The Host

Julie Rovner
KFF Health News

@jrovner

Read Julie's stories.

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.

Two months into the new administration, federal workers and contractors remain off-balance as the Trump administration ramps up its efforts to cancel jobs and programs — even as federal judges declare many of those efforts illegal and/or unconstitutional.

As it eliminates programs deemed duplicative or unnecessary, however, President Donald Trump’s Department of Government Efficiency is also cutting programs and workers aligned with Health and Human Services Secretary Robert F. Kennedy Jr.’s “Make America Healthy Again” agenda.

This week’s panelists are Julie Rovner of KFF Health News, Jessie Hellmann of CQ Roll Call, Sarah Karlin-Smith of the Pink Sheet, and Rachel Roubein of The Washington Post.

Panelists

Jessie Hellmann
CQ Roll Call

@jessiehellmann

Read Jessie's stories.

Sarah Karlin-Smith
Pink Sheet

@SarahKarlin

Read Sarah's stories.

Rachel Roubein
The Washington Post

@rachel_roubein

Read Rachel's stories.

Among the takeaways from this week’s episode:

• Kennedy’s comments this week about allowing bird flu to spread unchecked through farms provided another example of the new secretary of health and human services making claims that lack scientific support and could instead undermine public health.
• The Trump administration is experiencing more pushback from the federal courts over its efforts to reduce and dismantle federal agencies, and federal workers who have been rehired under court orders report returning to uncertainty and instability within government agencies.
• The second Trump administration is signaling it plans to dismantle HIV prevention programs in the United States, including efforts that the first Trump administration started. A Texas midwife is accused of performing illegal abortions. And a Trump appointee resigns after being targeted by a Republican senator.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: The Washington Post’s “The Free-Living Bureaucrat,” by Michael Lewis.

Rachel Roubein: The Washington Post’s “Her Research Grant Mentioned ‘Hesitancy.’ Now Her Funding Is Gone.” by Carolyn Y. Johnson.

Sarah Karlin-Smith: KFF Health News’ “Scientists Say NIH Officials Told Them To Scrub mRNA References on Grants,” by Arthur Allen.

Jessie Hellmann: Stat’s “NIH Cancels Funding for a Landmark Diabetes Study at a Time of Focus on Chronic Disease,” by Elaine Chen.

Also mentioned in this week’s podcast:

• The Wall Street Journal’s “Trump Administration Weighing Major Cuts to Funding for Domestic HIV Prevention,” by Liz Essley White, Dominique Mosbergen, and Jonathan D. Rockoff.
• The Washington Post’s “Disabled Americans Fear Losing Protections if States’ Lawsuit Succeeds,” by Amanda Morris.

click to open the transcript

Transcript: Federal Health Work in Flux

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It 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, March 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. 

Today we are joined via videoconference by Rachel Roubein of The Washington Post. 

Rachel Roubein: Hi. 

Rovner: Sarah Karlin-Smith of the Pink Sheet. 

Sarah Karlin-Smith: Hi, everybody. 

Rovner: And Jessie Hellmann of CQ Roll Call. 

Jessie Hellmann: Hello. 

Rovner: No interview today, but, as usual, way more news than we can get to, so let us jump right in. In case you missed it, there’s a bonus podcast episode in your feed. After last week’s Senate Finance Committee confirmation hearing for Dr. Mehmet Oz to head the Centers for Medicare & Medicaid Services, my KFF Health News colleagues Stephanie Armour and Rachana Pradhan and I summarized the hearing and caught up on all the HHS [Department of Health and Human Services] nomination actions. It will be the episode in your feed right before this one. 

So even without Senate-confirmed heads at — checks notes — all of the major agencies at HHS, the department does continue to make news. First, Robert F. Kennedy Jr., the new HHS secretary, speaks. Last week it was measles. This week it was bird flu, which he says should be allowed to spread unchecked in chicken flocks to see which birds are resistant or immune. This feels kind of like what some people recommended during covid. Sarah, is there any science to suggest this might be a good idea? 

Karlin-Smith: No, it seems like the science actually suggests the opposite, because doctors and veterinary specialists are saying basically every time you let the infection continue to infect birds, you’re giving the virus more and more chances to mutate, which can lead to more problems down the road. The other thing is they were talking about the way we raise animals, and for food these days, there isn’t going to be a lot of genetic variation for the chickens, so it’s not like you’re going to be able to find a huge subset of them that are going to survive bird flu. 

And then the other thing I thought is really interesting is just it doesn’t seem economically to make the most sense either as well, both for the individual farmers but then for U.S. industry as a whole, because it seems like other countries will be particularly unhappy with us and even maybe put prohibitions on trading with us or those products due to the spread of bird flu. 

Rovner: Yeah, it was eyebrow-raising, let us say. Well, HHS this week also announced its first big policy effort, called Operation Stork Speed. It will press infant formula makers for more complete lists of ingredients, increase testing for heavy metals in formula, make it easier to import formula from other countries, and order more research into the health outcomes of feeding infant formula. This feels like maybe one of those things that’s not totally controversial, except for the part that the FDA [Food and Drug Administration] workers who have been monitoring the infant formula shortage were part of the big DOGE [Department of Government Efficiency] layoffs. 

Roubein: I talked to some experts about this idea, and, like you said, they thought it kind of sounded good, but they basically needed more details. Like, what does it mean? Who’s going to review these ingredients? To your point, some people did say that the agency would need to staff up, and there was a neonatologist who is heading up infant formula that was hired after the 2022 shortage who was part of the probationary worker terminations. However, when the FDA rescinded the terminations of some workers, so, that doctor has been hired back. So I think that’s worth noting. 

Rovner: Yes. This is also, I guess, where we get to note that Calley Means, one of RFK Jr.’s, I guess, brain trusts in the MAHA movement, has been hired as, I guess, in an Elon Musk-like position in the White House as an adviser. But this is certainly an area where he would expect to weigh in. 

Hellmann: Yeah, I saw he’s really excited about this on Twitter, or X. There’s just been concerns in the MAHA movement, “Make America Healthy Again,” about the ingredients that are in baby formula. And the only thing is I saw that he also retweeted somebody who said that “breast is best,” and I’m just hoping that we’re not going back down that road again, because I feel like public health did a lot of work in pushing the message that formula and breast milk is good for the child, and so that’s just another angle that I’ve been thinking about on this. 

Rovner: Yes, I think this is one of those things that everybody agrees we should look at and has the potential to get really controversial at some point. While we are on the subject of the federal workforce and layoffs, federal judges and DOGE continue to play cat-and-mouse, with lots of real people’s lives and careers at stake. Various judges have ordered the reinstatement, as you mentioned, Rachel, of probationary and other workers. Although in many cases workers have been reinstated to an administrative leave status, meaning they get put back on the payroll and they get their benefits back, but they still can’t do their jobs. At least one judge has said that does not satisfy his order, and this is all changing so fast it’s basically impossible to keep up. But is it fair to say that it’s not a very stable time to be a federal worker? 

Karlin-Smith: That’s probably the nicest possible way to put it. When you talk to federal workers, everybody seems stressed and just unsure of their status. And if they do have a job, it’s often from their perspective tougher to do their job lately, and then they’re just not sure how stable it is. And many people are considering what options they have outside the federal government at this point. 

Rovner: So for those lucky federal workers who do still have jobs, the Trump administration has also ordered everyone back to offices, even if those offices aren’t equipped to accommodate them. FDA headquarters here in Maryland’s kind of been the poster child for this this week. 

Karlin-Smith: Yeah, FDA is an interesting one because well before covid normalized working from home and transitioned a lot of people to working from home, FDA’s headquarters couldn’t accommodate a lot of the new growth in the agency over the years, like the tobacco part of the FDA. So it was typical that people at least worked part of their workweek at home, and FDA really found once covid gave them additional work-from-home flexibilities, they were able to recruit staff they really, really needed with specialized degrees and training who don’t live near here, and it actually turned out to be quite a benefit from them. 

And now they’re saying everybody needs to be in an office five days a week, and you have people basically cramped into conference rooms. There’s not enough parking. People are trying to review technical scientific data, and you kind of can’t hear yourself think. Or you’re a lawyer — I heard of a situation where people are basically being told, Well, if you need to do a private phone call because of the confidentiality around what you’re doing, go take the call in your car. So I think in addition to all of the concerns people have around the stability of their jobs, there’s now this element of, on a personal level, I think for many of them it’s just made their lives more challenging. And then they just feel like they’re not actually able to do, have the same level of efficiency at their work as they normally would. 

Rovner: And for those who don’t know, the FDA campus is on a former military installation in the Maryland suburbs. It’s not really near any public transportation. So you pretty much have to drive to get there. And I think that the parking lots are not that big, because, as you pointed out, Sarah, the workforce is now bigger than the headquarters was created to accommodate it. And we’re seeing this across the government. This week it happened to be FDA. You have to ask the question: Is this really just an effort to make the government not work, to make federal workers, if they can’t fire them, to make them quit? 

Hellmann: I definitely think that’s part of the underlying goal. If you see some of the stuff that Elon Musk says about the federal workforce, it’s very dismissive. He doesn’t seem to have a lot of respect for the civil servants. And they’ve been running into a lot of pushback from federal judges over many lawsuits targeting these terminations. And so I think just making conditions as frustrating as possible for some of these workers until they quit is definitely part of the strategy. 

Roubein: And I think this is overlaid with the additional buyout offers, the additional early retirement offers. There’s also the reduction-in-force plans that federal workers have been unnerved about, bracing for future layoffs. So it’s very clear that they want to shrink the size of the federal workforce. 

Rovner: Yeah, we’ve seen a lot of these people, I’ve seen interviews with them, who are being reinstated, but they’re still worried that now they’re going to be RIF-ed. They’re back on the payroll, they’re off the payroll. I mean there’s nothing — this does not feel like a very efficient way to run the federal government. 

Karlin-Smith: Right. I think that’s what a lot of people are talking about is, again, going back to offices, for many of these people, is not leading to productivity. I talked to one person who said: I’m just leaving my laptop at the office now. I’m not going to take it home and do the extra hours of work that they might’ve normally gotten from me. And that includes losing time to commute. FDA is paying for parking-garage spaces in downtown Silver Spring [Maryland] near the Metro so that they can then shuttle people to the FDA headquarters. I’ve taken buses from that Metro to FDA headquarters. In traffic, that’s a 30-minute drive. They’re spending money on things that, again, I think are not going to in the long run create any government efficiency. 

And in fact, I’ve been talking to people who are worried it’s going to do the opposite, that drug review, device review, medical product review times and things like that are going to slow. We talked about food safety. I think The New York Times had a really good story this week about concerns about losing the people. We need to make sure that baby formula is actually safe. So there’s a lot of contradictions in the messaging of what they’re trying to accomplish and how the actions actually are playing out. 

Rovner: Well, and finally, I’m going to lay one more layer on this. There’s the question of whether you can even put the toothpaste back in the tube if you wanted to. After weeks of back-and-forth, the federal judge ruled on Tuesday that the dissolution of USAID [the U.S. Agency for International Development] was illegal and probably unconstitutional, and ordered email and computer access restored for the remaining workers while blocking further cuts. But with nearly everybody fired, called back from overseas, and contracts canceled, USAID couldn’t possibly come close to doing what it did before DOGE basically took it apart, right?. 

Karlin-Smith: You hear stories of if someone already takes a new job, they’re lucky enough to find a new job, why are they going to come back? Again, even if you’re brought back, my expectation is a lot of people who have been brought back are probably looking for new jobs regardless because you don’t have that stability. And I think the USAID thing is interesting, too, because again, you have people that were working in all corners of the world and you have partnerships with other countries and contractors that have to be able to trust you moving forward. And the question is, do those countries and those organizations want to continue working with the U.S. if they can’t have that sort of trust? And as people said, the U.S. government was known as, they could pay contractors less because they always paid you. And when you take that away, that creates a lot of problems for negotiating deals to work with them moving forward. 

Rovner: And I think that’s true for federal workers, too. There’s always been the idea that you probably could earn more in the private sector than you can working for the federal government, but it’s always been a pretty stable job. And I think right now it’s anything but, so comes the question of: Are we deterring people from wanting to work for the federal government? Eventually one would assume there’s still going to be a federal government to work for, and there may not be anybody who wants to do it. 

Roubein: Yeah, you saw various hiring authorities given to try and recruit scientists and other researchers who make a lot, lot more in the public health sector, and some of those were a part of the probationary workforce because they had been hired recently under those authorities. 

Rovner: Yeah, and now this is all sort of coming apart. Well, meanwhile, the cuts are continuing even faster than federal judges can rule against them. Last week, the administration said it would reduce the number of HHS regional offices from 10 to four. Considering these are where the department’s major fraud-fighting efforts take place, that doesn’t seem a very effective way of going after fraud and abuse in programs like Medicare and Medicaid. Those regional offices are also where lots of beneficiary protections come from, like inspections of nursing homes and Head Start facilities. How does this serve RFK Jr.’s Make America Healthy Again agenda? 

Karlin-Smith: I think it’s not clear that it does, right? You’re talking about, again, the Department of Government Efficiency has focused on efficiency, cost savings, and Medicare and Medicaid does a pretty good job of fighting fraud and making HHS OIG [Office of Inspector General], all those organizations, they collect a lot of money back. So when you lose people— 

Rovner: And of course the inspector general has also been laid off in all of this. 

Karlin-Smith: Right. It’s not clear to me, I think one of the things with that whole reorganization of their chief counsel is people are suggesting, again, this is sort of a power move of HHS wanting to get a little bit more control of the legal operations at the lower agencies, whether it’s NIH [the National Institutes of Health] or FDA and so forth. But, right, it’s reducing head count without really thinking about what people’s roles actually were and what you lose when you let them go. 

Rovner: Well, the Trump administration is also continuing to cut grants and contracts that seem like they’d be the kind of things that directly relate to Make America Healthy Again. Jessie, you’ve chosen one of those as your extra credit this week. Tell us about it. 

Hellmann: Yeah. So my story is from Stat [“NIH Cancels Funding for a Landmark Diabetes Study at a Time of Focus on Chronic Disease”], and it’s about a nationwide study that tracks patients with prediabetes and diabetes. And it was housed at Columbia University, which as we know has been the subject of some criticism from the Trump administration. They had lost about $400 million in grants because the administration didn’t like Columbia’s response to some of the protests that were on campus last year. But that has an effect on some research that really doesn’t have much to do with that, including a study that looked at diabetes over a really long period of time. 

So it was able to over decades result in 200 publications about prediabetes and diabetes, and led to some of the knowledge that we have now about the interventions for that. And the latest stage was going to focus on dementia and cognitive impairment, since some of the people that they’ve been following for years are now in their older ages. And now they have to put a stop to that. They don’t even have funding to analyze blood samples that they’ve done and the brain scans that they’ve collected. So it’s just another example of how what’s being done at the administration level is contradicting some of the goals that they say that they have. 

Rovner: Yeah, and it’s important to remember that Columbia’s funding is being cut not because they deemed this particular project to be not helpful but because they are, as you said, angry at Columbia for not cracking down more on pro-Palestinian protesters after Oct. 7. 

Well, meanwhile, people are bracing for still more cuts. The Wall Street Journal is reporting the administration plans to cut domestic AIDS-HIV programming on top of the cuts to the international PEPFAR [President’s Emergency Plan for AIDS Relief] program that was hammered as part of the USAID cancellation. Is fighting AIDS and HIV just way too George W. Bush for this administration? 

Hellmann: It’s interesting because President [Donald] Trump unveiled the Ending the HIV Epidemic initiative in his first term, and the goal was to end the epidemic in the United States. And so if they were talking about reducing some of that funding, or I know there were reports that maybe they would move the funding from CDC [the Centers for Disease Control and Prevention] to HRSA [the Health Resources and Services Administration], it’s very unclear at this point. Then it raises questions about whether it would undermine that effort. And there’s already actions that the Trump administration has done to undermine the initiative, like the attacks on trans people. They’ve canceled grants to researchers studying HIV. They have done a whole host of things. They canceled funding to HIV services organizations because they have “trans” in their programming or on their websites. So it’s already caused a lot of anxiety in this community. And yeah, it’s just a total turnaround from the first administration. 

Rovner: I know the Whitman-Walker clinic here in Washington, which has long been one of the premier AIDS-HIV clinics, had just huge layoffs. This is already happening, and as you point out, this was something that President Trump in his first term vowed to end AIDS-HIV in the U.S. So this is not one would think how one would go about that. 

Well, it’s not just the administration that’s working to constrict rights and services. A group of 17 states, led by Texas, of course, are suing to have Biden-era regulations concerning discrimination against trans people struck down, except as part of that suit, the states are asking that the entirety of Section 504 of the Rehabilitation Act be declared unconstitutional. Now, you may never have heard of Section 504, but it is a very big deal. It was the forerunner of the Americans With Disabilities Act, and it prevents discrimination on the basis of disability in all federally funded activities. It is literally a lifeline for millions of disabled people that enables them to live in the community rather than in institutions. Are we looking at an actual attempt to roll back basically all civil rights as part of this war on “woke” and DEI [diversity, equity, and inclusion] and trans people? 

Hellmann: The story is interesting, because it seems like some of the attorneys general are saying, That’s not our intent. But if you look at the court filings, it definitely seems like it is. And yeah, like you said, this is something that would just have a tremendous impact. And Medicaid coverage of home- and community-based services is one of those things that states are constantly struggling to pay for. You’re just continuing to see more and more people need these services. Some states have waiting lists, so— 

Rovner: I think most states have waiting lists. 

Hellmann: Yeah. It’s something, you have to really question what the intent is here. Even if people are saying, This isn’t our intent, it’s pretty black-and-white on paper in the court records, so— 

Rovner: Yeah, just to be clear, this was a Biden administration regulation, updating the rules for Section 504, that included reference to trans people. But in the process of trying to get that struck down, the court filings do, as you say, call for the entirety of Section 504 to be declared unconstitutional. This is obviously one of those court cases that’s still before the district court, so it’s a long way to go. But the entire disability community, certainly it has their attention. 

Well, we haven’t had any big abortion news the past couple of weeks, but that is changing. In Texas, a midwife and her associate have become the first people arrested under the state’s 2022 abortion ban. The details of the case are still pretty fuzzy, but if convicted, the midwife who reportedly worked as an OB-GYN doctor in her native Peru and served a mostly Spanish-speaking clientele, could be sentenced to up to 20 years in prison. So, obviously, be watching that one. Meanwhile, here in Washington, Hilary Perkins, a career lawyer chosen by FDA commissioner nominee Marty Makary to serve as the agency’s general counsel, resigned less than two days into her new position after complaints from Missouri Sen. Josh Hawley that she defended the Biden administration’s position on the abortion pill mifepristone. 

Now, Hilary Perkins is no liberal trying to hide out in the bureaucracy. She’s a self-described pro-life Christian conservative hired in the first Trump administration, but she was apparently forced out for the high crime of doing her job as a career lawyer. Is this administration really going to try to evict anyone who ever supported a Biden position? Will that leave anybody left? 

Roubein: I think what’s notable is Sen. Josh Hawley here, who expressed concerns and I had heard expressed concerns to the White House, and the post on X from the FDA came an hour before the hearing. There were concerns that he was not going to make it out of committee and— 

Rovner: Before the Marty Makary hearing. 

Roubein: Yes, sorry, before the vote in the HELP [Health, Education, Labor and Pensions] Committee on Marty Makary. And Hawley said because of that, he would vote to support him. What was interesting is two Democrats actually ended up supporting him, so he could have passed without Hawley’s vote. But I think in general it poses a test for Marty Makary when he’s an FDA commissioner, and how and whether he’s going to get his people in and how he’ll respond to different pressure points in Congress and with HHS and with the White House. 

Rovner: And of course, Hawley’s not a disinterested bystander here, right? 

Karlin-Smith: So his wife was one of the key attorneys in the recent big Supreme Court case that was pushed down to the lower courts for a lack of standing, but she was trying to essentially get tighter controls on the abortion pill mifepristone. But it seems like almost maybe Hawley jumped too soon before doing all of his research or fully understanding the role of people at Justice. Because even before this whole controversy erupted, I had talked to people the day before about this and asked them, “Should we read into this, her being involved in this?” And everybody I talked to, including, I think, a lot of people that have different views than Perkins does on the case, that they were saying she was in a role as a career attorney. You do what your boss, what the administration, wants. 

If you really, really had a big moral problem with that, you can quit your job. But it’s perfectly normal for an attorney in that kind of position to defend a client’s interest and then have another client and maybe have to defend them wrongly. So it seems like if they had just maybe even picked up the phone and had a conversation with her, the whole crisis could have been averted. And she was on CNN yesterday trying to plead her case and, again, emphasize her positions because perhaps she’s worried about her future career prospects, I guess, over this debacle. 

Rovner: Yeah, now she’s going to be blackballed by both sides for having done her job, basically. Anyway, all right, well, one big Biden initiative that looks like it will continue is the Medicare Drug Price Negotiation program. And we think we know this because CMS announced last week that the makers of all of the 15 drugs selected for the second round of negotiations have agreed to, well, negotiate. Sarah, this is news, right? Because we were wondering whether this was really going to go forward. 

Karlin-Smith: Yeah, they’ve made some other signals since taking over that they were going to keep going with this, including last week at his confirmation hearing, Dr. Oz, for CMS, also indicated he seemed like he would uphold that law and they were looking for ways to lower drug costs. So I think what people are going to be watching for is whether they yield around the edges in terms of tweaks the industry wants to the law, or is there something about the prices they actually negotiate that signal they’re not really trying to get them as low as they can go? But this seems to be one populist issue for Trump that he wants to keep leaning into and keep the same consistency, I think, from his first administration, where he always took a pretty hard line on the drug industry and drug pricing. 

Rovner: And I know Ozempic is on that list of 15 drugs, but the administration hasn’t said yet. I assume that’s Ozempic for its original purpose in treating diabetes. This administration hasn’t said yet whether they’ll continue the Biden declaration that these drugs could be available for people for weight loss, right? 

Karlin-Smith: Correct. And I think that’s going to be more complicated because that’s so costly. So negotiating the price of drugs saves money. So yes, basically because Ozempic and Wegovy are the same drug, that price should be available regardless of the indication. But I’m more skeptical that they continue that policy, because of the cost and also just because, again, HHS Secretary Robert F. Kennedy seems to be particularly skeptical of the drugs, or at least using that as a first line of defense, widespread use, reliance on that. He tends to, in general, I think, support other ways of medical, I guess, treatment or health treatments before turning to pharmaceuticals. 

Rovner: Eating better and exercising. 

Karlin-Smith: Correct, right. So I think that’s going to be a hard sell for them because it’s just so costly. 

Rovner: We will see. All right, that is as much news as we have time for this week. Now, it is time for our extra-credit segment, that’s where we each recognize the story we read this week we think you should read, too. Don’t worry if you miss it. We will put the links in our show notes on your phone or other mobile device. Jessie, you’ve done yours already this week. Rachel, why don’t you go next? 

Roubein: My extra credit, the headline is “Her Research Grant Mentioned ‘Hesitancy.’ Now Her Funding Is Gone.” In The Washington Post by my colleague Carolyn Y. Johnson. And I thought the story was particularly interesting because it really dove into the personal level. You hear about all these cuts from a high level, but you don’t always really know what it means and how it came about. So the backstory is the National Institutes of Health terminated dozens of research grants that focused on why some people are hesitant to accept vaccines. 

And Carolyn profiled one researcher, Nisha Acharya, but there was a twist, and the twist was she doesn’t actually study how to combat vaccine hesitancy or ways to increase vaccine uptake. Instead, she studies how well the shingles vaccine works to prevent the infection, with a focus on whether the shot also prevents the virus from affecting people’s eyes. But in the summary of her project, she had used the word “hesitancy” once and used the word “uptake” once. And so this highlights the sweeping approach to halting some of these vaccine hesitancy research grants. 

Rovner: Yeah that was like the DOD [Department of Defense] getting rid of the picture of the Enola Gay, the plane that dropped the atomic bomb, because it had the word “Gay” in it. This is the downside, I guess, of using AI for these sorts of things. Sarah. 

Karlin-Smith: I took a look at a KFF story by Arthur Allen, “Scientists Say NIH Officials Told Them to Scrub mRNA References on Grants,” and it’s about NIH officials urging people to remove any reference to mRNA vaccine technology from their grants. And the story indicates it’s not yet clear if that is going to translate to defunding of such research, but the implications are quite vast. I think most people probably remember the mRNA vaccine technology is really what helped many of us survive the covid pandemic and is credited with saving millions of lives, but the technology promise seems vast even beyond infectious diseases, and there’s a lot of hope for it in cancer. 

And so this has a lot of people worried. It’s not particularly surprising, I guess, because again, the anti-vaccine movement, which Kennedy has been a leader of, has been particularly skeptical of the mRNA technology. But it is problematic, I think, for research. And we spent a lot of time on this call talking about the decimation of the federal workforce that may happen here, and I think this story and some of the other things we talked about today also show how we may just decimate our entire scientific research infrastructure and workforce in the U.S. outside of just the federal government, because so much of it is funded by NIH, and the decisions they’re making are going to make it impossible for a lot of scientists to do their job. 

Rovner: Yeah, we’re also seeing scientists going to other countries, but that’s for another time. Well, my extra credit this week, probably along the same lines, also from The Washington Post. It’s part of a series called “Who Is Government?” This particular piece [“The Free-Living Bureaucrat”] is by bestselling author Michael Lewis, and it’s a sprawling — and I mean sprawling — story of how a mid-level FDA employee who wanted to help find new treatments for rare diseases ended up not only figuring out a cure for a child who was dying of a rare brain amoeba but managed to obtain the drug for the family in time to save her. It’s a really good piece, and it’s a really excellent series that tells the stories of mostly faceless bureaucrats who actually are working to try to make the country a better place. 

OK, that’s this week’s show. 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. Thanks as always to our producer, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, @jrovner, and at Bluesky, @julierovner. Where are you guys these days? Sarah? 

Karlin-Smith: A little bit everywhere. X, Bluesky, LinkedIn — @SarahKarlin or @sarahkarlin-smith. 

Rovner: Jessie. 

Hellmann: I’m @jessiehellmann on X and Bluesky, and I’m also on LinkedIn more these days. 

Rovner: Great. Rachel. 

Roubein: @rachelroubein at Bluesky, @rachel_roubein on X, and also on LinkedIn. 

Rovner: We will be back in your feed next week. Until then, be healthy. 

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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 2024 campaign — particularly the one for president — has been notably vague on policy. But health issues, especially those surrounding abortion and other reproductive health care, have nonetheless played a key role. And while the Affordable Care Act has not been the focus of debate the way it was over the previous three presidential campaigns, who becomes the next president will have a major impact on the fate of the 2010 health law.

The panelists for this week’s special election preview, taped before a live audience at KFF’s offices in Washington, are Julie Rovner of KFF Health News, Tamara Keith of NPR, Alice Miranda Ollstein of Politico, and Cynthia Cox and Ashley Kirzinger of KFF.

Panelists

Ashley Kirzinger
KFF

@AshleyKirzinger

Read Ashley's bio.

Cynthia Cox
KFF

@cynthiaccox

Read Cynthia's bio.

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories.

Tamara Keith
NPR

@tamarakeithNPR

Read and listen to Tamara's stories.

Among the takeaways from this week’s episode:

• As Election Day nears, who will emerge victorious from the presidential race is anyone’s guess. Enthusiasm among Democratic women has grown with the elevation of Vice President Kamala Harris to the top of the ticket, with more saying they are likely to turn out to vote. But broadly, polling reveals a margin-of-error race — too close to call.
• Several states have abortion measures on the ballot. Proponents of abortion rights are striving to frame the issue as nonpartisan, acknowledging that recent measures have passed thanks in part to Republican support. For some voters, resisting government control of women’s health is a conservative value. Many are willing to split their votes, supporting both an abortion rights measure and also candidates who oppose abortion rights.
• While policy debates have been noticeably lacking from this presidential election, the future of Medicaid and the Affordable Care Act hinges on its outcome. Republicans want to undermine the federal funding behind Medicaid expansion, and former President Donald Trump has a record of opposition to the ACA. Potentially on the chopping block are the federal subsidies expiring next year that have transformed the ACA by boosting enrollment and lowering premium costs.
• And as misinformation and disinformation proliferate, one area of concern is the “malleable middle”: people who are uncertain of whom or what to trust and therefore especially susceptible to misleading or downright false information. Could a second Trump administration embed misinformation in federal policy? The push to soften or even eliminate school vaccination mandates shows the public health consequences of falsehood creep.

Also mentioned on this week’s podcast:

• The New York Times’ “Resistance to Public Health, No Longer Fringe, Gains Foothold in G.O.P. Politics,” by Sheryl Gay Stolberg.
• KFF Health News’ “‘What the Health?’: SCOTUS Ruling Strips Power From Federal Health Agencies.”
• KFF’s Health Misinformation and Trust Initiative, a program aimed at tracking health misinformation in the U.S., analyzing its impact on the American people, and mobilizing media to address the problem.

click to open the transcript

Transcript: LIVE From KFF: Health Care and the 2024 Election

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.] 

Emmarie Huetteman: Please put your hands together and join me in welcoming our panel and our host, Julie Rovner. 

Julie Rovner: Hello, good morning, 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 very best and smartest health reporters in Washington, along with some very special guests today. We’re taping this special election episode on Thursday, October 17th, at 11:30 a.m., in front of a live audience at the Barbara Jordan Conference Center here at KFF in downtown D.C. Say hi, audience. 

As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

So I am super lucky to work at and have worked at some pretty great places and with some pretty great, smart people. And when I started to think about who I wanted to help us break down what this year’s elections might mean for health policy, it was pretty easy to assemble an all-star cast. So first, my former colleague from NPR, senior White House correspondent Tamara Keith. Tam, thanks for joining us. 

Tamara Keith: Thank you for having me. 

Rovner: Next, our regular “What the Health?” podcast panelist and my right hand all year on reproductive health issues, Alice Ollstein of Politico. 

Alice Miranda Ollstein: Hi Julie. 

Rovner: Finally, two of my incredible KFF colleagues. Cynthia Cox is a KFF vice president and director of the program on the ACA [Affordable Care Act] and one of the nation’s very top experts on what we know as Obamacare. Thank you, Cynthia. 

Cynthia Cox: Great to be here. 

Rovner: And finally, Ashley Kirzinger is director of survey methodology and associate director of our KFF Public Opinion and Survey Research Program, and my favorite explainer of all things polling. 

Ashley Kirzinger: Thanks for having me. 

Rovner: So, welcome to all of you. Thanks again for being here. We’re going to chat amongst ourselves for a half hour or so, and then we will open the floor to questions. So be ready here in the room. Tam, I want to start with the big picture. What’s the state of the race as of October 17th, both for president and for Congress? 

Keith: Well, let’s start with the race for President. That’s what I cover most closely. This is what you would call a margin-of-error race, and it has been a margin-of-error race pretty much the entire time, despite some really dramatic events, like a whole new candidate and two assassination attempts and things that we don’t expect to see in our lifetimes and yet they’ve happened. And yet it is an incredibly close race. What I would say is that at this exact moment, there seems to have been a slight shift in the average of polls in the direction of former President [Donald] Trump. He is in a slightly better position than he was before and is in a somewhat more comfortable position than Vice President [Kamala] Harris. 

She has been running as an underdog the whole time, though there was a time where she didn’t feel like an underdog, and right now she is also running like an underdog and the vibes have shifted, if you will. There’s been a more dramatic shift in the vibes than there has been in the polls. And the thing that we don’t know and we won’t know until Election Day is in 2016 and 2020, the polls underestimated Trump’s support. So at this moment, Harris looks to be in a weaker position against Trump than either [Hillary] Clinton or [Joe] Biden looked to be. It turns out that the polls were underestimating Trump both of those years. But in 2022 after the Dobbs decision, the polls overestimated Republican support and underestimated Democratic support. 

So what’s happening now? We don’t know. So there you go. That is my overview, I think, of the presidential race. The campaigning has really intensified in the last week or so, like really intensified, and it’s only going to get more intense. I think Harris has gotten a bit darker in her language and descriptions. The joyful warrior has been replaced somewhat by the person warning of dire consequences for democracy. And in terms of the House and the Senate, which will matter a lot, a lot a lot, whether Trump wins or Harris wins, if Harris wins and Democrats lose the Senate, Harris may not even be able to get Cabinet members confirmed. 

So it matters a lot, and the conventional wisdom — which is as useful as it is and sometimes is not all that useful — the conventional wisdom is that something kind of unusual could happen, which is that the House could flip to Democrats and the Senate could flip to Republicans, and usually these things don’t move in opposite directions in the same year. 

Rovner: And usually the presidential candidate has coattails, but we’re not really seeing that either, are we? 

Keith: Right. In fact, it’s the reverse. Several of the Senate candidates in key swing states, the Democratic candidates are polling much better than the Republican candidates in those races and polling with greater strength than Harris has in those states. Is this a polling error, or is this the return of split-ticket voting? I don’t know. 

Rovner: Well, leads us to our polling expert. Ashley, what are the latest polls telling us, and what should we keep in mind about the limitations of polling? I feel like every year people depend a lot on the polls and every year we say, Don’t depend too much on the polls. 

Kirzinger: Well, can I just steal Tamara’s line and say I don’t know? So in really close elections, when turnout is going to matter a lot, what the polls are really good at is telling us what is motivating voters to turn out and why. And so what the polls have been telling us for a while is that the economy is top of mind for voters. Now, health care costs — we’re at KFF. So health care plays a big role in how people think about the economy, in really two big ways. The first is unexpected costs. So unexpected medical bills, health care costs, are topping the list of the public’s financial worries, things that they’re worried about, what might happen to them or their family members. And putting off care. What we’re seeing is about a quarter of the public these days are putting off care because they say they can’t afford the cost of getting that needed care. 

So that really shows the way that the financial burdens are playing heavily on the electorate. What we have seen in recent polling is Harris is doing better on the household expenses than Biden did and is better than the Democratic Party largely. And that’s really important, especially among Black women and Latina voters. We are seeing some movement among those two groups of the electorate saying that Harris is doing a better job and they trust her more on those issues. But historically, if the election is about the economy, Republican candidates do better. The party does better on economic issues among the electorate. 

What we haven’t mentioned yet is abortion, and this is the first presidential election since post-Dobbs, in the post-Dobbs era, and we don’t know how abortion policy will play in a presidential election. It hasn’t happened before, so that’s something that we’re also keeping an eye on. We know that Harris is campaigning around reproductive rights, is working among a key group of the electorate, especially younger women voters. She is seen as a genuine candidate who can talk about these issues and an advocate for reproductive rights. We’re seeing abortion rise in importance as a voting issue among young women voters, and she’s seen as more authentic on this issue than Biden was. 

Rovner: Talk about last week’s poll about young women voters. 

Kirzinger: Yeah, one of the great things that we can do in polling is, when we see big changes in the campaign, is we can go back to our polls and respondents and ask how things have changed to them. So we worked on a poll of women voters back in June. Lots have changed since June, so we went back to them in September to see how things were changing for this one group, right? So we went back to the same people and we saw increased motivation to turn out, especially among Democratic women. Republican women were about the same level of motivation. They’re more enthusiastic and satisfied about their candidate, and they’re more likely to say abortion is a major reason why they’re going to be turning out. But we still don’t know how that will play across the electorate in all the states. 

Because for most voters, a candidate’s stance on abortion policy is just one of many factors that they’re weighing when it comes to turnout. And so those are one of the things that we’re looking at as well. I will say that I’m not a forecaster, thank goodness. I’m a pollster, and polls are not good at forecasts, right? So polls are very good at giving a snapshot of the electorate at a moment in time. So two weeks out, that’s what I know from the polls. What will happen in the next two weeks, I’m not sure. 

Rovner: Well, Alice, just to pick up on that, abortion, reproductive health writ large are by far the biggest health issues in this campaign. What impact is it having on the presidential race and the congressional races and the ballot issues? It’s all kind of a clutter, isn’t it? 

Ollstein: Yeah, well, I just really want to stress what Ashley said about this being uncharted territory. So we can gather some clues from the past few years where we’ve seen these abortion rights ballot measures win decisively in very red states, in very blue states, in very purple states. But presidential election years just have a different electorate. And so, yes, it did motivate more people to turn out in those midterm and off-year elections, but that’s just not the same group of folks and it’s not the same groups the candidates need this time, necessarily. And also we know that every time abortion has been on the ballot, it has won, but the impact and how that spills over into partisan races has been a real mixed bag. 

So we saw in Michigan in 2022, it really helped Democrats. It helped Governor Gretchen Whitmer. It helped Michigan Democrats take back control of the Statehouse for the first time in decades. But that didn’t work for Democrats in all states. My colleagues and I did an analysis of a bunch of different states that had these ballot measures, and these ballot measures largely succeeded because of Republican voters who voted for the ballot initiative and voted for Republican candidates. And that might seem contradictory. You’re voting for an abortion rights measure, and you’re voting for very anti-abortion candidates. We saw that in Kentucky, for example, where a lot of people voted for (Sen.) Rand Paul, who is very anti-abortion, and for the abortion rights side of the ballot measure. 

I’ve been on the road the last few months, and I think you’re going to see a lot of that again. I just got back from Arizona, and a lot of people are planning to vote for the abortion rights measure there and for candidates who have a record of opposing abortion rights. Part of that is Donald Trump’s somewhat recent line of: I won’t do any kind of national ban. I’ll leave it to the states. A lot of people are believing that, even though Democrats are like: Don’t believe him. It’s not true. But also, like Ashley said, folks are just prioritizing other issues. And so, yes, when you look at certain slices of the electorate, like young women, abortion is a top motivating issue. But when you look at the entire electorate, it’s, like, a distant fourth after the economy and immigration and several other things. 

I found the KFF polling really illuminating in that, yes, most people said that abortion is either just one of many factors in deciding their vote on the candidates or not a factor at all. And most people said that they would be willing to vote for a candidate who does not share their views on abortion. So I think that’s really key here. And these abortion rights ballot measures, the campaigns behind them are being really deliberate about remaining completely nonpartisan. They need to appeal to Republicans, Democrats, independents in order to pass, but that also … So their motivation is to appeal to everyone. Democrats’ motivation is to say: You have to vote for us, too. Abortion rights won’t be protected if you just pass the ballot measure. You also have to vote for Democrats up and down the ballot. Because, they argue, Trump could pursue a national ban that would override the state protections. 

Rovner: We’ve seen in the past — and this is for both of you — ballot measures as part of partisan strategies. In the early 2000s, there were anti-gay-marriage ballot measures that were intended to pull out Republicans, that were intended to drive turnout. That’s not exactly what’s happening this time, is it? 

Keith: So I was a reporter in the great state of Ohio in 2004, and there was an anti-gay-rights ballot measure on the ballot there, and it was a key part of George W. Bush’s reelection plan. And it worked. He won the state somewhat narrowly. We didn’t get the results until 5 a.m. the next day, but that’s better than we’ll likely have this time. And that was a critical part of driving Republican turnout. It’s remarkable how much has changed since then in terms of public views. It wouldn’t work in the same way this time. 

The interesting thing in Arizona, for instance, is that there’s also an anti-immigration ballot measure that’s also polling really well that was added by the legislature in sort of a rush to try to offset the expected Democratic-based turnout because of the abortion measure. But as you say, it is entirely possible that there could be a lot of Trump abortion, immigration and [House Democrat and Senate candidate] Ruben Gallego voters. 

Ollstein: Absolutely. And I met some of those voters, and one woman told me, look, she gets offended when people assume that she’s liberal because she identified as pro-choice. We don’t use that terminology in our reporting, but she identified as pro-choice, and she was saying: Look, to me, this is a very conservative value. I don’t want the government in my personal business. I believe in privacy. And so for her, that doesn’t translate over into, And therefore I am a Democrat. 

Rovner: I covered two abortion-related ballot measures in South Dakota that were two years, I think it was 2006 and 2008. 

Ollstein: They have another one this year. 

Rovner: Right. There is another one this year. But what was interesting, what I discovered in 2006 and 2008 is exactly what you were saying, that there’s a libertarian streak, particularly in the West, of people who vote Republican but who don’t believe that the government has any sort of business in your personal life, not just on abortion but on any number of other things, including guns. So this is one of those issues where there’s sort of a lot of distinction. Cynthia, this is the first time in however many elections the Affordable Care Act has not been a huge issue, but there’s an awful lot at stake for this law, depending on who gets elected, right? 

Cox: Yeah, that’s right. I mean, it’s the first time in recent memory that health care in general, aside from abortion, hasn’t really been the main topic of conversation in the race. And part of that is that the Affordable Care Act has really transformed the American health care system over the last decade or so. The uninsured rate is at a record low, and the ACA marketplaces, which had been really struggling 10 years ago, have started to not just survive but thrive. Maybe also less to dislike about the ACA, but it’s also not as much a policy election as previous elections had been. But yes, the future of the ACA still hinges on this election. 

So starting with President Trump, I think as anyone who follows health policy knows, or even politics or just turned on the TV in 2016 knows that Trump has a very, very clear history of opposing the Affordable Care Act, or Obamacare. He supported a number of efforts in Congress to try to repeal and replace the Affordable Care Act. And when those weren’t successful, he took a number of regulatory steps, joined legal challenges, and proposed in his budgets to slash funding for the Affordable Care Act and for Medicaid. But now in 2024, it’s a little bit less clear exactly where he’s going. 

I would say earlier in the 2024 presidential cycle, he made some very clear comments about saying Obamacare sucks, for example, or that Republicans should never give up on trying to repeal and replace the ACA, that the failure to do so when he was president was a low point for the party. But then he also has seemed to kind of walk that back a little bit. Now he’s saying that he would replace the ACA with something better or that he would make the ACA itself much, much better or make it cost less, but he’s not providing specifics. Of course, in the debate, he famously said that he had “concepts” of a plan, but there’s no … Nothing really specific has materialized. 

Rovner: We haven’t seen any of those concepts. 

Cox: Yes, the concept is … But we can look at his record. And so we do know that he has a very, very clear record of opposing the ACA and really taking any steps he could when he was president to try to, if not repeal and replace it, then significantly weaken it or roll it back. Harris, by contrast, is in favor of the Affordable Care Act. When she was a primary candidate in 2020, she had expressed support for more-progressive reforms like “Medicare for All” or “Medicare for More.” But since becoming vice president, especially now as the presidential candidate, she’s taken a more incremental approach. 

She’s talking about building upon the Affordable Care Act. In particular, a key aspect of her record and Biden’s is these enhanced subsidies that exist in the Affordable Care Act marketplaces. They were first, I think … They really closely mirror what Biden had run on as president in 2019, 2020, but they were passed as part of covid relief. So they were temporary, then they were extended as part of the Inflation Reduction Act but, again, temporarily. And so they’re set to expire next year, which is setting up a political showdown of sorts for Republicans and Democrats on the Hill about whether or not to extend them. And Harris would like to make these subsidies permanent because they have been responsible for really transforming the ACA marketplaces. 

The number of people signing up for coverage has doubled since Biden took office. Premium payments were cut almost in half. And so this is, I think, a key part of, now, her record, but also what she wants to see go forward. But it’s going to be an uphill battle, I think, to extend them. 

Rovner: Cynthia, to sort of build on that a little bit, as we mentioned earlier, a Democratic president won’t be able to get a lot accomplished with a Republican House and/or Senate and a Republican president won’t be able to get that much done with a Democratic House and/or Senate. What are some of the things we might expect to see if either side wins a trifecta control of the executive branch and both houses of Congress? 

Cox: So I think, there … So I guess I’ll start with Republicans. So if there is a trifecta, the key thing there to keep in mind is while there may not be a lot of appetite in Congress to try to repeal and replace the ACA, since that wasn’t really a winning issue in 2017, and since then public support for the ACA has grown. And I think also it’s worth noting that the individual mandate penalty being reduced to $0. So essentially there’s no individual mandate anymore. There’s less to hate about the law. 

Rovner: All the pay-fors are gone, too. 

Cox: Yeah the pay-fors are gone, too. 

Rovner: So the lobbyists have less to hate. 

Cox: Yes, that too. And so I don’t think there’s a ton of appetite for this, even though Trump has been saying, still, some negative comments about the ACA. That being said, if Republicans want to pass tax cuts, then they need to find savings somewhere. And so that could be any number of places, but I think it’s likely that certain health programs and other programs are off-limits. So Medicare probably wouldn’t be touched, maybe Social Security, defense, but that leaves Medicaid and the ACA subsidies. 

And so if they need savings in order to pass tax cuts, then I do think in particular Medicaid is at risk, not just rolling back the ACA’s Medicaid expansion but also likely block-granting the program or implementing per capita caps or some other form of really restricting the amount of federal dollars that are going towards Medicaid. 

Rovner: And this is kind of where we get into the Project 2025 that we’ve talked about a lot on the podcast over the course of this year, that, of course, Donald Trump has disavowed. But apparently [Senate Republican and vice presidential candidate] JD Vance has not, because he keeps mentioning pieces of it. 

Ollstein: And they’re only … They’re just one of several groups that have pitched deep cuts to health safety net programs, including Medicaid. You also have the Paragon group, where a lot of former Trump officials are putting forward health policy pitches and several others. And so I also think given the uncertainty about a trifecta, it’s also worth keeping in mind what they could do through waivers and executive actions in terms of work requirements. 

Rovner: That was my next question. I’ve had trouble explaining this. I’ve done a bunch of interviews in the last couple of weeks to explain how much more power Donald Trump would have, if he was reelected, to do things via the executive branch than a President Harris would have. So I have not come up with a good way to explain that. Please, one of you give it a shot. 

Keith: Someone else. 

Rovner: Why is it that President Trump could probably do a lot more with his executive power than a President Harris could do with hers? 

Cox: I think we can look back at the last few years and just see. What did Trump do with his executive power? What did Biden do with his executive power? And as far as the Affordable Care Act is concerned or Medicaid. But Trump, after the failure to repeal and replace the ACA, took a number of regulatory steps. For example, trying to expand short-term plans, which are not ACA-compliant, and therefore can discriminate against people with preexisting conditions, or cutting funding for certain things in the ACA, including outreach and enrollment assistance. 

And so I think there were a number — and also we’ve talked about Medicaid work requirements in the form of state waivers. And a lot of what Biden did, regulatory actions, were just rolling that back, changing that, but it’s hard to expand coverage or to provide a new program without Congress acting to authorize that spending. 

Kirzinger: I think it’s also really important to think about the public’s view of the ACA at this point in time. I mean, what the polls aren’t mixed about is that the ACA has higher favorability than Harris, Biden, Trump, any politician, right? So we have about two-thirds of the public. 

Rovner: So Nancy Pelosi was right. 

Kirzinger: I won’t go that far, but about two-thirds of the public’s now view the law favorably, and the provisions are even more popular. So while, yes, a Republican trifecta will have a lot of power, the public — they’re going to have a hard time rolling back protections for people with preexisting conditions, which have bipartisan support. They’re going to have a hard time making it no longer available for adult children under the age of 26 to be on their parents’ health insurance. All of those components of the ACA are really popular, and once people are given protections, it’s really hard to take them away. 

Cox: Although I would say that there are at least 10 ways the ACA protects people with preexisting conditions. I think on the surface it’s easy to say that you would protect people with preexisting conditions if you say that a health insurer has to offer coverage to someone with a preexisting condition. But there’s all those other ways that they say also protects preexisting conditions, and it makes coverage more comprehensive, which makes coverage more expensive. 

And so that’s why the subsidies there are key to make comprehensive coverage that protects people with preexisting conditions affordable to individuals. But if you take those subsidies away, then that coverage is out of reach for most people. 

Rovner: That’s also what JD Vance was talking about with changing risk pools. I mean, which most people, it makes your eyes glaze over, but that would be super important to the affordability of insurance, right? 

Cox: And his comment about risk pools is — I think a lot of people were trying to read something into that because it was pretty vague. But what a lot of people did think about when he made that comment was that before the Affordable Care Act, it used to be that if you were declined health insurance coverage, especially by multiple insurance companies, if you were basically uninsurable, then you could apply to what existed in many states was a high-risk pool. 

But the problem was that these high-risk pools were consistently underfunded. And in most of those high-risk pools, there were even waiting periods or exclusions on coverage for preexisting conditions or very high premiums or deductibles. So even though these were theoretically an option for coverage for people with preexisting conditions before the ACA, the lack of funding or support made it such that that coverage didn’t work very well for people who were sick. 

Ollstein: And something conservatives really want to do if they gain power is go after the Medicaid expansion. They’ve sort of set up this dichotomy of sort of the deserving and undeserving. They don’t say it in those words, but they argue that childless adults who are able-bodied don’t need this safety net the way, quote-unquote, “traditional” Medicaid enrollees do. And so they want to go after that part of the program by reducing the federal match. That’s something I would watch out for. I don’t know if they’ll be able to do that. That would require Congress, but also several states have in their laws that if the federal matches decreased, they would automatically unexpand, and that would mean coverage losses for a lot of people. That would be very politically unpopular. 

It’s worth keeping in mind that a lot of states, mainly red states, have expanded Medicaid since Republicans last tried to go after the Affordable Care Act in 2017. And so there’s just a lot more buy-in now. So it would be politically more challenging to do that. And it was already very politically challenging. They weren’t able to do it back then. 

Rovner: So I feel like one of the reasons that Trump might be able to get more done than Harris just using executive authority is the makeup of the judiciary, which has been very conservative, particularly at the Supreme Court, and we actually have some breaking news on this yesterday. Three of the states who intervened in what was originally a Texas lawsuit trying to revoke the FDA’s [Federal Drug Administration’s] approval of the abortion pill mifepristone, officially revived that lawsuit, which the Supreme Court had dismissed because the doctors who filed it initially didn’t have standing, according to the Supreme Court. 

The states want the courts to invoke the Comstock Act, an 1873 anti-vice law banning the mailing and receiving of, among other things, anything used in an abortion, to effectively ban the drug. This is one of those ways that Trump wouldn’t even have to lift a finger to bring about an abortion ban, right? I mean, he’d just have to let it happen. 

Ollstein: Right. I think so much of this election cycle has been dominated by, Would you sign a ban? And that’s just the wrong question. I mean, we’ve seen Congress unable to pass either abortion restrictions or abortion protections even when one party controls both chambers. It’s just really hard. 

Rovner: And going back 60 years. 

Ollstein: And so I think it’s way more important to look at what could happen administratively or through the courts. And so yes, lawsuits like that, that the Supreme Court punted on but didn’t totally resolve this term, could absolutely come back. A Trump administration could also direct the FDA to just unauthorize abortion pills, which are the majority of abortions that take place within the U.S. 

And so — or there’s this Comstock Act route. There’s — the Biden administration put out a memo saying, We do not think the Comstock Act applies to the mailing of abortion pills to patients. A Trump administration could put out their own memo and say, We believe the opposite. So there’s a lot that could happen. And so I really have been frustrated. All of the obsessive focus on: Would you sign a ban? Would you veto a ban? Because that is the least likely route that this would happen. 

Kirzinger: Well, and all of these court cases create an air of confusion among the public, right? And so, that also can have an effect in a way that signing a ban — I mean, if people don’t know what’s available to them in their state based on state policy or national policy. 

Ollstein: Or they’re afraid of getting arrested. 

Kirzinger: Yeah, even if it’s completely legal in their state, we’re finding that people aren’t aware of whether — what’s available to them in their state, what they can access legally or not. And so having those court cases pending creates this air of confusion among the public. 

Keith: Well, just to amplify the air of confusion, talking to Democrats who watch focus groups, they saw a lot of voters blaming President Biden for the Dobbs decision and saying: Well, why couldn’t he fix that? He’s president. At a much higher level, there is confusion about how our laws work. There’s a lot of confusion about civics, and as a result, you see blame landing in sort of unexpected places. 

Rovner: This is the vaguest presidential election I have ever covered. I’ve been doing this since 1988. We basically have both candidates refusing to answer specific questions — as a strategy, I mean, it’s not that I don’t think — I think they both would have a pretty good idea of what it is they would do, and both of them find it to their political advantage not to say. 

Keith: I think that’s absolutely right. I think that the Harris campaign, which I spend more time covering, has the view that if Trump is not going to answer questions directly and he is going to talk about “concepts” of a plan, and he’s just going to sort of, like, Well, if I was president, this wouldn’t be a problem, so I’m not going to answer your question — which is his answer to almost every question — then there’s not a lot of upside for them to get into great specifics about policy and to have think tank nerds telling them it won’t work, because there’s no upside to it. 

Cox: We’re right here. 

Panel: [Laughing] 

Rovner: So regular listeners to the podcast will know that one of my biggest personal frustrations with this campaign is the ever-increasing amount of mis- and outright disinformation in the health care realm, as we discussed at some length on last week’s podcast. You can go back and listen. This has become firmly established in public health, obviously pushed along by the divide over the covid pandemic. The New York Times last week had a pretty scary story by Sheryl Gay Stolberg — who’s working on a book about public health — about how some of these more fringe beliefs are getting embedded in the mainstream of the Republican Party. 

It used to be that we saw most of these kind of fringe, anti-science, anti-health beliefs were on the far right and on the far left, and that’s less the case. What could we be looking forward to on the public health front if Trump is returned to power, particularly with the help of anti-vaccine activist and now Trump endorser R.F.K. [Robert F. Kennedy] Jr.? 

Kirzinger: Oh, goodness to me. Well, so I’m going to talk about a group that I think is really important for us to focus on when we think about misinformation, and I call them the “malleable middle.” So it’s that group that once they hear misinformation or disinformation, they are unsure of whether that is true or false, right? So they’re stuck in this uncertainty of what to believe and who do they trust to get the right information. It used to be pre-pandemic that they would trust their government officials. 

We have seen declining trust in CDC [Centers for Disease Control and Prevention], all levels of public health officials. Who they still trust is their primary care providers. Unfortunately, the groups that are most susceptible to misinformation are also the groups that are less likely to have a primary care provider. So we’re not in a great scenario, where we have a group that is unsure of who to trust on information and doesn’t have someone to go to for good sources of information. I don’t have a solution. 

Cox: I also don’t have a solution. 

Rovner: No, I wasn’t — the question isn’t about a solution. The question is about, what can we expect? I mean, we’ve seen the sort of mis- and disinformation. Are we going to actually see it embedded in policy? I mean, we’ve mostly not, other than covid, which obviously now we see the big difference in some states where mask bans are banned and vaccine mandates are banned. Are we going to see childhood vaccines made voluntary for school? 

Ollstein: Well, there’s already a movement to massively broaden who can apply for an exception to those, and that’s already had some scary public health consequences. I mean, I think there are people who would absolutely push for that. 

Kirzinger: I think regardless of who wins the presidency, I think that the misinformation and disinformation is going to have an increasing role. Whether it makes it into policy will depend on who is in office and Congress and all of that. But I think that it is not something that’s going away, and I think we’re just going to continue to have to battle it. And that’s where I’m the most nervous. 

Keith: And when you talk about the trust for the media, those of us who are sitting here trying to get the truth out there, or to fact-check and debunk, trust for us is, like, in the basement, and it just keeps getting worse year after year after year. And the latest Gallup numbers have us worse than we were before, which is just, like, another institution that people are not turning to. We are in an era where some rando on YouTube who said they did their research is more trusted than what we publish. 

Rovner: And some of those randos on YouTube have millions of viewers, listeners. 

Keith: Yes, absolutely. 

Rovner: Subscribers, whatever you want to call them. 

Ollstein: One area where I’ve really seen this come forward, and it could definitely become part of policy in the future, is there’s just a lot of mis- and disinformation around transgender health care. There’s polling that show a lot of people believe what Trump and others have been saying, that, Oh, kids can come home from school and have a sex change operation. Which is obviously ridiculous. Everyone who has kids in school knows that they can’t even give them a Tylenol without parental permission. And it obviously doesn’t happen in a day, but people are like, Oh, well, I know it’s not happening at my school, but it’s sure happening somewhere. And that’s really resonating, and we’re already seeing a lot of legal restrictions on that front spilling. 

Rovner: All right, well, I’m going to open it up to the audience. Please wait to ask your question until you have a microphone, so the people who will be listening to the podcast will be able to hear your question. And please tell us who you are, and please make your question or question. 

Madeline: Hi, I’m Madeline. I am a grad student at the Milken Institute of Public Health at George Washington. My question is regarding polling. And I was just wondering, how has polling methodologies or tendencies to over-sample conservatives had on polls in the race? Are you seeing that as an issue or …? 

Kirzinger: OK. You know who’s less trusted than the media? It’s pollsters, but you can trust me. So I think what you’re seeing is there are now more polls than there have ever been, and I want to talk about legitimate scientific polls that are probability-based. They’re not letting people opt into taking the survey, and they’re making sure their samples are representative of the entire population that they’re surveying, whether it be the electorate or the American public, depending on that. 

I think what we have seen is that there have been some tendencies when people don’t like the poll results, they look at the makeup of that sample and say, oh, this poll’s too Democratic, or too conservative, has too many Trump voters. Or whatever it may be. That benefits no pollster to make their sample not look like the population that they’re aiming to represent. And so, yes, there are lots of really, really bad polls out there, but the ones that are legitimate and scientific are still striving to aim to make sure that it’s representative. The problem with election polls is we don’t know who the electorate’s going to be. We don’t know if Democrats are going to turn out more than Republicans. We don’t know if we’re going to see higher shares of rural voters than we saw in 2022. 

We don’t know. And so that’s where you really see the shifts in error happen. 

Keith: And if former President Trump’s — a big part of his strategy is turning out unlikely voters. 

Kirzinger: Yeah. We have no idea who they are. 

Rovner: Well, yeah, we saw in Georgia, their first day of in-person early voting, we had this huge upswell of voters, but we have no idea who any of those are, right? I mean, we don’t know what is necessarily turning them out. 

Kirzinger: Exactly. And historically, Democrats have been more likely to vote early and vote by mail, but that has really shifted since the pandemic. And so you see these day voting totals now, but that really doesn’t tell you anything at this point in the race. 

Rovner: Lots we still don’t know. Another question. 

Rae Woods: Hi there. Rae Woods. I’m with Advisory Board, which means that I work with health leaders who need to implement based on the policies and the politics and the results of the election that’s coming up. My question is, outside some of the big things that we’ve talked about so far today, are there some more specific, smaller policies or state-level dynamics that you think today’s health leaders will need to respond to in the next six months, the next eight months? What do health leaders need to be focused on right now based on what could change most quickly? 

Ollstein: Something I’ve been trying to shine a light on are state Supreme Courts, which the makeup of them could change dramatically this November. States have all kinds of different ways to … Some elect them on a partisan basis. Some elect them on a nonpartisan basis. Some have appointments by the governor, but then they have to run in these retention elections. But they are going to just have so much power over … I mean, I am most focused on how it can impact abortion rights, but they just have so much power on so many things. 

And given the high likelihood of divided federal government, I think just a ton of health policy is going to happen at the state level. And so I would say the electorate often overlooks those races. There’s a huge drop-off. A lot of people just vote the top of the ticket and then just leave those races blank. But yes, I think we should all be paying more attention to state Supreme Court races. 

Rovner: I think the other thing that we didn’t, that nobody mentioned we were talking about, what the next president could do, is the impact of the change to the regulatory environment and what the Supreme Court’s decision overturning Chevron is going to have on the next president. And we did a whole episode on this, so I can link back to that for those who don’t know. But basically, the Supreme Court has made it more difficult for whoever becomes president next time to change rules via their executive authority, and put more onus back on Congress. And we will see how that all plays out, but I think that’s going to be really important next year. 

Natalie Bercutt: Hi. My name is Natalie Bercutt. I’m also a master’s student at George Washington. I study health policy. I wanted to know a little bit more about, obviously, abortion rights, a huge issue on the ballot in this election, but a little bit more about IVF [in vitro fertilization], which I feel like has kind of come to the forefront a little bit more, both in state races but also candidates making comments on a national level, especially folks who have been out in the field and interacting with voters. Is that something that more people are coming out to the ballot for, or people who are maybe voting split ticket but in support of IVF, but for Republican candidate? 

Ollstein: That’s been fascinating. And so most folks know that this really exploded into the public consciousness earlier this year when the Alabama Supreme Court ruled that frozen embryos are people legally under the state’s abortion ban. And that disrupted IVF services temporarily until the state legislature swooped in. So Democrats’ argument is that because of these anti-abortion laws in lots of different states that were made possible by the Dobbs decision, lots of states could become the next Alabama. Republicans are saying: Oh, that’s ridiculous. Alabama was solved, and no other state’s going to do it. But they could. 

Rovner: Alabama could become the next Alabama. 

Ollstein: Alabama could certainly become the next Alabama. Buy tons of states have very similar language in their laws that would make that possible. Even as you see a lot of Republicans right now saying: Oh, Republicans are … We’re pro-IVF. We’re pro-family. We’re pro-babies. There are a lot of divisions on the right around IVF, including some who do want to prohibit it and others who want to restrict the way it’s most commonly practiced in the U.S., where excess embryos are created and only the most viable ones are implanted and the others are discarded. 

And so I think this will continue to be a huge fight. A lot of activists in the anti-abortion movement are really upset about how Republican candidates and officials have rushed to defend IVF and promised not to do anything to restrict it. And so I think that’s going to continue to be a huge fight no matter what happens. 

Rovner: Tam, are you seeing discussion about the threats to contraception? I know this is something that Democratic candidates are pushing, and Republican candidates are saying, Oh, no, that’s silly. 

Keith: Yeah, I think Democratic candidates are certainly talking about it. I think that because of that IVF situation in Alabama, because of concerns that it could move to contraception, I think Democrats have been able to talk about reproductive health care in a more expansive way and in a way that is perhaps more comfortable than just talking about abortion, in a way that’s more comfortable to voters that they’re talking to back when Joe Biden was running for president. Immediately when Dobbs happened, he was like, And this could affect contraception and it could affect gay rights. And Biden seemed much more comfortable in that realm. And so— 

Rovner: Yeah, Biden, who waited, I think it was a year and a half, before he said the word “abortion.” 

Keith: To say the word “abortion.” Yes. 

Rovner: There was a website: Has Biden Said Abortion Yet? 

Keith: Essentially what I’m saying is that there is this more expansive conversation about reproductive health care and reproductive freedom than there had been when Roe was in place and it was really just a debate about abortion. 

Rovner: Ashley, do people, particularly women voters, perceive that there’s a real threat to contraception? 

Kirzinger: I think what Tamara was saying about when Biden was the candidate, I do think that that was part of the larger conversation, that larger threat. And so they were more worried about IVF and contraception access during that. When you ask voters whether they’re worried about this, they’re not as worried, but they do give the Democratic Party and Harris a much stronger advantage on these issues. And so if you were to be motivated by that, you would be motivated to vote for Harris, but it really isn’t resonating with women voters and the way now that abortion, abortion access is resonating for them. 

Rovner: Basically, it won’t be resonating until they take it away. 

Kirzinger: Exactly. If, I think, the Alabama Supreme Court ruling happened yesterday, I think it would be a much bigger issue in the campaign, but all of this is timing. 

Ollstein: Well, and people really talked about a believability gap around the Dobbs decision, even though the activists who were following it closely were screaming that Roe is toast, from the moment the Supreme Court agreed to hear the case, and especially after they heard the case and people heard the tone of the arguments. And then of course the decision leaked, and even then there was a believability gap. And until it was actually gone, a lot of people just didn’t think that was possible. And I think you’re seeing that again around the idea of a national ban, and you’re seeing it around the idea of restrictions on contraception and IVF. There’s still this believability gap despite the evidence we’ve seen. 

Rovner: All right. I think we have time for one more question. 

Meg: Hi, my name’s Meg. I’m a freelance writer, and I wanted to ask you about something I’m not hearing about this election cycle, and that’s guns. Where do shootings and school shootings and gun violence fit into this conversation? 

Keith: I think that we have heard a fair bit about guns. It’s part of a laundry list, I guess you could say. In the Kamala Harris stump speech, she talks about freedom. She talks about reproductive freedom. She talks about freedom from being shot, going to the grocery store or at school. That’s where it fits into her stump speech. And certainly in terms of Trump, he is very pro–Second Amendment and has at times commented on the school shootings in ways that come across as insensitive. But for his base — and he is only running for his base — for his base, being very strongly pro–Second Amendment is critical. And I think there was even a question maybe in the Univision town hall yesterday to him about guns. 

It is not the issue in this campaign, but it is certainly an issue if we talk about how much politics have changed in a relatively short period of time. To have a Democratic nominee leaning in on restrictions on guns is a pretty big shift. When Hillary Clinton did it, it was like: Oh, gosh. She’s going there. She lost. I don’t think that’s why she lost, but certainly the NRA [National Rifle Association] spent a lot of money to help her lose. Biden, obviously an author of the assault weapons ban, was very much in that realm, and Harris has continued moving in that direction along with him, though also hilariously saying she has a Glock and she’d be willing to use it 

Ollstein: And emphasizing [Minnesota governor and Democratic vice presidential candidate Tim] Walz’s hunting. 

Keith: Oh, look, Tim Walz, he’s pheasant hunting this weekend. 

Rovner: And unlike John Kerry, he looked like he’d done it before. John Kerry rather famously went out hunting and clearly had not. 

Keith: I was at a rally in 2004 where John Kerry was wearing the jacket, the barn jacket, and the senator, the Democratic senator from Ohio hands him a shotgun, and he’s like … Ehh. 

Kirzinger: I was taken aback when Harris said that she had a Glock. I thought that was a very interesting response for a Democratic presidential candidate. I do think it is maybe part of her appeal to independent voters that, As a gun owner, I support Second Amendment rights, but with limitations. And I do think that that part of appeal, it could work for a more moderate voting block on gun rights. 

Rovner: We haven’t seen this sort of responsible gun owner faction in a long time. I mean, that was the origin of the NRA. 

Keith: But then more recently, Giffords has really taken on that mantle as, We own guns, but we want controls. 

Rovner: All right, well, I could go on for a while, but this is all the time we have. I want to thank you all for coming and helping me celebrate my birthday being a health nerd, because that’s what I do. We do have cake for those of you in the room. For those of you out in podcast land, as always, if you enjoy the podcast, you could subscribe wherever you get your podcast. 

We’d appreciate it if you left us a review. That helps other people find us, too. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman, and our live-show coordinator extraordinaire, Stephanie Stapleton, and our entire live-show team. Thanks a lot. This takes a lot more work than you realize. As always, you can email us your comments or questions. We’re at whatthehealth, all one word, @KFF.org, or you can still find me. I’m at X at @jrovner. Tam, where are you on social media? 

Keith: I’m @tamarakeithNPR. 

Rovner: Alice. 

Ollstein: @AliceOllstein. 

Rovner: Cynthia. 

Cox: @cynthiaccox. 

Rovner: Ashley. 

Kirzinger: @AshleyKirzinger. 

Rovner: We will be back in your feed next week. Until then, be healthy. 

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Y ven a la vicepresidenta y candidata demócrata como la mejor esperanza para preservar el acceso de los estadounidenses a seguros de salud. La cobertura integral que limita los costos directos de los pacientes es la mejor defensa contra el endeudamiento, dicen los expertos.

La administración Biden ha ampliado las protecciones financieras para los pacientes, incluyendo una propuesta histórica de la Oficina de Protección Financiera del Consumidor (CFPB) para eliminar la deuda médica de los informes de crédito de los consumidores.

En 2022, el presidente Joe Biden también firmó la Ley de Reducción de la Inflación, que limita cuánto deben pagar los afiliados de Medicare por medicamentos recetados, incluyendo un tope de $35 al mes para la insulina. Y en legislaturas de todo el país, demócratas y republicanos han trabajado juntos de manera discreta para promulgar leyes que frenen a los cobradores de deudas.

Sin embargo, defensores dicen que el gobierno federal podría hacer más para abordar un problema que afecta a 100 millones de estadounidenses, obligando a muchos a trabajar más, perder sus hogares y reducir el gasto en alimentos y otros artículos esenciales.

“Biden y Harris han hecho más para abordar la crisis de deuda médica en este país que cualquier otra administración”, dijo Mona Shah, directora senior de política y estrategia en Community Catalyst, una organización sin fines de lucro que ha liderado los esfuerzos nacionales para fortalecer las protecciones contra la deuda médica. “Pero hay más por hacer y debe ser una prioridad para el próximo Congreso y administración”.

Al mismo tiempo, los defensores de los pacientes temen que si el ex presidente Donald Trump gana un segundo mandato, debilitará las protecciones de los seguros permitiendo que los estados recorten sus programas de Medicaid o reduciendo la ayuda federal para que los estadounidenses compren cobertura médica. Eso pondría a millones de personas en mayor riesgo de endeudarse si enferman.

En su primer mandato, Trump y los republicanos del Congreso intentaron en 2017 derogar la Ley de Cuidado de Salud a Bajo Precio (ACA), un movimiento que, según analistas independientes, habría despojado de cobertura médica a millones de estadounidenses y habría aumentado los costos para las personas con afecciones preexistentes, como diabetes y cáncer.

Trump y sus aliados del Partido Republicano continúan atacando a ACA, y el ex presidente ha dicho que quiere revertir la Ley de Reducción de la Inflación, que también incluye ayuda para que los estadounidenses de bajos y medianos ingresos compren seguros de salud.

“Las personas enfrentarán una ola de deuda médica por pagar primas y precios de medicamentos recetados”, dijo Anthony Wright, director ejecutivo de Families USA, un grupo de consumidores que ha apoyado las protecciones federales de salud. “Los pacientes y el público deberían estar preocupados”.

La campaña de Trump no respondió a consultas sobre su agenda de salud. Y el ex presidente no suele hablar de atención médica o deuda médica en la campaña, aunque dijo en el debate del mes pasado que tenía “conceptos de un plan” para mejorar la ACA. Trump no ha ofrecido detalles.

Harris ha prometido repetidamente proteger ACA y renovar los subsidios ampliados para las primas mensuales del seguro creados por la Ley de Reducción de la Inflación. Esa ayuda está programada para expirar el próximo año.

La vicepresidenta también ha expresado su apoyo a un mayor gasto gubernamental para comprar y cancelar deudas médicas antiguas de los pacientes. En los últimos años, varios estados y ciudades han comprado deuda médica en nombre de sus residentes.

Estos esfuerzos han aliviado la deuda de cientos de miles de personas, aunque muchos defensores dicen que cancelar deudas antiguas es, en el mejor de los casos, una solución a corto plazo, ya que los pacientes seguirán acumulando facturas que no pueden pagar sin una acción más sustantiva.

“Es un bote con un agujero”, dijo Katie Berge, una cabildera de la Sociedad de Leucemia y Linfoma. Este grupo de pacientes fue una de más de 50 organizaciones que el año pasado enviaron cartas a la administración Biden instando a las agencias federales a tomar medidas más agresivas para proteger a los estadounidenses de la deuda médica.

“La deuda médica ya no es un problema de nicho”, dijo Kirsten Sloan, quien trabaja en política federal para la Red de Acción contra el Cáncer de la Sociedad Americana de Cáncer. “Es clave para el bienestar económico de millones de estadounidenses”.

La Oficina de Protección Financiera del Consumidor está desarrollando regulaciones que prohibirían que las facturas médicas aparezcan en los informes de crédito de los consumidores, lo que mejoraría los puntajes crediticios y facilitaría que millones de estadounidenses alquilen una vivienda, consigan un trabajo o consigan un préstamo para un automóvil.

Harris, quien ha calificado la deuda médica como “crítica para la salud financiera y el bienestar de millones de estadounidenses”, apoyó con entusiasmo la propuesta de regulación. “No se debería privar a nadie del acceso a oportunidades económicas simplemente porque experimentó una emergencia médica”, dijo en junio.

El compañero de fórmula de Harris, el gobernador de Minnesota, Tim Walz, quien ha dicho que su propia familia luchó con la deuda médica cuando era joven, firmó en junio una ley estatal que reprime el cobro de deudas.

Los funcionarios de la CFPB dijeron que las regulaciones se finalizarán a principios del próximo año. Trump no ha indicado si seguiría adelante con las protecciones contra la deuda médica. En su primer mandato, la CFPB hizo poco para abordarla, y los republicanos en el Congreso han criticado durante mucho tiempo a la agencia reguladora.

Si Harris gana, muchos grupos de consumidores quieren que la CFPB refuerce aún más las medidas, incluyendo una mayor supervisión de las tarjetas de crédito médicas y otros productos financieros que los hospitales y otros proveedores médicos han comenzado a ofrecer a los pacientes. Por estos préstamos, las personas están obligadas a pagar intereses adicionales sobre su deuda médica.

“Estamos viendo una variedad de nuevos productos financieros médicos”, dijo April Kuehnhoff, abogada senior del Centro Nacional de Derecho del Consumidor. “Estos pueden generar nuevas preocupaciones sobre las protecciones al consumidor, y es fundamental que la CFPB y otros reguladores supervisen a estas empresas”.

Algunos defensores quieren que otras agencias federales también se involucren.

Esto incluye al enorme Departamento de Salud y Servicios Humanos (HHS), que controla cientos de miles de millones de dólares a través de los programas de Medicare y Medicaid. Ese dinero otorga al gobierno federal una enorme influencia sobre los hospitales y otros proveedores médicos.

Hasta ahora, la administración Biden no ha utilizado esa influencia para abordar la deuda médica.

Pero en un posible anticipo de futuras acciones, los líderes estatales en Carolina del Norte recientemente obtuvieron la aprobación federal para una iniciativa de deuda médica que obligará a los hospitales a tomar medidas para aliviar las deudas de los pacientes a cambio de ayuda gubernamental. Harris elogió la iniciativa.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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That’s what he told me in this week’s episode of the “First Opinion Podcast.” He first started speaking with Alex Oshmyansky — the radiologist who would become his co-founder in Mark Cuban Cost Plus Drugs — around when Shkreli was heading to prison. Cuban asked about how Shkreli radically raised the price of Daraprim, and the answered startled him. According to Cuban, Oshmyansky said, “‘Well, he can buy it and sell it for whatever he wants, particularly since he’s got an exclusive on the manufacturing.’ I’m like, ‘that’s insane. Let me dig some more in.’ And it became quickly obvious that the pharmacy industry is as opaque as any industry … I’ve ever been involved with, and that the easiest way to counteract opacity is transparency.”

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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.

As part of a media blitz aimed at women voters, Vice President Kamala Harris this week rolled out a plan for Medicare to provide in-home long-term care services. It’s popular, particularly for families struggling to care for both young children and older relatives, but its enormous expense has prevented similar plans from being implemented for decades.

Meanwhile, President Joe Biden called out former President Donald Trump by name for having “led the onslaught of lies” about the federal efforts to help people affected by hurricanes Helene and Milton. Even some Republican officials say the misinformation about hurricane relief efforts is threatening public health.

This week’s panelists are Julie Rovner of KFF Health News, Shefali Luthra of The 19th, Jessie Hellmann of CQ Roll Call, and Joanne Kenen of the Johns Hopkins schools of public health and nursing and Politico.

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Jessie Hellmann
CQ Roll Call

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Joanne Kenen
Johns Hopkins University and Politico

@JoanneKenen

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Shefali Luthra
The 19th

@shefalil

Read Shefali's stories.

Among the takeaways from this week’s episode:

• Vice President Kamala Harris’ plan to expand Medicare to cover more long-term care is popular but not new, and in the past has proved prohibitively expensive.
• Former President Donald Trump has abandoned support for a drug price policy he pursued during his first term. The idea, which would lower drug prices in the U.S. to their levels in other industrialized countries, is vehemently opposed by the drug industry, raising the question of whether Trump is softening his hard line on the issue.
• Abortion continues to be the biggest health policy issue of 2024, as Republican candidates — in what seems to be a replay of 2022 — try to distance themselves from their support of abortion bans and other limits. Voters continue to favor reproductive rights, which creates a brand problem for the GOP. Trump’s going back and forth on his abortion positions is an exception to the tack other candidates have taken.
• The Supreme Court returned from its summer break and immediately declined to hear two abortion-related cases. One case pits Texas’ near-total abortion ban against a federal law that requires emergency abortions to be performed in certain cases. The other challenges a ruling earlier this year from the Alabama Supreme Court finding that embryos frozen for in vitro fertilization have the same legal rights as born humans.
• The 2024 KFF annual employer health benefits survey, released this week, showed a roughly 7% increase in premiums, with average family premiums now topping $25,000 per year. And that’s with most employers not covering two popular but expensive medical interventions: GLP-1 drugs for weight loss and IVF.

Also this week, excerpts from a KFF lunch with “Shark Tank” panelist and generic drug discounter Mark Cuban, who has been consulting with the Harris campaign about health care issues.

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’ “A Boy’s Bicycling Death Haunts a Black Neighborhood. 35 Years Later, There’s Still No Sidewalk,” by Renuka Rayasam and Fred Clasen-Kelly.

Shefali Luthra: The 19th’s “Arizona’s Ballot Measure Could Shift the Narrative on Latinas and Abortion,” by Mel Leonor Barclay.

Jessie Hellmann: The Assembly’s “Helene Left Some NC Elder-Care Homes Without Power,” by Carli Brosseau.

Joanne Kenen: The New York Times’ “Her Face Was Unrecognizable After an Explosion. A Placenta Restored It,” by Kate Morgan.

Also mentioned on this week’s podcast:

• The New York Times’ “Biden Accuses Trump of ‘Outright Lies’ About Hurricane Response,” by Michael D. Shear.
• The Miami Herald’s “Florida Threatens To Prosecute TV Stations Over Abortion Ad. FCC Head Calls It ‘Dangerous,’” by Claire Healy and Ana Ceballos.
• KFF’s “2024 Employer Health Benefits Survey.”

Click to open the Transcript

Transcript: Yet Another Promise for Long-Term Care Coverage

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It 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, October 10th, at 10 a.m. As always, news happens fast, and things might’ve changed by the time you hear this. So, here we go. 

Today we are joined via teleconference by Shefali Luthra of The 19th. 

Shefali Luthra: Hello. 

Rovner: Jesse Hellmann of CQ Roll Call. 

Jessie Hellmann: Hi there. 

Rovner: And Joanne Kenen of the Johns Hopkins Schools of Public Health and Nursing and Politico magazine. 

Joanne Kenen: Hi everybody. 

Rovner: Later in this episode, we’ll have some excerpts from the Newsmaker lunch we had here at KFF this week with Mark Cuban — “Shark Tank” star, part-owner of the Dallas Mavericks NBA team, and, for the purposes of our discussion, co-founder of the industry-disrupting pharmaceutical company Cost Plus Drugs. But first, this week’s news. 

We’re going to start this week with Vice President [Kamala] Harris, who’s been making the media rounds on women-focused podcasts and TV shows like “The View.” To go along with that, she’s released a proposal to expand Medicare to include home-based long-term care, to be paid for in part by expanding the number of drugs whose price Medicare can negotiate. Sounds simple and really popular. Why has no one else ever proposed something like that? she asks, knowing full well the answer. Joanne, tell us! 

Kenen: As the one full-fledged member of the sandwich generation here, who has lived the experience of being a family caregiver while raising children and working full time, long-term care is the unfulfillable, extremely expensive, but incredibly important missing link in our health care system. We do not have a system for long-term care, and people do not realize that. Many people think Medicare will, in fact, cover it, where Medicare covers it in a very limited, short-term basis. So the estimates of what families spend both in terms of lost work hours and what they put out-of-pockets is in, I think it’s something like $400 billion. It’s extraordinarily high. But the reason it’s been hard to fix is it’s extraordinarily expensive. And although Harris put out a plan to pay for this, that plan is going to have to be vetted by economists and budget scorers and skeptical Republicans. And probably some skeptical Democrats. It’s really expensive. It’s really hard to do. Julie has covered this for years, too. It’s just— 

Rovner: I would say this is where I get to say one of my favorite things, which is that I started covering health care in 1986, and in 1986 my first big feature was: Why don’t we have a long-term care policy in this country? Thirty-eight years later, and we still don’t, and not that people have not tried. There, in fact, was a long-term-care-in-the-home piece of the Affordable Care Act that passed Congress, and HHS [the Department of Health and Human Services] discovered that they could not implement it in the way it was written, because only the people who would’ve needed it would’ve signed up for it. It would’ve been too expensive. And there it went. So this is the continuing promise of something that everybody agrees that we need and nobody has ever been able to figure out how to do. Shefali, I see you nodding here. 

Luthra: I mean, I’m just thinking again about the pay-fors in here, which are largely the savings from Medicare negotiating drug prices. And what Harris says in her plan is that they’re going to get more savings by expanding the list of drugs that get lower prices. But that also feels very politically suspect when we have already heard congressional Republicans say that they would like to weaken some of those drug negotiation price provisions. And we also know that Democrats, even if they win the presidency, are not likely to have Congress. It really takes me back to 2020, when we are just talking about ideas that Democrats would love to do if they had full power of Congress, while all of us in Washington kind of know that that is just not going to happen. 

Rovner: Yes, I love that one of the pay-fors for this is cutting Medicare fraud. It’s like, where have we heard that before? Oh, yes. In every Medicare proposal for the last 45 years. 

Kenen: And it also involves closing some kind of international tax loopholes, and that also sounds easy on paper, and nothing with taxes is ever easy. The Democrats probably are not going to have the Senate. Nobody really knows about the House. It looks like the Democrats may have a narrow edge in that, but we’re going to have more years of gridlock unless something really changes politically, like something extraordinary changes politically. The Republicans are not going to give a President Harris, if she is in fact President Harris, her wish list on a golden platter. On the other hand there’s need for this. 

Rovner: But in fairness, this is what the campaign is for. 

Kenen: Right. There is a need for something on long-term care. 

Rovner: And everybody’s complaining: Well, what would she do? What would she do if she was elected? Well, here’s something she said she would do if she could, if she was elected. Well, meanwhile, former President [Donald] Trump has apparently abandoned a proposal that he made during his first term to require drugmakers to lower their prices for Medicare to no more than they charge in other developed countries where their prices are government-regulated. Is Trump going soft on the drug industry? Trump has been, what, the Republican, I think, who’s been most hostile towards the drug industry until now. 

Hellmann: I would say maybe. I think the “most favored nation” proposal is something that the pharmaceutical industry has feared even more than the Democrats’ Medicare negotiation program. And it’s something that Trump really pursued in his first term but wasn’t able to get done. In such a tight race, I think he’s really worried about angering pharmaceutical companies, especially after they were just kind of dealt this loss with Medicare price negotiation. And if he does win reelection, he’s going to be kind of limited in his ability to weaken that program. It’s going to be hard to repeal it. It’s extremely popular, and he may be able to weaken it. 

Rovner: “It” meaning price negotiation, not the “most favored nations” prices. 

Hellmann: Yeah. It’s going to be really hard to repeal that, and he may be able to weaken it through the negotiation process with drug companies. It’s definitely an interesting turn. 

Rovner: Joanne, you want to add something? 

Kenen: Trump rhetorically was very harsh on the drug companies right around the time of his inauguration. I think it was the week before, if I remember correctly. Said a lot of very tough stuff on drugs. Put out a list of something like dozens of potential steps. The drug companies have lots of allies in both parties, and more in one than the other, but they have allies on the Hill, and nothing revolutionary happened on drug pricing under Trump. 

Rovner: And his HHS secretary was a former drug company executive. 

Kenen: Yes, Eli Lilly. So we also pointed out here that former President Trump is not consistent in policy proposals. He says one thing, and then he says another thing, and it’s very hard to know where he’s going to come down. So Trump and drug pricing is an open question. 

Rovner: Yes, we will see. All right, well, moving on. Drug prices and Medicare aside, the biggest health issue of Campaign 2024 continues to be abortion and other reproductive health issues. And it’s not just Trump trying to back away from his anti-abortion record. We’ve had a spate of stories over the past week or so of Republicans running for the House, the Senate, and governorships who are trying to literally reinvent themselves as, if not actually supportive of abortion rights, at least anti abortion bans. And that includes Republicans who have not just voted for and advocated for bans but who have been outspokenly supportive of the anti-abortion effort, people like North Carolina Republican gubernatorial candidate Mark Robinson, New Hampshire Republican gubernatorial candidate and former U.S. Senator Kelly Ayotte, along with former Michigan Republican representative and now Senate candidate Mike Rogers. Donald Trump has gotten away repeatedly, as Joanne just said, with changing his positions, even on hot-button issues like abortion. Are these candidates going to be able to get away with doing the same thing, Shefali? 

Luthra: I think it’s just so much tougher when your name is not Donald Trump. And that’s because we know from focus group after focus group, and survey after survey, that voters kind of give Trump more leeway on abortion. Especially independent voters will look at him and say, Well, I don’t think he actually opposes abortion, because I’m sure he’s paid for them. And they don’t have that same grace that they give to Republican lawmakers and Republican candidates, because the party has a bad brand on abortion at large, and Trump is seen as this kind of maverick figure. But voters know that Republicans have a history of opposing abortion, of supporting restrictions. 

When you look at surveys, when you talk to voters, what they say is, Well, I don’t trust Republicans to represent my interests on this issue, because they largely support access. And one thing that I do think is really interesting is, once again, what we’re seeing is kind of a repeat of the 2022 elections when we saw some very brazen efforts by Republican candidates for the House and Senate try and scrub references to abortion and to fetal personhood from their websites. And it didn’t work, because people have eyes and people have memories, and, also, campaigns have access to the internet archive and are able to show people that, even a few weeks ago, Republican candidates were saying something very different from what they are saying now. I don’t think Mark Robinson can really escape from his relatively recent and very public comments about abortion. 

Rovner: Well, on the other hand, there’s some things that don’t change. Republican vice presidential candidate JD Vance told RealClearPolitics last week that if Trump is elected again, their administration would cut off funding to Planned Parenthood because, he said, and I quote, “We don’t think that taxpayers should fund late-term abortions.” Notwithstanding, of course, that even before the overturn of Roe, less than half of all Planned Parenthoods even performed abortions and almost none of those who did perform them later in pregnancy. Is it fair to say that Vance’s anti-abortion slip is showing? 

Luthra: I think it might be. And I will say, Julie, when I saw that he said that, I could hear you in my head just yelling about the Hyde Amendment, because we know that Planned Parenthood does not use taxpayer money to pay for abortions. But we also know that JD Vance has seen that he and his ticket are kind of in a tough corner talking about abortion. He has said many times, We need to rebrand — he’s very honest about that, at least — and trying to focus instead on this nonmedical term of “late term” abortions. 

It’s a gamble. It’s hoping that voters will be more sympathetic to that because they’ll think, Oh, well, that sounds very extreme. And they’re trying to shift back who is seen as credible and who is not, by focusing on something that historically was less popular. But again, it’s again tricky because when we look at the polling, voters’ understanding of abortion has shifted and they are now more likely to understand that when you have an abortion later in pregnancy, it is often for very medically complex reasons. And someone very high-profile who recently said that is Melania Trump in her new memoir, talking about how she supports abortion at all stages of pregnancy because often these are very heart-wrenching cases and not sort of the murder that Republicans have tried to characterize them as. 

Rovner: I think you’re right. I think this is the continuation of the 2022 campaign, except that we’ve had so many more women come forward. We’ve seen actual cases. It used to be anti-abortion forces would say, Oh, well, this never happened. I mean, these are wrenching, awful things that happened to a lot of these patients with pregnancy complications late in pregnancy. And it is, I know, because I’ve talked to them. It’s very hard to get them to talk publicly, because then they get trolled. Why should they step forward? 

Well, now we’ve seen a lot of these women stepping forward. So we now see a public that knows that this happens, because they’re hearing from the people that it’s happened to and they’re hearing from their doctors. I do know also from the polling that there are people who are going to vote in these 10 states where abortion is on the ballot. Many of them are going to vote for abortion access and then turn around and vote for Republicans who support restrictions, because they’re Republicans. It may or may not be their most important issue, but I still think it’s a big question mark where that happens and how it shakes out. Joanne, did you want to add something? 

Kenen: You’re seeing two competing things at the same time. You have a number of Republicans trying to moderate their stance or at least sound like they’re moderating their stance. At the same time, you also have the whole, where the Republican Party is on abortion has shifted to the right. They are talking about personhood at the moment of conception, the embryo — which is, scientifically put, a small ball of cells still at that point — that they actually have the same legal rights as any other post-birth person. 

So that’s become a fairly common view in the Republican Party, as opposed to something that just five or six years ago was seen as the fringe. And Trump is going around saying that Democrats allow babies to be executed after birth, which is not true. And they’re particularly saying this is true in Minnesota because of [Gov.] Tim Walz, and some voters must believe it, right? Because they keep saying it. So you have this trend that Shefali just described and that you’ve described, Julie, about this sort of attempting to win back trust, as Vance said. And it sounded more moderate, and at the same time as you’re hearing this rhetoric about personhood and execution. So I don’t think the Republicans have yet solved their own whiplash post-Roe. 

Rovner: Meanwhile, the abortion debate is getting mired in the free-speech debate. In Florida, Republican governor Ron DeSantis is threatening legal action against TV stations airing an ad in support of the ballot measure that would overturn the state’s six-week abortion ban. That has in turn triggered a rebuke from the head of the Federal Communications Commission warning that political speech is still protected here in the United States. Shefali, this is really kind of out there, isn’t it? 

Luthra: It’s just so fascinating, and it’s really part of a bigger effort by Ron DeSantis to try and leverage anything that he can politically or, frankly, in his capacity as head of the state to try and weaken the campaign for the ballot measure. They have used the health department in other ways to try and send out material suggesting that the campaign’s talking points, which are largely focused on the futility of exceptions to the abortion ban, they’re trying to argue that that is misinformation, and that’s not true. And they’re using the state health department to make that argument, which is something we don’t really see very often, because usually health departments are supposed to be nonpartisan. And what I will say is, in this case, at least to your point, Julie, the FCC has weighed in and said: You can’t do this. You can’t stop a TV station from airing a political ad that was bought and paid for. And the ads haven’t stopped showing at this point. I just heard from family yesterday in Florida who are seeing the ads in question on their TV, and it’s still— 

Rovner: And I will post a link to the ad just so you can see it. It’s about a woman who’s pregnant and had cancer and needed cancer treatment and needed to terminate the pregnancy in order to get the cancer treatment. It said that the exception would not allow her to, which the state says isn’t true and which is clearly one of these things that is debatable. That’s why we’re having a political debate. 

Luthra: Exactly. And one thing that I think is worth adding in here is, I mean, this really intense effort from Governor DeSantis and his administration comes at a time when already this ballot measure faces probably the toughest fight of any abortion rights measure. And we have seen abortion rights win again and again at the ballot, but in Florida you need 60% to pass. And if you look across the country at every abortion rights measure that has been voted on since Roe v. Wade was overturned, only two have cleared 60, and they are in California and they are in Vermont. So these more conservative-leaning states, and Florida is one of them, it’s just, it’s really, really hard to see how you get to that number. And we even saw this week there’s polling that suggests that the campaign has a lot of work to do if they’re hoping to clear that threshold. 

Rovner: And, of course, now they have two hurricanes to deal with, which we will deal with in a few minutes. But first, the Supreme Court is back in session here in Washington, and even though there’s no big abortion case on its official docket as of now this term, the court quickly declined to hear two cases on its first day back, one involving whether the abortion ban in Texas can override the federal emergency treatment law that’s supposed to guarantee abortion access in medical emergencies threatening the pregnant woman’s life or health. The court also declined to overrule the Alabama Supreme Court’s ruling that frozen embryos can be considered legally as unborn children. That’s what Joanne was just talking about. Where do these two decisions leave us? Neither one actually resolved either of these questions, right? 

Luthra: I mean, the EMTALA [Emergency Medical Treatment and Labor Act] question is still ongoing, not because of the Texas case but because of the Idaho case that is asking very similar questions that we’ve talked about previously on this podcast. And the end of last term, the court kicked that back down to the lower courts to continue making its way through. We anticipate it will eventually come back to the Supreme Court. So this is a question that we will, in fact, be hearing on at some point. 

Rovner: Although, the irony here is that in Idaho, the ban is on hold because there was a court stay. And in Texas, the ban is not on hold, even though we’re talking about exactly the same question: Does the federal law overrule the state’s ban? 

Luthra: And what that kind of highlights — right? — is just how much access to abortion, even under states with similar laws or legislatures, really does depend on so many factors, including what circuit court you fall into or the makeup of your state Supreme Court and how judges are appointed or whether they are elected. There is just so much at play that makes access so variable. And I think the other thing that one could speculate that maybe the court didn’t want headlines around reproductive health so soon into an election, but it’s not as if this is an issue that they’re going to be avoiding in the medium- or long-term future. These are questions that are just too pressing, and they will be coming back to the Supreme Court in some form. 

Rovner: Yes, I would say in the IVF [in vitro fertilization] case, they simply basically said, Go away for now. Right? 

Luthra: Yeah. And, I mean, right now in Alabama, people are largely able to get IVF because of the state law that was passed, even if it didn’t touch the substance of that state court’s ruling. This is something, for now, people can sort of think is maybe uninterrupted, even as we all know that the ideological and political groundwork is being laid for a much longer and more intense fight over this. 

Rovner: Well, remember back last week when we predicted that the judge’s decision overturning Georgia’s six-week ban was unlikely to be the last word? Well, sure enough, the Georgia Supreme Court this week overturned the immediate overturning of the ban, which officially went back into effect on Monday. Like these other cases, this one continues, right? 

Luthra: Yes, this continues. The Georgia case continued for a while, and it just sort of underscores again what we’ve been talking about, just how much access really changes back and forth. And I was talking to an abortion clinic provider who has clinics in North Carolina and Georgia. She literally found out about the decision both times and changed her plans for the next day because I texted her asking her for comment. And providers and patients are being tasked with keeping up with so much. And it’s just very, very difficult, because Georgia also has a 24-hour waiting period for abortions, which means that every time the decision around access has changed — and we know it very well could change again as this case progresses — people will have to scramble very quickly. And in Georgia, they have also been trying to do that on top of navigating the fallout of a hurricane. 

Rovner: Yeah. And as we pointed out a couple of weeks ago when the court overturned the North Dakota ban, there are no abortion providers left in North Dakota. Now that there’s no ban, it’s only in theory that abortion is now once again allowed in North Dakota. Well, before we leave abortion for this week, we have two new studies showing how abortion bans are impacting the health care workforce. In one survey, more than half of oncologists, cancer doctors, who were completing their fellowships, so people ready to go into practice, said they would consider the impact of abortion restrictions in their decisions about where to set up their practice. And a third said abortion restrictions hindered their ability to provide care. 

Meanwhile, a survey of OBGYNs in Texas by the consulting group Manatt Health found “a significant majority of practicing OB/GYN physicians … believe that the Texas abortion laws have inhibited their ability to provide highest-quality and medically necessary care to their patients,” and that many have already made or are considering making changes to their practice that would “reduce the availability of OB/GYN care in the state.” What’s the anti-abortion reaction to this growing body of evidence that abortion bans are having deleterious effects on the availability of other kinds of health care, too? I mean, I was particularly taken by the oncologists, the idea that you might not be able to get cancer care because cancer doctors are worried about treating pregnant women with cancer. 

Luthra: They’re blaming the doctors. And we saw this in Texas when the Zurawski case was argued and women patients and doctors in the state said that they had not been able to get essential, lifesaving medical care because of the state’s abortion ban and lack of clarity around what was actually permitted. And the state argued, and we have heard this talking point again and again, that actually the doctors are just not willing to do the hard work of practicing medicine and trying to interpret, Well, obviously this qualifies. That’s something we’ve seen in the Florida arguments. They say: Our exceptions are so clear, and if you aren’t able to navigate these exceptions, well, that’s your problem, because you are being risk-averse, and patients should really take this up with their doctors, who are just irresponsible. 

Rovner: Yes, this is obviously an issue that’s going to continue. Well, moving on. The cost of health care continues to grow, which is not really news, but this week we have more hard evidence, courtesy of my KFF colleagues via the annual 2024 Employer Health Benefit Survey, which finds the average family premium rose 7% this year to $25,572, with workers contributing an average of $6,296 towards that cost. And that’s with a distinct minority of firms covering two very popular but very expensive medical interventions, GLP-1 [glucagon-like peptide-1] drugs for obesity and IVF, which we’ve just been talking about. Anything else in this survey jump out at anybody? 

Hellmann: I mean, that’s just a massive amount of money. And the employer is really paying the majority of that, but that doesn’t mean it doesn’t have an impact on people. That means it’s going to limit how much your wages go up. And something I thought of when I read this study is these lawsuits that we’re beginning to see, accusing employers of not doing enough to make sure that they’re limiting health care costs. They’re not playing enough of a role in what their benefits look like. They’re kind of outsourcing this to consultants. And so when you look at this data and you see $25,000 they’re spending per year per family on health care premiums, you wonder, what are they doing? 

Health care, yes, it’s obviously very expensive, but you just kind of question, what role are employers actually playing in trying to drive down health care costs? Are they just taking what they get from consultants? And another thing that kind of stood out to me from this is, I think it’s said in there, employers are having a hard time lately of passing these costs on to employees, which is really interesting. It’s because of the tight labor market. But obviously health care is still very expensive for employees — $6,000 a year in premiums for family coverage is not a small amount of money. So employers are just continuing to absorb that, and it does really impact everyone. 

Rovner: It’s funny. Before the Affordable Care Act, it was employers who were sort of driving the, You must do something about the cost of health care, because inflation was so fast. And then, of course, we saw health care inflation, at least, slow down for several years. Now it’s picking up again. Are we going to see employers sort of getting back into this jumping up and down and saying, “We’ve got to do something about health care costs”? 

Hellmann: I feel like we are seeing more of that. You’re beginning to hear more from employers about it. I don’t know. It’s just such a hard issue to solve, and I’ve seen more and more interest from Congress about this, but they really struggle to regulate the commercial market. So … 

Rovner: Yes, as we talk about at length every week. But it’s still important, and they will still go for it. Well, finally, this week in health misinformation. Let us talk about hurricanes — the public health misinformation that’s being spread both about Hurricane Helene that hit the Southeast two weeks ago, and Hurricane Milton that’s exiting Florida even as we are taping this morning. President [Joe] Biden addressed the press yesterday from the White House, calling out former President Trump by name along with Georgia Republican congresswoman Marjorie Taylor Greene for spreading deliberate misinformation that’s not just undermining efforts at storm relief but actually putting people in more danger. Now, I remember Hurricane Katrina and all the criticism that was heaped, mostly deservedly, on George W. Bush and his administration, but I don’t remember deliberate misinformation like this. I mean, Joanne, have you ever seen anything like this? You lived in Florida for a while. 

Kenen: I went through Andrew, and there’s always a certain — there’s confusion and chaos after a big storm. But there’s a difference between stuff being wrong that can be corrected and stuff being intentionally said that then in this sort of divided, suspicious, two-realities world we’re now living in, that’s being repeated and perpetuated and amplified. It damages public health. It damages people economically trying to recover from this disastrous storm or in some cases storms. I don’t know how many people actually believe that Marjorie Taylor asserted that the Democrats are controlling the weather and sending storms to suppress Republican voters. She still has a following, right? But other things … 

Rovner: She still gets reelected. 

Kenen: … being told that if you go to FEMA [the Federal Emergency Management Agency] for help, your property will be confiscated and taken away from you. I mean, that’s all over the place, and it’s not true. Even a number of Republican lawmakers in the affected states have been on social media and making statements on local TV and whatever, saying: This is not true. Please, FEMA is there to help you. Let’s get through this. Stop the lies. A number of Republicans have actually been quite blunt about the misinformation coming from their colleagues and urging their constituents to seek and take the help that’s available. 

This is the public health crisis. We don’t know how many people have been killed. I don’t think we have an accurate total final count from Helene, and we sure don’t have from Milton. I mean, the people did seem to take this storm seriously and evacuated, but it also spawned something like three dozen tornadoes in places where people hadn’t been told, there’s normally no need to evacuate. There’s flooding. It’s a devastating storm. So when people are flooding, power outages, electricity, hard to get access to health care, you can’t refrigerate your insulin. All these— 

Rovner: Toxic floodwaters, I mean, the one thing … 

Kenen: Toxic, yeah. 

Rovner: … we know about hurricanes is that they’re more dangerous in the aftermath than during the actual storm in terms of public health. 

Kenen: Right. This is a life-threatening public health emergency to really millions of people. And misinformation, not just getting something wrong and then trying to correct it, but intentional disinformation, is something we haven’t seen before in a natural disaster. And we’re only going to have more natural disasters. And it was really — I mean, Julie, you already pointed this out — but it was really unusual how precise Biden was yesterday in calling out Trump by name, and I believe at two different times yesterday. So I heard one, but I think I read about what I think was the second one really saying, laying it at his feet that this is harming people. 

Rovner: Yeah, like I said, I remember Katrina vividly, and that was obviously a really devastating storm. I do also remember Democrats and Republicans, even while they were criticizing the federal government reaction to it, not spreading things that were obviously untrue. All right. Well, that is the news for this week. Now we will play a segment from our Newsmaker interview with Mark Cuban, and then we will be back with our extra credits. 

On Tuesday, October 8th, Mark Cuban met with a group of reporters for a Newsmaker lunch at KFF’s offices in Washington, D.C. Cuban, a billionaire best known as a panelist on the ABC TV show “Shark Tank,” has taken an interest in health policy in the past several years. He’s been consulting with the campaign of Vice President Harris, although he says he’s definitely not interested in a government post if she wins. Cuban started out talking about how, as he sees it, the biggest problem with drug prices in the U.S. is that no one knows what anyone else is paying. 

Mark Cuban: I mean, when I talk to corporations and I’ve tried to explain to them how they’re getting ripped off, the biggest of the biggest said, Well, so-and-so PBM [pharmacy benefit manager] is passing through all of their rebates to us. 

And I’m like: Does that include the subsidiary in Scotland or Japan? Is that where the other one is? 

I don’t know. 

And it doesn’t. By definition, you’re passing through all the rebates with the company you contracted with, but they’re not passing through all the rebates that they get or that they’re keeping in their subsidiary. And so, yeah, I truly, truly believe from there everybody can argue about the best way. Where do you use artificial intelligence? Where do you do this? What’s the EHR [electronic health record? What’s this? We can all argue about best practices there. But without a foundation of information that’s available to everybody, the market’s not efficient and there’s no place to go. 

Rovner: He says his online generic drug marketplace, costplusdrugs.com, is already addressing that problem. 

Cuban: The crazy thing about costplusdrugs.com, the greatest impact we had wasn’t the markup we chose or the way we approach it. It’s publishing our price list. That changed the game more than anything. So when you saw the FTC [Federal Trade Commission] go after the PBMs, they used a lot of our pricing for all the non-insulin stuff. When you saw these articles written by the Times and others, or even better yet, there was research from Vanderbilt, I think it was, that says nine oncology drugs, if they were purchased by Medicare through Cost Plus, would save $3.6 billion. These 15, whatever drugs would save six-point-whatever billion. All because we published our price list, people are starting to realize that things are really out of whack. And so that’s why I put the emphasis on transparency, because whether it’s inside of government or inside companies that self-insure, in particular, they’re going to be able to see. The number one rule of health care contracts, particularly PBM contracts, is you can’t talk about PBM contracts. 

Rovner: Cuban also says that more transparency can address problems in the rest of the health care system, not just for drug prices. Here’s how he responded to a question I asked describing his next big plan for health care. 

We’ve had, obviously, issues with the system being run by the government not very efficiently and being run by the private sector not very efficiently. 

Cuban: Very efficiently, yeah. 

Rovner: And right now we seem to have this sort of working at cross-purposes. If you could design a system from the ground up, which would you let do it? The government or— 

Cuban: I don’t think that’s really the issue. I think the issue is a lack of transparency. And you see that in any organization. The more communication and the more the culture is open and transparent, the more people hold each other responsible. And I think you get fiefdoms in private industry and you get fiefdoms in government, as well, because they know that if no one can see the results of their work, it doesn’t matter. I can say my deal was the best and I did the best and our outcomes are the best, but there’s no way to question it. And so talking to the Harris campaign, it’s like if you introduce transparency, even to the point of requiring PBMs and insurers to publish their contracts publicly, then you start to introduce an efficient market. And once you have an efficient market, then people are better able to make decisions and then you can hold them more accountable. 

And I think that’s going to spill over beyond pharm. We’re working on — it’s not a company — but we’re working on something called Cost Plus Wellness, where we’re eating our own dog food. And it’s not a company that’s going to be a for-profit or even a nonprofit, for that matter, just for the lives that I cover for my companies, that we self-insure. We’re doing direct contracting with providers, and we’re going to publish those contracts. And part and parcel to that is going through the — and I apologize if I’m stumbling here. I haven’t slept in two days, so bear with me. But going through the hierarchy of care and following the money, if you think about when we talk to CFOs and CEOs of providers, one of the things that was stunning to me that I never imagined is the relationship between deductibles for self-insured companies and payers, and the risk associated with collecting those deductibles to providers. 

And I think people don’t really realize the connection there. So whoever does Ann’s care [KFF Chief Communications Officer Ann DeFabio, who was present] — well, Kaiser’s a little bit different, but let’s just say you’re employed at The Washington Post or whoever and you have a $2,500 deductible. And something happens. Your kid breaks their leg and goes to the hospital, and you’re out of market, and it’s out of network. Well, whatever hospital you go to there, you might give your insurance card, but you’re responsible for that first $2,500. And that provider, depending on where it’s located, might have collection — bad debt, rather — of 50% or more. 

So what does that mean in terms of how they have to set their pricing? Obviously, that pricing goes up. So there’s literally a relationship between, particularly on pharmacy, if my company takes a bigger rebate, which in turn means I have a higher deductible because there’s less responsibility for the PBM-slash-insurance company. My higher deductible also means that my sickest employees are the ones paying that deductible, because they’re the ones that have to use it. And my older employees who have ongoing health issues and have chronic illnesses and need medication, they’re paying higher copays. But when they have to go to the hospital with that same deductible, because I took more of a rebate, the hospital is taking more of a credit risk for me. That’s insane. That makes absolutely no sense. 

And so what I’ve said is as part of our wellness program and what we’re doing to — Project Alpo is what we call it, eating our own dog food. What I’ve said is, we’ve gone to the providers and said: Look, we know you’re taking this deductible risk. We’ll pay you cash to eliminate that. But wait, there’s more. We also know that when you go through a typical insurer, even if it’s a self-insured employer using that insurer and you’re just using the insurance company not for insurance services but as a TPA [third-party administrator], the TPA still plays games with the provider, and they underpay them all the time. 

And so what happens as a result of the underpayment is that provider has to have offices and offices full of administrative assistants and lawyers, and they have to not only pay for those people, but they have the associated overhead and burden and the time. And then talking to them, to a big hospital system, they said that’s about 2% of their revenue. So because of that, that’s 2%. Then, wait, there’s more. You have the pre-ops, and you have the TPAs who fight you on the pre-ops. But the downstream economic impacts are enormous because, first, the doctor has to ask for the pre-op. That’s eating doctor’s time, and so they see fewer patients. And then not only does the doctor have to deal with them, they go to HR at the company who self-insures and says, Wait, my employee can’t come to work, because their child is sick, and you won’t approve this process or, whatever, this procedure, because it has to go through this pre-op. 

Or if it’s on medications, it’s you want to go through the step-up process or you want to go through a different utilization because you get more rebates. All these pieces are intertwined, and we don’t look at it holistically. And so what we’re saying with Cost Plus Wellness is, we’re going to do this all in a cash basis. We’re going to trust doctors so that we’re not going to go through a pre-op. Now we’ll trust but verify. So as we go through our population and we look at all of our claims, because we’ll own all of our claims, we’re going to look to see if there are repetitive issues with somebody who’s just trying to —there’s lots of back surgeries or there’s lots of this or there’s lots of that — to see if somebody’s abusing us. And because there’s no deductible, we pay it, and we pay it right when the procedure happens or right when the medication is prescribed. Because of all that, we want Medicare pricing. Nobody’s saying no. And in some cases I’m getting lower than Medicare pricing for primary care stuff. 

Rovner: OK, we are back. Now it’s time for our extra credits. That’s when we each recommend a story we read this week we think you should read too. Don’t worry if you miss the details. We will include the links to all these stories in our show notes on your phone or other device. Joanne, why don’t you go first this week. 

Kenen: There was a fascinating story in The New York Times by Kate Morgan. The headline was “Her Face Was Unrecognizable After an Explosion. A Placenta Restored It.” So I knew nothing about this, and it was so interesting. Placentas have amazing healing properties for wound care, burns, infections, pain control, regenerating skin tissue, just many, many things. And it’s been well known for years, and it’s not widely used. This is a story specifically about a really severe burn victim in a gas explosion and how her face was totally restored. We don’t use this, partly because placenta — every childbirth, there’s a placenta. There are lots of them around. There’s I think three and a half million births a year, or that’s the estimate I read in the Times. One of the reasons they weren’t being used is, during the AIDS crisis, there was some development toward using them, and then the AIDS crisis, there was a fear of contamination and spreading the virus, and it stopped decades later. 

We have a lot more ways of detecting, controlling, figuring out whether something’s contaminated by AIDS or whether a patient has been exposed. It is being used again on a limited basis after C-sections, but it seems to have pretty astonishing — think about all the wound care for just diabetes. I’m not a scientist, but I just looked at the story and said, it seems like a lot of people could be healed quicker and more safely and earlier if this was developed. They’re thrown away now. They’re sent to hospital waste incinerators and biohazard waste. They’re garbage, and they’re actually medicine. 

Rovner: Definitely a scientist’s cool story. Shefali. 

Luthra: My story is from my brilliant colleague Mel Leonor Barclay. The headline is “Arizona’s Ballot Measure Could Shift the Narrative on Latinas and Abortion,” and as part of this really tremendous series that she has running this week, looking at how Latinas as a much more influential and growingly influential voter group could shape gun violence, abortion rights, and housing. And in this story, which I really love, she went to Arizona and spent time talking to folks on all sides of the issue to better understand how Latinas are affected by abortion rights and also how they’ll be voting on this. 

And she really challenges the narrative that has existed for so long, which is that Latinas are largely Catholic, largely more conservative on abortion. And she finds something much more complex, which is that actually polls really show that a large share of Latina voters in Arizona and similar states support abortion rights and will be voting in favor of measures like the Arizona constitutional amendment. But at the same time, there are real divides within the community, and people talk about their faith in a different way and how it connects their stance on abortion. They talk about their relationships with family in different ways, and I think it just underscores how rarely Latina voters are treated with real nuance and care and thoughtfulness when talking about something as complex as abortion and abortion politics. And I really love the way that she approaches this piece. 

Rovner: It was a super-interesting story. Jesse. 

Hellmann: My story is from The Assembly. It’s an outlet in North Carolina. It’s called “Helene Left Some North Carolina Elder-Care Homes Without Power.” Some assisted living facilities have been without power and water since the hurricane hit. Several facilities had to evacuate residents, and the story just kind of gets into how North Carolina has more lax rules around emergency preparedness. While they do require nursing homes be prepared to provide backup power, the same requirements don’t apply to assisted living facilities. And it’s because there’s been industry pushback against that because of the cost. But as we see some more of these extreme weather events, it seems like something has to be done. We cannot just allow vulnerable people living in these facilities to go hours and hours without power and water. And I saw that there was a facility where they evacuated dozens of people who had dementia, and that’s just something that’s really upsetting and traumatizing for people. 

Rovner: Yeah, once again, now we are seeing these extreme weather events in places that, unlike Florida and Texas, are not set up and used to extreme weather events. And it is something I think that a lot of people are starting to think about. Well, my story this week is from our KFF Health News public health project called Health Beat, and it’s called “A Boy’s Bicycling Death Haunts a Black Neighborhood. 35 Years Later, There’s Still No Sidewalk,” by Renuka Rayasam and Fred Clasen-Kelly. And it’s one of those stories you never really think about until it’s pointed out that in areas, particularly those that had been redlined, in particular, the lack of safety infrastructure that most of us take for granted — crosswalks, sidewalks, traffic lights are not really there. And that’s a public health crisis of its own, and it’s one that rarely gets addressed, and it’s a really infuriating but a really good story. 

All right, that is our show. Next week, for my birthday, we’re doing a live election preview show here at KFF in D.C., because I have a slightly warped idea of fun. And you’re all invited to join us. I will put a link to the RSVP in the show notes. I am promised there will be cake. 

As always, if you enjoy the podcast, you can subscribe wherever you get your podcast. We’d appreciate it if you left us a review. That helps other people find us, too. Thanks as always to our technical guru, Francis Ying, and our fill-in editor this week, Stephanie Stapleton. Also, as always, you can email us your comments or questions. We’re at whatthehealth, all one word, @kff.org, or you can still find me for the moment at X. I’m @jrovner. Joanne, where are you? 

Kenen: @JoanneKenen sometimes on Twitter and @joannekenen1 on Threads.

Rovner: Jessie.

Hellmann: @jessiehellmann on Twitter.

Rovner: Shefali.

Luthra: @shefalil on Twitter.

Rovner: We will be back in your feed next week. Until then, be healthy.

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Most employers have little idea what the pharmacy benefit managers they hire do with the money they exchange for the medications used by their employees, according to a KFF survey released Wednesday morning.

In KFF’s latest employer health benefits survey, company officials were asked how much of the rebates collected from drugmakers by pharmacy benefit managers, or PBMs, is returned to them. In recent years, the pharmaceutical industry has tried to deflect criticism of high drug prices by saying much of that income is siphoned off by the PBMs, companies that manage patients’ drug benefits on behalf of employers and health plans.

PBM leaders say they save companies and patients billions of dollars annually by obtaining rebates from drugmakers that they pass along to employers. Drugmakers, meanwhile, say they raise their list prices so high in order to afford the rebates that PBMs demand in exchange for placing the drugs on formularies that make them available to patients.

Leaders of the three largest PBMs — CVS Caremark, Optum RX and Express Scripts — all testified in Congress in July that 95% to 98% of the rebates they collect from drugmakers flow to employers.

For KFF’s survey of 2,142 randomly selected companies, officials from those with 500 or more employees were asked how much of the rebates negotiated by PBMs returned to the company as savings. About 19% said they received most of the rebates, 27% said some, and 16% said little. Thirty-seven percent of the respondents didn’t know.

While a larger percentage of officials from the largest companies said they got most or some of the rebates, the answers — and their contrast with the testimony of PBM leaders — reflect the confusion or ignorance of employers about what their drug benefit managers do, said survey leader Gary Claxton, a senior vice president at KFF, a health information nonprofit that includes KFF Health News.

“I don’t think they can ever know all the ways the money moves around because there are so many layers, between the wholesalers and the pharmacies and the manufacturers,” he said.

Critics say big PBMs — which are parts of conglomerates that include pharmacies, providers, and insurers — may conceal the size of their rebates by conducting negotiations through corporate-controlled rebate aggregators, or group purchasers, mostly based overseas in tax havens, that siphon off a percentage of the cash before it goes on the PBMs’ books.

PBMs also make money by encouraging or requiring patients to use affiliated specialty pharmacies, by skimping on payments to other pharmacies, and by collecting extra cash from drug companies through the federal 340B drug pricing program, which is aimed at lowering drug costs for low-income patients, said Antonio Ciaccia, CEO of 46brooklyn Research.

The KFF survey indicates how little employers understand the PBMs and their pricing policies. “Employers are generally frustrated by the lack of transparency into all the prices out there,” Claxton said. “They can’t actually know what’s true.”

Billionaire Mark Cuban started a company to undercut the PBMs by selling pharmaceuticals with transparent pricing policies. He tells Fortune 500 executives he meets, “You’re getting ripped off, you’re losing money because it’s not your core competency to understand how your PBM and health insurance contracts work,” Cuban told KFF Health News in an interview Tuesday.

Ciaccia, who has conducted PBM investigations for several states, said employers are not equipped to understand the behavior of the PBMs and often are surprised at how unregulated the PBM business is.

“You’d assume that employers want to pay less, that they would want to pay more attention,” he said. “But what I’ve learned is they are often underequipped, underresourced, and oftentimes not understanding the severity of the lack of oversight and accountability.”

Employers may assume the PBMs are acting in their best interest, but they don’t have a legal obligation to do so.

Prices can be all over the map, even those charged by the same PBM, Ciaccia said. In a Medicaid study he recently conducted, a PBM was billing employers anywhere from $2,000 to $8,000 for a month’s worth of imatinib, a cancer drug that can be bought as a generic for as little as $30.

PBM contracts often guarantee discounts of certain percentage points for generics and brand-name drugs. But the contracts then contain five pages of exclusions, and “no employer will know what they mean,” Ciaccia said. “That person doesn’t have enough information to have an informed opinion.”

The KFF survey found that companies’ annual premiums for coverage of individual employees had increased from an average of $7,739 in 2021 to $8,951 this year, and $22,221 to $25,572 for families. Among employers’ greatest concerns was how to cover increasingly popular weight loss drugs that list at $2,000 a month or more.

Only 18% of respondents said their companies covered drugs such as Wegovy for weight loss. The largest group of employers offering such coverage — 28% — was those with 5,000 or more employees.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Californians in November will weigh in on a ballot initiative to increase scrutiny over the use of health-care dollars — particularly money from a federal drug discount program — meant to support patient care largely for low-income or indigent people. The revenue is sometimes used to address housing instability and homelessness among vulnerable patient populations.

Voters are being asked whether California should increase accountability in the 340B drug discount program, which provides money for community clinics, safety net hospitals and other nonprofit health-care providers.

The program requires pharmaceutical companies to give drug discounts to these clinics and nonprofit entities, which can bank revenue by charging higher reimbursement rates.

Advocates pushing the measure, Proposition 34, say some entities are using the drug discount program as a slush fund, plowing money into housing and homelessness initiatives that don’t meet basic patient safety standards. Researchers and advocates have called for greater oversight.

“There are 340B entities that are misusing these public dollars,” said Nathan Click, a spokesperson for the pro-Proposition 34 campaign. “The whole point of this program is to use this money to get more low-income people health-care services.”

The initiative wouldn’t bar 340B providers from using health-care funds for housing or homelessness programs. Instead, it targets providers that spend more than $100 million on purposes other than direct patient care over 10 years. It would mandate that 98 percentof 340B revenues go to direct patient care. It also targets 340B providers with health insurer contracts and pharmacy licenses and those serving low-income Medicaid or Medicare patients that have been dinged with at least 500 high-severity housing violations for substandard or unsafe conditions.

That has placed a bull’s eye on the Los Angeles-based AIDS Healthcare Foundation, a nonprofit that provides direct patient care via clinics and pharmacies in California and other states, including Illinois, Texas and New York. It also owns housing for low-income and homeless people.

A Los Angeles Times investigation found that many residents of AIDS Healthcare Foundation properties are living in deplorable, unhealthy conditions.

Michael Weinstein, the foundation’s president, disputes those claims and argues that Proposition 34 proponents, including real estate interests, are going after him for another ballot initiative that seeks to implement rent control in more communities across California.

“It’s a revenge initiative,” Weinstein said, arguing that the deep-pocketed California Apartment Association is targeting his foundation — and its health and housing operations — because it has backed ballot measures pushing rent control across California. “This is a two-pronged attack against us to defeat rent control.”

Weinstein is locked in a feud with the apartment association, the chief sponsor of the initiative, which has contributed handsomely to pass Proposition 34. Opponents argue that the initiative is “a wolf in sheep’s clothing.”

Weinstein acknowledged to KFF Health News that his nonprofit uses money from 340B drug discounts to support its housing initiatives but argued they are helping treat and house some of the most vulnerable people, who would otherwise be homeless.

The apartment association declined several requests for comment. But Proposition 34 backers say they aren’t going after rent control — or Weinstein and his nonprofit.

Supporters argue that “rising health care costs are squeezing millions of Californians” and say that the initiative would “give California patients and taxpayers much needed relief, and lowers state drug costs, while saving California taxpayers billions.”

If the initiative passes and 340B providers do not spend 98 percent of the revenue on direct patient care, they could lose their license to practice health care and their nonprofit status.

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Ohio Republican Sen. JD Vance and Minnesota Democratic Gov. Tim Walz met in an Oct. 1 vice presidential debate hosted by CBS News that was cordial and heavy on policy discussion — a striking change from the Sept. 10 debate between Vice President Kamala Harris and former President Donald Trump. 

Vance and Walz acknowledged occasional agreement on policy points and respectfully addressed each other throughout the debate. But they were more pointed in their attacks on their rival’s running mate for challenges facing the country, including immigration and inflation.

The moderators, “CBS Evening News” anchor Norah O’Donnell and “Face the Nation” host Margaret Brennan, had said they planned to encourage candidates to fact-check each other, but sometimes clarified statements from the candidates.

After Vance made assertions about Springfield, Ohio, being overrun by “illegal immigrants,” Brennan pointed out that a large number of Haitian immigrants in Springfield, Ohio, are in the country legally. Vance objected and, eventually, CBS exercised the debate ground rule that allowed the network to cut off the candidates’ microphones.

Most points were not fact-checked in real time by the moderators. Vance resurfaced a recent health care theme — that as president, Donald Trump sought to save the Affordable Care Act — and acknowledged that he would support a national abortion ban.

Walz described how health care looked before the ACA compared with today. Vance offered details about Trump’s health care “concepts of a plan” — a reference to comments Trump made during the presidential debate that drew jeers and criticism for the former president, who for years said he had a plan to replace the ACA that never surfaced. Vance pointed to regulatory changes advanced during the Trump administration, used weedy phrases like “reinsurance regulations,” and floated the idea of allowing states “to experiment a little bit on how to cover both the chronically ill but the non-chronically ill.”

Walz responded with a quick quip: “Here’s where being an old guy gives you some history. I was there at the creation of the ACA.” He said that before then insurers had more power to kick people off their plans. Then he detailed Trump’s efforts to undo the ACA as well as why the law’s preexisting condition protections were important.

“What Sen. Vance just explained might be worse than a concept, because what he explained is pre-Obamacare,” Walz said.

The candidates sparred on numerous topics. Our PolitiFact partners fact-checked the debate here and on their live blog.

The health-related excerpts follow.

The Affordable Care Act:

Vance: “Donald Trump could have destroyed the [Affordable Care Act]. Instead, he worked in a bipartisan way to ensure that Americans had access to affordable care.”

False.

As president, Trump worked to undermine and repeal the Affordable Care Act. He cut millions of dollars in federal funding for ACA outreach and navigators who help people sign up for health coverage. He enabled the sale of short-term health plans that don’t comply with the ACA consumer protections and allowed them to be sold for longer durations, which siphoned people away from the health law’s marketplaces.

Trump’s administration also backed state Medicaid waivers that imposed first-ever work requirements, reducing enrollment. He also ended insurance company subsidies that helped offset costs for low-income enrollees. He backed an unsuccessful repeal of the landmark 2010 health law and he backed the demise of a penalty imposed for failing to purchase health insurance.

Affordable Care Act enrollment declined by more than 2 million people during Trump’s presidency, and the number of uninsured Americans rose by 2.3 million, including 726,000 children, from 2016 to 2019, the U.S. Census Bureau reported; that includes three years of Trump’s presidency.  The number of insured Americans rose again during the Biden administration.

Abortion and Reproductive Health:

Vance: “As I read the Minnesota law that [Walz] signed into law … it says that a doctor who presides over an abortion where the baby survives, the doctor is under no obligation to provide lifesaving care to a baby who survives a botched late-term abortion.”

False.

Experts said cases in which a baby is born following an attempted abortion are rare. Less than 1% of abortions nationwide occur in the third trimester. And infanticide, the crime of killing a child within a year of its birth, is illegal in every state.

In May 2023, Walz, as Minnesota governor, signed legislation updating a state law for “infants who are born alive.” It said babies are “fully recognized” as human people and therefore protected under state law. The change did not alter regulations that already required doctors to provide patients with appropriate care.

Previously, state law said, “All reasonable measures consistent with good medical practice, including the compilation of appropriate medical records, shall be taken by the responsible medical personnel to preserve the life and health of the born alive infant.” The law was updated to instead say medical personnel must “care for the infant who is born alive.”

When there are fetal anomalies that make it likely the fetus will die before or soon after birth, some parents decide to terminate the pregnancy by inducing childbirth so that they can hold their dying baby, Democratic Minnesota state Sen. Erin Maye Quade told PolitiFact in September.

This update to the law means infants who are “born alive” receive appropriate medical care dependent on the pregnancy’s circumstances, Maye Quade said.

Vance supported a national abortion ban before becoming Trump’s running mate.

CBS News moderator Margaret Brennan told Vance, “You have supported a federal ban on abortion after 15 weeks. In fact, you said if someone can’t support legislation like that, quote, ‘you are making the United States the most barbaric pro-abortion regime anywhere in the entire world.’ My question is, why have you changed your position?”

Vance said that he “never supported a national ban” and, instead, previously supported setting “some minimum national standard.”

But in a January 2022 podcast interview, Vance said, “I certainly would like abortion to be illegal nationally.” In November, he told reporters that “we can’t give in to the idea that the federal Congress has no role in this matter.”

Since joining the Trump ticket, Vance has aligned his abortion rhetoric to match Trump’s and has said that abortion legislation should be left up to the states.

— Samantha Putterman of PolitiFact, on the live blog

A woman’s 2022 death in Georgia following the state passing its six-week abortion ban was deemed “preventable.”

Walz talked about the death of 28-year-old Amber Thurman, a Georgia woman who died after her care was delayed because of the state’s six-week abortion law. A judge called the law unconstitutional this week.

A Sept. 16 ProPublica report found that Thurman had taken abortion pills and encountered a rare complication. She sought care at Piedmont Henry Hospital in Atlanta to clear excess fetal tissue from her uterus, called a dilation and curettage, or D&C. The procedure is commonly used in abortions, and any doctor who violated Georgia’s law could be prosecuted and face up to a decade in prison.

Doctors waited 20 hours to finally operate, when Thurman’s organs were already failing, ProPublica reported. A panel of health experts tasked with examining pregnancy-related deaths to improve maternal health deemed Thurman’s death “preventable,” according to the report, and said the hospital’s delay in performing the procedure had a “large” impact.

— Samantha Putterman of PolitiFact, on the live blog

What Project 2025 Says About Some Forms of Contraception, Fertility Treatments

Walz said that Project 2025 would “make it more difficult, if not impossible, to get contraception and limit access, if not eliminate access, to fertility treatments.”

Mostly False. The Project 2025 document doesn’t call for restricting standard contraceptive methods, such as birth control pills, but it defines emergency contraceptives as “abortifacients” and says they should be eliminated from the Affordable Care Act’s covered preventive services. Emergency contraception, such as Plan B and ella, are not considered abortifacients, according to medical experts.

PolitiFact did not find any mention of in vitro fertilization throughout the document, or specific recommendations to curtail the practice in the U.S., but it contains language that supports legal rights for fetuses and embryos. Experts say this language can threaten family planning methods, including IVF and some forms of contraception.

— Samantha Putterman of PolitiFact, on the live blog

Walz: “Their Project 2025 is gonna have a registry of pregnancies.”

False. 

Project 2025 recommends that states submit more detailed abortion reporting to the federal government. It calls for more information about how and when abortions took place, as well as other statistics for miscarriages and stillbirths.

The manual does not mention, nor call for, a new federal agency tasked with registering pregnant women.

Fentanyl and Opioids:

Vance: “Kamala Harris let in fentanyl into our communities at record levels.”

Mostly False.

Illicit fentanyl seizures have been rising for years and reached record highs under Biden’s administration. In fiscal year 2015, for example, U.S. Customs and Border Protection seized 70 pounds of fentanyl. As of August 2024, agents have seized more than 19,000 pounds of fentanyl in fiscal year 2024, which ended in September.

But these are fentanyl seizures — not the amount of the narcotic being “let” into the United States. 

Vance made this claim while criticizing Harris’ immigration policies. But fentanyl enters the U.S. through the southern border mainly at official ports of entry. It’s mostly smuggled in by U.S. citizens, according to the U.S. Sentencing Commission. Most illicit fentanyl in the U.S. comes from Mexico made with chemicals from Chinese labs.

Drug policy experts have said that the illicit fentanyl crisis began years before Biden’s administration and that Biden’s border policies are not to blame for overdose deaths. 

Experts have also said Congress plays a role in reducing illicit fentanyl. Congressional funding for more vehicle scanners would help law enforcement seize more of the fentanyl that comes into the U.S. Harris has called for increased enforcement against illicit fentanyl use.

Walz: “And the good news on this is, is the last 12 months saw the largest decrease in opioid deaths in our nation’s history.”

Mostly True.

Overdose deaths involving opioids decreased from an estimated 84,181 in 2022 to 81,083 in 2023, based on the most recent provisional data from the Centers for Disease Control and Prevention. This decrease, which took place in the second half of 2023, followed a 67% increase in opioid-related deaths between 2017 and 2023.

The U.S. had an estimated 107,543 drug overdose deaths in 2023 — a 3% decrease from the 111,029 deaths estimated in 2022. This is the first annual decrease in overall drug overdose deaths since 2018. Nevertheless, the opioid death toll remains much higher than just a few years ago, according to KFF. 

More Health-Related Comments:

Vance Said ‘Hospitals Are Overwhelmed.’ Local Officials Disagree.

We asked health officials ahead of the debate what they thought about Vance’s claims about Springfield’s emergency rooms being overwhelmed.

“This claim is not accurate,” said Chris Cook, health commissioner for Springfield’s Clark County.

Comparison data from the Centers for Medicare & Medicaid Services tracks how many patients are “left without being seen” as part of its effort to characterize whether ERs are able to handle their patient loads. High percentages usually signal that the facility doesn’t have the staff or resources to provide timely and effective emergency care.

Cook said that the full-service hospital, Mercy Health Springfield Regional Medical Center, reports its emergency department is at or better than industry standard when it comes to this metric.

In July 2024, 3% of Mercy Health’s patients were counted in the “left-without-being-seen” category — the same level as both the state and national average for high-volume hospitals. In July 2019, Mercy Health tallied 2% of patients who “left without being seen.” That year, the state and national averages were 1% and 2%, respectively.  Another CMS 2024 data point shows Mercy Health patients spent less time in the ER per visit on average — 152 minutes — compared with state and national figures: 183 minutes and 211 minutes, respectively. Even so, Springfield Regional Medical Center’s Jennifer Robinson noted that Mercy Health has seen high utilization of women’s health, emergency, and primary care services. 

— Stephanie Armour, Holly Hacker, and Stephanie Stapleton of KFF Health News, on the live blog

Minnesota’s Paid Leave Takes Effect in 2026

Walz signed paid family leave into law in 2023 and it will take effect in 2026.

The law will provide employees up to 12 weeks of paid medical leave and up to 12 weeks of paid family leave, which includes bonding with a child, caring for a family member, supporting survivors of domestic violence or sexual assault, and supporting active-duty deployments. A maximum 20 weeks are available in a benefit year if someone takes both medical and family leave.

Minnesota used a projected budget surplus to jump-start the program; funding will then shift to a payroll tax split between employers and workers. 

— Amy Sherman of PolitiFact, on the live blog

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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The Host

Julie Rovner
KFF Health News

@jrovner

Read Julie's stories.

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 Washington for the campaign trail, but after the Nov. 5 general election lawmakers will have to complete work on the annual spending bills for the fiscal year that starts Oct. 1. While the GOP had hoped to push spending decisions into 2025, Democrats forced a short-term spending patch that’s set to expire before Christmas.

Meanwhile, on the campaign trail, abortion continues to be among the hottest issues. Democrats are pressing their advantage with women voters while Republicans struggle — with apparently mixed effects — to neutralize it.

This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of Politico and the Johns Hopkins schools of nursing and public health, Alice Miranda Ollstein of Politico, and Lauren Weber of The Washington Post.

Panelists

Joanne Kenen
Johns Hopkins University and Politico

@JoanneKenen

Read Joanne's stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories.

Lauren Weber
The Washington Post

@LaurenWeberHP

Read Lauren's stories.

Among the takeaways from this week’s episode:

• When Congress returns after the election, there’s a chance lawmakers could then make progress on government spending and more consensus health priorities, like expanding telehealth access. After all, after the midterm elections in 2022, Congress passed federal patient protections against surprise medical billing.
• As Election Day approaches, Democrats are banging the drum on health care — which polls show is a winning issue for the party with voters. This week, Democrats made a last push to extend Affordable Care Act subsidies expanded during the pandemic — an issue that will likely drag into next year in the face of Republican opposition.
• The outcry over the first reported deaths tied to state abortion bans seems to be resonating on the campaign trail. With some states offering the chance to weigh in on abortion access via ballot measures, advocates are telling voters: These tragedies are examples of what happens when you leave abortion access to the states.
• And Sen. Bernie Sanders of Vermont summoned the chief executive of Novo Nordisk before the health committee he chairs this week to demand accountability for high drug prices. Despite centering on a campaign issue, the hearing — like other examples of pharmaceutical executives being thrust into the congressional hot seat — yielded no concessions.

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 North Carolina Made Its Hospitals Do Something About Medical Debt,” by Noam N. Levey and Ames Alexander, The Charlotte Observer.

Lauren Weber: Stat’s “How the Next President Should Reform Medicare,” by Paul Ginsburg and Steve Lieberman. 

Joanne Kenen: The Atlantic’s “The Woo-Woo Caucus Meets,” by Elaine Godfrey. 

Alice Miranda Ollstein: Stat’s “How Special Olympics Kickstarted the Push for Better Disability Data,” by Timmy Broderick.

Also mentioned on this week’s podcast:

• KFF Health News’ “Florida’s New Covid Booster Guidance Is Straight-Up Misinformation,” by Arthur Allen, Daniel Chang, and Sam Whitehead.
• KFF Health News’ “Feds Killed Plan To Curb Medicare Advantage Overbilling After Industry Opposition,” by Fred Schulte.
• KFF Health News’ “Audits — Hidden Until Now — Reveal Millions in Medicare Advantage Overcharges,” by Fred Schulte and Holly K. Hacker.
• KFF Health News’ “ACA Plans Are Being Switched Without Enrollees’ OK,” by Julie Appleby.
• KFF Health News’ “Biden Administration Tightens Broker Access to Healthcare.gov To Thwart Rogue Sign-Ups,” by Julie Appleby.

click to open the transcript

Transcript: Congress Punts to a Looming Lame-Duck Session

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It 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, September 26th, 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 teleconference by Lauren Weber of The Washington Post. 

Lauren Weber: Hello hello. 

Rovner: Alice Ollstein of Politico. 

Alice Miranda Ollstein: Good morning. 

Rovner: And Joanne Kenen of the Johns Hopkins Schools of Public Health and Nursing, and Politico. 

Joanne Kenen: Hi, everybody. 

Rovner: Big props to Emmarie for hosting last week while I was in Ann Arbor at the Michigan Daily reunion. I had a great time, but I brought back an unwelcome souvenir in the form of my first confirmed case of covid. So apologies in advance for the state of my voice. Now, let us get to the news. 

To steal a headline from Politico earlier this week, Congress lined up in punt formation, passing a continuing resolution that will require them to come back after the election for what could be a busy lame-duck session. Somebody remind us who wanted this outcome — the Let’s only do the CR through December — and who wanted it to go into next year? Come on, easy question. 

Ollstein: Well, the kicking it to right before Christmas, which sets up the stage for what we’ve seen so many times before where it just gets jammed through and people who have objections, generally conservatives who want to slash spending and add on a bunch of policy riders, which they tried and failed to do this time, will have a weaker base to operate from, given that everybody wants to go home for the holidays. 

And so once again, we’re seeing people mad at Speaker Mike Johnson, who, again and again, even though he is fully from the hard right of the party, is not catering to their priorities as much as they would like. And so obviously his speakership depends on which party wins control of the House in November. But I think even if Republicans win control, I’m already starting to hear rumblings of throwing him overboard and replacing with someone who they think will cater to them more. 

Rovner: It was so déjà vu all over again, which is, last year, as we approached October 1st and the Republican House could not pass any kind of a continuing resolution with just Republican votes, that eventually Kevin McCarthy had to turn to Democrats, and that’s how he lost his job. 

And yet that’s exactly what happened here, which is the Republicans wanted to go until March, I guess on the theory that they were betting that they would be in full power in March and would have a chance to do a lot more of what they wanted in terms of spending bills than if they just wait and do it in the lame duck. And yet the speaker doesn’t seem to be paying the same price that Kevin McCarthy did. Is that just acknowledgment on the part of the right wing that they can’t do anything with their teeny tiny majority? 

Kenen: I mean, yes, it’s pretty stalemate-y up there right now, and nobody is certain who’s going to control the House, and at this point it is likely to still be a narrow majority, whoever wins it. I mean, they’re six weeks out. Things can change. This has been an insane year. Nobody’s making predictions, but it looks like pretty divided. 

Rovner: Whoever wins isn’t going to win by much. 

Kenen: We have a pretty divided country, and the likelihood is we’re going to have a pretty divided House. So the dynamic will change depending on who’s in charge, but the Republicans are more fractious and divided right now than the Democrats, although that’s really easy to change, and even the Democrats have gone through their rambunctious divided phases, too. 

Everybody just doesn’t know what’s next, because the top of the ticket is going to change things. So the more months you push out, the less money you’re spending. If you control the CR, if you make the CR, the continuing resolution, meaning current spending levels for six months, it’s a win for the Republicans in many ways because they’re keeping — they’re preventing increases. But in terms of policy, both sides get some of the things they want extended. 

I don’t know if you can call it a productive stalemate. That’s sort of a contradiction in terms. But I mean, for the Republicans, longer, it would’ve been better. 

Rovner: So now that we know that Congress has to come back after the election, there’s obviously things that they are able to do other than just the spending bills. And I’m thinking of a lot of unfinished health legislation like the telehealth extensions and the constant, Are we going to do something about pharmacy benefit managers? which has been this bipartisan issue that they never seem to solve. 

I would remind the listeners that in 2022 after the election, that’s when they finally did the surprise-bills legislation. So doing big things in the lame duck is not unheard of. Is there anything any of you are particularly looking toward this time that might actually happen? 

Kenen: It’s something like telehealth because it’s not that controversial. I mean, it’s easiest to get something through in — in lame duck, you want to get some things off the plate that are either overdue and need to be taken care of or that you don’t want hanging over you next year. So telehealth, which is, there are questions about does it save money, et cetera, and what form it should take and how some of it should be regulated, so forth, but the basic idea, telehealth is popular. Something like that, yes. 

PBMs [pharmacy benefit managers] is a lot harder, where there is some agreement on the need to do something but there’s less agreement about what that something should look like. So although I’m not personally covering that day-to-day basis, in any sense, that’s harder. The more consensus there is and the fewer moving parts, the easier it is to do, as a rule. I mean, sometimes they do get something big done in lame duck, but a lot of it gets kicked. 

And also there’s a huge, huge, huge tax fight next year, and it’s going to require a lot of wheeling and dealing no matter what shape it takes, because it’s expiring and things have to be either renewed or allowed to die. So that’s just going to be mega-enormous, and a lot of this stuff become bargaining chips in that larger debate, and that becomes the dominant domestic policy vehicle next year. 

Rovner: Well, even before we get to the lame duck, we have to finish the campaign, which is only a month and a half away. And we are still talking about the Affordable Care Act in an election where it was not going to be a campaign issue, everybody said. 

I know that you talked last week about all the specifics of the ways former President [Donald] Trump actually tried to sabotage rather than save the ACA and all the ways what [Sen.] JD Vance was talking about on “Meet the Press,” dividing up risk pools once again so sicker people would no longer be subsidized by the less sick, would turn the clock back to the individual insurance market as it existed before 2014. 

Now the Democrats in the Senate are taking one last shot at the ACA with a bill — that will fail — to renew the expanded marketplace subsidies, so it will expire unless Congress acts by the end of next year. Might this last effort have some impact in the swing states, or is it just a lot more campaign noise? 

Weber: I think this is a lot of campaign noise, to some extent. I mean, I think Democrats are clear in polling shows that the average American voter does trust Democrats more than Republicans on ACA and health issues and health insurance. So I do think this is a messaging push in part by the Dems to speak to voters. As we all know, this is a turnout election, so I think anything that they feel like voters care about, which often has to do with their pocketbook, I think they’re going to lead the drum on. 

I do think it’s interesting again that JD Vance really is reiterating a talking point that Donald Trump used in the debate, which is that he said he had improved the ACA and many experts would say it was very much the opposite. Again, I think I did this on the last podcast, but let me reread this because I think it’s important as a fact check. Most of the Trump administration’s ACA-related actions included cutting the program. 

So they reduced millions of dollars of funding for marketing and enrollment, and he repeatedly tried to overturn the law. So I think some of the messaging around this is getting convoluted, in part because it’s an election year, to your point. 

Rovner: And because it’s popular. Because Nancy Pelosi was right. When people found out what was in it, it got popular. 

Kenen: I think there are two things. I mean, I agree with what Lauren just said, but the Democrats came out in favor of extending the subsidies yesterday, which not only changed the eligibility criteria — more people, more higher up the middle-income chain could get subsidized — but also everybody in it had extra benefits for it, including people who were already covered. But it’s better for them. 

The idea that Republicans are going to try to take that benefit away from people six weeks before an election — they were probably not. How they handle it next year? I was really surprised by the silence yesterday. The Democrats rolled out their plans for renewing this, and I didn’t see a lot of Republican pushback. So they were really quiet about it. 

The other thing that struck me is that JD Vance went on on this risk pool thing last week on “Meet the Press” and in Raleigh, in North Carolina, and then there was pushback. And on that particular point, there’s been silence for the last week. I don’t think he stuck his neck out on that one again. Who knows what next week will bring, but it didn’t continue, and nor did I hear other Republicans saying, “Yeah, let’s go do that.” 

So if that was a trial balloon, it was somewhat leaden. So I think that we really don’t know how the subsidy fight is going to play —how or when the subsidy fight will play out. It’s really, you know, we’ve all said many times before, once you give people the benefit, it’s really hard to take it away. And— 

Rovner: Although we did that with the Child Tax Credit. We gave everybody the Child Tax Credit and then took it away. 

Kenen: We did, and other things that were temporary during the pandemic, and we’ll just see how many of those temporary things do in fact go away. I mean, does it come back next year? I mean, now SALT [state and local taxes], right? I mean, Trump backed backing what’s called SALT. It’s a limit based on mortgage and state taxes. And now he’s talking about he’s going to rescue that like it wasn’t him who … So it all comes around again. 

Ollstein: Yeah, and I think what you’re seeing is both sides drawing the battle lines for next year and signaling what the core arguments are going to be. And so you had Democrats come out with their bill this year, and you are hearing a lot of Republicans in hearings and speeches sprinkled around talking about claiming that there is a huge amount of fraud in the ACA marketplaces and linking that to the subsidies and saying, Why would we continue to subsidize something where there’s all this fraud? 

I think that is going to be a big argument on that side next year for not extending the subsidies. So I would urge people to keep listening for that. 

Kenen: And that came from a conservative think tank consulting firm in which they blame — I actually happened to read it this week, so it’s fresh in my mind. They’re blaming the fraud actually on brokers rather than individuals. They’re saying that people are— 

Rovner: That was an investigation uncovered by my colleague Julie Appleby here at KFF Health News. 

Kenen: Right. And they ran with that, and they were talking about the low end of the income bracket. And I’m waiting for the sequel in which the people at the upper end of the income bracket, which is the law that’s expiring that we’re talking about, it’s pretty — I’m waiting for the sequel Paragon paper saying, See, it’s even worse at the upper end, and that’s easy to get rid of because it’ll expire. That’s the argument of the day, but there’s so many flavors of anti-ACA arguments that we’ve just scratched the beginning of this round. 

Rovner: Exactly. It’ll come back. All right, well, let us move on to abortion. Vice President [Kamala] Harris said in an interview this week that she would support ending the filibuster in the Senate in order to restore abortion rights with 51 rather than 60 votes, which has apparently cost her the endorsement of retiring West Virginia Democratic senator Joe Manchin. Was Manchin’s endorsement even that valuable to her? It’s not like West Virginia was going to vote Democratic anytime soon. 

Ollstein: The Harris campaign has really leaned into emphasizing endorsements she’s been getting from across the ideological spectrum, from as far right as Dick Cheney to more centrist types and economists and national security people. And so she’s clearly trying to brandish her centrist credentials. So I guess in that sense. But like you said, Democrats are not going to win West Virginia, and so I think also he was getting upset about something, a position she’s been voicing for years now. This is not new, this question of the filibuster. So I doubt it’ll have much of an impact. 

Kenen: It’s a real careful-what-you-wish for, because if the Senate goes Republican, which at the moment looks like it’s going to be a narrow Republican majority. We don’t know until November. There’s always a surprise. There’s always a surprise. 

Rovner: You’re right. It’s more likely that it’ll be 51-49 Republican than it’ll be 51-49 Democrat. 

Kenen: Right. So if the filibuster is going to be abolished, it would be to advance Republican conservative goals. So it’s sort of dangerous territory to walk into right now. The Democrats have played with abolishing the filibuster. They wanted to do it for voting rights issues, and they decided not to go there on legislation. They did modify it a number of years ago on judicial appointments and other Cabinet appointments and so forth. 

But legislative, the filibuster still exists. It’s very, very, very heavily used, much more than historically, by both parties, whoever is in power. So changing it would be a really radical change in how things move or don’t move. So it could have a long tail, that remark. 

Rovner: Meanwhile, Senate Democrats, who don’t have the votes now, as we know, to abolish the filibuster, because Manchin is among their one-vote margin, are continuing to press Republicans on reproductive rights issues that they think work in their favor. Earlier this week, the Senate Finance Committee had a hearing on EMTALA, the Emergency Medical Treatment and Labor Act. 

It’s a federal law that’s supposed to guarantee women access to abortion in medical emergencies. But in practice, it has not. Last week we talked about the ProPublica stories on women whose pregnancy complications actually did lead to their death. Is this something that’s breaking through as a campaign issue? I do feel like we’ve seen so much more on pregnancy complications and the health impacts of those rather than just, straight, women who want to end pregnancies. 

Ollstein: I just got back from Michigan, and I would say it is having a big impact. I was really interested in how Democrats were trying to campaign on abortion in Michigan, even now that the state does have protections. And I heard over and over from voters and candidates that Trump’s leave-it-to-the-states stance, they really are still energized by that. 

They’re not mollified by that, because they are pointing to stories like the ones that just came out in Georgia and saying: See? That’s what happens when you leave it to the states. We may be fine, but we care about more than just ourselves. We’re going to vote based on our concern for women in other states as well. I found that really interesting to be hearing out in the field. 

Rovner: Lauren, you want to add something? 

Weber: Yeah, I just was going to add, I mean, Harris obviously highlighted this effectively in the debate, and I think that has helped bring it to more of a crescendo, but there’s obviously been a lot of reporting for months on this. I mean, the AP has talked about — I think they did a count. It’s over 100 women, at least, have been denied emergency care due to laws like this. 

I’d be curious — and it sounds like Alice has this, for voters that are in swing states, that it’s breaking through to — I’d be curious how much this has siloed to people that are outraged by this, and so we’re hearing it and how much it’s skidding down to those that — the Republican talking points have been that these are rare, they don’t really happen, it’s a liberal push to get against this. I’d be curious how much it’s breaking through to folks of all stripes. 

Rovner: I watched a big chunk of the Finance Committee hearing, and the anti-abortion witnesses were saying this is not how it worked, that ectopic pregnancies, pregnancy complications do not qualify as abortions, and basically just denying that it happened. They’re sitting here. They’re sitting at the witness table with the woman to whom this happened and saying that this does not happen. So it was a little bit difficult, shall we say. Go ahead. 

Ollstein: Well, and the pushback I’ve been hearing from the anti-abortion side is less that it’s not happening and more that it’s not the fault of the laws, it’s the fault of the doctors. They are claiming that doctors are either intentionally withholding care or are wrong in their interpretation of the law and are withholding care for that reason. They’re pointing to the letter of the law and saying, Oh no, it doesn’t say let women bleed out and die, so clearly it’s fine. They’re not really grappling with the chilling effect it’s having. 

Rovner: Although we do know that in Texas when, I think it was Amanda Zurawski, there was — no, it was Kate Cox who actually got a judge to say she should be allowed to have an abortion. Ken Paxton, the Texas attorney general, then threatened the hospital, said, If you do this, I will come after you. On the one hand, they say, Well, that’s not what the law says. On the other hand, there are people saying, Yeah, that’s what the law says. 

Turning to the Republicans, Donald Trump had some more things to say about abortion this week, including that he is women’s protector and that women will, and I quote, “be happy, healthy, confident, and free. You will no longer be thinking about abortion.” 

If that wasn’t enough, in Ohio, Bernie Moreno, who’s the Republican running against Senator Sherrod Brown in the otherwise very red state, said the other night that he doesn’t understand why women over 50 would even care about abortion, since, he suggested, they can no longer get pregnant, which isn’t correct, by the way. But who exactly are the voters that Trump and Moreno are going after here? 

Kenen: Moreno is already lagging in the polls. Sherrod Brown is a pretty liberal Democrat in an increasingly conservative state, and he’s also very popular. And it looks like he’s on a glide path to win, and this probably made it easier for him to win. And there are men who support abortion rights, and there are women who oppose. 

I mean, this country’s divided on abortion, but it’s not age-related. It’s not like if you’re under 50 and female, you care about abortion and nobody else does. I mean, that’s really not the way it works. Fifty-year-old and older women, some of whom had abortions when they were younger, would want that right for younger women, including their daughters. It’s not a quadrant. It’s not like, oh, only this segment cares. 

Ollstein: It’s interesting that it comes amid Democrats really working to broaden who they consider an abortion voter, like I said, trying to encourage people in states where abortion is protected to vote for people in states where abortion is not protected and doing more outreach to men and saying this is a family issue, not just a women’s issue, and this affects everybody. 

So as you see Democrats trying to broaden their outreach and get more people to care, you have Bernie Moreno saying the opposite, saying, I don’t understand why people care when it doesn’t affect their own particular life and situation. 

Rovner: Although I will say, having listened to a bunch of interviews with undecided voters in the last couple of weeks, I do hear more and more voters saying: Well, such and such candidate, and this is on both sides, is not speaking to me. It’s almost like this election is about them individually and not about society writ large. 

And I do hear that on both sides, and it’s kind of a surprise. And I don’t know, is that maybe where Moreno is coming from? Maybe that’s what he’s hearing, too, from his pollsters? It’s only that people are most interested in their own self-interest and not about others? Lauren, you wanted to add to that? 

Weber: I mean, I would just say I think that’s a kind interpretation, Julie. I think that more likely than not, he was just speaking out of turn. And in some prior reporting I did this year on misinformation around birth control and contraception, I spoke to a bunch of women legislators, I believe it was in Idaho, who found that in speaking with their male legislator friends, that a lot of them were uncomfortable talking about abortion, birth control, et cetera, which led to a lot of these misconceptions. And I wonder if we’re seeing that here. 

Ollstein: Just quickly, I think it’s also reflective of a particular conservative mind-set. I mean, it reminds me of when I was covering the Obamacare fight in Congress and you had Republican lawmakers making jokes about, Oh, well, wouldn’t want to lose coverage for my mammograms. And just what we were just talking about, about the separate risk pools and saying, Oh, I’m healthy. Why should I subsidize a sick person? when that’s literally how insurance works. 

But I think just the very individualistic go-it-alone, rugged-individual mind-set is coming out here in different ways. And so it seems like he did not want this particular comment to be scrutinized as it is getting now, but I think we hear versions of this from conservative lawmakers all the time in terms of, Why should I have to care about, pay for, subsidize, et cetera, other people in society? 

Rovner: Yeah, there’s a lot of that. Well, finally this week in reproductive health issues that never seem to go away, a federal judge in North Dakota this week slapped an injunction on the Equal Employment Opportunity Commission’s enforcement of some provisions of the 2022 Pregnant Workers Fairness Act, ruling that Catholic employers, including for-profit Catholic-owned entities, don’t have to provide workers with time off for abortions or fertility treatments that violate the church’s teachings. 

Now, lest you think this only applies to North Dakota, it does not. There’s a long way to go before this ruling is made permanent, but it’s kind of awkward timing for Republicans when they’re trying to convince voters of their strong support of IVF [in vitro fertilization], and yet here we have a large Catholic entity saying, We don’t even want to give our workers time off for IVF. 

Ollstein: Yeah, I think you’ve been hearing a lot of Republicans scoffing at the idea that anyone would oppose IVF, when there are many, many conservatives who do either oppose it in its entirety or oppose certain ways that it is currently commonly practiced. You had the Southern Baptist Convention vote earlier this year in opposition to IVF. You have these Catholic groups who are suing over it. 

And so I think there needs to be a real reckoning with the level of opposition there is on the right, and I think that’s why you’re seeing an interesting response to Trump’s promise for free IVF for all and whether or not that is feasible. I think this shows that it would get a lot of pushback from groups on the right if they were ever to pursue that. 

Rovner: Yeah, I will also note that this was a Trump-appointed judge, which is pretty … The EEOC, when they were doing these final regulations, acknowledged that there will be cases of religious employers and that they will look at those on a case-by-case basis. But this is a pretty sweeping ruling that basically says, we’re back to the Hobby Lobby Supreme Court case: If you don’t believe in something, you don’t have to do it. 

I mean, that’s essentially where we are with this, and we will see as this moves forward. Well, moving on to another big election issue, drug prices, the CEO of Novo Nordisk, makers of the blockbuster obesity and diabetes drugs Ozempic and Wegovy, appeared at the Senate Health, Education, Labor and Pensions Committee on Tuesday in front of Senator Bernie Sanders, who has been one of their top critics. 

And maybe it’s just my covid-addled brain, but I watched this hearing and I couldn’t make heads or tails of how Lars Jørgensen, the CEO, tried to explain why either the differences between prices in the U.S. and other countries for these drugs weren’t really that big, or how the prices here are actually the fault of PBMs, not his company. Was anybody able to follow this? It was super confusing, I will say, that he tried to … 

First he says that, well, 80% of the people with insurance coverage can get these drugs for $25 a month or less, which I’m pretty sure only applies to people who are using it for diabetes, not for obesity, because I think most insurers aren’t covering it for obesity. And there was much backing and forthing about how much it costs and how much we pay and how much it would cost the country to actually allow people, everybody who’s eligible for these drugs, to use them. And no real response. I mean, this is a big-deal campaign issue, and yet I feel like this hearing was something of a bust. 

Weber: I mean, do we really expect a CEO of a highly profitable drug to promise to reduce it immediately on the spot? I mean, I guess I’m not surprised that the hearing was a back-and-forth. From what I understand of what happened, I mean, most hearings with folks that have highly lucrative drugs, they’re not looking to give away pieces of the lucrative drugs. So I think to some extent we come back to that. 

But I did think what was interesting about the hearing itself was that Sanders did confront him with promises from PBMs that they would be able to offer these drugs and not short the American consumer, which was actually a fascinating tactic on Sanders part. But again, what did we really walk away with? I’m not sure that we know. 

Rovner: Yeah, I mean, even if you were interested in this issue — and I’m interested in this issue and I know this issue better than the average person, as I said —I literally could not follow it. I found it super frustrating. I mean, I know what Sanders was going for here. I just don’t feel like he got what he was hoping to. I don’t know. Maybe he was hoping to get the CEO to say, “We’ve been awful, and so many people need this drug, and we’re going to cut the price tomorrow.” And yes, you point out, Lauren, that did not happen. But we shall see. 

Well, speaking of PBMs, the Federal Trade Commission late last week filed an administrative complaint against the nation’s three largest PBMs, accusing them of inflating insulin prices and steering patients toward higher-cost products so they, the PBMs, can make more money, which is, of course, the big problem with PBMs, which is that they get a piece of the action. So the more expensive the drug, the bigger the piece of the action that they get. 

I was most interested in the fact that the FTC’s three Democratic appointees voted in favor of the legal action. Its two Republican appointees didn’t vote but actually recused themselves. This whole PBM issue is kind of awkward for Republicans who say they want to fight high drug prices, isn’t it? I feel like the whole PBM issue, which, as we said, is something that Congress in theory wants to get to during the lame-duck session, is tricky. 

I mean, it’s less tricky for Democrats who can just demagogue it and a little bit more tricky for Republicans who tend to have more support from both the drug industry and the insurance industry and the PBM industry. How much can they say they want to fight high drug prices without irritating the people with whom they are allied? 

Kenen: And the PBMs themselves are owned by insurers. The pharmaceutical drug pricing, it’s really, really, really confusing, right? 

Rovner: Nobody understands it. 

Kenen: The four of us, none of us cover pharma full time, but the four of us are all pretty sophisticated health care reporters. And if we had to take a final exam on the drug industry, none of us would probably get an A-plus. So I’d be surprised if they figure this out in lame duck. I mean, they could —there’s always the possibility that when they look at the outcome of things, they decide: We do need to cut a deal and get this off the plate. This is the best we’re going to get. We’re going to be in a worse position next month. And they do it. 

But it just seems really sticky and complicated, and it doesn’t feel like it’s totally jelled yet to the point that they can move it. I would expect this to spill into next year. If a deal comes through, if a big budget deal comes through at the end of the year, it does have a lot of trade-offs and moving parts, and this could, in fact, get wrapped into it. 

If I had to guess, I would say it’s more likely to spill into the following year, but maybe they’ve decided they’ve had enough and want to tie the bow on it and move on. And then it’ll go to court and we’ll spend the next year talking about the court fight against the PBM law. So it’s not going to be gone one way or another, and nor are high drug prices going to be gone one way or another. 

Rovner: The issue that keeps on giving. Well, finally this week, a new entry in out This Week in Health Misinformation segment from, surprise, Florida. This is a story from my KFF Health News colleagues Arthur Allen, Daniel Chang, and Sam Whitehead. And the headline kind of says it all: “Florida’s New Covid Booster Guidance Is Straight-Up Misinformation.” 

This is the continuing saga involving the state surgeon general, Joseph Ladapo, who’s been talking down the mRNA covid vaccine for several years now and is recommending that people at high risk from covid not get the latest booster. What surprised me about this story, though, was how reluctant other health leaders in Florida, including the Florida Medical Association, have been to call the surgeon general out on this. 

I guess to avoid angering his boss, Republican governor Ron DeSantis, who’s known to respond to criticism with retribution. Anybody else surprised by the lack of pushback to this there in Florida? Lauren? 

Weber: No, I’m not really surprised. I mean, we’ve seen the same thing over and over and over again. I mean, this is the man who really didn’t make a push to vaccinate against measles when there was an outbreak. He has previously stated that seniors over 65 should not get an mRNA vaccine, with misinformation about DNA fragments. We’ve seen this pattern over and over again. 

He is a bit of a rogue state public health officer in a crew that usually everyone else is on pretty much the same page, whether or not they’re red- or blue-state public health officers. And I think what’s interesting about this story and what continues to be interesting is as we see RFK [Robert F. Kennedy Jr.] gaining influence, obviously, in Trump’s potential health picks, you do wonder if this is a bit of a tryout. Although Ladapo is tied to DeSantis, who Trump obviously has feelings about. So who knows there. But it very clearly is the politicization of public health writ large. 

Kenen: And DeSantis, during the beginning of the pandemic, he disagreed with the CDC [Centers for Disease Control and Prevention] guidelines about who should get vaccinated, but he did push them for older people. And I think that was his cutoff. If you’re 15 up, you should have them. He was quite negative from the start on under. Florida’s vaccination rates for the older population back when they rolled out in late 2020, early 2021, were not — they were fairly high. And there’s been a change of tone. As the political base became more anti-vax, so did the Florida state government. 

Rovner: And obviously, Florida, full of older people who vote. So, I mean, super-important constituency there. Well, we will watch that space. All right, that is this week’s news. Now it is time for our extra credits. That’s when we each recommend a story we read this week we think you should read, too. Don’t worry if you miss the details. We will include links to all these stories in our show notes on your phone or other device. Joanne, why don’t you go first this week? 

Kenen: Elaine Godfrey in the Atlantic has a story called “The Woo-Woo Caucus Meets,” and it’s about a four-hour summit on the Hill with RFK Jr., moderated by Senator Ron Johnson of Wisconsin, who also has some unconventional ideas about vaccination and public health. The writer called it the “crunch-ificiation of conservatism.” 

It was the merging of the anti-vax pharma-skeptic left and the Trump right and RFK Jr. talking about MAHA, Making America Healthy Again, and his priorities for what he expects to be a leading figure in some capacity in a Trump administration fixing our health. It was a really fun — just a little bit of sarcasm in that story, but it was a good read. 

Rovner: Yeah, and I would point out that this goes, I mean, back more than two decades, which is that the anti-vax movement has always been this combination of the far left and the far right. 

Kenen: But it’s changed now. I mean, the medical liberty movement, medical freedom movement and the libertarian streak has changed. It started changing before covid, but it’s not the same as it was a few years ago. It’s much more conservative-dominated, or conservative-slash-libertarian-dominated. 

Rovner: Alice. 

Ollstein: I have an interesting story from Stat. It’s called “How Special Olympics Kickstarted the Push for Better Disability Data.” It’s about how the Special Olympics, which just happened, over the years have helped shine a light on just how many people with developmental and intellectual disabilities just aren’t getting the health care that they need and aren’t even getting recognized as having those disabilities. 

And the data we’re using today comes from the Clinton administration still. It’s way out of date. So there have been improvements because of these programs like Healthy Athletes that have been launched around this, but it’s still nowhere near good enough. And so this was a really fascinating story on that front and on a population that’s really falling through the cracks. 

Rovner: It really was. Lauren. 

Weber: I actually picked an opinion piece in Stat that’s called, quote, “How the Next President Should Reform Medicare,” by Paul Ginsburg and Steve Lieberman. And I want to give a shoutout to my former colleague Fred Schulte, who basically has single-handedly revealed — and now, obviously, there’s been a lot of fall-on coverage — but he was really beating this drum first, how much Medicare Advantage is overbilling the government. 

And Fred, through a lot of FOIAs [Freedom of Information Act requests] — and KFF has sued to get access to these documents — has shown that, through government audits, the government’s being charged billions and billions of dollars more than it should be to pay for Medicare Advantage, which was billed as better than Medicare and a free-market solution and so on. But the reality is … 

Rovner: It was billed as cheaper than Medicare. 

Weber: And billed as cheaper. 

Rovner: Which it’s not. 

Weber: It’s not. And this opinion piece is really fascinating because it says, look, no presidential candidate wants to talk about changing Medicare, because all the folks that want to vote usually have Medicare. But something that you really could do to reduce Medicare costs is getting a handle around these Medicare Advantage astronomical sums. And I just want to shout out Fred, because I really think this kind of opinion piece is possible due to his tireless coverage to really dig into what’s some really wonky stuff that reveals a lot of money. 

Rovner: Yes, I feel like we don’t talk about Medicare Advantage enough, and we will change that at some point in the not-too-distant future. All right, well, my story is from KFF Health News from my colleague Noam Levey, along with Ames Alexander of the Charlotte Observer. It’s called “How North Carolina Made Its Hospitals Do Something About Medical Debt.” 

Those of you who are regular listeners may remember back in August when we talked about the federal government approving North Carolina’s unique new program to have hospitals forgive medical debt in exchange for higher Medicaid payments. It turns out that getting that deal with the state hospitals was a lot harder than it looked, and this piece tells the story in pretty vivid detail about how it all eventually got done. It is quite the tale and well worth your time. 

OK, that is our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcast. We’d appreciate it if you left us a review. That helps other people find us, too. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X. I’m @jrovner. Lauren, where are you? 

Weber: I’m still on X @LaurenWeberHP. 

Rovner: Alice? 

Ollstein: On X at @AliceOllstein. 

Rovner: Joanne? 

Kenen: X @JoanneKenen and Threads @JoanneKenen1. 

Rovner: We will be back in your feed next week. Until then, be healthy. 

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What Caitlyn did next is a reminder of why a beloved former guest once said you should “never pay the first bill.” This episode of “An Arm and a Leg” is an extended version of the July installment of the “Bill of the Month” series, created in partnership with NPR.

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Don’t Get ‘Bullied’ Into Paying What You Don’t Owe

Dan: Hey there — 

One morning when she was in eighth grade, Caitlin Mai did what she always did when she woke up. 

Caitlyn Mai: Music has always been a big part of my life. And so I immediately put in my headphones and started putting on music as I was about to get out of bed and get ready. And I noticed my earbud in my right ear wasn’t working. 

Dan: It was obvious, because on this Beatles tune she’d cued up, Eleanor Rigby, the vocals are almost all on the right-hand side, and she couldn’t hear them. 

Caitlyn: I was like, that’s kind of weird. So I switched the earbuds and it worked fine. But then it was, the other one wasn’t working in my right ear. And I was like, what? 

Dan: Yeah, confusing. And then she tried getting out of bed. 

Caitlyn: I was so dizzy. It was my first time experiencing vertigo, and it was so severe, I couldn’t walk across the room without getting severely motion sick. 

Dan: With that vertigo, Caitlin could barely walk at all. She had no sense of balance — that actually relies on a mechanism inside our ears. Later, doctors found she had lost 87 percent of her hearing on the right side. 

Caitlyn: They think I just had some sort of virus that settled in my ear, and it damaged my ear. But I went to bed completely healthy the night before. Woke up, couldn’t hear out of my ear. 

Dan: She had to learn how to walk all over again.

Caitlyn: I have to rely on my eyes. My friends still find it hilarious if I close my eyes, I fall over. 

Dan: That was eighth grade. Caitlyn made it through high school, in Tulsa where she grew up without a lot of accommodations. 

Caitlyn: Cause in middle school, early high school, you don’t want to bring attention to your disability. At least I really didn’t want to at the time. I was super anxious about that. 

Dan: Catilyn’s 27 now, she works as a legal assistant in Oklahoma City. Her husband’s a lawyer. And for the longest time, she couldn’t access a tool that helps restore hearing for lots of people: Cochlear implants — small devices that stimulate nerves inside the ear. 

The FDA didn’t approve them for just one ear until a couple of years ago. Last year, Caitlin got her insurance to approve one for her. She had surgery in December to insert the implant. And in January, an audiologist attached an external component to switch on Caitlin’s right-side hearing. 

Caitlyn: She said, okay, at some point, you’re gonna start hearing some beeps, just say yes when you can hear them. And my husband said my face just, out of nowhere, lit up, and I go, yes! It was streaming directly to my cochlear implant. And I definitely started tearing up. 

Dan: Then, two weeks later, Caitlin got an alert from the hospital on her phone. 

Caitlyn: And I open it up, and I immediately started having a panic attack. 

Dan: It was a bill for a hundred and thirty-nine thousand dollars. The full amount for Caitlin’s surgery. 

Which, given that Caitlyn had gotten her insurance company’s OK for the procedure in advance, was a pretty big surprise. NPR featured Caitlyn’s story recently for a series they do with our pals at KFF Health News. 

NPR HOST: Time now for the latest installment in our bill of the month series, where we dissect and explain confusing or outrageous medical bills.

Dan: I interviewed Caitlyn for that story. And we’re bringing you an expanded version here because Caitlin’s situation — well, it was a good story. And it made me curious about a couple things. 

It also reminded me of some good advice we’ve heard here before — and it reminded me of an important colleague and teacher. And the bottom line to Caitlyn’s story? Stand up for yourself. Don’t cave. Make the next call. 

This is An Arm and a Leg — a show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann. I’m a reporter, and I like a challenge — so our job on this show is to take one of the most enraging, terrifying, depressing parts of American life, and bring you something entertaining, empowering, and useful. 

To get her insurance company’s approval, Caitlyn had already spent a lot of time — and a lot of money — in the months before surgery. For instance … 

Caitlyn: To prove to insurance that a hearing aid wouldn’t work had to be fitted for a hearing aid and then do a couple hours of testing to prove, yep, it doesn’t help. 

Dan: There were reviews with audiologists, with her surgeon, and an MRI to make sure there wasn’t too much scar tissue for an implant to take. 

Caitlyn: That took a long time to get scheduled, get insurance to approve, pay for, then get back for another appointment. I counted up at one point — it’s like around eight or ten appointments that I had before the final, okay, let’s schedule surgery. 

Dan: And — you caught that, right? Where she mentioned she had to get her insurance to approve paying for the MRI? Every one of these preliminary steps cost money, and she had to wrangle with her insurance to get their OK. 

But of course even with her insurance saying yes, there were still copays, and deductibles, and what’s called co-insurance — where you pay a percentage of any bill from a hospital. 

Which meant Caitlyn was chipping away at what’s called her out-of-pocket maximum: The most she could be on the hook for in a given calendar year. The surgery got scheduled for December — the same calendar year as all those tests — and she checked to see what she might have to pay. 

Caitlyn: I looked at my little portal for insurance, I’m showing what’s left on my out-of-pocket max for the year is around 2,000, give or take, 200 dollars. 

Dan: She called the insurance company to confirm that estimate. And then she cranked up her due diligence. 

Caitlyn: I called the hospital, and I asked for the names of the anesthesiologist, the radiologist. I asked for all of the details of who is possibly going to be on my case. And then I turned around and I called insurance and I said, I want to make sure all of these physicians are going to be in network on this date. 

Dan: Caitlyn had done her homework. Probably more than a lot of us would have thought to do. I asked her: How’d you get so diligent? And first, like a lot of folks I’ve talked with, she said: Having a major health issue as a kid — losing her hearing — gave her an early heads-up to watch out. 

Caitlyn: A little bit was, uh, experience of my mom dealing with insurance battles with me growing up. I remember her running into issues with that. 

Can: And she’s got some experts in her life now. Her brother and her sister in law work in health care. One of her best friends is a healthcare lawyer and had some tips. 

Caitlyn: But honestly, I think a lot of it is I have anxiety, and so I was just really paranoid. 

Dan: The surgery went great. And a few weeks later, Caitlyn was in the audiologist’s office, getting that external component attached, and hearing on her right side for the first time in 15 years. Caitlyn says it all took some getting used to. 

Caitlyn: I remember those, like, first few days especially, it wasn’t really like I was hearing full sounds. It was kind of just different pitches. I wasn’t hearing the words and everything, it was just the breakdown of the different pitches. And they also were just so much higher than they should be.

Dan: So interesting. Radiolab may have already done this story — [but] I’m just like, let’s find out what that’s about. 

Caitlyn: I love Radiolab. 

Dan: Me too! Anyway, two weeks after she starts getting used to her new hearing situation, Caitlyn gets that alert on her phone. 

Caitlyn: And it tells me I have a new invoice. And I was like, oh, awesome! I’m not stressed at all, I did my due diligence. I know it’s gonna be expensive, but affordable. 

Dan: Except, right: It’s a hundred and thirty-nine thousand dollars! Six figures. The full amount for her surgery. You might remember, Caitlyn said she had a panic attack. That was literal: Heart palpitations, hyperventilating. 

It took her 20 or 30 minutes to get calm enough to start making calls. And she says her insurance told her they hadn’t paid because the hospital had neglected to send something important. 

Caitlyn: The itemized bill. Which has all the codes and everything, 

Dan: Caitlyn says she immediately asked the hospital, in writing to send her insurance the itemized bill, and she says sent a follow-up a week later. But her phone kept pinging with alerts about owing the hospital a hundred and thirty-nine thousand dollars. 

Caitlyn: The app so conveniently told me that I could sign up for monthly payments of 11,000 dollars a month, which is just so absurd. 

Dan: After two weeks, she asked her insurance: Do you have that itemized bill yet? They didn’t. So she called the hospital again. 

Caitlyn: The girl I spoke with said she was putting in a request to have it faxed to my insurance and that would take two to three weeks. And I said, hold on, it takes you two to three weeks to fax a document?

Dan: Answer: Apparently yes? And Caitlyn says even three weeks later, her insurance company still hadn’t gotten that itemized bill the hospital promised to fax. 

And all this time Caitlyn was still getting notices from the hospital billing department. And the latest one said, “past due.” She tried something new: So she called the hospital and demanded they send the itemized bill directly to her, immediately. Which they did. 

Caitlyn: So I turned around and faxed it to my insurance. 

Dan: Yeah but, this did not end things, not yet. Caitlyn says she got more notices labeled past due. She fought her way to a direct conversation with a supervisor. 

Caitlyn: They kept saying,‘well, a supervisor’s not available right now.’ I said, No, you’re finding a supervisor. I don’t care if they’re cutting their lunch short. I’m talking to a supervisor right now. I don’t care if I sound like a Karen. It’s been a long, long year already. 

Dan: Eventually, Caitlyn got a supervisor on the line and got the supervisor to get permission from a manager to stop sending her bills while the hospital waited for insurance to pay. 

By this time, it was late March, almost two months after that first bill gave Caitlyn that panic attack. Also by this time, Caitlyn had sent her bill to the folks at NPR and KFF Health News for that Bill of the Month feature they do. 

Caitlyn: I was like, I just need to vent. And so I submitted it just to vent it out. Never expecting anyone to reach out. 

Dan: But they did. And on April 9th, Caitlyn got a call from a regional Patient Service Center manager. 

Caitlyn: And she was super nice and tried to be really apologetic, but never actually accepting any blame. Or outright saying,‘we’re so sorry.’ Just said, ‘I’m sorry for your frustration, that sounds awful.’ 

Dan: She DID tell Caitlyn that the hospital had received payment from her insurance. And that Caitlyn could expect a final bill within a week. And that instead of a hundred thirty nine thousand, it was gonna be one thousand, nine hundred eighty-two dollars and twenty-five cents. 

Caitlyn: I said,‘yep, that actually matches what my insurance said,’ and she said,‘oh, you know what was left on your out-of-pocket, most people don’t,’ and I said,‘I’m very well versed in every dollar sign at this point in this entire case.’ 

Dan: Caitlyn says she got that bill four days later and paid it immediately. 

Caitlyn: And I saved the receipt of that, I have saved everything. It feels like it’s resolved, but there’s part of me that’s still waiting for the other shoe to drop 

Dan: So, Caitlyn’s story brings up a LOT. Of course, I loved the way she kept fighting, and ultimately took control of the situation. And I hated how she got trapped between these two big entities and how much time and stress the whole thing cost her. 

Because, you know, the hospital could’ve resolved this so quickly by just sending that itemized bill to Caitlyn’s insurance company. 

Caitlyn: And the hospital did not do that. They just turned around and billed me. Which was a stupid idea, since the insurance company is more likely to have the money. Not the legal assistant in Oklahoma. 

Dan: Caitlyn’s story raised a few questions, and brought back a lot of themes we’ve touched on before. We dug in also found some new tips, and some memories I want to share. That’s coming right up. 

This episode of An Arm and a Leg is a co-production of Public Road Productions and KFF Health News, a nonprofit newsroom covering healthcare in America. Their senior contributing editor, Elisabeth Rosenthal, reported Caitlyn’s story for KFF and NPR. She wrote a book about U.S. healthcare. It’s called “An American Sickness,” and it was an inspiration for this show. 

One question we ask sometimes on this show when we see a bill that’s so wildly ridiculous and unfair is: Can they freaking DO that?!? Like, is that even legal?

Like in this instance, can they just keep billing you while they’re apparently not even playing ball with your insurance? And: Do we have any legal weapons to fight back with? 

We asked a bunch of legal experts, and they pretty much all said: Yes, they probably can do that, and no, we probably don’t have any easy legal weapons we can fight with. But then I talked with Berneta Haynes. She’s a senior attorney with the National Consumer Law Center. 

And she had some practical thoughts that are super-worth sharing. She used to work for a nonprofit called Georgia Watch — that’s a state-level consumer protection group. They operated a hotline people could call for help. 

Berneta Haynes: Consumers and patients would call us with all kinds of hospital billing issues and medical debt issues. And we’ve had these kinds of weird questions where really, there wasn’t a particular lever at the legal level to actually help them. But if they feel like they’re experiencing what could be considered potentially an unfair business practice, it is totally within their right to file a complaint within their state A. G.’s office. 

Dan: The A.G. The state attorney general. Whoever’s doing you wrong, you can file a complaint. 

Berneta: Whether or not there’s any real hook that your AG could use to hold them accountable is always a question that’s up in the air. But even just the act of filing a complaint is very likely to get that entity, that company, to behave correctly. 

Dan: Basically, go up the chain. Whether to a government watchdog, or in the organization that’s bugging you. We’ve heard this before, but I loved the specifics that Berneta Haynes shared with me about her own experiences. 

Berneta: I will tell you, one of the mechanisms my husband and I have had to utilize repeatedly, not in a hospital context, but in various other service contexts is to reach out or threaten to reach out to the CEO or president. And it gets results every time. It gets results every time! 

Dan: Oh, and here’s the pro tip.

Berneta: My husband has repeatedly, when he’s had to do it, set up a LinkedIn premium account just to find the CEO and message them directly. 

Dan: Ooh, that’s good! 

Berneta: That has been the way we’ve gotten resolution on all kinds of issues related to insurance companies not wanting to do right by us. And so forth. 

Dan: So that was fun. Now, I do want to talk a little bit about what Caitlyn did, and what allowed her to do it. Caitlyn figures she made at least a dozen phone calls. And she says she’s lucky — privileged — to have a job where she could do that. Here’s the first thing she says she did once she got over that panic attack when the bill arrived. 

Caitlyn: I just went to my boss’s office and I said, I’m going to have to make some phone calls. There’s a problem with my hospital bill. She’s like, don’t worry about it. Do what you need to. 

Dan: And she had people in her corner, like the friend who’s a healthcare lawyer. And legal advice wasn’t the big thing that friend gave Caitlyn. 

Caitlyn: Most of the time I was just venting to her, and she was like,‘you need to keep pushing, like, keep going at them. Don’t let them win. Don’t roll over. Just keep pushing. They should be paying.’ 

Dan: And at that point, I told Caitlyn, she and her story were really reminding me of someone. 

Dan: There’s a reporter named Marshall Allen. He worked for ProPublica for a long time. He wrote on healthcare, and he wrote on stuff like this. And eventually he wrote a book, giving advice to people. And the title of the book was, Never Pay the First Bill. 

Caitlyn: Oh! 

Dan: And I told Caitlyn, Marshall was on my mind at the time because when Caitlyn and I talked in May, Marshall had just died, like less than two weeks before. And he was young — 52. He had three kids.

Caitlyn: So sad. 

Dan: Super, super, super sad. 

Dan: And of course the title of Marshall’s book — Never Pay the First Bill — that’s exactly how Caitlyn played things. She wasn’t going to think about paying anything until she got her questions answered. And it is worth remembering. 

When we were talking with legal experts, one thing a few of them said was: If you pay something that insurance was supposed to cover, and then insurance comes through, you’re supposed to get a refund. But who wants to chase that? 

Yeah. Don’t pay that first bill until you’ve made sure this is money you really owe. So, this seems like a good time to memorialize Marshall Allen a little bit. He liked to compare the healthcare system to a schoolyard bully. Here’s what he told me when he was on this show in 2021 when his book had just come out. 

Marshall Allen: What I think we need to do is stand up to the bully. We need to stop being afraid. We need to stop thinking someone else is going to stick up for us. And I wrote the book to equip and empower people to stand up to the bullies. 

And I think it’s tremendously empowering, but it’s hard, and standing up to a bully takes incredible courage. It takes fortitude. It takes persistence. You might get beat up in the process. There’s no guarantee of victory. It’s risky, right? But if we don’t try, we don’t have a chance. 

Dan: Marshall was a Christian minister before he became a reporter. He wrote a thoughtful essay about how his work as an investigative reporter fit with his faith. The gist was: The Bible is pretty clear that cheating people and exploiting them is wrong. 

And to me, it seems like there was an element of ministry– not just evangelism — to what he did after his book came out. Here’s what he told me in 2021: 

Marshall: I’ve started taking calls, and I’m responding to emails that I get from people and I’m saying,‘call me, let’s talk it through, let me help you with this. Let’s work through this together.’ And now I’m helping people work through their bills, work through these situations where they’re being cheated. It’s super satisfying and gratifying, so it’s my new hobby. 

Dan: He kept at it. He left ProPublica and took a job with the Office of the Inspector General at the federal department of Health and Human Services. And he published a newsletter — it was free, but he encouraged people to pay if they could, and he used the money to hire medical-bill advocates to help people with especially tricky cases. 

And Marshall was funny. I want to close out this episode with a story he told me the first time we talked, in 2019. It’s kind of an origin story. 

Marshall: So when I was 16 years old, um, I worked for this dinner theater in Golden, Colorado, where I grew up. One day I show up for work, and they’ve closed down the business. They owed me like three weeks of pay. 

The guy had closed the place without paying us and said,‘there’s no money. We shut down the business. We can’t afford to pay you. You’re out of luck.’ Well, we were all pretty angry about that. We were really angry because they had opened a sister dinner theater under the same company umbrella across town. And we all knew that. And we were like, well, if you can afford to keep your other place open, you can afford to pay us. And they said,‘sorry, kids, you’re out of luck.’ 

Dan: Marshall goes home, tells his mom what’s going on. 

Marshall: And my mom tells me you should sue him. I’m like, mom, what do you mean? I can barely drive. How can I sue the guy? She goes,‘you should take him to small claims court.’ So lo and behold, I go down, I fill out the paperwork. 

It’s a few paragraphs. It’s easy to fill out the paperwork in small claims court. I fill out the paperwork and turn in like 10 bucks at the time or whatever it costs. It’s not that expensive to file one of these cases. And I get a notice in the mail like six weeks later. And I have a court date, and I’m like geared up for this big Perry Mason moment. 

Dan: Perry Mason was a lawyer on this super old TV show — courtroom drama. But this wasn’t a courtroom.

Marshall: It’s more like a conference room and there’s some administrative hearing judge in there. And lo and behold, the owner of the company and his attorney had to show up in court there with me. 

And I thought we’d have a big argument all the administrative judge did is he read my few paragraphs on the little thing I’d written up and he looks over at the owner and he goes,‘is what this kid saying true?’And the owner’s like, ‘well, yeah.’ And the judge is like,‘give this kid his money.’ And I was like, This is amazing. You know what? Maybe the court system does actually work every now and then maybe every now and then the little guy can win. 

Dan: Marshall and I both stayed interested in how people can use the legal system to get our rights. I learned a lot from Marshall, and like a lot of people, I just loved his spirit. Marshall Allen, thank you. And here’s the end of my conversation with Caitlyn. 

Dan: Marshall Allen would have been extremely proud of you. 

Caitlyn: Yeah. 

Dan: Caitlyn has the final word here. 

Caitlyn: I got to the point where I was like, it’s my fight. I’ve got gasoline in the fire. I’m, I’m going for it. 

Dan: We’ll be back with a new episode in a few weeks. Till then, take care of yourself. 

This episode of An Arm and a Leg was produced by me, Dan Weissmann, with help from Emily Pisacreta and Claire Davenport — and edited by Ellen Weiss. 

KFF senior contributing editor Elisabeth Rosenthal reported Caitlyn’s story for KFF and NPR. She was editor in chief there when she invited me to collaborate with KFF to make this show’s second season, and we’ve been colleagues ever since. I’ve never felt so lucky or so thankful. 

Special thanks to Christopher Robertson at Boston University’s School of Law, Wendy Epstein of the College of Law at DePaul University, Sabrina Corlette at Georgetown University’s Center on Health Insurance Reforms, and Elisabeth Benjamin from the Community Service Society of New York for pitching in with legal expertise here. 

Adam Raymonda is our audio wizard. Our music is by Dave Weiner and Blue Dot Sessions. Gabrielle Healy is our managing editor for audience. Bea Bosco is our consulting director of operations. Sarah Ballama is our operations manager. 

An Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in-depth journalism about healthcare in America and a core program at KFF, an independent source of health policy research, polling, and journalism. 

Zach Dyer is senior audio producer at KFF Health News. He’s editorial liaison to this show. And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor. They allow us to accept tax-exempt donations. You can learn more about INN at INN.org. Finally, thank you to everybody who supports this show financially. You can join in any time at https://armandalegshow.com/support/. Thank you so much for pitching in if you can — and, thanks for listening.

“An Arm and a Leg” is a co-production of KFF Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to its newsletters. You can also follow the show on Facebook and the social platform X. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

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KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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