KFF Health News' 'What the Health?': Less Than Two Weeks To Go
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 abortion and other reproductive issues gain more prominence in the looming election, some Republicans are trying to moderate their anti-abortion positions, particularly in states where access to the procedure remains politically popular.
Meanwhile, open enrollment is underway for Medicare, even as some health plans are challenging in court the federal government’s decision to reduce their quality ratings — with millions of dollars at stake.
This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs Zhang of Stat, Sarah Karlin-Smith of the Pink Sheet, and Victoria Knight of Axios.
Panelists
Rachel Cohrs Zhang
Stat News
Sarah Karlin-Smith
Pink Sheet
Victoria Knight
Axios
Among the takeaways from this week’s episode:
- With polls showing more voters citing abortion as a top voting issue, some candidates with long track records opposing abortion rights are working to moderate their positions.
- Many older Americans will spend less on prescription drugs next year due to a new out-of-pocket pricing cap, among other changes in store as provisions of the 2022 Inflation Reduction Act take effect. But some are realizing the limits on those benefits, as deeper problems persist in drug pricing, insurance coverage, and access.
- The FDA is reconsidering a weight-loss drug decision that caused confusion for patients and compounding pharmacies. Compounded drugs are intended for individual issues, like needing a different dosage — and while the process can be used to augment mass manufacturing during times of drug shortages, it is not well suited to address access and pricing issues.
- In abortion news, a comprehensive study shows abortions have increased since the overturn of Roe v. Wade, even among women in states with strict restrictions — and those states are seeing higher infant mortality rates, according to separate research. And an effort is underway to revive in a Texas court the challenge to mifepristone’s FDA approval. The last challenge failed because the Supreme Court found the plaintiffs lacked standing.
Also this week, Rovner interviews Tricia Neuman, senior vice president of KFF and executive director of its Program on Medicare Policy, about Medicare open enrollment and the changes to the program for 2025.
Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: NBC News’ “Crisis Pregnancy Center’s Forms Give Rare Insight Into Anti-Abortion Practices,” by Abigail Brooks.
Sarah Karlin-Smith: Vanity Fair’s “Inside the Bungled Bird Flu Response, Where Profits Collide With Public Health,” by Katherine Eban.
Rachel Cohrs Zhang: The Atlantic’s “The Perverse Consequences of Tuition-Free Medical School,” by Rose Horowitch.
Victoria Knight: NPR’s “Why Catholic Bishops Are Donating Less To Oppose Abortion Rights Measures This Year,” by Rosemary Westwood and Jack Jenkins.
Also mentioned on this week’s podcast:
- The New York Times’ “Abortions Have Increased, Even for Women in States With Rigid Bans, Study Says,” by Claire Cain Miller and Margot Sanger-Katz.
- CNN’s “Infants Died at Higher Rates After Abortion Bans in the US, Research Shows,” by Deidre McPhillips.
click to open the transcript
Transcript: Less Than Two Weeks To Go
[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, Oct. 24, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this, so here we go.
Today we are joined via video conference by Rachel Cohrs Zhang of Stat News.
Rachel Cohrs Zhang: Hi, everybody.
Rovner: Victoria Knight of Axios.
Victoria Knight: Hello, everyone.
Rovner: And Sarah Karlin-Smith of the Pink Sheet.
Sarah Karlin-Smith: Hi, everybody.
Rovner: Later in this episode we’ll have my interview with my friend and KFF colleague Tricia Neuman about Medicare open enrollment and what to expect in Medicare in the coming year.
But first, this week’s news. We will start on the campaign trail since Election Day is now less than two weeks away. Let that sink in. Abortion is, at least according to many polls, on the upswing as a voting issue and, probably not coincidentally, abortion-adjacent issues, like contraception, are also getting more attention. But while it’s clear that Democrats are still pretty much the party of abortion rights and Republicans are pretty much the party representing anti-abortion activists, we’re seeing some Republican candidates working pretty hard to muddy the waters. Yes?
Knight: Yeah, it’s been interesting this election cycle. We have seen some Republicans saying that they are pro-choice. And this is at a time when, finally, on the Democratic side in Congress, there really are not many anti-abortion Democrats left. We have in the House congressman Henry Cuellar [of Texas] is really the only one left. [Pennsylvania] Sen. Bob Casey, we’ve kind of seen him swing over time to be more in the camp of pro-choice, pro-abortion rights and so …
Rovner: … which was really, in Casey’s case, really interesting, because his father, who was the governor of Pennsylvania, was sort of the original anti-abortion Democrat back in the early 1990s.
Knight: Yeah. I’m interested to see if this works in — we’re seeing, particularly in some more moderate, swinging House seats, that Republicans are trying to message in this way that they’re more moderate on abortion, saying they’re more pro-choice. I’m interested to see if this actually works. And then we have perhaps this caucus within the House, if that works, that are more moderate. I mean, you already see in the current makeup of the House, there are some House Republicans, particularly the New York Republicans, that were really careful in this 118th Congress when they were having to vote on certain bills that would restrict, for example, access to mifepristone. That was kind of a rider in the FDA appropriations bill, and they didn’t want to vote for it, and they helped cause chaos on the House floor for that bill, particularly, because they didn’t want to pass it because they knew that would look bad on their record and they were having to run for the House again. So, will this messaging work for the kind of new people that are running this cycle? I’m not sure, but we’ll see.
Rovner: I was kind of surprised to see Liz Cheney this week (who was out campaigning with Vice President [Kamala] Harris), who’s strongly anti-abortion, has been her entire career, actually pipe up on her own — and she’s not running for anything; she’s basically a person without a party at the moment — but say that even though she’s anti-abortion, she is not in favor of some of the things that are happening with some of these abortion bans, like women having miscarriages not being able to get immediate medical [care]. I was fascinated to see somebody who, with as strong anti-abortion credentials as she has, speak out about these things that one would assume even people who are anti-abortion would not be against. We do see the anti-abortion group saying making abortion illegal doesn’t make it illegal to treat ectopic pregnancies and miscarriage care, even though it gets all muddled when you’re actually on the ground doing it and you’re a doctor facing potential jail time.
Knight: Well, and I think the thing is, people are seeing the realities of the abortion bans a couple of years in. I think that’s really the consequences. … When these first happened two years ago, people can say all these kind of things, but now that they’ve been in place for a couple years and women have died, we’re hearing these stories from news outlets of how that happens and it’s often women that want the babies. It’s like people are having to moderate their stances somewhat, I think.
Rovner: It’s — there’s nuance. … Politics is not great with nuance, but we’re seeing nuance.
Well, one abortion-adjacent story that jumped out at me this week is happening in Florida, where it seems that the office of Florida Gov. Ron DeSantis himself was behind legal threats to TV stations running ads in favor of the ballot measure that would enshrine abortion rights in the state’s constitution. According to the Tampa Bay Times, “Florida Department of Health general counsel John Wilson said he was given prewritten letters from one of DeSantis’ lawyers … Oct. 3 and told to send them under his own name, he wrote in a sworn affidavit.” Wilson subsequently resigned rather than send out more letters. In between, a judge warned the state to cease and desist with the threat, saying, and I quote, “It’s the First Amendment, stupid.” I have honestly never seen anything quite like this, although I would also point out I’ve never seen anything quite like Florida’s surgeon general recommending against people getting vaccines. What the heck is going on in Florida?
Cohrs Zhang: I think we’ve seen state officials in Florida try to enact their will and challenge public health recommendations. Certainly, we saw that happen during the covid-19 pandemic. They were trying to put out their own guidelines on vaccination, and so I don’t think it’s a particular surprise. I think it is just uglier than usual now that we get the full backstory on how these letters came to be. And court cases take a long time, and I think that’ll extend to beyond the next couple of weeks. But it’s an interesting publicity stunt for what it is, and yeah I …
Rovner: I wouldn’t want to be one of the TV stations threatening to have its license canceled, although the head of the FCC, I think, got involved too and said, “Um, this is not how this works.”
Cohrs Zhang: Yeah, I think so. I don’t expect that the court would find that political ads you don’t like are illegal, so, yeah.
Rovner: Yeah, I don’t think the governor can tell you to pull political ads that they don’t like. Pretty sure that’s not how these things work.
Well, meanwhile, given the very real possibility that Donald Trump will return to the White House, the D.C. rumor mill is already spinning out names of those who could fill Cabinet and other senior health posts. What are you guys hearing? And is RFK Jr. really going to end up in some big health policymaking job?
Knight: That’s funny that you say that because I was just having a talk with my editors about the names that we’re hearing. I have heard, and I am sure Rachel and Sarah have names on their mind as well, but someone said this to me, I think it’s funny: A very 2004 pick would be Bobby Jindal. He’s at the America First Policy Institute, which has a lot of former Trump administration people there, and it’s kind of seen this swing, I think recently, now that Project 2025 is kind of like no one wants to touch Project 2025 anymore. It seems like more people are, like, OK, AFPI is the place to pick people from if there’s a new Trump administration. And there’s been some stories this week about the chief of staff potentially coming from AFPI. So, people have been telling me Bobby Jindal, but I think he seems to have some solid grounding in that. You probably are more familiar with him, Julie, than I am, but …
Rovner: Oh, yes. I’ve known him since 2004. I’ve known him since before 2004. He was actually … he was brought to Washington by Democratic Sen. John Breaux to staff a Medicare commission back in, I think it was the very late 1990s. He served in Congress, he was the governor of Louisiana, and he served in HHS [the Department of Health and Human Services] in the George W. Bush administration. So he’s got lots of experience, and he’s coincidentally all over Twitter this week with a paid ad, trashing Kamala Harris’ support for “Medicare for All,” which, of course, she hasn’t supported since 2019. But yeah, suddenly Bobby Jindal, who we hadn’t seen in a while, is kind of everywhere. He was one of the bright young lights about, what, eight years ago?
Knight: Right, right.
Rovner: But I guess before Trump, he was one of the bright young Republican lights. So yeah, I keep hearing his name too.
Cohrs Zhang: I don’t know …
Rovner: Go ahead, Rachel.
Cohrs Zhang: I was just going to say that I don’t think there are a lot of people that we’ve been talking to who are worried about RFK himself getting appointed to one of these posts, but I think there has been a lot of buzz about some of his allies, like Calley and Casey Means. I know my colleague Isa Cueto did a great — just, profile of kind of who they are and kind of how their rise has just been so meteoric, and I think we’re also seeing some allies. So people who rose in the conservative movement over skepticism, over vaccine mandates, and just like the whole public health establishment have really gotten a new platform. And so I think people are a little nervous, as we’ve reported, both health care industry leaders who are worried about anti-pharmaceutical industry sentiment, anti-science sentiment, and even establishment Republican leaders and officials who served in prior Trump administrations that the picks could be more extreme than a Bobby Jindal establishment-Republican type and that this could be taking a turn.
Rovner: Sarah, what are you hearing with FDA?
Karlin-Smith: I mean, it’s a little less clear, I think, who might end up in FDA, but the sentiment has been probably a more typical Trump pick than maybe we got last time. FDA was sort of insulated in some ways, I think, from some of the drama, if you will, of the Trump administration last time. Scott Gottlieb was able to run FDA with pretty hands-off from other parts of the administration, and I think he ran FDA more like you would expect a traditional Republican to run FDA, not necessarily a Trump Republican. And I think people are recognizing that FDA will be a lot more vulnerable this time around that we’re probably not going to get another kind of Scott Gottlieb to save FDA if Trump is president. There’s certainly more concerns about how that impacts staff turnover as well, among civil service folks.
Rovner: Yeah, we will see.
All right, well, moving on. Open enrollment for Medicare began last week and continues until Dec. 7. That’s when people on Medicare can join or change their private prescription drug and/or Medicare Advantage plans. We explore this in more detail in my interview later in this episode with KFF’s Tricia Neuman. We know that most people with Medicare and most people with private insurance, where they can change plans during an open enrollment season, don’t actually bother to do anything. But this year there really are a lot of changes coming in Medicare, particularly on the prescription drug side. Why is it extra important this year that people take a look at their coverage?
Karlin-Smith: So, some of the big changes with the IRA [Inflation Reduction Act] that kick in this year for Medicare and the prescription side, like the $2,000 out-of-pocket cap. Your plan actually has to cover that. One thing, I was at a conference this week and they’re saying that drug has to be, actually be on your plan for you to reap those savings of hitting that cap, which seems obvious, but …
Rovner: Oh, I don’t know. I think people don’t quite realize that. It’s like they think that there’s a $2,000 cap no matter what, and it’s important. It’s, like, if your drug is not one of the drugs that’s covered by your plan, does not count.
Karlin-Smith: Right, and so it’s looking for all of those things to make sure all the pieces of your plan actually fit together with your medical needs. There’s been, I think, a reduction, in some degree, into the amount of particularly Part D stand-alone plans for people who elect to use traditional Medicare for their other health benefits. So you may just want to look a little bit more closely at what the options are, what the premiums are, because some of these changes to Part D have impacted premiums a bit, though the federal government has stepped in to try to alleviate that.
But I think this is seen as an adjustment year for the plans because one of the ideas behind the IRA is to put both health insurance companies as well as the pharmaceutical companies more on the hook, in some ways, for the cost of drugs. The old way Part D plans worked, the government ended up bearing a lot of the costs of the drugs to a point where it didn’t give a lot of incentives for both the drug companies to want to lower the prices, for the insurance companies to push for that. So I think it may take a little bit of time for them to figure out now how to adjust the benefits and the premiums and so forth, given this new dynamic. So people just may want to pay a little bit more close attention for premium aspects and others as well to the plans they’re picking.
Rovner: And if you’re helping someone on Medicare, which I know many people are, it’s good to do a little extra homework this year.
Well, another story that caught my eye is a survey of independent drugstores that suggests many of them won’t stock the very expensive drugs that Medicare negotiations are making less expensive, because they would actually lose money dispensing them. Sarah, is this an unexpected glitch, and can it be fixed, or is this just the price of bringing down drug prices?
Karlin-Smith: I would say not entirely unexpected. These independent pharmacies have warned CMS [the Centers for Medicare & Medicaid Services] and tried to push in guidance so that when they’re dispensing a drug, basically, they will be entitled to get quicker rebates from the drug companies so that they can make stocking these drugs more reasonable for them. And these pharmacies, I think in particular, have been raising alarm bells outside of Medicare drug price negotiations for a while now, that they’re being placed in these difficult positions where they have to buy drugs at whatever the wholesale acquisition cost is. And then there’s all of this insurance back-end stuff going on, and they sometimes get reimbursed by the plans and so forth for less than they’ve actually bought the drugs.
So it’s not just a Medicare drug price negotiation issue here. Some of it is, again, about the time that the pharmaceutical companies have to rebate the costs and they ask Medicare for a bit of leeway. And others, it’s just this broader way our system works, where they’re buying wholesale. You have a patient come to the counter that pays their small portion of it, their plan pays, whatever, and everybody has to sort of, right at the end … and these pharmacies are saying, “We can’t afford to do that.” I do think, politically, if this becomes a problem, if patients can’t get the negotiated prices/drugs at the pharmacies they’re used to, this could be politically problematic for the IRA moving forward. Even though, again, I’m not entirely sure. It’s illuminating a broader problem in the system that I think existed without it.
Rovner: Right, it’s all a big mess, and it’s underlining it.
Karlin-Smith: Right, but that doesn’t mean that politics won’t come into play and blame drug price negotiation. And certainly, anytime an opposing party hates something — we know Democrats are really into this, Republicans aren’t, and I’m sure they will try and blame it on the IRA as much as possible. And we’ll see if CMS maybe realizes that they had a little more leverage to try and make this a little bit easier and fixes it for the next round.
Rovner: Yeah. Before we leave Medicare, I want to talk briefly about Medicare Advantage. This Medicare Advantage market is so valuable to insurers and so competitive that we now have at least two lawsuits charging that Medicare wrongly lowered the number of quality stars some plans received. Now, this feels like a restaurant suing Yelp for lowering its rating from four stars to three, but in Medicare Advantage, this is a really big deal, right, when they lose a star?
Cohrs Zhang: Right, I think if the Yelp rating was worth $70 million, or whatever that figure is, then yeah, maybe they would sue. So I think we certainly — I think it’s a measure that is so important to insurers, to regulators, but that individual people might not understand. And there were some really interesting details from that lawsuit about the potential that there was one call-center call that tipped the balance into a quality measure and that there might’ve been some technical difficulties, and it does just cast these larger questions that I think I’ll be interested to see what documents come out during these lawsuits. And just questioning how useful these metrics really are, if that really was the case.
Rovner: Yeah, I found it, I also was taken aback. It’s like, really, one call to a customer service center didn’t happen properly, and so the whole plan loses a star? That seemed a little bit dramatic, but yes, like you, I’ll be interested to see. There’s a lot of pressure on Medicare Advantage from every conceivable angle, but we are now in litigation over it.
Well, while we are on the subject of private health companies suing the federal government, the compounding pharmacies who have been legally selling unapproved copies of the very popular and very expensive diabetes/obesity drugs Mounjaro and Zepbound have apparently successfully gotten the FDA to reverse its earlier finding, based on the pharmaceutical manufacturers’ say-so, that those drugs are no longer in shortage. That’s a decision that would’ve made it illegal for the compounders to continue to make and sell those drugs. At the same time, Novo Nordisk, maker of the very popular and very expensive diabetes/obesity drugs Ozempic and Wegovy, are trying to get the FDA to stop compounders from copying their drugs, which are still in shortage. Can somebody please explain what’s going on here?
Karlin-Smith: So, basically, compounding is where pharmacists can sometimes make drugs in a more customized fashion because a person maybe can’t swallow a pill or needs a slightly different dose or a different inactive ingredient, but there’s not …
Rovner: And they add flavoring for kids too, right?
Karlin-Smith: Right.
Rovner: Isn’t that a big compounding thing?
Karlin-Smith: But it’s not supposed to be something that takes the place of mass-manufactured drugs. But one of the times when it kind of can — and FDA, after some big safety incidents in 2013, developed a sort of scheme where there can be some degree mass compounding, but there’s a little bit more safety oversight from their end.
And one of the cases where you can do more compounding is when a drug is in shortage. But once FDA flipped the switch and said, “Oh, OK, actually, these drugs are no longer in shortage,” that makes it illegal. So these companies sued. My understanding from talking to legal experts is it’s not necessarily clear that FDA is entirely reversing course and agreeing that drugs aren’t in shortage. They’re agreeing to re-look at their decision, which may mean they are going to bolster their case so when they get back into court, they have a much clearer documentation of why the drugs are actually out of shortage. But in the meantime, we have probably at least another four weeks or so where everybody can compound these products.
At the same time, I think Novo Nordisk and, actually, Eli Lilly before them had also submitted a similar citizen petition to FDA trying to basically get these drugs from being on lists where you really could not compound them at all. And there’s clearly a lot of money at stake here. These are probably some of the most well-known drugs right now with huge markets in the U.S., but they’re also really expensive and they haven’t been picked up and covered by a lot of insurance plans, particularly when you’re talking about the weight loss element. I think for Type 2 diabetes, there’s pretty good coverage. And the thing here that’s really so significant is this is probably one of the first times in the U.S. where we’ve seen this mass-market compounding for a drug kind of at the beginning-ish of its exclusivity, at least when you’re talking about weight loss — again, not diabetes. And it’s not like a niche thing. So many people are using it, through compounding. And again, it’s really like …
Rovner: The advertising is everywhere on social media.
Karlin-Smith: Right, I mean, that just surprised me, I think, at first to begin with, how open these companies were about it being available via compounding pharmacies. And so I think FDA is in a really tricky position, particularly if they can clearly document it’s not a shortage situation anymore, because there still probably is going to be a lot of demand because of the cheaper prices coming from compounders, because of health insurance coverage issues. But, again, the compounding system is not meant to address those sorts of price and access issues. Right? It’s supposed to be for very particular situations where people really can’t use the exact manufactured drug, in most cases. And so maybe this tension will force us to address the other issues of price and insurance coverage, but it’s an awkward position for FDA to be in.
And again, because, I think, it’s just also important just to go backtrack and remember, you know, FDA facilitates an important role of inspecting the manufacturing facilities, ensuring every lot is being manufactured to a consistent quality, approving the drug to begin with. So there’s certainly this delicate dance of you want people to be able to get drugs they need and you also don’t want this kerfuffle to undermine the entire drug-approval system we have that ensures that when you get a drug, a prescription drug, you know it’s a certain quality.
Rovner: And it is what it says it is.
Karlin-Smith: Right.
Rovner: Yes. All right, well, turning back to abortion. A new study out this week suggests that not only has the number of abortions not gone down since the Supreme Court overturned Roe v. Wade, it actually might’ve gone up. Now there are lots of caveats with these numbers and, clearly, one big reason is the loosening of restrictions on obtaining abortion medication by mail. We also have a separate study this week that found infant mortality in states with abortion bans are rising, perhaps due to less available medical care in some of those states, as well as more fetuses with deadly anomalies being carried to term. But I have to wonder what these numbers will prompt from the anti-abortion side. Are they going to double down on efforts to impose some sort of nationwide restrictions or bans if Republicans regain control of the White House and Congress? And how are they going to address the rising infant mortality numbers? Victoria, are you hearing anything from the anti-abortion side? I’ve heard kind of not a lot. I’ve been surprised at how much I have not heard.
Knight: Yeah, I mean I think this has been an interesting election for them because I think Trump has said different things throughout this election cycle on his stance on abortion and being — taking credit for appointing the Supreme Court justices who overturned Roe, but then at the same time being, like, it’s a states issue. And I’ve seen some reporting on that a lot of these groups are frustrated with Trump, but they kind of are sticking with him for the moment because they’re, like, this is the guy we have.
So I think that perhaps they will put more pressure, depending on what the makeup of Congress is, and I think it’s important to remember it really depends on the majorities, this upcoming Congress, what will that look like? So if there is a Republican sweep, how many senators will be there? How many Republican senators? Also in the House, it may not be a huge majority either. And as we talked about earlier in this episode, there are some Republicans that are trying to walk the line more and be more moderate on abortion. And will they want to vote for a national abortion ban? That seems doubtful to me. And, for now, the filibuster is still in place in the Senate, so you still need 60 votes to pass anything. So, I think that they’re being quiet for now, but I think, depending on what Congress looks like, they could up their ante later.
Cohrs Zhang: Again, I think Congress just has no appetite really to talk about these things, and I don’t expect that to change, especially, like you said, with narrow majorities. And I just think that the cost-benefit, maybe we’re going to see new leadership in the Senate Republican party too, and I think a lot of that could shape how much appetite they have to pick a fight on this. So yeah, just a lot of unknowns at this point.
Rovner: And, as we’ve discussed before, if Trump is elected, he can do a lot from the executive branch that wouldn’t require Congress, and I completely agree with Rachel: I think Congress does not have a whole lot of appetite for this.
Knight: Right.
Rovner: Possibly on either side.
Knight: And I think one more thing also interesting to point out is that the current House speaker, Mike Johnson, is very anti-abortion. Throughout his congressional career and even his career as a state lawmaker, he’s always been very anti-abortion, but he’s been in power now over a year, at least a year, and he has done, really, nothing on this. And he has a slim majority, but also I think you see that, yeah, as Rachel said, there’s just not an appetite for it, so …
Rovner: He doesn’t have the votes.
Knight: Yeah, exactly. He doesn’t have the votes, but he’s staunchly anti-abortion, has done really nothing, so.
Rovner: Well, Sarah, you have a story on the revived lawsuit challenging the FDA over its rules for the abortion pill mifepristone. This is my chance to say I told you so, when the Supreme Court ruled that the original plaintiffs in this case did not have standing to sue. We said at the time: not over. Not over, right?
Karlin-Smith: Yeah, three states are trying to revive that case in the court in Texas, where it originated. And it’s not particularly a surprise, like you said, the Supreme Court didn’t totally throw out the case. They said, “You guys don’t have standing,” that the doctors’ group that filed suit there. One of the interesting things now, given the timing, is as this case moves forward and if Trump wins the election, it’s not really clear to me whether his FDA and his Justice Department and so forth would actually want to defend this case or whether they would just, again, use the powers they have and push FDA to go back to the older restrictions around mifepristone’s availability. And basically make it …
Rovner: We’re no longer talking about pulling it from the market right now? We’re just talking about the changes that were made in 2016 that makes it more easily available?
Karlin-Smith: Right, so they sort of …
Rovner: Is that a fair way to put it?
Karlin-Smith: That’s like one change, which by the time we got to the Supreme Court, we were largely arguing about this as well, but they had initially started to just — by trying to get it off the market entirely. But now we’re basically arguing about changes that have made it easier to take later in pregnancy, so up to 10 weeks, and just made it easier to access. So you can now get it via telehealth and via mail and so forth, which has been really important given some of the state-specific bans on abortion. And it’s why abortion pills have become a really much more popular method for abortion. So a lot of legal experts don’t actually think these three states have standing either, or have jurisdiction, certainly in this court. However, I think they also acknowledge there’s a good chance this case proceeds and proceeds very similarly to how it did before, if for no other reason than the judges involved in the past have been willing to let these states be heard in their courtroom.
Rovner: Yeah, it is in the 5th Circuit land of mostly Republican anti-abortion judges.
Karlin-Smith: Right. So there’s a good chance, again, barring this sort of scenario where Trump administration comes in and just says, “We’re not going to defend this. We’re going to revert to the old restrictions anyway.” But under a Democratic administration, they could end up back all the way at the Supreme Court having to defend mifepristone’s newer availability as well.
And the other thing that there’s been a number of mifepristone cases around the country, but there’s one that’s very similar in the 9th Circuit, where judges have basically ruled that the entire, what’s known as a REMS [risk evaluation and mitigation strategy], these restrictions related to mifepristone should actually be removed altogether. And they, actually, in some ways, want to make it more easily accessible. So whenever you have a circuits … but you also know that the Supreme Court is likely to take things up against. So yeah, I think the big thing is if people thought that last June’s Supreme Court ruling was kind of like Eh, it’s over, mifepristone is here to stay, that was just sort of the first round of many fights in access and availability of that in the courts.
Rovner: Could a Trump administration just say, “The FDA should never have approved this drug,” and pull it from the market? Or does somebody have to file a petition for that to happen?
Karlin-Smith: Ooh, that’s a good, tough question. I mean, there are very formal processes that go around withdrawing a drug. I think it would be challenging because at least the generic companies that manufacture the drug still want to be manufacturing it at this point. And I would imagine there would be quite a process FDA would have to go through, particularly to try and declare it no longer safe and effective to be marketed. And you, again, to raise strange history, I think if you looked at all the documents in science, because you have FDA scientists who over the years have declared it’s safe and effective and said, “Actually, as we’ve got more use with this, we realize you can actually give it to more women at different parts of pregnancy, and it’s safer than we thought. We don’t need to monitor a woman at a doctor’s office while she takes it.” So I think it would be challenging. I certainly wouldn’t put it past them trying this.
But it does get to, I think, what’s been worrying about this mifepristone case to begin with for just people outside of the abortion space, but who follow FDA and the drug industry, which is this lack of certainty you start to lose when politicians come in and start trying to undermine the scientific drug-approval process and using politics instead, and their whims, to shift what is available or not available, because, obviously, it undermines FDA’s authority.
And for the drug industry, I mean, a big thing they dislike is certainty, right? You’re investing millions, maybe even billions, of dollars to bring a drug to market. You want some confidence that if it’s successful and FDA says yes, it’s going to stay there unless some new, real, true safety event happens, which it does occasionally happen, but for the most part, you don’t want a new president to come into office or a new member of the Congress to flip and all of a sudden you have a drug that they’ve decided to challenge. So it’s an abortion case that’s always had these broader undertones of just confidence and trust and certainty around our scientific agencies in the U.S.
Rovner: Yet another space we will continue to watch. All right, that is this week’s news. Now we’ll play my interview with KFF’s Tricia Neuman, and then we’ll come back and do our extra credits.
I am so pleased to welcome to the podcast Tricia Newman, who’s KFF’s senior vice president and executive director of KFF’s Program on Medicare Policy, and senior adviser to the president, and the person I always turn to first when I have a question about Medicare and have done so for more than three decades. Tricia, welcome back to “What the Health?”
Tricia Neuman: Hi, Julie. Thanks for having me back.
Rovner: So, as anybody who watches over-the-air or cable TV knows, it’s Medicare open enrollment right now until Dec. 7. What should people in Medicare or people helping people in Medicare know about changes coming for 2025?
Neuman: This is the time for people to really compare coverage options. What we’ve seen in our own research is that most people don’t compare options during the open enrollment period, but plans change, people’s needs change, and this is a great moment. People have between now until Dec. 7, as you said. The important thing to do is figure out what is actually most important to either yourself or the person you’re helping.
Some people really need certain drugs covered by their plan, and so that might be the go-to question. Other people care very much about being able to see certain doctors or hospitals. So, for them, it’s a question of do they want to be in traditional Medicare, where they can see virtually any doctor and go to any hospital? Or if they want to be in a Medicare Advantage plan for a variety of reasons, the question is, are the doctors that they care most about covered by their plan?
Rovner: There are big changes coming next year both for prescription drugs and for Medicare Advantage, right?
Neuman: Absolutely. I mean, Medicare Advantage plans also cover prescription drugs, and what the big thing people need to know there is there’s a new out-of-pocket limit that’s coming. There’s not really much you have to do in order to get; it’s a Medicare benefit. So that’s really a huge change and it really is a change that helps people who take very expensive medications. I mean, I can tell you how helpful it would be to some family members of mine. I have a family member who is taking a drug, she had a Part D plan, and it was costing her $13,000 a year for this particular drug for her cancer treatment. With the new $2,000 out-of-pocket cap, her costs would drop from $13,000 to $2,000. Keep in mind that half of all people on Medicare live on an income of $36,000 or less, so this is a big deal. And not everybody is going to need this benefit in any given year, but over time, you never know. And so it’s a big change that will be helpful to people who take expensive medications.
Rovner: Over the spring and summer, it looked like, because of this $2,000 cap, Part D plans were going to raise their premiums dramatically. That mostly didn’t happen. Why not?
Neuman: The administration, the government put in place what they call a demonstration or a model, and essentially what it did is it limited premium increases. So no Part D plan will have a premium increase greater than $35 between 2024 and 2025.
Rovner: … of $35 a month.
Neuman: … of $35-a-month increase. Now that said, some will increase by $35, some will decrease. There are going to be changes, and that’s an important thing for people to keep an eye on as they consider their drug coverage for next year.
Rovner: There are Republicans in Congress who say that what the administration did was sort of unfairly politically tinkering with Medicare, but this isn’t the first time this kind of thing has been put into place, right?
Neuman: That’s absolutely true. I mean, I would agree that there was some concern that people in Medicare would see big increases in their drug premiums, and that was part of the concern that motivated the administration. But that was also a concern that motivated prior administrations. In fact, right after the drug benefit went into effect, and that was under the Bush administration, there were similar demonstrations that took effect. And at the time, nobody really complained because the main issue was protecting people from higher premiums.
Rovner: But now everything is more political.
Well, regular listeners to the podcast know that Medicare Advantage has become not just more popular among beneficiaries, but also much more controversial. Some companies are even using artificial intelligence to deny benefits and micromanaging doctors and other health care providers. Has the cost-benefit analysis for Medicare Advantage shifted over the past few years?
Neuman: I think the focus on Medicare Advantage has changed. The way people are thinking about it is changing. Medicare Advantage is quite popular among people because plans, for a variety of reasons related to their payments, are able to offer extra benefits, and they are appealing. I mean, dental, vision, hearing. Now, the latest thing is “flex cards,” which is just kind of offering money for people to sign up for a plan. So it’s really appealing, particularly for people with fixed incomes. But the medical community has sort of surfaced and started raising concerns about what these prior authorizations and other cost-management tools mean for them and for their patients.
So hospitals, for example, have expressed concerns about delayed payments. Doctors are now talking about prior authorization hassles. We recently did a study that documented 46 million prior-authorization requests, close to 2 million requests per enrollee. That’s a hassle for doctors. It also can delay or lead to no care for beneficiaries when it’s been prescribed by their doctor. It could, of course, limit inappropriate care, not necessary care, but I think the medical community now sees that Medicare Advantage is a big part of their patient profile and has some concerns.
We’ve also been reading stories about some medical groups that are saying that we’re not going to take any more Medicare Advantage patients. So I think there’s a little bit more of an eye toward, gee, this has gotten really big. We know it’s really popular, but it might require a closer look.
Rovner: Speaking of which, I mean, Medicare hasn’t really been a big campaign issue in 2024 when maybe it should have been. It doesn’t seem that safe to leave a program of its size and importance on autopilot, which is kind of what former President Trump is promising. What do we know about what Vice President Harris would do for Medicare if she were elected and what former President Trump would do if he was elected?
Neuman: We actually know very little about what former President Trump would do.
Rovner: He says he wouldn’t touch it.
Neuman: He said he wouldn’t touch it. He said he’s concerned about drug costs, but we’re not really sure what more he would do there. He was for a proposal called Most Favored Nation, but he’s now withdrawn support for that. So it’s hard to know whether he would implement anything new or scale back what has already become the law of the land. For example, it’s not clear what he would do about government negotiations and whether or not there would be sufficient pressure in his caucus to scale back that pretty popular proposal that was included in the Inflation Reduction Act.
Vice President Harris has talked about strengthening Medicare and improving the solvency, mostly through revenues on higher-income people. So that is one major proposal she has with regard to solvency. She has recently put out a proposal that would add a home care benefit to Medicare. This responds to a huge issue that you and I have talked about, that a lot of families across the country have talked about where people are really struggling to care for a family member. Family members are dropping out of the workforce in order to care for somebody because they cannot afford to get help at home. Medicare really does not currently provide a home care benefit except under limited circumstances. So this is recognizing a huge issue for families that are, it’s an economic issue if people, mostly women, have to step out of the workforce. It’s also an issue if you just cannot afford or you’re paying huge amounts for people to come into your home to help a parent, grandparent, spouse who’s unable to care for themselves. So that’s a big initiative on her part that would be funded primarily out of expanding Medicare’s ability to negotiate drugs.
Rovner: So neither candidate is talking about solvency issues with Medicare, though, and that’s a long-term issue that somebody’s going to need to address, right?
Neuman: Yes, that is absolutely true. It is an issue that is not going away. We have more and more people aging onto Medicare and the people who are on Medicare are getting older. And as people grow older, they tend to be more expensive. So this is not an imminent concern, but it is an issue that policymakers will have to deal with one way or the other in the years to come.
Rovner: Well, we will keep talking about it. Tricia Neuman, thank you so much.
Neuman: And thank you for having me, Julie.
Rovner: OK, we are back. 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 device. Victoria, why don’t you go first this week?
Knight: Sure. My extra credit is a story on NPR, it’s called “Why Catholic Bishops Are Donating Less To Oppose Abortion Rights Measures This Year.” It was on Weekend Edition, and it is by Rosemary Westwood and Jack Jenkins, basically detailing that in the past, the Catholic Church and bishops have been really big in the anti-abortion movement and that has also translated to donating a lot of money to anti-abortion campaigns. But this year, they’re kind of seeing almost a historic low in how little they’re donating to anti-abortion campaigns. And they didn’t really have a clear answer of what the reason for that was, except that maybe they’re just acknowledging the reality of the situation. When you look at particularly the ballot measures in states and how popular those have been — we’ve seen since 2022 that the ballot measures, even in more conservative-leaning states, that protect abortion access, and those vary depending on the state, what they look like, they’ve been really, really popular. And they really have been really overwhelmingly approved, even if there’s Republicans running on the same ballot with them and that people are voting for. People still really support abortion rights mostly.
So that seems to be the reason — they didn’t really have a clear reason, but it was an interesting marker in the trend of just kind of following where abortion rights are going, as well as where the Catholic Church is moving as well. It seems to be becoming somewhat more progressive over time.
Rovner: I was fascinated by this story, which I just heard on the radio as I was driving, because the Catholic Church is the originator of the right-to-life movement in the United States. And for a long time, it was almost exclusively the Catholic Church that was pushing this, and now it seems to have moved sort of into other places. So this is sort of the exclamation point on that, that it’s broadened and changed, but it’s no longer being driven as much by the Catholic Church as it used to be. Rachel, why don’t you go next?
Cohrs Zhang: Sure. So my piece is in The Atlantic, and the headline is “The Perverse Consequences of Tuition-Free Medical School,” by Rose Horowitch. And I just love this story because it’s a look back on this policy that seemed like a good idea at the time, where these really wealthy benefactors are donating to elite, often elite medical schools to make tuition free. And the whole idea was that more doctors will go into primary care if they don’t have debt, and it might open medical school to a more diverse cohort of students. And the opposite has almost happened, where they’re not seeing any more doctors going into primary care and their student body has actually gotten more wealthy than it was before. So I mean, it’s just a great check-in, because I feel like so often we’re just looking forward with the news that we don’t take a moment to question whether some of these policies or stories that we’ve covered, how they’ve worked out a couple of years later. So, I thought it was a great look back.
Rovner: Yes, in health care, so many things go in, we try things with so much promise, and sometimes they don’t work. So it’s good to notice when they don’t work. Sarah?
Karlin-Smith: I took a look at a Vanity Fair piece by Katherine Eban: “Inside the Bungled Bird Flu Response, Where Profits Collide With Public Health.” And it’s a fascinating deep dive to the challenges the U.S. has faced in containing what is, right now at least, mostly just an epidemic in animals, but certainly has public health folks worried about the potential for a human spillover pandemic, if not properly contained. And it’s just a really great story that shows you all of the tensions, and how it has a lot of these flashbacks to early days of covid, where you had different parts of the government with different responsibilities, not quite working together well, and not quite knowing how to play together well. Because you have the USDA in this case, which in many ways has the economics of farmers and the dairy industry in mind more than perhaps broader health concerns. You have FDA, which regulates milk; CDC, which comes in and does the human health; and then you have states, which don’t necessarily always have to answer to everything the federal government would like them to be doing here.
And the biggest, I think, crisis we face now is just we don’t have a lot of data. We don’t have enough information to truly know the scope of this outbreak. And without knowing that, I think you risk something bad happening before we are on top of it. And that’s really what people are really concerned about now, particularly with seasonal flu season coming up, is if you mix this virus and a human being with seasonal flu or even in an animal, you could develop an even more dangerous virus. So, it’s a warning to everybody in the public health space that this is something we need to be paying attention to because, obviously, the best thing to do is contain it and tamp it out and not have to deal with a much larger human pandemic.
Rovner: Yes, that would be nice. Something else to keep us awake at night.
My story this week is from NBC News, it’s called “Crisis Pregnancy Center’s Forms Give Rare Insight Into Anti-Abortion Practices,” by Abigail Brooks. She got a hold of the intake forms of a pregnancy center in Idaho, which included not just the typical medical questions, but also questions about religious and financial status. And one asking, “What decision would the father like you to make, regarding the outcome of your pregnancy?” The answers, which are not protected by HIPAA, because crisis pregnancy centers are not technically medical providers, allow the staff to score whether a patient is “abortion-vulnerable,” which would lead them to try to talk her out of ending the pregnancy.
It also includes a story of one patient who was strung along so long waiting for test results from this crisis pregnancy center that she ended up needing a second-trimester abortion. It’s quite the look at what goes on behind the scenes at some of these centers, and I strongly recommend it.
OK, that’s all the time we have today. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks, as always, to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, I’m @jrovner. Sarah, where are you hanging these days?
Karlin-Smith: A little bit on X, a little bit on Bluesky, at @SarahKarlin or @sarahkarlin-smith.
Rovner: Rachel?
Cohrs Zhang: I’m on X @rachelcohrs and also spending some time on LinkedIn, so feel free to follow me there.
Rovner: Great. Victoria?
Knight: I am @victoriaregisk still on X. I am trying to post more on LinkedIn, too.
Rovner: OK, well, we will be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': LIVE From KFF: Health Care and the 2024 Election
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Julie Rovner
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
The 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.
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Ashley Kirzinger
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Cynthia Cox
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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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KFF Health News' 'What the Health?': Yet Another Promise for Long-Term Care Coverage
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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.
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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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KFF Health News' 'What the Health?': The Health of the Campaign
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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.
When it comes to health care, this year’s presidential campaign is increasingly a matter of which candidate voters choose to believe. Democrats, led by Vice President Kamala Harris, say Republicans want to further restrict reproductive rights and repeal the Affordable Care Act, pointing to their previous actions and claims. Meanwhile, Republicans, led by former President Donald Trump, insist they have no such plans.
Meanwhile, with open enrollment approaching for Medicare, the Biden administration dodges a political bullet, avoiding a sharp spike next year in Medicare prescription drug plan premiums.
This week’s panelists are Julie Rovner of KFF Health News, Alice Miranda Ollstein of Politico, Sandhya Raman of CQ Roll Call, and Anna Edney of Bloomberg News.
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Anna Edney
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Alice Miranda Ollstein
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Sandhya Raman
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Among the takeaways from this week’s episode:
- This week, Sen. JD Vance of Ohio muddled his ticket’s stances on health policy during the vice presidential debate, including by downplaying the possibility of a national abortion ban. And Melania Trump, the former president’s wife, spoke out in support of abortion rights. Their comments seem designed to soothe voter concerns that former President Donald Trump could take actions to further block abortion access.
- Vance raised eyebrows with his debate-night claim that Trump “salvaged” the Affordable Care Act — when, in fact, the former president vowed to repeal the law and championed the GOP’s efforts to deliver on that promise. Meanwhile, Trump deflected questions from AARP about his plans for Medicare, replying, “What we have to do is make our country successful again.”
- On the Democratic side, Vice President Kamala Harris is campaigning on health, in particular by pushing out new ads highlighting the benefits of the ACA and Trump’s efforts to restrict abortion. Polls show health is a winning issue for Democrats and that the ACA is popular, especially its protections for those with preexisting conditions.
- Also in the news, the Centers for Medicare & Medicaid Services reported a slight dip in average Medicare drug plan premiums for next year. Coming in an annual report — out shortly before Election Day — it looks as though government subsidies cushioned changes to the system, sparing seniors from potentially paying in premiums what they may save under the new $2,000 annual out-of-pocket drug cost cap, for instance.
- And in abortion news, a judge struck down Georgia’s six-week abortion ban — but many providers have already left the state. And a new California law protects coverage for in vitro fertilization, including for LGBTQ+ couples.
Also this week, Rovner interviews KFF Health News’ Lauren Sausser, who reported and wrote the latest KFF Health News-Washington Post “Bill of the Month,” about a teen athlete whose needed surgery lacked a billing code. Do you have a confusing or outrageous medical bill you want to share? Tell us about it.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: KFF Health News’ “Doctors Urging Conference Boycotts Over Abortion Bans Face Uphill Battle,” by Ronnie Cohen.
Anna Edney: Bloomberg News’ “A Free Drug Experiment Bypasses the US Health System’s Secret Fees,” by John Tozzi.
Alice Miranda Ollstein: The Wall Street Journal’s “Hospitals Hit With IV Fluid Shortage After Hurricane Helene,” by Joseph Walker and Peter Loftus.
Sandhya Raman: The Asheville Citizen Times’ “Without Water After Helene, Residents at Asheville Public Housing Complex Fear for Their Health,” by Jacob Biba.
Also mentioned on this week’s podcast:
- SisterSong v. State of Georgia: Superior Court of Fulton County decision.
Click to open the transcript
Transcript: The Health of the Campaign
[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, October 4th, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go.
Rovner: Today we are joined via teleconference by Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Hello.
Rovner: Sandhya Raman of CQ Roll Call.
Raman: Hello, everyone.
Rovner: And Anna Edney of Bloomberg News.
Anna Edney: Hi there.
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 is a high school athlete whose problem got fixed, but his bill did not. But first, the news.
We’re going to start this week with the campaign. It is October. I don’t know how that happened. On Tuesday, vice-presidential candidates Senator JD Vance of Ohio and Governor Tim Walz of Minnesota held their first and only debate. It felt very Midwestern nice, with Walz playing his usual Aw shucks self and Vance trying very hard to seem, for want of a better word, likable. Did we learn anything new from either candidate?
Edney: I don’t think I heard anything new, no — not that I can remember.
Rovner: I know, obviously, they exchanged some views on abortion. Vance tried very hard to distance himself from his own hard-line views on the subject, including denying that he’d ever supported a national abortion ban, which he did, by the way. Meanwhile, during the debate, former President [Donald] Trump announced on social media that he would veto a national abortion ban, something he’d not said in those exact words before. Alice, you’ve got a pretty provocative story out this week suggesting that this all might actually be working on a skeptical public. Is it?
Ollstein: Yes. This has been a theme I’ve been tracking for a little bit. It was part of the reporting I was doing in Michigan a couple weeks ago. One, what I thought was interesting about that night was Trump and Vance have been talking past each other on abortion and contradicting each other, and now …
Rovner: Oh, yeah.
Ollstein: … it finally seems that they are on the same page, in terms of trying to convince the public: Nothing to see here. We won’t do a national ban. Don’t worry about it. Democrats and abortion rights groups are running around screaming: They’re lying. Look at their record. Look at what their allies have proposed in things like Project 2025. But the Republican message on this front does seem to be working. Polls show that even people who care about abortion rights and support abortion rights in some of these key battleground states still plan to vote for Trump. It’s a continuation of a pattern we’ve seen over the past few years where a decent chunk of people vote for these state ballot initiatives to protect abortion but then also vote for anti-abortion politicians.
Voters contain multitudes. We don’t know exactly if it’s because they are not worried that Trump and Vance will pursue national restrictions. We don’t know if it’s because just other issues are more important to them. But I think it’s really worth keeping an eye on in terms of a pattern. And KFF has done some really interesting polling showing that people in states where the ballot initiatives have already passed sort of view it as, Oh, we took care of that, it’s settled, and they don’t see the urgency and the threat of a national ban in the way that Democrats and abortion rights groups want them to.
Rovner: Which we’ll talk about separately in a minute. In late breaking news, Melania Trump this week came out and said that she supports abortion rights. Is this part of the continuing muddle where everybody can see what it is that they want to see, or is this going to have any impact at all?
Ollstein: Can I say one more thing about the debate first?
Rovner: Sure.
Ollstein: OK. So what really struck me about what Vance said about abortion at the debate is he really portrayed two arguments that I’ve seen sort of trickle up from the grass roots of the anti-abortion movement. So one, there were some semantics quibbles around what is a ban. There’s really been an effort in the anti-abortion movement to say that only a total ban throughout pregnancy with no exceptions, only that they call a ban. Everything else, they don’t consider it a ban.
Rovner: It’s a national standard.
Ollstein: Yeah, minimum standard, federal standard. There’s a lot of different words they use — “limit,” “restriction.” But what they’re describing is what others call a ban. It’s not a different policy, and so we saw that on full display on the debate stage. We also saw this argument sort of that these government programs and funding and support are the answer to abortion, so, basically, promoting the idea that with enough child care supports and health care supports, fewer people would have abortions — which the data is mixed on that, I will say, from the U.S. and from other countries. But financial hardship is just one of many reasons people have abortions, so that would impact some people and not others. It also goes against a lot of the sort of traditional small-government, cut-government-spending Republican ethos, and so it is this really interesting sort of pro-natalist direction that some of the party wants to go in and some of the activist movement wants to go in. But there’s definitely some tension around that. And, of course, we’ve seen Republicans vote against those programs and funding at the state and federal level.
Rovner: Things like paid family leave have been a Democratic priority much, much longer than it’s been a Republican priority, if it ever was and if it is now.
Ollstein: But it’s interesting that he was promoting that to sort of show a kinder, gentler face to the anti-abortion movement, which has been a trend we’ve been seeing.
Rovner: Yes. Yes, not just from JD Vance but from lots of Republicans on the anti-abortion side. And Melania—
Ollstein: Sorry, back to Melania.
Rovner: Is there any impact from this?
Edney: Oh, it’s certainly worked for the Trump campaign to muddy the waters on any subject. If you think about immigration, certainly that worked before, and I think you can see where they’re realizing that. And they are coming together, like Alice mentioned, with JD Vance and Trump talking on the same page now a bit better but using sort of a, I don’t want to say “underling,” but like a second …
Rovner: A surrogate.
Edney: Yeah, a surrogate, a secondary character to say, I support abortion rights. And she has Trump’s ear, and that could really be a solid salve to a lot of people.
Rovner: I was fascinated because she’s been pretty much invisible all year. I think this is the first time we have actually heard her voice, the first time I have heard her voice in 2024.
Raman: I would add that it’s not unprecedented for a first lady on the Republican side to come out in favor of abortion rights. I think what makes it so interesting is, A, how close we are to the election and that we are actively in a campaign. When we look at the remarks that Laura Bush made several years ago, it was after [former President George W.] Bush had left office for a few years. And so this, I think, is just what really makes it, if the book is going to come out about a month or so before the election that …
Rovner: Melania’s book.
Raman: Yeah, Melania’s book, yes.
Rovner: So yes, we will see. All right. Well, abortion was not the only health issue that came up during the debate. So did the Affordable Care Act. JD Vance went as far to claim that Donald Trump is actually the one that saved the Affordable Care Act. That’s not exactly how I remember things happening. You’re shaking your head.
Raman: I think this was one of the most striking parts of the debate for me, just because he made several comments about how this was a bipartisan process and Trump was trying to salvage the ACA. And for those of us that were reporting in 2017, he was kind of ringleading the effort to repeal and replace the Affordable Care Act. And I guess there were just numerous claims within the few statements he made that were just all incorrect. He was talking about how Trump had divided risk pools, and that was not something that happened. I think that we assume that he was referring to the reinsurance waivers, but those were also created under the Obama administration, so it wasn’t like a Trump invention. We just had some approved under Trump. And he’d mentioned that enrollment was reaching record heights. Health enrollment grew more under the Biden administration than it did under Trump.
Rovner: Yeah, I went back and actually looked up those numbers because I was so, like, “What are you talking about?” Actually, it was the moderator question: Didn’t enrollment go up during the Trump administration? No, it went down every year.
Ollstein: The number of uninsured went up, in fact, during the Trump administration.
Rovner: That’s right.
Ollstein: But, I mean, this is, again, part of a long pattern. Trump has routinely taken credit for things that were the decisions of other administrations, both before and after him.
Rovner: And things that he tried to do and failed to do.
Ollstein: Right.
Rovner: Like lowering drug prices.
Ollstein: Right. Right, right, right. Exactly. Exactly. Like Anna said, there was very little new that was revealed in this exchange.
Rovner: Well, elsewhere on the campaign trail, the Harris campaign is working hard to elevate health care as an issue, including rolling out not just a 60-second ad warning of what repealing the Affordable Care Act could mean, but also issuing a 43-page white paper theorizing what Trump and Vance are likely to have in mind with their, quote, “concepts” of a health care plan based on what they’ve said and done in the past. They must be seeing something in the polls suggesting this could have some legs, don’t you think? I’m a little surprised, because everybody keeps saying: Not a health care election. This is not a health care election. But I don’t know. The Harris campaign sure keeps behaving like it might be.
Raman: Hammering in on the preexisting conditions and protecting those, just because that is such a popular part of the ACA across the board, is probably a good strategy for them, just because that is something that is not the most wonky with that and that people can understand in a campaign ad and kind of distill down.
Edney: Yeah, that was what I was thinking as well, is it’s a popular issue for, certainly, to be talking about, but also just the idea that he’s talking about it in a way that people think, Oh, we don’t have to worry. And Alice has made this point on abortion before. There’s a lot that he can do through executive order and things like that, and did do like taking away money for the navigators and things to help people enroll. So even if they don’t think it’s maybe going to be about health care fully, it makes sense to try to counter some of that. And you can’t do that on a debate stage most of the time, not in an effective way, but certainly putting out this paper, I mean, it did get some press and things like that, and if you really wanted to go read it, you could.
Rovner: Even I didn’t want to read all 43 pages.
Edney: Yeah.
Rovner: Well, as Anna previewed, the AARP released what’s normally a pretty routine interview with both candidates about issues important to Americans over age 50, things like Medicare, Social Security, and caregiving. But I think it’s fair to say that, at least, former President Trump’s answers were anything but routine. Asked how he would protect Medicare from cuts and improve the program, he said, and I quote: “What we have to do is make our country successful again. This has to do with Medicare and Social Security and other things. We have to let our country become successful, make our country successful again, and we’ll be able to do that.” How do you even respond to things like that? Or is this campaign now so completely divorced from the issues that literally nothing matters?
Edney: Well, I kind of noticed a trend in between that answer and one JD Vance gave when he was talking about abortion, and he said: We just need to make women trust us. They need to trust us again. We need to make them trust us. I was like, I don’t understand how that even connects. But also, how are you going to do that? And I think that this is the same thing. You’re just saying these words over and over again in relation. So in somebody’s mind, Medicare and success is Trump’s word, and trust and abortion as JD Vance’s thing, and you’re connecting these in their minds. And I was seeing this as a trend. It just felt familiar to me after listening to the vice-presidential debate. They’re not going to talk about any policy or anything, but repeating these words over and over again like you were listening to morning affirmations or something was going to really get that through in a voter’s mind is maybe what they’re going for.
Rovner: And I have to say, I mean, when candidates start to talk about actual policy ideas, it gets really wonky really fast. Sort of going back to the debate, JD Vance was talking about visas and immigration, and I think it’s an app that he was talking about. I know this stuff pretty well. I had no idea what he was talking about. I mean, maybe it does work better when Trump says, I’m not going to cut Medicare or Social Security, and leave it at that.
Ollstein: Well, right, because when you talk specific policies, that opens it up to critique. And when you just talk total platitudes, then it’s harder to pick apart and criticize, even though it’s clearly not an answer to the questions they’re asking. And it was even a little bit funny to me for the AARP interview, because I believe they sent in written responses, and so they had the ability—
Rovner: I think they also talked on the phone.
Ollstein: Oh, OK.
Rovner: So I think it was a little bit of both.
Ollstein: Right. Right, right, right. It wasn’t the sort of live televised interview. They could have looked up — it was an open-book test.
Rovner: It was.
Ollstein: And yet all of the responses from Trump were just like, We’re going to do something and it’s going to be great and awesome and it’ll fix everything, and it was completely devoid of policy specifics, which again may be smarter politically than actually saying what you plan to do, which as we’ve seen in Project 2025, generates a lot of backlash. But it is also a little bit dangerous to go into the election not knowing the specifics of what someone wants to do on health care.
Rovner: Yeah, I know. I find when I listen to some of these focus groups with undecided voters, we want to know what exactly they’re going to do, except they don’t really want to know what exactly they’re going to do. They think they do, but it appears that that is not necessarily the case. One thing that we know does matter, at least to people on Medicare, is the premiums they pay for their coverage. And unfortunately, for every administration, that announcement comes just weeks before Election Day every year. So this year, the Biden administration was worried about big jumps in premiums for Medicare Part D drug coverage, mostly thanks to the new caps on spending that will save consumers money but will cost insurers more. That didn’t happen, though. And in fact, average premiums will actually fall slightly next year.
Now, I’m not sure I understand exactly what the administration did to avoid this, but they used existing demonstration authority to boost payments to insurers. And, not surprisingly, Republicans are pretty furious. On the other hand, Republicans used pretty much this same authority to avoid Medicare premium spikes in the past. Anna, is this just political manipulation or good governing, or a little bit of both?
Edney: Yeah, it is certainly very timely and probably necessary also because the IRA, the Inflation Reduction Act, kept the seniors’ out-of-pocket pay at $2,000 a year. And so that was going to skyrocket premiums, and they did not want to face that, particularly in an election year. And as you mentioned, this all happens around that time. And so they did this demonstration, and I have read a few things trying to figure out exactly what it does, and I can’t.
Rovner: So it’s not just me. It’s complicated.
Edney: It’s not just you. It’s really complicated, and it has to do with payments that usually come at the end that insurers are now going to get upfront. And that’s the best I can tell you. But they’ll be getting some subsidies upfront, and it’s to try to spread these premium increases to help mitigate those so that seniors don’t have to then pay on that end instead of for their drugs out-of-pocket. So I think that they need to do something. I mean, already, the premiums were able to go up. I think it’s $35 a month, and some plans did elect to do that and others have them staying even. And you even have some with them going down a little bit. So I guess the moral of the story is for consumers to shop around this year, certainly.
Rovner: That’s right, and we will talk more about Medicare open enrollment, which opens in a couple of weeks, because it’s October, and all of these things happen at once. Moving back to abortion, a judge in Georgia struck down, at least for now, the state’s six-week abortion ban, quoting from “The Handmaid’s Tale” about how the law requires women to serve as human incubators. And I’ll put a link to the decision, because that’s quite the decision. But Alice, this is far from the last word on this, right?
Ollstein: Yes. It’s just so fascinating what a slow burn these lawsuits are. I mean, this, the one in North Dakota recently that restored access, these just sort of simmer under the radar for months or even years, and then a decision can have a major impact. And so access has been restored in some of these states. Some interesting things that came to mind were, one, it could be reversed again and pingpong back and forth, and all of that is very challenging for doctors and patients to manage.
But also — and I’m thinking more of North Dakota, because Georgia is sort of a medical powerhouse with a lot of providers and hospitals and facilities and stuff — but in North Dakota, the state’s only abortion clinic moved out of state, and they do not plan to move back as a result of this decision. This isn’t a switch you can flip back and forth. And so when access is restored on paper in the law, that doesn’t mean it’s going to be restored in practice. You need doctors willing to work in these states and provide the procedure. And even with the court rulings, they may not feel comfortable doing so, or the logistics are just too daunting to move back. So I would urge people to keep that in mind.
Rovner: Yeah, and the state’s already said that it’s going to appeal to the next-higher court. So we will see this continue, but I think it was definitely worth mentioning. We’ve talked a lot this year about women experiencing pregnancy complications not being able to get care in states with abortion bans and restrictions. Well, it’s happening in states where abortion is supposed to be widely available, too.
In California, the state’s attorney general filed suit this week against a Catholic hospital in the rural northern part of the state that refused to terminate the doomed pregnancy of a woman carrying twins after her water broke at 15 weeks, because they said one of the twins still had a heartbeat. She eventually was driven to the only other hospital within a hundred miles of the labor and delivery unit, where she did get the care that she needed, although she was hemorrhaging, but not until after a nurse at the Catholic hospital gave her a bucket of towels, quote, “in case something happens in the car.” Meanwhile, the labor and delivery unit at the hospital she was taken to is itself scheduled to close. Are women starting to get the idea that this is about more than just selective abortions and that no matter where they live, that being pregnant could be more dangerous than it has been in the past?
Raman: I was going to say this is something that abortion rights advocates have been saying for years now, that it’s not just abortion, that they point to things like the whole ordeal that we’ve been having with IVF [in vitro fertilization] and birth control and so many other things. Even in the last couple years, people trying to get other medications that have nothing to do with pregnancy and not being able to get those because they might have an effect or cause miscarriage or things like that. So I think in one way, yes. But at the same time, when you look at something like what we saw happen with the two deaths in Georgia, right? The messaging from the anti-abortion crowd has been that this was not because of the abortion ban but because of the regulations that allowed these people to get a medication abortion and that’s what’s driving the death.
So we think that, in some ways, there’s certain camps that are just going to be focused on a different side of how the emergency might not be related to abortion at all, or the branding is that this is not an abortion in certain cases versus an abortion, it’s just semantics. So I don’t know how many minds it’s changing at this point.
Ollstein: Like Sandhya said, the awareness that this is not just for so-called elective abortions. Obviously, that term is disputed and there’s gray area of what that means. I think the overwhelming focus in messaging — from Democrats, anyway — has been about these wanted pregnancies that suffer medical complications and people can’t get care, and so the spillover effect on miscarriage care. But I think the piece that’s new that this could emphasize is that it’s not a strict red-state-blue-state divide, that Catholic hospitals and other facilities in states with protections, like California — it could happen there, too. So I think that’s what this case may be contributing in a new way to people’s understanding.
Rovner: And, of course, this was happening long before Dobbs — I mean, with Catholic hospitals, particularly Catholic hospitals in areas where there are not a lot of hospitals, denying care according to Catholic teachings and women having basically no place, at least nearby, to go. So I think people are seeing it in a new light now that it seems to be happening in many, many places at the same time. Well, while we are visiting California, Governor Gavin Newsom this week signed legislation requiring large group health insurance plans to cover IVF and other fertility treatments starting next year. California is far from the first state to do this. I think it’s now up to over a dozen. But it’s by far the most populous state to do this. Do we expect to see more of this, particularly given, as you were saying, Sandhya, the attention that IVF is suddenly getting?
Raman: I think we could. We’ve had a lot of states do different variations of those so far, and they haven’t necessarily been blue versus red. I think one thing that was interesting about the California law in particular was that it included LGBTQ people within the infertility definition, which we’ve been having IVF laws for over 20 years at this point and I don’t know that that has been necessarily there in other ones. So I would be watching for more things like that and seeing how widespread that would be in some of the bills coming up in the next legislative cycle.
Rovner: Yes, and another issue that I suspect will continue to simmer beyond this election. Well, finally this week, two big business-of-health-related stories: Over the summer, we talked about how the CEO of Steward Health Care, which is a chain of hospitals bought out by private equity and basically run into bankruptcy, refused to show up to testify before the Senate Health, Education, Labor and Pensions Committee. Well, in the last two weeks, the committee, followed by the full Senate, voted to hold CEO Ralph de la Torre in criminal contempt. And as of last week, he is now ex-CEO Ralph de la Torre, and now he is suing the Senate over that contempt vote. If nothing else, I guess this raises the stakes in Congress to continue to look at the impact of private equity in health care?
Edney: Yeah, I think it’s interesting, because when you look at [Sen.] Bernie Sanders calling in pharmaceutical CEOs, they typically show up and they take their hits and they go home. And in this case, it probably kind of heightens that idea that private equity is the evil person. And I’m not saying everyone thinks pharma is not, but they do understand Washington. And there’s a chance that a lot of New York–focused, Wall Street–focused private equity folks may not get that quite in the same way or just may not view it as important. But now, that may be changing.
Rovner: I was surprised by how bipartisan this was.
Edney: Yeah.
Rovner: I mean, beating up on pharma tends to be a Democratic thing, but this was bipartisan in the committee and bipartisan in the Senate. I mean, it’s also important to remember that Steward Health Care is a chain of hospitals in a whole bunch of states, so there are a lot of senators who are seeing hospitals in, now, dire straits through this whole private equity thing, who I imagine are not very happy about it. And their constituents are not very happy about it. But I think the bipartisanship of it is what sort of stuck out to me.
Raman: I was just going to say hospitals are such a big employer for so many districts that I think that, but I would say this was the first time in 50 years they’ve sent a contemptor to the DOJ [Department of Justice]. And especially doing that in a unanimous fashion is just very striking to me, and I’m curious if DOJ kind of goes forth and does, takes penalty and action with it.
Rovner: Yeah, this is a real under-the-radar story that I think could explode in a big way at some point. Well, the other big, evolving business story this week involves Medicare Advantage, the private sector alternative that gives enrollees extra benefits and makes insurance shareholders rich, mostly at taxpayer expense. Well, the party is, if not ending, then at least slowly closing down. Humana’s stock price dropped dramatically this week after the company reported the new way Medicare officials are calculating quality scores from Medicare Advantage. They get stars. The more stars, the better. The new way that Humana appears to be getting its stars could effectively deprive it of its entire operating profit.
In separate news, UnitedHealthcare is suing Medicare over its Medicare Advantage payments in one of those single-judge conservative districts in Texas, of course. Democrats have been working to at least somewhat rein in these excess payments to Medicare Advantage for the past, I don’t know, two decades or so, but I assume this will all likely be reversed if Trump wins. And Medicare Advantage has been a troublesome issue because it’s really popular with beneficiaries, but it’s really expensive, because it’s really popular, because they get extra money, and some of that extra money goes to give extra benefits. Talk about things that are hard to explain to people. It’s great that you get all these extra benefits, but it’s costing the government more than it should.
Edney: Yeah.
Raman: I guess I do wonder if people, how much attention they’re paying. Are they going to switch plans if it’s dropping that many stars? If you’re on a Humana plan and a huge number of them got demoted to a lower rating, the next time you’re looking for a plan, are you going to switch to something else? And how often people are doing that and just if that would move the needle, because it’s just a longer process than overnight.
Rovner: Although, I think it isn’t just that people have to switch. If people stay in those plans with fewer stars, the company gets less money.
Raman: Yeah.
Rovner: Because they get bonuses when people are in the, quote-unquote, “higher quality” plan. So even if their four-star plan is now a three-star plan and they stay in it, the company’s going to lose money, which I think is why the stock price took such a quick and dramatic bath.
Edney: Yeah, I was surprised. It’s such a seemingly wonky issue, but it did really hit Humana very hard in the stock price. Technically, I think — correct me if I’m wrong — the stars aren’t even out yet. This is people doing searches to see if they can find some of them that have been changed at all, and so they’re coming out soon, but Humana particularly is very Medicare-focused out of all of the insurers. They rely on that for a large part of their revenue, so it is a big deal for them. I don’t know how much, but certainly Wall Street was. And as you mentioned with Trump, the Republicans typically really have supported Medicare Advantage because it is private insurers offering this instead of being just government-run Medicare. So that could have an effect.
It’s hard to tell why their stars went down currently. With UnitedHealth, you at least get a little insight. They’re suing because, last year, their star rating went down for some plans, they said, because of one bad customer service phone call. So someone from Medicare calls and does a test thing, and UnitedHealth says they didn’t ask the right question, so the person never got a chance to answer it correctly, and then their star ratings went down. So, it does feel like it could happen at any point for any reason, so I don’t know how conducive that is, how much that actually plays into people who might have a Humana plan that think, “Oh, I haven’t had any issues, so why would I change?”
Rovner: Yeah. All these under-the-hood things, as you point out, we have all looked at and don’t quite understand is worth billions and billions and billions of dollars. It’s one of the reasons why health care is so expensive and such a big part of the economy. All right. Well, we will continue to watch that space, too. That is the news for the week. Now we will play my “Bill of the Month” interview with Lauren Sausser, and then we will come back with our extra credits.
I am pleased to welcome to the podcast my KFF Health News colleague Lauren Sausser, who reported and wrote the latest KFF Health News “Bill of the Month.” Lauren, thanks for joining us.
Lauren Sausser: Thanks for having me.
Rovner: So tell us about this month’s patient, who he is, and what kind of medical care he needed.
Sausser: This month’s patient is a young man named Preston Nafz. He’s 17. He’s a senior in high school. He lives in Hoover, Alabama, which is right outside of Birmingham. And he played youth sports his whole life and recently is focused on lacrosse, but like many kids in this country, he has sort of cycled through a bunch of different sports, and ended up injured last year.
Rovner: And what happened?
Sausser: He had really debilitating pain in his hip, and the pain was progressive. And, obviously, they tried some treatments on one end of the spectrum, but it kept growing worse and worse. And at one point last year, he ended up limping off of the lacrosse field. He couldn’t do really simple things like turning over in bed or getting in and out of a car. These things were really painful for him. So he ended up as a patient at a sports medicine clinic, and providers at that clinic recommended surgery.
Rovner: And to cut to the chase, the story, at least medically, has a happy ending, right? The surgery worked? He’s better?
Sausser: Yes, the surgery worked. He ended up getting something late last year, a procedure called a sports hernia repair, which is a little bit of a misnomer because he didn’t actually have a hernia. But it’s kind of a catchall phrase that orthopedic surgeons use to talk about a procedure to relieve this type of pain that he was having in his pelvis, groin area. And the recovery was longer than he was anticipating, but yes, it medically does have a happy ending. He was able to play lacrosse again, although the last time I spoke to him, he had another sports-related injury. But the sports hernia repair did do what it was supposed to do, so that’s the good news.
Rovner: So it sounded like it should have been routine. Kid growing up, gets hurt playing sports, family has health insurance, goes to sports medicine, doctor fixes problem. Except for the bill, right?
Sausser: Yeah. So the interesting thing about this story, and this is really why we pursued it, is because there is no CPT [Current Procedural Terminology] code for a sports hernia repair. CPT codes, your listeners are probably familiar with, but they’re the medical codes that providers and insurers use to figure out how things get paid for. And it can become more complicated when there’s no code for a procedure, which was the case here. So Preston’s dad was told before the surgery that he was going to have to pay upfront because his insurance company, which was Blue Cross Blue Shield of Alabama, likely wasn’t going to pay for it.
Rovner: And how much was it upfront?
Sausser: It was just over $7,000. So the surgery itself was $6,000. There was, I think, almost $500 for anesthesia, a little over $600 for the facility fee. And Preston’s dad paid for it on a few different credit cards.
Rovner: So kid has the surgery, is in rehab, and Dad is now trying to recoup this money that he has paid for upfront. And what happened then?
Sausser: Yeah. Before the surgery even happened, Preston’s dad tried to call his insurance company and say: Can I get this covered? My son’s doctor says this is medically necessary. And initially, he got good news. His insurer said: It sounds like this is something that should be covered. If this is something that’s medically necessary, your insurance plan generally covers those things. As the date of the surgery grew closer and closer, he found that the people he was talking to at the insurance company weren’t being as definitive with their answers. And so before the surgery, he got a no. He said he got a no from his insurer saying that they were not going to cover this. Now, on the back end of the surgery, after he’d paid the bill with those credit cards, he tried to appeal that decision by filing a lot of paperwork. And he did end up getting a few hundred dollars reimbursed, but when the insurer sent him that check, it was unclear exactly what they were covering. And, obviously, that didn’t come close to the $7,000-plus that they had paid for it.
Rovner: So that’s what eventually happened with the bill, right? He ended up getting stuck with almost all of it?
Sausser: Yeah.
Rovner: Is there anything he could have done differently that might’ve helped this get reimbursed?
Sausser: That’s the tricky thing about this story, because they did do almost everything right. But it’s almost a cautionary tale for people who are faced with this prospect in the future. So if your provider is recommending something that doesn’t have a CPT code, it is going to be harder to get reimbursed from your insurer. You should assume that. That’s not to say it’s impossible, but it’s going to take more work on your end. It’s going to take more paperwork, it may take more work on your doctor’s end, and you should be prepared to get some pushback, if that makes sense.
Rovner: And has he just sort of written this off?
Sausser: I mean, he paid off the surgery using the credit cards. And the last I spoke to this family, they were still getting some confusing communication from their insurer. I don’t know that they’ve gotten the final, final no yet. I think that he still is invested in getting reimbursed if he can. But at this point, we’re approaching almost the one-year anniversary of the surgery, so it’s looking less likely.
Rovner: Well, we will keep following it. Lauren Sausser, thank you so much.
Sausser: Thanks for having me.
Rovner: OK, we’re back. Now it’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read too. Don’t worry if you miss the details. We’ll include links to all these stories in our show notes on your phone or other mobile device. We have two hurricane-related extra credits this week. Sandhya, why don’t you go first?
Raman: My extra credit this week is called “Without Water After Helene: Residents at Asheville Public Housing Complex Fear for Their Health,” and it is from the Asheville [North Carolina] Citizen Times, by Jacob Biba. And the story just looks at the residents of a specific complex in Asheville that have been hit really hard by the hurricane. And, when this was written, they’d been without water for two days and it might not come back for weeks, and just some of the public health impacts they were facing. One person couldn’t clean their nebulizer or their tracheostomy tube. Others were worrying about sanitation from not being able to flush toilets. I think it’s a good one to check out.
Rovner: Yeah. We think about so many things with hurricanes. We think about being without power. We don’t tend to think about being without water. Alice, you have a related story.
Ollstein: Yeah, and this is more of a supply chain story but really shows that these hurricanes and natural disasters can have really widespread impacts outside the region that they’re in. And so this is from The Wall Street Journal. It’s called “Hospitals Hit With IV Fluid Shortage After Hurricane Helene.” It’s by Joseph Walker and Peter Loftus, and it’s about a facility in North Carolina that produces, like I said, IV bag fluids that hospitals around the country depend on. And yeah, we’ve talked before about just how vulnerable our medical supply chains are and we don’t spread the risk around maybe as much as we need to in this age of climate instability. And so, yeah, hospitals, they’re not rationing the fluids, but they are taking steps to conserve. And so they’re thinking, OK, certain patients can take fluids orally instead of intravenously in order to conserve. And so that’s happening now. Hopefully, it doesn’t become rationing down the road. But, yeah, with the long recovery the region is expecting, it’s a bit scary.
Rovner: Anna.
Edney: I did one from a colleague of mine at Bloomberg, John Tozzi. It’s “A Free Drug Experiment Bypasses the US Health System’s Secret Fees.” So he looked at this Blue Shield of California plan that is deciding to just bypass the pharmacy benefit managers and go directly to a drugmaker to get a biosimilar of Humira, the rheumatoid arthritis and many other ailments drug. And they’re going to be getting it for $525 a month for this drug that a lot of the PBMs are offering for more than a thousand dollars. And so the PBMs mentioned to him, We give rebates, and it’s less than a thousand dollars. But they didn’t say if it was as low as $525. And Blue Shield of California seems to think that this is a really good deal and that they’re basically going to give it for free just to show that it can reach Americans affordably. And so I thought it was a good look at this plan and at maybe a trend, I don’t know, that plans might start going outside of the PBM network.
Rovner: We shall see. Well, I chose a story from KFF Health News this week from Ronnie Cohen, and it’s called “Doctors Urging Conference Boycotts Over Abortion Bans Face Uphill Battle,” and it’s a really thoughtful piece about how to best protest things you disagree with. In this case, some doctors want medical groups to move professional conferences out of states with abortion bans, in order to exert financial pressure and to make a point. But there are those who worry that that amounts to punishing the victims and that it won’t do much anyway, frankly, unless you’re the Super Bowl or the baseball All-Star Game. It’s not like your conference is going to make or break some city’s annual budget. But it’s a microcosm of a bigger debate that’s going on in medicine that I’ve been covering. How do doctors balance their duty to serve patients with their duty to themselves and their own families? There are obviously pregnant medical professionals who do not wish to travel to states with abortion bans lest something bad happens. It’s a struggle that is obviously going to continue. It’s a really interesting story.
OK. That is our show. Before we go this week, it is October and we want your scariest Halloween haikus. The winner will get their haiku illustrated by our award-winning in-house artists, and I will read it on the podcast that we tape on Halloween. We will have a link to the entry page in our show notes.
As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us too. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. 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 at X. I’m @jrovner. Sandhya?
Raman: @SandhyaWrites.
Rovner: Anna?
Edney: @annaedney.
Rovner: Alice.
Ollstein: @AliceOllstein.
Rovner: We will be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': Congress Punts to a Looming Lame-Duck Session
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.
Congress has left Washington for the campaign trail, but after the Nov. 5 general election lawmakers will have to complete work on the annual spending bills for the fiscal year that starts Oct. 1. While the GOP had hoped to push spending decisions into 2025, Democrats forced a short-term spending patch that’s set to expire before Christmas.
Meanwhile, on the campaign trail, abortion continues to be among the hottest issues. Democrats are pressing their advantage with women voters while Republicans struggle — with apparently mixed effects — to neutralize it.
This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of Politico and the Johns Hopkins schools of nursing and public health, Alice Miranda Ollstein of Politico, and Lauren Weber of The Washington Post.
Panelists
Joanne Kenen
Johns Hopkins University and Politico
Alice Miranda Ollstein
Politico
Lauren Weber
The Washington Post
Among the takeaways from this week’s episode:
- When Congress returns after the election, there’s a chance lawmakers could then make progress on government spending and more consensus health priorities, like expanding telehealth access. After all, after the midterm elections in 2022, Congress passed federal patient protections against surprise medical billing.
- As Election Day approaches, Democrats are banging the drum on health care — which polls show is a winning issue for the party with voters. This week, Democrats made a last push to extend Affordable Care Act subsidies expanded during the pandemic — an issue that will likely drag into next year in the face of Republican opposition.
- The outcry over the first reported deaths tied to state abortion bans seems to be resonating on the campaign trail. With some states offering the chance to weigh in on abortion access via ballot measures, advocates are telling voters: These tragedies are examples of what happens when you leave abortion access to the states.
- And Sen. Bernie Sanders of Vermont summoned the chief executive of Novo Nordisk before the health committee he chairs this week to demand accountability for high drug prices. Despite centering on a campaign issue, the hearing — like other examples of pharmaceutical executives being thrust into the congressional hot seat — yielded no concessions.
Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: KFF Health News’ “How North Carolina Made Its Hospitals Do Something About Medical Debt,” by Noam N. Levey and Ames Alexander, The Charlotte Observer.
Lauren Weber: Stat’s “How the Next President Should Reform Medicare,” by Paul Ginsburg and Steve Lieberman.
Joanne Kenen: The Atlantic’s “The Woo-Woo Caucus Meets,” by Elaine Godfrey.
Alice Miranda Ollstein: Stat’s “How Special Olympics Kickstarted the Push for Better Disability Data,” by Timmy Broderick.
Also mentioned on this week’s podcast:
- KFF Health News’ “Florida’s New Covid Booster Guidance Is Straight-Up Misinformation,” by Arthur Allen, Daniel Chang, and Sam Whitehead.
- KFF Health News’ “Feds Killed Plan To Curb Medicare Advantage Overbilling After Industry Opposition,” by Fred Schulte.
- KFF Health News’ “Audits — Hidden Until Now — Reveal Millions in Medicare Advantage Overcharges,” by Fred Schulte and Holly K. Hacker.
- KFF Health News’ “ACA Plans Are Being Switched Without Enrollees’ OK,” by Julie Appleby.
- KFF Health News’ “Biden Administration Tightens Broker Access to Healthcare.gov To Thwart Rogue Sign-Ups,” by Julie Appleby.
click to open the transcript
Transcript: Congress Punts to a Looming Lame-Duck Session
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, September 26th, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So, here we go.
Today we are joined via teleconference by Lauren Weber of The Washington Post.
Lauren Weber: Hello hello.
Rovner: Alice Ollstein of Politico.
Alice Miranda Ollstein: Good morning.
Rovner: And Joanne Kenen of the Johns Hopkins Schools of Public Health and Nursing, and Politico.
Joanne Kenen: Hi, everybody.
Rovner: Big props to Emmarie for hosting last week while I was in Ann Arbor at the Michigan Daily reunion. I had a great time, but I brought back an unwelcome souvenir in the form of my first confirmed case of covid. So apologies in advance for the state of my voice. Now, let us get to the news.
To steal a headline from Politico earlier this week, Congress lined up in punt formation, passing a continuing resolution that will require them to come back after the election for what could be a busy lame-duck session. Somebody remind us who wanted this outcome — the Let’s only do the CR through December — and who wanted it to go into next year? Come on, easy question.
Ollstein: Well, the kicking it to right before Christmas, which sets up the stage for what we’ve seen so many times before where it just gets jammed through and people who have objections, generally conservatives who want to slash spending and add on a bunch of policy riders, which they tried and failed to do this time, will have a weaker base to operate from, given that everybody wants to go home for the holidays.
And so once again, we’re seeing people mad at Speaker Mike Johnson, who, again and again, even though he is fully from the hard right of the party, is not catering to their priorities as much as they would like. And so obviously his speakership depends on which party wins control of the House in November. But I think even if Republicans win control, I’m already starting to hear rumblings of throwing him overboard and replacing with someone who they think will cater to them more.
Rovner: It was so déjà vu all over again, which is, last year, as we approached October 1st and the Republican House could not pass any kind of a continuing resolution with just Republican votes, that eventually Kevin McCarthy had to turn to Democrats, and that’s how he lost his job.
And yet that’s exactly what happened here, which is the Republicans wanted to go until March, I guess on the theory that they were betting that they would be in full power in March and would have a chance to do a lot more of what they wanted in terms of spending bills than if they just wait and do it in the lame duck. And yet the speaker doesn’t seem to be paying the same price that Kevin McCarthy did. Is that just acknowledgment on the part of the right wing that they can’t do anything with their teeny tiny majority?
Kenen: I mean, yes, it’s pretty stalemate-y up there right now, and nobody is certain who’s going to control the House, and at this point it is likely to still be a narrow majority, whoever wins it. I mean, they’re six weeks out. Things can change. This has been an insane year. Nobody’s making predictions, but it looks like pretty divided.
Rovner: Whoever wins isn’t going to win by much.
Kenen: We have a pretty divided country, and the likelihood is we’re going to have a pretty divided House. So the dynamic will change depending on who’s in charge, but the Republicans are more fractious and divided right now than the Democrats, although that’s really easy to change, and even the Democrats have gone through their rambunctious divided phases, too.
Everybody just doesn’t know what’s next, because the top of the ticket is going to change things. So the more months you push out, the less money you’re spending. If you control the CR, if you make the CR, the continuing resolution, meaning current spending levels for six months, it’s a win for the Republicans in many ways because they’re keeping — they’re preventing increases. But in terms of policy, both sides get some of the things they want extended.
I don’t know if you can call it a productive stalemate. That’s sort of a contradiction in terms. But I mean, for the Republicans, longer, it would’ve been better.
Rovner: So now that we know that Congress has to come back after the election, there’s obviously things that they are able to do other than just the spending bills. And I’m thinking of a lot of unfinished health legislation like the telehealth extensions and the constant, Are we going to do something about pharmacy benefit managers? which has been this bipartisan issue that they never seem to solve.
I would remind the listeners that in 2022 after the election, that’s when they finally did the surprise-bills legislation. So doing big things in the lame duck is not unheard of. Is there anything any of you are particularly looking toward this time that might actually happen?
Kenen: It’s something like telehealth because it’s not that controversial. I mean, it’s easiest to get something through in — in lame duck, you want to get some things off the plate that are either overdue and need to be taken care of or that you don’t want hanging over you next year. So telehealth, which is, there are questions about does it save money, et cetera, and what form it should take and how some of it should be regulated, so forth, but the basic idea, telehealth is popular. Something like that, yes.
PBMs [pharmacy benefit managers] is a lot harder, where there is some agreement on the need to do something but there’s less agreement about what that something should look like. So although I’m not personally covering that day-to-day basis, in any sense, that’s harder. The more consensus there is and the fewer moving parts, the easier it is to do, as a rule. I mean, sometimes they do get something big done in lame duck, but a lot of it gets kicked.
And also there’s a huge, huge, huge tax fight next year, and it’s going to require a lot of wheeling and dealing no matter what shape it takes, because it’s expiring and things have to be either renewed or allowed to die. So that’s just going to be mega-enormous, and a lot of this stuff become bargaining chips in that larger debate, and that becomes the dominant domestic policy vehicle next year.
Rovner: Well, even before we get to the lame duck, we have to finish the campaign, which is only a month and a half away. And we are still talking about the Affordable Care Act in an election where it was not going to be a campaign issue, everybody said.
I know that you talked last week about all the specifics of the ways former President [Donald] Trump actually tried to sabotage rather than save the ACA and all the ways what [Sen.] JD Vance was talking about on “Meet the Press,” dividing up risk pools once again so sicker people would no longer be subsidized by the less sick, would turn the clock back to the individual insurance market as it existed before 2014.
Now the Democrats in the Senate are taking one last shot at the ACA with a bill — that will fail — to renew the expanded marketplace subsidies, so it will expire unless Congress acts by the end of next year. Might this last effort have some impact in the swing states, or is it just a lot more campaign noise?
Weber: I think this is a lot of campaign noise, to some extent. I mean, I think Democrats are clear in polling shows that the average American voter does trust Democrats more than Republicans on ACA and health issues and health insurance. So I do think this is a messaging push in part by the Dems to speak to voters. As we all know, this is a turnout election, so I think anything that they feel like voters care about, which often has to do with their pocketbook, I think they’re going to lead the drum on.
I do think it’s interesting again that JD Vance really is reiterating a talking point that Donald Trump used in the debate, which is that he said he had improved the ACA and many experts would say it was very much the opposite. Again, I think I did this on the last podcast, but let me reread this because I think it’s important as a fact check. Most of the Trump administration’s ACA-related actions included cutting the program.
So they reduced millions of dollars of funding for marketing and enrollment, and he repeatedly tried to overturn the law. So I think some of the messaging around this is getting convoluted, in part because it’s an election year, to your point.
Rovner: And because it’s popular. Because Nancy Pelosi was right. When people found out what was in it, it got popular.
Kenen: I think there are two things. I mean, I agree with what Lauren just said, but the Democrats came out in favor of extending the subsidies yesterday, which not only changed the eligibility criteria — more people, more higher up the middle-income chain could get subsidized — but also everybody in it had extra benefits for it, including people who were already covered. But it’s better for them.
The idea that Republicans are going to try to take that benefit away from people six weeks before an election — they were probably not. How they handle it next year? I was really surprised by the silence yesterday. The Democrats rolled out their plans for renewing this, and I didn’t see a lot of Republican pushback. So they were really quiet about it.
The other thing that struck me is that JD Vance went on on this risk pool thing last week on “Meet the Press” and in Raleigh, in North Carolina, and then there was pushback. And on that particular point, there’s been silence for the last week. I don’t think he stuck his neck out on that one again. Who knows what next week will bring, but it didn’t continue, and nor did I hear other Republicans saying, “Yeah, let’s go do that.”
So if that was a trial balloon, it was somewhat leaden. So I think that we really don’t know how the subsidy fight is going to play —how or when the subsidy fight will play out. It’s really, you know, we’ve all said many times before, once you give people the benefit, it’s really hard to take it away. And—
Rovner: Although we did that with the Child Tax Credit. We gave everybody the Child Tax Credit and then took it away.
Kenen: We did, and other things that were temporary during the pandemic, and we’ll just see how many of those temporary things do in fact go away. I mean, does it come back next year? I mean, now SALT [state and local taxes], right? I mean, Trump backed backing what’s called SALT. It’s a limit based on mortgage and state taxes. And now he’s talking about he’s going to rescue that like it wasn’t him who … So it all comes around again.
Ollstein: Yeah, and I think what you’re seeing is both sides drawing the battle lines for next year and signaling what the core arguments are going to be. And so you had Democrats come out with their bill this year, and you are hearing a lot of Republicans in hearings and speeches sprinkled around talking about claiming that there is a huge amount of fraud in the ACA marketplaces and linking that to the subsidies and saying, Why would we continue to subsidize something where there’s all this fraud?
I think that is going to be a big argument on that side next year for not extending the subsidies. So I would urge people to keep listening for that.
Kenen: And that came from a conservative think tank consulting firm in which they blame — I actually happened to read it this week, so it’s fresh in my mind. They’re blaming the fraud actually on brokers rather than individuals. They’re saying that people are—
Rovner: That was an investigation uncovered by my colleague Julie Appleby here at KFF Health News.
Kenen: Right. And they ran with that, and they were talking about the low end of the income bracket. And I’m waiting for the sequel in which the people at the upper end of the income bracket, which is the law that’s expiring that we’re talking about, it’s pretty — I’m waiting for the sequel Paragon paper saying, See, it’s even worse at the upper end, and that’s easy to get rid of because it’ll expire. That’s the argument of the day, but there’s so many flavors of anti-ACA arguments that we’ve just scratched the beginning of this round.
Rovner: Exactly. It’ll come back. All right, well, let us move on to abortion. Vice President [Kamala] Harris said in an interview this week that she would support ending the filibuster in the Senate in order to restore abortion rights with 51 rather than 60 votes, which has apparently cost her the endorsement of retiring West Virginia Democratic senator Joe Manchin. Was Manchin’s endorsement even that valuable to her? It’s not like West Virginia was going to vote Democratic anytime soon.
Ollstein: The Harris campaign has really leaned into emphasizing endorsements she’s been getting from across the ideological spectrum, from as far right as Dick Cheney to more centrist types and economists and national security people. And so she’s clearly trying to brandish her centrist credentials. So I guess in that sense. But like you said, Democrats are not going to win West Virginia, and so I think also he was getting upset about something, a position she’s been voicing for years now. This is not new, this question of the filibuster. So I doubt it’ll have much of an impact.
Kenen: It’s a real careful-what-you-wish for, because if the Senate goes Republican, which at the moment looks like it’s going to be a narrow Republican majority. We don’t know until November. There’s always a surprise. There’s always a surprise.
Rovner: You’re right. It’s more likely that it’ll be 51-49 Republican than it’ll be 51-49 Democrat.
Kenen: Right. So if the filibuster is going to be abolished, it would be to advance Republican conservative goals. So it’s sort of dangerous territory to walk into right now. The Democrats have played with abolishing the filibuster. They wanted to do it for voting rights issues, and they decided not to go there on legislation. They did modify it a number of years ago on judicial appointments and other Cabinet appointments and so forth.
But legislative, the filibuster still exists. It’s very, very, very heavily used, much more than historically, by both parties, whoever is in power. So changing it would be a really radical change in how things move or don’t move. So it could have a long tail, that remark.
Rovner: Meanwhile, Senate Democrats, who don’t have the votes now, as we know, to abolish the filibuster, because Manchin is among their one-vote margin, are continuing to press Republicans on reproductive rights issues that they think work in their favor. Earlier this week, the Senate Finance Committee had a hearing on EMTALA, the Emergency Medical Treatment and Labor Act.
It’s a federal law that’s supposed to guarantee women access to abortion in medical emergencies. But in practice, it has not. Last week we talked about the ProPublica stories on women whose pregnancy complications actually did lead to their death. Is this something that’s breaking through as a campaign issue? I do feel like we’ve seen so much more on pregnancy complications and the health impacts of those rather than just, straight, women who want to end pregnancies.
Ollstein: I just got back from Michigan, and I would say it is having a big impact. I was really interested in how Democrats were trying to campaign on abortion in Michigan, even now that the state does have protections. And I heard over and over from voters and candidates that Trump’s leave-it-to-the-states stance, they really are still energized by that.
They’re not mollified by that, because they are pointing to stories like the ones that just came out in Georgia and saying: See? That’s what happens when you leave it to the states. We may be fine, but we care about more than just ourselves. We’re going to vote based on our concern for women in other states as well. I found that really interesting to be hearing out in the field.
Rovner: Lauren, you want to add something?
Weber: Yeah, I just was going to add, I mean, Harris obviously highlighted this effectively in the debate, and I think that has helped bring it to more of a crescendo, but there’s obviously been a lot of reporting for months on this. I mean, the AP has talked about — I think they did a count. It’s over 100 women, at least, have been denied emergency care due to laws like this.
I’d be curious — and it sounds like Alice has this, for voters that are in swing states, that it’s breaking through to — I’d be curious how much this has siloed to people that are outraged by this, and so we’re hearing it and how much it’s skidding down to those that — the Republican talking points have been that these are rare, they don’t really happen, it’s a liberal push to get against this. I’d be curious how much it’s breaking through to folks of all stripes.
Rovner: I watched a big chunk of the Finance Committee hearing, and the anti-abortion witnesses were saying this is not how it worked, that ectopic pregnancies, pregnancy complications do not qualify as abortions, and basically just denying that it happened. They’re sitting here. They’re sitting at the witness table with the woman to whom this happened and saying that this does not happen. So it was a little bit difficult, shall we say. Go ahead.
Ollstein: Well, and the pushback I’ve been hearing from the anti-abortion side is less that it’s not happening and more that it’s not the fault of the laws, it’s the fault of the doctors. They are claiming that doctors are either intentionally withholding care or are wrong in their interpretation of the law and are withholding care for that reason. They’re pointing to the letter of the law and saying, Oh no, it doesn’t say let women bleed out and die, so clearly it’s fine. They’re not really grappling with the chilling effect it’s having.
Rovner: Although we do know that in Texas when, I think it was Amanda Zurawski, there was — no, it was Kate Cox who actually got a judge to say she should be allowed to have an abortion. Ken Paxton, the Texas attorney general, then threatened the hospital, said, If you do this, I will come after you. On the one hand, they say, Well, that’s not what the law says. On the other hand, there are people saying, Yeah, that’s what the law says.
Turning to the Republicans, Donald Trump had some more things to say about abortion this week, including that he is women’s protector and that women will, and I quote, “be happy, healthy, confident, and free. You will no longer be thinking about abortion.”
If that wasn’t enough, in Ohio, Bernie Moreno, who’s the Republican running against Senator Sherrod Brown in the otherwise very red state, said the other night that he doesn’t understand why women over 50 would even care about abortion, since, he suggested, they can no longer get pregnant, which isn’t correct, by the way. But who exactly are the voters that Trump and Moreno are going after here?
Kenen: Moreno is already lagging in the polls. Sherrod Brown is a pretty liberal Democrat in an increasingly conservative state, and he’s also very popular. And it looks like he’s on a glide path to win, and this probably made it easier for him to win. And there are men who support abortion rights, and there are women who oppose.
I mean, this country’s divided on abortion, but it’s not age-related. It’s not like if you’re under 50 and female, you care about abortion and nobody else does. I mean, that’s really not the way it works. Fifty-year-old and older women, some of whom had abortions when they were younger, would want that right for younger women, including their daughters. It’s not a quadrant. It’s not like, oh, only this segment cares.
Ollstein: It’s interesting that it comes amid Democrats really working to broaden who they consider an abortion voter, like I said, trying to encourage people in states where abortion is protected to vote for people in states where abortion is not protected and doing more outreach to men and saying this is a family issue, not just a women’s issue, and this affects everybody.
So as you see Democrats trying to broaden their outreach and get more people to care, you have Bernie Moreno saying the opposite, saying, I don’t understand why people care when it doesn’t affect their own particular life and situation.
Rovner: Although I will say, having listened to a bunch of interviews with undecided voters in the last couple of weeks, I do hear more and more voters saying: Well, such and such candidate, and this is on both sides, is not speaking to me. It’s almost like this election is about them individually and not about society writ large.
And I do hear that on both sides, and it’s kind of a surprise. And I don’t know, is that maybe where Moreno is coming from? Maybe that’s what he’s hearing, too, from his pollsters? It’s only that people are most interested in their own self-interest and not about others? Lauren, you wanted to add to that?
Weber: I mean, I would just say I think that’s a kind interpretation, Julie. I think that more likely than not, he was just speaking out of turn. And in some prior reporting I did this year on misinformation around birth control and contraception, I spoke to a bunch of women legislators, I believe it was in Idaho, who found that in speaking with their male legislator friends, that a lot of them were uncomfortable talking about abortion, birth control, et cetera, which led to a lot of these misconceptions. And I wonder if we’re seeing that here.
Ollstein: Just quickly, I think it’s also reflective of a particular conservative mind-set. I mean, it reminds me of when I was covering the Obamacare fight in Congress and you had Republican lawmakers making jokes about, Oh, well, wouldn’t want to lose coverage for my mammograms. And just what we were just talking about, about the separate risk pools and saying, Oh, I’m healthy. Why should I subsidize a sick person? when that’s literally how insurance works.
But I think just the very individualistic go-it-alone, rugged-individual mind-set is coming out here in different ways. And so it seems like he did not want this particular comment to be scrutinized as it is getting now, but I think we hear versions of this from conservative lawmakers all the time in terms of, Why should I have to care about, pay for, subsidize, et cetera, other people in society?
Rovner: Yeah, there’s a lot of that. Well, finally this week in reproductive health issues that never seem to go away, a federal judge in North Dakota this week slapped an injunction on the Equal Employment Opportunity Commission’s enforcement of some provisions of the 2022 Pregnant Workers Fairness Act, ruling that Catholic employers, including for-profit Catholic-owned entities, don’t have to provide workers with time off for abortions or fertility treatments that violate the church’s teachings.
Now, lest you think this only applies to North Dakota, it does not. There’s a long way to go before this ruling is made permanent, but it’s kind of awkward timing for Republicans when they’re trying to convince voters of their strong support of IVF [in vitro fertilization], and yet here we have a large Catholic entity saying, We don’t even want to give our workers time off for IVF.
Ollstein: Yeah, I think you’ve been hearing a lot of Republicans scoffing at the idea that anyone would oppose IVF, when there are many, many conservatives who do either oppose it in its entirety or oppose certain ways that it is currently commonly practiced. You had the Southern Baptist Convention vote earlier this year in opposition to IVF. You have these Catholic groups who are suing over it.
And so I think there needs to be a real reckoning with the level of opposition there is on the right, and I think that’s why you’re seeing an interesting response to Trump’s promise for free IVF for all and whether or not that is feasible. I think this shows that it would get a lot of pushback from groups on the right if they were ever to pursue that.
Rovner: Yeah, I will also note that this was a Trump-appointed judge, which is pretty … The EEOC, when they were doing these final regulations, acknowledged that there will be cases of religious employers and that they will look at those on a case-by-case basis. But this is a pretty sweeping ruling that basically says, we’re back to the Hobby Lobby Supreme Court case: If you don’t believe in something, you don’t have to do it.
I mean, that’s essentially where we are with this, and we will see as this moves forward. Well, moving on to another big election issue, drug prices, the CEO of Novo Nordisk, makers of the blockbuster obesity and diabetes drugs Ozempic and Wegovy, appeared at the Senate Health, Education, Labor and Pensions Committee on Tuesday in front of Senator Bernie Sanders, who has been one of their top critics.
And maybe it’s just my covid-addled brain, but I watched this hearing and I couldn’t make heads or tails of how Lars Jørgensen, the CEO, tried to explain why either the differences between prices in the U.S. and other countries for these drugs weren’t really that big, or how the prices here are actually the fault of PBMs, not his company. Was anybody able to follow this? It was super confusing, I will say, that he tried to …
First he says that, well, 80% of the people with insurance coverage can get these drugs for $25 a month or less, which I’m pretty sure only applies to people who are using it for diabetes, not for obesity, because I think most insurers aren’t covering it for obesity. And there was much backing and forthing about how much it costs and how much we pay and how much it would cost the country to actually allow people, everybody who’s eligible for these drugs, to use them. And no real response. I mean, this is a big-deal campaign issue, and yet I feel like this hearing was something of a bust.
Weber: I mean, do we really expect a CEO of a highly profitable drug to promise to reduce it immediately on the spot? I mean, I guess I’m not surprised that the hearing was a back-and-forth. From what I understand of what happened, I mean, most hearings with folks that have highly lucrative drugs, they’re not looking to give away pieces of the lucrative drugs. So I think to some extent we come back to that.
But I did think what was interesting about the hearing itself was that Sanders did confront him with promises from PBMs that they would be able to offer these drugs and not short the American consumer, which was actually a fascinating tactic on Sanders part. But again, what did we really walk away with? I’m not sure that we know.
Rovner: Yeah, I mean, even if you were interested in this issue — and I’m interested in this issue and I know this issue better than the average person, as I said —I literally could not follow it. I found it super frustrating. I mean, I know what Sanders was going for here. I just don’t feel like he got what he was hoping to. I don’t know. Maybe he was hoping to get the CEO to say, “We’ve been awful, and so many people need this drug, and we’re going to cut the price tomorrow.” And yes, you point out, Lauren, that did not happen. But we shall see.
Well, speaking of PBMs, the Federal Trade Commission late last week filed an administrative complaint against the nation’s three largest PBMs, accusing them of inflating insulin prices and steering patients toward higher-cost products so they, the PBMs, can make more money, which is, of course, the big problem with PBMs, which is that they get a piece of the action. So the more expensive the drug, the bigger the piece of the action that they get.
I was most interested in the fact that the FTC’s three Democratic appointees voted in favor of the legal action. Its two Republican appointees didn’t vote but actually recused themselves. This whole PBM issue is kind of awkward for Republicans who say they want to fight high drug prices, isn’t it? I feel like the whole PBM issue, which, as we said, is something that Congress in theory wants to get to during the lame-duck session, is tricky.
I mean, it’s less tricky for Democrats who can just demagogue it and a little bit more tricky for Republicans who tend to have more support from both the drug industry and the insurance industry and the PBM industry. How much can they say they want to fight high drug prices without irritating the people with whom they are allied?
Kenen: And the PBMs themselves are owned by insurers. The pharmaceutical drug pricing, it’s really, really, really confusing, right?
Rovner: Nobody understands it.
Kenen: The four of us, none of us cover pharma full time, but the four of us are all pretty sophisticated health care reporters. And if we had to take a final exam on the drug industry, none of us would probably get an A-plus. So I’d be surprised if they figure this out in lame duck. I mean, they could —there’s always the possibility that when they look at the outcome of things, they decide: We do need to cut a deal and get this off the plate. This is the best we’re going to get. We’re going to be in a worse position next month. And they do it.
But it just seems really sticky and complicated, and it doesn’t feel like it’s totally jelled yet to the point that they can move it. I would expect this to spill into next year. If a deal comes through, if a big budget deal comes through at the end of the year, it does have a lot of trade-offs and moving parts, and this could, in fact, get wrapped into it.
If I had to guess, I would say it’s more likely to spill into the following year, but maybe they’ve decided they’ve had enough and want to tie the bow on it and move on. And then it’ll go to court and we’ll spend the next year talking about the court fight against the PBM law. So it’s not going to be gone one way or another, and nor are high drug prices going to be gone one way or another.
Rovner: The issue that keeps on giving. Well, finally this week, a new entry in out This Week in Health Misinformation segment from, surprise, Florida. This is a story from my KFF Health News colleagues Arthur Allen, Daniel Chang, and Sam Whitehead. And the headline kind of says it all: “Florida’s New Covid Booster Guidance Is Straight-Up Misinformation.”
This is the continuing saga involving the state surgeon general, Joseph Ladapo, who’s been talking down the mRNA covid vaccine for several years now and is recommending that people at high risk from covid not get the latest booster. What surprised me about this story, though, was how reluctant other health leaders in Florida, including the Florida Medical Association, have been to call the surgeon general out on this.
I guess to avoid angering his boss, Republican governor Ron DeSantis, who’s known to respond to criticism with retribution. Anybody else surprised by the lack of pushback to this there in Florida? Lauren?
Weber: No, I’m not really surprised. I mean, we’ve seen the same thing over and over and over again. I mean, this is the man who really didn’t make a push to vaccinate against measles when there was an outbreak. He has previously stated that seniors over 65 should not get an mRNA vaccine, with misinformation about DNA fragments. We’ve seen this pattern over and over again.
He is a bit of a rogue state public health officer in a crew that usually everyone else is on pretty much the same page, whether or not they’re red- or blue-state public health officers. And I think what’s interesting about this story and what continues to be interesting is as we see RFK [Robert F. Kennedy Jr.] gaining influence, obviously, in Trump’s potential health picks, you do wonder if this is a bit of a tryout. Although Ladapo is tied to DeSantis, who Trump obviously has feelings about. So who knows there. But it very clearly is the politicization of public health writ large.
Kenen: And DeSantis, during the beginning of the pandemic, he disagreed with the CDC [Centers for Disease Control and Prevention] guidelines about who should get vaccinated, but he did push them for older people. And I think that was his cutoff. If you’re 15 up, you should have them. He was quite negative from the start on under. Florida’s vaccination rates for the older population back when they rolled out in late 2020, early 2021, were not — they were fairly high. And there’s been a change of tone. As the political base became more anti-vax, so did the Florida state government.
Rovner: And obviously, Florida, full of older people who vote. So, I mean, super-important constituency there. Well, we will watch that space. All right, that is this week’s news. Now it is time for our extra credits. That’s when we each recommend a story we read this week we think you should read, too. Don’t worry if you miss the details. We will include links to all these stories in our show notes on your phone or other device. Joanne, why don’t you go first this week?
Kenen: Elaine Godfrey in the Atlantic has a story called “The Woo-Woo Caucus Meets,” and it’s about a four-hour summit on the Hill with RFK Jr., moderated by Senator Ron Johnson of Wisconsin, who also has some unconventional ideas about vaccination and public health. The writer called it the “crunch-ificiation of conservatism.”
It was the merging of the anti-vax pharma-skeptic left and the Trump right and RFK Jr. talking about MAHA, Making America Healthy Again, and his priorities for what he expects to be a leading figure in some capacity in a Trump administration fixing our health. It was a really fun — just a little bit of sarcasm in that story, but it was a good read.
Rovner: Yeah, and I would point out that this goes, I mean, back more than two decades, which is that the anti-vax movement has always been this combination of the far left and the far right.
Kenen: But it’s changed now. I mean, the medical liberty movement, medical freedom movement and the libertarian streak has changed. It started changing before covid, but it’s not the same as it was a few years ago. It’s much more conservative-dominated, or conservative-slash-libertarian-dominated.
Rovner: Alice.
Ollstein: I have an interesting story from Stat. It’s called “How Special Olympics Kickstarted the Push for Better Disability Data.” It’s about how the Special Olympics, which just happened, over the years have helped shine a light on just how many people with developmental and intellectual disabilities just aren’t getting the health care that they need and aren’t even getting recognized as having those disabilities.
And the data we’re using today comes from the Clinton administration still. It’s way out of date. So there have been improvements because of these programs like Healthy Athletes that have been launched around this, but it’s still nowhere near good enough. And so this was a really fascinating story on that front and on a population that’s really falling through the cracks.
Rovner: It really was. Lauren.
Weber: I actually picked an opinion piece in Stat that’s called, quote, “How the Next President Should Reform Medicare,” by Paul Ginsburg and Steve Lieberman. And I want to give a shoutout to my former colleague Fred Schulte, who basically has single-handedly revealed — and now, obviously, there’s been a lot of fall-on coverage — but he was really beating this drum first, how much Medicare Advantage is overbilling the government.
And Fred, through a lot of FOIAs [Freedom of Information Act requests] — and KFF has sued to get access to these documents — has shown that, through government audits, the government’s being charged billions and billions of dollars more than it should be to pay for Medicare Advantage, which was billed as better than Medicare and a free-market solution and so on. But the reality is …
Rovner: It was billed as cheaper than Medicare.
Weber: And billed as cheaper.
Rovner: Which it’s not.
Weber: It’s not. And this opinion piece is really fascinating because it says, look, no presidential candidate wants to talk about changing Medicare, because all the folks that want to vote usually have Medicare. But something that you really could do to reduce Medicare costs is getting a handle around these Medicare Advantage astronomical sums. And I just want to shout out Fred, because I really think this kind of opinion piece is possible due to his tireless coverage to really dig into what’s some really wonky stuff that reveals a lot of money.
Rovner: Yes, I feel like we don’t talk about Medicare Advantage enough, and we will change that at some point in the not-too-distant future. All right, well, my story is from KFF Health News from my colleague Noam Levey, along with Ames Alexander of the Charlotte Observer. It’s called “How North Carolina Made Its Hospitals Do Something About Medical Debt.”
Those of you who are regular listeners may remember back in August when we talked about the federal government approving North Carolina’s unique new program to have hospitals forgive medical debt in exchange for higher Medicaid payments. It turns out that getting that deal with the state hospitals was a lot harder than it looked, and this piece tells the story in pretty vivid detail about how it all eventually got done. It is quite the tale and well worth your time.
OK, that is our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcast. We’d appreciate it if you left us a review. That helps other people find us, too. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X. I’m @jrovner. Lauren, where are you?
Weber: I’m still on X @LaurenWeberHP.
Rovner: Alice?
Ollstein: On X at @AliceOllstein.
Rovner: Joanne?
Kenen: X @JoanneKenen and Threads @JoanneKenen1.
Rovner: We will be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': American Health Under Trump — Past, Present, and Future
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Emmarie Huetteman
KFF Health News
Emmarie Huetteman, senior editor, oversees a team of Washington reporters, as well as “Bill of the Month” and KFF Health News’ “What the Health?” She previously spent more than a decade reporting on the federal government, most recently covering surprise medical bills, drug pricing reform, and other health policy debates in Washington and on the campaign trail.
Recent comments from former President Donald Trump and Republican lawmakers preview potential health policy pursuits under a second Trump administration. Trump is yet again eyeing changes to the Affordable Care Act, while key lawmakers want to repeal Medicare drug price negotiations.
Also, this week brought news of the first publicly reported death attributed to delayed care under a state abortion ban. Vice President Kamala Harris said the death shows the consequences of Trump’s actions to block abortion access.
This week’s panelists are Emmarie Huetteman of KFF Health News, Joanne Kenen of Politico and the Johns Hopkins University’s schools of nursing and public health, Tami Luhby of CNN, and Shefali Luthra of The 19th.
Panelists
Joanne Kenen
Johns Hopkins University and Politico
Tami Luhby
CNN
Shefali Luthra
The 19th
Among the takeaways from this week’s episode:
- Sen. JD Vance (R-Ohio), Trump’s running mate, says Trump is interested in loosening ACA rules to make cheaper policies available. While the campaign has said little about what Trump would do or how it would work, the changes could include eliminating protections against higher premiums for those with preexisting conditions. Republicans would also likely let enhanced subsidies for ACA premiums expire.
- Key Republican lawmakers said this week that they’re interested in repealing the Inflation Reduction Act’s provisions enabling Medicare drug pricing negotiations. Should Trump win, that stance could create intraparty tensions with the former president, who has vowed to “take on Big Pharma.”
- A state review board in Georgia ruled that the death in 2022 of a 28-year-old mother, after her doctors delayed performing a dilatation and curettage procedure, was preventable. Harris tied the death to Trump’s efforts to overturn Roe v. Wade, which included appointing three Supreme Court justices who voted to eliminate the constitutional right to an abortion.
- And in health tech news, the FDA has separately green-lighted two new Apple product functions: an Apple Watch feature that assesses the wearer’s risk of sleep apnea, and an AirPods feature that turns the earbuds into hearing aids.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Emmarie Huetteman: The Washington Post’s “What Warning Labels Could Look Like on Your Favorite Foods,” by Lauren Weber and Rachel Roubein.
Shefali Luthra: KFF Health News’ “At Catholic Hospitals, a Mission of Charity Runs Up Against High Care Costs for Patients,” by Rachana Pradhan.
Tami Luhby: Politico Magazine’s “Doctors Are Leaving Conservative States To Learn To Perform Abortions. We Followed One,” by Alice Miranda Ollstein.
Joanne Kenen: The New York Times’ “This Chatbot Pulls People Away From Conspiracy Theories,” by Teddy Rosenbluth, and The Atlantic’s “When Fact-Checks Backfire,” by Jerusalem Demsas.
Also mentioned on this week’s podcast:
ProPublica’s “Abortion Bans Have Delayed Emergency Medical Care. In Georgia, Experts Say This Mother’s Death Was Preventable,” by Kavitha Surana.
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Transcript: American Health Under Trump — Past, Present, and Future
[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: Hello, and welcome back to “What The Health?” I’m Emmarie Huetteman, a senior editor for KFF Health News and the regular editor on this podcast. I’m filling in for Julie this week, joined by some of the best and smartest health reporters in Washington. We’re taping on Thursday, September 19th, at 10 a.m. As always, news happens fast and things might’ve changed by the time you hear this. So, here we go.
We’re joined today, by videoconference, by Tami Luhby of CNN.
Tami Luhby: Good morning.
Huetteman: Shefali Luthra of The 19th.
Shefali Luthra: Hello.
Huetteman: And Joanne Kenan of Politico and Johns Hopkins University Schools of Nursing and Public Health.
Joanne Kenan: Hi everybody.
Huetteman: No interview this week, so let’s get right to the news, shall we? It’s big, it’s popular, and if Donald Trump reclaims the presidency, it could be on the chopping block again. Yes, I’m talking, of course, about the Affordable Care Act. Over the weekend, Senator JD Vance claimed that Trump had “protected Americans” insured under the ACA from “losing their health coverage.” Trump himself made a similar claim during the recent debate, where he also said he has the “concepts of a plan” for health reform. Vance, who is Trump’s running mate, suggested the GOP could loosen regulations to make cheaper policies available. But otherwise, the Trump campaign has not said much about what his administration might change.
Meanwhile, Vice President Kamala Harris has backed off her own plan to change the ACA. You may remember that when she was running for president in 2019, Harris embraced a “Medicare for All” plan. Now, Harris says she plans to build on the existing health system rather than replace it. So let’s talk about what Trump might do as president. What sort of changes could Trump implement to make policies cheaper, as Vance has suggested?
Luhby: Well, one of the things that Vance has talked about, when he talks about deregulating the market, giving people more choice of plans, it’s actually separating people, the healthier people and the sicker enrollees, into separate, different risk pools, which is what existed before the ACA. And that may be, actually, better for the healthy people. That might lower their premiums. But it would cause a lot of problems for sicker enrollees, those with chronic health conditions or serious illnesses, because they would see their premium skyrocket. And this is one of the reasons why health care was so unaffordable for many people prior to the ACA. So Vance says that he wants to protect people with preexisting conditions. That’s what everyone says. It’s a very popular and well-known provision of the ACA. But by separating people into different risk pools, it would actually hurt people with preexisting conditions, because it may make their health insurance unaffordable.
Kenan: The difference between pre-ACA and post-ACA is it might actually even be as bad or possibly worse for people with preexisting conditions. Right now, everybody’s in one unified risk pool, right? Whether you’re sick or healthy, your costs, more or less, get averaged out, and that’s how premiums are calculated. Before ACA, people with preexisting conditions just couldn’t get covered necessarily, or if they got covered, it was sky-high, the premiums. By doing what Tami just described, the people, presumably, in the riskiest pool, the sickest people, the insurers would have to offer them coverage. They couldn’t say, “No, you’re sick, you can’t have it,” because there’s guaranteed coverage. But it would be sky-high. So it would be de facto no insurance for most of those people unless the government were to subsidize them to a really high extent, which I didn’t hear JD Vance mention the other day.
Luthra: Right.
Luhby: And one of the other things that they talked about, more choice. I mean, one of the issues that a lot of people complained about in the ACA, early on, was that they didn’t want substance abuse coverage. There’s 10 health-essential benefits which every insurer has to cover — pregnancy, maternal care, et cetera. And 60-year-old men or even 60-year-old women said: Why am I paying for this? This is making my plan more expensive. But again, as Joanne said, it’s evening out the costs among everyone so that it’s making health care more affordable for everyone. And if you allow people to start picking and choosing what benefits they want covered, it’s going to make the plans more expensive for those who need the higher-cost care.
Luthra: Tami alluded to something that is really important, which is that these conditions we’re talking about are very common. A lot of people get pregnant, for example. A lot of people have chronic health conditions. We are not the healthiest country in the world. And so when you think about who would be affected by this, it’s quite a large number of Americans who would no longer be able to get affordable health coverage and a small group of people who probably would. Because, I mean, one thing that’s worth noting —right? — is even if you are healthy for a time, that’s a transient state. And you can be healthy when you are young and get older and suddenly have knee problems, and then things look very different.
Huetteman: It seems like if they use the exact words, “preexisting-condition protections,” and said they were trying to roll them back in order to make policies cheaper, that might be just a bad political move all around. Preexisting-condition protections are pretty popular, right?
Luhby: Yes, they certainly are. But that’s why they’re saying they’re going to continue it. But what’s also popular is choice. And that’s been one of the knocks against the Affordable Care Act, is that, while there are a lot of plans out there, they do have to conform to certain requirements, and therefore that gives people less choice. I mean, and remember, one of the things that we started by talking about, what a second Trump administration might look like for health care. One of the things the first Trump administration did is loosen the rules on short-term plans, which don’t have to conform to the ACA. And prior, they were available for a short time as a bridge between policies, but the Trump administration lengthened them to up to three years. And the goal of the Trump administration was that people would have more choice. They could pick skinnier plans that they felt would cover them. But they didn’t always realize that if they got into a car accident, if they were diagnosed with cancer, if something bad happened, they did not have all of the protections that ACA plans have.
Huetteman: Joanne, you have something to add.
Kenan: So the first thing is that they spent years and a lot of political capital trying and failing to repeal the ACA or to make major changes in the ACA. The reason it failed is because even then, when the ACA was sort of quasi-popular and there was a lot of controversy still, the preexisting-condition part was extremely popular. Since then, the ACA has become even more popular. What [former President Barack] Obama said when he was speaking to the Democratic National Committee convention the other night — remember that aside where he said, Hey, they don’t call it Obamacare anymore now that it’s popular. It is popular. You’ve even had Republican senators going on record saying it’s here to stay.
So major overhaul of it is, politically, not going to be popular. Plus, the Republicans, even if they capture the Senate, which is what most of the prognosticators are saying right now, it would be a small majority. If the Republicans have 51, 52, none of us know exactly what’s going to happen, because we’re in a rather rapidly changing political environment. But say the Republicans capture the Senate and say Trump is in the White House. They’re not going to have 60 votes. They’re not going to have anywhere near 60 votes. I’m not even sure if there was a way to do this under reconciliation, which would require 51. I’m not sure they have 51 votes. So and then if they do it through some kind of regulatory approach — which I think is harder to do, something this massive, but people find a way — then it ends up in court.
So I think it’s politically unfeasible, and I think it’s practically unfeasible. I think there are smaller things they could do to weaken it. I mean, they did last time, and coverage dropped under Trump, last time. I mean, they could not promote it. They could not market it. They could not have navigators helping people. There’s lots of things they could do to shrink it and damage it, but there’s a difference between denting something and having a frontal collision. And we’ve all seen Vance have to roll back other things that he’s predicted Trump would do, so this is very TBD.
Huetteman: One of the bigger issues with the ACA going into next year is these enhanced subsidies that Joe Biden implemented under the pandemic, that helped a lot of people pay for their premiums, will expire at the end of 2025. And depending on which party has control after this election, that could decide the fate of the subsidies. Joanne, you had something to add on this.
Kenan: That’s the big vulnerability. And it’s not so much, are they going to repeal it or define their concept of a plan? I mean, the subsidies are vulnerable because they expire without action, and they’re part of a larger debate that’s going to happen no matter who wins the presidency and no matter who wins Congress. It’s that a lot of the tax cuts expire in 2025. The subsidies are part of that tax, but many aspects of the tax bill are going to be a huge issue no matter who’s in charge.
The subsidies are vulnerable, right? Republicans think that they went too high. Basically those subsidies let more middle-class people with a higher income get ACA subsidies, so insurance is more affordable. And quite a few million people — Tami might remember how many, because I don’t — are getting subsidized this way. It’s not free. They don’t get the biggest subsidies as somebody who’s lower-income, but they are getting enough subsidies that we saw ACA enrollment go up. That is where the big political battle over the ACA is inevitable. I mean, that is going to happen no matter what else happens around aspects of repealing or redesigning or anything else. This is inevitable. They expire unless there’s action. There will be a fight.
Luhby: Yeah, these—
Kenan: And I don’t know how it’ll turn out, right?
Luhby: These subsidies were created as part of the American Rescue Plan in 2021 and were extended for two years as part of the Inflation Reduction Act, which the Republicans don’t like. And they have, as Joanne said, they’ve allowed more middle-class people to come in, and also, they’re more generous subsidies than in the past. Plus they’ve made policies free for a lot of lower-income people. Folks can get these policies without premiums. So enrollment has skyrocketed, in large part because of these subsidies. Now there are more than 20 million people enrolled. It’s a record. So the Biden administration would like to keep that intact, especially if Harris wins the presidency. But it will be a big fight in Congress next year, as part of the overall Tax Cuts and Jobs Act negotiations, and we’ll see what the Democrats might have to give up in order to retain the subsidies. The—
Kenan: It’s going to be, yeah.
Luhby: Enhanced subsidies.
Kenan: There are deals to be had with tax cuts versus subsidies, because these are large, sprawling bills with many moving parts. But it’s way too early to know if Republicans are willing to deal on this and what a deal would look like. We’re nowhere near there. But yeah, if you talk about ACA battles in 2025, that’s number one.
Huetteman: Well, speaking of health policies that are on the GOP agenda, some high-ranking Republican lawmakers are saying they want to repeal the Inflation Reduction Act if the party wins big in November, particularly the part that enables Medicare drug negotiations. You may recall their objections from when Congress passed the law two years ago. Republicans argue the negotiations harm innovation and amount to government price controls. But on the other hand, drug prices are an issue where Trump kind of sort of agrees with Democrats. He has promised to “take on Big Pharma.” Does this mean we could see a Republican Congress fighting with Trump over drug price negotiations?
Luhby: Well, he did have a lot of executive orders and a lot of efforts that were very un-Republican-like. One was called Most Favored Nation. He didn’t say that we should do negotiations. We were just going to piggyback on the negotiations done in other countries and get their lower prices. He didn’t really get very far in a lot of those measures, so it didn’t come to a fight with the Republican Congress. But he may leave the negotiation process alone, the next set of drugs, that’ll be 15 drugs, that, we’ll find out next year, that will be negotiated. So he could leave that alone. If he tries to expand it, yeah, he may have some problems with the Republican Congress. But as we’ve also seen, a Republican Congress has acquiesced to his demands in the past.
Huetteman: And Congress certainly has no shortage of battles teed up for 2025, of course. Speaking of, here we are again. Yesterday, in the House of Representatives, Democrats and Republicans joined together to defeat a stopgap spending bill that would’ve kept the government open. To be sure they didn’t have the same objections, Democrats opposed a Republican amendment that would impose new voter registration requirements about proving citizenship. And hard-right Republicans objected to the size of the temporary spending bill, $1.6 trillion. Trump weighed in on social media, calling on Republicans to oppose any government spending bill at all, unless it comes with a citizenship measure.
Now, Senate Republican leaders, in particular, are not thrilled about this. Here are the words of [Senate minority Leader] Mitch McConnell, who said it better than I can: “It would be politically beyond stupid for us to do that right before the election, because certainly, we’d get the blame” for that government shutdown. What happens now?
Kenan: Last-minute agreement, like, I feel. I used to cover the Hill full time. I no longer do, but it was, like, late nights standing in the hallway for a last-minute reprieve. At some point, they’re going to probably keep the government open, but with Trump’s demands and the citizenship proof of a life for voters and all that, it’s going to be really messy. Mike Johnson became speaker after a whole bunch of other speakers failed to keep the government open.
Huetteman: That’s right.
Kenan: Probation spell, we went through chaos, he has a small majority. He survived because the Democrats intervened on his behalf once, because of Ukraine. We have no idea the dynamics of — do the Democrats want to see complete chaos so the Republicans get blamed? Who knows? I don’t think it’s going to be a handshake tomorrow and Let’s do a deal. What they usually do is continue current spending levels and what they call a continuing resolution. So you keep status quo for one month, two months, three months, sometimes 10 months. The odds are, the government will stay open at some kind of a last-minute patchwork deal that nobody particularly likes, but that’s likely. I wouldn’t say that certain. Republicans have backed off shutting the government down for a while now, a couple of years.
Huetteman: It’s worth noting, though, that even this bill that they just voted down would’ve only kicked the can down to March. So we are still talking about something that the new Congress would have to deal with pretty quickly, even if we can get something done short-term. But we’ve got a lot of news today. So moving on to reproductive health news.
This week, Senate Republicans, again, blocked a bill that would’ve guaranteed access to in vitro fertilization nationwide. That federal bill would, of course, have overridden state laws that restrict access to the procedure. You may recall that Republicans also blocked that bill earlier this summer, describing it as a political show vote. And indeed, Democrats are trying to get Republicans on the record, opposing IVF, in order to draw contrast with the GOP before voters go to the polls. What do we think? Did Democrats succeed here in showing voters their lawmakers really think about IVF?
Luthra: I mean, realistically, yes, I think this is a very effective strategy for Democrats. If they could talk about abortion and IVF every day, all day, they would. We can look at Taylor Swift’s endorsement of Kamala Harris and [Minnesota Gov.] Tim Walz. She specifically mentions reproductive rights, and she mentions IVF in particular, noting that she thinks that these are the candidates who will support access to that fertility regimen. IVF is very popular, and it is obviously going to be a major battle, because it is the next frontier for the anti-abortion movement, and the Republican Party is allied very closely to this movement. Even if there have been more fractures emerging lately, I just don’t see how Republicans can find a way to make this a political winner for them, unless they figure out a way to change their tune, at least temporarily, without alienating that ally they have.
Huetteman: Absolutely. And meanwhile, speaking of the consequences of these actions on abortion lately, this week we learned of the first publicly reported death from delayed care under a state abortion ban. ProPublica reported the heart-wrenching story of a 28-year-old mother in Georgia who died in 2022 after her doctors held off on performing a D&C [dilation and curettage procedure]. Performing a D&C in Georgia is a felony, with a few exceptions. Sorry, this is difficult to talk about, especially if you or someone you know has needed a D&C, and that may be a lot of us, whether we know it or not.
Her name was Amber Thurman. Amber needed the D&C because she was suffering from a rare complication after taking the abortion pill. She developed a serious infection, and she died on the operating table. Georgia’s Maternal Mortality Review Committee determined that Amber Thurman’s death was preventable. ProPublica says at least one other woman has died from being unable to access illegal abortions and timely medical care. And as the story said, “There are almost certainly others.” On Tuesday, Vice President Harris said Amber’s death shows the consequences of Trump’s actions to block abortion access. How does this affect the national conversation about abortion? Does it change anything?
Luthra: I mean, it should, and I don’t think it’s that simple. And it’s tough, because, I mean, these stories are incredible pieces of journalism, and what they show us are that two women are dead because of abortion bans — and that there are almost certainly many more, because these deaths were in 2022, very soon after the Dobbs decision. And what has been really striking, at the same time, is that the anti-abortion movement has very clear talking points on these deaths. And they’re doing what we have seen them do, in so many cases, where women have almost lost their lives, and now, in these cases where they have, which is they blame the doctors. And they have been going out of their way to argue that, actually, the exceptions that exist in these laws are very clear, even though doctor after doctor will tell you they are not, and that it is the doctor’s fault for not providing care when there is very obviously an exception.
They are also arguing that this is further proof that medication abortion, which is responsible for the vast majority of abortions in this country, is unsafe, even though, as you noted and as these stories noted, the complications these women experienced are very rare and could be addressed and treated for and do not have to be fatal if you have access to health care and doctors who are not handcuffed by your state’s abortion laws. And so what I think happens then is this is something that should matter and that should change our conversation. And there are people talking about this and making clear that this is because of the reproductive health world that we live in, but I don’t think it will necessarily change the course of where we are headed, despite the fact that what abortion opponents are saying is not true and despite the fact that these abortion bans remain very unpopular.
Kenan: I think you can, and she said it really well, but I think in terms of, does it change minds? Think about the two bumper stickers, right? One is “Abortion bans kill,” and the other one is “The abortion pill kills.” And both of these women had medication abortions. Those side effects are very, very, very unusual, that dangerous side effects, are extremely unusual. There’s years of data, there’s like no drug on Earth that is a hundred percent, a thousand percent, a hundred thousand percent safe. So these were tragedies in which the women did develop severe life-threatening side effects, didn’t get the proper treatment. But think about your bumper stickers. I don’t think this changes a lot of minds.
Huetteman: All right. Well, unfortunately we will keep watching for this and more news on this subject. But in state news, Nevada will become the 18th state to use its Medicaid funds to cover abortions after a recent court ruling. While federal funds are generally barred from paying for abortions, states do have more flexibility to use their own Medicaid funds to cover the procedure. And, North Dakota’s abortion ban has been overturned, after a judge ruled that the state’s constitution protects a woman’s right to an abortion until the fetus is viable. But there’s a bigger challenge: The state has no abortion clinics left. We’ve talked a lot on this podcast about how overturning Roe has effectively created new, largely geographical classes of haves and have-nots, people who can access abortion care and people who can’t. It seems like the lesson out of North Dakota right now is that evening that playing field isn’t as simple as changing the law, yes?
Luthra: Absolutely. And this is something that we have seen even before Roe was overturned. I mean, an example that I think about a lot is Texas, which had had this very big abortion law passed in 2013, and it was litigated in the courts, was in and out of effect before it went to the Supreme Court and was largely struck down. But clinics closed in the meantime. And what that tells us is that when clinics close, they largely don’t reopen. It is very, very hard to open an abortion clinic. It is expensive. It can be dangerous because of harassment. You need to find providers. You need to build up a medical infrastructure that doesn’t exist. And we are seeing several states with ballot measures to try to undo abortion bans in their states — Florida, Missouri, Nebraska with their 12-week ban. We are seeing efforts across the country to try and restore access to these states.
But the question is exactly what you pointed out, which is there is a right in name and there is a right in practice. And for all the difficulties of creating a right in name, creating a right in practice is even harder. And there is just so much more that we will need to be following as journalists, and also as people who consume health care, to fully see what it takes for people to be able to get reproductive health care, including abortion, after they have lost it.
Huetteman: All right. And with fewer than 50 days left until Election Day and way fewer before early voting begins, a court in Nebraska has ruled that competing abortion rights measures can appear on the ballot there this fall. Two measures, one that would expand access and one that would restrict it, qualified for the ballot. Nebraska will be the first state to ask residents to vote on two opposing abortion ballot measures. Currently, the state bans abortion in most cases, starting at 12 weeks. There are at least nine other states with ballot measures to protect abortion rights this fall, but this one’s pretty unusual. What do we think? Will this be confusing to Nebraska voters?
Luthra: I mean, I imagine if I were a voter, I would be confused. Most people don’t follow the ins and outs of what’s on their ballot until you get close to Election Day and you are bombarded with advertisements. And I think this is really striking, because it is just part of, I guess, maybe not long, because this only happened two years ago, but part of a repeated pattern of abortion opponents trying to find different ways to get around the fact that ballot measures restoring abortion rights or protecting abortion rights largely win. And so how do you find a way around that? You can try and create confusion. You can try and raise the threshold for approval like they tried and failed to do in Ohio. You can, maybe in Nebraska this is more effective, put multiple measures on the ballot. You can try, as they tried and failed to do in Missouri, try and stop something from appearing on the ballot.
And I think this is just something that we need to watch and see. Is this the thing that finally sticks? Does this finally undercut efforts to use direct voting to restore abortion rights? Which we should also note is a strategy with an expiration date of sorts, because not every state allows for this direct democracy approach. And we’re actually hitting the end of the list of states very soon where this is a viable strategy.
Huetteman: And as we know, every state where a ballot measure has addressed this issue since Roe was overturned has fallen on the side of abortion rights, ultimately. It’ll be curious to see what happens here, where voters have both choices right before them.
Well, let’s wrap up with tech news this week. Are you wearing an Apple Watch right now? Or maybe you’re listening to us on AirPods? Well, that watch could soon tell you if you might have sleep apnea. Or, if you have trouble hearing, those earbuds could soon help you hear better. The FDA has given separate green lights to two new Apple product functions. One is an Apple Watch change that assesses the wearer’s risk of sleep apnea. And the FDA also authorized Apple AirPods as the first over-the-counter hearing-aid software, to assist those with mild to moderate hearing loss. Hearing aids can be pretty expensive, and some resist wearing them due to stigma or stubbornness. What does this mean for people with these conditions, and also about the possibilities for health tech?
Kenan: I mean, none of us are covering the FDA’s tech division full time or even much at all. So basically there’s been a trend toward sort of overlap with consumer and health products. Many of us have something on our wrists or something in our phone that is monitoring something or other, and there’s been some controversy about how accurate some of them are. My understanding with the sleep apnea thing, that it doesn’t actually diagnose it. It tracks your sleep patterns, and if it sees some red flags, it says: You might have sleep apnea. You should go see a doctor. That’s what I think that does.
Huetteman: That’s right.
Kenan: You’re asleep when you’re having sleep apnea. You don’t necessarily know what’s happening. So it’s arguably a useful thing that you have kind of an alert system. The hearing aids, it’s not just these. The FDA, a few months ago, authorized more over-the-counter hearing aids of various types, which have made them much cheaper and much more accessible. This is an advance, another category, another type to have people wearing earbuds anyway. I know people who have the over-the-counter hearing aids, and they are small and cheap, so that industry has really been disrupted by tech. So we are seeing not necessarily some of the sky-in-the-pie promises of health and tech from a few years ago but some useful things for consumers to either make things more accessible or affordable, like the earbuds — although I would lose them — or just a useful tool or a potentially useful tool, I don’t know how great the data is, saying ask your doctor about this. Sleep apnea is dangerous.
So my mom is about to turn 90, and we have a fall monitor on her watch that we actually pay for, an extra service, that they alert emergency. I was with her once when she fell. They called her and said, Are you okay? And she said, Yes, my daughter’s here and et cetera. Except, at 90, she still plays pingpong, doubles pingpong, not a lot of movement for 90 year olds, and it does get the fall monitor very confused. I think it’s been trained. So yeah, I mean, it’s not that expensive, and it’s great peace of mind. People would much rather have it on their watch, because young cool people wear smartwatches, than those buttons around their neck. I would’ve never gotten my mother to wear a button around her neck. So it’s part of a larger trend of tech becoming a health tool, and it’s not a panacea, but the affordability for over-the-counter hearing aids is a big deal.
Huetteman: Right, right. This is expanded access. If you’ve got this consumer product already in your pocket, on your wrist, in your ears, why not have it help with your health? We’ve already kind of adjusted, in many ways, to health tech. We had Fitbits. We’ve had things that have tracked our heart rates and that sort of thing, or even our phones can do that at this point. But hearing aids, in many cases for people who have mild or moderate hearing loss, they don’t even go for a hearing aid, because they don’t want to be stigmatized as being maybe a little older and being unable to hear, even if they might just muddle through. But if you’ve already got those AirPods in, because you’re going to take a call later, I mean, that’s pretty below the radar. You don’t have to feel too self-conscious about that one, so …
Kenan: Yeah, my mom would look cool, but she actually doesn’t need them, so that’s OK.
Huetteman: If she’s playing pingpong at her age, she already looks cool.
Kenan: She plays pingpong very slowly. I hope I’m doing the equivalent when I’m 90. I hope I’m 90, you know?
Huetteman: Hear, hear.
Kenan: You know.
Huetteman: OK, that’s this week’s news. Now it’s time for our extra credit segment. That’s when we each recommend a story we read this week that we think you should read, too. As always, don’t worry if you miss it. We’ll post the links in the podcast page at kffhealthnews.org and in our show notes, on your phone or other mobile device. Shefali, why don’t you go first this week?
Luthra: All right. My story is from KFF Health News by the great Rachana Pradhan. The headline is, “At Catholic Hospitals, a Mission of Charity Runs Up Against High Care Costs for Patients.” The story is one of my favorite genres of stories, which is stories about how everyone loves their hospital and their hospital is a business. And Rachana does a great job looking at the history of Catholic hospitals and the extent to which they were founded as these beacons of charitable care meant to improve the community. But actually, when you look at where Catholic hospitals are now — and Catholic hospitals have really proliferated in the past several years — they look a lot like businesses and a lot less like charities. There’s some fascinating patient stories and also analyses in here, showing that Catholic hospitals are less likely than other nonprofit hospitals to treat Medicaid patients. They are great at going after patients for unpaid medical bills, including suing them, garnishing wages, reporting them to credit bureaus. It’s really great. It’s the exact kind of journalism that I think we need more of, and I love this story, and I hope others do, too.
Huetteman: Excellent. It is a great piece of journalism. We hope everyone will take some time to read it. Tami, why don’t you go?
Luhby: OK. My extra credit is an in-depth piece by one of our very own, Alice Miranda Ollstein of Politico, and it’s titled, “Doctors Are Leaving Conservative States to Perform Abortions. We Followed One.” So Alice followed a doctor who spent a month in Delaware learning how to perform abortions, because she couldn’t obtain that training in her home state, across the country. Alice notes that Politico granted the doctor anonymity due to her fear of professional repercussions and the threat of physical violence for seeking abortion training, which is concerning to hear. While many stories have written about states’ abortion bans, Alice’s piece provides a different perspective. She writes about the lengths the doctors must go to obtain training in the procedure and the negative effects that the overturning of Roe has had on medical education.
The doctor she profiled spent nearly two years searching for a position where she could obtain this training, before landing at Delaware’s Planned Parenthood. It cost nearly $8,000. The doctor had to pull together grants and scholarships in order to cover the costs. Alice walked readers through the doctor’s training in both surgical and medical abortions and through her ethical and medical thoughts after seeing — and this is one thing that stuck with me in the story — what’s called the “products of conception” on a little tray. So the story is very moving, and it’s well worth your time.
Huetteman: Absolutely. And the more detail we can get about what these sorts of procedures and this training looks like for doctors, the better we understand what we’re actually talking about when we’re talking about these abortion bans and other restrictions on reproductive health. Joanne, why don’t you talk to us about your extra credit this week?
Luthra: OK. There’s a piece in the New York Times by Teddy Rosenbluth called “This Chatbot Pulls People Away from Conspiracy Theories.” And there’s also a related podcast at the Atlantic called, by Jerusalem Demsas, “When Fact-Checks Backfire.” They’re both about the same piece of research that appeared in Science. Basically, debunking, or fact-checking, has not really worked very well in pulling people away from misinformation and conspiracy theories. There had been some research suggesting that if you try to debunk something, it was the backfire effect, that you actually made it stick more. That doesn’t always happen. There’s sort of some people that it does and some people it doesn’t — that’s beginning to be understood more.
And what this study, the Times reported on and the Atlantic podcast discussed, is using AI, because we all think that AI is going to be generating more disinformation, but AI is also going to be fighting disinformation. And this is an example of it, where the people in this study had a dialogue, a written, typed-in dialogue, where the chatbot that gave a bespoke response to conspiracy beliefs, including vaccines and other public health things. And that these individually tailored, back-and-forth dialogue, with an AI bot, actually made about 20% of the people, which is, in this field, a lot, drop their or modify their beliefs or drop their conspiracy beliefs. And that it stuck. It wasn’t just because some of these fact-checks work for like a week or two. These, they checked in with people two months later and the changes in their thinking had stuck. So it’s not a solution to disinformation and conspiracy belief, but it is a fairly significant arrow to new techniques and more research to how to debunk it better without a backfire effect.
Huetteman: That’s great. Thanks for sharing those. All right. My extra credit this week comes from two of our podcast pals at The Washington Post, Lauren Weber and Rachel Roubein. The headline is, “What Warning Labels Could Look Like on Your Favorite Foods.” They report that the FDA is considering labeling food to identify when they have a high saturated fat content, sodium, sugar, those sorts of things that we should all be paying attention to on nutrition labels. But their proposal falls short, critics say. It’s not quite as good, they say, at identifying the health risk factors of certain amounts of sodium and sugar in our food, especially compared to other countries.
They do an extensive study on Chile’s food labeling, in fact. And if you’re like me and you buy a lot of your groceries for your household and you try to look at the nutrition labels, you might be surprised by some of the items the article identifies as being particularly high in sodium, like Cheerios. Bad news for my family this morning.
All right, that’s our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left a review. That helps other people find us, too. Special thanks, as always, to our amazing engineer, Francis Ying. And as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you could try tweeting me. I’m lurking on X, @emmarieDC. Shefali.
Luthra: I’m @shefalil.
Huetteman: Joanne.
Kenan: @JoanneKenen on Twitter, @joanneKenen1 on Threads.
Huetteman: And Tami.
Luhby: Best place to find me is cnn.com.
Huetteman: We’ll be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': Trump-Harris Debate Showcases Health Policy Differences
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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.
As expected, the presidential debate between former President Donald Trump and Vice President Kamala Harris offered few new details of their positions on abortion, the Affordable Care Act, and other critical health issues. But it did underscore for voters dramatic differences between the two candidates.
Meanwhile, the Biden administration issued rules attempting to better enforce mental health parity — the federal government’s requirement that services for mental health care and substance use disorders be covered by insurance to the same extent as other medical services.
This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs Zhang of Stat, Riley Griffin of Bloomberg News, and Lauren Weber of The Washington Post.
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Riley Griffin
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Lauren Weber
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Among the takeaways from this week’s episode:
- Trump declined to say during the debate whether he’d veto legislation implementing a nationwide abortion ban. But he could effectively ban the procedure without Congress passing anything because of the 150-year-old Comstock Act. And Project 2025, a policy blueprint by the conservative Heritage Foundation, calls for doing just that.
- There is a good chance that enhanced federal subsidies for ACA coverage that were introduced during the pandemic could expire next year, depending on which party controls Congress. The subsidies have helped more people secure zero-premium health coverage through the ACA exchanges, though Republicans say the subsidies cost too much to keep. Residents in states that haven’t expanded Medicaid coverage — including Florida and Texas — would be most affected.
- The Census Bureau reports that the uninsured rate didn’t change much last year after hitting a record low in the first quarter. But the report’s methodology prevented it from capturing the experiences of many people disenrolled and left uninsured after what’s known as the Medicaid “unwinding” began. Meanwhile, a Treasury Department report sheds light on just how many Americans have benefited from the ACA, as polls show the health law has also grown more popular.
- And Congress has yet to pass key government spending bills, meaning the nation (again) faces a possible federal government shutdown starting Oct. 1. It remains to be seen what could pass during a lame-duck session after the November elections. In 2020, the end-of-the-year spending package featured many health care priorities — and that could happen again.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: The Wall Street Journal’s “A Nurse Practitioner’s $25,000 in Student-Debt Relief Turned Into a $217,500 Bill From the Government,” by Rebecca Ballhaus.
Lauren Weber: Stat’s “Youth Vaping Continues Its Tumble From a Juul-Fueled High,” by Lizzy Lawrence.
Riley Griffin: Bloomberg News’ “Lilly Bulks Up Irish Operations in Obesity Drug Production Push,” by Madison Muller.
Rachel Cohrs Zhang: ProPublica’s “‘I Don’t Want To Die’: Needing Mental Health Care, He Got Trapped in His Insurer’s Ghost Network,” by Max Blau.
Also mentioned on this week’s podcast:
- KFF Health News’ “US Uninsured Rate Was Stable in 2023, Even as States’ Medicaid Purge Began,” by Phil Galewitz.
- Louisiana Illuminator’s “Doctors Grapple With How To Save Women’s Lives Amid ‘Confusion and Angst’ Over New Louisiana Law,” by Lorena O’Neil.
- ProPublica’s “Why I Left the Network,” by Annie Waldman, Maya Miller, Duaa Eldeib, and Max Blau.
- The New York Times’ “How a Leading Chain of Psychiatric Hospitals Traps Patients,” by Jessica Silver-Greenberg and Katie Thomas.
- Stat’s “Troubled For-Profit Chains Are Stealthily Operating Dozens of Psychiatric Hospitals Under Nonprofits’ Names,” by Tara Bannow.
click to open the transcript
Transcript: Trump-Harris Debate Showcases Health Policy Differences
[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, Sept. 12, 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 Rachel Cohrs Zhang of Stat News.
Rachel Cohrs Zhang: Hi, everybody.
Rovner: Riley Griffin of Bloomberg News.
Riley Griffin: Hey, hey.
Rovner: And Lauren Weber of The Washington Post.
Lauren Weber: Hello, hello.
Rovner: I hope you enjoyed last week’s special episode on health equity from the Texas Tribune Festival. Now we have a lot of news to catch up on, so we will get right to it. We’re going to start with politics and with the much-anticipated presidential debate Tuesday night, obviously the big health issue was abortion. And as I said afterwards on the radio, the most consistent thing about former President Trump’s abortion position is how inconsistent it has been. Did we learn anything new from everything he tried to say about abortion?
Cohrs Zhang: I think he didn’t provide a lot of clarity on the issue of whether he would veto a nationwide abortion ban, and I think that has been the question that is kind of hard to nail down. And his response is that, Well, that’s not going to pass Congress, so I won’t have to worry about it.
Rovner: Which is kind of true. I mean, it’s not going to pass Congress. That was Nikki Haley’s point.
Cohrs Zhang: Yeah, so I think we have seen, though, some talk floating around about ending the filibuster for abortion from [Sen.] Chuck Schumer’s side of things, at least. So I think it’s not completely out of the question to think that things could be different in the future. We don’t entirely know. But that’s his argument that I don’t really have to answer that question, because it’s not actually going to happen. So I think that’s not really an answer to the question.
Rovner: Riley?
Griffin: It does beg the question what he has to gain from answering that question. If he says he supports vetoing a national abortion ban, it’s certain to anger some of his base, and the opposite is true, too. He’s been threading a really tenuous needle here in trying to appease very different crowds within the Republican Party. And I think that is perhaps, at this point, more interesting to think about his positioning around abortion than the Democratic Party’s.
Rovner: So this is where I get to jump up and down and say for the millionth time: He doesn’t have to sign a nationwide ban to ban abortion nationwide. This is where the Comstock Act comes in that we have talked about so many times and that Project 2025 talks about starting to enforce it, which it has not been in decades and decades, but it is still on the books. And a lot of people say, oh, they could ban the abortion pill by enforcing the Comstock Act, which bans the mailing of things that can be used for abortion. But as others point out, it could be not just the abortion pill. Anything that is used to perform any sort of abortion travels in the mail or FedEx or UPS, all of which are covered by the Comstock Act. So in fact, he could support a nationwide abortion ban and still say that he would veto legislation calling for a nationwide abortion ban.
Cohrs Zhang: Right. And it seems like when he’s been questioned about this in the past, he hasn’t quite understood or seems like he understands the nuances of that. And I think our frequent panelist Alice Ollstein had some good reporting indicating that the pro-life groups wanted more commitments from him on the Comstock Act and aren’t getting them. So I think there are certainly some questions out there. But as a reporter in D.C., we have the privilege of covering health care almost exclusively, and sometimes you can tell when a lawmaker or a public official doesn’t understand the question, and I think that’s a little bit of what’s happening here. But obviously it’s his campaign’s job to prep him and make clear what his position is so voters can make an informed decision.
Rovner: And, of course, with Trump, you’re never sure whether he really doesn’t understand it or whether he’s purposely pretending that he doesn’t understand it.
Cohrs Zhang: Right, right.
Rovner: Lauren, you wanted to add something?
Weber: On a lot of issues, Trump doesn’t necessarily always give a straight answer and often walks them back. So it’s somewhat representative of also playing, as Riley pointed out, to political points as we get so very close to the election and to pick up some of the folks that are undecided. So as you said, we didn’t learn much.
Rovner: So what about Vice President [Kamala] Harris? Those of us sitting here and those of us who listen to the podcast know that she’s been on the trail talking about reproductive health since before the fall of Roe. It’s an issue that she is super comfortable with. I was, I think, surprised at how surprised people watching were when she was able to articulate a really thorough answer. Did that surprise any of you?
Weber: That did not surprise me at all. But I think what was so shocking about it was everyone remembers where they were when Joe Biden got the abortion question at the debate, not so long ago, and truly butchered that answer. That was one of the worst moments of the debate for him. He really could not get through it. The man has notoriously not felt comfortable talking about abortion — older man, Catholic, et cetera. But the contrast, I think, is what was so surprising, because Democrats consider this very much an essential issue for winning the election. Abortion issues are polling incredibly well, obviously with women. You have abortion rights on the ballot in several states, including swing states. This is kind of a make-or-break issue to win the presidential for Democrats. And for Kamala Harris to be able to give not just a coherent answer but one that actually had some resonance, I think, was just so markedly different that people ended up as surprised as you pointed out.
Griffin: Just want to add here that this is a space that she is so incredibly comfortable talking about on the campaign trail. Even before she assumed the top of the ticket, this had been her marquee subject. And I’ve been moonlighting as a Kamala Harris campaign reporter for the last few months. Every rally you go to, this is where she gets the biggest applause. This is the note that strikes, that resonates with the crowd. She had been doing what she called a “Reproductive Freedom” tour through swing states four months prior to assuming the top of the ticket. So it’s no surprise that she is quick not just to talk about the stakes of the overturning of Roe v. Wade but also fact-check the former president. There was a really fitting moment during the debate where she said: “Nowhere in America is a woman carrying a pregnancy to term and asking for an abortion. That is not happening.” So that she could not only come and deliver the lines but also listen to Donald Trump respond to some of the factual errors in real time was again a marked difference from President Joe Biden.
Rovner: Yes, it was a very different debate, I will say. There was actually, a bit surprising to me also, some discussion of the Affordable Care Act. Apparently Donald Trump is now saying that he’s the one who saved it, which is not exactly how I remember things going down. Is that an acknowledgment that the ACA is now here to stay? Or should we still assume that if Republicans take control of the White House and Congress they will, at the very least, let those expanded ACA subsidies expire?
Cohrs Zhang: I think there’s a very good chance that those subsidies do expire. It just obviously depends on control of Congress and how much leverage Democrats have and what they’re willing to give up to get them. And again, it’s kind of difficult because a lot of the states that benefit the most from these subsidies are Republican states that have not expanded Medicaid. So I think there are some difficult political considerations for the Republican Caucus on that issue. But I think Trump was implying that maybe he could have done more to sabotage the ACA without actually revealing it.
Rovner: That’s kind of true.
Cohrs Zhang: Yeah, so I think that was an interesting point. And of course he returned to the refrain that he’s going to have a plan. We haven’t seen a plan for nine years.
Rovner: He has the …
Rovner and Weber (together): … “concepts” of a plan.
Cohrs Zhang: We’ll see it soon.
Weber: I think it’s important to also fact-check Trump on saying he improved the ACA. I want to read a list of things from a great Stat article: “While in office, Trump’s administration shortened open enrollment periods, cut funding for navigators who help people enroll … expanded short-term insurance plans, lowered standards for health benefits provided by small employers that banded [together] into larger groups and enabled employers with religious or moral objections to contraceptive coverage to opt out of requirements to provide no-cost coverage.” So I think some of his as assertations about improving the ACA are up for debate, depending on how you feel about that list of things I just read.
Griffin: And you can also see the impact in enrollment. We had some really interesting data released just before the debate, conveniently, by the Treasury Department showing that the Biden administration had ushered in this all-time-high enrollment in the ACA insurance marketplaces. But what was also tucked into that data was that under the Trump administration, there was also pretty significant lows compared to the other parts of the last 10 years. So that’s notable, too.
Rovner: Yes. And actually you’re anticipating my very next question, which is, while we are on the subject of the ACA, the Census Bureau was also out this week with its annual estimate of people without insurance, and, surprise, even with the Medicaid unwinding and people being dumped off of the Medicaid rolls, the 2023 uninsured rate of about 8% remained near the all-time low that it achieved under the Biden administration. Now, this is not the complete picture of the uninsured. Those who lost coverage at any point during 2023, which is when everybody on the unwinding lost coverage, wouldn’t be counted as uninsured for the purposes of this particular survey, which counts people who were uninsured for the entire year. But the Biden administration, the day before, released an analysis finding that over the 10 years that the Affordable Care Act marketplaces have been operational, 1 in 7 Americans has been enrolled in one of the plans. Is this a first election where the ACA could turn out to be a boon for its backers rather than an albatross around their necks?
Weber: I think KFF polling, recent numbers say some 60% of Americans support the ACA. So that would be a majority of Americans that would be very unhappy if it was repealed. So I mean to your point, Julie, I think the popular opinion has shifted on the ACA and we’re in new ground here.
Cohrs Zhang: Even in 2020, I think after all of that happened, I think there was this realization that maybe this isn’t a viable option, so we should stop promising it to people. And I think Democrats had gotten so much momentum on all of the claims that Republicans did want to take apart the ACA, and we saw that conversation in the Supreme Court as well. And I think that reality has just become so much more real with Dobbs and seeing that when the makeup of a court changes, court decisions can change, and that elections matter in that calculus. So I think we started to see the movement in 2020, but obviously there was so much pandemic going on that I think some of these other health care lines got lost in that election, that we’re seeing come out a little more clearly this time around.
Rovner: And, of course, despite Donald Trump now becoming a latter-day champion of the ACA — sort of — if Republicans win back control of Congress and the White House, we’ve got both these expanded subsidies — that, as we pointed out, have enabled this big enrollment — expiring, and the Trump tax cuts expiring. It’s hard to imagine both of those getting extended. One would think that the Republicans’ priority would be the tax cuts and not the subsidies, right?
Cohrs Zhang: Yeah. Again, depends on whether Democrats are able to hold a chamber of Congress and what kind of leverage they have.
Rovner: Yeah, that’s obviously a 2025 issue. Well, turning to elected officials who are already in office, today is Sept. 12, and that means Congress has basically eight more working days to avoid a government shutdown by either passing all of the 12 regular spending bills or some sort of continuing resolution to keep agencies funded after the Oct. 1 start of fiscal 2025. This is where I get to say for the millionth time that when Congress settled the funding for fiscal 2024 last — checks notes — March, House Republicans vowed again to have this year’s funding bills finished on time. Rachel, that did not happen. So where are we?
Cohrs Zhang: It does not happen. Yeah, I think it’s business as usual around here. I think, honestly, the posturing has started earlier than I expected with the House speaker, Mike Johnson, putting out this proposal for a CR [continuing resolution] that he couldn’t even get through the House. He kind of pulled that before it came to a vote on the floor. So I guess that’s, at least, an opening salvo earlier than we see, usually, early in September.
Rovner: Well, this was the big fight about: Do we want a CR that goes to after Thanksgiving, which would be the typical CR, and then we’ll come back after the election and fight about next year’s funding? Or, in this case, they wanted a CR that went until next March, I guess betting that maybe the Republicans will be in charge then and they’ll have more of a say over this year’s spending than they do now?
Cohrs Zhang: Right. I think that’s certainly an open question, and I think it seems like Senate appropriators are not necessarily on board with that March timeline at this point. They really would like to wrap things up in December. And again, I think, looking back in 2020, we did see a really significant appropriations package with a lot of health care policy pass at the end, kind of in the December time frame of 2020, in lame-duck. So I think it’s a really big question.
And then the other question is: Do all these expiring health care programs that are currently slated to end in December get extended with that appropriations package? I think there’s just a lot of moving parts here, and we don’t exactly know what the deadlines are going to be yet. But at least they’re arguing about it in the public sphere, so that’s a start.
Rovner: They’re legislating. That’s what they do. Lauren?
Weber: I just wanted to say, Julie, I think you should have a segment that’s a tally of how many times you ask on this podcast if the funding bill has passed. Because I know myself, I’ve been on many, and I really think it’d be kind of funny. So I’m just saying it’s quite fascinating over the years, the many, many times these bills do not seem to make it.
Rovner: Well, this is just me as the lifelong Capitol Hill reporter who — we’re always talking about what’s going to happen next year and the year after. It’s like: You have a job to do this year. Let’s see how you’re doing in the job that you have to do this year. Does anybody think there’s actually going to be a shutdown? I mean, that’s still a possibility if they don’t get a deal, although that would be — I’m trying to remember if we’ve ever seen a government shutdown in a presidential election year. That seems risky politically? Riley, I see you sort of raising your eyebrows.
Griffin: Yeah, it’s definitely risky and clearly something right now you can see that the Biden administration wants to avoid. I was sitting in the White House press briefing room on Monday and Karine [Jean-Pierre], the press secretary, was like: This is Congress’ one job. This is their main job. It’s to keep the government open. So there’s a level of frustration that, I think, this is coming into the discourse yet again, but to be expected.
Rovner: Yeah. And I should point out, it’s not just Republicans that are unable to get funding bills done on time. The Democrats are unable to get their funding bills done on time, either. I believe that the last time all of the funding bills were actually passed before Oct. 1 was the year 2000.
Weber: This is why this should be a Julie segment. I’m telling you, you should run a tally.
Rovner: Yes. Well, it is kind of a Julie segment.
Weber: Yes.
Rovner: And I will keep at it, because this is my job, too. All right, turning back to abortion, in the debate Tuesday night, Vice President Harris talked at some length about some of the unintended consequences of abortion bans, as we discussed — women unable to get miscarriage care, girls being forced to carry pregnancies resulting from incest all the way to term. Now we have another new potential health risk in Louisiana. The new law that makes the abortion medications mifepristone and misoprostol controlled substances is resulting in a major disruption to hemorrhage care. It seems that misoprostol, which is used for a variety of purposes other than abortion — it was originally an ulcer drug — is a key emergency drug used in a wide variety of reproductive health emergencies. And it’s not clear what will take its place on emergency carts, since you can’t have controlled substances just hanging around in the hallways. Is this yet another example of lawmakers basically practicing medicine without a license?
Weber: I think that’s right, Julie. I spoke to a Louisiana ER doctor last week who put it pretty bluntly. He’s like, Look, I have a woman who’s bleeding out in front of me, and I need to call down to the pharmacy and put in an order? That could take not just seconds, not just minutes, but many minutes, even longer in possibly rural pharmacieswhere the access may not be as readily available. He’s like, This is truly a life-or-death issue. Women, when you are bleeding out from post-birth complications, which by the way is not as uncommon as people would like to think it is, this is really quite something. And so folks in Louisiana are obviously very up in arms.
And I think it speaks, as you pointed out, to the larger environment that Kamala Harris has pointed to — and many reporters that have been on your show and that we have discussed many times on the show — is that there are many unintended consequences for laws that limit abortion and for women seeking access to care where hospitals afraid that they’re not going to interpret the law correctly are leaving women to seek care elsewhere. And what are the health ramifications of that? But this is a pretty frightening unintended consequence.
Rovner: Yeah, this was something that I was not aware of, that I had not seen. Of course, Louisiana is the first state to basically declare these controlled substances. So it seems that every time we get a new restriction, there’s a new twist to it that I think most people did not expect.
There’s also been lots of court actions, obviously, on abortion in the past few weeks. In Missouri, last week a judge tried to strike the state’s abortion rights referendum from the ballot, although this week a higher court ordered it back on the ballot. I believe that’s the final word on Missouri. They will vote on it in November. In Alaska, a judge struck down a state law that limited who could perform abortions to just doctors rather than doctors and other medical professionals. And in Texas, Attorney General Ken Paxton filed suit against a new federal rule that shields the medical records of women who cross state lines to obtain an abortion in a state where it’s legal, which it’s not in Texas. It would seem the implication here is that Texas wants to prosecute women who leave the state for a legal medical procedure. Or am I misinterpreting that somehow?
Griffin: That’s my understanding as well. And it’s a development that, I believe the rule was announced in April when Biden had said that no one should have their medical records used against them, and lo and behold we’re a few months later, but this Texas lawsuit does suggest that this could be a part of criminal prosecution.
Rovner: I know. I mean this seems to be sort of this underlying issue of what happens to women who live in banned states who go to other states to obtain abortions. And there’s been a lot of back-and-forth and a lot of people, even on the anti-abortion side, trying to say that this is not our intent. But this certainly seems to be the intent of some people. Seeing nods all around. We will continue to follow this string.
Finally this week, I want to talk about mental health. Over the objections of some insurers and large employer groups, the Biden administration finalized the latest set of rules attempting to guarantee parity between coverage for mental health and substance abuse and every other type of medical care. This is literally a 30-year fight that’s been going on to regularize, if you will, coverage of mental health. This action comes just as ProPublica is unveiling a pretty remarkable series on the inability of patients, even patients with insurance — in fact, mostly patients with insurance — to obtain needed health care, often with catastrophic consequences. Rachel, one of those stories is your extra credit this week. Why don’t you tell us about it?
Cohrs Zhang: It is, yes. So my extra credit is “‘I Don’t Want To Die’: Needing Mental Health Care, He Got Trapped in His Insurer’s Ghost Network,” by Max Blau and ProPublica. And I think this story kind of really makes clear the consequences for certain patients, especially mental health patients in crisis, of when the list that you get from your insurer of in-network providers is inaccurate.
And I think ghost networks, it’s kind of a weird, jargon-y term, I think. There have been some hearings on the issue on the Hill. But when we think about somebody who desperately needs some crisis counseling and they’re doing everything they can, they’re exhausted, they’re already dealing with so much to already have to call provider after provider who doesn’t take their insurance anymore, doesn’t know what they’re talking about, it’s just such a frustrating process that I think many of us have experienced. I personally have experienced it getting an MRI in Los Angeles, and the list is out of date. And I think there’s definitely room for regulation here. And I think that mental health care, through this series, was just highlighted as such an important part of that conversation.
Rovner: Yeah, we’ve all had this, and we’ve all written the stories about people who have lists of in-network providers and can’t find one or can’t find one who’s taking new patients, or the provider there does not do what the directory suggests that they do. They may say they may only treat children, or they may not treat children. But I think in mental health, these are people in mental health crises trying to get care that they are guaranteed by law and guaranteed under their insurance and being unable to do it — and as I say, often, sometimes, not un-often with catastrophic consequences. Needing mental health care is not just somebody who says, “Oh, I don’t feel well today.” These often are people who are in actual crisis situations.
So speaking of people who are in actual mental health crisis situations, The New York Times has a piece this week on a chain of mental hospitals that’s basically holding patients in their facilities against their will to get as much as they can collect from insurance. In some cases, patients’ relatives have had to get court orders to get their patients released. How did we let our mental health system get so far off the tracks? Either you can’t get care or you get care that you can’t get out of.
Weber: Well, this piece by Jessica Silver-Greenberg and Katie Thomas, which is truly phenomenal — everyone who’s listening to this should read it — makes a very astute point, which is that the government and nonprofits have really gotten out of the psychiatric hospital business, and for-profit companies have swept in. And they interview several former employees who make it very clear that these were run with profit incentives in mind, of holding patients to maximize the insurance money they could get, to catastrophic effects. The details in this are wild. They talk about people having to go to court to get folks out, very clear violations. And again, they speak to not just one, not just two, but multiple former employees who allege that this company was acting in such a way that was not for its patients’ best interest.
Cohrs Zhang: And I do have to do a plug for my colleague Tara Bannow, who also reported on Acadia and how they’re kind of operating mental health institutions under the brand names of Catholic hospitals. So people might even think that they’re going to a well-respected community hospital under the name, but these for-profit institutions have even made their way into not-for-profit spaces, and these services are just being contracted out, because they’re simply unprofitable.
Rovner: And we talked about Tara’s story when it came out.
Cohrs Zhang: We did, yeah.
Rovner: A month or two ago.
Cohrs Zhang: Yeah, this next story is a great — kind of building on, building just a fuller story around the implications of for-profit.
Rovner: It does sort of, both this and, I think, the ProPublica series highlight in the ’60s and ’70s, the problem was people who were in state-run facilities. And they were warehoused, and they were underfunded, and people just didn’t get the care that they needed. And that was one of the things that led to deinstitutionalization, which of course is one of the things that ended up leading us to the homeless, because when they deinstitutionalized these patients, they were promised outpatient care which never materialized. So now we’ve kind of profitized this, if you will, and we have a different set of problems. It’s every bit as bad. It’s kind of a microcosm of the entire health care system. It’s like, well, we don’t really trust the nonprofit sector to run it right, because they don’t have enough money. And now we don’t trust the for-profit sector to run it right, because they have too much of a profit motive. Is there any middle ground here?
Griffin: I think we could spend weeks, you could have a whole podcast just dedicated to this question, and it’s a harrowing one. And there’s a parallel discussion to be had also about the centers that navigate patients who are seeking treatment for substance use, right? Often those are one and the same, but I think the same dynamics are playing out here. And to the mental health parity regulation that was finalized, that included substance use benefits, too. It wasn’t just mental health. So yeah, I don’t know. I say with a heavy heart that we could talk about this a long time, but I don’t have any answers for where the best care is going to be.
Rovner: Yeah, none of us, I think, does. And that’s why we were all going to have jobs from now until eternity as we at least keep working on this.
All right, well, that is the news for this week. Now it is time for our extra credits. That’s when we each recommend a story we read this week, we think you should read, too. Don’t worry if you miss the details. We will include links to all these stories in our show notes, on your phone or other mobile device. Rachel, you’ve already done yours. Lauren, why don’t you go next?
Weber: So I picked a story from Stat titled “Youth Vaping Continues Its Tumble From a Juul-Fueled High,” written by Lizzy Lawrence. And I was really struck, I’m sure public health officials are really struck, by how far vaping rates have gone. I mean, they’re down to 6% of middle and high school students using vapes in 2024. That’s down from 8% last year and 20% in 2019. I mean, that is a marked change. And I expected to read this article and see, Oh, but don’t worry, they’re all using Zyn, which is another nicotine product. But, actually, that had only gone up to about 1.8%. It was not nearly the same bit. And I think if you’re a public health official, you’ve got to be pretty pleased with yourself, because this would seem to show that the public health action that they very aggressively took at both the federal, national, and in some places locality level to limit flavored vapes and have other actions for kids has resulted in a pretty steep decline, much faster than you saw cigarette use decline. So I was really impressed to see these numbers. It’s quite a change.
Rovner: Yeah. Yay public health. Riley?
Griffin: Yeah, I want to tout a story from my colleague Madison Muller. It’s titled “Lilly Bulks Up Irish Operations in Obesity Drug Production Push.” And she’s actually in Ireland right now. She was reporting out this story. Ultimately, we all know there’s been this immense demand for obesity drugs — Eli Lilly and Co. has two, Mounjaro and Zepbound — and they just can’t seem to build out production quickly enough. My colleague did some data analysis here and actually found that since 2020, believe it or not, Lilly has poured 17.3 billion [dollars] into weight-loss drug manufacturing. I mean, what an insane number. And the latest push is in Ireland, which is notable because here in Washington there’s been a lot of work to scrutinize and even prevent U.S. drugmakers from collaborating with Chinese manufacturers of biologics. So sometimes they talk about “near-shoring” or “friend-shoring” in D.C., which is really a kitschy term to refer to seeing more friendly countries to the United States bolstering up manufacturing, and here you see Lilly doing just that. So it’s a fun story, and kudos to Madison, who went out to Ireland to tell it.
Rovner: I’d love to be sent to Ireland.
Weber: Yeah, I need to get more stories in Ireland. I mean, what? That’s amazing.
Rovner: Just saying. It is a good story. All right. Well, my story this week is from The Wall Street Journal, by Rebecca Ballhaus, and it’s called “A Nurse Practitioner’s $25,000 in Student-Debt Relief Turned Into a $217,500 Bill From the Government.” And it’s a really infuriating story about a really excellent government program called the National Health Service Corps that helps medical professionals pay off their loans if they agree to practice in underserved areas. The problem is that there are penalties if you fail to complete your term of service, which obviously there should be.
But in this case, one of the nurse practitioners’ supervising physicians died, and the other one retired, and there were no other eligible placements within two hours of her Alabama home, where she cared for her three young children as well as her elderly parents. Obviously there should be consequences for breaching a contract, but this is far from the only case where people who are obviously deserving of exceptions are being denied them. The National Student Legal Defense Network has filed suit on the nurse practitioner’s behalf, and I’ll be watching to see how this all turns out.
OK. That is our 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. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X. I’m @jrovner. Riley, where are you hanging these days?
Griffin: I’m on X, though infrequently, @rileyraygriffin.
Rovner: Lauren?
Weber: Still only on X, @LaurenWeberHP.
Rovner: Rachel?
Cohrs Zhang: Still on X, @rachelcohrs.
Rovner: We will be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': Live from Austin, Examining Health Equity
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 term “health equity” means different things to different people. It’s about access to medical care — but not only access to medical care. It’s about race, ethnicity, and gender; income, wealth, and class; and even geography — but not only those things. And it’s about how historical and institutional racism, manifested in things like over-policing and contaminated drinking water, can inflict health problems years and even generations later.
In a live taping on Sept. 6 at the Texas Tribune Festival, special guests Carol Alvarado, the Texas state Senate’s Democratic leader, and Ann Barnes, president and CEO of the Episcopal Health Foundation, along with KFF Health News’ Southern bureau chief Sabriya Rice and Midwest correspondent Cara Anthony, joined KFF Health News’ chief Washington correspondent, Julie Rovner, to discuss all that health equity encompasses and how current inequities can most effectively be addressed.
Anthony also previewed “Silence in Sikeston,” a four-part podcast and documentary debuting this month exploring how a history of lynching and racism continues to negatively affect the health of one rural community in Missouri.
Panelists
Carol Alvarado
Texas state senator (D-Houston)
Cara Anthony
Midwest correspondent, KFF Health News
Ann Barnes
President and CEO, Episcopal Health Foundation
Sabriya Rice
Southern bureau chief, KFF Health News
Also mentioned on this week’s podcast, from KFF Health News’ “Systemic Sickness” project:
- “A Teen’s Murder, Mold in the Walls: Unfulfilled Promises Haunt Public Housing,” by Fred Clasen-Kelly and Renuka Rayasam.
- “Med Schools Face a New Obstacle in the Push To Train More Black Doctors,” by Lauren Sausser.
- “‘I Feel Dismissed’: People Experiencing Colorism Say Health System Fails Them,” by Chaseedaw Giles.
- “As Record Heat Sweeps the US, Some People Must Choose Between Food and Energy Bills,” by Melba Newsome.
- “Black Hospitals Vanished in the U.S. Decades Ago. Some Communities Have Paid a Price,” by Lauren Sausser.
click to open the transcript
Transcript: Live from Austin, Examining Health Equity
[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 usually I’m joined by some of the best and smartest health reporters in Washington. But today we have a special episode for you all about health equity taped before a live audience at the Texas Tribune Festival on Sept. 6, 2024. I hope you enjoy it. We’ll be back with our regular panel and all the news on Sept. 12. So here we go.
I am pleased to be joined on this panel by two of my KFF Health News colleagues, Southern bureau chief Sabriya Rice, who’s right here next to me, and Midwest correspondent Cara Anthony, down at the end. We are also honored to be joined by two guests with a lot of combined expertise on this issue, [Texas] Senate Democratic leader Carol Alvarado, who represents the 6th District of Texas, which includes parts of Houston, and Dr. Ann Barnes, president and CEO of the Episcopal Health Foundation, also based in Houston.
We’re going to talk amongst ourselves for the next, I don’t know, 40 minutes or so. Then we will go to you in the audience for your questions. So go ahead and be thinking. I have to say I am personally really excited about this episode because health equity is something I think about a lot, but I’ve never been able to accurately define, even for myself. I know it’s about race and ethnicity and gender, but it’s not just about race and ethnicity and gender. It’s about income and wealth and class, but it’s not just about income and wealth and class. It’s about geography, but not just about geography. And it’s about medical care, but not just about medical care. So I want to kick off this discussion by asking each of you how you define health equity. And why don’t we just sort of go down the row? So we’ll start with you, Sabriya.
Sabriya Rice: Really great question and it gave me a lot of things to think about. And I want to start with a little anecdote from something that happened yesterday evening. I was having a conversation with a group of visitors from South Africa who work for an investigative news site there called The Daily Maverick, and my colleague, Aneri Pattani, who’s also a KFF Health News reporter. We were explaining some of the things about the U.S. health care system and just some basic stuff like how a lot of people can’t afford to just go for preventive care, how you may or may not have access to care in your neighborhood, and what that means in terms of your health outcomes.
And in the middle, they paused us and were like, “Wait a minute, wait a minute. This doesn’t make any sense. We have these things in South Africa.” It’s something you hear regularly from other people who are visiting here and they’re like, “But you’re like the wealthiest country in the world. How do you not have these things?” And I was thinking about that and thinking of, in terms of your question. So, for me, I think of health equity as just creating the opportunity for everyone to be able to achieve their optimal health no matter their background. And I think that’s something we could really work on in the U.S.
Ann Barnes: Great.When I think about health equity, I share a similar definition where folks have a just and fair opportunity to live their healthiest lives. And this is largely from the Robert Wood Johnson Foundation’s definition of health equity. But coupled with that is the requirement to dismantle barriers to health. And so we have to remember that that is part of the equation, not just dreaming that we all have optimal health, but thinking about how we’re going to eliminate the barriers, especially for populations that are most vulnerable.
Carol Alvarado: I think about accessibility and affordability. And if you don’t have those two things in health care, then you create this environment of the haves and the have-nots, those who can afford to have health insurance and those who can’t. Maybe it’s because of their job, their social economic status. And I also think that we have to take partisanship and politics out of health care. I mean, when did that become such a divisive issue that really reached the height during the Obamacare debate and the many, many times to repeal it? And I know we’re going to dive into this a little bit more, but health care and access should never be political.
Cara Anthony: When I think about health equity, I agree with all of the panelists here today, but I’m also thinking about the future and the next generation. I’m a single mom. I have a 7-year-old daughter, and I think about how is she going to be able to live a longer and healthier life than previous generations. I’m going back home tomorrow and one of the first things that I’m going to do is sign my daughter up for a swim lesson, right? That’s health equity because I’m also signing up for a lesson as well. Why? Because I never learned to swim. It’s about each generation doing better. And why didn’t I learn to swim? Because my parents were born in 1948 in the South and did not have access to swimming pools. So it’s those daily practical applications that I think about when I think about health equity. So yeah.
Rovner: Sen. Alvarado and Dr. Barnes, I want to talk about Texas a little bit since, obviously, we’re sitting here. Texas is, we try not to think about just insurance when we talk about health equity, although it’s a big deal, and in Texas it’s still a big deal as opposed to a lot of other states. What impact does Texas’ failure to, so far at least, expand Medicaid have on health equity in this state?
Barnes: Well, we know that health care and access to health care is critically important to health. It accounts for 20% of a person’s health, and nonmedical drivers account for the other 80%. But 20% is important. We still have the highest rate of uninsured. So that means that there are parts of our community that can’t get the preventive care that they need, that can’t talk to people who might connect them to social services to support their nonmedical needs. And so the larger conversation is about increasing health coverage overall in Texas. And certainly expansion of Medicaid is one piece of that. About 5 million people are uninsured right now in our state, and so we’ve got a lot of ground to cover. Affordable Care Act is one way, Medicaid expansion is another. And so a lot of work to do, for sure.
Alvarado: And I’ll pick up where you left off. Medicaid expansion has been, believe it or not, a hot political hot potato here in Texas. I’ve been filing, along with many of my colleagues, bills every session since 2009, maybe. We can’t get hearings. And no one really gives you a good explanation why. They’ll have things that really don’t make a lot of sense that there are too many strings attached. Well, somehow 40 other states don’t have that problem.
And we’ve seen that the cost that we’re leaving on the table, millions of dollars. I think the last number I saw was 2023, maybe $11 billion just there on the table; other states are utilizing it. And then here in Texas, it’s kind of complicated. I’ll just give you the elevator speech on that. But they kept the Medicaid enrollment going during the pandemic, and then afterwards they did this winding, what they called winding down, and almost 2 million people were left without Medicaid. And a good portion of that are children, and a good portion of those children are Black and brown kids who are already living in environments where they don’t have access to green space or grocery stores, fresh fruits and vegetables. So you pile all of that together and that’s why we are in this place of many uninsured, almost twice the number of the national rate, which is at 8[%]. We’re at 17[%]. Yeah, everything’s bigger in Texas especially the number of uninsured.
Rovner: So, Dr. Barnes, I want you to talk about what it is that your foundation does. I find it fascinating that even though you would think that you’re all about medical care, you’re really not all about medical care, right?
Barnes: No, that’s right. So we are committed to promoting equity by addressing health and not just health care. And so we use our resources in partnership with community members and organizations and change-makers to address factors that occur outside of the clinical setting and the doctor’s office. And representative [Sen.] Alvarado listed so many of them: housing, food security, employment, education. All of these are critically important to health. And so we use our resources to help address those needs because we know that that will set people up for a healthy life and not just a sick life that ends them up in clinical care at the very tail end of their illness. One of the things I wanted to share, I’m a physician by training, in internal medicine and primary care, and my patients taught me so much when I saw them and I prescribed medicines for diabetes or high blood pressure. It was the stories about their lives outside of the clinic that really helped me understand what was impacting their health, which is why I got into this space of health and not just the clinical side.
Rovner: Cara, you’re about to debut a project that you’ve been working on for four years that has to do with exactly this, with sort of the nonmedical implications of other things and the lack of health equity. So why don’t you tell us a little bit about it?
Anthony: Yeah, so coming up next week, we’re going to premiere a new podcast, and also it’s a documentary film, called “Silence in Sikeston.” It focuses on police violence and police killings, but looking at them not as crime stories, but more as a public health threat. Also looking at the lynchings of yesterday as a public health threat. Maybe people didn’t use those terms back then, but certainly we recognize them as such now.
And so I hope everyone checks this out because it really talks about how racism and chronic stress are linked. And so oftentimes it can weigh not only on your mental health — anxiety, depression, you can become suicidal because of these things — but also you can have physical health effects as well, higher rates of high blood pressure, cancer, et cetera. And so I’ve been traveling for the last four years to Sikeston, Missouri. It’s a small community in rural Missouri where there was a man who was lynched there in 1942. His name was Cleo Wright. This is America’s first federally investigated lynching, the first time the FBI decided to look at lynching as a federal crime. They came to Sikeston, Missouri. But the story has never really been told and not in this way, not looking at it as a public health story, because as public health reporters we’re tasked with looking at what makes a community sick, what’s harming a community, and sometimes that can be something like lynching, something like police killings. And so we’re looking at that head-on and talking about the health impacts there.
Rovner: And Sabriya, obviously this is a big project that we’ve been working on, but we’ve been working on a lot of other health equity stories that you’re sort of in charge of. So why don’t you tell us about some of those?
Rice: Yeah, certainly. And it’s a great parallel to the work that Cara’s been doing. I came to KFF in 2022, and my charge was to start up a Southern bureau and look at the health equity disparities that happen across the South. So my team ranges from Texas to Florida up until North Carolina, and we meet weekly and have conversations. And one thing I was constantly hearing from the reporters — I’m not a policy expert and I’m not a statistician, but I’m a people person and I listen to people — and my reporters were saying over and over again, “Yeah, we spoke to this expert about Medicaid expansion, but they were like, ‘Yeah, we could do that, but it’s not going to stop the root of the problem, which is racism.’”
“Yeah, we wrote about maternal mortality or infant mortality, but still at the root of this is racism.” So that term kept coming up. And so we decided this year to take a look at systemic racism in the health care system, and our series is called “Systemic Sickness,” and it looks at some of the things that Cara talked about, including policing, but we also look at redlining or the history of redlining, of public housing challenges. We’re looking modern-day, like attacks on diversity, equity, and inclusion programs in education, specifically the field of medicine. So that’s the nature of our project that we have for this year. And it’s been just a real fascinating experience.
Rovner: I think I’ve heard this come up a couple of times in the panels we’ve had this morning about some of the other issues that really impact this in a bigger way than many people think. And I think housing is definitely one of those. You talked about redlining. A lot of this is historic racism and literal redlining: “You cannot live here. If you live here, you cannot get a mortgage.” There’s been a lot of that. How significant, I assume, the problem is here in Texas?
Barnes: Yeah, it is significant in a lot of those racist structures. We continue to experience the aftereffects of those. Even today, those neighborhoods are still under-resourced, and that includes, like you mentioned, grocery stores, safe spaces to play, green spaces, good transportation options. And so those old and, I suppose, acceptable forms of structural racism that were enacted are still playing out today in the health of people.
Alvarado: It’s very important. And housing doesn’t get a lot of attention. It’s not a very glamorous or sexy issue, but I’m glad to hear presidential candidate Kamala Harris, she talked about housing and what she would like to see to build more affordable housing, or I guess we’re calling it “workforce housing” now. And then our state comptroller, Glenn Hegar, recognizing how many people we have moving to Texas all the time. And to accommodate that, we’d need about 300,000 new units or housing. So people don’t have a place to lie their head that’s comfortable and a place to cook meals. And then if they don’t have those safety nets, then their last concern is probably, “Oh, am I getting my workout in today?” Or “Am I eating enough fruits and vegetables?” when they’re in survival mode.
Rice: And I’ll piggyback on what representative [Sen.] Alvarado said. It’s hard for people to see how this kind of plays out in real time. And two of our reporters on the Southern team just recently looked at a community in Savannah, Georgia, called Yamacraw Village. It’s a public housing community that started around World War II. And historically, at that time, the residents were white. Disinvestment happened within this community over the years and the population of the community changed.
So now it’s a predominantly Black and Latino community, but what you see is a large amount of disinvestment. People can’t get things fixed, so you’re living in very unhealthy housing, when you do have housing. There’s no playgrounds, there’s no green space, there’s an extreme amount of violence. But one man told our reporters, “The walls sweat like working men.” This person moved into this community and got vouchers to be able to live there and immediately developed asthma and has been taking medication even years after he left the community. So when you think about how the system is harming people, these communities are there and they’re not being invested in. Instead, people are given things like Section 8, if they can get the vouchers, and then if you can find affordable living that will take your Section 8 voucher. So it’s a really big problem. And housing is often not talked about as a public health crisis.
Barnes: Absolutely. And not just the place that you lay your head, but high-quality housing, not substandard that actually can impact your health.
Rovner: One of the things we’ve seen, I guess in the last couple of years, are these extraordinarily hot summers. And I know the government has always helped underwrite heating assistance in the winter, but apparently air-conditioning assistance is not considered of the same importance. I just read Phoenix has been 100 degrees every day for the last hundred days. I know that here in Texas you’ve had some pretty extended heat waves. I mean, how big an issue is heat as a public health and equity issue?
Alvarado: It’s a big problem, and especially when we’ve had things like power outages, storms that we had very close to one another. We had the derecho in May and then we had followed by the Hurricane Beryl, and that was tough. I mean, people were out of power anywhere from a couple of days to 10 days, and for some, it’s life or death, especially if they have medical equipment that they have to be hooked up to. We’re going to be tackling some of those issues in this session, but our city does a good job in our county of opening cooling centers so that people have a place to go and retreat and charge their devices. But the weather is getting much more turbulent. The summers are getting hotter, the hurricane season is more active. And until people realize that there’s a reason all this is happening and people don’t want to talk about it or put policy forth that addresses what’s taking place in our environment. So they go hand in hand.
Barnes: One of the other things, as we talk about communities where there isn’t investment, is that there are these heat islands, and typically they are where people are low-income communities of color where simple things like trees being planted that could cool the temperature in the area, these neighborhoods don’t have those amenities. So there are efforts in Texas and in Houston to try to green up some of those communities, but it requires investment and attention and acknowledging that we have these disparities across the community.
Rovner: Yeah, there was a study, I think it was in Baltimore a couple of years ago, where the temperature differential was like 15 degrees. I mean, it would be 85 in the suburbs and it would be 100 in some of these sort of concrete jungles downtown where the buildings hold onto the heat. And, of course, those are places where people live and often can’t afford their utilities, and obviously their utility bills would be higher because it’s going to cost more to cool those places.
Barnes: And as representative [Sen.] Alvarado mentioned, heat, when you have chronic conditions, so the elderly in particular, these are the communities that have the greatest burden of those conditions. And so it’s particularly alarming. That need is there and we really have to pay attention to it.
Rice: One of the things we just looked at in a story was this idea of energy poverty. And one interesting factoid that I learned from that that I was unaware of myself is the idea that many of our federal policies tend to focus on cold weather and that this idea, in federal and state, so for example in North Carolina where the story was centered, there are requirements that apartments and other kind of housing that they mandate that you have heat in the winter. It’s not the same for AC in the summer, and that’s probably something that should be looked at.
Rovner: I want to talk about women. When we talk about health equity differences between men and women, where one of the first places we saw before the Affordable Care Act, insurers were allowed to charge women more simply because they were women and they lived longer and had more health expenses associated with being pregnant and having children. That was eliminated. But, obviously, there are still a lot of inequities between men and women and it’s there. I know that they’re exacerbated by race, but it’s not purely race. I mean, how big an issue is this still? Obviously, reproductive health in general, abortion in specific, is the central health issue in this year’s campaigns. So where does it fall in the pantheon of health equity?
Alvarado: I think if we had more women elected to office, definitely in Texas and in statewide positions, that things like Medicaid would pass, expansion of Medicaid. And it does matter who is at the table, who is making the decisions. And this happened just on one side of the aisle, but just 12-month postpartum for women, so that they can take advantage of Medicaid, and it finally got done. But that’s the only piece that we’ve been able to do. And they were two women, Democrat and Republican, Toni Rose and Sen. Huffman, who led that effort. And I just know if we had more women in the right places, that issues like health care wouldn’t be so partisan and divisive.
Barnes: Yeah, I was going to say the same thing. We finally got 12 months of coverage postpartum, and it’s really unfortunate that we have to piecemeal the care that women need. I think about the fact that we expect good pregnancy outcomes when someone hasn’t had care until they’re pregnant, and up until recently, only eight weeks after they were pregnant. And so yeah, there are a lot of disparities, and for many women being pregnant is their ticket to Medicaid. And so it just perpetuates this fragmented continuum of health, and women are falling out of it regularly.
Alvarado: And especially with women of color, 64% of Latinas and 62% of African American women will at some point be on Medicaid.
Anthony: I just want to chime in here too. You talk about reproductive rights. I considered, Julie, writing a personal essay about, at the time I was 35, I went on … I’m only 37 now, but as a Black woman in the U.S., going on birth control for the first time in my life. Now, I mentioned I’m a single mom, so that wasn’t always my story, but I think we’re in an era of progress and education that is still really, really important. So I just wanted to share that.
Rovner: So I want to talk a little bit about the actual inequities within medical care. One thing, Stat News has a wonderful story that’s part of a series they’re starting this week on algorithms that are embedded into care — when doctors make a diagnosis and then the algorithm comes up and shows all the things you should consider in deciding what kind of treatment. And a lot of these now have: Is the patient Black? And some of them, I think, were originally, I assume most of them, were originally born out of some sort of thought that there’s a differential in risk depending on skin color, but obviously a lot of them … have been completely overturned by science and yet they’re still there. What impact does embedded racism in medicine, in general, have on health equity?
Barnes: Yeah, specific to that, in particular, what it resulted in is individuals who had evidence of risk, because they were Black there was a higher threshold that had to be crossed before they got additional testing or additional treatment, which means that there are populations of people who didn’t get timely care because of those embedded algorithms. One of the other things, there’s not an overriding body — I guess CMS could be that overriding body — but right now no one is standing up saying, “Absolutely you cannot use race-based algorithms.” And so it’s really up to individual health systems. States could implement penalties if you use them, but right now it’s up to an individual institution, and it takes a lot to undo an algorithm and change an electronic medical record. But we are at the threshold, I think, of that beginning to happen.
Anthony: And it’s such a common issue. I spent the last few years looking particularly at kidney disease testing, and if you put a Black person’s kidney on a table and you put a white person’s kidney on the table, you would not be able to tell the difference. People really need to understand that race and biology are not the same, but for years, I mean decades, people have mixed this up and it has delayed care from people who are not getting the treatment that they need.
We wrote a story a couple of years ago about a Black man who needed a kidney, a white woman read the story and decided to donate a kidney to him, but that’s not everybody’s case. I can only write about so many patients that are in that same scenario. And so there’s still a lot of work that needs to be done, but progress is being made. The hospital in particular that we were looking at in St. Louis, they’ve made some policy changes since we published that particular article, but we still have a long way to go. I can’t say that enough. Race and biology are not the same.
Rovner: I mentioned at the top geography, and we talk about people who are grouped together because they have to be, but it’s also about where people decide to live, in rural versus urban. I mean, how can we look population-wide and try to even out, I mean, we talk constantly about the closures of rural hospitals and the difficulty of getting care in far-flung areas, and obviously Texas has a lot of far-flung areas, I know. That is another issue that sort of plays into this whole thing, right?
Alvarado: Oh, absolutely. And one of the arguments, again, this all keeps going back to Medicaid expansion, but you’re talking to my colleagues on the other side of the aisle, I said, your districts, some of your rural districts are suffering the most. Hospitals have shut down. They have to drive to the next big city. It might be Houston or Dallas or San Antonio, but it has, I think, disproportionately hurt rural areas. And until folks want to own that, embrace that, and try to fix it, we’re going to continue to be in this place and probably the gap will widen even more.
Rice: And I’d say we saw this kind of play out in Georgia this week. I live in Atlanta, and there was the unfortunate school shooting incident that happened there. And the community that that school is in had no hospital in that area. So the closest place would’ve been 40 miles away in either direction to Athens, Georgia, which is about 40 miles from the Barrow County and then Atlanta. So even in an incident like that, just coordinating to get people treatment in a major incident is just another example of why we need to do something, right? It’s not just Black communities or Hispanic communities. I think it’s all of us and any given moment may need access to care. And if you think about it, in light of that, 40 miles is no easy feat on Atlanta highways in rush-hour traffic or even being airlifted, it’s still a distance and you have a small window of time to save a life.
Barnes: And there’s been specific conversations in Texas about access to maternal health care in rural communities. And so again, the distance that someone would have to drive is hard for many of us to imagine, especially in a time of crisis.
Rovner: One of the other continuing issues when we talk about health equity is the desire of people to be treated by people who look like them or people who have similar backgrounds to them. That’s obviously been an issue for years that the medical community has been trying to deal with. I want to ask specifically what impact the Supreme Court’s decision banning affirmative action is going to have on the future of the medical workforce and the few strides that have been made to get more people of color, not just into medical school, but into practice.
Rice: I’d say that was pretty immediate, and especially in some of our Southern states, given the history. But I think there were immediate bans on DEI programs or dismantling of those at schools across the South. I can think of Alabama, Mississippi, Texas, even Georgia introduced a bill. It didn’t pass, but I think we saw that happen pretty immediately. And the doctors that at least reporters on my team have spoken to have said, even in their programs, they can’t even say, “We’re trying to increase the number of Black doctors or Hispanic doctors or Native American doctors.” You can’t target those groups to come to special programs, to have access to visitations to schools or that sort of thing. You can’t even say it. So they’re having to kind of circumvent how they reach people to increase the low numbers of doctors of these ethnic groups.
Alvarado: I think we’ve only begun to see the consequences that have taken place because of that. When you mentioned the medical center, we have people that come from all over the world and having physicians that they can relate to or just speaking the language, 48% of people from Houston speak other languages other than English at home. So Houston is known for being very international, very diverse, and it’s only going to continue to grow. So having the language barrier also contributes to many other issues regarding your health. But having that comfort with someone that understands your background, may understand your challenges, that’s important. And I don’t think that the people who were coming up with DEI legislation here in Texas and, those things don’t cross their mind because they’re shortsighted. They’re trying to check a box or get that “A-plus” on their whatever scorecard by whatever group in their party.
Rovner: But people think, well, a doctor is a doctor is a doctor. Why does it matter if that doctor, if you’re able to relate to that doctor, how important is it really to have a medical community that looks like the community it’s serving?
Barnes: Yeah, I would say it’s a huge trust issue. I remember having patients in my practice, African American patients, and there was a wonderful trust that we had with one another. And then I would refer them to a specialist who didn’t look like them, and they would ask me questions, “Do you really think they’re going to do the procedure that they said?” And I was just thinking, “Oh my gosh, I am taking for granted that someone would trust me.” And when we think about how we make recommendations to patients, if the trust isn’t there, why would they listen to what you had to say? And then that will, of course, put you at a disadvantage from a health perspective. And in terms of eliminating affirmative action, I don’t know the medical school data, but a lot of higher education institutions are already reporting lower numbers in their incoming classes. And that certainly is going to be the same in medical schools, nursing schools, PA schools.
Rovner: I did have in my notes that medical schools are freaked out by this.
Anthony: And it’s really …
Barnes: Absolutely.
Anthony: And what you’re talking about, and I’ve written a lot about this topic, and just to name it, we’re talking about “culturally competent care,” and culturally competent care is really, really hard to find because the numbers are low, because there has been a shift. But I think the conversation is also shifting towards culturally humble care or cultural humility in health care. So even if I can’t find a doctor who looks like me, I need someone who’s culturally humble to say, “You know what? I don’t understand everything that you’re going through as a Black woman raising a child in America, but I can admit that, I can say that out loud, and I can maybe direct you towards someone who can be more helpful. Or maybe we could just have a really candid conversation about that.” And so I just want to give people the terminology that I think could be useful if you want to learn more.
Rice: We also just did a story looking at colorism in the U.S. and the impact that that has on people. Interviewed a woman, for example, who had been bleaching her skin for all of these years, had these side effects from that, but clinicians weren’t catching it. They didn’t know to look for specific things. So there were mental health challenges there because of feeling unhappy being in her own body, but there were also manifestations on her physical health because the chemicals that she was introducing were causing harm. So I think that kind of cultural competence, someone that looked like her and could relate to her background might be like, “Wait a minute, is this what’s happening here?” And that’s what happened in the case of that particular patient.
Rovner: So at our session this morning on why does care cost so much? My colleague Noam Levey talked about something he calls a culture of greed in health care, it does seem as if every aspect of the system is or has been monetized. I mean, it really is all about the money. How does that impact health equity? I mean, you could think that if the incentives were in the right place, it might be able to help.
Alvarado: And it drives up the cost of insurance too. I mean, if you’ve ever had a loved one in the hospital, they don’t want you to bring your medications from home. So you have to take what they have there. And it is the same thing, but it’s very expensive. You can buy a bottle of Advil for 5, 6 bucks; each pill is about that much, and then it drives up cost of insurance, and it has an economic impact that trickles down to the consumer.
Barnes: And then it becomes a barrier. So if you are paying out-of-pocket and things are incredibly expensive and you also have to buy food and pay your rent, you may forgo or delay care, which again is going to leave you in a worse situation from a health standpoint and just perpetuate the disparities.
Rovner: Now we have managed-care companies who serve not just most of the Medicare population, but most of the Medicaid population, who get paid for presumably the incentive there was, you’re going to take care of these people and we’re going to pay you, and the more people you can find to take care of, the more we’re going to pay you. And in theory, they have adequate networks where people can actually find care, which is not always the case with Medicaid. It’s hard to find providers who will take Medicaid. I’ve started seeing ads for managed-care companies for people who are eligible for both Medicare and Medicaid, the “dual eligibles.” They don’t call them that, but it’s like, “Wow, I’m looking at TV ads for dual eligibles.” Somebody must be making some amount of money off of these people. Is anything good coming from it?
Alvarado: I mean, the pharmaceutical companies are raking it in pretty good. And in some countries you can’t even have direct promotion for pharmaceuticals from the pharmaceutical company to the consumer.
Rovner: Most other countries.
Alvarado: Yeah, except I mean every commercial. I mean, you pick your drug, what is it, Skyrizi or Cialis, whatever. I mean, it’s out there.
Rovner: Yes, we all know the names of the drugs now.
Alvarado: Something for everybody.
Rovner: I’m going turn it over to questions in a minute, but before I do, I don’t want this to be a complete downer. So I would like each of you to talk about something that you’ve seen in the last year or two that’s made you optimistic about being able to at least address the issue of health equity.
Rice: I mean, the fact that we’re having these conversations more, I think, is something that brings optimism, for me. I don’t remember my family having these conversations as a kid. It was just like, “Well, this is just the way it is. Or “This is how the system is.” And I think it’s positive that we’re having conversations not just about how the system is currently, but about changing it, as Cara mentioned, for the next generation.
Barnes: As a philanthropy, I can talk about some specific investments that we’ve made that have allowed community health workers to work with women throughout their pregnancy period. And so in a small way, for those women, we have increased the opportunity for them to have a healthy outcome. But we’ve also done some policy work. We were part of a large coalition of folks pushing for 12 months of Medicaid coverage postpartum. And those system-level changes affect millions of Texans. And so again, we felt that was really an important way to change the health equity equation.
Alvarado: And thank you for your work on that. Many of us on my side of the aisle have been filing those bills to get it extended to 12 months. But again, everything goes back to politics. They weren’t going to let somebody in the minority party carry it. And at that point, you don’t care who gets the credit, just get it done. Or as we say in Texas, “Git-er-done” and take care of folks. But another thing that we’ve been talking about on our side of the aisle was the tampon tax, the pink tax, and wow, all of a sudden my colleagues on the other side thought, “Oh, that’s a good idea.” And so anyway, we didn’t get to carry it. They passed it, OK, it’s done. So we’ve got to play this game, dance this dance here, and we’ll do it. The most important thing is to make things accessible and affordable to people.
And one of the other things too, we didn’t get to talk about this much, but when you talk about the environment and health impacts, my district has so many concrete batch plants. And so we are seeing more people become aware of particulate matter and the negative impact that these facilities have. And they’re almost all, I’d say 99% all, located in African American and Latino neighborhoods. And Harris County has the largest number of concrete batch plants in any other county in Texas. And a third of those concrete batch plants are walking distance to schools and to day cares. We have more work to do in this area, but at least now the public is holding people accountable and we’re putting more pressure on the agencies that regulate these facilities.
Anthony: We often think about data and there’s negativity associated with that. But one thing that I’ve learned, particularly in the last four years, is that there’s good data too. There’s change that is happening, right? I mentioned early on in our conversation about the swim lesson with my daughter, and that’s progress, right? There’s institutional change happening as well. We talk about the algorithms and the issues there, but we know that there are institutions that have said, “Yes, this is a mistake.” I have concerns, and this is another conversation about what’s going to happen with AI. But I think that there are positive ways to look at that as well. So change is happening, and we have to think about also moving forward, and we want to tell those stories too.
Rovner: All right, well, I’m going to turn it over to the audience now. I see we already have someone waiting to ask a question. Please, before you ask your question, tell us who you are and where you’re from and please make it a question. Go ahead.
Abimisola: Hi, my name is Abimisola. I am from Nigeria, but I live in Austin, Texas. My question is about education. I feel like a big part of access and equity is education. So what are we doing to let people know that there are some services that are available to help them access the care that they need? I imagine that as, I guess, working through the pandemic, health literacy is not really a thing in the public. And so what are we doing to let people know that some of these services exist? And then also on the cultural humility end of things, what are we doing to make sure that providers are aware of this gap and how can they be helpful in their own way to make sure that equitable care does exist when people come in?
Barnes: So I think that we are at a moment of awakening when it comes to recognizing that you need trusted messengers in communities to actually engage in conversations about navigating health care systems or engaging in preventive health measures. Community health workers are really starting to have their day, and there is recent legislation that will actually allow them to be reimbursed for case management services related to their care of pregnant women. And so we are in a moment, that same legislation will also cover doulas and their case management services. But I think to your point, education, health literacy, having someone you trust who can walk you through that process is so critically important and those caregivers are finally getting the recognition that they deserve and being elevated and reimbursed. And so I think that that is a great step.
Linda Jackson: Hello, thank you for the information that you’ve provided. So I’m Linda Jackson and I’m with Huston-Tillotson University, which is a historically Black university a few miles from here. And I want to talk about the speed. One thing that happened again during the coronavirus is that because the university had systems in place, for example, the university was able to move from on-campus, on-ground, to online almost immediately with all of those funds and programs that were available. We’re in that same situation now with what we’re experiencing now, we have an increase in the number of students who want to attend college, an increase in our enrollment. We are a pipeline for the health industry, for some of the issues that we have to deal with, but the issue is that we can move quickly, but to get to all of those entities that are out there that can provide the funding that’s needed.
We have students we turned away who are waiting to get into college, and they’re interested in computer science and they’re interested in the health care industry and they’re interested in all those fields, but it’s the speed. We are here waiting, but the speed for which all of those resources have to come into place. And for example, we had entities who came to us with a doula program, with a doula idea, and we offer a certificate in the doula program to ensure that there are more doulas to provide that culturally sensitive care. And so my question is we’re here. We’re waiting. The resources need to come faster. And so I guess that’s a statement as opposed to a question.
Rovner: But thank you for raising the topic.
Barnes: I will just say, well, first off, my mother and my aunt are both graduates of Huston-Tillotson. So very excited to have you here. I think connecting the industries that need the workforce with the institutions who can provide the training is a key connection that we haven’t figured out how to do well because that’s where your resources would come to be able to support students getting trained to then fill the jobs where we have needs in the health care setting.
Rovner: And this is not just a health equity issue, this is the entire health system writ large.
Barnes: Absolutely.
Rovner: The difficulties with matching workforce needs with patient needs.
Robert Lilly: Good afternoon. Thank you very much for this lively conversation. My name is Robert Lilly. I am a criminal justice participatory defense organizer with Grassroots Leadership, and I’m also justice-impacted, formerly incarcerated, 54 years old with 21 years of my life spent in some institution or another. I want to just comment or not comment, but inquire from the two points that were made about equity. You mentioned that you wanted to, equity was about optimal health, no matter the background of the individual and also to eliminate barriers, especially for populations that are most vulnerable.
Texas has over 110 prisons, 135,000 people currently incarcerated, 600,000 every year exiting the system. Medicaid expansion is a challenge in Texas. My question before you is, in this era of mass incarceration, what options do we have? If policy can’t fix this problem, what other options exist? With the creative minds that you have, the thoughtful insights that you’re gaining from your research and reflection, how can you advise us to move, if our legislature won’t move? Do we depend on them alone to solve these problems, or is there an alternative route that supersedes them? And the last thing I’ll ask is how much of what we’re experiencing today, and we know America’s been historically racist, but how much of what we experiencing is a backlash to George Floyd?
Rovner: Oh, excellent question. Somebody want to take him on?
Anthony: I really think about if policy can’t do it, what can? And that’s where I think about for me, often it’s the institution of the Black family and starting young, what conversations do we need to have with our children as we move forward? That’s one thing that I, in particular, think about because I really think it comes down to literacy, education, being made aware, and also thinking about what can we do as individuals? But it really requires institutional change. I don’t want to act like that’s not at the core of the issue, but really want to talk about our future a lot and think about our future a lot. And so I think it starts at a really young age.
Rice: I wish we could tackle the whole iceberg all at once and just tear the whole thing down and start over. But the reality is we have to chip at it. And I think as we continue to do that, I think it starts to dismantle. And I don’t know that that offers much hope, but I think it’s kind of where we’re at and what we have to do is to keep moving because we wouldn’t have had this progress without that kind of fight.
Rovner: But … go ahead.
Rice: And vote.
Carley Deardorff: Hi, y’all. My name is Carley Deardorff, born and raised in Texas. I have lived in Texas my whole life, except I ran away to Spain for a little bit. Born in Lubbock, been in Austin for about 15 years now. I want to say one, thank you so much for your question previously. My question involves both formerly incarcerated but also aging. So aging parents, aging families. My partner and I were both raised by single moms, and so the outcomes for them, health-wise and also financially in terms of retirement and things like that are very, very slim. And so now in this next phase of life, navigating equity and health outcomes for them, it’s really scary because I don’t know. So before I cry, what do y’all have as opportunities and resources as you help someone age, and what that can look like in the space of life?
Barnes: So, thank you for being so vulnerable in talking about how incredibly challenging navigating the health care system and the systems that address nonmedical factors are for individuals. I don’t have an easy answer. There are organizations, and some that we have funded, that provide navigation services so that folks who know how to walk their way through these complicated systems can be helpful and maybe we can talk offline after we’re done. Again, they rely on trusted messengers in the communities who know what’s going on in the environment and then can actually help with the complicated side of things as well. And I think that’s probably the best bet for traversing something that doesn’t have to be as complicated as it is, but it is what it is at this point.
Meer Jumani: Do we have time for one more?
Barnes: We do.
Jumani: Perfect.
Rovner: Go ahead.
Jumani: So Meer Jumani, I work as a public health policy adviser to Commissioner Adrian Garcia, Harris County, Precinct 2. Sen. Alvarado’s District and Precinct 2 overlap a ton, but Precinct 2 has approximately 1.1 million constituents, of which 65% are Hispanic. We also have some of the most vast health disparities ranging from the highest mortality rate to the lowest home ownership rate. We touched on that amongst others, and despite launching programs ranging from free community-based clinics to lead abatement programs, we see a trend that these are most underutilized by the most vulnerable populations. So my question is, can you speak to what measures can be taken or what folks are not doing to change the mindset of these populations from a curative mindset to a preventative mindset?
Rice: I think it’s, as you mentioned before, trust, right? Those community navigators and making sure they’re out there giving voice to the community and sharing what resources are there. During covid, there was a community in northeast Georgia with a large immigrant population, and they actually ended up having some of the lowest rates of covid for the state because of those community navigators. They really hit the ground and it was kind of amazing what they did, going door to door if they had to, having weekly events and having conversations, making screenings accessible to everyone, and having navigators that spoke various different languages. I think those kind of things continue to help with that kind of outreach.
Anthony: I totally agree. And acknowledging painful history too. I think we have to realize who is tasked to do the fixing, and are we really giving agency and empowering those that need help the most? I’m thinking about particularly in Sikeston, Missouri, where the police chief tried to institute a program where people were to come, particularly Black residents in town. He wanted to have meetings with them and have conversations, but it just didn’t take off. But part of the reason why is because the level of mistrust, but also some acknowledgment of the history of racial violence that had gone on in the past in that community that people were still trying to heal from today. So I think that there’s so much work that has to be done in institutions. One of the first steps that they can take is acknowledging painful history as a way to move forward because we have to acknowledge our pain to have some joy too.
Rovner: I think that’s a wonderful place to leave it. I want to thank our panel so much and thank you to the audience for your great questions.
I hasten to add, if you enjoyed the podcast, you can subscribe wherever you get your podcasts. We’d always appreciate it if you left us a review; that helps other people find us, too. Special thanks, as always, to our technical guru back in Washington, D.C., Francis Ying, and our editor, Emmarie Huetteman. And thanks to the kind folks here at TribFest for helping us put this all together. We’ll be back in D.C. with our regular panel and all the news on Sept. 12. Until then, everyone, be healthy.
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KFF Health News' 'What the Health?': Let the General Election Commence
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
The conventions are over, and the general-election campaign is officially on. While reproductive health is sure to play a key role in the race between Vice President Kamala Harris and former President Donald Trump, it’s less clear what role other health issues will play.
Meanwhile, Medicare recently announced negotiated prices of the first 10 drugs selected under the 2022 Inflation Reduction Act. The announcement is boosting attention to what was already a major pocketbook issue for both Republicans and Democrats.
This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of Politico and Johns Hopkins University’s schools of nursing and public health, Shefali Luthra of The 19th, and Alice Miranda Ollstein of Politico.
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Among the takeaways from this week’s episode:
- The Democratic National Convention highlighted reproductive rights issues as never before, with a parade of public officials and private citizens recounting some of their most personal, painful memories of needing abortion care. But abortion rights activists remain concerned that Harris has not promised to push beyond codifying the rights established under Roe v. Wade, which they believe allows too many barriers to care.
- As reproductive rights have taken center stage in her campaign, Harris has been less forthcoming about her other health policy plans so far. In her career, she has embraced fights against anticompetitive behavior by insurers and hospitals and in drug pricing.
- Would former President Donald Trump make Robert Kennedy Jr. his next health secretary? Even many Republicans would consider his elevation a bridge too far. Polls show Trump stands to gain from Kennedy’s departure from the presidential race, but likely only slightly more than Harris.
- In other national health news, abortion access will be on the ballot this fall in Arizona and Montana, and the federal government recently announced the first drug prices secured under Medicare’s new drug-negotiation program.
Also this week, Rovner interviews KFF Health News’ Tony Leys, who reported and wrote the latest KFF Health News-NPR “Bill of the Month” installment about a woman who fought back after being charged for two surgeries despite undergoing only one. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: The New York Times’ “Hot Summer Threatens Efficacy of Mail-Order Medications,” by Emily Baumgaertner.
Joanne Kenen: The Milwaukee Journal Sentinel’s “Who Is Gus Walz and What Is a Non-Verbal Learning Disorder?” by Natalie Eilbert.
Alice Miranda Ollstein: The Wall Street Journal’s “The Fight Against DEI Programs Shifts to Medical Care,” by Theo Francis and Melanie Evans.
Shefali Luthra: The Washington Post’s “Weight-Loss Drugs Are a Hot Commodity. But Not in Low-Income Neighborhoods,” by Ariana Eunjung Cha.
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Transcript: Let the General Election Commence
KFF Health News’ ‘What the Health?’Episode Title: ‘Let the General Election Commence’Episode Number: 361Published: Aug. 23, 2024
[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, Aug. 23, 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 Joanne Kenen of the Johns Hopkins schools of public health and nursing and Politico Magazine.
Joanne Kenen: Hi, everybody.
Rovner: Shefali Luthra of The 19th.
Shefali Luthra: Good morning.
Rovner: And Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Hello.
Rovner: Later in this episode, we’ll have my interview with KFF Health News’ Tony Leys, who reported and wrote the latest KFF Health News-NPR “Bill of the Month,” about a woman who got two bills for the same surgery and refused to back down. But first, this week’s news. So, now both conventions are over. Labor Day is just over a week away. And I think it’s safe to declare the general election campaign officially on. What did we learn from the just-completed Democratic [National] Convention, other than that Beyoncé didn’t show up?
Luthra: I think the obvious thing we learned is there is a lot of abortion for Democrats to talk about and very little abortion Republicans would like to. I did the fun brain exercise of going back through old Democratic conventions to see how much abortion came up. It might be interesting to note that in 2012, for instance, [the former president of Planned Parenthood] Cecile Richards spoke, never mentioned abortion.
A Planned Parenthood patient came and didn’t talk about abortion, talked about endometriosis care. And I think that really underscores what a shift we have seen in the party from treating abortion as an issue for the base, but not one that got center stage very often. And that shifted a bit in 2016, but is really very different now.
We had abortion every night, and that is just such a marked contrast from the RNC, where Republicans went to great lengths to avoid the topic because Democrats are largely on the winning side of this issue and Republicans are not.
Rovner: I’ve watched every Democratic convention since 1984. I have to say, I’m still trying to wrap my brain around the idea of all of these, and not just women, but men and [Sen.] Tammy Duckworth talking about IVF and women who had various difficulties with pregnancy. Usually, it would be tucked into a section of one night, but every single night we had people getting up and telling their individual stories. I was kind of surprised. Alice, you wanted to add something?
Ollstein: Yeah. We also wrote about how the breadth of the kinds of abortion stories being told has also changed. There’s been frustration on the left for a while that only these medical emergency cases have been lifted up.
Rovner: The good abortions.
Ollstein: Exactly. So there’s a fear that that further stigmatizes people who just had an abortion because they simply didn’t want to be pregnant, which is the majority of cases. These really awful medical emergencies are the minority, even though they are happening, and people do want those stories told. But I think it was notable that the head of Planned Parenthood talked about a case that was simply someone who didn’t want to be pregnant and the lengths she had to go through to get an abortion.
I think we’re still mostly seeing the more politically palatable, sympathetic stories of sexual assault and medical emergencies, but I think you’re starting to see the discourse broaden a little bit more. It’s still not what a lot of activists want, but it’s widening. It’s opening the door a little bit more to those different stories.
Rovner: And certainly having [Kamala] Harris at the top of the ticket rather than Biden, I mean, she’s been the point person of this administration on reproductive health even before Roe v. Wade got overturned.
Ollstein: Right. And I think it’s been interesting to see the policy versus politics side of this, where politically she’s seen as such a stronger ally on abortion rights, and her messaging is much more aggressive than [President Joe] Biden’s, a lot more specific. But when it comes to the policy, she’s exactly where Biden was. She says, “I want to restore Roe v. Wade,” where a lot of activists say that’s not enough. Roe v. Wade left a lot of people out in the cold who couldn’t get an abortion that they wanted later in pregnancy, or they ran into all these restrictions earlier in pregnancy that were allowed under Roe. And so I think we’re going to see that tension going forward of the messaging is more along the lines of what the progressive activists want, but the policy isn’t.
Luthra: And to build on Alice’s point, I mean, a lot of the speakers we had this week are speakers who would’ve been there for a Biden campaign as well. Amanda Zurawski was a very effective Biden surrogate. She is now a Harris surrogate.
And I think what’s really important for us to remember as we look not just to November, but to potentially January and beyond, is that what Harris is campaigning on, what Biden tried to campaign on, although he struggled to say the words, is something that probably isn’t going to happen because they’re talking about signing a law to codify Roe’s protections and they in all likelihood won’t have the votes to do so.
Rovner: Yes. And they either have to get rid of the filibuster in the Senate or they have to have 60 votes, neither of which seems probable. And as I have pointed out many times, the Democrats have never had enough votes to codify Roe v. Wade. There’s never actually been a basically pro-choice Congress. The House has never been pro-choice until Trump was president, when obviously there was nothing they could do.
It’s not that Congress didn’t want to, or the Democrats in Congress didn’t want to or didn’t try, they never had the votes. For years and years and years, I would say, there were a significant number of Republicans who were pro-abortion rights and a significant, even larger number of Democrats who were anti-abortion. It’s only in the last decade that it’s become absolutely partisan, that basically each party has kicked out the ones on the other side. Joanne, you wanted to add something?
Kenen: Remember that the very last snag that almost pulled down the Affordable Care Act at zero hour, or zero minus, after zero hour, was anti-abortion Democrats. And that was massaged out and they cut a deal and they put in language and they got it through. But no, the phenomenon Julie’s talking about was that the dynamics have changed because of the polarization.
I mean, it wasn’t just abortion; there were centrists in both parties, and they’re pretty much gone. The other thing that struck me last night is there was rape victims and victims of traffic and abuse speaking both within the context of abortion. I mean, that was a mesmerizing presentation by a really courageous young woman.
And then there were other episodes about sexual violence against women, a nod to Biden a couple of times, who actually wrote the original Violence Against Women Act in ’94, part of the crime bill, but also in terms of liberal Democrats or progressives who … “prosecutor” isn’t their favorite title. But because they tied these themes together or at least link them or they were there in a basket together of her as a protector of victims of trafficking, rape, and abuse, starting when she was in high school with her friend.
So I thought that that was another thing that we would not have spoken about. You did not have young women talking about being raped by their stepfather and impregnated at age 12.
Rovner: So aside from reproductive rights, which was obviously a headline of this convention, it’s almost impossible to discern what a second Trump administration might mean for health because Trump has been literally all over the place on most health issues. And he may or may not hire back the former staffers who compiled Project 2025.
But we don’t really know what a Harris administration would mean either. There is still no policy section on the official Harris for President website. One thing we do seem to know is that she seems to have backed away from her support for “Medicare for All,” which she kind of ran on in 2019.
Luthra: Sort of.
Rovner: Yeah, kind of, sort of. What else do we know about what she would do on health care other than on reproductive health, where she’s been quite clear?
Ollstein: So the focus on the policies that have been rolled out so far have been cost of living and going after price-gouging. She also has a history, as California attorney general, of using antitrust and those kinds of legal tools to go after monopolistic practices in health care. In California, she did that on the insurance front and the hospital front and the drug pricing front. So there is an expectation that that would be a focus. But again, they have not disclosed to us what the plans are.
Kenen: I mean, one of the immediate things, and I watched a fair amount of the convention and none of us absorbed every word, but I don’t think I heard a single mention of it was the extension of the ACA subsidies, which expire next year. I mean, if they mentioned it, it was in passing by somebody. So you didn’t really hear too much ACA, right? You hear that wonderful line from President [Barack] Obama when he said the Affordable Care Act, and then he said that aside: “Now that it’s popular, they don’t call it Obamacare anymore.”
But you didn’t hear a lot of ACA discussion. You heard a lot of drug price and you heard a lot of some vague Medicare, mostly in the context of drug prices. But there wasn’t a segment of one night devoted to the health policy. So I mean, I think we can assume she’s pretty much going to be Biden-like. I would be surprised if she didn’t fight to preserve the subsidies.
The Medicare drug stuff is in law now and going ahead. I think Julie wants to come back to that, but I don’t think we know what’s different. And I don’t know what, in that to-do list, I don’t think she articulated the priorities, although I would imagine she’ll start talking about the subsidies because the Republicans are probably going to oppose that. But no, it wasn’t a big focus. It was like sprinkles on an ice cream cone instead of serving a sundae.
Rovner: It’s hard to remember that just four years ago in 2020, there was this huge fight about the future of health care. Do we want to go to Medicare for All? What do we want to do about the ACA? Biden was actually the most conservative, I think, of the Democratic candidates when it came to health care.
Kenen: And then he expanded things way more than people expected him to.
Rovner: Yes, that’s true. I was going to say, but the other thing that jumped out at me is how many liberals, [Rep.] Alexandria Ocasio-Cortez, talking like a moderate basically, I mean, giving this big speech. It feels like the left wing of the Democratic Party, at least on health care, has figured out that it’s better to be pragmatic and get something done, which apparently the right wing of the Republican Party has not figured out.
Luthra: Well, part of what happened, right, is, I mean, the left lost in 2020. Joe Biden won. He became president. And there’s this real interesting effort that we saw this week to try and recapture the energy of 2008, 2012, the Obama era, and that wasn’t a Medicare-for-All-type time. That was much more vibes and pragmatism, which is what we are seeing now.
Kenen: The other thing is that the progressives, more centrist, more moderate, whatever you call the mainstream bring, they kissed and made up. I mean, [Sen.] Bernie Sanders became an incredible backer of Biden. I mean, they fought on the original Bring [Build] Back Better. That became the watered-down Inflation Reduction [Act]. They had some policy differences and some of which were stark.
But basically, Bernie Sanders became this bulwark for it, helped create party unity, helped move it ahead, supported Biden when he was thinking about staying in the race. So I think that Bernie’s support of Biden, who did do an awful lot of things on the progressive agenda; he did expand health care, although not through single-payer, but through expanded ACA. He did do a lot on climate. He did do a lot of things they cared about, and the party is less divided. We don’t know how long that’ll last. We had, not just unusual, but unprecedented last two months. So these things like Medicare for All versus strengthening the ACA, they’ll bubble up again, but they’re not going to divide the party in the next seven weeks, eight weeks, whatever we’re out: 77 days. Do the math, 10 weeks.
Rovner: Seventy-some days. In other political news, third-party candidate and anti-vax crusader Robert F. Kennedy Jr. is going to drop out of the race later today and perhaps endorse Donald Trump. The rumor is he’s hoping to win a position in a second Trump administration, if there is one, possibly even secretary of Health and Human Services. What would that look like? A lot of odd faces from our panelists here.
Ollstein: I’m always skeptical. There’s also talk about Elon Musk getting a Cabinet job. I’m always skeptical of these incredibly wealthy individuals — who, currently, as private citizens, can basically do whatever they want — I have a hard time imagining them wanting to submit to the constrictures and the oversight of being in the Cabinet. I would be surprised. I think that it sounds good to have that power, but to actually have to do that job, I think, would not be appealing to such people. But I could be surprised.
Rovner: We did have Steve Mnuchin as secretary of the Treasury, and he seemed to have a pretty good time doing it.
Ollstein: I guess so, but I think his background was maybe a little more suited to that. I don’t know.
Kenen: Mnuchin, you’ve also had Democrats who appoint Wall Street types. Rubin being one of several, at least.
Rovner: We tend to have billionaires at the Treasury Department.
Kenen: The idea of Bobby Kennedy running HHS, I think even many Republicans who support Trump would find a bridge too far. And remember they want … if you look at the part of the Republican Party that really equate … their priority is anti-abortion, that’s it for them. There’s some on the right who talked about — I’m pretty sure this is in 2025, but at least it’s out there — change it to the Department of Life.
There’s a faction within the Republican Party who sees HHS as the way of driving an anti-abortion agenda. What’s left of abortion, right? It has oversight over the NIH [National Institutes of Health] and FDA [Food and Drug Administration] and CDC [Centers for Disease Control and Prevention], et cetera. You can’t say that Trump won’t do something because he is a very unpredictable person. So, who knows what Donald Trump would do? I don’t think it’s all that likely that Bobby Kennedy gets HHS.
But I do think that in order to get the endorsement that Trump wants, he’d have to promise him something in the health realm — whether it’s a special adviser for vaccine safety, who knows what it would be? But something that makes him feel like he got something in exchange for the support.
Rovner: I do wonder what the support would mean politically to have prominent anti-vaxxer. If Trump is out trying to capture swing voters, this doesn’t seem necessarily a way to appeal to suburban moms.
Kenen: Remember the vaccine commission to study vaccine safety? And it was Bobby Kennedy who came out of a meeting with Trump and said it was going to happen, that he was going to be the chair of it. The commission didn’t happen, and Bobby Kennedy didn’t chair it. So we already know that this goes back, what, eight years now. So there’s going to be a tit-for-tat. That’s politics. Whether the tat is HHS secretary, I’m skeptical. But again, I’d never say anything isn’t possible in Washington.
Rovner: If nothing else, this year has shown us that …
Kenen: I think it’s extremely unlikely.
Luthra: To your point about who Bobby Kennedy appeals to, the polls tell us that everyone who supports him, by and large, would vote for Trump if he dropped out. So I mean, that’s obviously why this would happen. It’s because it is a net gain for Trump and his calculus is probably that it would outweigh the losses he might get from having someone with a strong anti-vax bent on his side. I think that’s a pretty obvious, to me at least, gain for him rather than loss, especially given how close the race is.
Rovner: While we are on the subject of national politics and abortion, former President Trump this week said in an interview with CBS that he would not enforce the Comstock Act to basically impose a national abortion ban, reiterating that he wants to leave it to the states to decide what they want to do. Alice, it’s fair to say this did not go over very well with the anti-abortion base, right?
Ollstein: That’s right. It’s interesting. I reached out to lots of different folks in the anti-abortion movement to get their take, and I expected at least some of them to say, “Oh, Trump’s just saying that. He doesn’t really mean it. He’ll still do it anyways.” None of them said that. They all completely took him seriously and said that they were extremely upset about this. I mean, it’s also not happening in a vacuum.
They were already upset about the RNC [Republican National Convention] platform having some anti-abortion language being taken out of it. There is still some anti-abortion language in there. Folks should remember him declining to endorse a national abortion ban. Him refusing to say how he plans to vote in Florida’s referendum on abortion coming up. So this is one more thing that they’re upset about. And they told me that they think it could really cost him some votes and enthusiasm from the base.
He’s having trouble winning over these moderate swing voters. If that’s true, then he needs every vote on the more religious right/conservative wing of things. And they’re saying, look, most people are probably going to vote for him anyways because they don’t want Kamala Harris to be president. But will they volunteer? Will they tell a friend? Will they go knock on doors? Begrudgingly voting for someone versus being enthusiastic difference.
Rovner: I think it’s fair to say that it was the anti-abortion right that basically got him over the finish line in 2016 when he put out that list of potential Supreme Court nominees and signed a now-infamous letter that Marjorie Dannenfelser of the SBA [Susan B. Anthony Pro-Life America] list put together. Then the anti-abortion movement put a lot of money into door-knocking and getting out the vote. And obviously, as we all remember, it was just a few thousand votes in a couple of states that made him president.
So I was a little bit surprised that he was that definitive — although as we said 14 times already this morning — he often says one thing and does another, or says one thing and says another thing later, right.
Kenen: In the same day!
Rovner: Or in the same conversation sometimes. I was interested to see Kamala Harris in her speech refer to the Comstock Act without doing it by name. I thought that was artfully done.
Ollstein: Yeah, and several other speakers did talk about it by name, which is interesting because I think earlier this year there was this attitude among Democrats and some abortion rights leaders that there should not be a lot of talk about the Comstock Act because they didn’t want to give the right ideas. But I think now it’s pretty clear that the right doesn’t need to be given ideas. They already had these ideas. And so there’s a lot more open talk about it.
And just this piece of Project 2025, along with all of the focus on Project 2025 in general, just really seemed to resonate with voters in a really unusual way. And no matter how much Trump tries to disavow it or distance himself from it, it doesn’t seem like people are convinced, because these are very close allies of Trump who worked for him, who are likely to work for him in the future, who are the authors of this.
Rovner: And who put together this whole list of people who could work in a second administration. It’s basically the second Trump term all ready to go. It’s hard to imagine where he would then find a list of people to populate his agencies if not turning to the list that was put together by Project 2025.
So Trump says, as we’ve mentioned, that he wants voters in each state to decide how to regulate abortion. And that’s pretty much what he’s getting. Since we last talked, several states have finalized abortion rights ballot questions. But some have come with a couple of twists. Alice, where are we on the state ballot measure checklist?
Ollstein: It’s been a crazy couple of weeks. So we have Arizona and Montana certified for the ballot. Those are two huge states that also have major Senate races. Arizona is a presidential swing state. Montana, arguably not. But these are states that are going to get a blitz of ads and campaign attention. I think there is an expectation that the abortion measures on the ballot will benefit the Democratic candidates.
I would caution people to be skeptical about this. We’ve done analyses of the abortion ballot measures that have been on the ballot in the past couple of years in other states, and they did not always benefit the Democratic candidates who shared the ballot. Of course, this is a presidential year. It could be totally different.
At the same time, the big news this week was that a Arkansas Supreme Court ruling means that their abortion rights ballot measure will almost certainly not be on the ballot in November. And there’s a lot of consternation about that. The dissenting justices accused the majority of making up rules out of whole cloth and treating different ballot measures differently based on the content.
So basically there was a medical marijuana ballot measure and the sponsors of it wrote a brief saying, “Hey, we made the same alleged paperwork error that the abortion rights folks are accused of making, yet ours was certified for the ballot and theirs wasn’t. What gives?” So there are accusations of the conservative officials of Arkansas making these rulings to prevent a vote on abortion rights in that state. So they could try again in 2026. They are weighing their options right now.
Rovner: So abortion issues are not just bubbling among voters and in the elections. We now have a series of lawsuits with patients accusing hospitals that deny them emergency care of violating the Emergency Medical Treatment and Active Labor Act. Some may remember this was also the subject of a Supreme Court case this term. For those who have forgotten, Shefali, what happened with that Supreme Court case? Where are we with EMTALA?
Luthra: Great question, Julie. We are waiting, as ever, and we will be waiting for a long time because the Supreme Court after taking up that case said, “Actually, never mind. We were wrong to take this case up now. It should go back to the lower courts and continue to progress.” And what that means is uncertainty. It does mean that EMTALA’s protections exist for now in Idaho. They do not exist in Texas, where there is a related corresponding case going through the courts as well.
But regardless, EMTALA’s protections are quite meaningful for providers compared to not having them. But they are still pretty vague and pretty limited in terms of how abortion can come up in pregnancy. And that’s why we are still seeing patients filing these complaints saying, “My rights were violated. I did not get this emergency care I needed until it was very late.” But the problem there is that: A, EMTALA is retroactive.
So these complaints only come up when people know to file them; when they have perhaps already suffered medical consequences such as losing a fallopian tube, as two women in Texas both reported experiencing. You know, serious implications for their future fertility. And the other thing that’s important to note is that complaints are one step, but enforcement is another one.
And we haven’t seen a ton of hospitals being penalized by the federal government for not giving people care in these medical emergencies. And so if you’re a hospital, the dilemma is complicated, but in some ways not. Because if you provide care for someone and you find yourself in violation of state law, that’s a felony, potentially. But if you are going against EMTALA, well, maybe it’ll be reported, maybe it won’t be. Maybe you’ll be fined or penalized by the federal government, but maybe you won’t be. And that creates a real challenge for patients in particular because they are once again caught in a situation where they need emergency medical care, and the incentives are against hospitals providing it.
Ollstein: The Biden administration has not been transparent on how many complaints have been filed, how many hospitals they’ve investigated, what measures they’ve taken to make hospitals correct their behavior, whether they’ve come into compliance or not, whether they are getting these penalties, including losing Medicare status, which is one of the most severe penalties possible.
We just don’t know. And so they say they’re making this big focus on EMTALA enforcement, but we are not really seeing the evidence of that. And the only way we even know anything is happening is when the patients themselves are choosing to disclose it, either to advocacy groups or the media.
Rovner: Or the Democratic National Convention, where we saw several of these stories. It is a continuing theme as we go forward. Well, moving on. While we were celebrating the 50th anniversary of ERISA [Employee Retirement Income Security Act] here on “What the Health?” last week — and if you did not hear that special episode, I highly recommend it — the Biden administration unveiled negotiated prices for the first 10 drugs chosen under the new authority granted by the Inflation Reduction Act.
It’s hard to tell how much better the prices that they got are because so much of the information remains proprietary. But Joanne, what’s the reaction been, both in the drug industry and larger in the political realm?
Kenen: The drug industry obviously doesn’t like it. This is only 10 drugs this year, but it’ll be more in the future. Look, I’m not so sure how well that message has gotten through yet. The Medicare drugs came under what ended up being called the Inflation Reduction Act. There’s several measures in it. There’s protection for everybody in Medicare, how much you spend on drugs in a year, it’s $2,000. That’s it. Which is a big difference from what some of the out-of-pocket vulnerabilities people had in the past.
When you look at the polls or you look at interviews with undecided voters, you wonder who’s paying attention other than us? The Democrats have wanted this for more than 20 years. Twenty years is a conservative estimate. I mean, it was part of the fight over what became the Medicare Modernization Act in 2003.
They fought for it every year. They lost every year. They finally got it through. So the idea of having Medicare negotiating drug prices is a huge victory for the Democrats. Ten drugs, not a big deal for the industry, but they know something changed. They will fight every opportunity for a lawsuit or a lobbying campaign or blocking a new regulation or the next round of negotiations.
This is going to be probably just like these annual fights we have about physician pay. This’ll be an annual fight about how much can PhRMA punch back. That would assume that a Democrat wins and that these policies don’t get rescinded. It’s a big deal. It’s not a big deal for individual pocketbooks yet, but it’s a big, big deal on the balance of power between PhRMA, which is so powerful, and the federal government, which pays for these drugs.
Rovner: I’m reminded of a sentence I wrote about the Medicare Catastrophic Coverage Act, which was passed and repealed much at the behest of the drug industry because it had what would’ve been the first Medicare outpatient drug benefit ever. And I wrote, the drug industry fought this tooth and nail because they were concerned that if Medicare started covering drugs, they would want to have some say in how much they cost. That was, I think, 1989.
Kenen: Right.
Rovner: And here we are, however many years later it is.
Kenen: It’s really hard to take away a benefit, as the Republicans learned when they spent all that energy trying and failing to repeal the ACA. Once people have a benefit, it’s hard to say, “Whoops! No more.” However, that doesn’t mean there’s not fights about technical matters or how the regulations are worded or how deep discounts are or what other things they could get in exchange that make up for the losses on this.
I mean, PhRMA is really a huge lobby, hugely influential, and sympathetic in some ways because they do create a pro … — unlike something like tobacco — they do create products that saves our lives, right? And their argument, innovation, and those arguments resonate with people. But I don’t really see this turning back. I don’t think any of us can predict how PhRMA will regain some of the influence that it did lose in this battle.
It’s certainly not permanent defeat of PhRMA. I mean, PhRMA is powerful. PhRMA has allies in both parties. But this was a huge victory for the Democrats. They got something after 20-plus years.
Rovner: Well, finally this week, earlier this spring we talked at some length about the Biden administration’s Federal Trade Commission proposal to ban noncompete clauses, which in health care often applied to even the lowest-level jobs. It was supposed to take effect Sept. 4, but a federal district court judge in Texas has ruled in favor of the U.S. Chamber of Commerce that the agency lacks the authority to implement such a sweeping rule.
And the appeals court there in the 5th Circuit is notoriously conservative and unlikely to overturn that lower-court decision even if Vice President Harris wins and becomes president. Are we just going to continue to see every agency effort blocked by some Trump-appointed judge in Texas? That seems to be what’s happening now.
Ollstein: I mean, I think especially with the recent Supreme Court rulings on Chevron, I think we’re just … I mean, that plus the makeup of the judiciary means that executive power is just a lot more curtailed than it used to be. Theoretically, that should apply to both parties to whoever is president, but we have seen courts be very politicized and treat different things differently. So I think that it will be a special challenge for a Democratic or progressive administration to push those policies going forward.
Rovner: And of course in Texas, as we have pointed out on many occasions, there are all these single-judge districts, where if you file in certain places you know which judge you’re going to get. I mean, it’s the ultimate in judge shopping.
Luthra: I was just thinking about [U.S. District Judge] Reed O’Connor and [U.S. District Judge] Matthew Kacsmaryk, two names that listeners know well.
Rovner: Yes, that’s right. And this was a third judge, by the way. This was neither Reed O’Connor nor Matthew Kacsmaryk in this case.
Ollstein: But a secret third thing.
Rovner: A secret, a secret third thing.
Kenen: I mean, what Alice just referred to as the Supreme Court reducing the power of the regulators, and they said Congress has to pass the laws. You’re not going to get something this sweeping through Congress. But could you end up getting bits of it written into legislation about hospital personnel or doctors or things like that? I can see nibbles added in certain fields. And also you’re going to see some of it at the state level. I’m pretty sure Maryland has passed some kind of a noncompete.
Rovner: Yeah, there are states that have their own noncompete laws.
Kenen: I think they’ll go at it piecemeal. They may not be able to do anything that huge, all noncompetes, but by profession, or sector by sector, I think they may try to keep nibbling away at it. But the effort that we saw is gone.
Rovner: I mean, just to broaden it out, obviously this was something that the Biden administration has relied on the power of the FTC, the Federal Trade Commission, something that the Biden administration has highlighted. It’s something that I think Vice President Harris is relying on going forward. So this is probably not a good sign for wanting to make policy in this way.
See, nods all around. All right, that is this week’s news. Now we will play my “Bill of the Month” interview with Tony Leys, and then we will come back and do our extra credits.
I am so pleased to welcome to the podcast my KFF Health News colleague Tony Leys, who reported and wrote the latest KFF Health News-NPR “Bill of the Month.” Tony, welcome back to “What the Health?”
Tony Leys: Hi, Julie.
Rovner: So tell us about this month’s patient: who she is, where she’s from, and what kind of medical care she got.
Leys: The patient is Jamie Holmes, who lives in Washington state. In 2019, she went to a surgical center to have her fallopian tubes tied. While she was on her anesthesia, the surgeon noticed early signs of endometriosis, a common condition in which fibrous tissue grows in and around the uterus. The surgeon took care of that secondary issue. Holmes said he later told her the whole operation was done within the allotted time for the original surgery, which was about an hour.
Rovner: As one who’s had and knows a lot of people who’ve had endometriosis, it is extremely painful and very difficult to treat. So medically, at least this story seems to have a happy ending, a doctor who was on his toes spotted an impending problem and took care of it on the spot. But then, as we say, the bill came.
Leys: The bill came. The surgery center billed her for two separate operations, $4,810 each.
Rovner: So even though she only went under anesthesia once and simply had two different things done to her at the time.
Leys: Right. And the surgery center is the place that does the support work for the operation. And there was just one operation.
Rovner: So obviously she figured this must be a mistake and complained. What happened?
Leys: She thought once she explained what really happened, they would go, “Oh,” and they would fix it. But that didn’t work. And after adjustments and the insurance payment for the one operation, they said that she still owed the surgery center $2,605, and she said, “Nope.”
Rovner: This was in 2019. So obviously things have happened since then.
Leys: Right. The bill was turned over to a collections agency, which wound up suing Holmes last year for about $3,800, including interest and fees.
Rovner: Now, to be clear, Jamie says she doesn’t object to paying extra for the extra service that she got. What she does object to is being charged as if it was two separate surgical procedures. So what happened next?
Leys: I mean, she joked that it was as if she went to a fast-food restaurant and ordered a value meal, ended up with one extra order of fries and then got charged for two full meals. The collections agency went to court. They asked for a summary judgment, which could have allowed the collection agency to garnish Holmes’ wages.
But she went to a couple of court hearings and explained her side, and the judge ruled last February that he wasn’t going to grant summary judgment to the collection agency. And if it really wanted to pursue the matter, it would have to go to trial. And she has not heard from them since then.
Rovner: Because presumably it would cost them more to go to trial than it would to collect her … however many couple of thousand dollars they say she still owes, right?
Leys: That could certainly be the explanation. We don’t know.
Rovner: So what’s a takeaway here?
Leys: The takeaway is if you get a bill that’s totally bogus, don’t necessarily pay it. Don’t be afraid to fight it. And if someone sues you, don’t be afraid to go to court and tell your side of it.
Rovner: Yeah, because I mean, that’s mostly what happens is that these collection agencies go to court, nobody shows up on the other side, and they get to start garnishing wages, right?
Leys: Exactly. That’s probably what would’ve happened here.
Rovner: She didn’t even have to hire a lawyer. She just showed up and told her side of the story.
Leys: And her take on it is she could have arranged to pay it. It’s not a huge, huge amount of money. But she just wasn’t going to do it. So she stood her ground.
Rovner: And as we pointed out, she was willing to pay for the extra order of fries. She just wasn’t willing to pay for an entire second meal that she didn’t get.
Leys: Right. I mean, she told me, “I didn’t get the extra burger and drink and a toy.”
Rovner: There we go. So basically fight back if you have a problem, and don’t be afraid to fight back.
Leys: Exactly.
Rovner: Tony Leys, thank you so much.
Leys: Thanks, Julie.
Rovner: OK, we are back. 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 links to all of these stories in our show notes on your phone or other device. Alice, you chose first this week. Why don’t you go first?
Ollstein: Sure. So I had an interesting piece from The Wall Street Journal by Theo Francis and Melanie Evans called “The Fight Against DEI Programs Shifts to Medical Care.” So we’ve seen this growing effort from conservative activists to go after so-called DEI [diversity, equity, and inclusion] programs, to go after affirmative action, to go after a lot of various programs in government and in the private sector that take race into account when allocating resources.
And so now this is coming to health care where you have a lot of major players. This story is about a complaint filed against the Cleveland Clinic. But throughout health care, you have efforts to say, OK, certain racial groups and other demographics have higher risk and are less likely to get treatment for various diseases. This one is about strokes, but it applies in many areas of health care. And so they have created these targeted programs to try to help those populations because they are at higher risk and have been historically marginalized and denied care. And now those efforts are coming under attack. And so it’s unclear. So this is a federal complaint, and so the federal government would have to agree with it and take action. I don’t think that’s super likely from the Biden administration to crack down on a minority health care program. But this could be yet another thing people should keep in mind regarding the stakes of the election because a conservative administration could very well take a different approach.
Rovner: Shefali.
Luthra: My story is from The Washington Post. It is by Ariana Eunjung Cha, and the headline is “Weight-Loss Drugs Are a Hot Commodity. But Not in Low-Income Neighborhoods.” I think this is a really smart framing and it gets at something that folks have been worried about for a long time, which is that we have these revolutionary drugs like Ozempic and Wegovy. They show massive improvements for people with diabetes, for people with obesity. And they are so expensive and often not covered by Medicaid. Or if you are uninsured, you cannot get them. And what this story gets at really …
Rovner: If you’re insured, you can’t get them in a lot of cases.
Luthra: It’s true. What I love about this story is it sets us in place. It takes us to Atlanta and helps us see in the different parts of the city, based on income, on access to all sorts of other, to use the jargon, race, social determinants of health, obesity and diabetes are already very unequal diseases. They hit people differently because of access to safe places to exercise, walkable streets, affordable groceries, time to cook, all of that. And then you add on it another layer, which is this drug that can be very helpful is just out of reach for people who are already at higher risk because of systemic inequalities. The story also gets into some of the more social challenges that you might see from a drug like Ozempic. People saying, “Well, I know that rich people get that drug, but how do I know they would be giving the same thing to me? How do I know that the side effects will not be really damaging down the line because these drugs are so new?” And what it speaks to, in a way that I think we’re seeing a lot more journalism do very intelligently, is that there are going to be very real challenges — economic and cultural and social and political — to helping these drugs have the impact that they were touted as potentially able to have.
Rovner: Indeed. Joanne.
Kenen: Well, after that amazing moment with Gus Walz and his dad on the convention floor, I looked up the quick 24-hour coverage of what was going to best explain what a nonverbal learning disorder is and a little bit about who Gus Walz is. And Natalie Eilbert of The Milwaukee Journal Sentinel did a nice piece [“Who Is Gus Walz and What Is a Non-Verbal Learning Disorder?”]
Nothing I read yesterday answered every question I had about this particular processing disorder, but this was a good one and it explained what kind of things kids with these kinds of issues have trouble comprehending, and also what kind of things they’re really good at. This is not a learning disability. You can be really, really smart and still have a learning disability.
There’s actually an acronym, as there always is, which is GTLD: gifted and talented and learning disabled. Much of the country responded really warmly, as we all saw, and some of the country did not. But in terms of just what is this disorder and how does it affect your ability to communicate, which is part of what it is, understanding language cues, Natalie Eilbert did a good job.
Rovner: And no matter what you can be proud of your dad, particularly when he’s just been nominated to run for vice president. All right, my extra credit this week is from The New York Times. It’s called “Hot Summer Threatens Efficacy of Mail-Order Medications.” And it’s something I’ve been thinking about for a while because packages get subjected to major extremes of temperature in both the summer and the winter.
Indeed, now we have studies that show particularly that heat can degrade the efficacy and safety of some medications. One new study that embedded data-logging thermometers in packages found that those packages spent more than two-thirds of their transit time outside the recommended temperature range.
While the FDA has very strict temperature guidelines for shipping and storing medications between manufacturers and wholesalers and pharmacies, once it leaves the pharmacy it’s apparently up to each state to regulate. Just one more unexpected consequence of climate change.
OK, that is our 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. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, I’m @jrovner. Shefali, where are you these days?
Luthra: I am on the former Twitter platform @shefalil.
Rovner: Alice?
Ollstein: On X @aliceollstein.
Rovner: Joanne?
Kenen: On X @JoanneKenen and on Threads @JoanneKenen1.
Rovner: Before we go, a quick note about our schedule. We are taking next week off. I’m going to the beach. The week after that, we’ll have a very special show from The Texas Tribune TribFest in Austin. We’ll be back with our regular panel and all the news we might’ve missed on Sept. 12. Until then, be healthy.
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KFF Health News' 'What the Health?': Happy 50th, ERISA
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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.
On September 2, 1974, President Gerald Ford signed into law the Employee Retirement Income Security Act, better known as ERISA. While the law was primarily intended to regulate and protect worker pensions, it also fundamentally changed how health insurance is provided and regulated in the United States. Fifty years on, ERISA plays a role in nearly every detail of health insurance and has had a profound impact on the entire health care sector.
To note this anniversary, in this week’s special episode of KFF Health News’ “What the Health?”, host and KFF Health News chief Washington correspondent Julie Rovner discusses the law’s past, present, and future with three experts on ERISA: Larry Levitt of KFF, a health information nonprofit that includes KFF Health News; Paul Fronstin of the Employee Benefit Research Institute, a nonprofit; and Ilyse Schuman of the American Benefits Council, a trade group advocating for employers that sponsor worker benefit plans.
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Transcript: Happy 50th, ERISA
KFF Health News’ ‘What the Health?’ Episode Title: ‘Happy 50th, ERISA’ Episode Number: 360Published: Thursday, Aug. 15, 2024
[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. Usually, I’m joined by some of the best and smartest health reporters in Washington, but today, we have a special episode for you. We’re taping this week on Monday, Aug. 12th, at 2 p.m. As always, news happens fast, and things might’ve changed by the time you hear this — although this time, I hope not. So here we go.
So if you follow health policy, you’re likely familiar with the big federal laws that have shaped how health care in the U.S. is organized and delivered and paid for. Medicare and Medicaid in 1965, HIPAA in 1996, and the Affordable Care Act in 2010, just to name a few.
One you may not have heard as much about is ERISA, the Employee Retirement Income Security Act, which was signed in 1974 by then-President Gerald Ford. This fall marks 50 years since ERISA became law. ERISA, as its name suggests, is mostly about protecting pension benefits for workers. It was inspired, at least in part, by the collapse of a pension fund when a plant that built Studebaker cars in Ohio shut down in 1963. But, at least as legend has it, at the very last minute in the House-Senate Conference in 1974, someone decided to add health benefits to ERISA’s scope, and that literally changed the entirety of how health benefits are regulated in the U.S.
I am pleased to have an all-star panel here to join us to talk about what ERISA has meant to health policy and what it’s likely to mean going forward as it begins its second half-century. Larry Levitt is executive vice president for policy here at KFF and one of only a few people in the organization even nerdier than I am about things like ERISA. Paul Fronstin is director of health benefits research at the Employee Benefit Research Institute, a nonpartisan think tank that does research and education. Paul has also taught me more about ERISA over the years than probably any other single person.
Finally, Ilyse Schuman is senior vice president of the American Benefits Council, which represents large employers and other providers of health and retirement benefits through employer-sponsored plans. Ilyse also spent several years on Capitol Hill working on the Senate committee that oversees ERISA policy. So, a lot of knowledge here in our podcast box. Thanks for all of you for being here.
Ilyse Schuman: Thank you
Larry Levitt: Great to be here.
Rovner: So let’s start at the beginning. How did health benefits wind up being covered in a law that was aimed at retiree pensions?
Paul Fronstin: None of us were here or there at the time, so I think anything we know is second- or third-hand information. And like you said, the provision was inserted at the last minute, but I think there were a lot of conversations about it leading up to it being inserted at the last minute. I think a lot of it had to do with some tensions between state regulation and federal regulation, because there were self-insured health plans in existence and self-insured benefits more generally in existence before ERISA passed.
And clearly those plans wanted some federal protection regarding what they were doing, and the states wanted more regulation. And I’ve read a little bit about this over the years, and there was certainly some lobbying for and against having a provision in there to protect self-insured plans from state regulation. So the conversations were happening. It just … the language probably just didn’t make it into the legislation till the last minute.
Schuman: And I think certainly the landscape back in 1974, as Paul talked about, was that more and more states were creating, with respect to health care, their own versions of various laws. And so self-funded plans, large employers like our members — a number of them were back in existence 50 years ago, some weren’t — were finding it increasingly difficult to be able to administer their self-funded plans on a uniform basis nationwide.
So it wasn’t in the backrooms when they were actually drafting the legislation, but certainly note that the nationwide landscape in this growing patchwork of state health laws was becoming increasingly problematical for self-funded health plans.
Levitt: Yeah. I mean, this was also a period when health insurance was changing quite dramatically. I mean, before this time health insurance was pretty simple. It was called indemnity insurance, right.
You went to the doctor, you went to the hospital, you got a claim, you filed it with your insurance company, and they paid 80% of it. This was a time when PPOs [preferred provider organizations] were starting, managed care, HMOs were really just getting their start. So there was a need for much more regulation because insurance was getting more complicated.
Fronstin: Yeah. To some degree, the HMO Act of, what, 1973, right, just the year before. So HMOs were just coming on the scene, and that may have played into this as well.
Rovner: So back in 1945, when really none of us were in the room, Congress passed something called the McCarran-Ferguson Act, which was supposed to ensure that states rather than the federal government retained the authority to regulate insurance. What happened in ERISA to change that? Ilyse, I think you were already sort of referring to this. And what do we mean when we talk about ERISA preemption? That’s a phrase that people hear a lot and their eyes glaze over.
Schuman: Sure. Well, their eyes may glaze over but it really is foundational to millions of Americans and their families that are covered by employers who decide that they want to self-fund their plans. That means that they’re the ones that decide that, “Hey, we’re going to take the risk as offering these benefits instead of the carrier.”
Rovner: So they’re not actually buying insurance because …
Schuman: That’s …
Rovner: … they’re paying the bills.
Schuman: They’re doing more than just paying the bill. They’re the ones that are ultimately assuming the risks of those claims, too. And I think the value. So maybe — just to step back before we talk about what a preemption is — is what we talk about employers who decide to self-fund versus those that don’t. Admittedly, many of those that self-fund are larger employers, but again, they say that “We will take the risk of paying for the claims of our health insurance coverage instead of the carrier. But along with that, we get the flexibility and we get the ability to design and implement health coverage that we think meets the needs of our population. That’s enabled us to” — speaking again from self-funded employers — “to implement innovative designs with the assurances that they could implement those, they could administer that on a uniform basis nationwide.” So that’s really what we’re talking about. Preemption is the ability of self-funded employers to administer those benefits on a uniform basis nationwide.
And yes, getting back to McCarran-Ferguson, and if you want to talk through the sort of various layers of ERISA preemption, is there’s something called the savings clause, which is OK. So ERISA says: “First threshold level, we are going to preempt state laws.” But there’s a savings provision that says basically: “If you’re in the business of insurance, states can regulate that.” But then there’s this deemer clause — this is really nerdy now, so some of your audience may be wondering here what we’re talking about …
Rovner: I remember learning this many, many years ago.
Schuman: No. Yeah. So if you’re in law school, take note that the deemer clause means that self-funded group health plan is deemed not to be in the business of insurance; meaning that they don’t have to comply with those state insurance laws.
Levitt: And here’s where this gets really tangible for people, right? So 150 million people have insurance coverage through an employer. It’s the biggest source of health coverage. But 65% of them are in self-insured plans, like Ilyse was talking about. And those self-insured plans are exempt from state regulation.
So if a state is regulating insurance, let’s say mandating benefits, mandating coverage of IVF, mandating coverage of preventive care, mastectomies, whatever — those regulations that states are putting in place do not apply to most people with employer-sponsored insurance because they are in these self-funded plans.
Rovner: And, of course, the continuing complications that a lot of people who are in these self-funded plans don’t know it because they have an insurance card and it says Blue Cross or Aetna or whatever, because, in their case, they have an insurance card, but the insurer is not providing insurance, right?
Levitt: No, it’s remarkable. We did a survey of consumers about their experiences with health insurance. And we asked them, “What government agency do you think you would turn to with a problem with your insurance?” And literally zero people said the Department of Labor, which is the government agency that actually enforces ERISA.
Rovner: But I guess what I was asking about are third-party administrators, which I think most people have never heard of until they discover that they’re not subject to their state’s requirement.
Levitt: Absolutely. I mean, it gets really confusing, right? Because it might be that UnitedHealthcare is administering this self-funded plan, but you, as an employee in this plan, have no way of really understanding is that a self-insured plan administered by UnitedHealthcare? Or is that an insurance plan administered by UnitedHealthcare? And then there are these third-party administrators that you’ve never even heard of that are administering them for many employers.
Rovner: Paul, you wanted to add something.
Fronstin: We need to distinguish between ERISA and self-insured plans, right, because they’re not one and the same. ERISA also covers fully insured plans.
Schuman: Right.
Fronstin: So fully insured plans are regulated both by ERISA and at the state level. And then you’ve got some self-insured plans like government plans that are not covered by ERISA, right? But they’re self-insured. So it’s even more complicated than what we’re making it out to be when we talk about ERISA, preemption, and self-insurance. That’s just one aspect of ERISA.
Schuman: And I think to the point about employees not sure what covers them, what doesn’t cover them. Again, for self-funded large employers, I mean, I think most of the employees understand from their employer, from the group health plan, what the terms of the plan are, and what the benefits are. And I think in some ways, perhaps less complex than, OK, if you’re an employee working in Kentucky, you have one plan. If you’re an employee working in New York, you have another plan. And employees talking to each other and saying, “Hey, how come you have that and I don’t have this?”
So I think that the clarity or the consistency is important not just for employers who are administering the plan, but for employees understanding what the terms of the plans are. And also, two things about sort of the benefits and what’s covered. There’s a difference between a state saying, “OK, you have to cover this benefit and have to cover it in precisely this way” versus employers who say, “Look, it’s really important for our population, to be healthy and productive, to have these benefits, and so we’re going to offer this benefit. We’re just going to do it in the same way nationwide.”
And remember, ERISA, if the federal government, as it has done over the past, wants to make changes to … that are applicable to group health plans, it can amend and has amended ERISA to do that. So the market reforms, for example, in the Affordable Care Act, were applicable, and the Public Health Service Act, were sort of incorporated into ERISA. The Genetic Information Nondiscrimination Act, for example, amended ERISA. So it’s like that’s the lever to make changes to ERISA that will be applicable to self-funded plans as well is at the federal level.
Rovner: When I was first covering Congress in the 19… late-1980s and early-1990s, you didn’t go there. If you wanted to do something about health policy, you didn’t touch ERISA. I think lawmakers were afraid of reopening it and getting into all kinds of fights. Why did that finally change?
Levitt: I mean, I think there was a growing recognition, particularly with the Affordable Care Act, that there were just some minimum thresholds that health coverage had to meet to be legitimate coverage. So if you look at what the ACA did, and as Ilyse said, those applied to all employers, all group health plans through the amendments to ERISA.
And these were things like no preexisting condition exclusions, coverage of preventive services with no patient cost sharing, no annual on lifetime limits, a cap on out-of-pocket costs. And probably the most popular provision of the ACA, coverage of dependents up to age 26. There was no way to reach everyone with insurance without amending ERISA under the Affordable Care Act.
Fronstin: Yeah. But there were examples, pre-ACA, that affected all plans, or most plans, like mental health parity we didn’t mention. Well, there’s been a couple of instances of that. And certainly the Clinton health plan tried this and didn’t succeed in the early 1990s.
Rovner: And HIPAA …
Levitt: I mean …
Rovner: … which was, I guess, the first major walk into ERISA since ERISA had been passed.
Levitt: Right. Or even COBRA. The ability to continue your insurance after you leave an employer was an amendment to ERISA.
Rovner: That’s right. And that was in 1986.
Fronstin: Yeah, and even that could be confusing because it exempts smaller employers, right. But you got the mini-COBRA laws at state level that affect some of those employers, but not every state has one.
Rovner: Yeah. And Paul, you were referring to this. We should probably talk about who’s not subject to ERISA because I don’t think anybody mentioned church plans. There’s a rule, and then there’s all these exceptions.
Fronstin: I think the two major categories are church plans, and I’m not sure we even have a good handle on how many people are covered by church plans because a lot of them tend to be small businesses, and they may not even offer coverage. And federal, state, and local government. I’m not sure if there’s another category in there that’s not covered by ERISA. I believe that the state and local governments have their own law that’s similar to ERISA, but it’s not ERISA.
Schuman: And I think when we talk about covered by ERISA, certainly it’s, What does ERISA afford? It’s not just about self-funded employers being able to offer uniform benefits nationwide. There are important protections. There are important disclosure requirements for employees, for participants that are included in there that are applicable to all ERISA plans, self-funded and insured plans, and obviously on the retirement plans, too.
But I just think it’s really important that we look to see the idea behind ERISA was that, yes, there will be this uniformity for self-funded plans. But for all ERISA plans, there are these protections and safeguards in there that are embedded in the law for the benefit of participants.
Rovner: And that’s why you used to get a phone-book-thick, “This is your plan documentation.” Now, it’s all online, and it’s all in 4-point type. But that’s where that comes from, right? At the requirement that you be told everything that your plan covers.
Schuman: Right. Correct.
Rovner: So, Larry, you kind of referred to this earlier. Self-funded ERISA plans are regulated not by the states but by the Department of Labor, which most people don’t know. And for a long time, if you were injured or someone died as a result of being denied care, the only thing that they could recover was the cost of the care that was denied. Not any damages for what happened. When did that finally change? And has it finally changed? What do you do now if you’re injured — you can’t go to your state regulatory agency?
Levitt: No, there have been some changes to that, but enforcement of ERISA is still relatively light at the administrative level compared to what state insurance departments do. And the Department of Labor just seems very far away to people compared to a state insurance department.
I think it’s really this structure of ERISA that, Julie, you said people were always resistant to amending in Congress, that has been resistant to amendment, right? I mean, this idea that states regulate insurance directly but that states cannot regulate group health plans under ERISA. And that’s had far-reaching health policy implications. So states looking to do employer mandates or anything that directly affects those group health plans, employer health plans, and that’s maybe …
Rovner: Also, states looking to do single-payer plans, right?
Levitt: Yeah. No, I mean, single-payer there might be some ways around ERISA through single-payer and taxation, but ERISA has been a barrier to state health reform efforts, for better or for worse.
Schuman: If maybe we can just step back 50 years, I think it’s … I wrote down this quote from one of the authors of ERISA, specifically on the ERISA preemption, and that was by Rep. John Dent, who was a Democrat from Pennsylvania who identified the ERISA preemption as the law’s crowning achievement.
And he said it was the crowning achievement because, without it, the legislation would not have enjoyed the support of both labor and management since it’s so fundamental for the ability of multistate employers to sponsor benefit plans to workers nationwide. So I think just kind of getting back into the minds of the drafters of ERISA, that bargain, if you will, that became ERISA preemption was really foundational to the law passing.
Rovner: And you could see why it would make sense. If you work for a national company and you get transferred from one state to another, your insurance shouldn’t change dramatically.
Schuman: Yeah. And I think fast-forward 50 years, and we’ve got, certainly, post-pandemic or after the pandemic, an increasingly mobile and remote workforce. And we have heard repeatedly about how ERISA preemption really promotes that worker mobility and the ability to work out of your house in another state or to be able to transfer from one location to another.
So think a little bit if we just see how the workforce itself has evolved, I think that ERISA preemption provision may become even more important. And I think increasingly, it’s not just large employers that find themselves — like nationwide or multistate employers — but because the workforce is more remote and mobile, and wants to be, that more and more employers of multistate employers, too.
Levitt: I would say we have increasingly seen smaller employers self-funding, and there are some advantages to that, right? They don’t necessarily have to pay premium taxes to states, and they are exempt from state benefit mandates that apply over and above beyond the Affordable Care Act. I mean, insurers have come up with very creative ways of allowing smaller businesses to self-fund and avoiding some of the risk by layering lots of reinsurance on top of that.
Fronstin: I was going to say, along with self-funding comes ease of administration here. Ilyse, you call it uniformity of benefits. But I think of employers, they don’t want to be offering 50 different health plans in 50 different states. And to the degree you’ve got the states doing something — whether it’s a single-payer or something short of that — employers, they just want to offer everyone the same benefit and make it as easy as possible to do so.
And my concern is if they had to comply with 50 different state laws to do so or create 50 different benefit plans, especially today with the ACA guaranteed issue and subsidized coverage, you’ll get to the point where if employers didn’t have the ability to provide one benefit plan across all 50 states, they’re not going to do it anymore, right? They’ve got … pre-ACA might’ve been different, but now they’ve got an alternative where their employees could get coverage if they didn’t offer coverage themselves.
Rovner: So that was all predicted. This huge movement away from employer-provided coverage after the ACA passed was predicted, and it didn’t happen.
Fronstin: I was one of those people predicting it. Yeah. Before the ACA passed, I was one of those people predicting it. And I think what happened is: One, being employers, they still value the benefit. They still understand there are business reasons to offer it, and they haven’t had a good excuse to get rid of it.
We haven’t had — other than the recession tied to covid — we haven’t had a recession. Our unemployment rate has been at historically low rates. And I think employers, they don’t want to mess with something that’s working for the most part because they use it to recruit and retain employees for the same thing they were doing back in the 1940s and ’50s when they first started offering it.
Schuman: I think it’s important to delineate the employer voice in here. And I think maybe there’s a perception that employers are just writing the checks or employers and health plans are kind of conflated. But employers are doing a lot more than just writing a check. And I think those, again, that have decided to self-fund want to be able to have control over how they’re spending their health care dollars. So again, they can try to drive more affordable, higher-value, higher-quality health care.
And so it’s not just about who writes the check, but the reasons behind employers saying, “Hey, we’re going to be spending … we spend a whole lot of money on our health benefits because we recognize that it’s good business. It’s good for employees. But we want to be able to have the ability to try to drive improvements in that to drive higher-value care.” And so that’s enabled by ERISA. So the health reforms and the health innovation, certainly there’s a lot coming from the states, but there’s a lot coming from employers, too.
Rovner: So what are the big issues going forward for ERISA? I mean, obviously, there’s still, if you Google ERISA, you get all kinds of lawsuits and challenges. And I mean, it’s still a very lively part of the law 50 years on.
Levitt: I mean, I think, Julie, you mentioned these lawsuits, and that is potentially a big issue going forward. Something called the Consolidated Appropriations Act added some transparency in fees that self-insured employer plans paid to providers. And that’s opened the door to some lawsuits challenging whether group health plans, ERISA plans, are acting as appropriate fiduciaries in trying to get the lowest costs, particularly for prescription drugs. And these started out as kind of a fringe movement, but I think pose some potential risks for group health plans.
Rovner: Ilyse, what are employers most concerned about?
Schuman: Well, I think that employers seeing the growing number of states that are trying to chip away, if not erode in a fundamental way, ERISA preemption is really alarming. A lot of these efforts have come up around pharmacy benefit managers and efforts to regulate pharmacy benefit managers at the state level.
But the way that they’ve done it, the states have really taken direct aim at ERISA preemption and self-funded plans and, I think, has much broader implications for self-funded group health plans beyond just the PBM context. And so I think that they’re looking at the growing number of states that are interested in passing laws that really erode ERISA preemption as very alarming.
Rovner: So I want to go around the table before we end. Sort of what do you think has been the biggest impact on the health system of ERISA, both for good and for not so good? I mean, it’s certainly one of the things that makes it so confusing to understand and explain. Larry, you want to go first?
Levitt: I think the biggest impact of ERISA has been putting the brakes on some state health reform efforts. States have found ways to get around it. Some raise some issues for employers, like Ilyse was saying, but it has really circumscribed what states can do around health reform. That said, ERISA has provided a very stable regulatory environment for employers and likely allowed employer coverage to grow over time in that environment.
Rovner: Paul?
Fronstin: Yeah, I’d say, in addition to that, it’s allowed employers to be innovative. Not every self-insured employer has been innovative, right? And there’s something like a million employers out there with a thousand or more employees. And the smaller of those are not necessarily being innovative, but they’re learning from the largest ones, right? The jumbo employers, who are trying to do different things when it comes to engaging the health system, right? Engaging hospitals and physicians and pharmaceutical managers.
And I think that that … the lessons learned from what they’re doing trickles down to the smaller self-insured employers, and it trickles out to the health insurers that are offering fully insured plans to small employers.
Rovner: Ilyse.
Schuman: I think ERISA has allowed employers to provide value-driven, comprehensive, affordable, higher-quality health coverage to working families across the country — 150 million, 180 million, guess it depends what stats you’re looking at, and that it’s withstood the test of time.
And I think that probably no stressor, like the pandemic, where many wondered what would emerge from that, and with some dents, but also with a lot of silver linings in terms of employers offering benefits to help their employees navigate through the pandemic. And so I think there’s a resiliency to the employer-sponsored system coupled with the innovation that Paul has mentioned.
Rovner: Last question. Yes or no? Is ERISA going to be around in another 50 years? In other words, are we still going to have this system of health coverage? I promise I will not hold you to it. Just best guess. Larry.
Levitt: I say no.
Rovner: Paul.
Fronstin: I answer “don’t know.”
Rovner:: That’s OK. Ilyse.
Schuman: Well, I will say that I just recently got a tortoise for my family that I’ve found will live 50 or 100 years, so beyond me. So will ERISA be around as long as Veggie, the tortoise? I don’t know.
I think that there’s really an important inflection point. And I think if addressing some of the underlying drivers of rising health care costs and consolidation, I think that if those are addressed, I think employer-provided coverage certainly has the ability to withstand the test of time over the next 50 years.
Rovner: Good. Thank you all so much. This has been great.
Schuman: Thanks a lot.
Levitt: Great. Thanks, Julie.
Schuman: Thank your team.
Levitt: Thanks all.
Schuman: Bye-bye.
Fronstin: Take care, everybody.
Levitt: Bye.
Rovner: Bye. OK, that’s our ERISA anniversary show. Big thanks to our guests, Larry Levitt of KFF, Paul Fronstin of EBRI, and Ilyse Schuman of the American Benefits Council. And before we go this week, we’re looking for your help on a project here at KFF Health News. Are you a young adult confused about navigating the exchanges used to pick plans? Have you bought a plan on an ACA exchange and found that it didn’t cover care you needed? Have you married or taken a job just to get insurance? Did you decide to go without coverage?
Whatever your story, KFF Health News and The New York Times want to hear it. Email your experience to Elisabeth Rosenthal — that’s elisabethr with an S, not a Z — @kff.org. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks, as usual, to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth, all one word, @kff.org, where you can still find me. I’m @jrovner on X. We’ll be back in your feed next week. Until then, be healthy.
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