KFF Health News' 'What the Health?': Trump’s ‘One Big Beautiful Bill’ Lands in Senate. Our 400th Episode!
The Host
Julie Rovner
KFF Health News
Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
After narrowly passing in the House in May, President Donald Trump’s “One Big Beautiful Bill” has now arrived in the Senate, where Republicans are struggling to decide whether to pass it, change it, or — as Elon Musk, who recently stepped back from advising Trump, is demanding — kill it.
Adding fuel to the fire, the Congressional Budget Office estimates the bill as written would increase the number of Americans without health insurance by nearly 11 million over the next decade. That number would grow to approximately 16 million should Republicans also not extend additional subsidies for the Affordable Care Act, which expire at year’s end.
This week’s panelists are Julie Rovner of KFF Health News, Jessie Hellmann of CQ Roll Call, Alice Miranda Ollstein of Politico, and Lauren Weber of The Washington Post.
Panelists
Jessie Hellmann
CQ Roll Call
Alice Miranda Ollstein
Politico
Lauren Weber
The Washington Post
Among the takeaways from this week’s episode:
- Even before the CBO released estimates of how many Americans stand to lose health coverage under the House-passed budget reconciliation bill, Republicans in Washington were casting doubt on the nonpartisan office’s findings — as they did during their 2017 Affordable Care Act repeal effort.
- Responding to concerns about proposed Medicaid cuts, Iowa Sen. Joni Ernst, a Republican, this week stood behind her controversial rejoinder at a town hall that “we’re all going to die.” The remark and its public response illuminated the problematic politics Republicans face in reducing benefits on which their constituents rely — and may foreshadow campaign fights to come.
- Journalists revealed that Health and Human Services Secretary Robert F. Kennedy Jr.’s report on children’s health may have been generated at least in part by artificial intelligence. The telltale signs in the report of what are called “AI hallucinations” included citations to scientific studies that don’t exist and a garbled interpretation of the findings of other research, raising further questions about the validity of the report’s recommendations.
- And the Trump administration this week revoked Biden-era guidance on the Emergency Medical Treatment and Active Labor Act. Regardless, the underlying law instructing hospitals to care for those experiencing pregnancy emergencies still applies.
Also this week, Rovner interviews KFF Health News’ Arielle Zionts, who reported and wrote the latest “Bill of the Month” feature, about a Medicaid patient who had an emergency in another state and the big bill he got for his troubles. If you have an infuriating, outrageous, or baffling medical bill you’d like to share with us, you can do that here.
Plus, for “extra credit,” the panelists suggest health policy stories they read (or wrote) this week that they think you should read, too:
Julie Rovner: KFF Health News’ “Native Americans Hurt by Federal Health Cuts, Despite RFK Jr.’s Promises of Protection,” by Katheryn Houghton, Jazmin Orozco Rodriguez, and Arielle Zionts.
Alice Miranda Ollstein: Politico’s “‘They’re the Backbone’: Trump’s Targeting of Legal Immigrants Threatens Health Sector,” by Alice Miranda Ollstein.
Lauren Weber: The New York Times’ “Take the Quiz: Could You Manage as a Poor American?” by Emily Badger and Margot Sanger-Katz.
Jessie Hellmann: The New York Times’ “A DNA Technique Is Finding Women Who Left Their Babies for Dead,” by Isabelle Taft.
Also mentioned in this week’s podcast:
- NOTUS.org’s “The MAHA Report Cites Studies That Don’t Exist,” by Emily Kennard and Margaret Manto.
- The Washington Post’s “White House MAHA Report May Have Garbled Science by Using AI, Experts Say,” by Lauren Weber and Caitlin Gilbert.
click to open the transcript
Transcript: Trump’s ‘One Big Beautiful Bill’ Lands in Senate. Our 400th Episode!
[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, June 5, 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 Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Hello.
Rovner: Lauren Weber of The Washington Post.
Lauren Weber: Hello, hello.
Rovner: And Jessie Hellmann of CQ Roll Call.
Jessie Hellmann: Hi there.
Rovner: Later in this episode we’ll have my interview with my colleague Arielle Zionts, who reported and wrote the KFF Health News “Bill of the Month,” about a Medicaid patient who had a medical emergency out of state and got a really big bill to boot. But first the news. And buckle up — there is a lot of it.
We’ll start on Capitol Hill, where the Senate is back this week and turning its attention to that “Big Beautiful” budget reconciliation bill passed by the House last month, and we’ll get to the fights over it in a moment. But first, the Congressional Budget Office on Wednesday finished its analysis of the House-passed bill, and the final verdict is in. It would reduce federal health care spending by more than a trillion dollars, with a T, over the next decade. That’s largely from Medicaid but also significantly from the Affordable Care Act. And in a separate letter from CBO Wednesday afternoon, analysts projected that 10.9 million more people would be uninsured over the next decade as a result of the bill’s provisions.
Additionally, 5.1 million more people would lose ACA coverage as a result of the bill, in combination with letting the Biden-era enhanced subsidies expire, for a grand total of 16 million more people uninsured as a result of Congress’ action and inaction. I don’t expect that number is going to help this bill get passed in the Senate, will it?
Ollstein: We’re seeing a lot of what we saw during the Obamacare repeal fight in that, even before this report came out, Republicans were working to discredit the CBO in the eyes of the public and sow the seeds of mistrust ahead of time so that these pretty damaging numbers wouldn’t derail the effort. They did in that case, among other things. And so they could now, despite their protestations.
But I think they’re saying a combination of true things about the CBO, like it’s based on guesses and estimates and models and you have to predict what human behavior is going to be. Are people going to just drop coverage altogether? Are they going to do this? Are they going to do that? But these are the experts we have. This is the nonpartisan body that Congress has chosen to rely on, so you’re not really seeing them present their own credible sources and data. They’re more just saying, Don’t believe these guys.
Rovner: Yeah, and some of these things we know. We’ve seen. We’ve talked about the work requirement a million times, that when you have work requirements in Medicaid, the people who lose coverage are not people who refuse to work. It’s people who can’t navigate the bureaucracy. And when premiums go up, which they will for the Affordable Care Act, not just because they’re letting these extra subsidies expire but because they’re going back to the way premiums were calculated before 2017. The more expensive premiums get, the fewer people sign up. So it’s not exactly rocket science figuring out that you’re going to have a lot more people without health insurance as a result of this.
Ollstein: Honestly, it seems from the reactions so far that Republicans on the Hill are more impacted by the CBO’s deficit increase estimates than they are by the number of uninsured-people increase estimates.
Rovner: And that frankly feels a little more inexplicable to me that the Republicans are just saying, This won’t add to the deficit. And the CBO — it’s arithmetic. It’s not higher math. It’s like if you cut taxes this much so there’s less money coming in, there’s going to be less money and a bigger deficit. I’m not a math person, but I can do that part, at least in my head.
Jessie, you’re on the Hill. What are you seeing over in the Senate? We don’t even have really a schedule for how this is going to go yet, right? We don’t know if the committees are going to do work, if they’re just going to plunk the House bill on the floor and amend it. It’s all sort of a big question mark.
Hellmann: Yeah, we don’t have text yet from any of the committees that have health jurisdiction. There’s been a few bills from other committees, but obviously Senate Finance has a monumental task ahead of them. They are the ones that have jurisdiction over Medicaid. Their members said that they have met dozens of times already to work out the details. The members of the Finance Committee were at the White House yesterday with President [Donald] Trump to talk about the bill.
It doesn’t seem like they got into the nitty-gritty policy details. And the message from the president seemed to mostly be, like, Just pass this bill and don’t make any major changes to it. Which is a tall order, I think, for some of the members like [Sens.] Lisa Murkowski of Alaska and Susan Collins of Maine, and even a few others that are starting to come out and raise concerns about some of the changes that the House made, like to the way that states finance their share of Medicaid spending through the provider tax.
Lisa Murkowski has raised concerns about how soon the work requirements would take effect, because, she was saying, Alaska doesn’t have the infrastructure right now and that would take a little bit to work out. So there are clearly still a lot of details that need to be worked out.
Rovner: Well, I would note that Senate Republicans were already having trouble communicating about this bill even before these latest CBO numbers came out. At a town hall meeting last weekend in Iowa, where nearly 1 in 5 residents are on Medicaid, Republican Sen. Joni Ernst had an unfortunate reaction to a heckler in the audience, and, rather than apologize — well, here’s what she posted on Instagram.
Sen. Joni Ernst: Hello, everyone. I would like to take this opportunity to sincerely apologize for a statement that I made yesterday at my town hall. See, I was in the process of answering a question that had been asked by an audience member when a woman who was extremely distraught screamed out from the back corner of the auditorium, “People are going to die!” And I made an incorrect assumption that everyone in the auditorium understood that, yes, we are all going to perish from this earth.
So I apologize. And I’m really, really glad that I did not have to bring up the subject of the tooth fairy as well. But for those that would like to see eternal and everlasting life, I encourage you to embrace my Lord and Savior, Jesus Christ.
Rovner: And what you can’t see, just to add some emphasis, Ernst recorded this message in a cemetery with tombstones visible behind her. I know it is early in this debate, but I feel like we might look back on this moment later like [Sen. John] McCain’s famous thumbs-down in the 2017 repeal-and-replace debate. Or is it too soon? Lauren.
Weber: For all the messaging they’ve tried to do around Medicaid cuts, for all the messaging, We’re all going to die I cannot imagine was on the list of approved talking points. And at the end of the day, I think it gets at how uncomfortable it is to face the reality of your constituents saying, I no longer have health care. This has been true since the beginning of time. Once you roll out an entitlement program, it’s very difficult to roll it back.
So I think that this is just a preview of how poorly this will go for elected officials, because there will be plenty of people thrown off of Medicaid who are also Republicans. That could come back to bite them in the midterms and in general, I think, could lead — combine it with the anti-DOGE [Department of Government Efficiency] fervor— I think you could have a real recipe for quite the feedback.
Rovner: Yes, and we’re going to talk about DOGE in a second. As we all now know, Elon Musk’s time as a government employee has come to an end, and we’ll talk about his legacy in a minute. But on his way out the door, he let loose a barrage of criticism of the bill, calling it, among other things, a, quote “disgusting abomination” that will saddle Americans with, quote, “crushingly unsustainable debt.”
So basically we have a handful of Republicans threatening to oppose the bill because it adds to the deficit, another handful of Republicans worried about the health cuts — and then what? Any ideas how this battle plays out. I think in the House they managed to get it through by just saying, Keep the ball rolling and send it to the Senate. Now the Senate, it’s going to be harder, I think, for the Senate to say, Oh, we’ll keep the ball rolling and send it back to the House.
Ollstein: Well, and to jump off Lauren’s point, I think the political blowback is really going to be because this is insult on top of injury in terms of not only are people going to lose Medicaid, Republicans, if this passes, but they’re being told that the only people who are going to lose Medicaid are undocumented immigrants and the undeserving. So not only do you lose Medicaid because of choices made by the people you elected, but then they turn around and imply or directly say you never deserved it in the first place. That’s pretty tough.
Rovner: And we’re all going to die.
Ollstein: And we’re all going to die.
Weber: Just to add onto this, I do think it’s important to note that work requirements poll very popularly among the American people. A majority of Americans here “work requirements” and say, Gee, that sounds like a commonsense solution. What the reality that we’ve talked about in this podcast many, many times is, that it ends up kicking off people for bureaucratic reasons. It’s a way to reduce the rolls. It doesn’t necessarily encourage work.
But to the average bear, it sounds great. Yes, absolutely. Why wouldn’t we want more people working? So I do think there is some messaging there, but at the end of the day, like Alice said, like I pointed out, they have not figured out the messaging enough, and it is going to add insult to injury to imply to some of these folks that they did not deserve their health care.
Ollstein: And what’s really baffling is they are running around saying that Medicaid is going to people who should never have been on the program in the first place, able-bodied people without children who are not too young and not too old, sort of implying that these people are enrolling against the wishes of the program’s creators.
But Congress explicitly voted for these people to be eligible for the program. And then after the Supreme Court made it optional, all of these states, most states, voted either by a direct popular vote or through the legislature to extend Medicaid to this population. And now they’re turning around and saying they were never supposed to be on it in the first place. We didn’t get here by accident or fraud.
Rovner: Or by executive order.
Ollstein: Exactly.
Rovner: Well, even before the Senate digs in, there’s still a lot of stuff that got packed into that House bill, some of it at the last minute that most people still aren’t aware of. And I’m not talking about [Rep.] Marjorie Taylor Greene and AI, although that, too, among other things. And shout out here to our podcast panelist Maya Goldman over at Axios. The bill would reduce the amount of money medical students could borrow, threatening the ability of people to train to become doctors, even while the nation is already suffering a doctor shortage.
It would also make it harder for medical residents to pay their loans back and do a variety of other things. The idea behind this is apparently to force medical schools to lower their tuition, which would be nice, but this feels like a very indirect way of doing it.
Weber: I just don’t think it’s very popular in an era in which we’re constantly talking about physician shortages and encouraging folks that are from minority communities or underserved communities to become primary care physicians or infectious disease physicians, to go to the communities that need them, that reflect them, to then say, Look, we’re going to cut your loans. And what that’s going to do — short of RFK [Robert F. Kennedy Jr.], who has toyed with playing with the code. So who knows? We could see.
But as the current structure stands, here’s the deal: You have a lot of medical debt. You are incentivized to go into a more lucrative specialty. That means that you’re not going into primary care. You’re not going into infectious disease care. You’re not going to rural America, because they can’t pay you what it costs to repay all of your loans. So, I do think — and, it was interesting. I think the Guardian spoke to some of the folks from the study that said that this could change it. That study was based off of metrics from 2006, and for some reason they were like, The financial private pay loans are not really going to cut it today.
I find it hard to believe this won’t get fixed, to be quite honest, just because I think hating on medical students is usually a losing battle in the current system. But who knows?
Rovner: And hospitals have a lot of clout.
Weber: Yeah.
Rovner: Although there’s a lot of things in this bill that they would like to fix. And, I don’t know. Maybe—
Weber: Well, and hospitals have a lot of financial incentive, because essentially they make medical residents indentured servants. So, yeah, they also would like them to have less loans.
Rovner: As I mentioned earlier, Elon Musk has decamped from DOGE, but in his wake is a lot of disruption at the Department of Health and Human Services and not necessarily a lot of savings. Thousands of federal workers are still in limbo on administrative leave, to possibly be reinstated or possibly not, with no one doing their jobs in the meantime. Those who are still there are finding their hands tied by a raft of new rules, including the need to get a political-appointee sign-off for even the most routine tasks.
And around the country, thousands of scientific grants and contracts have been summarily frozen or terminated for no stated cause, as the administration seeks to punish universities for a raft of supposed crimes that have nothing to do with what’s being studied. I know that it just happened, but how is DOGE going to be remembered? I imagine not for all of the efficiencies that it has wrung out of the health care system.
Ollstein: Well, one, I wouldn’t be so sure things are over, either between Elon and the Trump administration or what the amorphous blob that is DOGE. I think that the overall slash-and-burn of government is going to continue in some form. They are trying to formalize it by sending a bill to Congress to make these cuts, that they already made without Congress’ permission, official. We’ll see where that goes, but I think that it’s not an ending. It’s just morphing into whatever its next iteration is.
Rovner: I would note that the first rescission request that the administration has sent up formally includes getting rid of USAID [the U.S. Agency for International Development] and PEPFAR [the President’s Emergency Plan for AIDS Relief] and public broadcasting, which seems unlikely to garner a majority in both houses.
Ollstein: Except, like I said, this is asking them to rubber-stamp something they’re already trying to do without them. Congress doesn’t like its power being infringed on, especially appropriators. They guard that power very jealously. Now, we have seen them a little quieter in this administration than maybe you would’ve thought, but I think there are some who, even if they agree on the substance of the cuts, might object to the process and just being asked to rubber-stamp it after the fact.
Rovner: Well, meanwhile, Health and Human Services Secretary Kennedy continues to try to remake what’s left of HHS, although his big reorganization is currently blocked by a federal judge. And it turns out that his big MAHA, “Make America Healthy Again,” report may have been at least in part written by AI, which apparently became obvious when the folks at the news service NOTUS decided to do something that was never on my reporting bingo card, which is to check the footnotes in the report to see if they were real, which apparently many are not. Then, Lauren, you and your colleagues took that yet another step. So tell us about that.
Weber: Yeah. NOTUS did a great job. They went through all the footnotes to find out that several of the studies didn’t exist, and my colleagues and I saw that and said, Hm, let’s look a little closer at these footnotes and see. And what we were able to do in speaking with AI experts is find telltale signs of AI. It’s basically a sign of artificial intelligence when things are hallucinated — which is what they call it — which is when it sounds right but isn’t completely factual, which is one of the dangers of using AI.
And it appears that some of AI was used in the footnotes of this MAHA report, again, to, as NOTUS pointed out, create studies that don’t exist. It also kind of garbled some of the science on the other pieces of this. We found something called “oaicite,” which is a marker of OpenAI system, throughout the report. And at the end of the day, it casts a lot of questions on the report as a whole and: How exactly did it get made? What is the science behind this report?
And even before anyone found any of these footnotes of any of this, a fair amount of these studies that this report cites to back up its thesis are a stretch. Even putting aside the fake studies and the garbled studies, I think it’s important to also note that a lot of the studies the report cites, a lot of what Kennedy does, take it a lot further than what they actually say.
Rovner: So, this is all going well. Meanwhile, there is continuing confusion in vaccine land after Secretary Kennedy, flanked by FDA [Food and Drug Administration] Commissioner Marty Makary and NIH [National Institutes of Health] Director Jay Bhattacharya, announced in a video on X that the department would no longer recommend covid vaccines for pregnant women and healthy children, sidestepping the expert advice of the Centers for Disease Control and Prevention and its advisory committee of experts.
The HHS officials say people who may still be at risk can discuss whether to get the vaccine with their doctors, but if the vaccines are no longer on the recommended list, then insurance is less likely to cover them and medical facilities are less likely to stock them. Paging Sen. [Bill] Cassidy, who still, as far as I can tell, hasn’t said anything about the secretary’s violation of his promise to the senator during his confirmation hearings that he wouldn’t mess with the vaccine schedule. Have we heard a peep from Sen. Cassidy about any of this?
Ollstein: I have not, but a lot of the medical field has been very vocal and very upset. I was actually at the annual conference of the American College of Obstetricians and Gynecologists when this news broke, and they were just so confused and so upset. They had seen pregnant patients die of covid before the vaccines were available, or because there was so much misinformation and mistrust about the vaccines’ safety for pregnant people that a lot of people avoided it, and really suffered the consequences of avoiding it.
A lot of the issue was that there were not good studies of the vaccine in pregnant people at the beginning of the rollout. There have since been, and those studies have since shown that it is safe and effective for pregnant people. But it was, in a lot of people’s minds, too late, because they already got it in their head that it was unsafe or untested. So the OB-GYNs at this conference were really, really worried about this.
Rovner: And, confusingly, the CDC on its website amended its recommendations to leave children recommended but not pregnant women, which is kind of the opposite of, I think, what most of the medical experts were recommending. Jessie, you were about to add something.
Hellmann: I just feel like the confusion is the point. I think Kennedy has made it a pattern now to get out ahead of an official agency decision and kind of set the narrative, even if it is completely opposite of what his agencies are recommending or are stating. He’s done this with a report that the CDC came out with autism, when he said rising autism cases aren’t because of more recognition and the CDC report said it’s a large part because of more recognition.
He’s done this with food dyes. He said, We’re banning food dyes. And then it turns out they just asked manufacturers to stop putting food dyes into it. So I think it’s part of, he’s this figurehead of the agency and he likes to get out in front of it and just state something as fact, and that is what people are going to remember, not something on a CDC webpage that most people aren’t going to be able to find.
Rovner: Yeah, it sounds like President Trump. It’s like, saying it is more important than doing it, in a lot of cases. So of course there’s abortion news this week, too. The Trump administration on Tuesday reversed the Biden administration guidance regarding EMTALA, the Emergency Medical Treatment and Active Labor Act. Biden officials, in the wake of the overturn of Roe v. Wade three years ago, had reminded hospitals that take Medicare and Medicaid, which is all of them, basically, that the requirement to provide emergency care includes abortion when warranted, regardless of state bans. Now, Alice, this wasn’t really unexpected. In fact, it’s happening later than I think a lot of people expected it to happen. How much impact is it going to have, beyond a giant barrage of press releases from both sides in the abortion debate?
Ollstein: Yeah, so, OK, it’s important for people to remember that what the Biden administration, the guidance they put out was just sort of an interpretation of the underlying law. So the underlying law isn’t changing. The Biden administration was just saying: We are stressing that the underlying law means in the abortion context, in the post-Dobbs context, blah, blah, blah, blah, blah, that hospitals cannot turn away a pregnant woman who’s having a medical crisis. And if the necessary treatment to save her life or stabilize her is an abortion, then that’s what they have to do, regardless of the laws in the state.
In a sense, nothing’s changed, because EMTALA itself is still in place, but it does send a signal that could make hospitals feel more comfortable turning people away or denying treatment, since the government is signaling that they don’t consider that a violation. Now, I will say, you’re totally right that this was expected. In the big lawsuit over this that is playing out now in Idaho, one of the state’s hospitals intervened as a plaintiff, basically in anticipation of this happening, saying, The Trump administration might not defend EMTALA in the abortion context, so we’re going to do it for them, basically, to keep this case alive.
Rovner: And I would point out that ProPublica just won a Pulitzer for its series detailing the women who were turned away and then died because they were having pregnancy complications. So we do know that this is happening. Interestingly, the day before the administration’s announcement, the American College of Obstetricians and Gynecologists put out a new, quote, “practice advisory” on the treatment of preterm pre-labor rupture of membranes, which is one of the more common late-pregnancy complications that result in abortion, because of the risk of infection to the pregnant person.
Reading from that guidance, quote, “the Practice Advisory affirms that ob-gyns and other clinicians must be able to intervene and, in cases of previable and periviable PPROM” — that’s the premature rupture of membranes — “provide abortion care before the patient becomes critically ill.” Meanwhile, this statement came out Wednesday from the American College of Emergency Physicians, quote, ,“Regardless of variances in the regulatory landscape from one administration to another, emergency physicians remain committed not just by law, but by their professional oath, to provide this care.”
So on the one hand, professional organizations are speaking out more strongly than I think we’ve seen them do it before, but they’re not the ones that are in the emergency room facing potential jail time for, Do I obey the federal law or do I obey the state ban?
Ollstein: And when I talk to doctors who are grappling with this, they say that even with the Biden administration’s interpretation of EMTALA, that didn’t solve the problem for them. It was some measure of protection and confidence. But still, exactly like you said, they’re still caught in between seemingly conflicting state and federal law. And really a lot of them, based on what they told me, were saying that the threat of the state law is more severe. It’s more immediate.
It means being charged with a felony, being charged with a crime if they do provide the abortion, versus it’s a federal penalty, it’s not on the doctor itself. It’s on the institution. And it may or may not happen at some point. So when you have criminal charges on one side and maybe some federal regulation or an investigation on the other side, what are you going to choose?
Rovner: And it’s hard to imagine this administration doing a lot of these investigations. They seem to be turning to other things. Well, we will watch this space, and obviously this is all still playing out in court. All right, that is this week’s news, or at least as much as we could squeeze in. Now we’ll play my “Bill of the Month” interview with Arielle Zionts, and then we’ll come back and do our extra credits.
I am pleased to welcome back to the podcast KFF Health News’ Arielle Zionts, who reported and wrote the latest KFF Health News “Bill of the Month.” Arielle, welcome back.
Arielle Zionts: Hi. Thanks for having me.
Rovner: So this month’s patient has Medicaid as his health insurance, and he left his home state of Florida to visit family in South Dakota for the holidays, where he had a medical emergency. Tell us who he is and what happened that landed him in the hospital.
Zionts: Sure. So I spoke with Hans Wirt. He was visiting family in the Black Hills. That’s where Mount Rushmore is and its beautiful outdoors. He was at a water park, following his son up and down the stairs and getting kind of winded. And at first he thought it might just be the elevation difference, because in Florida it’s like 33 feet above sea level. Here it’s above 3,000 in Rapid City.
But then they got him back to the hotel room and he was getting a lot worse, his breathing, and then he turned pale. And his 12-year-old son is the one who called 911. And medics were like, Yep, you’re having a heart attack. And they took him to the hospital in town, and that is the only place to go. There’s just one hospital with an ER in Rapid City.
Rovner: So the good news is that he was ultimately OK, but the bad news is that the hospital tried to stick them with the bill. How big was it?
Zionts: It was nearly $78,000.
Rovner: Wow. So let’s back up a bit. How did Mr. Wirt come to be on Medicaid?
Zionts: Yeah. So it is significant that he is from Florida, because that is one of the 10 states that has not opted in to expand Medicaid. So in Florida, if you’re an adult, you can’t just be low-income. You have to also be disabled or caring for a minor child. And Hans says that’s his case. He works part time at a family business, but he also cares for his 12-year-old son, who is also on Medicaid.
Rovner: So Medicaid patients, as we know, are not supposed to be charged even small copays for care in most cases. Is that still the case when they get care in other states?
Zionts: So Medicaid will not pay for patient care if they are getting more of an elective or non-medically necessary kind of optional procedure or care in another state. But there are several exceptions, and one of the exceptions is if they have an emergency in another state. So federal law says that state Medicaid programs have to reimburse those hospitals if it was for emergency care.
Rovner: And presumably a heart attack is an emergency.
Zionts: Yes.
Rovner: So why did the hospital try to bill him anyway? They should have billed Florida Medicaid, right?
Zionts: So what’s interesting is while there’s a law that says the Medicaid program has to reimburse the hospital, there’s no law saying the hospital has to send the bill to Medicaid. And that was really interesting to learn. In this case, the hospital, it’s called Monument Health, and they said they only bill plans in South Dakota and four of our bordering states. So basically they said for them to bill for the Medicaid, they would have to enroll.
And they say they don’t do that in every state, because there is a separate application process for each state. And their spokesperson described it as a burdensome process. So in this case, they billed Hans instead.
Rovner: So what eventually happened with this bill? He presumably didn’t have $78,000 to spare.
Zionts: Correct. Yeah. And he had told them that, and he said they only offered, Hey, you can set up a payment plan. But that would’ve still been really expensive, the monthly payments. So he reached out to KFF Health News, and I had sent my questions to the hospital, and then a few days later I get a text from Hans and he says, Hey, my balance is at zero now. He and I both eventually learned that that’s because the hospital paid for his care through a program called Charity Care.
All nonprofit hospitals are required to have this program, which provides free or very discounted pricing for patients who are uninsured or very underinsured. And the hospital said that they screen everyone for this program before sending them to collections. But what that meant is that for months, Hans was under the impression that he was getting this bill. And he was, got a notice saying, This is your last warning before we send you to collection.
Rovner: So, maybe they would’ve done it anyway, or maybe you gave them a nudge.
Zionts: They say they would’ve done it anyways.
Rovner: OK. So what’s the takeaway here? It can’t be that if you have Medicaid, you can’t travel to another state to visit family at Christmas.
Zionts: Right. So Hans made that same joke. He said, quote, “If I get sick and have a heart attack, I have to be sure that I do that here in Florida now instead of some other state.” Obviously, he’s kidding. You can’t control when you have an emergency. So the takeaway is that you do risk being billed and that if you don’t know how to advocate yourself, you might get sent to collections. But I also learned that there’s things that you can do.
So you could file a complaint with your state Medicaid program, and also, if you have a managed-care program, and they might have — you should ask for a caseworker, like, Hey, can you communicate with the hospital? Or you can contact an attorney. There’s free legal-aid ones. An attorney I spoke with said that she would’ve immediately sent a letter to the hospital saying, Look, you need to either register with Florida Medicaid and submit it. If not, you need to offer the Charity Care. So that’s the advice.
Rovner: So, basically, be ready to advocate for yourself.
Zionts: Yes.
Rovner: OK. Arielle Zionts, thank you so much.
Zionts: Thank you.
Rovner: OK. We’re back, and it’s 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, why don’t you go first this week?
Hellmann: My story is from The New York Times. It’s called “A [DNA] Technique Is Finding Women Who Left Their Babies for Dead,” which I don’t know how I feel about that headline, but the story was really interesting. It’s about how police departments are using DNA technology to find the mothers of infants that had been found dead years and years ago. And it gets a little bit into just the complicated situation.
Some of these women have gone on to have families. They have successful careers. And now some of them are being charged with murder, and some who have been approached about this have unfortunately died by suicide. And it just gets into the ethics of the issue and what police and doctors, families, should be considering about the context around some of these situations, about what the circumstances were, in some cases, 40 years ago and what should be done with that.
Rovner: Really thought-provoking story. Lauren.
Weber: With credit to Julie, too, because she brought this up again, was brought back to a classic from The New York Times back in 2020, which is called “Take a Quiz: Could You Manage as a Poor American?” And here are the questions: I will read them for the group.
Rovner: And I will point out that this is once again relevant. That’s why it was brought back.
Weber: It’s once again relevant, and one of them is, “Do you have paper mail you plan to read that has been unopened for more than a week?” Yes. I’m looking at paper mail on my desk. “Have you forgotten to pay a utility bill on time?” If I didn’t set up auto pay, I probably would forget to pay a utility bill on time. “Have you received a government document in the mail that you did not understand?” Many times. “Have you missed a doctor’s appointment because you forgot you scheduled it or something came up?”
These are the basic facts that can derail someone from having access to health care or saddle them, because they lose access to health care and don’t realize it, with massive hospital bills. And this is a lot of what we could see in the coming months if some of these Medicaid changes come through. And I just, I think I would challenge a lot of people to think seriously about how much mail they leave unopened and what that could mean for them, especially if you are living in different homes, if you are moving frequently, etc. This paperwork burden is something to definitely be considered.
Rovner: Yeah, I think we should sort of refloat this every time we have another one of these debates. Alice.
Ollstein: So I wanted to recommend something I wrote [“‘They’re the Backbone’: Trump’s Targeting of Legal Immigrants Threatens Health Sector”]. It was my last story before taking some time off this summer. It is about the intersection of Trump’s immigration policies and our health care system. And so this is jumping off the Supreme Court allowing the Trump administration to strip legal status from hundreds of thousands of immigrants. Again, these are people who came legally through a designated program, and they are being made undocumented by the Trump administration, with the Supreme Court’s blessing. And tens of thousands of them are health care workers.
And so I visited an elder care facility in Northern Virginia that was set to lose 65 staff members, and I talked to the residents and the other workers about how this would affect them, and the owner. And it was just a microcosm of the damage this could have on our health sector more broadly. Elder care is especially immigrant-heavy in its workforce, and everyone there was saying there just are not the people to replace these folks.
And not only is that the case right now, but as the baby boomer generation ages and requires care, the shortages we see now are going to be nothing compared to what we could see down the road. With the lower birth rates here, we’re just not producing enough workers to do these jobs. The piece also looks into how public health and management of infectious diseases is also being worsened by these immigration raids and crackdowns and deportations. So, would love people to take a look.
Rovner: I’m so glad you did this story, because it’s something that I keep running up and down screaming. And you can tell us why you’re taking some time off this summer, Alice.
Ollstein: I’m writing a book. Hopefully it will be out next year, and I can’t wait to tell everyone more about it.
Rovner: Excellent. All right. My extra credit this week is from my KFF Health News colleagues Katheryn Houghton, Jazmin Orozco Rodriguez, and Arielle Zionts, who you just heard talking about her “Bill of the Month,” and it’s called “Native Americans Hurt by Federal Health Cuts, Despite RFK Jr.’s Promises of Protection.” And that sums it up pretty well. The HHS secretary had a splashy photo op earlier this year out west, where he promised to prioritize Native American health. But while he did spare the Indian Health Service from personnel cuts, it turns out that the Native American population is also served by dozens of other HHS programs that were cut, some of them dramatically, everything from home energy assistance to programs that improve access to healthy food, to preventing overdoses. The Native community has been disproportionately hurt by the purging of DEI [diversity, equity, and inclusion] programs, because Native populations have systematically been subjected to unequal treatment over many generations. It’s a really good if somewhat infuriating story.
OK. That is this week’s show. Before we go, if you will indulge me for a minute, this is our 400th episode of “What the Health?” We launched in 2017 during that year’s repeal-and-replace debate. I want to thank all of my panelists, current and former, for teaching me something new every single week. And everyone here at KFF Health News who makes this podcast possible. That includes not only my chief partners in crime, Francis Ying and Emmarie Huetteman, but also the copy desk and social media and web teams who do all the behind-the-scenes work that brings our podcast to you every week. And of course, big thanks to you, the listeners, who have stuck with us all these years.
I won’t promise you 400 more episodes, but I will keep doing this as long as you keep wanting it. 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. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can find me on X, @jrovner, or on Bluesky, @julierovner. Where are you folks these days? Jessie?
Hellmann: @jessiehellmann on X and Bluesky, and LinkedIn.
Rovner: Lauren.
Weber: I’m @LaurenWeberHP on X and on Bluesky, shockingly, now.
Rovner: Alice.
Ollstein: @alicemiranda on Bluesky and @AliceOllstein on X.
Rovner: We will be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': Bill With Billions in Health Program Cuts Passes House
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Julie Rovner
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
With only a single vote to spare, the House passed a controversial budget bill that includes billions of dollars in tax cuts for the wealthy, along with billions of dollars of cuts to Medicaid, the Affordable Care Act, and the food stamp program — most of which will affect those at the lower end of the income scale. But the bill faces an uncertain future in the Senate.
Meanwhile, Health and Human Services Secretary Robert F. Kennedy Jr. released a report from his commission to “Make America Healthy Again” that described threats to the health of the American public — but notably included nothing on threats from tobacco, gun violence, or a lack of health insurance.
This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Sarah Karlin-Smith of the Pink Sheet, and Alice Miranda Ollstein of Politico.
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Among the takeaways from this week’s episode:
- House Republicans passed their “big, beautiful” bill 215-214 this week, with one Republican critic voting present. But the Senate may have its own “big, beautiful” rewrite. Some conservative senators who worry about federal debt are concerned that the bill is not fully paid for and would add to the budget deficit. Others, including some red-state Republicans, say the bill’s cuts to Medicaid and food assistance go too far and would hurt low-income Americans. The bill’s cuts would represent the biggest reductions to Medicaid in the program’s 60-year history.
- Many of the bill’s Medicaid cuts would come from adding work requirements. Most people receiving Medicaid already work, but such requirements in Arkansas and Georgia showed that people often lose coverage under these rules because they have trouble documenting their work hours, including because of technological problems. The nonpartisan Congressional Budget Office estimated an earlier version of the bill would reduce the number of people with Medicaid by at least 8.6 million over a decade. The requirements also could add a burden for employers. The bill’s work requirements are relatively broad and would affect people who are 19 to 64 years old.
- People whose Medicaid coverage is canceled also would no longer qualify for ACA subsidies for marketplace plans. Medicare also would be affected, because the bill would be expected to trigger an across-the-board sequestration cut.
- The bill also would impact abortion by effectively banning it in ACA marketplace plans, which would disrupt a compromise struck in the 2010 law. And the bill would block funding for Planned Parenthood in Medicaid, although that federal money is used for other care such as cancer screenings, not abortions. In the past, the Senate parliamentarian has said that kind of provision is not allowed under budget rules, but some Republicans want to take the unusual step of overruling the parliamentarian.
- This week, FDA leaders released covid-19 vaccine recommendations in a medical journal. They plan to limit future access to the vaccines to people 65 and older and others who are at high risk of serious illness if infected, and they want to require manufacturers to do further clinical trials to show whether the vaccines benefit healthy younger people. There are questions about whether this is legal, which products would be affected, when this would take effect, and whether it’s ethical to require these studies.
- HHS released a report on chronic disease starting in childhood. The report doesn’t include many new findings but is noteworthy in part because of what it doesn’t discuss — gun violence, the leading cause of death for children and teens in the United States; tobacco; the lack of health insurance coverage; and socioeconomic factors that affect access to healthy food.
Also this week, Rovner interviews University of California-Davis School of Law professor and abortion historian Mary Ziegler about her new book on the past and future of the “personhood” movement aimed at granting legal rights to fetuses and embryos.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week they think you should read, too:
Julie Rovner: The Washington Post’s “White House Officials Wanted To Put Federal Workers ‘in Trauma.’ It’s Working,” by William Wan and Hannah Natanson.
Alice Miranda Ollstein: NPR’s “Diseases Are Spreading. The CDC Isn’t Warning the Public Like It Was Months Ago,” by Chiara Eisner.
Anna Edney: Bloomberg News’ “The Potential Cancer, Health Risks Lurking in One Popular OTC Drug,” by Anna Edney.
Sarah Karlin-Smith: The Farmingdale Observer’s “Scientists Have Been Studying Remote Work for Four Years and Have Reached a Very Clear Conclusion: ‘Working From Home Makes Us Happier,’” by Bob Rubila.
Also mentioned in this week’s podcast:
- The New York Times’ “As Congress Debates Cutting Medicaid, a Major Study Shows It Saves Lives,” by Sarah Kliff and Margot Sanger-Katz.
- NBC News’ “Georgia Mother Says She Is Being Forced To Keep Brain-Dead Pregnant Daughter Alive Under Abortion Ban Law,” by Minyvonne Burke.
- The Washington Post’s “Trump and GOP’s Tax Bill Would Force Cuts to Medicare, CBO Says,” by Jacob Bogage and Abha Bhattarai.
- The New England Journal of Medicine’s “An Evidence-Based Approach to Covid-19 Vaccination,” by Vinay Prasad and Martin A. Makary.
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Transcript: Bill With Billions in Health Program Cuts Passes House
[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 Friday, May 23, at 10 a.m. As always, and particularly this week, 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 Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Hello.
Rovner: Anna Edney of Bloomberg News.
Anna Edney: Hi, everybody.
Rovner: And Sarah Karlin-Smith of the Pink Sheet.
Sarah Karlin-Smith: Hello there.
Rovner: Later in this episode we’ll have my interview with law professor and abortion historian Mary Ziegler, who has a new book out on the history and possible future of the “personhood” movement. But first, this week’s news.
So, against all odds and many predictions, including my own, the House around 7 a.m. Thursday morning, after being in session all night, passed President [Donald] Trump’s One Big Beautiful Bill — that is its actual, official name — by a vote of 215-214, with one Republican voting present. Before we get into the details of the House-passed bill, what are the prospects for this budget reconciliation bill in this form in the Senate? Very different, I would think.
Ollstein: Yeah, this is not going to come out the way it went in. Senate is already openly talking about a “‘One, Big Beautiful’ Rewrite” — that was the headline at Politico.
And you’re going to see some of the same dynamics. You’re going to see hard-liners saying this doesn’t go far enough, this actually adds a lot to the deficit even with all of the deep cuts to government programs. And you’re going to have moderates who have a lot of people in their state who depend on Medicaid and other programs that are set to be cut who say this goes too far. And so you’re going to have that same push and pull. And the House, barely, by one vote, got this through. And so we’ll see if the Senate is able to do the same.
Rovner: Yeah, so all eyes on [Sen.] John McCain in 2017. This year it could be all eyes on Josh Hawley, I suspect, the very conservative senator from Missouri who keeps saying “Don’t touch Medicaid.”
But back to the House bill. We don’t have official scores yet from the Congressional Budget Office, and we won’t for a while, I suspect. But given some last-minute changes made to pacify conservatives who, as Alice pointed out, said this bill didn’t cut deeply enough, I think it’s clear that if it became law in this form, it would represent the biggest cuts to federal health programs in the 60-year history of Medicare and Medicaid.
Those last-minute changes also took pretty square aim at the Affordable Care Act, too, so much that I think it’s safe to call this even more than a partial repeal of the health law. And Medicare does not go unscathed in this measure, either, despite repeated promises by President Trump on the campaign trail and since he took office.
Let’s take these one at a time, starting with Medicaid. I would note that at a meeting with House Republicans on Tuesday, President Trump told them not to expletive around with Medicaid. You can go look up the exact quote yourself if you like. But apparently he’s OK with the $700 billion plus that would be cut in the bill, which Republicans say is just waste, fraud, and abuse. Where does that money come from? And would Medicaid really continue to cover everyone who’s eligible now, which is kind of what the president and moderate Republicans are promising?
Edney: Well, it sounds like the bulk of it is coming from the work requirements that Alice mentioned earlier. And would it be able to cover them? Sure, but will it? No, in the sense that, as Alice has talked about often on this podcast, it’s basically a time tax. It’s not easy to comply with. All federal regulations, they’re not going to a website and putting in what you did for work. Particularly, if you are a freelancer or something, it can be really difficult to meet all the requirements that they’re looking for. And also, for some people, they just don’t have the ability, even the internet, to be able to do that reliably. So they’re going to save money because people are going to lose their health care.
Rovner: I saw a lot of people referring to them this week not as work requirements anymore but as work reporting requirements. Somebody suggested it was like the equivalent of having to file your income taxes every month. It’s not just check a box and say, I worked this month. It’s producing documentation. And a lot of people have jobs that are inconsistent. They may work some hours some week and other hours the other week. And even people who work for small businesses, that would put an enormous burden on the employers to come up with all this.
Obviously, the CBO thinks that a lot of people won’t be able to do this and therefore people are going to lose their health insurance. But Alice, as you have told us numerous times when we did this in Arkansas, it’s not that people aren’t working — it’s that people aren’t successfully reporting their work.
Ollstein: Right. And we’ve seen this in Georgia, too, where this has been implemented, where there are many different ways that people who are working lose their insurance with this. People who don’t have good internet access struggle. People who have fluctuating work schedules, whether it’s agricultural work, tourism work, things that are more seasonal, they can’t comply with this strict monthly requirement.
So there are numerous reports from the ground of people who should be eligible losing their coverage. And I’ll note that one of the last-minute changes the House made was moving up the start date of the requirements. And I’m hearing a lot of state officials and advocates warn that that gives states less time to set up a system where people won’t fall through the cracks. And so the predicted larger savings is in part because they imagine more people will be kicked off the program.
Rovner: It’s also the most stringent work requirement we’ve seen. It would cover people from age 19 through age 64, like right up until you’re eligible for Medicare. And if you lose Medicaid because you fail to meet these reporting requirements, you’re no longer eligible for a subsidy to buy insurance in the ACA exchange. Is there a policy point to this? Or are they just trying to get the most people off the program so they can get the most savings?
Edney: If you ask Republicans, they would tell you: We’re going to get people back working. We’re going to give them the pride of working — as if people don’t want that on their own. But the actual outcome is not that people end up working more. And there are cases even where they lose their health insurance and can’t work a job they already had. On the surface, and this is why it’s such a popular program, because it seems like it would get more people working. Even a large swath of Democrats support the idea when they just hear the name — of voters. But the actual outcome, that doesn’t happen. People aren’t in Medicaid because they aren’t working.
Rovner: Right. And I get to say for the millionth time, nobody is sitting on their couch living on their Medicaid coverage.
Edney: Right, right.
Rovner: There’s no money that comes with Medicaid. It’s just health insurance. The health providers get paid for Medicaid and occasionally the managed-care companies. But there’s no check to the beneficiary, so there’s no way to live on your Medicaid.
As Alice points out, most of the people who are working and have Medicaid are working at jobs, obviously, that don’t offer employer health insurance. So having, in many cases, as you say, Anna, having Medicaid is what enables you to work.
All right, well, our podcast pals Margot Sanger-Katz and Sarah Kliff have an excellent Medicaid story out this week on a new study that looks very broadly at Medicaid and finds that it actually does improve the health of its beneficiaries. Now this seems logical, but that has been quite a talking point for Republicans for many years, that we spend all this money and it doesn’t produce better health, because we’ve had a lot of studies that have been kind of neither here nor there on this.
Do we finally have proof that Democrats need? Because I have heard, over many years — there was a big Oregon study in 2011 that found that it helped people financially and that it helped their mental health, but there was not a lot of physical health benefit that they saw. Of course, it was a brief. It was like two years. And it takes a longer time to figure out the importance of health insurance. But I’m wondering if maybe the Democrats will finally be able to put down that talking point. I didn’t hear it, actually, as much this week as I have in years past: Why are we spending all this money on Medicaid when we don’t know whether it’s producing better health?
Karlin-Smith: One of the interesting things I thought about this study and sort of the timing of it, post-Obamacare expansion of Medicaid and more younger people being covered, is that it seems to really show that, not only does this study show it saves lives, but it’s really helping these younger populations.
And I think there are some theories as to why it might have been harder to show the economic cost-effectiveness benefits people were looking for before, when you had Medicaid covering populations that were already either severely ill or older. Which doesn’t mean it’s not valuable, right? To provide health coverage to somebody who’s 75 or 80, but unfortunately we have not found the everlasting secret to life yet.
So, but I think for economists who want to be able to show this sort of, as they show in this paper, this “quality-adjusted life year” benefit, this provides some really good evidence of what that expansion of Medicaid — which is a lot of what’s being rolled back, potentially, under the reconciliation process — did, which is, helps younger people be healthier and thus, right, hopefully, ideally, live a higher quality of life, and where you need less health coverage over time, and cost the government less.
It’s quite interesting, for people who want to go look at the graph The New York Times put in their story, of just where Medicaid fits, in terms of other sort of interventions we spend a lot of money on to help save lives. Because I was kind of surprised, given how much health insurance does cover, that it comes out on sort of the lower end, as being a pretty good bargain.
Rovner: Yeah. Well, we don’t have time to get into everything that’s in this bill, and there is a lot. It also includes a full ban of Medicaid coverage for gender-affirming care for both minors and adults. And it cuts reimbursement to states that use their own funds to provide coverage to undocumented people. Is this a twofer for Republicans, saving money while fighting the culture wars?
Edney: Certainly. And I was surprised to see some very liberal states on the immigration front saying: We just have to deal with this. And this really sucks, but we have to balance our budget. And if we’re not going to get those tax dollars, then we aren’t going to be able to offer health insurance to people who are undocumented, or Medicaid to people who are undocumented.
Rovner: Yeah, California, most notably.
Edney: Yeah, California for sure. And they found a way to do it, hit them in the pocketbook, and that that’s a way for them to win the culture war, for sure.
Rovner: Alice, you’ve spent a lot of time looking at gender-affirming care. Were you surprised to see it banned for adults, too? Obviously the gender-affirming care for minors has been a continuing issue for a while.
Ollstein: Yeah, I would say not surprised, because this is sort of a common pattern that we see across different things, including in the abortion space, where first policies are targeted just at minors. That often is more politically palatable. And then it gets expanded to the general population. And so I think, given the wave of state bans on care for minors that we’ve seen, I think a lot of people had been projecting that this was the trajectory.
I think that there’s been some really good reporting from The 19th and other outlets about what an impact this would have. Trans people are disproportionately low-income and dependent on Medicaid, and so this would have really sweeping impacts on a lot of people.
Rovner: Well, turning to the Affordable Care Act, if you thought Republicans weren’t going to try to repeal the health law this time around, you thought wrong. There are a bucket of provisions in this bill that will make the Affordable Care Act coverage both more expensive and harder to get, so much that some analysts think it could reduce enrollment by as much as half of the 24 million people who have it now. Hasn’t someone told Republicans that many of these people are their voters?
Edney: Yeah, that’s a good question. I don’t know what the Republican strategists are telling them. But certainly they needed to save money. And so they found their loopholes and their different things that they thought they could scrape from. And maybe no one will notice? But I don’t think that’s going to happen.
A lot of people suddenly have much higher ACA premiums because of the way they’re going to take away this ability that the insurers have had to silver-load, essentially, the way that they deal with the premium tax credits by setting some of the savings, kind of the cost sharing that they need to do, right into the silver plan, because the silver plan is where the premiums are set off of. And so they were able to offer the plans with lower premiums, essentially, but still get paid for cost-sharing reductions. So they were able to still get that money taken away from them.
Rovner: So let me see if I can do it. It was, and this was something that Trump tried to do in 2017, that he thought was going to hurt the marketplace plans. And it ended up doing the opposite—
Edney: Right.
Rovner: —because it basically shifted money from the insurance companies and the beneficiaries back to the federal government, because it made the premium subsidies bigger.
So I think the point I want to make is that we’ve been talking all year about these extra subsidies that are going to expire, and that will make premiums go up, and the Republicans did not move to extend those subsidies. But this going back to the government paying these cost-sharing reduction payments is going to basically reverse the accidental lowering of premiums that Trump did in 2017. And therefore, raise them again.
So now we have a double whammy. We have premiums going up because the extra subsidies expire, and then we’ll have premiums going up even more because they’re going back to this original cost-sharing reduction. And yet, as we have said many times, a lot of these additional people who are now on the Affordable Care Act are people in the very red states that didn’t expand Medicaid. These are Republican voters.
Karlin-Smith: We haven’t talked a lot about the process of how they got this bill through this week. It was incredibly fast and done literally in the dead of night.
Ollstein: Multiple nights.
Karlin-Smith: So you have to wonder, particularly, if you think back to the last time Republicans tried to overturn Obamacare — and they did come pretty close — eventually, I think, that unpalatableness of taking away health care from so many of their own constituents came back to really hurt them. And you do have to wonder if the jamming was in part to make more people unaware of what was happening. You’d still think there’d be political repercussions later down the line when they realize it. But I think, especially, again, just thinking back on all the years when Republicans were saying Democrats were pushing the ACA through too fast and nobody could read the bill, or their CBO scores. This was a much, much faster version of that, with a lot less debate and public transparency and so forth.
Rovner: Yeah, they went to the Rules Committee at 1 a.m. Wednesday, so Tuesday night. The Rules Committee went until almost 9 o’clock the next evening, just consecutively. And shout out to Rules Committee chairman Virginia Foxx, who sat there for, I think, the entire time. And then they went straight from rules to the floor.
So it’s now Wednesday night at 10 o’clock at night, and then went all the way through and voted, I think, just before 7 a.m. I’ve done a lot of all-nighters in the Capitol. I haven’t seen one that was two nights in a row like this. And I have great admiration for the people who really were up for 48 hours to push this thing through.
Well, finally, let’s remember President Trump’s vow not to touch Medicare. Well, Medicare gets touched in this bill, too. In addition to restricting eligibility for some legal immigrants who are able to get coverage now, and making it harder for some low-income Medicare beneficiaries to get extra financial help, mostly through Medicaid, the bill as a whole is also likely to trigger a 4% Medicare sequester. Because, even all those other health cuts and food stamp cuts and other cuts don’t pay for all the huge tax breaks in the bill. Alice, you pointed that out. Is there any suggestion that this part might give people some pause, maybe when it gets to the Senate?
Edney: I’ve heard the Senate mostly seem upset about Medicaid. And I also feel like this idea that sequestration is coming back up into our consciousness is a little bit new. Like you said, it was pushed through and it was like, Oh, wait, this is enough to trigger sequestration. I think it certainly could become a talking point, because Trump said he would not cut Medicare. I don’t think, if senators are worried about Medicaid — and I think maybe some of us were a little surprised that that is coming from some red-state senators. Medicare is a whole different thing, and in the sense of being even more wildly popular with a lot of members of Congress.
Rovner: Yeah, I think this whole thing hasn’t, you’re right, sort of seeped into the general consciousness yet. Alice, did you want to say something?
Ollstein: Yeah, so a couple things, a couple patterns we’ve seen. So one, there are a lot of lawmakers on the right who have been discrediting the CBO, even in advance of estimates coming out, basically disparaging their methodology and trying to convince the public that it’s not accurate. And so I think that’s both around the deficit projections as well as how many people would be uninsured under different policies. So that’s been one reaction to this.
We’ve seen a pattern over many administrations where certain politicians are very concerned about things adding to the deficit when the opposition party is in power. And suddenly those concerns evaporate when their own party is in power and they don’t mind running up the deficit if it’s to advance policies that they want to advance. And so I think, yes, this could bother some fiscal hawks, and we saw that in the House, but I think, also, these other factors are at play.
Rovner: Yeah, I think this has a long way to go. There’s still a lot that people, I think you’re right, have not quite realized is in there. And we will get to more of it in coming weeks, because this has a long process in the Senate.
All right, well, segueing to abortion, the One Big Beautiful Bill also includes a couple of pretty significant abortion provisions. One would effectively ban abortion and marketplace plans for people with lower incomes. Affordable Care Act plans are not currently a big source of insurance coverage for abortion. Many states already ban abortion from coverage in these plans. But this would disrupt one of the big compromises that ultimately got the ACA passed in 2010.
The other provision would evict Planned Parenthood from the Medicaid program, even though federal Medicaid funds don’t and never have been used for abortions. Many, many Medicaid patients use Planned Parenthood for routine medical care, including contraception and cancer screenings, and that is covered by Medicaid.
But while I see lots of anti-abortion groups taking victory laps over this, when the House passed a similar provision in 2017 as part of its repeal bill, the Senate parliamentarian ruled that it could not go in a budget reconciliation bill, because its purpose was not, quote, “primarily budgetary.” So is this all for show? Or is there a belief that something different might happen this time?
Ollstein: Well, I think there is more interest in ignoring or overruling the parliamentarian among Senate Republicans than there has been in the past. We’re seeing that now on an unrelated environmental issue. And so that could signal that they’re willing to do it more in the future. Of course, things like that cut both ways, and that raises the idea that the Democrats could also do that the next time they’re in power.
Rovner: And we should say, that if you overrule the parliamentarian in reconciliation — it’s a she right now — when she says it can’t go in reconciliation, that is equivalent to getting rid of the filibuster.
Ollstein: Correct.
Rovner: So I mean, that’s why both parties say, We want to keep the filibuster. But the moment you say, Hey, parliamentarian, we disagree with you and we’re just going to ignore that, that has ramifications way beyond budget reconciliation legislation.
Ollstein: That’s right. And so that’s been a line that a lot of senators have not been willing to cross, but I think you’re seeing more willingness than before. So that’s definitely something to watch on that. But I think, in terms of abortion, I think this is a real expansion of trends that were already underway, in ever-expanding the concept of what federal dollars going to abortion means. And it’s now in this very indirect way, where it’s reaching into the private insurance market, and it’s using federal funding as a cudgel to prevent groups like Planned Parenthood, and then also these private plans, from using other non-federal money to support abortions. And so it’s a real expansion beyond just you can’t use federal money to pay directly for abortions.
Rovner: Well, meanwhile, two other reproductive-associated health stories worth mentioning. In California, a fertility clinic got bombed. The bomber apparently died in the explosion, but this is the first time I can remember a purposeful bombing to a health center that was not an abortion clinic. How significant is it to the debate, that we’re now seeing fertility clinics bombed as well? And what do we know, if anything, about why the bomber went after a fertility clinic?
Karlin-Smith: There has been, obviously, some pressure on the right, I think, to go after fertility processes, and IVF [in vitro fertilization], and lump that in with abortion. Although, I think Trump and others have pushed back a bit on that, realizing how common and popular some of these fertility treatments are. And also it conflicts, I think, to some extent with their desire to grow the American population.
The motives of this particular person don’t seem aligned with, I guess, the anti-abortion movement. He sort of seems more anti-natalist movement and stuff. So from that perspective, I didn’t see it as being aligned with kind of a bigger, more common political debate we’ve had recently, which is, again, does the Republican Party want to expand the anti-abortion debate even further into fertility treatments and stuff.
Rovner: I was going to say, it certainly has drawn fertility clinics into the abortion debate, even if neither side in the abortion debate would presumably have an interest in blowing up a fertility clinic. But it is now sort of, I guess, in the general consciousness of antisocial people, if you will, that’s out there.
The other story in the news this week is about a woman named Adriana Smith, a nurse and mother from Georgia who was nine weeks pregnant in February when she was declared brain-dead after a medical emergency. Smith has been kept alive on life support ever since, not because her family wants that but because her medical team at Emory University Hospital is worried about running afoul of Georgia’s abortion ban, which prohibits terminations after cardiac activity can be detected. Even if the mother is clinically dead? I feel like this case could have really ominous repercussions at some point.
Ollstein: Well, I just want to point out that, yes, the state’s abortion ban is playing a role here, but this was happening while Roe v. Wade was still in place. There were cases like this. Some of it has to do with legislation around advanced directives and pregnancy. So I will point out that this is not solely a post-Dobbs phenomenon.
Rovner: Yeah, I think it also bears watching. Well, there was lots of vaccine news this week — I’m so glad we have Anna and Sarah here — with both the HHS [Department of Health and Human Services] and FDA [Food and Drug Administration] declaring an end to recommending covid vaccines for what seems to be most of the population. Sarah, what did they do? And what does this mean?
Karlin-Smith: So the new director of FDA’s biologics center and the FDA commissioner released a framework for approving covid shots moving forward. And basically they are saying that, because covid, the virus, shifts, and we want to try and update our vaccines at least yearly, usually, to keep up with the changing viruses, but we want to do that in a reasonable time so that by the time when you update the vaccine it’s actually available within that time — right? — FDA has allowed companies to do studies that don’t require full clinical trials anymore, because we sort of have already done those trials. We know these vaccines are safe and effective. We’re making minor tweaks to them, and they do immunogenicity studies, which are studies that basically show they mount the proper immune response. And then they approve them.
FDA is now, seems to be, saying, We’re only going to allow those studies to approve new covid vaccine updates for people who are over 65, or under 65 and have health conditions, because they are saying, in their mind, the risk-benefit balance of offering these shots doesn’t necessarily pan out favorably for younger, healthier populations, and we should do clinical trials.
It’s not entirely clear yet, despite them rolling out a framework, how this will actually play out. Can they relabel shots already approved? Will this only impact once companies do need to do a strain change next as the virus adapts? Did they go about doing this in a sort of legal manner? It came out through a journal kind of editorial commentary piece, not through the Federal Register or formal guidance. There’s been no notice of comment.
So there’s a lot of questions to remain as to how this will be implemented, which products it would affect, and when. But there is a lot of concern that there may be reduced access to the products moving forward.
Rovner: That’s because the vaccine makers aren’t going to — it’s not probably worth it financially to them — to remount all these studies. Right?
Karlin-Smith: First off, a lot of people I’ve talked to, and this came up yesterday at a meeting FDA had, don’t believe it’s actually ethical to do some of the studies FDA is now calling for. Even though the benefits, particularly when you’re talking about boosting people who already had a primary vaccination series for covid, or some covid, is not the same as the benefits of getting an original covid vaccine series.
There still are benefits, and there still are benefits for pretty much everybody that outweigh the risks. On average, these are extremely safe shots. We know a lot about their safety, and the balance is positive. So people are saying, once that exists, you cannot ethically test it on placebo. Even as [FDA Commissioner Marty] Makary says, Well, so many Americans are declining to take the shot, so let’s test it and see. A lot of ethicists would say it’s actually, even if people are willing to do something that may not be ideal for their health, that doesn’t mean it’s ethical to test it in a trial.
So, I think there’s questions about, just, ethics, but also, right, whether companies would want to invest the time and money it would take to achieve and try to do them under this situation. So that is a big elephant in the room here. And I think some people feel like this is just sort of a push by Makary and his new CBER [Center for Biologics Evaluation and Research] director, essentially, to cut off vaccine access in a little bit of a sneaky way.
Rovner: Well, I did see, also this week, was I think it was Moderna, that was going to make a combination flu covid vaccine, has decided not to. I assume that’s related to all of this?
Karlin-Smith: Right. So Moderna had a, what people call a next-generation vaccine, which is supposed to be an improved update over the original shot, which is a bigger deal than just making a strain change. They actually think they provide a better response to protecting against the virus. And then they also added flu vaccine into it to sort of make it easier for people to get protected from both, and also provided solid data to show it would work well for flu.
And they seem to have probably pulled their application at this point over, again, these new concerns, and what we know Novavax went through in trying to get their covid vaccine across the finish line dealing with this new administration. So I think people have their sort of alert lights up going forward as to how this administration is going to handle vaccine approvals and what that will mean for access going forward.
Rovner: Well, in somewhat related news, we got the long-awaited report from Health and Human Services Secretary Robert F. Kennedy Jr.’s Make America Healthy Again Commission, which is supposed to lay out a blueprint for an action plan that will come later this summer. Not much in the 68-page report seems all that surprising. Some is fairly noncontroversial, calling for more study of ultra-processed foods and less screen time and more physical activity for kids.
And some is controversial but at this point kind of predictable, calling for another look at the childhood vaccine schedule, including, as we just discussed, more placebo studies for vaccines, and also less fluoride available, except in toothpaste. Anything jump out at you guys from the report that we should keep an eye on?
Karlin-Smith: I think one thing to think about is what it doesn’t address and doesn’t talk about. It’s not surprising the issues they call out for harming health in America, and some of them are debatable as to how much they do or don’t harm health, or whether their solutions would actually address those problems.
But they never talk about the U.S.’ lack of a health insurance system that assures people have coverage. They don’t mention the Republican Party’s and likely president’s willingness to sign onto a major bill that’s going to impact health. They don’t really talk about the socioeconomic drivers that impact health, which I find particularly interesting when they talk about food, because, obviously, the U.S. has a lot of healthy and unhealthy food available. And a lot of people know sort of how they could make better choices, but there are these situational factors outside of, often, an individual’s control to lead to that.
And I think the other thing that jumped out to me is, I think The Washington Post had a good line in their paragraph about just how many of the points are either overstated or misstated scientific findings. And they did a pretty good job of going through some of those. And it’s a difficult situation, I think, for the public to grapple with when you have leadership and the top echelons of our health department that is pushing so much misinformation, often very carefully, and having to weed out what is correct, where is the grains of truth, where does it go off into misinformation.
I don’t know. I find it really hard as a journalist. And so I do worry about, again, how this all plays into public perception and misunderstanding of these topics.
Rovner: And apparently they forgot about gun violence in all of this, which is rather notably not there.
Ollstein: Cars and guns are the big killers. And yeah, no mention of that.
Edney: I thought another glaring omission was tobacco. Kids are using e-cigarettes at high rates. We don’t really know much about them. And to Sarah’s point about misinformation, too, I think the hard part of being able to discern a lot of this, even as a member of the public, is everything they’ve done so far is only rhetoric. There hasn’t been actual regulation, or — this could be anything that you’re talking about. It could be food dyes. It could be “most favored nations.” We don’t know what they actually want to implement and what the potential for doing so — I think maybe on vaccines we’re seeing the most action. But as Sarah mentioned, we don’t know how that, whether it legally is going to be something that they can continue doing.
So even with this report, it was highly anticipated, but I don’t think we got anything beyond what I probably heard Kennedy say over and over throughout the campaign and in his bid for health secretary. So I am wondering when they actually decide to move into the policymaking part of it, instead of just telling us they’re going to do something.
Rovner: And interestingly, Secretary Kennedy was interviewed on CNN last night and walked back some of the timelines, even, including that vow that they were going to know the cause of autism by September and that they were going to have an action plan for this ready in another, I think, a hundred days. So this is going to be a hurry-up-and-wait.
All right, well, that is as much news as we have time for in this incredibly busy week. Now we will play my interview with law professor and abortion historian Mary Ziegler, and then we will come back and do our extra credits.
I am pleased to welcome back to the podcast Mary Ziegler, the Martin Luther King Jr. professor of law at the University of California-Davis. She’s also a historian of the abortion movement. And her newest book, just out, is called “Personhood: The New Civil War Over Reproduction.”
Mary Ziegler, thanks for joining us again.
Mary Ziegler: Thanks for having me.
Rovner: So we’ve talked about personhood a lot on our podcast, including with you, but it means different things to different people. What’s your working definition, at least for the purpose of this book?
Ziegler: Yeah, I’m interested in this book in the legal fight for personhood, right? Some people have religious ideas of personhood. Bioethicists have ideas of personhood. Philosophers debate personhood. But I’m really interested in the legal claim that the word “person” in the 14th Amendment, which gives us liberty and equality, applies the moment an egg is fertilized. Because it’s that legal claim that’s had a lot of knock-on effects with abortion, with IVF, and potentially even beyond.
Rovner: So if we as a society were to accept that fetuses or embryos or zygotes were people with full constitutional rights at the moment of creation, that can impact things way beyond abortion, right?
Ziegler: Definitely, yeah, especially if you make the moves that the anti-abortion movement, or the pro-life movement, in the United States has made, right? So one of the other things that’s probably worth saying is, if you believe the claim I laid out about fetal personhood, that doesn’t mean you necessarily think abortion should be criminalized or that IVF should be criminalized, either.
But the people who are leading the anti-abortion movement do, in large part, right? So it would have ramifications in lots of other contexts, because there’s a conclusion not only that human life begins at fertilization and that constitutional rights begin at fertilization but that the way you honor those constitutional rights is primarily by restricting or criminalizing certain things that threaten that life, in the views of the people who advocate for it.
Rovner: Right. And that includes IVF and forms of contraception. That’s where we sort of get to this idea that an abortion is murder or that, in this case, doing anything that harms even a zygote is murder.
Ziegler: Yeah. And it gets us to the Adriana Smith case in Georgia, too. So there’s sort of end-of-life cases that emerge. So, it obviously would have a big impact on abortion. So it’s not wrong to think about abortion in this context. It’s just that would definitely not be the stopping point.
Rovner: So, many people have only talked about personhood, really, since the Supreme Court overturned Roe in 2022, but the concept is a lot older than that. I started covering personhood in like 2010, I think, when a couple of states were trying to vote on it. I didn’t realize until I read your book that it goes back well beyond even that.
Ziegler: Yeah. So I think a lot of people had that conception. And in the 2010s, there were state constitutional amendment efforts to write the idea of fetal personhood into state constitutions. And they all failed. So I think the narrative coming out of that was that you had the anti-abortion movement on the one hand, and then you had this more extreme fetal personhood movement on the other hand.
And that narrative fundamentally is wrong. There is no one in the anti-abortion movement who’s opposed to fetal personhood. There are disagreements about how and when it can be recognized. There’s strategic disagreements. There are no substantive disagreements much to speak of on the basics of fetal personhood.
So the idea goes all the way back to the 1960s, when states were first reforming the 19th-century criminal laws you sometimes see coming back to life as zombie laws. And initially it started as a strategic necessity, because it was very hard for the early anti-abortion movement to stop this reform wave, right? They were saying things like, Oh, abortion is going to lead to more sexual promiscuity, or, No one really needs abortion, because pregnancy is no longer dangerous. And that just wasn’t getting the job done.
So they began to argue that no one had a choice to legalize abortion in worse circumstances, because it would violate the rights of the unborn child. What’s interesting is that argument went from being this kind of strategic expedient to being this tremendously emotionally resonant long-term thing that has lived on the American right for now like a half-century. Even in moments when, I think arguably like right now, when it’s not politically smart to be making the argument, people will continue to, because this speaks to something, I think, for a lot of people who are opposed to abortion and other things like IVF.
Rovner: I know you’ve got access in writing this book to a lot of internal documents from people in the anti-abortion movement. I’m jealous, I have to say. Was there something there that surprised you?
Ziegler: Yeah, I think I was somewhat surprised by how much people talked this language of personhood when they were alone, right? This was not just something for the consumption of judges, or the consumption of politicians, or sort of like a nicer way to talk about what people really wanted. This was what people said when there was no one else there.
That didn’t mean they didn’t say other things that suggested that there were lots of other values and beliefs underlying this concept of personhood. But I think one of the important lessons of that is if you’re trying to understand people who are opposed to abortion, just assuming that everything they’re saying is just pure strategy is not helpful, right? Any more than it would be for people who support reproductive rights, to have it assume that everything they’re saying is not genuine. You just fail to understand what people are doing, I think. And I think that was probably what I was the most surprised about.
Rovner: I was struck that you point out that personhood doesn’t have to begin and end with the criminalization of abortion. How could more acceptance of the rights of the unborn change society in perhaps less polarized ways?
Ziegler: Yeah, one of the things that’s really striking is that there are other countries that recognize a right to life for a fetus or unborn child that don’t criminalize abortion or don’t enforce criminal abortion laws. And often what they say is that it’s not OK for the state to start with criminalization when it isn’t doing things to support pregnant women, who after all are necessary for a fetus or unborn child to survive, right?
So there are strategies that you could use to reduce infant mortality, for example, to reduce neonatal mortality, to reduce miscarriage and stillbirth, to improve maternal health, to really eliminate some of the reasons that people who may want, all things being equal, to carry a child to term. That’s not, obviously, going to be everybody. Some people don’t want to be parents at all.
But there are other people for whom it’s a matter of resources, or it’s a matter of overcoming racial discrimination, or it’s a matter of leaving an abusive relationship. And if governments were more committed to doing some of those things, it’s reasonable to assume that a subset of those people would carry pregnancies to term, right?
So there are lots of ways that if a state were serious about honoring fetal life, that it could. I think one of the other things that’s striking that I realized in writing the book is that that tracks with what a subset of Americans think. You’ll find these artifacts in polls where you’ll get something like 33% of people in Pew Forum’s 2022 poll saying they thought that life and rights began at conception, but also that abortion shouldn’t be criminalized.
So there are a subset of Americans who, whether they’re coming from a place of faith or otherwise, can hold those two beliefs at once. So I think an interesting question is, could we have a politics that accommodates that kind of belief? And at the moment the answer is probably not, but it’s interesting to imagine how that could change.
Rovner: It’s nice to know that there is a place that we can hope to get.
Ziegler: Yeah, exactly.
Rovner: Mary Ziegler, thank you so much for joining us again.
Ziegler: Thanks for having me.
Rovner: OK, we’re back. And now it’s time for our extra-credit segment. That’s where we each recognize a 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 devices. Sarah, you chose first this week. You go first.
Karlin-Smith: I purposely chose a sort of light story from Australia, where scientists studied remote work, and the headline is “[Scientists Have Been Studying Remote Work for Four Years and Have] Reached a Very Clear Conclusion: ‘Working From Home Makes Us Happier.’” And it just goes through some of the benefits and perks people have found from working remotely, including more sleep, more time with friends and family, things like that. And it just felt like a nice, interesting read in a time where there’s a lot of heavy health news.
Rovner: Also, scientific evidence of things that I think we all could have predicted. Anna.
Edney: Apologies for going the other direction here, but it’s a story that I wrote this week, an investigation that I’ve been working on for a long time, “The Potential Cancer, Health Risks Lurking in One Popular OTC Drug.” So this is one, in particularly a lot of women have used. You can go in any CVS, Target, Walmart, stores like that, and buy it. Called Azo, for urinary tract infections. And all these stores sell their own generic versions as well, under phenazopyridine.
And this drug, I was kind of shocked to learn, is not FDA-approved. There are prescription versions that are not FDA-approved, either. It’s just been around so long that it’s been grandfathered in. And that may not be a big deal, except that this one, the FDA has raised questions about whether it causes cancer and whether it needs a stronger cancer warning, because the National Cancer Institute found in 1978 that it causes tumors in rats and mice. But no other work has been done on this drug, because it hasn’t been approved. So no one’s looked at it in humans. And it masks issues that really need antibiotics and causes a host of other issues.
There were — University of Virginia toxicologists told me they found, in the last 20 years, at least 200 suspected teen suicides where they used this drug, because of how dangerous this drug can be in any higher amounts than what’s on the box. So I went through this drug, but there are other ones on the market as well that are not approved. And there’s this whole FDA system that has allowed the OTC [over-the-counter] market to be pretty lax.
Rovner: OK, that’s terrifying. But thank you for your work. Alice.
Ollstein: Speaking of terrifying, I chose a piece from NPR called, “Diseases Are Spreading. The CDC Isn’t Warning the Public Like It Was Months Ago.” And this is a look at all of the ways our public health agency that is supposed to be letting us know when outbreaks are happening, and where, and how to protect ourselves, they’ve gone dark. They are not posting on social media. They are not sending out alerts. They are not sending out newsletters. And it walks through the danger of all of that happening, with interviews with people who are still on the inside and on the outside experiencing the repercussions.
Rovner: Well, my extra credit, it helps explain why Alice’s extra credit, because it’s about all the people who were doing that who have been fired or laid off from the federal government. It’s called, “White House Officials Wanted To Put Federal Workers ‘in Trauma.’ It’s Working,” by William Wan and Hannah Natanson.
And it’s the result of interviews with more than 30 current and former federal workers, along with the families of some who died or killed themselves. And it’s a review of documents to confirm those stories. It’s a super-depressing but beautifully told piece about the dramatic mental health impact of the federal DOGE [Department of Government Efficiency] layoffs and firings, and the impact that that’s been having on these workers, their families, and their communities.
OK, that is 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 to our fill-in editor this week, Rebecca Adams, and our producer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can find me on X, @jrovner, or on Bluesky, @julierovner. Where are you guys hanging these days? Anna?
Edney: Both of those [X and Bluesky], @annaedney.
Rovner: Sarah.
Karlin-Smith: Everywhere — X, Bluesky, LinkedIn, @SarahKarlin or @sarahkarlin-smith.
Rovner: Alice.
Ollstein: @AliceOllstein on X and @alicemiranda on Bluesky.
Rovner: I am off to California next week, where we’ll be taping the podcast at the annual meeting of the Association for Health Care Journalists, which we won’t post until the following Monday. So everyone please have a great Memorial Day holiday week. And until then, be healthy.
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Republicanos buscan castigar a estados que ofrecen seguro de salud a inmigrantes sin papeles
La emblemática legislación del presupuesto del presidente Donald Trump castigaría a 14 estados que ofrecen cobertura de salud a personas que viven en el país sin papeles.
Estos estados, la mayoría liderados por demócratas, dan seguro médico a algunos inmigrantes de bajos ingresos —a menudo niños—, independientemente de su estatus migratorio. Defensores argumentan que la política es humanitaria y que, en última instancia, ahorra costos.
Sin embargo, la legislación federal, que los republicanos han denominado One Big Beautiful Bill (Un hermoso gran proyecto de ley), recortaría drásticamente los reembolsos federales de Medicaid a esos estados en miles de millones de dólares anuales en total, a menos que reduzcan esos beneficios.
El proyecto de ley fue aprobado por un estrecho margen en la Cámara de Representantes el jueves 22 de mayo, y ahora pasa al Senado.
Si bien avanza gran parte de la agenda nacional de Trump, incluyendo grandes recortes de impuestos que benefician principalmente a los estadounidenses más ricos, la legislación también realiza recortes sustanciales del gasto en Medicaid que, según los responsables del presupuesto del Congreso, dejará a millones de personas de bajos ingresos sin seguro médico.
De ser aprobados por el Senado, estos recortes representarían un complejo obstáculo político y económico para los estados y Washington, DC, que utilizan sus propios fondos para brindar seguro médico a algunas personas que viven en Estados Unidos sin autorización.
Estos estados verían reducidos en 10 puntos porcentuales los reembolsos federales para las personas cubiertas por la expansión de Medicaid que se realize bajo la Ley de Cuidado de Salud a Bajo Precio (ACA).
Estos recortes le costarían a California, el estado que más tiene que perder, hasta $3 mil millones al año, según un análisis de KFF, una organización sin fines de lucro dedicada a información de salud que incluye a KFF Health News.
En conjunto, los 15 lugares afectados (los 14 estados y DC) cubren a aproximadamente 1.9 millones de inmigrantes sin papeles, según KFF. La entidad indica que la sanción también podría aplicarse a otros estados que cubren a inmigrantes con residencia legal.
Dos de los estados, Illinois y Utah, tienen leyes de “activación” que exigen terminar con sus expansiones de Medicaid si el gobierno federal reduce su aporte de fondos. Esto significa que, a menos que esos estados deroguen sus leyes de activación o dejen de cubrir a las personas sin estatus migratorio legal, muchos más estadounidenses de bajos ingresos podrían quedarse sin seguro.
Si continúan cubriendo a personas sin papeles, a partir del año fiscal 2027, los estados restantes y Washington, DC, tendrían que aportar millones o miles de millones de dólares adicionales cada año, para compensar las reducciones en sus reembolsos federales de Medicaid.
Después de California, Nueva York podría perder la mayor parte de la financiación federal: cerca de 1.600 millones de dólares anuales, según KFF.
El senador estatal de California, Scott Wiener, demócrata y presidente del Comité de Presupuesto del Senado, afirmó que la legislación de Trump ha sembrado el caos mientras los legisladores estatales trabajan para aprobar su propio presupuesto antes del 15 de junio.
“Tenemos que mantenernos firmes”, declaró. “California ha decidido que queremos una atención médica universal y que vamos a garantizar que todos tengan acceso a la atención médica, y que no vamos a permitir que millones de personas indocumentadas reciban atención primaria en salas de emergencia”.
El gobernador de California, el demócrata Gavin Newsom, declaró en un comunicado que el proyecto de ley de Trump devastaría la atención médica en su estado.
“Millones de personas perderán cobertura, los hospitales cerrarán y las redes de seguridad social podrían colapsar bajo ese peso”, dijo Newsom.
En su propuesta de presupuesto del 14 de mayo, Newsom instó a los legisladores a recortar algunos beneficios para inmigrantes sin papeles, citando el aumento desmedido de los costos del programa estatal de Medicaid. Si el Congreso recorta los fondos para la expansión de Medicaid, el estado no estaría en condiciones de cubrir los gastos, afirmó el gobernador.
Newsom cuestionó si el Congreso tiene la autoridad para penalizar a los estados por cómo gastan su propio dinero, y afirmó que su estado consideraría impugnar la medida en los tribunales.
El representante estatal de Utah, Jim Dunnigan, republicano que ayudó a impulsar un proyecto de ley para cubrir a los niños en su estado independientemente de su estatus migratorio, afirmó que Utah necesita mantener la expansión de Medicaid que comenzó en 2020.
“No podemos permitirnos, ni monetaria ni políticamente, que se recorten nuestros fondos federales para la expansión”, declaró. Dunnigan no especificó si cree que el estado debería cancelar su cobertura para inmigrantes si la disposición republicana sobre sanciones se convierte en ley.
El programa de Utah cubre a unos 2.000 niños, el máximo permitido por su ley. Los inmigrantes adultos sin estatus legal no son elegibles. La expansión de Medicaid de Utah cubre a unos 75.000 adultos, quienes deben ser ciudadanos o inmigrantes con residencia legal.
Matt Slonaker, director ejecutivo del Utah Health Policy Project, una organización de defensa del consumidor, afirmó que el proyecto de ley de la Cámara federal deja al estado en una posición difícil.
“Políticamente, no hay grandes alternativas”, declaró. “Es el dilema del prisionero: cualquier movimiento en cualquier dirección no tiene mucho sentido”.
Slonaker apuntó que un escenario probable es que los legisladores estatales eliminen su ley de activación, y luego encuentren la manera de compensar la pérdida de fondos federales para la expansión.
Utah ha financiado su parte del costo de la expansión de Medicaid con impuestos sobre las ventas y los hospitales.
“El Congreso pondría al estado de Utah en posición de tener que tomar una decisión política muy difícil”, declaró Slonaker.
En Illinois, la sanción del Partido Republicano tendría incluso consecuencias más graves. Esto se debe a que podría llevar a que 770.000 adultos perdieran la cobertura médica que obtuvieron con la expansión estatal de Medicaid.
Stephanie Altman, directora de justicia sanitaria del Shriver Center on Poverty Law, un grupo de defensa con sede en Chicago, afirmó que es posible que su estado, liderado por demócratas, derogue su ley de activación antes de permitir que se dé por terminada la expansión de Medicaid.
Agregó que el estado también podría eludir la sanción solicitando a los condados que financien la cobertura para inmigrantes. “Obviamente, sería una situación difícil”, declaró.
Altman indicó que el proyecto de ley de la Cámara de Representantes parece redactado para penalizar a los estados controlados por demócratas, ya que estos suelen brindar cobertura a inmigrantes sin importar su estatus migratorio.
Agregó que la disposición demuestra la “hostilidad de los republicanos contra los inmigrantes” y que “no quieren que vengan aquí y reciban cobertura pública”.
Mike Johnson, el presidente de la Cámara de Representantes de Estados Unidos, declaró en mayo que los programas estatales que brindan cobertura pública a personas sin importar su estatus migratorio actúan como un “felpudo abierto”, invitando a más personas a cruzar la frontera sin autorización. Afirmó que los esfuerzos para eliminar estos programas cuentan con el apoyo de las encuestas públicas.
Una encuesta de Reuters-Ipsos realizada entre el 16 y el 18 de mayo reveló que el 47% de los estadounidenses aprueba las políticas migratorias de Trump y el 45% las desaprueba. La encuesta reveló que el índice de aprobación general de Trump ha caído 5 puntos porcentuales desde que regresó al cargo en enero, hasta el 42%, con un 52% de los estadounidenses desaprobando su gestión.
ACA, también conocida como Obamacare, impulsó a los estados a ampliar Medicaid a adultos con ingresos de hasta el 138% del nivel federal de pobreza, o $21.597 por persona este año. Cuarenta estados y Washington, DC, ampliaron su cobertura, lo que contribuyó a reducir la tasa nacional de personas sin seguro a un mínimo histórico.
El gobierno federal ahora cubre el 90% de los costos de las personas incluidas en Medicaid gracias a la ampliación del Obamacare.
En los estados que cubren la atención médica de inmigrantes sin autorización, el proyecto de ley republicano reduciría la contribución del gobierno federal del 90% al 80% del costo de la cobertura para cualquier persona que se incorpore a Medicaid bajo la expansión de ACA.
Por ley, los fondos federales de Medicaid no pueden utilizarse para cubrir a personas que se encuentran en el país papeles, excepto para servicios de embarazo y emergencias.
Los otros estados que utilizan sus propios fondos para cubrir a personas sin importar su estatus migratorio son: Colorado, Connecticut, Maine, Massachusetts, Minnesota, Nueva Jersey, Oregon, Rhode Island, Vermont y Washington, según KFF.
Ryan Long, director de relaciones con el Congreso del Paragon Health Institute, un influyente grupo político conservador, afirmó que incluso si utilizan sus propios fondos para la cobertura de inmigrantes, los estados aún dependen de los fondos federales para “apoyar sistemas que faciliten la inscripción de inmigrantes indocumentados”.
Long afirmó que la preocupación por que los estados con leyes de activación puedan ver finalizada la expansión de Medicaid es una “pista falsa”, ya que los estados tienen la opción de eliminar sus activadores, como hizo Michigan en 2023.
La sanción por ofrecer cobrtura de salud a personas en el país sin papeles es una de las distintas maneras en que el proyecto de ley de la Cámara de Representantes recorta el gasto federal en Medicaid.
La legislación también trasladaría más costos de Medicaid a los estados al exigirles que verifiquen si los adultos cubiertos por el programa trabajan. Los estados también tendrían que recertificar la elegibilidad de los beneficiarios de la expansión de Medicaid cada seis meses, en lugar de una vez al año o menos, como lo hacen actualmente la mayoría.
El proyecto de ley también congelaría la práctica de los estados de gravar con impuestos a hospitales, residencias de adultos mayores, planes de atención médica administrada y otras compañías de atención médica para financiar su parte de los costos de Medicaid.
En una estimación preliminar del 11 de mayo, la Oficina de Presupuesto del Congreso (CBO) indicó que, según el proyecto de ley aprobado por la Cámara de Representantes, alrededor de 8,6 millones de personas más perderían la cobertura médica en 2034.
Esa cifra aumentará a casi 14 millones, según la CBO, después que la administración Trump finalice las nuevas regulaciones de ACA y, si el Congreso, liderado por los republicanos, como se prevé, se niegue a extender los subsidios mejorados para ayudar a pagar las primas de los planes de salud comerciales vendidos a través de los mercados del Obamacare.
Los subsidios mejorados, una prioridad del ex presidente Joe Biden, eliminaron por completo las primas mensuales para algunas personas que adquirieran planes de Obamacare. Y expiran a fin de año.
Esta historia fue producida por Kaiser Health News, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation.
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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2 weeks 3 days ago
Health Care Costs, Insurance, Medi-Cal, Medicaid, Noticias En Español, Race and Health, States, The Health Law, Uninsured, california, District Of Columbia, Latinos, Legislation, Minnesota, New Jersey, New York, Rhode Island, Utah, Washington
Republicans Aim To Punish States That Insure Unauthorized Immigrants
President Donald Trump’s signature budget legislation would punish 14 states that offer health coverage to people in the U.S. without authorization.
The states, most of them Democratic-led, provide insurance to some low-income immigrants — often children — regardless of their legal status. Advocates argue the policy is both humane and ultimately cost-saving.
President Donald Trump’s signature budget legislation would punish 14 states that offer health coverage to people in the U.S. without authorization.
The states, most of them Democratic-led, provide insurance to some low-income immigrants — often children — regardless of their legal status. Advocates argue the policy is both humane and ultimately cost-saving.
But the federal legislation, which Republicans have titled the “One Big Beautiful Bill,” would slash federal Medicaid reimbursements to those states by billions of dollars a year in total unless they roll back the benefits.
The bill narrowly passed the House on Thursday and next moves to the Senate. While enacting much of Trump’s domestic agenda, including big tax cuts largely benefiting wealthier Americans, the legislation also makes substantial spending cuts to Medicaid that congressional budget scorekeepers say will leave millions of low-income people without health insurance.
The cuts, if approved by the Senate, would pose a tricky political and economic hurdle for the states and Washington, D.C., which use their own funds to provide health insurance to some people in the U.S. without authorization.
Those states would see their federal reimbursement for people covered under the Affordable Care Act’s Medicaid expansion cut by 10 percentage points. The cuts would cost California, the state with the most to lose, as much as $3 billion a year, according to an analysis by KFF, a health information nonprofit that includes KFF Health News.
Together, the 15 affected places cover about 1.9 million immigrants without legal status, according to KFF. The penalty might also apply to other states that cover lawfully residing immigrants, KFF says.
Two of the states — Utah and Illinois — have “trigger” laws that call for their Medicaid expansions to terminate if the feds reduce their funding match. That means unless those states either repeal their trigger laws or stop covering people without legal immigration status, many more low-income Americans could be left uninsured.
The remaining states and Washington, D.C., would have to come up with millions or billions more dollars every year, starting in the 2027 fiscal year, to make up for reductions in their federal Medicaid reimbursements, if they keep covering people in the U.S. without authorization.
Behind California, New York stands to lose the most federal funding — about $1.6 billion annually, according to KFF.
California state Sen. Scott Wiener, a Democrat who chairs the Senate budget committee, said Trump’s legislation has sown chaos as state legislators work to pass their own budget by June 15.
“We need to stand our ground,” he said. “California has made a decision that we want universal health care and that we are going to ensure that everyone has access to health care, and that we’re not going to have millions of undocumented people getting their primary care in emergency rooms.”
California Gov. Gavin Newsom, a Democrat, said in a statement that Trump’s bill would devastate health care in his state.
“Millions will lose coverage, hospitals will close, and safety nets could collapse under the weight,” Newsom said.
In his May 14 budget proposal, Newsom called on lawmakers to cut some benefits for immigrants without legal status, citing ballooning costs in the state’s Medicaid program. If Congress cuts Medicaid expansion funding, the state would be in no position to backfill, the governor said.
Newsom questioned whether Congress has the authority to penalize states for how they spend their own money and said his state would consider challenging the move in court.
Utah state Rep. Jim Dunnigan, a Republican who helped spearhead a bill to cover children in his state regardless of their immigration status, said Utah needs to maintain its Medicaid expansion that began in 2020.
“We cannot afford, monetary-wise or policy-wise, to see our federal expansion funding cut,” he said. Dunnigan wouldn’t say whether he thinks the state should end its immigrant coverage if the Republican penalty provision becomes law.
Utah’s program covers about 2,000 children, the maximum allowed under its law. Adult immigrants without legal status are not eligible. Utah’s Medicaid expansion covers about 75,000 adults, who must be citizens or lawfully present immigrants.
Matt Slonaker, executive director of the Utah Health Policy Project, a consumer advocacy organization, said the federal House bill leaves the state in a difficult position.
“There are no great alternatives, politically,” he said. “It’s a prisoner’s dilemma — a move in either direction does not make much sense.”
Slonaker said one likely scenario is that state lawmakers eliminate their trigger law then find a way to make up the loss of federal expansion funding.
Utah has funded its share of the cost of Medicaid expansion with sales and hospital taxes.
“This is a very hard political decision that Congress would put the state of Utah in,” Slonaker said.
In Illinois, the GOP penalty would have even larger consequences. That’s because it could lead to 770,000 adults’ losing the health coverage they gained under the state’s Medicaid expansion.
Stephanie Altman, director of health care justice at the Shriver Center on Poverty Law, a Chicago-based advocacy group, said it’s possible her Democratic-led state would end its trigger law before allowing its Medicaid expansion to terminate. She said the state might also sidestep the penalty by asking counties to fund coverage for immigrants. “It would be a hard situation, obviously,” she said.
Altman said the House bill appeared written to penalize Democratic-controlled states because they more commonly provide immigrants coverage without regard for their legal status.
She said the provision shows Republicans’ “hostility against immigrants” and that “they do not want them coming here and receiving public coverage.”
U.S. House Speaker Mike Johnson said this month that state programs that provide public coverage to people regardless of immigration status serve as “an open doormat,” inviting more people to cross the border without authorization. He said efforts to end such programs have support in public polling.
A Reuters-Ipsos poll conducted May 16-18 found that 47% of Americans approve of Trump’s immigration policies and 45% disapprove. The poll found that Trump’s overall approval rating has sunk 5 percentage points since he returned to office in January, to 42%, with 52% of Americans disapproving of his performance.
The Affordable Care Act, widely known as Obamacare, enabled states to expand Medicaid to adults with incomes of up to 138% of the federal poverty level, or $21,597 for an individual this year. Forty states and Washington, D.C., expanded, helping reduce the national uninsured rate to a historic low.
The federal government now pays 90% of the costs for people added to Medicaid under the Obamacare expansion.
In states that cover health care for immigrants in the U.S. without authorization, the Republican bill would reduce the federal government’s contribution from 90% to 80% of the cost of coverage for anyone added to Medicaid under the ACA expansion.
By law, federal Medicaid funds cannot be used to cover people who are in the country without authorization, except for pregnancy and emergency services.
The other states that use their own money to cover people regardless of immigration status are Colorado, Connecticut, Maine, Massachusetts, Minnesota, New Jersey, Oregon, Rhode Island, Vermont, and Washington, according to KFF.
Ryan Long, director of congressional relations at Paragon Health Institute, an influential conservative policy group, said that even if they use their own money for immigrant coverage, states still depend on federal funds to “support systems that facilitate enrollment of illegal aliens.”
Long said the concern that states with trigger laws could see their Medicaid expansion end is a “red herring” because states have the option to remove their triggers, as Michigan did in 2023.
The penalty for covering people in the country without authorization is one of several ways the House bill cuts federal Medicaid spending.
The legislation would shift more Medicaid costs to states by requiring them to verify whether adults covered by the program are working. States would also have to recertify Medicaid expansion enrollees’ eligibility every six months, rather than once a year or less, as most states currently do.
The bill would also freeze states’ practice of taxing hospitals, nursing homes, managed-care plans, and other health care companies to fund their share of Medicaid costs.
The Congressional Budget Office said in a May 11 preliminary estimate that, under the House-passed bill, about 8.6 million more people would be without health insurance in 2034. That number will rise to nearly 14 million, the CBO estimates, after the Trump administration finishes new ACA regulations and if the Republican-led Congress, as expected, declines to extend enhanced premium subsidies for commercial insurance plans sold through Obamacare marketplaces.
The enhanced subsidies, a priority of former President Joe Biden, eliminated monthly premiums altogether for some people buying Obamacare plans. They are set to expire at the end of the year.
This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.
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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2 weeks 4 days ago
california, Health Care Costs, Insurance, Medicaid, States, Colorado, Connecticut, District Of Columbia, Illinois, Immigrants, Legislation, Maine, Massachusetts, Medicaid Watch, Minnesota, New Jersey, New York, Oregon, Rhode Island, U.S. Congress, Utah, Vermont, Washington
KFF Health News' 'What the Health?': Cutting Medicaid Is Hard — Even for the GOP
The Host
Julie Rovner
KFF Health News
Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
After narrowly passing a budget resolution this spring foreshadowing major Medicaid cuts, Republicans in Congress are having trouble agreeing on specific ways to save billions of dollars from a pool of funding that pays for the program without cutting benefits on which millions of Americans rely. Moderates resist changes they say would harm their constituents, while fiscal conservatives say they won’t vote for smaller cuts than those called for in the budget resolution. The fate of President Donald Trump’s “one big, beautiful bill” containing renewed tax cuts and boosted immigration enforcement could hang on a Medicaid deal.
Meanwhile, the Trump administration surprised those on both sides of the abortion debate by agreeing with the Biden administration that a Texas case challenging the FDA’s approval of the abortion pill mifepristone should be dropped. It’s clear the administration’s request is purely technical, though, and has no bearing on whether officials plan to protect the abortion pill’s availability.
This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Maya Goldman of Axios, and Sandhya Raman of CQ Roll Call.
Panelists
Anna Edney
Bloomberg News
Maya Goldman
Axios
Sandhya Raman
CQ Roll Call
Among the takeaways from this week’s episode:
- Congressional Republicans are making halting progress on negotiations over government spending cuts. As hard-line House conservatives push for deeper cuts to the Medicaid program, their GOP colleagues representing districts that heavily depend on Medicaid coverage are pushing back. House Republican leaders are eying a Memorial Day deadline, and key committees are scheduled to review the legislation next week — but first, Republicans need to agree on what that legislation says.
- Trump withdrew his nomination of Janette Nesheiwat for U.S. surgeon general amid accusations she misrepresented her academic credentials and criticism from the far right. In her place, he nominated Casey Means, a physician who is an ally of HHS Secretary Robert F. Kennedy Jr.’s and a prominent advocate of the “Make America Healthy Again” movement.
- The pharmaceutical industry is on alert as Trump prepares to sign an executive order directing agencies to look into “most-favored-nation” pricing, a policy that would set U.S. drug prices to the lowest level paid by similar countries. The president explored that policy during his first administration, and the drug industry sued to stop it. Drugmakers are already on edge over Trump’s plan to impose tariffs on drugs and their ingredients.
- And Kennedy is scheduled to appear before the Senate’s Health, Education, Labor and Pensions Committee next week. The hearing would be the first time the secretary of Health and Human Services has appeared before the HELP Committee since his confirmation hearings — and all eyes are on the committee’s GOP chairman, Sen. Bill Cassidy of Louisiana, a physician who expressed deep concerns at the time, including about Kennedy’s stances on vaccines.
Also this week, Rovner interviews KFF Health News’ Lauren Sausser, who co-reported and co-wrote the latest KFF Health News’ “Bill of the Month” installment, about an unexpected bill for what seemed like preventive care. If you have an outrageous, baffling, or infuriating medical bill you’d like to share with us, you can do that here.
Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: NPR’s “Fired, Rehired, and Fired Again: Some Federal Workers Find They’re Suddenly Uninsured,” by Andrea Hsu.
Maya Goldman: Stat’s “Europe Unveils $565 Million Package To Retain Scientists, and Attract New Ones,” by Andrew Joseph.
Anna Edney: Bloomberg News’ “A Former TV Writer Found a Health-Care Loophole That Threatens To Blow Up Obamacare,” by Zachary R. Mider and Zeke Faux.
Sandhya Raman: The Louisiana Illuminator’s “In the Deep South, Health Care Fights Echo Civil Rights Battles,” by Anna Claire Vollers.
Also mentioned in this week’s podcast:
- ProPublica’s series “Life of the Mother: How Abortion Bans Lead to Preventable Deaths,” by Kavitha Surana, Lizzie Presser, Cassandra Jaramillo, and Stacy Kranitz, and the winner of the 2025 Pulitzer Prize for public service journalism.
- The New York Times’ “G.O.P. Targets a Medicaid Loophole Used by 49 States To Grab Federal Money,” by Margot Sanger-Katz and Sarah Kliff.
- KFF Health News’ “Seeking Spending Cuts, GOP Lawmakers Target a Tax Hospitals Love to Pay,” by Phil Galewitz.
- Axios’ “Out-of-Pocket Drug Spending Hit $98B in 2024: Report,” by Maya Goldman.
click to open the transcript
Transcript: Cutting Medicaid Is Hard — Even for the GOP
[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, May 8, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go.
Today we are joined via a videoconference by Anna Edney of Bloomberg News.
Anna Edney: Hi, everybody.
Rovner: Maya Goldman of Axios News.
Maya Goldman: Great to be here.
Rovner: And Sandhya Raman of CQ Roll Call.
Sandhya Raman: Good morning, everyone.
Rovner: Later in this episode we’ll have my “Bill of the Month” interview with my KFF Health News colleague Lauren Sausser. This month’s patient got preventive care they assumed would be covered by their Affordable Care Act health plan, except it wasn’t. But first, this week’s news.
We’re going to start on Capitol Hill, where Sandhya is coming directly from, where regular listeners to this podcast will be not one bit surprised that Republicans working on President [Donald] Trump’s one “big, beautiful” budget reconciliation bill are at an impasse over how and how deeply to cut the Medicaid program. Originally, the House Energy and Commerce Committee was supposed to mark up its portion of the bill this week, but that turned out to be too optimistic. Now they’re shooting for next week, apparently Tuesday or so, they’re saying, and apparently that Memorial Day goal to finish the bill is shifting to maybe the Fourth of July? But given what’s leaking out of the closed Republican meetings on this, even that might be too soon. Where are we with these Medicaid negotiations?
Raman: I would say a lot has been happening, but also a lot has not been happening. I think that anytime we’ve gotten any little progress on knowing what exactly is at the top of the list, it gets walked back. So earlier this week we had a meeting with a lot of the moderates in Speaker [Mike] Johnson’s office and trying to get them on board with some of the things that they were hesitant about, and following the meeting, Speaker Johnson had said that two of the things that have been a little bit more contentious — changing the federal match for the expansion population and instituting per capita caps for states — were off the table. But the way that he phrased it is kind of interesting in that he said stay tuned and that it possibly could change.
And so then yesterday when we were hearing from the Energy and Commerce Committee, it seemed like these things are still on the table. And then Speaker Johnson has kind of gone back on that and said, I said it was likely. So every time we kind of have any sort of change, it’s really unclear if these things are in the mix, outside the mix. When we pulled them off the table, we had a lot of the hard-line conservatives get really upset about this because it’s not enough savings. So I think any way that you push it with such narrow margins, it’s been difficult to make any progress, even though they’ve been having a lot of meetings this week.
Rovner: One of the things that surprised me was apparently the Senate Republicans are weighing in. The Senate Republicans who aren’t even set to make Medicaid cuts under their version of the budget resolution are saying that the House needs to go further. Where did that come from?
Raman: It’s just been a difficult process to get anything across. I mean, in the House side, a lot of it has been, I think, election-driven. You see the people that are not willing to make as many concessions are in competitive districts. The people that want to go a little bit more extreme on what they’re thinking are in much more safe districts. And then in the Senate, I think there’s a lot more at play just because they have longer terms, they have more to work with. So some of the pushback has been from people that it would directly affect their states or if the governors have weighed in. But I think that there are so many things that they do want to get done, since there is much stronger agreement on some of the immigration stuff and the taxes that they want to find the savings somewhere. If they don’t find it, then the whole thing is moot.
Rovner: So meanwhile, the Congressional Budget Office at the request of Democrats is out with estimates of what some of these Medicaid options would mean for coverage, and it gives lie to some of these Republican claims that they can cut nearly a trillion dollars from Medicaid without touching benefits, right? I mean all of these — and Maya, your nodding.
Goldman: Yeah.
Rovner: All of these things would come with coverage losses.
Goldman: Yeah, I think it’s important to think about things like work requirements, which has gotten a lot of support from moderate Republicans. The only way that that produces savings is if people come off Medicaid as a result. Work requirements in and of themselves are not saving any money. So I know advocates are very concerned about any level of cuts. I talked to somebody from a nursing home association who said: We can’t pick and choose. We’re not in a position to pick and choose which are better or worse, because at this point, everything on the table is bad for us. So I think people are definitely waiting with bated breath there.
Rovner: Yeah, I’ve heard a lot of Republicans over the last week or so with the talking points. If we’re just going after fraud and abuse then we’re not going to cut anybody’s benefits. And it’s like — um, good luck with that.
Goldman: And President Trump has said that as well.
Rovner: That’s right. Well, one place Congress could recoup a lot of money from Medicaid is by cracking down on provider taxes, which 49 of the 50 states use to plump up their federal Medicaid match, if you will. Basically the state levies a tax on hospitals or nursing homes or some other group of providers, claims that money as their state share to draw down additional federal matching Medicaid funds, then returns it to the providers in the form of increased reimbursement while pocketing the difference. You can call it money laundering as some do, or creative financing as others do, or just another way to provide health care to low-income people.
But one thing it definitely is, at least right now, is legal. Congress has occasionally tried to crack down on it since the late 1980s. I have spent way more time covering this fight than I wish I had, but the combination of state and health provider pushback has always prevented it from being eliminated entirely. If you want a really good backgrounder, I point you to the excellent piece in The New York Times this week by our podcast pals Margot Sanger-Katz and Sarah Kliff. What are you guys hearing about provider taxes and other forms of state contributions and their future in all of this? Is this where they’re finally going to look to get a pot of money?
Raman: It’s still in the mix. The tricky thing is how narrow the margins are, and when you have certain moderates having a hard line saying, I don’t want to cut more than $500 billion or $600 billion, or something like that. And then you have others that don’t want to dip below the $880 billion set for the Energy and Commerce Committee. And then there are others that have said it’s not about a specific number, it’s what is being cut. So I think once we have some more numbers for some of the other things, it’ll provide a better idea of what else can fit in. Because right now for work requirements, we’re going based on some older CBO [Congressional Budget Office] numbers. We have the CBO numbers that the Democrats asked for, but it doesn’t include everything. And piecing that together is the puzzle, will illuminate some of that, if there are things that people are a little bit more on board with. But it’s still kind of soon to figure out if we’re not going to see draft text until early next week.
Goldman: I think the tricky thing with provider taxes is that it’s so baked into the way that Medicaid functions in each state. And I think I totally co-sign on the New York Times article. It was a really helpful explanation of all of this, and I would bet that you’ll see a lot of pushback from state governments, including Republicans, on a proposal that makes severe changes to that.
Rovner: Someday, but not today, I will tell the story of the 1991 fight over this in which there was basically a bizarre dealmaking with individual senators to keep this legal. That was a year when the Democrats were trying to get rid of it. So it’s a bipartisan thing. All right, well, moving on.
It wouldn’t be a Thursday morning if we didn’t have breaking federal health personnel news. Today was supposed to be the confirmation hearing for surgeon general nominee and Fox News contributor Janette Nesheiwat. But now her nomination has been pulled over some questions about whether she was misrepresenting her medical education credentials, and she’s already been replaced with the nomination of Casey Means, the sister of top [Health and Human Services] Secretary [Robert F.] Kennedy [Jr.] aide Calley Means, who are both leaders in the MAHA [“Make America Healthy Again”] movement. This feels like a lot of science deniers moving in at one time. Or is it just me?
Edney: Yeah, I think that the Meanses have been in this circle, names floated for various things at various times, and this was a place where Casey Means fit in. And certainly she espouses a lot of the views on, like, functional medicine and things that this administration, at least RFK Jr., seems to also subscribe to. But the one thing I’m not as clear on her is where she stands with vaccines, because obviously Nesheiwat had fudged on her school a little bit, and—
Rovner: Yeah, I think she did her residency at the University of Arkansas—
Edney: That’s where.
Rovner: —and she implied that she’d graduated from the University of Arkansas medical school when in fact she graduated from an accredited Caribbean medical school, which lots of doctors go to. It’s not a sin—
Edney: Right.
Rovner: —and it’s a perfectly, as I say, accredited medical school. That was basically — but she did fudge it on her resume.
Edney: Yeah.
Rovner: So apparently that was one of the things that got her pulled.
Edney: Right. And the other, kind of, that we’ve seen in recent days, again, is Laura Loomer coming out against her because she thinks she’s not anti-vaccine enough. So what the question I think to maybe be looking into today and after is: Is Casey Means anti-vaccine enough for them? I don’t know exactly the answer to that and whether she’ll make it through as well.
Rovner: Well, we also learned this week that Vinay Prasad, a controversial figure in the covid movement and even before that, has been named to head the FDA [Food and Drug Administration] Center for Biologics and Evaluation Research, making him the nation’s lead vaccine regulator, among other things. Now he does have research bona fides but is a known skeptic of things like accelerated approval of new drugs, and apparently the biotech industry, less than thrilled with this pick, Anna?
Edney: Yeah, they are quite afraid of this pick. You could see it in the stocks for a lot of vaccine companies, for some other companies particularly. He was quite vocal and quite against the covid vaccines during covid and even compared them to the Nazi regime. So we know that there could be a lot of trouble where, already, you know, FDA has said that they’re going to require placebo-controlled trials for new vaccines and imply that any update to a covid vaccine makes it a new vaccine. So this just spells more trouble for getting vaccines to market and quickly to people. He also—you mentioned accelerated approval. This is a way that the FDA uses to try to get promising medicines to people faster. There are issues with it, and people have written about the fact that they rely on what are called surrogate endpoints. So not Did you live longer? but Did your tumor shrink?
And you would think that that would make you live longer, but it actually turns out a lot of times it doesn’t. So you maybe went through a very strong medication and felt more terrible than you might have and didn’t extend your life. So there’s a lot of that discussion, and so that. There are other drugs. Like this Sarepta drug for Duchenne muscular dystrophy is a big one that Vinay Prasad has come out against, saying that should have never been approved, because it was using these kind of surrogate endpoints. So I think biotech’s pretty — thinking they’re going to have a lot tougher road ahead to bring stuff to market.
Rovner: And I should point out that over the very long term, this has been the continuing struggle at FDA. It’s like, do you protect the public but make people wait longer for drugs or do you get the drugs out and make sure that people who have no other treatments available have something available? And it’s been a constant push and pull. It’s not really been partisan. Sometimes you get one side pushing and the other side pushing back. It’s really nothing new. It’s just the sort of latest iteration of this.
Edney: Right. Yeah. This is the pendulum swing, back to the Maybe we need to be slowing it down side. It’s also interesting because there are other discussions from RFK Jr. that, like, We need to be speeding up approvals and Trump wants to speed up approvals. So I don’t know where any of this will actually come down when the rubber meets the road, I guess.
Rovner: Sandhya and Maya, I see you both nodding. Do you want to add something?
Raman: I think this was kind of a theme that I also heard this week in the — we had the Senate Finance hearing for some of the HHS [Department of Health and Human Services] nominees, and Jim O’Neill, who’s one of the nominees, that was something that was brought up by Finance ranking member Ron Wyden, that some of his past remarks when he was originally considered to be on the short list for FDA commissioner last Trump administration is that he basically said as long as it’s safe, it should go ahead regardless of efficacy. So those comments were kind of brought back again, and he’s in another hearing now, so that might come up as an issue in HELP [the Senate Committee on Health, Education, Labor and Pensions] today.
Rovner: And he’s the nominee for deputy secretary, right? Have to make sure I keep all these things straight. Maya, you wanting to add something?
Goldman: Yeah, I was just going to say, I think there is a divide between these two philosophies on pharmaceuticals, and my sense is that the selection of Prasad is kind of showing that the anti-accelerated-approval side is winning out. But I think Anna is correct that we still don’t know where it’s going to land.
Rovner: Yes, and I will point out that accelerated approval first started during AIDS when there was no treatments and basically people were storming the — literally physically storming — the FDA, demanding access to AIDS drugs, which they did finally get. But that’s where accelerated approval came from. This is not a new fight, and it will continue.
Turning to abortion, the Trump administration surprised a lot of people this week when it continued the Biden administration’s position asking for that case in Texas challenging the abortion pill to be dropped. For those who’ve forgotten, this was a case originally filed by a bunch of Texas medical providers demanding the judge overrule the FDA’s approval of the abortion pill mifepristone in the year 2000. The Supreme Court ruled the original plaintiff lacked standing to sue, but in the meantime, three states —Missouri, Idaho, and Kansas — have taken their place as plaintiffs. But now the Trump administration points out that those states have no business suing in the Northern District of Texas, which kind of seems true on its face. But we should not mistake this to think that the Trump administration now supports the current approval status of the abortion bill. Right, Sandhya?
Raman: Yeah, I think you’re exactly right. It doesn’t surprise me. If they had allowed these three states, none of which are Texas — they shouldn’t have standing. And if they did allow them to, that would open a whole new can of worms for so many other cases where the other side on so many issues could cherry-pick in the same way. And so I think, I assume, that this will come up in future cases for them and they will continue with the positions they’ve had before. But this was probably in their best interest not to in this specific one.
Rovner: Yeah. There are also those who point out that this could be a way of the administration protecting itself. If it wants to roll back or reimpose restrictions on the abortion pill, it would help prevent blue states from suing to stop that. So it serves a double purpose here, right?
Raman: Yeah. I couldn’t see them doing it another way. And even if you go through the ruling, the language they use, it’s very careful. It’s not dipping into talking fully about abortion. It’s going purely on standing. Yeah.
Rovner: There’s nothing that says, We think the abortion pill is fine the way it is. It clearly does not say that, although they did get the headlines — and I’m sure the president wanted — that makes it look like they’re towing this middle ground on abortion, which they may be but not necessarily in this case.
Well, before we move off of reproductive health, a shoutout here to the incredible work of ProPublica, which was awarded the Pulitzer Prize for public service this week for its stories on women who died due to abortion bans that prevented them from getting care for their pregnancy complications. Regular listeners of the podcast will remember that we talked about these stories as they came out last year, but I will post another link to them in the show notes today.
OK, moving on. There’s even more drug price news this week, starting with the return of, quote, “most favored nation” drug pricing. Anna, remind us what this is and why it’s controversial.
Edney: Yeah. So the idea of most favored nation, this is something President Trump has brought up before in his first administration, but it creates a basket, essentially, of different prices that nations pay. And we’re going to base ours on the lowest price that is paid for—
Rovner: We’re importing other countries’—
Edney: —prices.
Rovner: —price limits.
Edney: Yeah. Essentially, yes. We can’t import their drugs, but we can import their prices. And so the goal is to just basically piggyback off of whoever is paying the lowest price and to base ours off of that. And clearly the drug industry does not like this and, I think, has faced a number of kind of hits this week where things are looming that could really come after them. So Politico broke that news that Trump is going to sign or expected to sign an executive order that will direct his agencies to look into this most-favored-nation effort. And it feels very much like 2.0, like we were here before. And it didn’t exactly work out, obviously.
Rovner: They sued, didn’t they? The drug industry sued, as I recall.
Edney: Yeah, I think you’re right. Yes.
Goldman: If I’m remembering—
Rovner: But I think they won.
Goldman: If I’m remembering correctly, it was an Administrative Procedure Act lawsuit though, right? So—
Rovner: It was. Yes. It was about a regulation. Yes.
Goldman: —who knows what would happen if they go through a different procedure this time.
Rovner: So the other thing, obviously, that the drug industry is freaked out about right now are tariffs, which have been on again, off again, on again, off again. Where are we with tariffs on — and it’s not just tariffs on drugs being imported. It’s tariffs on drug ingredients being imported, right?
Edney: Yeah. And that’s a particularly rough one because many ingredients are imported, and then some of the drugs are then finished here, just like a car. All the pieces are brought in and then put together in one place. And so this is something the Trump administration has began the process of investigating. And PhRMA [Pharmaceutical Research and Manufacturers of America], the trade group for the drug industry, has come out officially, as you would expect, against the tariffs, saying that: This will reduce our ability to do R&D. It will raise the price of drugs that Americans pay, because we’re just going to pass this on to everyone. And so we’re still in this waiting zone of seeing when or exactly how much and all of that for the tariffs for pharma.
Rovner: And yet Americans are paying — already paying — more than they ever have. Maya, you have a story just about that. Tell us.
Goldman: Yeah, there was a really interesting report from an analytics data firm that showed the price that Americans are paying for prescriptions is continuing to climb. Also, the number of prescriptions that Americans are taking is continuing to climb. It certainly will be interesting to see if this administration can be any more successful. That report, I don’t think this made it into the article that I ended up writing, but it did show that the cost of insulin is down. And that’s something that has been a federal policy intervention. We haven’t seen a lot of the effects yet of the Medicare drug price negotiations, but I think there are signs that that could lower the prices that people are paying. So I think it’s interesting to just see the evolution of all of this. It’s very much in flux.
Rovner: A continuing effort. Well, we are now well into the second hundred days of Trump 2.0, and we’re still learning about the cuts to health and health-related programs the administration is making. Just in this week’s rundown are stories about hundreds more people being laid off at the National Cancer Institute, a stop-work order at the National Institute of Allergy and Infectious Diseases research lab at Fort Detrick, Maryland, that studies Ebola and other deadly infectious diseases, and the layoff of most of the remaining staff at the National Institute for Occupational Safety and Health.
A reminder that this is all separate from the discretionary-spending budget request that the administration sent up to lawmakers last week. That document calls for a 26% cut in non-mandatory funding at HHS, meaning just about everything other than Medicare and Medicaid. And it includes a proposed $18 billion cut to the NIH [National Institutes of Health] and elimination of the $4 billion Low Income Home Energy Assistance Program, which helps millions of low-income Americans pay their heating and air conditioning bills. Now, this is normally the part of the federal budget that’s deemed dead on arrival. The president sends up his budget request, and Congress says, Yeah, we’re not doing that. But this at least does give us an idea of what direction the administration wants to take at HHS, right? What’s the likelihood of Congress endorsing any of these really huge, deep cuts?
Raman: From both sides—
Rovner: Go ahead, Sandhya.
Raman: It’s not going to happen, and they need 60 votes in the Senate to pass the appropriations bills. I think that when we’re looking in the House in particular, there are a lot of things in what we know from this so-called skinny budget document that they could take up and put in their bill for Labor, HHS, and Education. But I think the Senate’s going to be a different story, just because the Senate Appropriations chair is Susan Collins and she, as soon as this came out, had some pretty sharp words about the big cuts to NIH. They’ve had one in a series of two hearings on biomedical research. Concerned about some of these kinds of things. So I cannot necessarily see that sharp of a cut coming to fruition for NIH, but they might need to make some concessions on some other things.
This is also just a not full document. It has some things and others. I didn’t see any to FDA in there at all. So that was a question mark, even though they had some more information in some of the documents that had leaked kind of earlier on a larger version of this budget request. So I think we’ll see more about how people are feeling next week when we start having Secretary Kennedy testify on some of these. But I would not expect most of this to make it into whatever appropriations law we get.
Goldman: I was just going to say that. You take it seriously but not literally, is what I’ve been hearing from people.
Edney: We don’t have a full picture of what has already been cut. So to go in and then endorse cutting some more, maybe a little bit too early for that, because even at this point they’re still bringing people back that they cut. They’re finding out, Oh, this is actually something that is really important and that we need, so to do even more doesn’t seem to make a lot of sense right now.
Rovner: Yeah, that state of disarray is purposeful, I would guess, and doing a really good job at sort of clouding things up.
Goldman: One note on the cuts. I talked to someone at HHS this week who said as they’re bringing back some of these specialized people, in order to maintain the legality of, what they see as the legality of, the RIF [reduction in force], they need to lay off additional people to keep that number consistent. So I think that is very much in flux still and interesting to watch.
Rovner: Yeah, and I think that’s part of what we were seeing this week is that the groups that got spared are now getting cut because they’ve had to bring back other people. And as I point out, I guess, every week, pretty much all of this is illegal. And as it goes to courts, judges say, You can’t do this. So everything is in flux and will continue.
All right, finally this week, Health and Human Services Secretary Robert F. Kennedy Jr., who as of now is scheduled to appear before the Senate Health, Education, Labor, and Pensions Committee next week to talk about the department’s proposed budget, is asking CDC [the Centers for Disease Control and Prevention] to develop new guidance for treating measles with drugs and vitamins. This comes a week after he ordered a change in vaccine policy you already mentioned, Anna, so that new vaccines would have to be tested against placebos rather than older versions of the vaccine. These are all exactly the kinds of things that Kennedy promised health committee chairman Bill Cassidy he wouldn’t do. And yet we’ve heard almost nothing from Cassidy about anything the secretary has said or done since he’s been in office. So what do we expect to happen when they come face-to-face with each other in front of the cameras next week, assuming that it happens?
Edney: I’m very curious. I don’t know. Do I expect a senator to take a stand? I don’t necessarily, but this—
Rovner: He hasn’t yet.
Edney: Yeah, he hasn’t yet. But this is maybe about face-saving too for him. So I don’t know.
Rovner: Face-saving for Kennedy or for Cassidy?
Edney: For Cassidy, given he said: I’m going to keep an eye on him. We’re going to talk all the time, and he is not going to do this thing without my input. I’m not sure how Cassidy will approach that. I think it’ll be a really interesting hearing that we’ll all be watching.
Rovner: Yes. And just little announcement, if it does happen, that we are going to do sort of a special Wednesday afternoon after the hearing with some of our KFF Health News colleagues. So we are looking forward to that hearing. All right, that is this week’s news. Now we will play my “Bill of the Month” interview with Lauren Sausser, and then we will come back and do our extra credits.
I am pleased to welcome back to the podcast KFF Health News’ Lauren Sausser, who co-reported and wrote the latest KFF Health News “Bill of the Month.” Lauren, welcome back.
Lauren Sausser: Thank you. Thanks for having me.
Rovner: So this month’s patient got preventive care, which the Affordable Care Act was supposed to incentivize by making it cost-free at the point of service — except it wasn’t. Tell us who the patient is and what kind of care they got.
Sausser: Carmen Aiken is from Chicago. Carmen uses they/them pronouns. And Carmen made an appointment in the summer of 2023 for an annual checkup. This is just like a wellness check that you are very familiar with. You get your vaccines updated. You get your weight checked. You talk to your doctor about your physical activity and your family history. You might get some blood work done. Standard stuff.
Rovner: And how big was the bill?
Sausser: The bill ended up being more than $1,400 when it should, in Carmen’s mind, have been free.
Rovner: Which is a lot.
Sausser: A lot.
Rovner: I assume that there was a complaint to the health plan and the health plan said, Nope, not covered. Why did they say that?
Sausser: It turns out that alongside with some blood work that was preventive, Carmen also had some blood work done to monitor an ongoing prescription. Because that blood test is not considered a standard preventive service, the entire appointment was categorized as diagnostic and not preventive. So all of these services that would’ve been free to them, available at no cost, all of a sudden Carmen became responsible for.
Rovner: So even if the care was diagnostic rather than strictly preventive — obviously debatable — that sounds like a lot of money for a vaccine and some blood test. Why was the bill so high?
Sausser: Part of the reason the bill was so high was because Carmen’s blood work was sent to a hospital for processing, and hospitals, as you know, can charge a lot more for the same services. So under Carmen’s health plan, they were responsible for, I believe it was, 50% of the cost of services performed in an outpatient hospital setting. And that’s what that blood work fell under. So the charges were high.
Rovner: So we’ve talked a lot on the podcast about this fight in Congress to create site-neutral payments. This is a case where that probably would’ve made a big difference.
Sausser: Yeah, it would. And there’s discussion, there’s bipartisan support for it. The idea is that you should not have to pay more for the same services that are delivered at different places. But right now there’s no legislation to protect patients like Carmen from incurring higher charges.
Rovner: So what eventually happened with this bill?
Sausser: Carmen ended up paying it. They put it on a credit card. This was of course after they tried appealing it to their insurance company. Their insurance company decided that they agreed with the provider that these services were diagnostic, not preventive. And so, yeah, Carmen was losing sleep over this and decided ultimately that they were just going to pay it.
Rovner: And at least it was a four-figure bill and not a five-figure bill.
Sausser: Right.
Rovner: What’s the takeaway here? I imagine it is not that you should skip needed preventive/diagnostic care. Some drugs, when you’re on them, they say that you should have blood work done periodically to make sure you’re not having side effects.
Sausser: Right. You should not skip preventive services. And that’s the whole intent behind this in the ACA. It catches stuff early so that it becomes more treatable. I think you have to be really, really careful and specific when you’re making appointments, and about your intention for the appointment, so that you don’t incur charges like this. I think that you can also be really careful about where you get your blood work conducted. A lot of times you’ll see these signs in the doctor’s office like: We use this lab. If this isn’t in-network with you, you need to let us know. Because the charges that you can face really vary depending on where those labs are processed. So you can be really careful about that, too.
Rovner: And adding to all of this, there’s the pending Supreme Court case that could change it, right?
Sausser: Right. The Supreme Court heard oral arguments. It was in April. I think it was on the 21st. And it is a case that originated out in Texas. There is a group of Christian businesses that are challenging the mandate in the ACA that requires health insurers to cover a lot of these preventive services. So obviously we don’t have a decision in the case yet, but we’ll see.
Rovner: We will, and we will cover it on the podcast. Lauren Sausser, thank you so much.
Sausser: Thank you.
Rovner: OK, we’re back. Now it’s 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. Maya, you were the first to choose this week, so why don’t you go first?
Goldman: My extra credit is from Stat. It’s called “Europe Unveils $565 Million Package To Retain Scientists, and Attract New Ones,” by Andrew Joseph. And I just think it’s a really interesting evidence point to the United States’ losses, other countries’ gain. The U.S. has long been the pinnacle of research science, and people flock to this country to do research. And I think we’re already seeing a reversal of that as cuts to NIH funding and other scientific enterprises is reduced.
Rovner: Yep. A lot of stories about this, too. Anna.
Edney: So mine is from a couple of my colleagues that they did earlier this week. “A Former TV Writer Found a Health-Care Loophole That Threatens To Blow Up Obamacare.” And I thought it was really interesting because it had brought me back to these cheap, bare-bones plans that people were allowed to start selling that don’t meet any of the Obamacare requirements. And so this guy who used to, in the ’80s and ’90s, wrote for sitcoms — “Coach” or “Night Court,” if anyone goes to watch those on reruns. But he did a series of random things after that and has sort of now landed on selling these junk plans, but doing it in a really weird way that signs people up for a job that they don’t know they’re being signed up for. And I think it’s just, it’s an interesting read because we knew when these things were coming online that this was shady and people weren’t going to get the coverage they needed. And this takes it to an extra level. They’re still around, and they’re still ripping people off.
Rovner: Or as I’d like to subhead this story: Creative people think of creative things.
Edney: “Creative” is a nice word.
Rovner: Sandhya.
Raman: So my pick is “In the Deep South, Health Care Fights Echo Civil Rights Battles,” and it’s from Anna Claire Vollers at the Louisiana Illuminator. And her story looks at some of the ties between civil rights and health. So 2025 is the 70th anniversary of the bus boycott, the 60th anniversary of Selma-to-Montgomery marches, the Voting Rights Act. And it’s also the 60th anniversary of Medicaid. And she goes into, Medicaid isn’t something you usually consider a civil rights win, but health as a human right was part of the civil rights movement. And I think it’s an interesting piece.
Rovner: It is an interesting piece, and we should point out Medicare was also a huge civil rights, important piece of law because it desegregated all the hospitals in the South. All right, my extra credit this week is a truly infuriating story from NPR by Andrea Hsu. It’s called “Fired, Rehired, and Fired Again: Some Federal Workers Find They’re Suddenly Uninsured.” And it’s a situation that if a private employer did it, Congress would be all over them and it would be making huge headlines. These are federal workers who are trying to do the right thing for themselves and their families but who are being jerked around in impossible ways and have no idea not just whether they have jobs but whether they have health insurance, and whether the medical care that they’re getting while this all gets sorted out will be covered. It’s one thing to shrink the federal workforce, but there is some basic human decency for people who haven’t done anything wrong, and a lot of now-former federal workers are not getting it at the moment.
OK, that is this week’s show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate if you left us a review. That helps other people find us, too. Thanks as always to our editor, Emmarie Huetteman, and our producer, Francis Ying. Also, as always, you can email us your comments or questions, We’re at whatthehealth@kff.org, or you can still find me on X, @jrovner, or on Bluesky, @julierovner. Where are you folks hanging these days? Sandhya?
Raman: I’m on X, @SandhyaWrites, and also on Bluesky, @SandhyaWrites at Bluesky.
Rovner: Anna.
Edney: X and Bluesky, @annaedney.
Rovner: Maya.
Goldman: I am on X, @mayagoldman_. Same on Bluesky and also increasingly on LinkedIn.
Rovner: All right, we’ll be back in your feed next week. Until then, be healthy.
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When Hospitals Ditch Medicare Advantage Plans, Thousands of Members Get To Leave, Too
For several years, Fred Neary had been seeing five doctors at the Baylor Scott & White Health system, whose 52 hospitals serve central and northern Texas, including Neary’s home in Dallas. But in October, his Humana Medicare Advantage plan — an alternative to government-run Medicare — warned that Baylor and the insurer were fighting over a new contract.
If they couldn’t reach an agreement, he’d have to find new doctors or new health insurance.
“All my medical information is with Baylor Scott & White,” said Neary, 87, who retired from a career in financial services. His doctors are a five-minute drive from his house. “After so many years, starting over with that many new doctor relationships didn’t feel like an option.”
After several anxious weeks, Neary learned Humana and Baylor were parting ways as of this year, and he was forced to choose between the two. Because the breakup happened during the annual fall enrollment period for Medicare Advantage, he was able to pick a new Advantage plan with coverage starting Jan. 1, a day after his Humana plan ended.
Other Advantage members who lose providers are not as lucky. Although disputes between health systems and insurers happen all the time, members are usually locked into their plans for the year and restricted to a network of providers, even if that network shrinks. Unless members qualify for what’s called a special enrollment period, switching plans or returning to traditional Medicare is allowed only at year’s end, with new coverage starting in January.
But in the past 15 months, the Centers for Medicare & Medicaid Services, which oversees the Medicare Advantage program, has quietly offered roughly three-month special enrollment periods allowing thousands of Advantage members in at least 13 states to change plans. They were also allowed to leave Advantage plans entirely and choose traditional Medicare coverage without penalty, regardless of when they lost their providers. But even when CMS lets Advantage members leave a plan that lost a key provider, insurers can still enroll new members without telling them the network has shrunk.
At least 41 hospital systems have dropped out of 62 Advantage plans serving all or parts of 25 states since July, according to Becker’s Hospital Review. Over the past two years, separations between Advantage plans and health systems have tripled, said FTI Consulting, which tracks reports of the disputes.
CMS spokesperson Catherine Howden said it is “a routine occurrence” for the agency to determine that provider network changes trigger a special enrollment period for their members. “It has happened many times in the past, though we have seen an uptick in recent years.”
Still, CMS would not identify plans whose members were allowed to disenroll after losing health providers. The agency also would not say whether the plans violated federal provider network rules intended to ensure that Medicare Advantage members have sufficient providers within certain distances and travel times.
The secrecy around when and how Advantage members can escape plans after their doctors and hospitals drop out worries Sen. Ron Wyden of Oregon, the senior Democrat on the Senate Finance Committee, which oversees CMS.
“Seniors enrolled in Medicare Advantage plans deserve to know they can change their plan when their local doctor or hospital exits the plan due to profit-driven business practices,” Wyden said.
The increase in insurer-provider breakups isn’t surprising, given the growing popularity of Medicare Advantage. The plans attracted about 54% of the 61.2 million people who had both Medicare Parts A and B and were eligible to sign up for Medicare Advantage in 2024, according to KFF, a health information nonprofit that includes KFF Health News.
The plans can offer supplemental benefits unavailable from traditional Medicare because the federal government pays insurers about 20% more per member than traditional Medicare per-member costs, according to the Medicare Payment Advisory Commission, which advises Congress. The extra spending, which some lawmakers call wasteful, will total about $84 billion in 2025, MedPAC estimates. While traditional Medicare does not offer the additional benefits Advantage plans advertise, it does not limit beneficiaries’ choice of providers. They can go to any doctor or hospital that accepts Medicare, as nearly all do.
Sanford Health, the largest rural health system in the U.S., serving parts of seven states from South Dakota to Michigan, decided to leave a Humana Medicare Advantage plan last year that covered 15,000 of its patients. “It’s not so much about the finances or administrative burden, although those are real concerns,” said Nick Olson, Sanford Health’s chief financial officer. “The most important thing for us is the fact that coverage denials and prior authorization delays impact the care a patient receives, and that’s unacceptable.”
The National Association of Insurance Commissioners, representing insurance regulators from every state, Puerto Rico, and the District of Columbia, has appealed to CMS to help Advantage members.
“State regulators in several states are seeing hospitals and crucial provider groups making decisions to no longer contract with any MA plans, which can leave enrollees without ready access to care,” the group wrote in September. “Lack of CMS guidance could result in unnecessary financial or medical injury to America’s seniors.”
The commissioners appealed again last month to Health and Human Services Secretary Robert F. Kennedy Jr. “Significant network changes trigger important rights for beneficiaries, and they should receive clear notice of their rights and have access to counseling to help them make appropriate choices,” they wrote.
The insurance commissioners asked CMS to consider offering a special enrollment period for all Advantage members who lose the same major provider, instead of placing the burden on individuals to find help on their own. No matter what time of year, members would be able to change plans or enroll in government-run Medicare.
Advantage members granted this special enrollment period who choose traditional Medicare get a bonus: If they want to purchase a Medigap policy — supplemental insurance that helps cover Medicare’s considerable out-of-pocket costs — insurers can’t turn them away or charge them more because of preexisting health conditions.
Those potential extra costs have long been a deterrent for people who want to leave Medicare Advantage for traditional Medicare.
“People are being trapped in Medicare Advantage because they can’t get a Medigap plan,” said Bonnie Burns, a training and policy specialist at California Health Advocates, a nonprofit watchdog that helps seniors navigate Medicare.
Guaranteed access to Medigap coverage is especially important when providers drop out of all Advantage plans. Only four states — Connecticut, Massachusetts, Maine, and New York — offer that guarantee to anyone who wants to reenroll in Medicare.
But some hospital systems, including Great Plains Health in North Platte, Nebraska, are so frustrated by Advantage plans that they won’t participate in any of them.
It had the same problems with delays and denials of coverage as other providers, but one incident stands out for CEO Ivan Mitchell: A patient too sick to go home had to stay in the hospital an extra six weeks because her plan wouldn’t cover care in a rehabilitation facility.
With traditional Medicare the only option this year for Great Plains Health patients, Nebraska insurance commissioner Eric Dunning asked for a special enrollment period with guaranteed Medigap access for some 1,200 beneficiaries. After six months, CMS agreed.
Once Delaware’s insurance commissioner contacted CMS about the Bayhealth medical system dropping out of a Cigna Advantage plan, members received a special enrollment period starting in January.
Maine’s congressional delegation pushed for an enrollment period for nearly 4,000 patients of Northern Light Health after the 10-hospital system dropped out of a Humana Advantage plan last year.
“Our constituents have told us that they are anticipating serious challenges, ranging from worries about substantial changes to cost-sharing rates to concerns about maintaining care with current providers,” the delegation told CMS.
CMS granted the request to ensure “that MA enrollees have access to medically necessary care,” then-CMS Administrator Chiquita Brooks-LaSure wrote to Sen. Angus King (I-Maine).
Minnesota insurance officials appealed to CMS on behalf of some 75,000 members of Aetna, Humana, and UnitedHealthcare Advantage plans after six health systems announced last year they would leave the plans in 2025. So many provider changes caused “tremendous problems,” said Kelli Jo Greiner, director of the Minnesota State Health Insurance Assistance Program, known as a SHIP, at the Minnesota Board on Aging. SHIP counselors across the country provide Medicare beneficiaries free help choosing and using Medicare drug and Advantage plans.
Providers serving about 15,000 of Minnesota’s Advantage members ultimately agreed to stay in the insurers’ networks. CMS decided 14,000 Humana members qualified for a network-change special enrollment period.
The remaining 46,000 people — Aetna and UnitedHealthcare Advantage members — who lost access to four health systems were not eligible for the special enrollment period. CMS decided their plans still had enough other providers to care for them.
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KFF Health News' 'What the Health?': LIVE From KFF: Health Care and the 2024 Election
The Host
Julie Rovner
KFF Health News
Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
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
Cynthia Cox
KFF
Alice Miranda Ollstein
Politico
Tamara Keith
NPR
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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7 months 3 weeks ago
Elections, Health Care Costs, Insurance, Medicaid, Multimedia, Public Health, The Health Law, Abortion, KFF, KFF Health News' 'What The Health?', Medicaid Expansion, Misinformation, Podcasts, Premiums, reproductive health, Subsidies, Women's Health
Harris apoya la reducción de la deuda médica. Los “conceptos” de Trump preocupan a defensores.
Defensores de pacientes y consumidores confían en que Kamala Harris acelere los esfuerzos federales para ayudar a las personas que luchan con deudas médicas, si gana en las elecciones presidenciales del próximo mes.
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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7 months 3 weeks ago
Elections, Health Care Costs, Health Industry, Insurance, Noticias En Español, States, Biden Administration, Diagnosis: Debt, Investigation, Obamacare Plans, Trump Administration
KFF Health News' 'What the Health?': Yet Another Promise for Long-Term Care Coverage
The Host
Julie Rovner
KFF Health News
Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
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.
Panelists
Jessie Hellmann
CQ Roll Call
Joanne Kenen
Johns Hopkins University and Politico
Shefali Luthra
The 19th
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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8 months 2 days ago
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Employers Haven’t a Clue How Their Drug Benefits Are Managed
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.
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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This story can be republished for free (details).
8 months 4 days ago
Health Care Costs, Health Industry, Insurance, Pharmaceuticals, Drug Costs, Prescription Drugs