Treatment and Labor Act], was leveraging Medicare’s power. Can you leverage it here to try and push some of these hospitals to do things they seem reluctant to do?
Seshamani: Where we have our levers in the Medicare program, we absolutely are working with hospitals around issues of equity, so as I mentioned, you know, really embedding equity not only in our quality requirements but also in hospital operations — for example, that as part of their operations they need to be looking at health equity. You know, where we are looking at how they are providing care and addressing issues of patient safety. So, we continue to look into all of these angles, and where we can support good practices. For example, we just proposed in our inpatient prospective payment system rule that when hospitals are taking care of homeless patients, that can be considered in their payment, because we have found through our analyses that additional resources are being used to make sure that those patients are supported for all of their needs, and we’re encouraging hospitals to code for these social needs so that we can continue to assess with them where resources and supports are needed to provide the kind of care that we all want for our populations.
Rovner: Last question, and I know that this is big, so it’s almost unfair. One of the reasons we know that it’s getting so expensive to manage medical costs is the increasing involvement of private equity in health care. What’s the Biden administration doing to address this growing profit motive?
Seshamani: Yeah, Julie, I’ll come back to, you know, what I alluded to before around transparency. We are really committed to transparency in health care, and we are continuing to focus on gathering data that sheds light on what is happening in the health care market so that we can be good stewards of the taxpayer dollar. So I mentioned our work in hospital price transparency, where we have streamlined the enforcement process; we have proposed to require standard ways that hospitals are reporting their charges and standard locations where they have to put a footer on the hospital’s homepage so that people can find that data easily. In Medicare Advantage, we are requiring more reporting for the medical loss ratio for plans to report spending on supplemental benefits like dental, vision, etc. And we really want to hone in on where else we can gather more data to be able to enable all of us to see what is happening in this dynamic health care market; what’s working? What isn’t? And so we’re very interested in getting ideas.from everyone of where more data can be helpful to enable us to then enact policies that can make sure that the health care industries and the market are really serving people in the most effective way possible.
Rovner: Well, you’ve got a very big job, so I will let you get back to it. Thank you so much, Meena Seshamani.
Seshamani: Thank you for having me.
Rovner: OK, we’re back and it’s time for our extra credit segment. That’s when we each recommend a story we read this week we think you should read too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Shefali, why don’t you go first this week?
Luthra: Sure. So mine is from KFF Health News by a dream team, Bram Sable-Smith, Daniel Chang, Jazmin Orozco Rodriguez, and Sandy West. The headline is “Medical Exiles: Families Flee States Amid Crackdown on Transgender Care.” And I mean, it’s exactly what it sounds like. It’s this really person-grounded, quite deeply reported story about how restrictions on gender-affirming health care, especially for young people, are forcing families to leave their homes. And this is a really tough thing for people to do, you know, leave somewhere where you’ve lived for 10 years or longer and go somewhere where you don’t have ties. Moving is quite expensive. And I think this is a really important look at something that we anecdotally know is happening, haven’t seen enough really great deep dives on, and is something that potentially will happen more and more as people are forced to leave their homes if they can afford to do so because they don’t feel safe there anymore.
Rovner: Yeah, and this is the issue of doing these social issues state by state by state, just what’s happening now. Alice.
Ollstein: So I chose a piece from The Atlantic called “What Happened When Oregon Decriminalized Hard Drugs,” by Jim Hinch. It was really fascinating. On the one side, they say this is evidence that the policy has failed, that decriminalizing possession of small amounts of cocaine, heroin, all hard drugs, has been a failure because overdoses have actually gone up since then. But other experts quoted in this article say that, look, we tried the punitive war on drugs model for decades and decades and decades before declaring it a failure; how can we evaluate this after just a few years? It just takes more time to make this transition and takes more time to, you know, ramp up treatment and services for people, and because this happened three years ago, it was disrupted by the pandemic and, you know, services were not able to reach people, etc. So a really fascinating look.
Rovner: Yes, it’s quite the social experiment that’s going on in Oregon. Rachel.
Cohrs: So mine is from The New York Times, a group of reporters and a new series called “Operating Profits.” And the headline is “They Lost Their Legs. Doctors and Health Care Giants Profited.” And I think I’m just really excited to see more about this line of reporting about overutilization in health care and how certain payment incentives — I mean, they made a story about payment incentives in hospital outpatient departments and how pay rates change really personal and interesting, and it’s important. So, I mean, all these really dense rules that we’re seeing drop this summer do really have implications for patients. And there are bad actors out there who are kind of capitalizing on that. So I felt it was like really responsible reporting, mostly focused on one physician who, you know, was doing procedures that he shouldn’t have and other doctors ultimately were left to clean up the damage for these patients. And they had amputations that they maybe shouldn’t have had, which is such a serious and devastating consequence. I thought that was very important reporting, and I’m excited to see what’s next.
Rovner: Yeah, I’m looking forward to seeing the rest of the series. Well, my story this week is in the Los Angeles Times from my KFF Health News colleague Noam Levey, who’s been working on a giant project on medical debt. It’s called “Crushing Medical Debt Is Turning Americans Against Their Doctors.” And it points out something I hadn’t really thought about before, that outrageous and unexpected bills are undermining public confidence in medical providers and the medical system writ large. And so far, nobody’s doing very much about it. To quote from Noam’s piece, “Hospitals and doctors blame the government for underpaying them and blame insurers for selling plans with unaffordable deductibles. Insurers blame providers for obscene prices. Everyone blames drug companies.” Well, it’s going to take a lot of time to dig out of this hole, but probably it would help if everybody stopped digging. OK. That is our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us too. Special thanks, as always, to our producer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can tweet me. I’m still @jrovner, and I’m on Threads @julie.rovner. Shefali.
Luthra: I’m @shefalil.
Rovner: Alice.
Ollstein: @AliceOllstein.
Rovner: Rachel.
Cohrs: I’m @rachelcohrs.
Rovner: We will be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': A Year Without Roe
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Julie Rovner
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
It’s an understatement to say a lot has happened in the year since the Supreme Court overturned the nationwide right to abortion in its decision in Dobbs v. Jackson Women’s Health Organization.
But while many of the subsequent legislative and court actions to either ban or preserve access to abortion were predicted, the decision has had other, sometimes far-reaching consequences.
In this special episode of KFF Health News’ “What the Health?” four reporters who have closely covered the issue — host and KFF Health News chief Washington correspondent Julie Rovner, Alice Miranda Ollstein of Politico, Shefali Luthra of The 19th, and Sandhya Raman of CQ Roll Call — try to condense all that has happened since the nationwide right to abortion was revoked.
Panelists
Shefali Luthra
The 19th
Alice Miranda Ollstein
Politico
Sandhya Raman
CQ Roll Call
Among the takeaways from this week’s episode:
- In the Dobbs ruling last year, some justices said the decision would settle the issue of abortion in the courts. That has turned out not to be the case; jurisprudence about abortion access continues, largely in state courts.
- President Joe Biden has issued executive orders to preserve access to reproductive health care, including recently by directing federal agencies to find ways to increase access to contraception. But not all of the administration’s calls have translated into federal action, and some progressive groups are disappointed the Biden administration has not gone further in protecting abortion care.
- Perhaps the most significant action in Congress has been Sen. Tommy Tuberville (R-Ala.) blocking Pentagon nominations over a Defense Department policy supporting the ability of troops and their dependents to travel for abortion care. So far he has held up more than 250 nominations amid accusations that he is undermining national security.
- After Dobbs, there was anxiety in Democratic-run states that abortion restrictions would seep across state borders and lead to interstate prosecutions targeting abortion care. Those concerns have, so far, not materialized. Meanwhile, some states are attempting more roundabout ways to ban abortion, such as requiring all abortions be performed in hospitals when there are no hospitals in the state that perform the procedure.
- Polls show voters are now more supportive of abortion access than they have been in many years; more opposed to second-trimester bans; and more likely to identify abortion as a key priority when they vote. Health care providers are finding themselves pressed into advocacy or choosing to move to other states, potentially creating long-term care deserts.
- Plus, our panel of reporters reflects on one thing that will stick with them from their experiences covering abortion in the first year after the overturning of Roe v. Wade.
Also this week, Rovner interviews Alina Salganicoff, senior vice president and director for Women’s Health Policy at KFF. For KFF research and resources on reproductive health, click here.
Plus, for “extra credit,” the panelists suggest the favorite abortion-related stories they wrote in the past year they think you should read, too:
Julie Rovner: KFF Health News’ “Three Things About the Abortion Debate That Many People Get Wrong,” by Julie Rovner.
Shefali Luthra: The 19th’s “93 Days: The Summer America Lost Roe v. Wade,” by Shefali Luthra.
Alice Miranda Ollstein: Politico’s “Kansas’ Abortion Vote Kicks Off New Post-Roe Era,” by Alice Miranda Ollstein.
Sandhya Raman: Roll Call’s “Conservatives Use Abortion Strategies in Fight Over Trans Care,” by Sandhya Raman.
click to open the transcript
Transcript: A Year Without Roe
KFF Health News’ ‘What the Health?’
Episode Title: A Year Without Roe
Episode Number: 304
Published: June 29, 2023
[Editor’s note: This transcript, generated using transcription software, has been edited for style and clarity.]
Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent at KFF Health News. We’re back in Washington this week, joined by some of the best and smartest health reporters. We’re taping this week on Thursday, June 29, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So here we go. We are joined today via video conference by Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Good morning.
Rovner: Shefali Luthra of The 19th.
Luthra: Hello.
Rovner: And Sandhya Raman of CQ Roll Call.
Raman: Good morning.
Rovner: So after last week’s special with the current and two former Health and Human Services secretaries, which I hope you all enjoyed, we have another special episode for you this week, one year after Roe fell. Saturday, June 24, marked a year since the Supreme Court overturned the nationwide right to abortion with its decision in Dobbs v. Jackson Women’s Health Organization. We’re going to start with an interview with my KFF colleague Alina Salganicoff, all about the work KFF has done on this topic over the last year. Spoiler alert: It’s been a lot. Then we’ll have our regular panel discussion. So, without further ado, here is the interview. I am pleased to welcome to the podcast my colleague Alina Salganicoff, senior vice president and director of Women’s Health Policy here at KFF. Alina, welcome to “What the Health?”
Alina Salganicoff: Thank you. Delighted to be here.
Rovner: So it’s an understatement to say that a lot has happened on the women’s health front in the year since the Supreme Court decided Dobbs. But I think your group has produced an enormous volume of information that a lot of journalists and researchers have already used to help paint a picture of those changes. For those who haven’t taken a stroll through the resources available at kff.org/womens-health-policy, give us an idea of what can be found there.
Salganicoff: Well, we have been collecting a tremendous amount of information. Most recently we released a survey of OB-GYNs on their experiences pre- and post-Dobbs and really found some very, I think, alarming findings in terms of the impact of Dobbs on clinical care. We’re also tracking abortion coverage, as well as tracking the availability of abortion at the state level, and we do that routinely. We have a litigation tracker that tracks litigation at the federal and the state level, and that’s just been a very active part of our portfolio and analysis as well. And that’s just an example of a few things that we have going on. But we also have an abortion dashboard, where we provide up-to-date information and analysis and data, not only for work that KFF has been doing, but also synthesis and analysis of other work that’s going on in the field.
Rovner: This is information that, I will confess, a lot of reporters have been using over the course of the year. So thank you for that. How would you describe the state of abortion rights in the U.S. a year post the overturn of Roe?
Salganicoff: Well, that’s a huge question. The answer, of course, truly depends on where you live. In states where abortion is banned, access has been all but eliminated, except for in the rarest circumstances. And honestly, in most cases, even women who qualify for those exceptions have nowhere to go or aren’t being served. In many other states, there are restrictions, particularly those with gestational bans that restrict where people seeking abortion can go. And even in states that uphold abortion rights, people may still need to travel far for abortions, even if … and maybe not even have access to telehealth abortions where they live.
Rovner: So I know this is an even harder question. Can you take 30 seconds to tell us what you think the biggest difference has been compared to a year ago, or I guess it’s now a year and a week ago?
Salganicoff: Well, that is a big ask, Julie. But I will say, for those who live in states where abortion is banned or greatly restricted, this is where you really see the biggest change. And this has, as we anticipated, disproportionately affected pregnant people of color, those who are young and low-income. But also, abortion bans have made it more dangerous for pregnant women and others to have a baby or to get needed medical care. Those seeking abortions have been the hardest hit, but they’re not the only group. And I think also that there’s growing awareness and acceptance that abortion cannot be relegated to the shadows of health care or banned without having broad repercussions on other aspects of health care. Maternity care, emergency care, treatment for cancer and autoimmune disease have all been impacted as well.
Rovner: Yeah, I think that’s been a big revelation for a lot of people, that lots of pregnant women who worked hard to get pregnant and are trying to have babies but have problems in their pregnancy are caught in some of these restrictions, even if unintentionally.
Salganicoff: Absolutely. And I think that the issue of the large disparities we have in this nation on maternal mortality really has brought this issue much more into the limelight, and really seeing how abortion is going to be connected to maternal mortality in this country.
Rovner: So, like me, you’ve been doing this work for a long time now. What surprised you most about the fallout from a year without Roe?
Salganicoff: Right. Well, when Roe fell, I think many of us anticipated in a short time half the states would ban abortion. And while that has happened in 14 states, legal challenges, along with ballot initiatives and elections, have made it clear that there is a will to maintain abortion access in many places where we didn’t think that was possible. Kansas, Kentucky, Michigan, they’re all great examples of that, but they’re not the only states. The other, I think, has been the issue of the FDA and mifepristone, where the Supreme Court has temporarily blocked the lower-court ruling that would have essentially overturned the FDA’s scientific assessment of the safety and effectiveness of the drug, as well as the guardrails that are necessary for dispensing. But that case is not resolved. And then, finally, we have the issue of the Comstock Act, which is also related to that, which is an anti-vice law from 1873 that holds the potential, if enforced, to block the distribution of not only mifepristone but potentially anything that’s used with the intent to perform an abortion. That doesn’t mean just mailing the pill from the clinician to the patient, but also distributing the medication. And it’s going to affect states across the country, not just those where abortion is banned.
Rovner: So lots more to watch. One of your reports that surprised me was how many abortion restrictions there are in states even where abortion isn’t banned, and what we think of as pretty blue, like Massachusetts and Maryland. What kind of restrictions still exist in places that are otherwise considered abortion-destination states?
Salganicoff: Yes, that’s some work that we’ve recently done some analysis on. Yeah. Even if abortion is not legally banned, states can establish regulations and other requirements that effectively restrict access. In states like Maryland and Massachusetts, those are parental consent, or notification, laws. But there are other requirements such as waiting periods, ultrasound requirements, as well as laws that only permit those who have medical degrees to perform or dispense medication abortion pills, even though we know that advanced-practice clinicians, like physician assistants or nurse-midwives, can safely perform these procedures. That makes it harder for people, even in those states, as well as those who travel to get access to abortion.
Rovner: So, presumably, abortion rights advocates have work to do in many states, not just ones with bans.
Salganicoff: That’s right.
Rovner: I think another thing that came as a surprise to me, and we’ve already mentioned this briefly, is how health care for women that is not abortion has been affected. What are doctors telling you?
Salganicoff: Yeah. We recently did a survey of OB-GYNs, and I’ve also been out in the field in several conferences and meetings. And, you know, there’s been a lot of attention recently to the issue of miscarriage management, but also dealing with pregnancy in general and possibly also in the context of cancer care, care for chronic diseases, and emergency care. For example, there have been concerns about access to drugs like methotrexate, which is an abortifacient. It’s used to treat ectopic pregnancies, but it’s also used to treat cancer and autoimmune disease. And we’ve been seeing and hearing at least anecdotal reports about difficulties in accessing that drug. Our OB-GYN survey finds that clinicians are really worried about maternal mortality, their ability to provide care that meets the standards of care — medical care and the norms — and also to provide miscarriage care. That should worry not only those who can get pregnant, but many others as well.
Rovner: So what are you working on now that we should keep an eye out for?
Salganicoff: Well, of course, we’re laser-focused on tracking and analyzing the broader implications of the Dobbs ruling on abortion access. But we’re also focused on contraceptive access as well. And I think that hasn’t gotten nearly as much attention. There’s the issue of how Title X, which is the federal family planning program, is going to proceed in light of a federal decision to withhold the Title X grants for Oklahoma and Tennessee, states that are refusing to follow the requirement that Title X patients be given nondirective pregnancy counseling and referral. So this is an area that I think is going to get some attention on the Hill and in the courts, and I think other states are watching that. The other issue … are developments around emergency contraception and the real confusion that our polling has really documented about whether it’s legal and available. And we actually saw in our OB-GYN survey very low rates of physicians providing emergency contraception to their patients. And then finally, where all eyes are, of course, on the FDA for their decision about the over-the-counter status of an oral contraceptive pill. And we’re going to be looking at how that’s all going to roll out in the pharmacies, as well as whether there’s going to be an opportunity to provide insurance coverage for that newly available method.
Rovner: Lots more to come. I guess we’ll have to do this again next year. Alina Salganicoff, thank you so much for joining us.
Salganicoff: Thank you for inviting me. It’s been a pleasure.
Rovner: OK. We are back and I’m so pleased to have three of my favorite reproductive health specialists at the table today, who have spent a lot of the last year reporting from around the country and, in some cases, around the world. Alice, Shefali, Sandhya: Thank you all for being here. So I want to start with the people who are most affected by the Supreme Court’s action last year. What has happened to women seeking abortions since last year and women seeking other types of health care, too, for that matter?
Luthra: I think the data is pretty compelling, right? We can look at the WeCount numbers that just came out right before the anniversary. The number of recorded legal abortions has fallen quite precipitously. We have seen thousands fewer people get abortions. We’ve also seen dramatic increases in people traveling for care, going to Florida, to Illinois, to North Carolina, among many others. And what those numbers don’t always tell us is how difficult that journey is, how expensive it is. I think a lot about this study from when SB 8, the Texas six-week abortion ban, took effect, and they found there that some of the people who were traveling out of state, it took them so much money they couldn’t afford food for a week and then they ate whatever they could; they couldn’t afford dog food because it was just that difficult of a trip. And what we’re seeing is just people are, in some cases, accessing health care and other cases they are not. And it is becoming a lot harder and in some cases life-threatening. We’re all hearing the stories about people experiencing pregnancy complications and not being able to get timely care flying across several states while afraid they could go into premature labor on the plane.
Ollstein: Everything Shefali said is true. I also think that we need to put our critical hats on when we look at some of this early, preliminary data that’s coming out. It just takes time to get very solid, reliable data. And while the WeCount report is helpful, it has a lot of holes in it, and it makes estimates, and it doesn’t include people who are obtaining mifepristone and self-managing their abortions outside the medical system. You know, it doesn’t include data from certain providers and certain states. And so I think it will just take time to get a really accurate picture of what’s going on. We are sort of cobbling it together. You know, we have providers in blue states reporting how much increase they’re seeing in people coming in. We get some data from groups like Aid Access that mail the pills about the demand they are seeing. But there are a lot of people who aren’t going to show up in any of those counts. And we just sort of don’t know what’s happening to that, other than anecdotally, based on our reporting on the ground. And so I think, yes, there are a lot of people obtaining pills, there are a lot of people traveling, and there are a lot of people for whom neither of those are possible options and that they are going forward with pregnancies that they otherwise would have terminated.
Rovner: I think one of my biggest takeaways from the last year is the broader understanding of how common pregnancy complications are. I think a lot of people did not expect to see so many women with wanted pregnancies have difficulty getting care that they needed. I think people didn’t realize how common pregnancy complications are; they affect about 8% of pregnancies, or that’s 1 in every 12.5. That is a lot of people. And of course, as we all know, maternal mortality and morbidity in this country is embarrassingly high compared to other industrialized countries. I think people, particularly in the anti-abortion movement, used to talk about, you know, these serious pregnancy complications as being extremely rare. They just aren’t. I think we’re finally starting to see people talk about that.
Raman: You know, the past year I’ve seen so much more in the public consciousness about miscarriage management, which is something that we’ve all covered in the past, but it’s not something that I think has been talked about as much, brought up as much, some of the complications there. And especially when the treatment for miscarriages in many cases is very similar to what is done for abortions, and just some of the difficulties that different folks have been experiencing being able to get that care for miscarriages even if they are not seeking an abortion and it’s a wanted pregnancy. I think that has really come to light a lot as well.
Rovner: So the Supreme Court majority, I think in their majority opinion, sort of said they hoped that this would be the last word on abortion for a while. It obviously was not. So let let’s do a quick review of what’s happened in the courts since Dobbs was decided last year. I guess the big one that we’re waiting on is the case of mifepristone, the abortion pill, right?
Ollstein: That’s the main federal one, although there are some other ones. But as we all sort of knew at the time, this is really a state-by-state fight. And the state-level cases are still continuing to play out. You know, just recently there were some major rulings, in Wyoming, in South Carolina. We’re waiting on Iowa. There was this declaration by the justices that overturned Roe v. Wade that this would sort of “settle the issue,” quote-unquote. And it is extremely unsettled.
Rovner: It is. And of course we should mention that a lot of these state cases are because even though the Supreme Court ruled that the federal Constitution doesn’t have any right to abortion, a lot of states say that their state constitutions do.
Luthra: And the South Carolina one is particularly interesting because, in January, we had the state Supreme Court say that their constitution did not allow for a six-week ban. And just this week, that same Supreme Court, with one change in membership, heard almost the same version, a slightly different six-week ban, and there is a good chance they uphold it, which really speaks to not only the role of the courts in dictating abortion rights on a state-by-state level, but also the role of individual changes in the makeup of those courts and how just this one really small thing, like someone aging out of being on the state Supreme Court, can change access for thousands of people.
Ollstein: And state constitutions, even though they don’t have the word “abortion,” often are way more protective of abortion than people might have predicted. To Shefali’s point, that goes to which judges are interpreting it. But also you have some of these rulings in states we think of as very far to the right that are surprisingly protective of abortion. And I think that fight is continuing to play out. And I’m sure we’re going to get into later the attempts to insert language into the state constitutions that’s explicitly protective of abortion.
Luthra: One element on the federal courts that I think is worth flagging that is relevant to this mifepristone case as well, right — which, to recap, is currently at the 5th Circuit; they are debating whether to take mifepristone off the market, to impose more restrictions on how it’s prescribed. This will probably end up at the Supreme Court again, maybe within the year. But dormant in that case, and something that a lot of scholars have talked about, is this new legal questioning around the Comstock Act, this very old anti-obscenity law used in the past to censor Walt Whitman, to ban “Ulysses,” all sorts of crazy things, and is now being argued as a legal vehicle to end access not only to mifepristone, but to anything that can be mailed for an abortion. And scholars are quite critical of these arguments, but there is a reasonable chance that they come up again and again, and that, given the right case, the right lawyers, the right justices, that a case based on this reading of the Comstock Act could be used to argue for and potentially even implement a national abortion ban through the federal courts without using Congress.
Rovner: Yeah. Mary Ziegler, who’s been on this podcast, who’s one of the top abortion history scholars and a law professor, has been talking about this a lot. You know, everybody is sort of talking about whether or not they can implement or pass a national abortion ban. She says, depending on how they interpret Comstock, there already is, in theory, a national abortion ban. And it wouldn’t just be pills. It would be anything that’s mailed that really has to do with abortion, right?
Ollstein: Yeah. I also just want to go back to the mifepristone case and note that there’s not just one; there’s, like, five — five that I that I know of, maybe even more. The main one that could decide the federal regulation at the FDA level of mifepristone; there are several groups of states saying, Hey, if there’s a federal ban, it shouldn’t apply to us; and then there are two lawsuits that are attempting to challenge state-level bans on the drugs as violating the rights either of doctors and patients or of the pharmaceutical companies. So there are so many different permutations and ways this could go. It’s not just, you know, an up or down vote.
Rovner: Yeah, it’s definitely a full-employment-for-lawyers decision.
Ollstein: And health care reporters.
Rovner: And health care reporters. Well, I want to talk about the administration a little bit. President Biden has been both praised by abortion rights supporters for his administration’s support of abortion rights and chided for his personal reluctance to talk about an issue he is clearly not very comfortable with. What has the administration done in this arena, besides everybody paying attention to what President Biden does or doesn’t say himself?
Raman: I would boil down what I guess the president has done has been the three executive orders that he’s done since the Dobbs decision. So we had two last year that were more focused on abortion and things that he was asking various agencies and departments to do there. And then most recently, last week, we had one that was focused on birth control and contraception, broadening accessibility there. And I think the trick here is that all of these points within the executive order are calling on the agencies and departments to consider doing this, consider doing that. And while some of those things have come to fruition — we’ve had, you know, the VA [Department of Veterans Affairs] and the Department of Defense have changed their policies to kind of make access easier — we’ve also had certain things that have been outlined there not come out. We had in I think the first or second one last year that they had asked CMS [the Centers for Medicare & Medicaid Services] to find ways to make it so that there could be, you know, an 1115 waiver for Medicaid programs to cover out-of-state patients. And states haven’t really jumped at that or figured out a way for that to work out. So it’s a mixed bag.
Luthra: I think another sort of interesting element — for everything the administration has done, tried to expand access to mifepristone in pharmacies, tried to use EMTALA [the Emergency Medical Treatment and Labor Act], the emergency medication law, to help people get abortions when they are needed for life-threatening situations in hospitals, it feels like there is always a Republican response that is quite effective in, if not neutering, then quite weakening that. And we’ve seen that with the Texas attorney general, potentially someday soon former attorney general, suing to challenge the EMTALA regs that we’ve seen that in the —
Rovner: He’s being impeached, for those of you who have not kept up — that the Texas attorney general. So we’re waiting for the trial of that impeachment.
Luthra: Yeah, we’ve seen like Alice’s really great reporting on the efforts by Republican attorneys general, including in blue states, to limit access to mifepristone in pharmacies, right, sort of going directly against what the administration is trying to do and what it sort of gets to is: For everything that they try, it is hard to see in reality how much of an impact it will make and can make on the ground in expanding access to abortion.
Ollstein: Oh, yes. And we should say that there are, you know, progressive advocacy groups who are disappointed and think the administration has not tried everything it could be trying. And so, you know, the administration has been touting everything it’s doing. And like we have said, some of it has made an impact, particularly defending these policies in court and stopping them from being struck down. But there is a lot of frustration. You know, I’ve heard specific calls for more to be done through Medicaid, more to be done in terms of exploring whether abortion providers could operate on federal land, even in red states. There’s just a lot of areas, and this administration is pretty cautious. And, you know, we can see, because of all the legal challenges, why that is. An adverse legal ruling could be damaging going forward. But, you know, I do want to note that there are pro-abortion rights advocacy groups who are not satisfied with the level of effort from the Biden administration so far.
Rovner: Frustrated, I think, is the accurate word there. Well, let us move to Congress because that’s relevant to what we were just talking about. As we have discussed on this podcast many times, Congress is pretty much gridlocked on all issues involving reproductive health. There are not 60 votes in the Senate for anything on either side, but there’s been some action in Congress the last year, right, Sandhya?
Raman: Yeah, I would say 1) historically, there’s rarely much movement on abortion policy in Congress. It’s just someone bringing something up a lot for messaging. But I think the main thing that that has had an effect is [Republican] Sen. [Tommy] Tuberville from Alabama has been holding up Pentagon nominations over the Department of Defense’s abortion policy, which allows service members who are stationed somewhere where abortion is not legal to be able to take off time and travel somewhere to get that abortion. And this has been holding up over 250 nominations so far. It’s been a big issue given that, I think, there have been folks from either side and former defense officials have said this is a matter of national security, that we’re not able to get this done over one person.
Rovner: This is a big deal that’s been kind of flying under the radar for two or three months now, right?
Ollstein: They’re at a total impasse.
Raman: Yeah, I think that the latest is mainly that, you know, Sen. [Joni] Ernst [R-Iowa] does want to have a vote on this when the NDAA goes to the Senate floor.
Rovner: The defense authorization — the annual defense authorization bill.
Raman: Right.
Rovner: Yes.
Raman: To kind of have a vote on that and try to get that. But they’re at an impasse right now. And it’s kind of unusual. I mean, it’s something that — people have held up nominations, but I think this in particular is a pretty interesting one.
Rovner: Yeah, I know the secretary of defense is very upset about it. It really is a matter of national security and they really haven’t been able to work this out. You know, we know, as we mentioned, Congress can’t sort of do anything. There is not a supermajority to either tighten federal abortion restrictions or loosen them. But one of the things that might have happened and that anti-abortion legislators talked about early in the year were things to better support pregnant women or pregnant women who’ve then had children, and trying to support those children. Even things like Title X, like contraception, Head Start, expanded Medicaid for maternal health for a year. We actually haven’t seen very much of that happening either, have we?
Ollstein: No, we have not. I will say we have in some states; some states that are very conservative have — they say it’s specifically because of the elimination of abortion access — moved to have more funding for moms and babies and even contraception. And so you have seen that. But no, at the federal level, it is running right into this anxiety about debt and spending and not wanting to open the pocketbooks on that front. I also think it’s interesting that House Republicans have not really used their majority to vote on an abortion ban. In a sense, it’s kind of a free vote for them because it won’t become law. And it’s just interesting and speaks to the tricky politics that they haven’t even done a symbolic vote. Meanwhile, you’ve had Senate Democrats do a bunch of symbolic votes to try to make Republicans uncomfortable with the issue. But again, these are all just sort of show votes that are not going to become law.
Rovner: Yeah, somebody should total up the show votes at some point over the last 10 years. I bet it would be a lot.
Raman: I will say that, you know, the one thing that I will acknowledge on a federal level is that, you know, when we had the omnibus last year, they did make the 12-month postpartum Medicaid pilot coverage permanent. And I think that will be a big thing, given that so many states have so quickly adopted the pilot of that. So that would see something that that there can be an effect, but —
Rovner: But it is still optional. States don’t have to — I mean right now —
Raman: It is still optional.
Rovner: Standard Medicaid cuts off new moms after 60 days, is that right?
Raman: Yeah, But I mean, it’s hard. I mean, I think it’s A) kind of what Alice said with the funding and the fact that we’re working with less than we had before. But also, if you look at the language of a lot of the bills that have been introduced that kind of focus on some of these things, you know, whether it’s different things for new moms — a lot of it has language that will polarize the other side. I think that if you see some of the packages and bills that have been put out by Republicans, there’s funding or redirecting resources for crisis pregnancy resource centers, which, you know, Democrats are not in favor of given that they don’t support abortion. And then we also have, I think, a lot of the Democrats’ bills might not specifically carve out certain things. I think that they “butt heads” …[unintelligible] … I think you have to kind of water it down, the language. And we haven’t really seen something that kind of can appeal to everyone kind of come forward, and also that doesn’t cost money. And finding that happy medium is very difficult.
Rovner: And ever was. Well, Congress hasn’t been able to do very much, but state legislatures have been really busy, right? I mean, and it’s more than just, you know, bans, working on different variations of bans. We’ve seen some very, sort of, creative ideas, right?
Luthra: It’s been fascinating to see what’s happening on the state level. One thread I actually thought of during Sandhya’s remarks was the expansion of crisis pregnancy centers, in particular in states with abortion bans, right? Putting more state funding to support them, which, for a reminder, they not only don’t support abortion; many of them don’t actually employ qualified medical personnel and are not bound by HIPAA [Health Insurance Portability and Accountability Act]. We have that lawsuit from this week where the woman said she went to a crisis pregnancy center, and they missed her ectopic pregnancy. So, quite dangerous. But beyond that, what’s really interesting is Republicans in state legislatures seem like they are really trying to figure out how to navigate these tricky abortion politics, and they’re not quite sure how to go about doing it, which is why we saw the six-week abortion ban pass in Florida and in South Carolina. And then we saw differences in other states, right? North Carolina did the 12-week ban, which is being litigated right now. And what clinics are actually more concerned about there is a requirement for two in-person visits separated by three days, which they say will just make the procedure unaffordable. We saw Nebraska do a 12-week ban as well, sort of concerned that six weeks appears too extreme now that voters are responding to abortion bans. And the other thing that is just really, really interesting is: We saw at the beginning of the year some pre-filing of bills around the fetal personhood movement, around ways to try and criminalize the morning-after pill or IUDs [intrauterine devices], trying to consider whether you make the person who gets an abortion liable herself. None of those have really taken off yet, and it seems that it’s because that is a bridge that, for many in the movement, is still too far — just this concern that then they would really have to say it is not just that we are trying to quote-unquote “protect the pregnant person,” but we actually think abortion is murder itself. And so I think that will be a really interesting battle within anti-abortion lawmakers, to see how that ends up in the coming years.
Rovner: And that’s a battle that goes back like a decade and a half now. They still aren’t quite there. I think the other thing that we saw a lot of that hasn’t really come to pass are bills to try to ban travel, to try to ban pregnant women from going to other states to obtain abortions, which strikes me as something — strikes many people as something that seems probably not constitutional, but not to say that they won’t try.
Ollstein: Yeah, I think we’ve seen Idaho go the furthest down this road. Missouri was also sort of exploring it, putting a toe in the water, but it never really went anywhere. But I totally agree, Julie. I think there was so much anxiety over this past year about red states trying to reach across their borders in different ways to police abortion, whether it’s suing doctors or trying to ban travel or obtaining people’s medical records or — there was just a lot of anxiety, and you saw that reflected in what blue states passed. Blue states passed a lot of protections to stop those sort of cross-border prosecutions. But we haven’t seen the cross-border prosecutions. That hasn’t really come to fruition yet and may or may not going forward. So it’s interesting because a lot of fears of what would happen when Roe fell have played out exactly as predicted and this is one that kind of hasn’t. Two other really quick state-level things that I wanted to flag that I just think are interesting and are examples of conservatives trying to get very creative and not do just a straightforward ban. I would flag Utah is trying to ban abortion by banning abortion clinics and saying it has to only take place in hospitals. Twist: No hospital in the state will do abortions because they’re religiously affiliated. So that’s sort of a total ban in practicality, if not in name. That’s been enjoined in court. And then in Wyoming, they’ve tried to ban the pills. And pills are what people use because there are no facilities that perform abortions. And so these are ways they’re trying to get creative and do it in different ways. That has been enjoined, too. So we’ll see. But it’s very like, throw everything at the wall and see what sticks.
Rovner: And I would add to that, although I think we haven’t really talked about it on the podcast — is some cities now trying to create bans. So even within blue states there would be bans in red cities, which is another complicated legal thing.
Raman: I looked up some Guttmacher Institute data and we had fewer abortion laws adopted last year compared to the year before. It was 50 last year versus 108 the year before. And, you know, the Dobbs decision dropped after some of these states had gone out of session. But the one thing that I thought — that resonated with me because, you know, A) a lot of these states, maybe they’ve implemented wider bans or they were able to bring back older laws, but it was a drop in the number that we were seeing. And the thing that I have kind of taken away from this year is that the states that we’ve been talking about before — you know, North Carolina, South Carolina, and Florida — that are implementing these, or trying to, much stronger abortion bans are the ones that have been kind of the safe havens, quote-unquote, since the news dropped, where if you live elsewhere in the South, you are trying to go to one of these states to get an abortion. So it’s kind of like a whack-a-mole and that these are the places that have been seeing an influx of patients, especially Florida, that, you know, these are — the cracking-down there to kind of minimize that.
Rovner: So, and to go back to what we said at the beginning, that just makes abortion more expensive for people who have to leave their own state to go somewhere else. Well, we’ve been kind of dancing around this a little bit. But one of the reasons that states have not done some of the things that we thought they might do is that voters have not reacted the way we expected or, I don’t know, the way some people expected. I mean, it’s been surprising. Somebody summarize for us what voters have done on this issue in the last year.
Ollstein: Every time voters have been able to weigh in directly, they have weighed in directly against restrictions and for protections — you know, broadly. Because of that, you have a lot more activists in states trying to set up these votes for later this year, next year, the following years. Every state has different rules around this, and some states don’t allow it at all. But because of just the sweep of the pro-abortion rights side last year in six states —
Rovner: Including some pretty red states like Kentucky and Kansas.
Ollstein: Including some very red states. Yeah, although, you know, it’s a good reminder that, you know, we think in terms of red state, blue state. But, you know, it’s really nuanced. I mean, Kansas has a Democratic governor. Kentucky has a Democratic governor. But, yes, these are states that voted for Trump, have an overwhelmingly Republican state legislature. So it’s how you look at things. But, yes, very conservative, very religious. And both the vote results, but also reporting, polling, focus groups, show that even people who self-identify as very conservative and even personally anti-abortion, a lot of them are not supportive of laws that are this restrictive and think that this should be someone’s personal choice. So I think that’s why these campaigns that really had a conservative-friendly message of getting the government out of your personal business were so successful.
Luthra: And what’s been striking has been seeing the polling just in general around abortion rights. It’s been fairly stagnant up until last year. And basically every big polling organization has seen a shift, and voters are more supportive now of abortion rights than they were before, more opposed in some cases, even to, like, the second-trimester bans, which in the past were a bit more popular, and also in some cases more likely to place this as a high priority for voting. And that will be really interesting to see, especially next year, when we have more abortion rights ballot initiatives, as Alice mentioned, but also more candidates, including the president, running on abortion specifically, and seeing whether this particular issue does influence voters to become, in particular, more Democratic than they otherwise might have been.
Rovner: Yeah, it’s funny; abortion has been a big voting issue for the anti-abortion movement for years, which is how they got to this point basically. It has not been a huge issue for those who support abortion rights because a lot of people thought Roe would never go away, so they didn’t need to vote on it. And I think that’s going to be sort of a big realization. And next year is going to be the first presidential election since Roe went away. Before we leave the states, I would flag, though, the fact that, Alice, you were saying that because of the success of some of these state ballot initiatives, there are other states that are trying to do it, but there are also efforts to stop states that are trying to do it. I’m thinking mostly of Ohio and Missouri, in particular, which has a bizarre fight going on.
Ollstein: Yeah, absolutely. And those are the most immediate ones. But lots of red states took up bills this year to make direct ballot initiatives harder in lots of different ways — either, you know, raising the number of signatures that need to be collected, having weird geographical requirements for where the signatures are collected, and then the main one, which is in play in Ohio, is this question of requiring a supermajority vote to pass instead of just a bare majority. And so Ohio Republican legislators are setting up this August special vote on whether to raise the threshold from 50 to 60% to approve a ballot initiative. And they have been on the record about this specifically aimed at making sure the vote to restore abortion access in the state can’t pass in the fall. And then in Missouri, there’s all sorts of different things in play, some weird stuff, but —
Rovner: I think I can explain Missouri. The state attorney general is trying to make the state auditor change his estimate of how much it would cost if they were to pass this ballot measure expanding abortion access. And I think that the state auditor has said it would cost something like $51,000 or $51 million and that the state attorney general wants to make him increase that by a factor of 10 or a hundred. I mean, there’s just this huge fight. And of course, that would have to go on the ballot measure. So if the anti-abortion attorney general thinks if people go to the polls and see that this is going to cost millions or hundreds of millions or billions of dollars, they’re less likely to vote for it. And so that fight sort of continues. And I believe it has not been resolved yet.
Raman: And they’re both from the same party, which I think just makes it more interesting.
Rovner: Yeah. But you know, this is the first time I can remember a fight, a big important fight, between a state auditor and a state attorney general. I want to talk a little bit about what’s happened to doctors and other health professionals, because they’re kind of caught in the middle here. I mean, they had not been — I’ve written at length about the AMA [American Medical Association]’s sort of checkered history of trying to be on every single side of this issue over the years. But now we’re seeing doctors put in some pretty hairy positions, right?
Luthra: One thing I’ve been really struck by is talking to a lot of — and this is especially doctors, but true probably of all health professionals, is this idea that they didn’t have to take a position on abortion before, so many of them simply didn’t. They were happy to sort of think of it in a silo separate from the rest of their jobs. And that was because, like you said, Julie, they weren’t concerned about losing Roe. And now that we’re in this world, many of them have been really stunned to see what the consequences are, and a lot have described to me this feeling of being sort of called to political activism that they did not expect, did not train for, it’s not the job that they have — but being really pushed to talk about abortion in a way they otherwise wouldn’t have. And what we’ve also seen, of course, is many moving from states that have bans on abortion. Many of those states that have bans on abortion are also passing bans on gender-affirming care for minors, which puts even more doctors, nurses, med students, residents in a bind. We should also note that the health care workforce is a majority woman workforce, and so many of them feel personally affected by these laws as well and are factoring that in their decisions as to whether to practice. And it’s still quite early to say what the implications will be. But there is a lot of real concern in these states that already were these, you know, lower-health-care-access states, especially in rural areas, losing even more health care professionals because of the bans they’ve put in place.
Ollstein: Doctors are becoming more vocal. I think a lot of players in the medical space that haven’t been as vocal about this are weighing in, telling state legislatures, “You’re putting our members in danger.” And so I completely agree. And I think that a lot of this anxiety seems to be from the medical community, like, If we accept this intrusion into our work, what’s next? What else will state legislators who are not doctors try to dictate that we can and can’t do? And so there’s sort of a sense of, If we don’t stand up to this, we’re sort of opening the door to a lot more intrusion into the patient-provider relationship.
Raman: So I have done a lot of looking at the long-term. I’ve been following, since last year, kind of the steps with workforce because I think, for context, we’re expected in a few years to have a shortage of obstetrics providers already, given a higher percentage of women of reproductive age and a lot of folks just leaving that workforce altogether. And I have been kind of curious how this is going to affect that. And I think some of the takeaways, I think, to echo Shefali, is A) it’s early. So it’s hard to go through the data and see what is because of this, what’s because of that. But I think one thing that I’ve noticed is that it hasn’t been just obstetrics or just emergency room or family medicine. I’ve been hearing from folks in all sorts of specialties, even if they aren’t even related to this, because wherever you do your training, it might affect your family or yourself. And that is something that I’ve heard come up — you know, harassment and is there options for themselves? And I think also just unclarity in the laws. I’ve heard multiple either folks training to be physicians or who have just become them say that they didn’t go to school to become a lawyer; they went to school to become a health care provider. And having to have that intermediary and consult the legal team of the hospital in between is just very difficult for them to do their care. But datawise, I think that we had, according to the AMA, a drop in residency apps for obstetrics and gynecology, and it was higher in the more restrictive states, but it also dropped some in the states that are more progressive on abortion, like it dropped in California. So it’s kind of hard to tell so soon what that could mean. But I think if you look at what happened in Texas, which had pretty flat numbers before SB 8, and then they had a huge drop after that law was implemented and who was applying to go there, and they have the third most programs in the country — like, that can provide some clues that we could see kind of further on as we keep looking. But yeah, a lot of it’s not going to be felt for a while.
Rovner: I think two really important points there, though, is one is that it’s not just restricted to the specialties that we would think because, as you point out, health care, particularly graduating medical students, are now majority women and they are mostly of childbearing age, so they are concerned about themselves and their families. And if they’re men, they likely have partners, so they’re still considered worried about themselves and their families. So it can be kind of a big deal. And the other one, of course, is that where medical students train after medical school, where they do their residencies, is very, very indicative of where they’re going to end up practicing. So if you don’t have people training in those states, you’re going to have fewer people practicing in those states. And that we do know from way, way, way back. So I think that’s also going to be an issue going forward. Well, we are running out of time, but I wanted to go around the table once really quickly and say you’ve all been obviously very steeped in this for the last year. I want everybody to tell us sort of the one thing that’s going to stick with you most from reporting over the course of this first year without Roe. Shefali, why don’t you start?
Luthra: I think the thing that will stick with me this year and probably the rest of my life is hearing from the people who have tried to get abortions in states where they cannot, whether that was because of a wanted pregnancy that went wrong, whether that was to save their own lives, whether that was because they already had two kids and didn’t want another or they didn’t want any kids. And just the themes that you keep hearing from them, right? The anger; the betrayal; the feeling like they are less of a person because they can’t get this in their home state; the financial distress that they go through; and, in many cases, the isolation, because they have no one they can talk to about this. It’s really, really striking to hear those stories. And I think they’re some of the most important things that we as reporters can hear about and that our readers can see and internalize and think about when they conceive of what abortion bans mean.
Rovner: Sandhya.
Raman: I think the thing that sticks with me is just really how far the reverberations from this decision have gone. You know, what really comes to mind is last year when I was at an international family planning conference, this woman from a Kenyan nonprofit said to me, “You know, when the U.S. sneezes, the rest of the countries catch a cold.” And I think that was really striking and just seeing how far a U.S. court case can be felt around the world, whether it is countries that have made more progressive abortion laws or more restrictive abortion laws, kind of in the light of something the U.S. does, and just kind of how something that I think is easy to think of as just here, how that can have an effect on other leaders and the people there, or just countries that rely on the U.S. for a variety of things. So that, that really sticks with me.
Rovner: Alice.
Ollstein: Yeah. In traveling, it’s just been really striking to see how abortion bans have had these knock-on effects and limited the availability of other kinds of health care, whether that’s by putting clinics out of business or causing an exodus of doctors and residents and medical students from particular parts of the country that already were experiencing shortages and really just making these medical deserts, and particularly maternal health deserts, that were already there even worse, and just meeting people who were telling me, “I was told it would be, you know, a four-month wait just to get an IUD.” You know, these are people who are trying to prevent an unwanted pregnancy. And there’s just nowhere for them to go in a lot of places in the country, more than we think. And so just looking at people who are not pregnant, are not seeking an abortion, are also being hit by these legal changes.
Rovner: I’ve been struck just by how accurate a lot of the predictions were about what would happen if Roe went down. I mean, there were things that were unexpected. But I think most of the things, particularly the red state, blue state, have and have-not, have been exactly what people predicted would happen. All right. It is time for our extra credit segment. That’s normally when we each recommend a story we read this week that we think you should read too. This week, though, I’ve asked the panelists to choose their favorite story about reproductive health that they have written in this past year. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Sandhya, why don’t you go first this week?
Raman: So the story I picked is called “Conservatives Use Abortion Strategies in Fight Over Trans Care,” and I wrote this for Roll Call in February. What I did was kind of take a look at how we got to the Dobbs decision in the first place, is after the passing of legislation and the litigation and a number of state abortion laws and how those parallels are pretty striking to what’s been happening with trans health right now that has been really ramping up as a political messaging issue. And so, you know, in some cases it’s been very clear, where they’ve been putting language about abortion and gender-affirming care in the same bill, or restrictions there. But I think there are a lot of parallels that I was kind of finding in that, you know, starting with minors and then scaling up in restrictions or looking at science that’s odds with major medical organizations or messaging on safety or looking to penalize doctors or just, like, amplifying very rare cases of regret — that kind of thing. And so looking forward, that’s something that just keeps resonating with me as something to watch, that the abortion blueprint is not unique. It’s going to be there for other things.
Rovner: Alice.
Ollstein: So I chose the piece I did from the ground in Kansas when they voted. They were the first state where voters could weigh in directly on abortion access post-Roe, and it just revealed so many things that continue to be true for the states that are voting on this. It was just such a clear preview of what was to come. It was the flood of out-of-state money and staff on both sides. It was just how heated it got on the ground. It was the attempts by Republican state legislatures to structurally make it harder for folks to vote and more likely for things to go their way. And yet it was a blowout vote for the pro-abortion rights side in the end. And that was just such a preview of what was to come on both sides, and just being there on the ground and being able to see this and to see how people were feeling when the Dobbs decision was so fresh will really stay with me.
Rovner: Shefali.
Luthra: My story published in May at the anniversary of the Dobbs leak. It’s called “93 Days: The Summer America Lost Roe v. Wade.” And for this, it was an oral history that my editor and I had talked about. And we spent a few months working on it, talking to a dozen different folks about what it was like to live through last summer, from the Dobbs leak to the Dobbs decision up to the Kansas election. And there are stories from doctors; from politicians; from activists; people who organized on the Kansas abortion rights initiative; lawmakers who talked about their experience of learning of the decision; Kristan Hawkins, the head of Students for Life. But the people whose stories I think are most worth reading are the, I think it was three women I spoke to, who talked about their experiences navigating abortion, including one woman who was trying to schedule her abortion. She was in line at Disney when the decision came out and she found out her appointment had been canceled. She was never able to get another one and she had a baby soon afterward. There was another who was taking her medication abortion pills at home when the decision was revealed, and she wasn’t sure if she was breaking the law by taking misoprostol in her bathtub. And I think these stories just — they really cemented for me that this is not only the world that we live in, but that these are the real-life implications on the people who are affected. And I just always really love getting a chance to tell those stories.
Rovner: Well, my story is a piece that I wrote last July, so almost a year ago, called “Three Things About the Abortion Debate That Many People Get Wrong.” And one myth, of course, is that abortion bans and restrictions would only affect people seeking abortions, which we now know in sometimes horrifying detail is not true. Women with very wanted pregnancies gone wrong are also caught in the crossfire, and, as we said, forced to travel long distances or wait until they are literally at death’s door to get needed care. But it’s worth reminding people about the other two myths. One is that Congress could have codified abortion rights at any time since Roe but never really tried very hard, and the other one that Congress could have acted in 2022 — the end of last year — when Democrats still had majorities, albeit very tiny ones, in the House and Senate. In fact, Congress never had the votes to enshrine abortion rights for the entire life of Roe. There were several attempts to do that, many of which I personally covered. And to those who think Congress could have done something last year, I ask, “Have you met Democratic Senators Joe Manchin and Kyrsten Sinema?” That wasn’t going to happen either. All right. Well, that is our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks, as always, to our producer, Francis Ying. Also as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can tweet me. I’m @jrovner.
Rovner: Shefali?
Luthra: I’m @shefalil.
Rovner: Sandhya.
Raman: I’m @SandhyaWrites.
Rovner: Alice.
Ollstein: @AliceOllstein.
Rovner: We are taking next week off for the Fourth of July holiday, so we will be back in your feed with our regular news update on July 13. Until then, be healthy.
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Slow Your Disenroll
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Partnerships Editor and Senior Correspondent, oversees placement of KFF Health News content in publications nationwide and covers health reform and federal health policy. Before joining KFF Health News, Mary Agnes was associate editor of CQ HealthBeat, Capitol Hill Bureau Chief for Congressional Quarterly, and a reporter with Dow Jones Newswires. A frequent radio and television commentator, she has appeared on CNN, C-SPAN, the PBS NewsHour, and on NPR affiliates nationwide. Her stories have appeared in The Washington Post, USA Today, TheAtlantic.com, Time.com, Money.com, and The Daily Beast, among other publications. She worked for newspapers in Connecticut and Pennsylvania, and has a master’s degree in journalism from Columbia University.
The Biden administration this week pleaded with states to slow the post-pandemic removal of beneficiaries from their Medicaid rolls, as government data shows more than a million Americans have lost coverage since pandemic protections ended in April. Meanwhile, the Supreme Court ruled Medicaid beneficiaries may sue over their care.
In an appearance at the U.S. Capitol, the outgoing chief of the Centers for Disease Control and Prevention, Rochelle Walensky, offered no revelations as House Republicans pressed her about the agency’s response to the covid-19 pandemic. And senators are pushing for action on drug pricing, with Sen. Bernie Sanders (I-Vt.) vowing to hold up nominations to press the Biden administration for drug pricing reform.
This week’s panelists are Mary Agnes Carey of KFF Health News, Rachel Cohrs of Stat, Alice Miranda Ollstein of Politico, and Sandhya Raman of CQ Roll Call.
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Sandhya Raman
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Among the takeaways from this week’s episode:
- Asking states to slow the pace of Medicaid disenrollment, Health and Human Services Secretary Xavier Becerra offered options intended to reduce the number of Americans who lose coverage due to bureaucratic hurdles, such as by allowing community organizations to help people get coverage reinstated. But those options are only guidance for Medicaid programs across the country, and nothing says that states — especially conservative ones that have rushed to trim the number of low-income and disabled people relying on the program — will adopt the administration’s suggestions.
- A deal in the Braidwood Management v. Becerra court case will preserve, for now, the mandate requiring insurance coverage of preventive services for all but the litigants. The threat of a court order halting that coverage mandate nationwide has contributed to growing concerns about the overuse of injunctions allowing a single judge to bring down an entire program or law.
- The Supreme Court ruled that a woman is entitled to sue over the nursing home care her husband received that was covered by Medicaid, setting a precedent that allows beneficiaries to pursue legal action over their care.
- This week, House Republicans pressed CDC Director Walensky about the agency’s response to the pandemic, but, producing few new details, the hearing mostly proved an attempt by Republicans to relitigate concerns over issues like gain-of-function research funding. And Ashish Jha, the White House’s covid coordinator, is preparing to step down without a successor, offering more fodder for the argument that the Biden administration is de-emphasizing covid policy.
- Reports of threats against an Alabama clinic that does not provide abortions illuminate the realities of the post-Dobbs era: Even the state attorney general has taken issue with the clinic’s efforts to provide non-abortion maternal health care — and 40% of Alabama counties already have no access to maternal care.
- And on Capitol Hill, Sanders — head of a key Senate health committee — has said he will hold up reviewing nominations in an effort to pressure the Biden administration to produce a comprehensive drug pricing plan. Meanwhile, another key Senate committee releases its proposal to rein in fees charged by pharmacy benefit managers.
Also this week, KFF Health News’ Julie Rovner interviews Dan Mendelson, chief executive of Morgan Health — the successor project to Haven Healthcare, a joint venture by Amazon, Berkshire Hathaway, and JPMorgan Chase that aimed in 2018 to disrupt how Americans get health coverage but quickly disbanded. Rovner and Mendelson discuss the role of employers in insuring American workers.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Mary Agnes Carey: The Washington Post’s “I Lost 40 Pounds on Ozempic. But I’m Left With Even More Questions,” by Ruth Marcus.
Alice Miranda Ollstein: Stat’s “AMA Asks Doctors to De-Emphasize Use of BMI in Gauging Health and Obesity,” by Brittany Trang and Elaine Chen.
Rachel Cohrs: Politico’s “Thousands Lose Medicaid in Arkansas: Is This America’s Future?” by Megan Messerly.
Sandhya Raman: The Markup’s “Suicide Hotlines Promise Anonymity. Dozens of Their Websites Send Sensitive Data to Facebook,” by Colin Lecher and Jon Keegan.
Also mentioned in this week’s episode:
- KFF Health News’ “Biden Admin Implores States to Slow Medicaid Cuts After More Than 1M Enrollees Dropped,” by Hannah Recht.
- Politico Magazine’s “This Alabama Health Clinic Is Under Threat. It Doesn’t Provide Abortions,” by Alice Miranda Ollstein.
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Transcript: Slow Your Disenroll
KFF Health News’ ‘What the Health?’
Episode Title: Slow Your Disenroll
Episode Number: 302
Published: June 15, 2023
[Editor’s note: This transcript, generated using transcription software, has been edited for style and clarity.]
Mary Agnes Carey: Hello and welcome back to “What the Health?”. I’m Mary Agnes Carey, partnerships editor at KFF Health News, filling in for Julie Rovner this week. I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, June 15, at 10:30 a.m. As always, news happens fast and things might have changed by the time you hear this. So here we go. We’re joined today by video conference by Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Good morning.
Carey: Rachel Cohrs of Stat.
Rachel Cohrs: Hi, everybody.
Carey: And Sandhya Raman of CQ Roll Call.
Sandhya Raman: Good morning.
Carey: Later in the episode, we’ll have Julie’s interview with Dan Mendelson, CEO of Morgan Health. That’s the successor organization to the ambitious but ultimately unsuccessful effort by JPMorgan Chase, Amazon, and Berkshire Hathaway to remake employee health benefits. But first, let’s go to this week’s news. The Biden administration announced that more than a million Americans have lost their Medicaid coverage since early April as part of the ending of the covid public health emergency. Administration officials said that too many people were losing Medicaid due to red tape. About 4 in 5 people dropped so far either didn’t return paperwork to verify their eligibility or they omitted documents, according to federal and state data from 20 states. Department of Health and Human Services Secretary [Xavier] Becerra has sent a letter to state governors with some ideas on how to help stop this trend. What is he asking states to do?
Raman: So he gave states a few options. He said states could let Medicaid managed care organizations do a renewal on the beneficiaries’ behalf or let states kind of delay some of these cuts to allow for more outreach or let the community organizations in the state help individuals reinstate their coverage if they’ve fallen through some of the gaps here. But I think the thing to keep in mind is that all this is a guidance. All the Medicaid programs are different from each other. So while Becerra says that these are options, it doesn’t mean that any number of states will actually take on any of these opportunities to get more folks back into the program if they’re eligible.
Carey: To your point, some of the biggest drops in the enrollment in Medicaid have been in those more conservative states that are at political odds with the Biden administration. For example, in last week’s podcast, there was a lot of discussion about Arkansas and Indiana. For the panel, what are your thoughts on how state governments will respond to this guidance from HHS?
Ollstein: This is why there was so much anxiety last year when this was all being hashed out in the bill in Congress. Advocacy groups were sounding the alarm that there just weren’t enough guardrails to prevent this from happening. There were carrots; there were incentives for states to go slower and be more deliberate and careful in how they kick ineligible or, you know, can’t-determine-eligibility people off the rolls. But there weren’t a lot of sticks. There were carrots and not a lot of sticks. There weren’t a lot of penalties or repercussions for states that wanted to go as fast as possible and kick as many people off as possible, even if that meant folks falling through the cracks, which is what’s now happening.
Carey: So Sandhya sort of referenced this a moment ago. But I know, I mean, Medicaid is a shared federal-state program, but states, are they legally required to follow any of this guidance? I mean, what happens if a state just doesn’t do anything that’s in the letter? Does it matter?
Raman: I think the issue is that it doesn’t. I mean, there are some requirements that are applied to all programs if it’s in the Medicaid statute and sometimes when states do things that violate that and it ends up going to court. But I think anything here is they still have to follow what has been in the law that had said that after the public health emergency ended, that they could start slowly ripping people off the program. And that’s kind of the issue here.
Carey: Well, we’ll keep our eye on that one. And it sounds like another solution to find its way through the courts. Speaking of the courts, let’s move on to another major news development, and this one is regarding the preventive services coverage under the Affordable Care Act. It’s also known as the ACA. Texas conservatives that challenge the law’s preventive care mandate have reached a tentative compromise with the Justice Department that preserves free coverage for a range of medical services. Alice, I know you wrote about this agreement this week. Could you start us off and take us through the highlights?
Ollstein: Sure. So this was teased during oral arguments. The judges at the 5th Circuit [Court of Appeals] said explicitly, “Can’t you guys work something out?” And it turns out they could. So basically what the deal does is the Justice Department is agreeing not to enforce the preventive services mandate against the folks who are suing. So this is a group of conservative employers and some individual workers who say that the requirement to buy insurance that covers things like the HIV prevention drug PrEP violate their rights. And so the Biden administration is agreeing, OK, we won’t force you to buy the insurance that the law says you are required to buy. And in exchange, they agree not to push for the law to be frozen nationwide. So basically, everybody else’s insurance coverage gets to stay the same for now. There was a lot of anxiety about the nationwide injunction on the mandate that the lower judge ordered. So that is going to be on hold for now. The arguments on this case are going to drag on a lot longer, but this means that, for now, nationwide, the roles stay the same.
Carey: So how, if you know, how usual is this, in the middle of litigation, to come up with a deal that protects the people that are suing to stop a law, but it doesn’t affect the rest of the population, at least for now? I mean, is that unusual to kind of cut this kind of deal?
Ollstein: I think there has been a lot of debate recently about nationwide injunctions and the fact that some judges seem to like handing them out like candy. And just because of one person or a few people suing somewhere can bring down an entire law or program for the entire country. And there has been anxiety in the legal world about this getting kind of too common and out of hand. And so I think this is a sign that even very conservative judges like the ones on the 5th Circuit are looking for ways to rein it in and limit impacts.
Carey: Rachel, do you want to jump in? I see you nodding your head.
Cohrs: Yeah, it is just important to think about that trend, you know, as we see so many lawsuits play out. I know we’re seeing lawsuits over the Inflation Reduction Act as well. It’s a tactic that is being used. And I think if there is some more intention by DOJ to try to kind of limit the reach of these injunctions, then I think that is a really interesting trend, looking to other areas as well.
Carey: So that sounds like there’s no threat to the fall ACA enrollment season, that a ruling wouldn’t come before that enrollment season that could threaten preventive services for the entire ACA enrollment population and for those employer-sponsored plans as well.
Ollstein: So the 5th Circuit, after they blessed this deal officially, put out a briefing schedule that runs into November, so even after that, there could be more arguments, there could be an appeal up to the Supreme Court. So, yes, this is definitely running on into next year, if not longer.
Carey: OK. Well, the Supreme Court had a ruling this week that preserves Medicaid recipients’ right to sue , and policy watchers are saying that this is a major, major civil rights victory for Medicaid recipients. Before we were taping, we were chatting about it a little bit. Alice, fill us in here.
Ollstein: I mean, the specifics are that this is about a woman’s right to sue the state over the treatment of her husband in a nursing home. He was given chemical restraints, which is a horrible thing, if you look it up, that worsened his dementia. He was drugged, you know, in order to be easier to control, essentially, which is a very damaging practice. But that was sort of just the narrow issue at play. But this was seen as a major victory for any Medicaid beneficiary’s right to sue over not getting the care that they’re entitled to., and so this could have implications in the future for things like coverage of reproductive health services, including abortion, and other areas as well. So there was a lot of anxiety that this conservative Supreme Court majority would move to limit Medicaid beneficiaries’ rights to bring challenges. And that didn’t happen here.
Carey: It was a7-2 ruling, right?
Ollstein: Yeah. Yeah. It wasn’t as close as people thought.
Carey: There you go. So let’s move our discussion from the courts to Capitol Hill. Outgoing Centers for Disease Control and Prevention director Rochelle Walensky appeared before a House panel this week to talk about her agency’s response to the covid pandemic. Rachel, you covered the hearing. What were your key takeaways?
Cohrs: I mean, I think my key takeaway is that Republicans are re-litigating some of these comments that were made in early 2021 and that there wasn’t a whole lot of new revelation that came out. Walensky was pretty well prepared to stay on topic. She kind of deflected questions about gain-of-function research at NIH [the National Institutes of Health, a separate division within HHS] and lawsuits around kind of how CDC officials interacted with social media networks and regarding vaccine misinformation. So, I mean, lawmakers brought those things up, and she didn’t really engage on that at all. But she really didn’t give a lot of ground. I mean, there were criticisms of comments she had made about vaccines preventing the spread of covid-19. And I think her position was that her comments were backed by science at the time, and that as the virus has mutated, the truth about covid has changed. So I think she was not apologizing. It was not really engaging with them. And I think it was just kind of this anticlimactic kind of end. I mean, there had been so much buildup. Lawmakers had been requesting her testimony for, like, two months, and it was over and I don’t think she suffered any really significant hits there.
Carey: Were there any sort of agreement on lessons learned from how the CDC and, more broadly, the Biden administration handled its response to the pandemic? I mean, are there lessons learned here? Is there any road map to doing things differently or better next time?
Cohrs: Well, one thing she did bring up was, she said that the CDC didn’t really have visibility into how many people who were hospitalized with covid were also vaccinated. And I think that led to kind of an interesting back-and-forth. I think Republicans were obviously implying that vaccines didn’t work as well as they were initially pitched to. But I think she pivoted that to saying that “CDC would love more data on this. We don’t have the authority to collect it. And doctors are putting all this information into electronic health records and it’s not making its way to public health departments.” And so I think that kind of fits into the administration’s asks for the pandemic preparedness legislation that Congress is kind of working through right now. So I think she pivoted that to ask for more authority for her agency, which I don’t know that Republicans will be particularly enthusiastic about. But I think that was an interesting back-and-forth where she did concede that they just didn’t have a whole lot of information in the moment.
Carey: Would state health departments have to direct hospitals to collect that and then share it with the federal government, if she’s saying she doesn’t have the regulatory authority to do it?
Cohrs: I’m not an expert in this area, I’ll say. But my understanding is that the CDC was collecting information and had to, like, have individual agreements with health departments on how that was going to be collected. They couldn’t mandate that. So I think it would just make it a lot faster and I think give CDC a lot more authority to compel states to report some of this information in real time.
Carey: Sure. No, I know, that’s been one of the most interesting things in watching and reporting and reading all the coverage of how so many things changed with the covid pandemic as [we] received new information. I mean, it was a place we hadn’t been before, but we might be back there again, so. There’s another high-profile covid official who’s stepping down. Dr. Ashish Jha is leaving his post. I think today is actually his last day as the White House covid-19 response coordinator. This departure was announced a while ago, and it’s not a surprise, especially with the end of the public health emergency. But what do these departures mean for the administration’s future plans to handle covid? I mean, what message does it send to the public with these two folks leaving at this time?
Ollstein: I think if folks are already primed to think this administration is not making it a priority, this is more fodder for that viewpoint. You know, you could also note that these folks have been serving a long time in a very difficult role and this is, you know, sort of natural turnover. But I think that, with all of the protections lifting right now, and hearing very little about covid at all from the administration — I mean, the president hasn’t talked about it publicly in months; he didn’t say anything on the day the public health emergency ended, which folks were a little upset about. So you could see this as more evidence that it might not be a priority for them going forward. You know, on the other hand, they are setting up this, like, permanent pandemic office in the White House, although it doesn’t have a leader yet. So it’s a little TBD.
Raman: With Jha, you know, we don’t have someone replacing him in the way we do with a lot of other positions. So it’s going to be the first time in 14 months now that he’s not there, but it’s also, there’s not someone else there. And if you’re quietly removing that role, it just is another layer of saying, you know, this is less of a priority compared to some of the other things as it gets phased out.
Cohrs: I was just going to pop in and say that I think there’s a really interesting opening for Mandy Cohen here at CDC. There is this vacuum of leadership here. You know, the White House hasn’t appointed anyone to fill that spot. Secretary Becerra really hasn’t shown any appetite in leading on covid, and Dr. Fauci is gone, Walensky’s gone — just so many of these, like, old-guard kind of the covid response in the Biden administration have turned over. And my colleague Helen Branswell had a great story, I think that was sharp about how, you know, Mandy Cohen really is prepared, unlike a lot of other CDC directors in the past, to navigate these political dynamics. And I think it is a recognition that the CDC is political and public health is now political, and they can’t ignore that any longer. So I will be curious to see if they elevate her to communicate some more of that information in the absence of Dr. Jha.
Carey: Sure. And can you just remind our listeners who Mandy Cohen is and why she’s expected to get this job, or be nominated for this job?
Cohrs: Yes, she’s a longtime federal and state health official. I think she was in North Carolina, and most recently she was at a ACO [accountable care organization] company working with another former Obama administration official. And the White House, I think — there’s been a lot of reporting; I don’t know that they have officially tapped her yet.
Carey: I don’t think that’s happened yet. No, that has not.
Cohrs: Right. But it doesn’t have to go through a confirmation process. So if they do choose to move forward, I think the process would move pretty quickly to have her in place. So that is what our reporting has shown. Many other outlets have reported the same thing. So I think that’s just kind of the expectation for who’s next in line.
Carey: Well, let’s move on to another topic that appears frequently on this podcast, abortion. It continues to be a major news story around the country. And I’d like to start our discussion with a story that Alice did for Politico Magazine. Here’s the headline: “This Alabama Clinic Is Under Threat. It Doesn’t Provide Abortions.” So, Alice, tell us why a clinic that doesn’t provide abortion is being threatened.
Ollstein: Yeah. So when abortion became illegal in Alabama from conception, with no exemptions for rape and incest, abortion clinics either closed their doors, some picked up and moved to other states, but some, like the one I profiled, West Alabama Women’s Center, decided to stay and pivot to nonabortion services. And they have found it’s still a very hostile landscape and they very well might go out of business themselves in the coming months. They’re running into legal threats. The state attorney general has suggested that he views the kind of abortion-adjacent care they provide, you know, such as letting people know what their options are in terms of ordering pills or traveling to another state — that he might consider that aiding and abetting an abortion under the state’s criminal law. And so they are bracing for that at all times. At the same time, they have also really struggled financially. Most of their revenue in the past was from abortions, and they mainly serve a population now that struggles to pay for services and is often uninsured. The state has not expanded Medicaid, and so lots and lots of low-income people are uninsured. And so it’s just showing that what it means to be under threat in the post-Dobbs era is really different than what it meant to be under threat in the pre-Dobbs era and just how sparse the health care landscape is at all. There are just so few providers, hospitals in these areas, lots of places going out of business. And if clinics like this and other red-state clinics can’t survive, there’s going to be a lot of health care consequences.
Carey: I think in your story you said that 40% of the state was considered a maternal health desert.
Ollstein: Yeah. Right. Which means no access in those counties. And even more of the state is considered low-access, and so people are really struggling to find anywhere to go. A lot of rural hospitals have closed entirely. A lot are on the brink of closure. Some have closed their maternal care units. And so there’s just fewer and fewer options, especially fewer and fewer options for people to feel safe going to if they have an abortion either out of state or at home with pills and need follow-up care. Folks are afraid to go to a regular provider or hospital over fear of being reported to law enforcement, which is actually happening in a lot of places.
Carey: We just talked about the South. Let’s move to the Midwest. In Ohio, voters are going to head to the polls in August to weigh in on a proposal that, if passed, would require at least 60% of voters to pass any amendment to the state’s constitution. And that’s up from the current requirement of a simple majority. There would also be new, higher requirements on the number of signatures needed to get a constitutional amendment on the ballot. A Republican lawmaker in favor of the changes said they were aimed at blocking an abortion rights question that abortion rights supporters had hoped to get on the November ballot. So that’s Ohio. So in Indiana, there’s a separate issue. A class-action lawsuit asserts that the state’s abortion ban violates Hoosiers’ religious freedom. That lawsuit, which was filed by the ACLU [American Civil Liberties Union], says that Indiana’s abortion ban violates a religious freedom law that was once championed by former Indiana Gov. Mike Pence, who we know served as vice president to Donald Trump and is now challenging former President Trump and other Republicans for the 2024 GOP presidential nomination. Thoughts from the panel on these developments?
Raman: I think what’s happening in Ohio is pretty interesting because, you know, we’ve had other states before kind of try to change the threshold for passing something by ballot. And a lot of times it’s not said explicitly, but advocates have said that it’s targeting some measure, whether it’s Medicaid expansion or something else. And here we have a representative and the secretary of state kind of being pretty clear that it is about abortion in this case. And I think it being the secretary of state is especially interesting, because the secretary of state is who is certifying ballot measures and who you would look to for being the person in charge of that and making sure, you know, the t’s are crossed, the i’s dotted. So what happens there will be pretty interesting because that’s kind of an unusual play. And already we’re looking at an August ballot versus traditionally the November ballot. And a lot of times when things are pushed for a different date versus, like, traditional election day, it’s kind of, see if we can get a different turnout or kind of discourage people that might vote one way or the other. So it’ll be interesting to see how this kind of plays out in August or if there are changes before then.
Ollstein: And as for Indiana, I mean, this is one of a bunch of cases around the country where religious people are challenging abortion bans as infringing on their beliefs and right to practice. It’s sort of flipping the assumption on its head. You know, you have a lot of religious support of abortion bans. And this is showing that there are folks on the other side as well within the faith community. And it’s especially interesting in Indiana because they’re challenging one law signed by Mike Pence — the state’s pre-Dobbs abortion ban — by using another law signed by Mike Pence, which is the state’s RFRA law [Religious Freedom Restoration Act], the religious freedom law, and saying that, you know, the state law imposes one particular religion’s view of when life begins and when abortion is or is not acceptable. And that’s not shared by all people of faith. And in Judaism, a child is not a child until it takes its first breath, and that conflicts with abortion bans that are much earlier in pregnancy that sort of posit that it is a child and a life before that. So this will be really interesting to watch.
Carey: Sure. We’ll be watching all these cases very closely. But we’re going to turn now to another topic that’s important to millions of Americans, and that’s the cost of prescription drugs. Sen. Bernie Sanders — he’s a Vermont independent who chairs the Senate Health, Education, Labor and Pensions Committee, also known as the HELP Committee — he’s vowed not to move forward with any Biden administration health nominees, including the president’s pick to head the National Institutes of Health. That’s Dr. Monica Bertagnolli. Sen. Sanders is saying he’s going to keep this hold on until he sees a comprehensive plan from the White House on how to lower drug prices. What is he upset about specifically? And is he going to have other senators — have they joined him? Do you think that will be in the cards, or is this kind of a one-man band here?
Cohrs: My take on this is that he knows he can’t get the votes in Congress, so this is kind of his only option, is to try to pressure the administration to do it. And the only lever he has is nominees, so he’s using that. I don’t know how long he’ll hold out on this. I mean, it is — basically he’s arguing that the public has invested research dollars to help develop kind of the basic science that’s the foundation for a lot of important medications. And right now, the government isn’t really getting enough return on that investment. And there’s no requirement that companies that end up actually manufacturing these drugs and bringing them to market would price them in a fair, reasonable way. And so, I think his staff put out a report as well, with a release to the Post, making that argument, that the NIH could have leverage here if they chose to, and that in the past there have been clauses in contracts that could have given the government some leverage to go after these companies more aggressively but they’re just choosing not to. And so far, the Biden administration has shown no appetite to go after companies’ patents because of pricing issues. It’s never been done before. But I think, you know, Sen. Sanders realizes that he has an opening here, and he’s using the bully pulpit as much as he can. But I think ultimately I don’t see how this is resolved. And I think given that the Biden administration has overseen the passage of the most significant drug pricing reform in 20 years — which doesn’t fix all the problems, will say that. I think Sen. Sanders sent a letter about —
Carey: It’s in the Inflation Reduction Act, right?
Cohrs: Yes. Yes. The Inflation Reduction Act.
Carey: Which he voted for, OK.
Cohrs: Yes, he did vote for that. But I think there are outstanding issues about new medications especially that he’s trying to highlight here and saying, The problem isn’t fixed. We need to do more.
Carey: And so separately, a bipartisan group of Senate Finance Committee members have unveiled a proposal that they said would reform pharmacy benefit managers, or PBMs. That’s another entity we talk a lot about on the podcast. And the belief is that this measure would lower the cost of drugs. Rachel, I know that you have been covering this plan. Can you tell us about it?
Cohrs: I don’t know that this would lower the cost of drugs necessarily, and I think it’s more limited than the lawmakers who are sponsoring it have claimed it is. I think the problem that it’s trying to solve is that the payments between drugmakers and PBMs, and PBMs and the insurance companies or the employees that they’re working for, have traditionally been tied to a drug’s price. And so, just kind of like the — if anyone’s familiar with the medical loss ratio from the Affordable Care Act — it’s a similar idea, that if the price is higher, then there’s a bigger piece of the pie for everyone, percentagewise. So this bill aims to delink some of the fees in contracts with PBMs from the price of drugs. Now, this doesn’t change the rebates that drugmakers and PBMs negotiate on themselves, doesn’t touch that at all. It’s just fees. So I think it’s kind of hard to know how these work. You know, we don’t have them. They’re not public, but I think they’re trying to get at regulating this space a little bit more and trying to align those incentives a little bit better to make sure PBMs aren’t preferring more expensive medications for their own gain.
Carey: And what’s been the response from the PBM industry?
Cohrs: It is pretty fresh, but I think in general they have argued that the reason for high prices is drugmakers, because they set the prices. And I think this has been a food fight that’s been going on for a very long time. But I think lawmakers are kind of coming around to the idea of doing some sort of reform to the PBM industry. We’ll just have to wait and see what that ends up looking like.
Carey: All right. Well, we’ll keep our eyes on that one as well. And that’s this week’s news. Now we’re going to play Julie Rovner’s interview with Dan Mendelson of Morgan Health, and then we’ll be back with our extra credits.
Julie Rovner: I am pleased to welcome to the podcast Dan Mendelson, CEO of Morgan Health, a new business unit of the financial services giant JPMorgan Chase. Morgan Health’s goal is to improve health care for the company’s more than a quarter of a million employees and dependents, as well as everyone else with employer-provided insurance. If that sounds familiar, that’s because Morgan Health is the successor organization to Haven Healthcare. That was the high-profile 2018 project of JPMorgan, Amazon, and Berkshire Hathaway to remake the U.S. health care system from the ground up, led by one of the nation’s leading health care thinkers, surgeon, author, and policy wonk Atul Gawande. Today, Gawande is running global health programs at the U.S. Agency for International Development. Haven is no more. And if you listened to our special 300th episode earlier this month, our experts came down pretty hard on employers’ contributions to fixing what ails the health care system. So I’ve asked Dan here to talk about what is going on. Welcome, Dan.
Dan Mendelson: My pleasure.
Rovner: So, Dan may not have as high a public profile as Atul Gawande, but he has broad and long experience in health policy, from overseeing federal health programs at the Office of Management and Budget during the Bill Clinton administration to founding and growing Avalere Health, a successful health care consulting and advisory group. Dan, why did this job appeal to you and what made you think you could succeed where so many have tried before and failed, including very recently?
Mendelson: Look, this is a collaborative effort, and we’re working closely with a whole range of stakeholders from insurers to providers. I mean, the work that we’re doing in Columbus, for example, is with a really innovative primary care practice called Central Ohio Primary Care that has broad experience in delivering value through accountable care models in Medicare. So, I’d say that our belief that we will succeed really comes from the fact that we’re taking a very collaborative approach with other stakeholders in the health care system.
Rovner: Let’s start at the very beginning. Why are employers interested in the nation’s health care system and how it works? For most of them, it’s not their main line of business.
Mendelson: Well, I’d say that employers feel an obligation to provide insurance for their employees, and it’s an important benefit, and it’s one that employees expect. And it’s also an opportunity for employers to provide for the health and well-being of their employees.
Rovner: So employers really did used to drive a lot of health care innovation, probably coming only after Medicare in terms of shifting actual health care delivery. But they seem to have taken a back seat lately. What changed?
Mendelson: Well, look, you know, you had employers really active in the quality movement, and NCQA came out of employer interest, for example. So there really was kind of a head of steam. But it did wane. And I think that anyone who’s looking at the scene sees that Medicare and Medicaid have made a lot of progress with respect to driving accountable care and quality, whereas, at this point, there’s really … most of what’s happening through employers is fee for service. And it’s really problematic in terms of driving the quality agenda.
Rovner: And NCQA, that’s …?
Mendelson: National Commission for Quality Assurance.
Rovner: Thank you. The National Commission for Quality Assurance. Yeah, which used to be a big deal. And you’re right, I think most of what we’re seeing is now going on in the Medicare and Medicaid space. I feel like, you know, the millions of people who have employer-provided insurance right now have three main problems: the increasing unaffordability of care, with large and growing deductibles and copays; the increasing time and effort it takes to figure out what is and isn’t covered, and fighting for things that aren’t covered to be covered sometimes; and the fragmentation of the delivery system, making what was already hard to navigate very nearly impenetrable for some people, including people who are sick. I assume you’re trying to address all of those.
Mendelson: Yeah, we’re focused on quality and improving the quality of services, for sure. We’re focused on affordability. And then the one that you didn’t mention is health equity, which is one of the most difficult aspects of health care in America today, and certainly our focus as well. I mean, we see inequity in the health care system in the employer space, as well as in Medicare and Medicaid. So that’s also a target for us.
Rovner: What kind of steps are you taking to fix some of these problems? I mean, I know it’s what people get frustrated most with. It’s, like, they have insurance, but they feel like they can’t use it very well.
Mendelson: Yes. So, the way that we’re structured, there are three things that we’re doing to address these issues. And I’d say that we see our efforts as very collaborative. So we don’t believe that we alone can fix these problems, but rather what we’re doing is really driving innovation and trying to get employers, more broadly, focused on innovation in health care. So there are three ways that we’re doing this. First is that we’re investing, from the JPMorgan Chase balance sheet, in innovative health care companies that are proven to drive quality, improve quality, reduce costs, and better health equity. So that’s the first piece. And we can talk a little bit about some of the investments that we’ve made in the first two years of our operation.
Rovner: Give me one example of a company that’s doing that that you’re investing in.
Mendelson: Yes. An example is apree health. apree is a company that offers a[n] accountable care product to employers. And we’re using apree in Columbus, where we have 40,000 employees and dependents, and we’re now offering their services to our employees as an option to drive better health care.
Rovner: What do you see as the biggest challenge in health care going forward, particularly from the employer point of view?
Mendelson: Well, look, we’ve talked about a number of the issues. I’d say that, you know, we’re focused broadly on accountable care — and “accountable care” meaning making sure that there is a focus on quality and cost that is being held by an organization that can really take responsibility for care. So, to me, it’s really about alignment of incentives and making sure that those incentives are aligned not only in the employer sector but also across in the public programs.
Rovner: So you’re involved in private equity and, you know, the track record of private equity in health care, which was supposed to be an effort to get incentives aligned, hasn’t always worked out so well. I mean, in a lot of cases we’ve seen private equity just sucking money out of the health care system rather than putting it back in.
Mendelson: Look, as an investor, what we’re focused on is finding companies that are driving innovation and helping them succeed. And we’re putting our capital behind these companies, but we’re also really spending the time with them to make sure that they can be effective. And so, you know, we’ve done five investments over the course of two years, and they’re not only in accountable care, but also making sure that there’s good primary care in the system, driving better digital care, shifting expensive care from inpatient and outpatient settings into the home. So these are all facets of how employer-sponsored health care needs to be improved, and that’s the focus of our investing.
Rovner: So what does it look like when you get it all fixed?
Mendelson: When we get it all fixed …? I mean, look, I think we’re going to be at this for quite some time. But it’s really important for employers to articulate their needs and to make sure that those who are offering insurance for their employees are actually being attentive to not only cost but also quality and health equity. And I think that the facet that we’re really looking for is to make sure that health care improves and that these improvements are coming along not only in the public programs but also in the employer sector.
Rovner: Dan Mendelson, thank you so much for joining us.
Mendelson: My pleasure.
Carey: All right. We’re back, and it’s time for our extra credit segment. That’s when we each recommend a story that we read this week and we think you should read it, too. As always, don’t worry if you miss it. We’ll post the links on the podcast page at kffhealthnews.org and in the show notes on your phone or other mobile device. So, Alice, why don’t you go first this week?
Ollstein: Sure. I chose a piece in Stat by Brittany Trang and Elaine Chen. It’s called “AMA Asks Doctors to De-Emphasize Use of BMI in Gauging Health and Obesity.” I’ve heard in the medical community there has been a lot of discussion about moving away from using the BMI [body mass index] to evaluate people’s health. It was created to track population-level statistics and was never intended to be used to gauge individual health. It was not invented by someone with a medical background at all. And so people have been saying that, you know, it’s inaccurate and it leads to a lot of stigma. And so it’s interesting to see that sort of bubble up to this very mainstream, leading health care organization saying, “Look, you can’t just rely on the BMI. You also have to look at all these other factors.” Because extremely fit NFL players have really high BMIs, you know. You can’t — someone’s size does not necessarily determine their health. You can have people of all sizes be healthy or unhealthy. So this was encouraging to see.
Carey: Great. And for folks interested in more on that, we have a lot of coverage on that at kffhealthnews.org, so check that out. Rachel, why don’t you go next?
Cohrs: Sure. My piece this week is by one of Alice’s colleagues in Politico, Megan Messerly, and the headline is “Thousands Lose Medicaid in Arkansas: Is This America’s Future?” And she kind of got out beyond the Beltway and just spent some time in Arkansas really talking to everyday people who were having trouble staying on Medicaid. And I think it’s easy to get caught up in just talking about numbers and talking about policies and all of that. But I think she really brought to life the issues and the barriers that some people are facing in Arkansas, which really is the center of these disenrollments that we’re seeing right now. So I think it was really timely, really well done, very much put the human face on both the people who are getting disenrolled, but also kind of some of the on-the-ground efforts to stop that from happening and just kind of the challenges that they are working on with these compressed timelines. I thought it was really well done.
Carey: Yeah, it’s a great story. Sandhya.
Raman: My extra credit this week is called “Suicide Hotlines Promise Anonymity. Dozens of Their Websites Send Sensitive Data to Facebook.” It’s by Colin Lecher and Jon Keegan for The Markup in partnership with Stat. And I thought this was just a really interesting piece that investigated whether crisis center websites that were using Meta Pixel, which is like a piece of code that tracks user behavior for advertising that a lot of sites use — and just, like, the worry here is sharing sensitive information to Facebook, especially when it is personally identifiable. And with the crisis center, it’s much, much more sensitive data than, you know, maybe, like, shopping habits. And so they looked at data from 186 local call center websites. And I will let you read to see how many of them were using this.
Carey: Mine is from Ruth Marcus at The Washington Post. And it’s called “I Lost 40 Pounds on Ozempic. But I’m Left With Even More Questions.” In this article, she talks about her lifelong struggle to lose weight, to keep it off, but how those pounds always find their way back. And Marcus explores the history and the science behind the weight loss drugs. And she also takes on societal debate over obesity itself: Do we think of it as a personal failing, or is it a disease, a chronic condition whose underpinnings are in genetics and brain chemistry? It is a great read. All right. That’s our show for the week. And as always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left a review; that helps other people find us too. Special thanks, as always, to the amazing Francis Ying, our producer. You can email us with your comments or questions. We’re at whatthehealth@kff.org. Or you can tweet me. I’m @maryagnescarey.
Carey: Alice.
Ollstein: @AliceOllstein.
Carey: Rachel.
Cohrs: @rachelcohrs.
Carey: And Sandhya.
Raman: @SandhyaWrites.
Carey: We’ll be back in your feed next week. Until then, be healthy.
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Health Care Costs, Health Industry, Medicaid, Medicare, Multimedia, Abortion, Drug Costs, KFF Health News' 'What The Health?', Legislation, Podcasts, U.S. Congress, Women's Health
Debt Deal Leaves Health Programs (Mostly) Intact
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Julie Rovner
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
A final deal cut between President Joe Biden and House Republicans extends the U.S. debt ceiling deadline to 2025 and reins in some spending. The bill signed into law by the president will preserve many programs at their current funding levels, and Democrats were able to prevent any changes to the Medicare and Medicaid programs.
Still, millions of Americans are likely to lose their Medicaid coverage this year as states are once again allowed to redetermine who is eligible and who is not; Medicaid rolls were frozen for three years due to the pandemic. Data from states that have begun to disenroll people suggests that the vast majority of those losing insurance are not those who are no longer eligible, but instead people who failed to complete required paperwork — if they received it in the first place.
This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico, Lauren Weber of The Washington Post, and Jessie Hellmann of CQ Roll Call.
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Jessie Hellmann
CQ Roll Call
Joanne Kenen
Johns Hopkins Bloomberg School of Public Health and Politico
Lauren Weber
The Washington Post
Among the takeaways from this week’s episode:
- Lawmakers and White House officials spared health programs from substantial spending cuts in a last-minute agreement to raise the nation’s debt ceiling. And Biden named Mandy Cohen, a former North Carolina health director who worked in the Obama administration, to be the next director of the Centers for Disease Control and Prevention. Though she lacks academic credentials in infectious diseases, Cohen enters the job with a reputation as someone who can listen and be listened to by both Democrats and Republicans.
- The removal of many Americans from the Medicaid program, post-public health emergency, is going as expected: With hundreds of thousands already stripped from the rolls, most have been deemed ineligible not because they don’t meet the criteria, but because they failed to file the proper paperwork in time. Nearly 95 million people were on Medicaid before the unwinding began.
- Eastern and now southern parts of the United States are experiencing hazardous air quality conditions as wildfire smoke drifts from Canada, raising the urgency surrounding conversations about the health effects of climate change.
- The drugmaker Merck & Co. sued the federal government this week, challenging its ability to press drugmakers into negotiations over what Medicare will pay for some of the most expensive drugs. Experts predict Merck’s coercion argument could fall flat because drugmakers voluntarily choose to participate in Medicare, though it is unlikely this will be the last lawsuit over the issue.
- In abortion news, some doctors are pushing back against the Indiana medical board’s decision to reprimand and fine an OB-GYN who spoke out about providing an abortion to a 10-year-old rape victim from Ohio. The doctors argue the decision could set a bad precedent and suppress doctors’ efforts to communicate with the public about health issues.
Also this week, Rovner interviews KFF Health News senior correspondent Sarah Jane Tribble, who reported the latest KFF Health News-NPR “Bill of the Month” feature, about a patient with Swiss health insurance who experienced the sticker shock of the U.S. health care system after an emergency appendectomy. If you have an outrageous or exorbitant medical bill you want to share with us, you can do that here.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: The New York Times’ “This Nonprofit Health System Cuts Off Patients With Medical Debt,” by Sarah Kliff and Jessica Silver-Greenberg.
Jessie Hellmann: MLive’s “During the Darkest Days of COVID, Some Michigan Hospitals Made 100s of Millions,” by Matthew Miller and Danielle Salisbury.
Joanne Kenen: Politico Magazine’s “Can Hospitals Turn Into Climate Change Fighting Machines?” by Joanne Kenen.
Lauren Weber: The Washington Post’s “Smoke Brings a Warning: There’s No Escaping Climate’s Threat to Health,” by Dan Diamond, Joshua Partlow, Brady Dennis, and Emmanuel Felton.
Also mentioned in this week’s episode:
KFF Health News’ “As Medicaid Purge Begins, ‘Staggering Numbers’ of Americans Lose Coverage,” by Hannah Recht.
Click to open the transcript
Transcript: Debt Deal Leaves Health Programs (Mostly) Intact
KFF Health News’ ‘What the Health?’Episode Title: Debt Deal Leaves Health Programs (Mostly) IntactEpisode Number: 301Published: June 8, 2023
[Editor’s note: This transcript, generated using transcription software, has been edited for style and clarity.]
Julie Rovner: Hello and welcome back to “What the Health?”. I’m Julie Rovner, chief Washington correspondent at KFF Health News. And I’m joined by some of the best and smartest health reporters in Washington. We are taping this week from the smoky, hazy, “code purple” Washington, D.C., area on Thursday, June 8, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So here we go. We are joined today via video conference by Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico.
Joanne Kenen: Hi, everybody.
Rovner: Lauren Weber, of The Washington Post.
Lauren Weber: Hi.
Rovner: And Jessie Hellmann, of CQ Roll Call.
Hellmann: Hello.
Rovner: Later in this episode we’ll have my interview with KFF Health News’s Sarah Jane Tribble about the latest KFF Health News-NPR “Bill of the Month.” This month is about the sticker shock of the American health care system experienced by residents of other countries. Before we get to this week’s news, I hope you all enjoyed our special panel of big health policy thinkers for our 300th episode. If you didn’t listen, you might want to go back and do that at some point. Also, that means we have two weeks of news to catch up on, so let us get to it. We’re going to start this week, I hope, for the last time with the fight over the debt ceiling. Despite lots of doubts, President Biden managed to strike a budget deal with House Republicans, which fairly promptly passed the House and Senate and was signed into law a whole two days before the Treasury Department had warned that the U.S. might default. The final package extends the debt ceiling until January 1, 2025, so after the next election, which was a big win for the Democrats, who don’t want to do this exercise again anytime soon. In exchange, Republicans got some budget savings, but nothing like the dramatic bill that House Republicans passed earlier this spring. So, Jessie, what would it do to health programs?
Hellmann: The deal cuts spending by 1.5 trillion over 10 years. It has caps on nondefense discretionary funding. That would have a big impact on agencies and programs like the NIH [National Institutes of Health], which has been accustomed to getting pretty large increases over the years. So nondefense discretionary spending will be limited to about 704 billion next fiscal year, which is a cut of about 5%. And then there’s going to be a 1% increase in fiscal 2025, which, when you consider inflation, probably isn’t much of an increase at all. So the next steps are seeing what the appropriators do. They’re going to have to find a balance between what programs get increases, which ones get flat funding — it’s probably going to be a lot of flat funding, and we’re probably at the end of an era for now with these large increases for NIH and other programs, which have traditionally been very bipartisan, but it’s just a different climate right now.
Rovner: And just to be clear, I mean, this agreement doesn’t actually touch the big sources of federal health spending, which are Medicare and Medicaid, not even any work requirements that the Republicans really wanted for Medicaid. In some ways, the Democrats who wanted to protect health spending got off pretty easy, or easier than I imagine they expected they would, right?
Hellmann: Advocates would say it could have been much worse. All things considered, when you look at the current climate and what some of the more conservative members of the House were initially asking for, this is a win for Democrats and for people who wanted to protect health care spending, especially the entitlements, because they — Republicans did want Medicaid work requirements and those just did not end up in the bill; they were a nonstarter. So, kind of health-care-related, depending on how you look at it, there was an increase in work requirements for SNAP [Supplemental Nutrition Assistance Program], which is, like, a food assistance program. So that will be extended to age 55, though they did include more exemptions for people who are veterans —
Rovner: Yeah, overall, that may be a wash, right? There may be the same or fewer people who are subject to work requirements.
Hellmann: Yeah. And all those changes would end in 2030, so —
Weber: Yeah, I just wanted to say, I mean, if we think about this — we’re coming out of a pandemic and we’re not exactly investing in the health system — I think it’s necessary to have that kind of step-back context. And we’ve seen this before. You know, it’s the boom-bust cycle of pandemic preparedness funding, except accelerated to some extent. I mean, from what I understand, the debt deal also clawed back some of the public health spending that they were expecting in the billions of dollars. And I think the long-term ramifications of that remain to be seen. But we could all be writing about that in 10 years again when we’re looking at ways that funding fell short in preparedness.
Rovner: Yeah, Joanne and I will remember that. Yeah, going back to 2001. Yeah. Is that what you were about to say?
Kenen: I mean, this happens all the time.
Weber: All the time, right.
Kenen: And we learn lessons. I mean, the pandemic was the most vivid lesson, but we have learned lessons in the past. After anthrax, they spent more money, and then they cut it back again. I mean, I remember in 2008, 2009, there was a big fiscal battle — I don’t remember which battle it was — you know, Susan Collins being, you know, one of the key moderates to cut the deal. You know, what she wanted was to get rid of the pandemic flu funding. And then a year later, we had H1N1, which turned out not to be as bad as it could have been for a whole variety of reasons. But it’s a cliche: Public health, when it works, you don’t see it and therefore people think you don’t need it. Put that — put the politics of what’s happened to public health over the last three years on top of that, and, you know, public health is always going to have to struggle for funds. Public health and larger preparedness is always going to happen to have to struggle for funds. And it would have, whether it was the normal appropriations process this year, which is still to come, or the debt ceiling. It is a lesson we do not learn the hard way.
Weber: That’s exactly right. I’ll never forget that Tom Harkin said to me that after Obama cut, he sacrificed a bunch of prevention funding for the CDC [Centers for Disease Control and Prevention] in the ACA [Affordable Care Act] deal, and he never spoke to him again, he told me, because he was so upset because he felt like those billions of dollars could have made a difference. And who knows if 10 years from now we’ll all be talking about this pivotal moment once more.
Rovner: Yeah, Tom Harkin, the now-former senator from Iowa, who put a lot of prevention into the ACA; that was the one thing he really worked hard to do. And he got it in. And as you point out, and it was almost immediately taken back out.
Weber: Yeah.
Kenen: Not all of it.
Weber: Not all of it, but a lot of it.
Kenen: It wasn’t zero.
Rovner: It became a piggy bank for other things. I do want to talk about the NIH for a minute, though, because Jessie, as you mentioned, there isn’t going to be a lot of extra money, and NIH is used to — over the last 30 years — being a bipartisan darling for spending. Well, now it seems like Congress, particularly some of the Republicans, are not so happy with the NIH, particularly the way it handled covid. There’s a new NIH director who has been nominated, Dr. Monica Bertagnolli, who is currently the head of the National Cancer Institute. This could be a rocky summer for the NIH on Capitol Hill, couldn’t it?
Hellmann: Yeah, I think there’s been a strong desire for Republicans to do a lot of oversight. They’ve been looking at the CDC. I think they’re probably going to be looking at the NIH next. Francis Collins is no longer at NIH. Anthony Fauci is no longer there. But I think Republicans have indicated they want to bring them back in to talk about some of the things that happened during the pandemic, especially when it comes to some of the projects that were funded.
Kenen: There was a lull in raising NIH spending. It was flat for a number of years. I can’t remember the exact dates, but I remember it was — Arlen Specter was still alive, and it … [unintelligible] … because he is the one who traditionally has gotten a lot of bump ups in spending. And then there was a few years, quite a few years, where it was flat. And then Specter got the spigots opened again and they stayed open for a good 10 or 15 years. So we’re seeing, and partly a fiscal pause, and partly the — again, it’s the politicization of science and public health that we did not have to this extent before this pandemic.
Rovner: Yeah, I think it’s been a while since NIH has been under serious scrutiny on Capitol Hill. Well, speaking of the CDC, which has been under serious scrutiny since the beginning of the pandemic, apparently is getting a new director in Dr. Mandy Cohen, assuming that she is appointed as expected. She won’t have to be confirmed by the Senate because the CDC director won’t be subject to Senate approval until 2025. Now, Mandy Cohen has done a lot of things. She worked in the Obama administration on the implementation of the Affordable Care Act. She ran North Carolina’s Department of Health [and Human Services], but she’s not really a noted public health expert or even an infectious disease doctor. Why her for this very embattled agency at this very difficult time?
Kenen: I think there are a number of reasons. A lot of her career was on Obamacare kind of things and on CMS kind of quality-over-quantity kind of things, payment reform, all that. She is a physician, but she did a good job in North Carolina as the top state official during the pandemic. I reported a couple of magazine pieces. I spent a lot of time in North Carolina before the pandemic when she was the state health secretary, and she was an innovator. And not only was she an innovator on things like, you know, integrating social determinants into the Medicaid system; she got bipartisan support. She developed not perfect, but pretty good relations with the state Republicans, and they are not moderates. So I think I remember writing a line that said something, you know, in one of those articles, saying something like, “She would talk to the Republicans about the return on investment and then say, ‘And it’s also the right thing to do.’ And then she would go to the Democrats and say, ‘This is the right thing to do. And there’s also an ROI.’”. So, so I think in a sort of low-key way, she has developed a reputation for someone who can listen and be listened to. I still think it’s a really hard job and it’s going to batter anyone who takes it.
Rovner: I suspect right now at CDC that those are probably more important qualities than somebody who’s actually a public health expert but does not know how to, you know, basically rescue this agency from the current being beaten about the head and shoulders by just about everyone.
Kenen: Yeah, but she also was the face of pandemic response in her state. And she did vaccination and she did disparities and she did messaging and she did a lot of the things that — she does not have an infectious disease degree, but she basically did practice it for the last couple of years.
Rovner: She’s far from a total novice.
Kenen: Yeah.
Rovner: All right. Well, it’s been a while since we talked about the Medicaid “unwinding” that began in some states in early April. And the early results that we’re seeing are pretty much as expected. Many people are being purged from the Medicaid rolls, not because they’re earning too much or have found other insurance, but because of paperwork issues; either they have not returned their paperwork or, in some cases, have not gotten the needed paperwork. Lauren, what are we seeing about how this is starting to work out, particularly in the early states?
Weber: So as you said, I mean, much like we expected to see: So 600,000 Americans have been disenrolled so far, since April 1. And some great reporting that my former colleague Hannah Recht did this past week: She reached out to a bunch of states and got ahold of data from 19 of them, I believe. And in Florida, it was like 250,000 people were disenrolled and somewhere north of 80% of them, it was for paperwork reasons. And when we think about paperwork reasons, I just want us all to take a step back. I don’t know about anyone listening to this, but it’s not like I fill out my bills on the most prompt of terms all of the time. And in some of these cases, people had two weeks to return paperwork where they may not have lived at the same address. Some of these forms are really onerous to fill out. They require payroll tax forms, you know, that you may not have easily accessible — all things that have been predicted, but the hard numbers just show is the vast majority of people getting disenrolled right now are being [dis]enrolled for paperwork, not because of eligibility reasons. And too, it’s worth noting, the reason this great Medicaid unwinding is happening is because this was all frozen for three years, so people are not in the habit of having to fill out a renewal form. So it’s important to keep that in mind, that as we’re seeing the hard data show, that a lot of this is, is straight-up paperwork issues. The people that are missing that paperwork may not be receiving it or just may not know they’re supposed to be doing it.
Rovner: As a reminder, I think by the time the three-year freeze was over, there were 90 million people on Medicaid.
Kenen: Ninety-five.
Rovner: Yeah. So it’s a lot; it’s like a quarter of the population of the country. So, I mean, this is really impacting a lot of people. You know, I know particularly red states want to do this because they feel like they’re wasting money keeping ineligible people on the rolls. But if eligible people become uninsured, you can see how they’re going to eventually get sicker, seek care; those providers are going to check and see if they’re eligible for Medicaid, and if they are, they’re going to put them back on Medicaid. So they’re going to end up costing even more. Joanne, you wanted to say something?
Kenen: Yeah. Almost everybody is eligible for something. The exceptions are the people who fall into the Medicaid gap, which is now down to 10 states.
Rovner: You mean, almost everybody currently on Medicaid is eligible.
Kenen: Anyone getting this disenrollment notification or supposed to receive the disenrollment notification that never reaches them — almost everybody is eligible for, they’re still eligible for Medicaid, which is true for the bulk of them. If they’re not, they’re going to be eligible for the ACA. These are low-income people. They’re going to get a lot heavily subsidized. Whether they understand that or not, someone needs to explain it to them. They’re working now, and the job market is strong. You know, it’s not 2020 anymore. They may be able to get coverage at work. Some of them are getting coverage at work. One of the things that I wrote about recently was the role of providers. States are really uneven. Some states are doing a much better job. You know, we’ve seen the numbers out of Florida. They’re really huge disenrollment numbers. Some states are doing a better job. Georgetown Center on Health Insurance — what’s the right acronym? — Children’s and Family. They’re tracking, they have a state tracker, but providers can step up, and there’s a lot of variability. I interviewed a health system, a safety net in Indiana, which is a red state, and they have this really extensive outreach system set up through mail, phone, texts, through the electronic health records, and when you walk in. And they have everybody in the whole system, from the front desk to the insurance specialists, able to help people sort this through. So some of the providers are quite proactive in helping people connect, because there’s three things: There’s understanding you’re no longer eligible, there’s understanding what you are eligible for, and then actually signing up. They’re all hard. You know, if your government’s not going to do a good job, are your providers or your community health clinics or your safety net hospitals — what are they doing in your state? That’s an important question to ask.
Rovner: Providers have an incentive because they would like to be paid.
Kenen: Paid.
Weber: Well, the thing about Indiana too, Joanne, I mean — so that was one of the states that Hannah got the data from. They had I think it was 53,000 residents that have lost coverage in the first amount of unwinding. 89% of them were for paperwork. I mean, these are not small fractions. I mean, it is the vast majority that is being lost for this reason. So that’s really interesting to hear that the providers there are stepping up to face that.
Kenen: It’s not all of them, but you can capture these people. I mean, there’s a lot that can go wrong. There’s a lot that — in the best system, you’re dealing with [a] population that moves around, they don’t have stable lives, they’ve got lots of other things to deal with day to day, and dealing with a health insurance notice in a language you may not speak delivered to an address that you no longer live at — that’s a lot of strikes.
Rovner: It is not easy. All right. Well, because we’re in Washington, D.C., we have to talk about climate change this week. My mother, the journalist, used to say whenever she would go give a speech, that news is what happens to or in the presence of an editor. I have amended that to say now news is what happens in Washington, D.C., or New York City. And since Washington, D.C., and New York City are both having terrible air quality — legendary, historically high air quality — weeks, people are noticing climate change. And yes, I know you guys on the West Coast are saying, “Uh, hello. We’ve been dealing with this for a couple of years.” But Joanne and Lauren, both of your extra credits this week have to do with it. So I’m going to let you do them early. Lauren, why don’t you go first?
Weber: Yeah, I’ve highlighted a piece by my colleague Dan Diamond and a bunch of other of my colleagues, who wrote all about how this is just a sign of what’s to come. I mean, this is not something that is going away. The piece is titled “Smoke Brings a Warning: There’s No Escaping Climate’s Threat to Health.” I think, Julie, you hit the nail on the head. You know, we all live here in Washington, D.C. A lot of other journalist friends live in New York. There’s been a lot of grousing on Twitter that everyone is now covering this because they can see it. But the reality is, when people can see it, they pay attention. And so the point of the story is, you know, look, I mean, this is climate change in action. We’re watching it. You know, it’s interesting; this story includes a quote from Mitch McConnell saying [to] follow the public health authorities, which I found to be quite fascinating considering the current Republican stance on some public health authorities during the pandemic. And I’m just very curious to see, as we continue to see this climate change in reality, how that messaging changes from both parties.
[Editor’s note: The quote Weber referenced did not come from McConnell but from Senate Majority Leader Chuck Schumer, a Democrat, and would not have warranted as much fascination in this context.]
Kenen: But I think that you’ve seen, with the fires on the West Coast, nobody is denying that there’s smoke and pollutants in the air — of either party. You know, we can look out our windows and see it right now, right? But they’re not necessarily accepting that it’s because of climate change, and that — I’m not sure that this episode changes that. Because many of the conservatives say it’s not climate change; it’s poor management of forests. That’s the one you hear a lot. But there are other explain — or it’s just, you know, natural variation and it’ll settle down. So it remains to be seen whether this creates any kind of public acknowledgment. I mean, you have conservative lawmakers who live in parts of the country that are already very — on coasts, on hurricane areas, and, you know, forest fire areas there. You have people who are already experiencing it in their own communities, and it does not make them embrace the awareness of poor air quality because of a forest fire. Yes. Does it do what Julie was alluding to, which is change policy or acknowledging what, you know, the four of us know, and many millions of other people, you know, that this is related to climate change, not just — you know, I’m not an expert in forestry, but this is not just — how many fires in Canada, 230?
Rovner: Yeah. Nova Scotia and Quebec don’t tend to have serious forest fire issues.
Kenen: Right. This is across — this is across huge parts of the United States now. It’s going into the South now. I was on the sixth floor of a building in Baltimore yesterday, and you could see it rolling in.
Rovner: Yeah. You have a story about people trying to do something about it. So why don’t you tell us about that.
Kenen: Well it was a coincidence that that story posted this week, because I had been working on it for a couple of months, but I wrote a story. The headline was — it’s in Politico Magazine — it’s “Can Hospitals Turn Into Climate Change Fighting Machines?” Although one version of it had a headline that I personally liked more, which was “Turn Off the Laughing Gas.” And it’s about how hospitals are trying to reduce their own carbon footprint. And when I wrote this story, I was just stunned to learn how big that carbon footprint is. The health sector is 8.5% of greenhouse gas emissions in the United States, and that’s twice as high as the health sector in comparable industrial countries, and —
Rovner: We’re No. 1!
Kenen: Yes, once again, and most of it’s from hospitals. And there’s a lot that the early adopters, which is now, I would say about 15% of U.S. hospitals are really out there trying to do things, ranging from changing their laughing gas pipes to composting to all sorts of, you know, energy, food, waste, huge amount of waste. But one of the — you know, everything in hospitals is use once and throw it out or unwrap it and don’t even use it and still have to throw it out. But one of the themes of the people I spoke to is that hospitals and doctors and nurses and everybody else are making the connection between climate change and the health of their own communities. And that’s what we’re seeing today. That’s where the phenomenon Laura was talking about is connected. Because if you look out the window and you can see the harmful air, and some of these people are going to be showing up in the emergency rooms today and tomorrow, and in respiratory clinics, and people whose conditions are aggravated, people who are already vulnerable, that the medical establishment is making the connection between the health of their own community, the health of their own patients, and climate. And that’s where you see more buy-in into this, you know, greening of American hospitals.
Rovner: Speaking of issues that that seem insoluble but people are starting to work on, drug prices. In drug price news, drug giant Merck this week filed suit against the federal government, charging that the new requirements for Medicare price negotiation are unconstitutional for a variety of reasons. Now, a lot of health lawyers seem pretty dubious about most of those claims. What’s Merck trying to argue here, and why aren’t people buying what they’re selling?
Hellmann: So there’s two main arguments they’re trying to make. The primary one is they say this drug price negotiation program violates the Fifth Amendment, which prohibits the government from taking private property for public use without just compensation. So they argue that under this negotiation process they would basically be coerced or forced into selling these drugs for a price that they think is below its worth. And then the other argument they make is it violates their First Amendment rights because they would be forced to sign an agreement they didn’t agree with, because if they walk away from the negotiations, they have to pay a tax. And so it’s this coercive argument that they are making. But there’s been some skepticism. You know, Nick Bagley noted on Twitter that it’s voluntary to participate in Medicare. Merck doesn’t have a constitutional right to sell its drugs to the government at a price that they have set. And he also noted — I thought this was interesting — I didn’t know that there was kind of a similar case 50 years ago, when Medicare was created. Doctors had sued over a law Congress passed requiring that a panel review treatment decisions that doctors were making. The doctors sued also under the Fifth Amendment in the courts, and the Supreme Court sided with the government. So he seems to think there’s a precedent in favor of the government’s approach here. And there just seems to be a lot of skepticism around these arguments.
Rovner: And Nick Bagley, for those of you who don’t know, is a noted law professor at the University of Michigan who specializes in health law. So he knows whereof he speaks on this stuff. I mean, Joanne, you were, you were mentioning, I mean, this was pretty expected somebody was going to sue over this.
Kenen: It’s probably not the last suit either. It’s probably the first of, but, I mean, the government sets other prices in health care. And, you know, it sets Medicare Advantage rates. It sets rates for all sorts of Medicare procedures. The VA [U.S. Department of Veterans Affairs] sets prices for every drug that’s in its formulary or, you know, buys it at a negotiated —
Rovner: Private insurers set prices.
Kenen: Right. But that’s not government. That’s different.
Rovner: That’s true.
Kenen: They’re not suing private insurers. So, you know, I’m not Nick Bagley, but I usually respect what Nick Bagley has to say. On the other hand, we’ve also seen the courts do all sorts of things we have not expected them to do. There’s another Obamacare case right now. So, precedent, schmecedent, you know, like — although on this one we did expect the lawsuits. Somebody also pointed out, I can’t remember where I read it, so I’m sorry not to credit it, maybe it was even Nick — that even if they lose, if they buy a extra year or two, they get another year or two of profits, and that might be all they care about.
Rovner: It may well be. All right. Well, let us turn to abortion. It’s actually been relatively quiet on the abortion front these last couple of weeks as we approach the one-year anniversary of the Supreme Court striking down Roe v Wade. I did want to mention something that’s still going on in Indiana, however. You may remember the case last year of the 10-year-old who was raped in Ohio and had to go to Indiana to have the pregnancy terminated. That was the case that anti-abortion activists insisted was made up until the rapist was arraigned in court and basically admitted that he had done it. Well, the Indiana doctor who provided that care is still feeling the repercussions of that case. Caitlin Bernard, who’s a prominent OB-GYN at the Indiana University Health system, was first challenged by the state’s attorney general, who accused her of not reporting the child abuse to the proper state authorities. That was not the case; she actually had. But the attorney general, who’s actually a former congressman, Todd Rokita, then asked the state’s medical licensing board to discipline her for talking about the case, without naming the patient, to the media. Last month, the majority of the board voted to formally reprimand her and fine her $3,000. Now, however, lots of other doctors, including those who don’t have anything to do with reproductive health care, are arguing that the precedent of punishing doctors for speaking out about important and sometimes controversial issues is something that is dangerous. How serious a precedent could this turn out to be? She didn’t really violate anybody’s private — she didn’t name the patient. Lauren, you wanted to respond.
Weber: Yeah, I just think it’s really interesting. If you look at the context, the number of doctors that actually get dinged by the medical board, it’s only a couple thousand a year. So this is pretty rare. And usually what you get dinged for by the medical board are really severe things like sexual assault, drug abuse, alcohol abuse. So this would seem to indicate quite some politicization, and the fact that the AG was involved. And I do think that, especially in the backdrop of all these OB-GYN residents that are looking to apply to different states, I think this is one of the things that adds a chilling effect for some reproductive care in some of these red states, where you see a medical board take action like this. And I just think in general — it cannot be stated enough — this is a rare action, and a lot of medical board actions will be, even if there is an action, will be a letter in your file. I mean, to even have a fine is quite something and not it be like a continuing education credit. So it’s quite noteworthy.
Rovner: Well, meanwhile, back in Texas, the judge who declared the abortion pill to have been wrongly approved by the FDA, Trump appointee Matthew Kacsmaryk, is now considering a case that could effectively bankrupt Planned Parenthood for continuing to provide family planning and other health services to Medicaid patients while Texas and Louisiana were trying to kick them out of the program because the clinics also provided abortions in some cases. Now, during the time in question, a federal court had ordered the clinics to continue to operate as usual, banning funding for abortions, which always has been the case, but allowing other services to be provided and reimbursed by Medicaid. This is another of those cases that feels very far-fetched, except that it’s before a judge who has found in favor of just about every conservative plaintiff that has sought him out. This could also be a big deal nationally, right? I mean, Planned Parenthood has been a participant in the Medicaid program in most states for years — again, not paying for abortion, but for paying for lots of other services that they provide.
Kenen: The way this case was structured, there’s all these enormous number of penalties, like 11,000 per case or something, and it basically comes out to be $1.8 billion. It would bankrupt Planned Parenthood nationally, which is clearly the goal of this group, which has a long history that — we don’t have time to go into their long history. They’re an anti-abortion group that’s — you know, they were filming people, and there’s a lot of history there. It’s the same people. But, you know, this judge may in fact come out with a ruling that attempts to shut down Planned Parenthood completely. It doesn’t mean that this particular decision would be upheld by the 5th Circuit or anybody else.
Rovner: Or not. The same way the mifepristone ruling finally woke up other drugmakers who don’t have anything to do with the abortion fight because, oh my goodness, if a judge can overturn the approval of a drug, what does the FDA approval mean? This could be any government contractor — that you can end up being sued for having accepted money that was legal at the time you accepted it, which feels like not really a very good business partner issue. So another one that we will definitely keep an eye on.
Kenen: I mean, that’s the way it may get framed later, is that this isn’t really about Planned Parenthood; this is about a business or entity obeying the law, or court order. I mean, that’s how the pushback might come. I mean, I think people think Planned Parenthood, abortion, they equate those. And most Planned Parenthood clinics do not provide abortion, while those that do are not using federal funds, as a rule; there are exceptions. And Planned Parenthood is also a women’s health provider. They do prenatal care in some cases; they do STD [sexually transmitted disease] treatment and testing. They do contraception. They, you know, they do other things. Shutting down Planned Parenthood would mean cutting off many women’s access to a lot of basic health care.
Rovner: And men too, I am always reminded, because, particularly for sexually transmitted diseases, they’re an important provider.
Kenen: Yeah. HIV and other things.
Rovner: All right. Well, that is this week’s news. Now we will play my “Bill of the Month” interview with Sarah Jane Tribble, and then we will be back with our extra credits. We are pleased to welcome back to the podcast Sarah Jane Tribble, who reported and wrote the latest KFF Health News-NPR “Bill of the Month” story. Sarah, thanks for coming in.
Sarah Jane Tribble: Thanks for having me.
Rovner: So this month’s patient is a former American who now lives in Switzerland, a country with a very comprehensive health insurance system. But apparently it’s not comprehensive enough to cover the astronomical cost of U.S. health care. So tell us who the patient is and how he ended up with a big bill.
Tribble: Yeah. Jay Comfort is an American expatriate, and he has lived overseas for years. He’s a former educator. He’s 66 years old. And he decided to retire in Switzerland. He has that country’s basic health insurance plan. He pays his monthly fee and gets a deductible, like we do here in the U.S. He traveled last year for his daughter’s wedding and ended up with an emergency appendectomy in the ER [emergency room] at the University of Pittsburgh in Williamsport.
Rovner: And how big was the ultimate bill?
Tribble: Well, he was in the hospital just about 14 hours, and he ended up with a bill of just over $42,000.
Rovner: So not even overnight.
Tribble: No.
Rovner: That feels like a lot for what was presumably a simple appendectomy. Is it a lot?
Tribble: We talked to some experts, and it was above what they had predicted it would be. It did include the emergency appendectomy, some scans, some laboratory testing, three hours in the recovery room. There was also some additional diagnostic testing. They had sent off some cells for a diagnostics and did find cancer at the time. Still, it didn’t really explain all the extra cost. Healthcare Bluebook, which you can look up online, has this at about $14,000 for an appendectomy. One expert told me, if you look at Medicare prices and average out in that region, it would be between $6,500 and $18,000-ish. So, yeah, this was expensive compared to what the experts told us.
Rovner: So he goes home and he files a claim with his Swiss insurance. What did they say?
Tribble: Well, first let me just say, cost in the U.S. can be two to three times that in other countries. Switzerland isn’t known as a cheap country, actually. Its health care is —
Rovner: It’s the second most expensive after the U.S.
Tribble: Considered the most expensive in Europe, right. So this is pretty well known. So he was still surprised, though, when he got the response from his Swiss insurance. They said they were willing to pay double because it was an emergency abroad. Total, with the appendectomy and some extra additional scans and so forth: About $8,000 is what they were willing to pay.
Rovner: So, double what they would have paid if he’d had it done in Switzerland.
Tribble: Yeah.
Rovner: So 42 minus 8 leaves a large balance left. Yeah. I mean, he’s stuck with — what is that — $34,000. He’s on the hook for that. I mean, it’s better than having nothing, obviously, but it’s a lot of money and it’s really striking, the difference, because, you know, in Switzerland, they’re very much like, we would pay this amount, then we’ll double it to pay you back. And he still has this enormous bill he’s left paying. He’s on a fixed income. He’s retired. So it’s quite the shock to his system.
Rovner: So what happened? Has this been resolved?
Tribble: Let me first tell you what happened at the ER, because Jay was very diligent about providing documents and explaining everything. We had multiple Zoom calls. Jay’s wife was with him, and she provided the Swiss insurance card to UPMC. Now, UPMC had confirmed that there was some confusion, and it took months for Jay to get his bill. He had to call and reach out to UPMC to get his bill. He wants to pay his bill. He wants to pay his fair share, but he doesn’t consider $42,000 a fair share. So he wants to now negotiate the bill. We’ve left it at that, actually. UPMC says they are charging standard charges and that he has not requested financial assistance. And Jay says he would like to negotiate his bill.
Rovner: So that’s where we are. What is the takeaway here? Obviously, “don’t have an emergency in a country where you don’t have insurance” doesn’t feel very practical.
Tribble: Well, yeah, I mean, this was really interesting for me. I’ve been a health care reporter a long time. I’ve heard about travel insurance. The takeaway here for Jay is he would have been wise to get some travel insurance. Now, Jay did tell me previously he had tried to get Medicare. He is a U.S. citizen residing in Switzerland. He does qualify. He had worked in the U.S. long enough to qualify for it. He had gone through some phone calls and so forth and didn’t have it before coming here. He told me in the last couple of weeks that he now has gotten Medicare. However, that may not have helped him too much because it was an outpatient procedure. And it’s important to note that if you have Medicare and you’re 65 in the U.S., when you go overseas, it’s not likely to cover much. So the takeaway: Costs in the U.S. are more expensive than most places in the world, and you should be prepared if you’re traveling overseas and you find yourself in a situation, you might consider travel insurance anyway.
Rovner: So both ways.
Tribble: Yeah.
Rovner: Americans going somewhere else and people from somewhere else coming here.
Tribble: Well, if you’re a contract worker or a student on visa or somebody visiting the U.S., you’re definitely [going to] want to get some insurance because, wherever you’re coming from, most likely that insurance isn’t going to pay the full freight of what the costs are in the U.S.
Rovner: OK. Sarah Jane Tribble, thank you very much.
Tribble: Thanks so much.
Rovner: OK, we’re back, and it’s time for our extra credit segment. That’s where we each recommend a story we read this week that we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Lauren and Joanne, you’ve already given us yours, so Jessie, you’re next.
Hellmann: Yeah. My extra credit is from MLive.com, an outlet in Michigan. It’s titled “During the Darkest Days of COVID, Some Michigan Hospitals Made 100s of Millions.” They looked at tax records, audited financial statements in federal data, and found that some hospitals and health systems in Michigan actually did really well during the pandemic, with increases in operating profits and overall net assets. A big part of this was because of the covid relief funding that was coming in, but the article noted that, despite this, hospitals were still saying that they were stretched really thin, where they were having to lay off people. They didn’t have money for PPE [personal protective equipment], and they were having to institute, like, other cost-saving measures. So I thought this was a really interesting, like, a local look at how hospitals are kind of facing a backlash now. We’ve seen it in Congress a little bit, just more of an interest in looking at their finances and how they were impacted by the pandemic, because while some hospitals really did see losses, like small, rural, or independent hospitals, some of the bigger health systems came out on top. But you’re still hearing those arguments that they need more help, they need more funding.
Rovner: Well, my story is also about a hospital system. It’s yet another piece of reporting about nonprofit hospitals failing to live up to their requirement to provide, quote, “community benefits,” by our podcast panelist at The New York Times Sarah Kliff and Jessica Silver-Greenberg. It’s called “This Nonprofit Health System Cuts Off Patients With Medical Debt.” And it’s about a highly respected and highly profitable health system based in Minnesota called Allina and its policy of cutting off patients from all nonemergency services until they pay back their debts in full. Now, nonemergency services because federal law requires them to treat patients in emergencies. It’s not all patients. It’s just those who have run up debt of at least $1,500 on three separate occasions. But that is very easy to do in today’s health system. And the policy isn’t optional. Allina’s computerized appointment system will actually block the accounts of those who have debts that they need to pay off. It is quite a story, and yet another in this long list of stories about hospitals behaving badly. OK, that is our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us too. Special thanks, as always, to our ever-patient producer, Francis Ying. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can tweet me, at least for now. I’m still there. I’m @jrovner. Joanne?
Kenen: @JoanneKenen
Rovner: Jessie.
Hellmann: @jessiehellmann
Rovner: Lauren.
Weber: @LaurenWeberHP
Rovner: We will be back in your feed next week. Until then, be healthy.
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When an Anti-Vaccine Activist Runs for President
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Julie Rovner
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
How should journalists cover political candidates who make false claims about the safety and effectiveness of vaccines? That question will need to be answered now that noted anti-vaccine activist Robert F. Kennedy Jr. has officially entered the 2024 presidential race.
Meanwhile, South Carolina has become one of the last states in the South to pass an abortion ban, making the procedure all but impossible to obtain for women across a broad swath of the country.
This week’s panelists are Julie Rovner of KFF Health News, Alice Miranda Ollstein of Politico, Rachel Cohrs of Stat, and Sarah Karlin-Smith of the Pink Sheet.
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Rachel Cohrs
Stat News
Sarah Karlin-Smith
Pink Sheet
Alice Miranda Ollstein
Politico
Among the takeaways from this week’s episode:
- Republican lawmakers and President Joe Biden continue to bargain over a deal to avert a debt ceiling collapse. Unspent pandemic funding is on the negotiating table, as the White House pushes to protect money for vaccine development — though the administration has drawn criticism for a lack of transparency over what would be included in a clawback of unspent dollars.
- In abortion news, South Carolina is the latest state to vote to restrict access to abortion, passing legislation this week that would ban abortion after six weeks of pregnancy — shortly after pregnant people miss their first period. And Texas is seeing more legal challenges to the state law’s exceptions to protect a mother’s life, as cases increasingly show that many doctors are erring on the side of not providing care to avoid criminal and professional liability.
- Congress is scrutinizing the role of group purchasing organizations in drug pricing as more is revealed about how pharmacy benefit managers negotiate discounts. So-called GPOs offer health care organizations, like hospitals, the ability to work together to leverage market power and negotiate better deals from suppliers.
- Lawmakers are also exploring changes to the way Medicare pays for the same care performed in a doctor’s office versus a hospital setting. Currently, providers can charge more in a hospital setting, but some members of Congress want to end that discrepancy — and potentially save the government billions.
- And our panel of health journalists discusses an important question after a prominent anti-vaccine activist entered the presidential race last month: How do you responsibly cover a candidate who promotes conspiracy theories? The answer may be found in a “truth sandwich.”
Also this week, Rovner interviews KFF Health News senior correspondent Aneri Pattani about her project to track the money from the national opioid settlement.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: KFF Health News’ “Remote Work: An Underestimated Benefit for Family Caregivers,” by Joanne Kenen
Alice Miranda Ollstein: Reuters’ “How Doctors Buy Their Way out of Trouble,” by Michael Berens
Rachel Cohrs: ProPublica’s “In the ‘Wild West’ of Outpatient Vascular Care, Doctors Can Reap Huge Payments as Patients Risk Life and Limb,” by Annie Waldman
Sarah Karlin-Smith: The New York Times’ “Heat Wave and Blackout Would Send Half of Phoenix to E.R., Study Says,” by Michael Levenson
Also mentioned in this week’s episode:
- KFF Health News’ “Abortion Bans Are Driving Off Doctors and Closing Clinics, Putting Basic Health Care at Risk,” by Julie Rovner.
- Stat’s “House Panel Takes First Steps Toward Reining In Hospitals With ‘Site-Neutral’ Changes,” by Rachel Cohrs.
- Vice’s “ABC News and CNN Manage to Demonstrate Exactly What Not to Do With Robert F. Kennedy Jr.,” by Anna Merlan.
click to open the transcript
Transcript: When an Anti-Vaccine Activist Runs for President
KFF Health News’ ‘What the Health?’
Episode Title: When an Anti-Vaccine Activist Runs for President
Episode Number: 299
Published: May 25, 2023
[Editor’s note: This transcript, generated using transcription software, has been edited for style and clarity.]
Julie Rovner: Hello and welcome back to “What the Health?”. I’m Julie Rovner, chief Washington correspondent at KFF Health News. And I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, May 25, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So here we go. Today we are joined via video conference by Rachel Cohrs of Stat News.
Rachel Cohrs: Hi, everybody.
Rovner: Sarah Karlin-Smith of the Pink Sheet.
Sarah Karlin-Smith: Hi, Julie.
Rovner: And Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Hello.
Rovner: Later in this episode we’ll have my interview with KFF Health News’ Aneri Pattani about her project tracking where all of that opioid settlement money is going. But first, this week’s news. I suppose we have to start with the debt ceiling again, because how this all eventually plays out will likely impact everything else that happens in Washington for the rest of the year. First of all, as of this taping, at 10 o’clock on Thursday morning, there’s still no settlement here, right?
Ollstein: There is not. And depending who you listen to, we are either close or not close at all, on the brink of disaster or on the brink of being all saved from disaster. There’s a lot of competing narratives going around. But yes, as of this taping, no solution.
Rovner: I want to do a spreadsheet of how often the principals come out and say, “It was productive,” “It’s falling apart,” “It was productive,” “It’s falling apart.” I mean, it seems like literally every other time, particularly when Speaker [Kevin] McCarthy comes out, it was either “very productive” or “we’re nowhere near.” That seems to have been the gist for the past two weeks or so. Meanwhile, it seems like one thing Republicans and Democrats have at least tentatively agreed to do is claw back something like $30 billion in unspent covid funds. But, not so fast. The New York Times reports that the Biden administration wants to preserve $5 billion of that to fund the next generation of covid vaccines and treatment and another $1 billion to continue giving free covid vaccines to people without insurance. I feel like this is the perfect microcosm of why these talks are almost impossible to finish. They’re trying to negotiate a budget resolution, an omnibus spending bill, and a reconciliation bill all at the same time, with the sword of Damocles hanging over their head and a long holiday weekend in between. Somebody please tell me that I’m wrong about this.
Ollstein: Well, Congress never does anything unless there’s a sword of Damocles hanging over them and a vacation coming up that they really want to go on. I mean, do they ever make it happen otherwise? Not — not in our experience. But I do want to note that it is interesting that the Biden administration is trying to fight for some of that covid funding. Meanwhile, what they’re not reportedly fighting for is some of the other public health funding that’s at risk in that clawback, and I reported last week that some of Biden’s own health officials are warning that losing those tens of billions of dollars could undermine other public health efforts, including the fight against HIV and STDs [sexually transmitted diseases]. We have syphilis at record rates right now, and public health departments all around the country are counting on that money to preserve their workforces and do contact tracing, etc. And so that is another piece of this that isn’t getting as much attention.
Cohrs: There has been this ongoing fight between the White House and Republicans over covid money and how it’s being spent, for years at this point. And the White House has never really been fully transparent about exactly what was going to get clawed back. The Appropriations Committee was the one who actually put out some real information about this. And I think that trust has just been broken that the money is used where it’s supposed to be. I mean, even for the next-generation research project [Project NextGen] — I mean, they launched that like a couple of months ago, after Republicans had already threatened to take the money back. So I think there are some questions about the timing of the funding. [White House COVID-19 Response Coordinator] Ashish Jha said they didn’t know they had leftovers until recently, but I think this has just really turned into a mess for the White House, and I think the fact that they’re willing to offer some of this money up is just kind of a symbol and just a “ending with a whimper” of this whole fight that’s been going on for two years where they’ve been unsuccessful in extracting any more money.
Rovner: And yeah, I was just going to say, the White House keeps asking for more money and then they keep, quote-unquote, “finding money” to do things that are really important. Sarah, I wanted to ask you, how freaked out is the research establishment and the drug industry at whether, you know, will they or won’t they actually pony up money here?
Karlin-Smith: I think this could be pretty problematic because some of the type of companies that get this funding — some of them might be in a position to do this on their own, but others would essentially — you know, there isn’t necessarily a market for this without the government support, and that’s why they do it. That’s why the U.S. created this BARDA [Biomedical Advanced Research and Development Authority], which kind of funds this type of pandemic and other threats research. And so I think there are companies that definitely wouldn’t be able to continue without this money, because some of it is for things that we think we might need but don’t know if we definitely will. And so you don’t necessarily want to make the investment in the same way you know you need cancer drugs or something like that.
Rovner: We will see how this plays out. Perhaps it will be played out by next week or perhaps they will find some sort of short-term patch, which is another tried-and-true favorite for Congress. All right. Let’s turn to abortion. Last week, the North Carolina Legislature overrode the Democratic governor’s veto to pass a 12-week ban. This week was the South Carolina Legislature’s chance to say, “Hold my beer.” Alice, what happened in South Carolina, and what does it mean for availability of abortion in the whole rest of the South?
Ollstein: The governor is expected to sign this new restriction into law. Like many other GOP-led states. South Carolina was expected to quickly pass restrictions last year as soon as Roe v. Wade was overturned, but they got into fights within the Republican Party over how far to go, whether to have exceptions, what kind of exceptions, etc. It was the classic story we’ve seen play out over and over and over where, while Roe v. Wade was still in place, it was very easy for people to say, “I’m pro-life, I’m against abortion,” and not have to make those difficult, detailed decisions. So, yes, this could have a big impact, you know, especially with Florida moving for a much stricter ban. You know, the whole region is becoming more and more unavailable, and people are going to have to travel further and further.
Rovner: And South Carolina ended up with one of these six-week, quote-unquote, “heartbeat bills,” right?
Ollstein: That’s right.
Rovner: So it’s sort of shutting off yet another state where abortion is or really could be available. There’s more abortion-related court action, too. This week, in Texas, eight more women who experienced dangerous pregnancy complications joined a lawsuit seeking to force just a clarification of that state’s abortion ban that they say threatened their lives. One of them, Kiersten Hogan, had her water break prematurely, putting her at risk of infection and death, but says she was told by the hospital that if she tried to leave to seek care elsewhere, she could be arrested for trying to kill her baby. Four days later, the baby was born stillborn. Yet sponsors of the state’s abortion bill say it was never intended to bar, quote, “medically necessary abortions.” Why is there such a disconnect? And Texas is hardly the only place this is happening, right?
Ollstein: Yeah. Situations like this are why people are arguing that the whole debate over exceptions is sort of a fig leaf. It’s papering over how these work in practice. You can have exceptions on the book that say “life-threatening situations, medical emergencies,” etc. But because doctors are so afraid of being charged with a crime or losing their license or other professional repercussions, that’s just creating a huge chilling effect and making them afraid to provide care in these situations. A lot of times the state law also contradicts with federal law when it comes to medical emergencies, and so doctors feel caught in the middle and unsure what they’re supposed to do. And as we’re seeing, a lot of them are erring on the side of not providing care rather than providing care. So this is playing out in a lot of places. So I’m interested to see if this informs the debate in other states about whether to have these exceptions or not.
Rovner: And I get to promote my own story here, which is that we’re seeing in a lot of states either doctors leaving or doctors deciding not to train in states with abortion bans because they’re afraid of exactly those restrictions that could land them, you know, either in court or, even worse, in jail. We’ve long had abortion care deserts. Now we could see entire women’s health care deserts in a lot of these states, which would, you know, hurt not just the people who want to have abortions, but the people who want to get pregnant and have babies. We will continue to watch that space. Well, meanwhile, in West Virginia, another court case, filed by the maker of the generic version of the abortion pill mifepristone, could turn on a recent Supreme Court decision about pork products in California. Can somebody explain what one has to do with the other?
Karlin-Smith: There is basically a ruling that the Supreme Court issued the other week in a California case where the state was regulating how pigs were treated on farms in California. And the court basically allowed the law to stand, saying, you know, it didn’t interfere with interstate commerce. And the people who are protesting GenBioPro’s suit in West Virginia are basically saying that this, again, is an example where West Virginia’s regulation of the abortion drug, again, doesn’t really impact the distribution of the drug outside of the state or the availability of the drug outside of the state, and so this should be allowable. Of course, GenBioPro and the folks who are protesting how West Virginia is curtailing access to the suit are trying to argue the same ruling helps their cause. To me, what I read — and it seems like the comparison works better against the drug company, but it always is interesting to see this overlapping — you know, the cases you don’t expect. But I also, I think, when this ruling came out, saw somebody else making another argument that this should help GenBioPro. So it’s very hard to know.
Rovner: If it’s not confusing enough, I’m going to add another layer here: While we’re talking about the abortion pill, a group of House Democrats are reaching out to drug distribution company AmerisourceBergen, following reports that it would decline to deliver the pill to pharmacies in as many as 31 states, apparently fearing that they would be drawn into litigation between states and the federal government, the litigation we’ve talked about now a lot. So far, the company has only said that it will distribute the drug in states, quote, “where it is consistent with the law.” In the end, this could end up being more important than who wins these lawsuits, right? If — I think they’re the sole distributor — is not going to distribute it, then it’s not going to be available.
Ollstein: It also depends on the — at the 5th Circuit, and that will go back to the Supreme Court, because if it’s not an FDA-approved drug, then nobody can distribute it. That’s the ultimate controlling factor. But yes, since they are the sole distributor, they will have a lot of power over where this goes. And when I was reporting on Walgreens’ decision, they were pointing to this and saying that their decisions, you know, depend on other factors as well.
Karlin-Smith: And there’s a lot of nuance to this because my understanding is AmerisourceBergen, they’re particularly talking about distributing it to pharmacies where you could — under this new FDA permission to let pharmacies distribute the drug, which in the past they hadn’t.
Rovner: And which hasn’t happened yet.
Karlin-Smith: Right. They haven’t actually gone through the process of certifying the pharmacies. So it’s like a little bit premature, which is why I think Walgreens realized they probably jumped the gun on making any decision because it couldn’t happen yet anyway. But AmerisourceBergen is still saying, “Oh, we’re giving it to providers and other places that can distribute the drug in some of these states.” So it’s not necessarily like the drug is completely unavailable. It’s just about ease of access, I think, at this point.
Rovner: Yeah, we’re not just in “watch that space”; now we’ve progressed to “watch all those spaces,” which we will continue to do. Well, while we were on the discussion of drug middlepeople, there’s a story in Stat about the Federal Trade Commission widening its investigation of pharmacy benefit managers to include group purchasing organizations. Sarah, what are group purchasing organizations and how do they impact the price of prescription drugs?
Karlin-Smith: So group purchasing organizations are basically where you sort of pool your purchasing power to try and get better deals or discounts. So like, in this case, one of the GPOs FTC is looking at negotiates drug rebates on behalf of a number of different PBMs, not just one PBM. And so, again, you know, the idea is the more people you have, the more marketing you have, the better discount you should be able to get, which is — I think some people have been a little shocked by this because they’re like, “Wait, we thought the PBMs were the ones that did the negotiation. Why are they outsourcing this? Isn’t that the whole purpose of why they exist?” Yeah, so FTC has sort of a broader investigation into PBMs, so this is kind of the next step in it to kind of figure out, OK, what is the role of these companies? How are they potentially creating bad incentives, contributing to increased drug pricing, making it harder for people to perhaps, like, get their drug at particular pharmacies or more expensive at particular pharmacies? Again, because there’s been a lot of integration of ownership of these companies. So like the PBMs, the health insurance, some of these pharmacy systems are sort of all connected, and there’s a lot of concern that that’s led to incentives that are harming consumers and the prices we’re paying for our health care.
Rovner: Yeah, there’s all that money sloshing around that doesn’t seem to be getting either to the drug companies or to the consumers. Rachel, you wanted to add something?
Cohrs: Sure. I think GPOs are more used with hospitals when they buy drugs, because I think PBMs — you think of, like, going to pick up your drug at the pharmacy counter. But obviously hospitals are buying so many drugs, too. And their, you know, market power is pretty dispersed across the country. And so they also are a big customer of GPOs. So I think they’re also trying to get at this, like, different part of the drug market where, you know, a lot of these really expensive medications are administered in hospitals. So it will be interesting. They’re certainly not very transparent either. So, yeah, interesting development as to how they relate to PBMs, but also the rest of — you know, encompassing a larger part of the health care system.
Karlin-Smith: Yeah, I have seen complaints from hospital systems that the GPOs require them to enter into contracts that make it very difficult for the hospital to pivot if, say, the GPO can’t supply them with a particular product or maybe it’s … [unintelligible] … and then they end up stuck in a situation where they should, in theory, be able to get a product from another supplier and they can’t. So there’s lots of different levels of, again, concern about potential bad behavior.
Rovner: Well, while we are on the topic of nerdy practice-of-medicine stuff, Rachel, you had a story on the latest on the, quote, “site-neutral” Medicare payment policy. Remind us what that is and who’s on which side, and wasn’t that one of the bills — or I guess that wasn’t one of the bills that was approved by the House Energy and Commerce Committee yesterday, right?
Cohrs: No, so “site neutral” is basically hospitals’ worst nightmare. It essentially makes sure that Medicare is paying the same amount for a service that a doctor provides, whether it’s on a hospital campus or provided in a doctor’s office. And I think hospitals argue that they need to charge more because they have to be open 24/7. You know, they don’t have predictable hours. They have to serve anyone, you know, regardless of willingness to pay. It costs more overhead. That kind of thing. But I think lawmakers are kind of losing patience with that argument to some degree, that the government should be paying more for the same service at one location versus another. And it’s true that House Republicans had really wanted an aggressive form of this policy, and it could save like tens of billions of dollars. I mean, this is a really big offset we’re talking about here, if they go really aggressively toward this path, but instead they weren’t able to get Democrats on board with that plan yet. I think the chair, Cathy McMorris Rodgers, and the ranking member, Frank Pallone, have said they want to keep working on this. But what they did do this week is took a tiny little part out of that and advanced it through the committee. And it would equalize payment for, like, drug administration in physician’s offices versus a physician doing it in the hospital, and the savings to the federal government on that policy was roughly $3 billion. So, again, not a huge hit to industry, but it’s, you know, significant savings, certainly, and a first step in this direction as they think about how they want to do this, if they want to go bigger.
Rovner: So while we’re talking about the Energy and Commerce Committee, those members, in a fairly bipartisan fashion, are moving a bunch of other bills aimed at price transparency, value-based care, and a lot of other popular health buzzwords. Sarah, I know you watched, if not all, then most of yesterday’s markup. Anything in particular that we should be watching as it perhaps moves through the House and maybe the Senate?
Karlin-Smith: Yeah. So there was — probably the most contentious health bill that cleared yesterday was a provision that basically would codify a Trump-era rule in Medicaid that the Biden administration has sort of tweaked a bit but generally supported that basically tweaks Medicaid’s “best price” rule. So Medicaid is kind of guaranteed the best price that the private sector gets for drugs. But drugmakers have argued this prevents them from doing these unique value-based arrangements where we say, “OK, if the patient doesn’t perform well or the drug doesn’t work well for the patient, we’ll kind of give you maybe even all your money back.” Well, they don’t want the Medicaid best price to be zero. So they came up with a kind of a very confusing way to tweak that and also as part of that to, you know, hopefully allow Medicaid to maybe even take advantage of these programs. And Rep. [Brett] Guthrie [(R-Ky.)], Rep. [Anna] Eshoo [(D-Calif.)] on the Democratic side, want to codify that. But a number of the Democrats pushed back and over worries this might actually raise prices Medicaid pays for drugs and be a bit more problematic. And the argument from the Democrats, the majority of Democrats on the committee who oppose it, were not completely against this idea but let it play out in rulemaking, because if it stays in rulemaking, it’s a lot easier to —er, sorry — as a rule, it’s already made.
Rovner: To fix it if they need to.
Karlin-Smith: Right. It’s a lot easier to fix it, which, as anybody who follows health policy knows, it’s not actually as easy as you would think to fix a rule, but it’s definitely a lot easier to fix a rule than it is to fix something codified in law. So that’s sort of a very wonky but meaningful thing, I think, to how much drugs cost in Medicaid.
Rovner: Last nerdy thing, I promise, for this week: The Biden administration says it plans to conduct an annual audit of the cost of the most expensive drugs covered by Medicaid and make those prices public in what one of your colleagues, Alice, described as a “name and shame” operation? I mean, could this actually work, or could it end up like other HHS [Department of Health and Human Services] transparency rules, either not very followed or tied up in court?
Karlin-Smith: Experts that my colleague Cathy Kelly talked to to write about this basically were not particularly optimistic it would lead to big changes in savings to Medicaid, basically. One of the reasons is because Medicaid actually gets pretty good deals on drugs to begin with. But that said, even, again, like I said, they’re guaranteed these really large rebates are the best price. But in exchange for that, they have to cover all drugs. So that’s where you start to lose some of your leverage. So the hope with some of this extra transparency is they’ll get more information to have, like, a little bit of additional leverage to say, “Oh, well your manufacturing costs are only this, so you should be able to give us an additional rebate,” which they can negotiate that. Again, I think people think there’ll be sort of maybe some moderate, if any, benefits to that. But some states have actually tried similar things in kind of similar “name, shame” affordability boards. And the drugmakers have basically just said, “No, we’re not going to give you any more discounts.” And they’re kind of stuck.
Rovner: “And we’re not ashamed of the price that we’re charging.”
Karlin-Smith: Right.
Rovner: “Or we wouldn’t be charging it.”
Karlin-Smith: So it’s a tough one, but there’s, like, an argument to be made that drugmakers just don’t want to be on this list. So maybe some of them will more proactively figure out like how to get their price point and everything discounts to a point where they at least won’t get on the list. So maybe, again, it might tweak things around the edges, but it’s not a big price savings move.
Rovner: And we shall see. All right. Well, this is — finally this week, it’s something I’ve wanted to talk about for a couple of weeks. I’m calling it the “How do you solve a problem like RFK Jr.?” For those of you who don’t already know, the son of the former senator and liberal icon Robert Kennedy has declared his candidacy for president. He’s an environmental lawyer, but at the same time, he’s one of the most noted anti-vaxxers, not just in the country but in the world. Vice has a provocative story — this actually goes back a couple of weeks — about how the media should cover this candidacy or, more specifically, how it shouldn’t. According to the story, ABC did an interview with RFK Jr. and then simply cut out what they deemed the false vaccine claims that he made. CNN, on the other hand, did an interview and simply didn’t mention his anti-vaccine activism. I am honestly torn here about how should you cover someone running for president who traffics in conspiracy theories that you know are not true? I realize here I am now speaking of a wider — wider universe than just RFK Jr. But as a journalist, I mean, how do you handle things that — when they get repeated and you know them to be untrue, at least in the health care realm?
Karlin-Smith: I mean, I really like the thing that Vice mentioned, and I think maybe Jay Rosen, who’s a journalism professor at NYU [New York University], he might be the person that sort of coined this, I’m not sure — this, like, “truth sandwich” idea, where you make sure you sort of start with what is true, in the middle you put the sort of — this is what the false claim of X person — and then you go back to the truth. Because I think that really helps people grasp onto what’s true, versus a lot of times you see the coverage starts with the lie or the falsehood. And I think sometimes people might even just see that headline or just see the little bit of what’s correct and never make it to the truth. And I understand some of the decisions by the news outlets that decided not to air these segments and just didn’t want to deal with the topic. But then I guess I thought they did make a good point that then you let somebody like Kennedy say, “Oh, they’re suppressing me, they’re deliberately hiding this information.” So the Vice argument was that this truth sandwich idea kind of gets you in a better … [unintelligible]. And again, as journalists, our job is not to suppress what politicians are saying. People should know what these people claim, because that is what the positions they stand for. But it’s figuring out how to add the context and be able to, you know, in real time if you need to, fact-check it.
Rovner: I confess, over the years I have been guilty of the CNN thing of just not bringing it up and hoping it doesn’t come up. But then, I mean, it’s true, the worst-case scenario — probably not going to happen with somebody running for president — but I think we’ve discovered all these people running for lower offices, that they get elected, you don’t talk about the controversial things and then you discover that you have a legislator in office who literally believes that the Earth is flat. There are — can Google that. So if these things aren’t aired, then there’s no way for voters to know. Anybody else have a personal or organizational rule for how to handle this sort of stuff?
Ollstein: I think there can be smart decisions about when to let someone say in their own voice what they believe versus saying as the news organization, “In the speech, he spent X minutes advancing the discredited assertion of blah, blah, blah, blah, blah,” and not just handing over the platform for them to share the misinformation.
Rovner: Yeah, I just want the audience to know that we do think seriously about this stuff. We are not just as sort of blithe as some may believe. All right. Well, that is this week’s news. Now, we will play my interview with Aneri Pattani, and then we will come back with our extra credits. I am pleased to welcome back to the podcast my colleague Aneri Pattani, who is here to talk about her investigation into where those billions of dollars states are getting in pharmaceutical industry settlements for the opioid crisis are actually going. Aneri, I am so glad to have you back.
Aneri Pattani: Thanks so much for having me.
Rovner: So let’s start at the beginning. How much money are we talking about? Where’s it coming from, and where is it supposed to be going?
Pattani: So the money comes from companies that made, distributed, or sold opioid painkillers. So these are places like Purdue Pharma, AmerisourceBergen, Walgreens, and a bunch of others. They were all accused of aggressively marketing the pills and falsely claiming that they weren’t addictive. So thousands of states and cities sued those companies. And rather than go through with all the lawsuits, most of the companies settled. And as a result, they’ve agreed to pay out more than $50 billion over the next 15 or so years. And the money is meant to be used on opioid remediation, which is a term that means basically anything that addresses or fixes the current addiction crisis and helps to prevent future ones.
Rovner: So the fact is that many or most states — we don’t actually know where this money is going or will go in the future because that information isn’t being made public. How is that even legal, or, I guess it’s not public funds, but it’s funds that are being obtained by public entities, i.e., the attorneys general.
Pattani: Yeah, a lot of people feel this way. But the thing is, the national settlement agreements have very few requirements for states to publicly report how they use the money. In fact, the only thing that’s in there that they’re required to report is when they use money for non-opioid purposes. And that can be at most 15% of the total funds they’re getting. And that reporting, too, is on an honor system. So if a state doesn’t report anything, then the settlement administrators are supposed to assume that the state used all of its money on things related to the opioid crisis. Now, states and localities can enact stricter requirements. For example, North Carolina and Colorado are two places that have created these public dashboards that are supposed to show where the money goes, how much each county gets, how the county spends it. But honestly, the vast majority of states are not taking steps like that.
Rovner: So for people of a certain age, this all feels kind of familiar. In the late 1990s, a group of state attorneys general banded together and sued the tobacco companies for the harm their products had done to the public. They eventually reached a settlement that sent more than $200 billion to states over 25 years, so that money is only just now running out. But it didn’t all get used for tobacco cessation or even public health, did it?
Pattani: No. In fact, most of it didn’t get used for that. The Campaign for Tobacco-Free Kids, which has been tracking that tobacco settlement money for years, found that about only 3% of the money goes to anti-smoking programs a year. The rest of it has gone towards plugging state budget gaps, infrastructure projects like paving roads, or, in the case of North Carolina and South Carolina, the money even went to subsidizing tobacco farmers.
Rovner: Great. Given the lessons of the tobacco settlement, how do the attorneys general in this case try to make sure that wasn’t going to happen? I mean, was it just by requiring that that non-opioid-related money be made public?
Pattani: So they have added some specific language to the settlements that they point to as trying to avoid, you know, the, quote, “tobacco nightmare.” Essentially, the opioid settlements say that at least 85% of the money must be spent on opioid remediation. Again, that term — that’s like things that stop and prevent addiction. And there’s also a list included at the end of the settlement, called Exhibit E, with potential expenses that fall under opioid remediation. That’s things like paying for addiction treatment for people who don’t have insurance or building recovery housing or funding prevention programs in schools. But the thing is, that list is pretty broad and it’s nonexhaustive, so governments can choose to do things that aren’t on that list, too. So there are guidelines, but there’s not a lot of hard enforcement to make sure that the money is spent on these uses.
Rovner: So, as you’ve pointed out in your reporting, it’s not always simple to determine what is an appropriate or an inappropriate use of these settlement funds, particularly in places that have been so hard-hit by the opioid crisis and that it affects the entire economy of that state or county or city. So tell us what you found in Greene County, Tennessee. That was a good example, right?
Pattani: Yeah, Greene County is an interesting place. And what I learned is happening there is actually, you know, repeating in a lot of places across the country. So Greene County, it’s an Appalachian county, it’s been hard-hit. It has a higher rate of overdose deaths than the state of Tennessee overall or even the country. But when the county got several million dollars in opioid settlement funds, it first put that money towards paying off the county’s debt. And that included putting some money into their capital projects fund, which was then used to buy a pickup truck for the sheriff’s office. So a lot of folks are looking at that, saying, “That’s not really opioid-related.” But county officials said to me, you know, this use of the money makes sense, because the opioid epidemic has hurt their economy for decades; it’s taken people out of the workforce, it’s led to increased costs for their sheriff’s office and their jail with people committing addiction-related crimes, it’s hurt the tax base when people move out of the county. So now they need that money to pay themselves back. Of course, on the other hand, you have advocates and people affected by the crisis saying, “If we’re using all the money now to pay back old debts, then who’s addressing the current crisis? People are still dying of overdoses, and we need to be putting the opioid settlement money towards the current problem.”
Rovner: So I suppose ideally they could be doing both.
Pattani: I think that’s the hard thing. Although $54 billion sounds like a lot of money, it’s coming over a long period of time. And so at the end of the day, it’s not enough to fund every single thing people want, and there is a need for prioritization.
Rovner: So I know part of your project is helping urge local reporters to look into where money is being used in their communities. How is that going?
Pattani: It’s going well. I think it’s important because the money is not only going to state governments, but to counties and cities too. So local reporters can play a really big role in tracking that money and holding local officials accountable for how they use it. So I’m trying to help by sharing some of the national data sets we’re pulling together that can be used by local reporters. And I’ve also hopped on the phone with local reporters to talk about where they can go to talk to folks about this or finding story ideas. Some of the reporters I’ve spoken with have already published stories. There was one just a week ago in the Worcester Telegram from a student journalist, actually, in that area —
Rovner: Cool.
Pattani: — so there’s a lot of good coverage coming.
Rovner: I’m curious: What got you interested in pursuing this topic? I know you cover addiction, but this is the kind of reporting that can get really frustrating.
Pattani: It definitely can. But I think it’s what you said: As someone who’s been covering addiction and mental health issues for a while, kind of focusing on some of the problems and the systemic gaps, when I learned that this money was coming in, it was exciting to me too, like, maybe this money will be used to address the issues that I’m often reporting on, and so I want to follow that and I want to see if it delivers on that promise.
Rovner: So what else is coming up in this project? I assume it’s going to continue for a while.
Pattani: Yes. So this will be a yearlong project, maybe even more, because, as I said, the funds are coming for a long time. But essentially the next few things I’m looking at, I have a big data project looking at who sits on opioid settlement councils. These are groups that advise or direct the money in different states and, you know, may represent different interests. And then we’re going to be looking at some common themes in the ways different states are using this money. So a lot of them are putting it towards law enforcement agencies, a lot of them are putting them toward in-school prevention programs, and taking a look at what the research tells us about how effective these strategies are or aren’t.
Rovner: Well, Aneri Pattani, thank you so much, and we will post links to some of Aneri’s work on the podcast homepage at kffhealthnews.org and in this week’s show notes. Thanks again.
Pattani: Thank you so much.
Rovner: OK, we’re back and it’s time for our extra credit segment. That’s when we each recommend a story we read this week we think you should read too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Sarah, why don’t you go first this week?
Karlin-Smith: Sure. I looked at a piece in The New York Times called “Heat Wave and Blackout Would Send Half of Phoenix to E.R., Study Says,” by Michael Levenson. And it’s just really sort of a horrifying piece where researchers were sort of able to model the impact of the growing frequency of heat waves due to climate change, and obviously, the U.S. had some electric grid stability issues, and just the disconnect between the amount of hospital beds and people that would be able to care for people in a very hot city due to, you know, heat waves without being able to access air conditioning and other cooling methods. And the amount of people that would be hospitalized or die or just wouldn’t have a hospital bed. The one thing I did think was sort of positive is the piece does have some suggestions, and some of them are fairly simple that could really change the degrees in cities in relevant ways, like planting more trees in particular areas, and often this affects sort of — the poorest areas of cities tend to be the ones with less trees — or, you know, changing colors or the material on roofing. So as much as sometimes I think climate change becomes sort of such an overwhelming topic where you feel like you can’t solve it, I think the one nice thing here is it does sort of show, like, we have power to make the situation better.
Rovner: We can perhaps adapt. Alice.
Ollstein: I picked a upsetting piece but really good investigation from Reuters by Michael Berens. It’s called “How Doctors Buy Their Way out of Trouble.” It’s about doctors who are charged federally with all kinds of wrongdoing, including operating on patients who don’t need to be operated on for profit and having a pattern of doing so. And it’s about how often these cases settle with federal prosecutors and the settlement allows them to keep practicing, and the settlement money goes to the government, not to the victims. And often the victims aren’t even aware that the settlement took place at all. And new patients are not aware that the doctor they may be going to has been charged. And so it’s a really messed up system and I hope this shines a light on it.
Rovner: Rachel.
Cohrs: All right. So mine is from ProPublica, and the headline is, “In the ‘Wild West’ of Outpatient Vascular Care, Doctors Can Reap Huge Payments as Patients Risk Life and Limb,” by Annie Waldman. And I think I found this story timed really well kind of as lawmakers do start to talk a little bit more about incentives for patients to be seen in a hospital versus in more physician offices. And certainly there are cost reasons that that makes sense for some procedures. But I think this story does a really good job of kind of following one doctor, who I think, similar to kind of the story Alice was talking about, you know, was taking advantage of these inflated payments that were supposed to incentivize outpatient treatment to perform way more of these procedures than patients needed. And so I think it’s just important, a cautionary tale about the safeguards that could be necessary, you know, if more of this care is provided elsewhere.
Rovner: Yeah, I think these two stories are very good to be read together. My story this week is from our fellow podcast panelist Joanne Kenen for KFF Health News. It’s called “Remote Work: An Underestimated Benefit for Family Caregivers,” and it’s about how the U.S., still one of the few countries without any formal program for long-term care, that most of us will need at some point, has accidentally fallen into a way to make family caregiving just a little bit easier by letting caregivers do their regular jobs from home, either all the time or sometimes. While many, if not most, employers have policies around childbirth and child care, relatively few have benefits that make it easier for workers to care for other sick family members, even though a fifth of all U.S. workers are family caregivers. More flexible schedules can at least make that a little easier and possibly prevent workers from quitting so that they can provide care that’s needed. It’s no substitute for an actual national policy on long-term care, but it’s a start, even if an accidental one. OK, that is our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks, as always, to our ever-patient producer, Francis Ying. And next week is our 300th episode. If all goes as planned, we’ll have something special, so be sure to tune in. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can tweet me. I’m still there. I’m @jrovner. Sarah?
Karlin-Smith: I’m @SarahKarlin.
Rovner: Alice.
Ollstein: @AliceOllstein.
Rovner: Rachel.
Cohrs: @rachelcohrs.
Rovner: We will be back in your feed next week. Until then, be healthy.
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