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Julie Rovner
KFF Health News

@jrovner

Read Julie's stories.

Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

The presidential election is less than five months away, and while abortion is the only health policy issue expected to play a leading role, others are likely to be raised in the presidential and down-ballot races. This election could be critical in determining the future of key health care programs, such as Medicaid and the Affordable Care Act.

In this special episode of KFF Health News’ “What the Health?” taped at the Aspen Ideas: Health festival in Aspen, Colorado, Margot Sanger-Katz of The New York Times and Sandhya Raman of CQ Roll Call join Julie Rovner, KFF Health News’ chief Washington correspondent, to discuss what the election season portends for top health issues.

Panelists

Margot Sanger-Katz
The New York Times

@sangerkatz

Read Margot's stories.

Sandhya Raman
CQ Roll Call

@SandhyaWrites

Read Sandhya's stories.

Among the takeaways from this week’s episode:

• Policies surrounding abortion — and reproductive health issues, in general — likely will dominate in many races, as Democrats try to exploit an issue that is motivating their voters and dividing Republican voters. The topics of contraception and in vitro fertilization are playing a more prominent role in 2024 than they have in past elections.
• High prescription drug prices — which, for frustrated Americans, are a longtime symbol, and symptom, of the nation’s dysfunctional health care system — have been a priority for the Biden administration and, previously, the Trump administration. But the issue is so confusing and progress so incremental that it is hard to say whether either party has an advantage.
• The fate of many major health programs will be determined by who wins the presidency and who controls Congress after this fall’s elections. For example, the temporary subsidies that have made Affordable Care Act health plans more affordable will expire at the end of 2025. If the subsidies are not renewed, millions of Americans will likely be priced out of coverage again.
• Previously hot-button issues like gun violence, opioid addiction, and mental health are not playing a high-profile role in the 2024 races. But that could change case by case.
• Finally, huge health issues that could use public airing and debate — like what to do about the nation’s crumbling long-term care system and the growing shortage of vital health professionals — are not likely to become campaign issues.

click to open the transcript

Transcript: Live From Aspen: Health and the 2024 Elections

KFF Health News’ ‘What the Health?’ Episode Title: ‘Live From Aspen: Health and the 2024 Elections’Episode Number: 352Published: June 21, 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.] 

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Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent at KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. I am joined tonight by a couple of our regular panelists: Margot Sanger-Katz, The New York Times.

Sanger-Katz: Hey, everybody.

Rovner: And Sandhya Raman of CQ Roll Call.

Raman: Good evening everyone.

Rovner: For those of you who aren’t regular listeners, we have a rotating panel of more than a dozen health policy reporters, all of whom just happen to be women, and every week we recap and analyze the week’s top health news. But tonight we’ve been given a slightly different assignment to talk about how health policy is likely to shape the 2024 elections and, vice versa, how the elections are likely to shape health policy.

So, this is actually my 10th presidential election season as a health reporter, which is terrifying, and I can say with some experience that health is one of those issues that’s always part of the political debate but is relatively rarely mentioned when pollsters ask voters what their top issue is. Of those of you who went to the pollsters session this afternoon might’ve seen that or said we’re not going to… it’s not going to be a health election this year.

This year, though, I think will be slightly different. As you’ll hear, I’ve divided these issues into three different buckets: Those that are likely to be pivotal or very important to how people vote; those that are likely to come up over the next few months in the presidential and/or congressional and Senate races; and finally, a couple of issues that aren’t as likely to come up but probably should. It would be good to have a debate about them.

So we will start with the political elephant in the room: reproductive health. Since the Supreme Court overturned Roe v. Wade two years ago next week, abortion has been front and center in just about every political contest, usually, though not always, with the abortion-right side prevailing. How do you two see abortion playing out both at the presidential and congressional level these next couple of months?

Raman: I see it playing out in kind of two different ways. We see already at the presidential level that President Joe Biden has been really going in, all in, that this is his No. 1 issue, and I think this will continue to play out, especially next week with the anniversary of the Dobbs [v. Jackson Women’s Health Organization] decision.

And a lot of the Democrats in the Senate have kind of been taking lead from that and also really amping up the issue. They’ve been doing kind of messaging votes on things within the reproductive health spectrum and it seems like they’re going to continue that in July. So we’re going to see it really focused on there. On the Republican side, they’ve been not focused on this issue as much.

Rovner: They’ve been ducking this issue.

Raman: Yes, they’ve been ducking this issue, so I think it’ll just be continued to be downplayed. They’ve really been going in on immigration more than any other of the issues that they’ve got this year.

Sanger-Katz: If you look at the public polling, abortion is one of really the only issues where the Democrats and Joe Biden seem to have a real advantage over the Republicans and Donald Trump. And so I think that that tells you that they’re going to have to be hitting it a lot. This is an issue where the voters are with the Democrats. They trust Biden more. They agree more with the policies the Democrats are promoting around reproductive health care. So it’s just impossible for me to imagine a scenario in which we don’t see Democrats kind of up and down the ticket really taking advantage of this issue, running ads on it, talking about it, and trying to really foreground it.

I think for Biden, in particular, it’s a hard issue. I think he has always had some personal ambivalence about abortion. He’s a Catholic. He, early in his career, had opposed certain abortion rights measures that other Democrats had endorsed, and you can kind of see him slowly getting comfortable with this issue. I think he said the word abortion for the first time just in the last six months. I think I would anticipate a real ramping up of discussion of this issue among Democrats. The other dynamic that I think is pretty important is that there are a number of states that have ballot initiatives to try to kind of permanently enshrine abortion rights into state constitutions.

And some of those are in states that are not pivotal to the election, and they will be important in those states, and for those state senate races and governor races and other things, because they may pull in more of these voters who care a lot about reproductive rights. But there are some of these ballot measures that are in pivotal states for the presidential race, the kind of battleground states that we’re all watching. And so there’s a big emphasis on those as well. And I think there’s some interesting tensions with those measures because abortion rights actually are valued by people across the political spectrum.

So I think we tend to think of this as a Democrat-Republican issue where Republicans want to restrict abortion rights, and Democrats want to promote them. But we’re seeing in the public polling now that’s not really true. There are a lot of Republicans that are uncomfortable with the kind of abortion bans that we’re seeing in certain parts of the country now. So it’s this question: Are they going to come out and vote and split their ticket where they’ll vote for constitutional measure to protect abortion rights and still vote for President Trump? Or will the abortion issue mobilize them so much that they will vote across the board as Democrats?

And I think that’s a big question, and I think it’s a big challenge. In fact, for many of the people that are running these campaigns to get these ballot measures passed, how much they want to kind of lean into the Democratic messaging and try to help prop up Democratic candidates in their state. And how much they want to just take a step back and try to get Republicans to support their particular measure, even if it doesn’t help Democratic candidates on the ticket.

Rovner: Well, of course, it’s not just abortion that’s on the ballot, literally and figuratively. There’s a not-insignificant portion of the anti-abortion movement that not only wants to ban abortion nationwide but wants to establish in law something called personhood. The concept that a person with full legal rights is created at fertilization.

That would result in outlawing many forms of contraception, as well as if we have seen rather vividly this spring, IVF. Unlike abortion, contraception and IVF are very widely supported, not nearly as divisive as abortion itself is. Are we potentially looking at a divorce between the Republican Party and its longtime absolutist, anti-abortion backers?

Raman: I think that Republicans have been toeing the line on this issue so far. We’ve seen them not support some of the Democrats’ bills on the state level, the federal level, that are related to IVF, but at the same time, kind of introducing their counterparts or issuing broad statements in support of IVF, in support of contraception. Even just like a couple of weeks ago, we had Sen. Rick Scott of Florida release an IVF-themed full ad.

And so we have a lot of messaging on this, but I think at the same time a lot of these are tiptoeing the line in that they might not add any new protections. They might not codify protections for any of these procedures. They might just issue support or not address some of the other issues there that people have been going back and forth with the personhood issue.

Sanger-Katz: I think this is a big challenge for the Republican Party, not just over the course of this particular election cycle, but I think thinking further into the future. The pro-life movement has been such a pivotal group of activists that have helped elect Republicans and have been so strongly allied with various other Republican interest groups across the last few decades. And you can see that those activists helped overturn Roe after nearly 50 years of having a constitutional right to abortion.

Many of them don’t want to give up there. They really want to abolish abortion. They think it’s a morally abhorrent and something that shouldn’t happen in this country. And they’re concerned that certain types of contraception are similar to abortion in certain ways and that IVF is also morally abhorrent. And we saw recently with the [Southern] Baptist Convention that there was a vote basically to say that they did not support in vitro fertilization and assisted reproductive technologies.

Yet, at the same time, you can see in public polling and in the way that the public responds to these kinds of messages that the activists are way out further than the typical voter and certainly way out further than the typical Republican voter. And there’s this interesting case study that happened a few months ago where the Alabama Supreme Court issued a ruling — the implications of which suggested that IVF might be imperiled in that state — and it was kind of uncertain what the result that would be.

And what happened, in fact, is that Republicans and the Alabama State Legislature and the Republican governor of Alabama, many of whom had sort of longtime pro-life connections and promises, immediately passed a bill to protect in vitro fertilization because they saw that it was something that their voters really cared about and that’s something that could really hurt them politically if they were being seen as being allied with a movement that wanted to ban it.

But the activists in this movement are really important part of the Republican coalition, and they’re very close to leadership. And I think this is going to be a real tension going forward about how does the party accommodate itself to this? Do they win hearts and minds? They figure out a way to get the public on their side? Or do they kind of throw over these people who have helped them for so long, and these ideological commitments that I do think that many Republican politicians really deeply do hold?

Rovner: How much wild card is Donald Trump can be in this? He’s been literally everywhere on this issue, on reproductive rights in general. He is not shy about saying he thinks that abortion is a loser of an issue for Republicans. He wants to just continue to say, “Let the states do whatever they want.”

But then, of course, when the states do things like perhaps ban IVF — that I would think would even make Donald Trump uncomfortable — he seems to get away with being anywhere he wants with these very strong evangelical and pro-life groups who have supported him because, after all, he appointed the two Supreme Court justices that overturned Roe. But I’m wondering if, down-ballot, how all these other candidates are going to cope with the forever sort of changing position of the head of their ticket.

Sanger-Katz: I think it’s pretty interesting. I was talking with a colleague about this recently. It seems like Trump’s strategy is to just have every position. If you look at his statements, he said just about every possible thing that you could possibly say about abortion and where he stands on it. And I think it’s actually quite confusing to voters in a way that may help him because I think if you’re only looking for the thing that you want to hear, you can find it.

If you’re someone who’s really a pro-life activist who cares a lot about restricting abortion, he brags about having been responsible for overturning Roe. And if you’re someone who really cares about protecting IVF, he’s said that he wants that. If you’re someone who want… lives in a state that has… continues to have legal abortion, he said, “We’re going to leave that up to the states.”

If you’re in a state that has banned abortion, that has very extreme bans, he said something that pleases you. And so, I don’t know. I did a story a few weeks ago where I interviewed voters who had been part of a New York Times/Siena poll, and these were voters who, they were asked a question: Who do you find responsible for the Dobbs decision for the overturning of Roe v. Wade? And these were voters who supported abortion rights but thought that Joe Biden was responsible. And there’re like… it’s not a lot of people, but it’s …

Rovner: But it’s like 20%, isn’t it?

Sanger-Katz: Yeah, it’s like 10[%], 15% of voters in battleground states, people whose votes are really going to matter and who support abortion rights. They don’t know who was responsible. They don’t really understand the dynamics of where the candidates are on this issue. And I think for those of us who are very politically engaged and who are following it closely, it’s kind of hard to imagine. But they’re just a lot of people who are not paying close attention.

And so I think that makes Trump being everywhere on the issue, it makes it easier for those people to not really engage with abortion. And I think that’s again why I think we’re going to see the Biden campaign and other Democrats kind of hitting it over and over and over again. “This is Trump’s fault. We are going to protect abortion rights.” Because I think that there are a lot of voters who don’t really know what to make of the candidates and don’t know what to make of Trump on this particular issue.

Rovner: Well, Sandhya, they keep trying to bring it up in Congress, but I don’t think that’s really breaking through as a big news story.

Raman: No, and I think that for Congress, we’ve seen the same thing this year, but we’ve also seen it in previous years where they coalesce around a certain week or a certain time and bring up different bills depending on who’s in control of that chamber to message on an issue. But it hasn’t really moved the needle either way that we get similar tallies, whether it was this year or three years ago or 10 years ago.

One thing that I think activists are really looking at on the pro-life side is just really Trump’s record on these issues. Regardless of what he’s saying this week or last week or in some of these different interviews that’s a little all over the place. They’ve pointed to a lot of things that he’s done, like different things that he’s expanded more than previous Republican presidents. And for them, that might be enough.

That’s if it’s just the dichotomy of Biden versus Trump, that to get to their end goal of more pro-life policies, then Trump is the easy choice. And in the past years, the amount of money that they have poured into these elections to just really support issues… candidates that are really active on these issues, has grown astronomically. So I don’t know that necessarily if he does make some of these statements it’s going to make a huge difference in their support.

Sanger-Katz: And I think it also comes back to Julie’s opening point, which is I think abortion is an issue on which the Democrats have a huge edge, and I do think it is an issue that is very mobilizing for certain types of voters. But I also think that this is an election in which a lot of voters, whatever their commitments are on abortion, may be deciding who to vote for based on another set of issues. Those people that I talked to who were kind of confused about abortion, they really cared a lot about the economy.

They were really concerned about the cost of groceries. And so I think for those people, they may have a preference on abortion. If they could sort of pick each individual issue, they might pick something different. But I think the fact that they supported abortion rights did not necessarily mean that even if they really understood where the candidates were that they were necessarily going to vote for Joe Biden. I think a lot of them were going to vote for Donald Trump anyway because they thought he was better on the issues that were affecting their daily lives more.

Rovner: Well, Margot, to your point about voters not knowing who’s responsible for what, I think another big issue in this campaign is going to be prescription drug prices. As we know, drug prices are kind of the stand-in for everything that’s currently wrong with the nation’s health care system. The system is byzantine. It can threaten people’s health and even their lives if they can’t afford it.

And just about every other country does it better than we do. Interestingly, both President Biden and former President Trump made drug prices a top health priority, and both have receipts to show what they have done, but it’s so confusing that it’s not clear who’s going to get credit for these things that have gotten done.

Trump said that Biden was lying when Biden said that he had done the insulin cap for Medicare, which in fact was done by the Democrats, although Trump had done sort of a precursor to it. So, who wins this point, or do you think it’s going to end up being a draw? Because people are not going to be able to figure out who was responsible for which parts of this. And by the way, we haven’t really fixed it anyway.

Raman: I would say it was a draw for two reasons. I think, one, when we deal with something like drug prices, it takes a while for you to see the effects. When we have the IRA [Inflation Reduction Act] that made it so that we can negotiate the price of some drugs under Medicare, the effects of that are over a long tailwind. And so it’s not as easy to kind of bring that up in political ads and that kind of thing when people aren’t seeing that when they go to the pharmacy counter.

And I think another thing is that for at least on the congressional level, there’s been a little bit of a gap in them being able to pass anything that kind of moves the point along. They made some efforts over the past year but weren’t able to get it over the finish line. I think it’s a lot more difficult to say, “Hey, we tried but didn’t get this done” without a … as a clear campaign message and to get votes on that.

Sanger-Katz: I also think it’s this issue that’s really quite hard because — setting aside $35 insulin, which we should talk about — most people have insurance, and so the price of the drug doesn’t always affect them in a direct way. A lot of times, when people are complaining about the high cost of drugs, they’re really complaining about the way that their insurance covers the drug. And so the price of the drug might, in fact, be astronomical, but it’s the $100 copayment that people are responding to.

And so it could be that the government is taking all these actions, or the companies by themselves, and the price has gone down, but if you’re still paying that $100 copayment, you’re not really experiencing the benefits of that change. So I do think that the Democrats and Joe Biden have done two things that are helpful in that regard. So, one, is this $35 cap on copayments for insulin. So that’s just for people in Medicare, so it’s not everyone. But I do think that is… it’s a great talking point. You can put that on an ad. It’s a real thing.

People are going to go to the pharmacy counter, and they’re not going to pay more than that. It’s easy to understand. The other thing that they did, and I think this is actually harder to understand, is they redesigned the drug benefit for people who have Medicare. So it used to be in Medicare that if you had a really expensive set of drugs that you took, like, say, you had cancer and you were taking one of these newer cancer drugs that cost tens of thousands dollars a year, you could be on the hook for tens of thousands of dollars a year out of your own pocket, on top of what your insurance covered.

If you took less-expensive drugs, your insurance kind of worked the way it works for people in the commercial market where you have some copayments, not that you don’t pay anything, but it wasn’t sort of unlimited. But for really high-cost drugs in Medicare, people in Medicare were on the hook for quite a lot of money, and the Inflation Reduction Act changed that. They changed the Medicare drug benefit, and now these people who have these really expensive health conditions have a limit. They only have to pay a couple of thousand dollars a year.

Rovner: But it doesn’t start until next year.

Sanger-Katz: But it doesn’t start until next year. So I just think a lot of this stuff around drug prices is, people feel this sense of outrage that the drugs are so expensive. And so I think that’s why there’s this huge appetite for, for example, having Medicare negotiate the price of drugs. Which is another thing that the Inflation Reduction Act enabled, but it’s not going to happen in time for the election.

But I don’t think that really hits people at the pharmacy counter. That is more the benefits of that policy are going to affect taxpayers and the government. They’re not going to affect individual people so much. And I think that’s part of why it’s such a hard issue. And I think that President Trump bumped up against this as well.

His administration was trying all of these little techniques deep in the works of the drug pricing and distribution system to try to find ways to lever down the prices of drugs. And some of them worked, and some of them didn’t. And some of them got finalized, and some of them didn’t. But I think very few of them had this obvious consumer impact. And so it was hard for them to go to the voters and say, “We did this thing. It affected your life.”

Rovner: I see some of these ads, “We’ve got to do something about the PBMs [Pharmacy Benefit Managers].” And I’m like, “Who’s this ad even aimed at? I cover this for a living, and I don’t really understand what you’re talking about.” I wonder, though, if some… if candidates really on both sides, I mean, this is a unique election in that we’ve got two candidates, both of whom have records behind them.

I mean, normally, you would have at least one who’s saying, “This is what I will do.” And, of course, when it comes to drug prices, the whipping boy has always been the drug companies. And I’m wondering if we’re not going to see candidates from both parties at all levels just going up against the drug companies because that’s worked in the past.

Raman: I think it’s kind of a difficult thing to do when I think so many candidates, congressional level especially, have good relationships with pharmaceutical companies as some of the top donors for their campaigns. And so there’s always that hesitation to go too hard on them when that is helping keep them in office.

So it’s a little bit more difficult there to see teeth-out going into an ad for something like that. I think when we go back to something like PBMs where it seems like everyone in Congress just has made that kind of the bully of this past couple years, then that might be something that’d be easier to throw into ads saying, “I will go after PBMs.”

Sanger-Katz: I think we’re likely to see, especially in congressional races, a lot of candidates just promising to lower your drug prices without a whole lot of detail under that.

I don’t know that it’s necessarily going to be like the evil pharmaceutical companies, and I don’t think it’s going to be detailed policy proposals for all the reasons I just said: because it’s complicated; doesn’t always affect people directly; it’s hard to understand. But I think it will be a staple promise that we’ll particularly see from Democrats and that I expect we will hear from President Trump as well because it’s something that has been part of his kind of staple of talking points.

Rovner: So let’s move on to some of the issues that are sort of the second-tier issues that I expect will come up, just won’t be as big as immigration and abortion. And I want to start with the Affordable Care Act. I think this is the first time in a presidential election year that it seems that the continuing existence of the ACA is no longer in question. If you disagree, do let me know, but that’s not to suggest …

Sanger-Katz: Maybe last time.

Rovner: Little bit. That’s not to suggest, though, that the fate of the Affordable Care Act is not also on the line in this election. The additional subsidies that the Democrats added in the Inflation Reduction Act, which will sunset at the end of next year unless they are renewed, are responsible in large part for the largest percentage of Americans with health insurance ever measured.

And conversely, the Congressional Budget Office estimates that enrollment would fall by an immediate 20% if the subsidies are allowed to expire. It’s hard to see how this becomes a campaign issue, but it’s obviously going to be really important to what… I mean who is elected is going to be really important to what happens on this issue, and it’s a lot of people.

Raman: Using the subsidies as a campaign point is a difficult thing to do. It’s a complicated issue to put in a digestible kind of ad thing. It’s the same thing with a lot of the prescription drug pricing policies where, to get it down to the average voter, is hard to do.

And I think had we not gotten those subsidies extended, we would’ve seen people more going into that in ads. But when it’s keeping the status quo, people aren’t noticing that anything has changed. So it’s an even more difficult thing to kind of get across.

Sanger-Katz: I think this is one of, in health care, one of the highest-stakes things. That I feel like there’s just a very obvious difference in policy depending on who is elected president. Whereas a lot of the things that we’ve talked about so far, drug prices, abortion, a little harder to predict. But just to get out of the weeds for a second, Congress increased the amount of money that poor and middle-class people can get when they buy their own health insurance on the Obamacare exchanges. And they also made it possible for way more people to get health insurance for free.

So there are a lot of Americans who were uninsured before who now have insurance that they don’t pay a single dollar for. And there are also a lot of Americans that are higher, the kind of people that were disadvantaged in the early years of Obamacare, sort of self-employed people, small business owners who bought their own insurance and used to just have sort of uncapped crazy premiums. People who earn more than $100,000 a year now have financial assistance for the first time ever. And that policy has been in place for several years, and we’ve seen record enrollment.

There’s lots more people with insurance now, and their insurance is more affordable than it’s ever been. And those things are, of course, related. I think it’s almost definitely going to go away if Trump is elected to the presidency and if Republicans take at least one house of Congress because basically it’s on a glide path to expiration. So if nothing is done, that money will go away. What needs to happen is for Congress to pass a new law that spends new money to extend those subsidies and for a president to sign it.

And I just think that the basic ACA, the stuff that passed in 2010, I think is relatively safe, as Julie says. But lots of people are going to face much more expensive insurance and maybe unaffordable insurance. And again, the CBO [Congressional Budget Office] projects that a lot of people will end up giving up their insurance as a result of those changes if these policies are allowed to expire. And so I don’t know. I think we don’t see candidates talking about it very much. But I don’t actually think it’s that hard to message on. You could just say, “If you vote for this guy, your insurance premiums are going to go up by 50% or whatever.”

That doesn’t seem like a terrible message. So I do wonder if we’ll see more of that, particularly as we get closer to the election. Because it does feel like a real pocketbook issue for people. The cost of health care, the cost of health insurance, like the cost of drugs, I think, is something that really weighs on people. And we’ve seen in these last few years that making insurance cheaper has just made it much more appealing, much more accessible for people. There’s lots more Americans who have health insurance now, and that’s at risk of going away.

Rovner: Well, also on the list of things that are likely to come up, probably not in the presidential race, but certainly lower down on the ballot, is gender-affirming care. Republicans are right now are all about parental control over what books their children read and what they’re taught in school, but not apparently about medical care for their children.

They want that to be determined by lawmakers. This is very much a wedge issue, but I’m wondering for which side. I mean, traditionally, it would’ve been the conservatives and the evangelicals sort of pushing on this. But as abortion has sort of flip-flopped in importance among voters, I’m wondering where this kind of falls into that.

Raman: I think that the messaging that I’ve seen so far has still prominently been from Republicans on this issue. Whether or not it’s bills that they’ve been introducing and kind of messaging on in Congress or just even in the ads, there’s still been a lot of parental safeguards and the language related to that with relation to gender-affirming care. I have not actually seen as many Democratic ads going super into this. I think they have been way more focused on abortion.

I’m thinking back to, I saw a statistic that 1 in 4 Democratic ads go into abortion, which is really high compared to previous years. And so I don’t know that it will be as big of an issue. I even see some people kind of playing it down because the more attention it gets, sometimes it rallies people up, and they don’t… It’s kind of the flip of Republicans not wanting to bring attention to the abortion issue. And I think a lot of Democrats are trying to shy away so that some of these things aren’t elevated, that we aren’t talking about some of the talking points and the messaging that Republicans are bringing up on the same thing.

Sanger-Katz: Yeah, it feels to me almost like a mirror image of the abortion issue in the sense that the Democrats have this challenge where their activists are out in front of their voters. There clearly are parts of the Democratic coalition that are really concerned about transgender rights and wanting to protect them and are very opposed to some of the action that we’re seeing at the state and local level, both in terms of what’s happening in schools, but also regulation of medical care. But I think voters I think are less comfortable with transgender rights.

Even Democratic voters, you see sort of there’s more of a generational split on this issue than on some of these other issues where I think older voters are just a little bit less comfortable. And so I do think that it is an issue where — particularly certain parts of it like transgender athletes — that seems to be an area where you see the Republican message really getting more traction among certain subsets of Democratic voters. And I think it’s a hard issue for Democrats except in the places where there’s really broad acceptance.

Rovner: So I want to move on to the things that are less likely to come up, but probably should. We’re going to start with Medicaid. During the pandemic, it grew to cover over 90 million Americans. That’s like a third more than Medicare, which most people still think of as the largest government health program.

But as states pare back their roles after the expiration of the public health emergency, it seems that lots of people — particularly children, who are still eligible — are getting dropped nonetheless. During the fight over repealing the Affordable Care Act in 2017, it was the fate of Medicaid in large part that saved the program.

Suddenly, people realized that their grandmother was getting Medicaid and that one out of every three births, maybe one of every two births, is paid for by Medicaid. But now it seems not so much. Has Medicaid gotten invisible again in national politics?

Raman: I think, in a way, it has. I mean, it doesn’t mean that it’s any less important, but I haven’t seen as big of a push on it, as many people talking about it. And I think it is more of a tricky thing to message on at this point, given that if you look at where the states that have been disenrolling a lot of people, a lot of the ones that are near the top, are blue states.

California is a bigger population, but it’s also the one where they’ve disenrolled the most people. And so messaging on this is going to be difficult. It’s a harder thing to kind of attack your opponent on if this is something that is also being … been difficult in your state. It’s something that states have been grappling with even before we even got to this point.

Sanger-Katz: I think this is another issue where, I think, the stakes of the election are actually quite high. I do think it’s relatively invisible as an issue. I think part of the reason is that we don’t really see the Republicans talking about it, and I think the Democrats don’t really know how to message on it. I think they were really good at, “We’re going to protect you. We’re going to prevent the Republicans from taking this away from you.” But I think they don’t have a good affirmative message about, “How we love this program and we want to support and extend it.”

I don’t think voters are really responding to that. But if you look at what President Trump did in his first administration, he had budgets every single year that proposed savage cuts to Medicaid, big changes to the structure and funding of the program. Those did not get enacted into law. But even after Obamacare repeal was abandoned, you did not see the Trump budgets and the Trump administration, economic officials and health officials, abandoning those plans to make significant cuts to Medicaid.

And I think there are quite a lot of people in the Republican health policy world who think that Medicaid is sort of a bloated and wasteful program that needs to be rethought in a kind of fundamental way, needs to be handed back to the states to give them more fiscal responsibility and also more autonomy to run the program in their own way. I think we will see that again. I also think it’s very hard to know, of course, I feel like anytime… whoever’s in power is always less concerned about the deficit than they are when they are running for election.

But something we haven’t talked about because it’s not a health care issue, is that the expiration of the Trump tax reform bill is going to come up next year, and all of our budget projections that we rely on now assume that those tax cuts are going to expire. I think we all know that most of them probably are not going to expire regardless of who is elected. But I think if Trump and the Republicans take power again, they’re going to want to do certainly a full renewal and maybe additional tax cuts.

And so I think that does put pressure, fiscal pressure on programs like Medicaid because that’s one of the places where there’s a lot of dollars that you could cut if you want to counterbalance some of the revenues that you’re not taking in when you cut taxes. I think Medicaid looks like a pretty ripe target, especially because Trump has been so clear that he does not want to make major cuts to Medicare or to Social Security, which are kind of the other big programs where there’s a lot of money that you could find to offset major tax cuts if you wanted to.

Rovner: Yet, the only big program left that he hasn’t promised not to cut, basically. I guess this is where we have to mention Project 2025, which is this 900-page blueprint for what could happen in a second Trump term that the Trump campaign likes to say, whenever something that’s gets publicized that seems unpopular, saying, “It doesn’t speak for us. That’s not necessarily our position.”

But there’s every suggestion that it would indeed be the position of the Trump administration because one of the pieces of this is that they’re also vetting people who would be put into the government to carry out a lot of these policies. This is another one that’s really hard to communicate to voters but could have an enormous impact, up and down, what happens to health.

Sanger-Katz: And I think this is true across the issue spectrum that I think presidential candidates, certainly congressional candidates and voters, tend to focus on what’s going to happen in Congress. What’s the legislation that you’re going to pass? Are you going to pass a national abortion ban, or are you going to pass a national protect-abortion law? But actually, most of the action in government happens in regulatory agencies. There’s just a ton of power that the executive branch has to tweak this program this way or that.

And so on abortion, I think there’s a whole host of things that are identified in that Project 2025 report that if Trump is elected and if the people who wrote that report get their way, you could see lots of effects on abortion access nationwide that just happened because the federal agencies change the rules about who can get certain drugs or how things are transported across state lines. What happens to members of the military? What kind of funding goes to organizations that provide contraception coverage and other related services?

So, in all of these programs, there’s lots of things that could happen even without legislation. And I think that always tends to get sort of undercovered or underappreciated in elections because sort of hard to explain, and it also feels kind of technical. I think, speaking as a journalist, one thing that’s very hard is that this Project 2025 effort is kind of unprecedented in the sense that we don’t usually have this detailed of a blueprint for what a president would do in all of these very detailed ways. They have, I mean, it’s 100…

Rovner: Nine-hundred …

Sanger-Katz: … 900-page document. It’s like every little thing that they could do they’ve sort of thought about in advance and written down. But it’s very hard to know whether this document actually speaks for Trump and for the people that will be in leadership positions if he’s reelected and to what degree this is sort of the wish casting of the people who wrote this report.

Rovner: We will definitely find out. Well, kind of like Medicaid, the opioid crisis is something that is by no means over, but the public debate appears to have just moved on. Do we have short attention spans, or are people just tired of an issue that they feel like they don’t know how to fix? Or the fact that Congress threw a lot of money at it? Do they feel like it’s been addressed to the extent that it can be?

Raman: I think this is a really difficult one to get at because it’s — at the same time where the problem has been so universal across the country — it has also become a little fragmented in terms of certain places, with different drugs becoming more popular. I think that, in the past, it was just so much that it was the prescription opioids, and then we had heroin and just different things. And now we have issues in certain places with meth and other drugs. And I think that some of that attention span has kind of deviated for folks. Even though we are still seeing over 100,000 drug-related deaths per year; it hasn’t dipped.

And the pandemic, it started going up again after we’d made some progress. And I’m not sure what exactly has shifted the attention, if it’s that people have moved on to one of these other issues or what. But even in Congress, where there have been a lot of people that were very active on changing some of the preventative measures and the treatment and all of that, I think some of those folks have also left. And then when there’s less of the people focused on that issue, it also just slowly trickles as like a less-hyped-up issue in Congress.

Sanger-Katz: I think it continues to be an issue in state and local politics. In certain parts of the country I think this is a very front-of-mind issue, and there’s a lot of state policy happening. There’s a lot also happening at the urban level where you’re seeing prosecutors, mayors, and others really being held accountable for this really terrible problem. And also with the ancillary problems of crime and homelessness associated with people who are addicted to drugs. So, at the federal level, I agree, it’s gotten a little bit sleepy, but I think in certain parts of the country, this is still a very hot issue.

And I do think this is a huge, huge, huge public health crisis that we have so many people who are dying of drug overdoses and some parts of the country where it is just continuing to get worse. I will say that the latest data, which is provisional, it’s not final from the CDC [Centers for Disease Control and Prevention], but it does look like it’s getting a little bit better this year. So it’s getting better from the worst ever by far. But it’s the first time in a long time that overdoses seem to be going down even a little. So I do think there’s a glimmer of hope there.

Raman: Yeah. But then the last time that we had that, it immediately changed again. I feel like everyone is just so hesitant to celebrate too much just because it has deviated so much.

Sanger-Katz: It’s definitely, it’s a difficult issue. And even the small improvements that we’ve seen, it’s a small improvement from a very, very large problem, so.

Rovner: Well, speaking of public health, we should speak of public health. We’re still debating whether or not covid came from a wet market or from a lab leak, and whether Dr. [Anthony] Fauci is a hero or a villain. But there seems to be a growing distrust in public health in general. We’ve seen from President Trump sort of threatened to take federal funds away from schools with vaccine mandates.

The context of what he’s been saying suggests he’s talking about covid vaccines, but we don’t know that. This feels like one of these issues that, if it comes up at all, is going to be from the point of view of do you trust or do you not trust expertise? I mean, it is bigger than public health, right?

Raman: Yeah. I think that… I mean, the things that I’ve seen so far have been largely on the distrust of whether vaccines are just government mandates and just ads that very much are aligning with Trump that I’ve seen so far that have gone into that. But it does, broader than expertise.

I mean, even when you go back to some of the gender-affirming care issues, when we have all of the leading medical organizations that are experts on this issue speaking one way. And then we having to all of the talking points that are very on the opposite spectrum of that. It’s another issue where even if there is expertise saying that this is a helpful thing for a lot of folks that it’s hard to message on that.

Sanger-Katz: And we also have a third-party candidate for the presidency who is, I think, polling around 10% of the electorate — and polling both from Democratic and Republican constituencies — whose kind of main message is an anti-vaccine message, an antipublic health message.

And so I think that reflects deep antipublic health sentiments in this country that I think, in some ways, were made much more prominent and widespread by the covid pandemic. But it’s a tough issue for that reason.

I think there is a lot of distrust of the public health infrastructure, and you just don’t see politicians really rushing into defend public health officials in this moment where there’s not a crisis and there’s not a lot of political upside.

Rovner: Finally, I have a category that I call big-picture stuff. I feel like it would be really refreshing to see broad debates over things like long-term care. How we’re going to take care of the 10,000 people who are becoming seniors every day. The future solvency of Medicare. President Trump has said he won’t cut Medicare, but that’s not going to help fix the financial issues that still ail at end, frankly, the structure of our dysfunctional health care system.

Everything that we’ve talked about in terms of drug prices and some of these other things is just… are all just symptoms of a system that is simply not working very well. Is there a way to raise these issues, or are they just sort of too big? I mean, they’re exactly the kinds of things that candidates should be debating.

Raman: That is something that I have been wondering that when we do see the debate next week, if we already have such a rich background on both of these candidates in terms of they’ve both been president before, they have been matched up before, that if we could explore some of the other issues that we haven’t had yet. I mean, we know the answers to so many questions. But there are certain things like these where it would be more refreshing to hear some of that, but it’s unclear if we would get any new questions there.

Rovner: All right. Well, I have one more topic for the panel, and then I’m going to turn it over to the audience. There are folks with microphones, so if you have questions, be thinking of them and wait until a microphone gets to you.

One thing that we haven’t really talked about very much, but I think it’s becoming increasingly important, is data privacy in health care. We’ve seen all of these big hacks of enormous storages of people’s very personal information. I get the distinct impression that lawmakers don’t even know what to do. I mean, it’s not really an election issue, but boy, it almost should be.

Sanger-Katz: I did some reporting on this issue because there was this very large hack that affected this company called Change Healthcare. And so many things were not working because this one company got hacked. And the impression I got was just that this is just an absolute mess. That, first of all, there are a ton of vulnerabilities both at the level of hospitals and at the level of these big vendors that kind of cut across health care where many of them just don’t have good cybersecurity practices.

And at the level of regulation where I think there just aren’t good standards, there isn’t good oversight. There are a lot of conflicting and non-aligned jurisdictions where this agency takes care of this part, and this agency takes care of that part. And I think that is why it has been hard for the government to respond, that there’s not sort of one person where the buck stops there. And I think the legislative solutions actually will be quite technical and difficult. I do think that both lawmakers and some key administration officials are aware of the magnitude of this problem and are thinking about how to solve it.

It doesn’t mean that they will reach an answer quickly or that something will necessarily pass Congress. But I think this is a big problem, and the sense I got from talking to experts is this is going to be a growing problem. And it’s one that sounds technical but actually has pretty big potential health impacts because when the hospital computer system doesn’t work, hospitals can’t actually do the thing that they do. Everything is computerized now. And so when there’s a ransomware attack on a main computer electronic health record system, that is just a really big problem. That there’s documentation has led to deaths in certain cases because people couldn’t get the care that they need.

Rovner: They couldn’t … I mean, couldn’t get test results, couldn’t do surgeries. I mean, there was just an enormous implications of all this. Although I did see that there was a hack of the national health system in Britain, too. So, at least, that’s one of the things that we’re not alone in.

Sanger-Katz: And it’s not just health care. I mean, it’s like everything is hackable. All it takes is one foolish employee who gives away their password, and you think, often, the hackers can get in.

Raman: Well, that’s one of the tricky parts is that we don’t have nationally, a federal data privacy law like they do in the E.U. and stuff. And so it’s difficult to go and hone in on just health care when we don’t have a baseline for just, broadly … We have different things happening in different states. And that’s kind of made it more difficult to get done when you have different baselines that not everyone wants to come and follow the model that we have in California or some of the other states.

Rovner: But apparently Change Healthcare didn’t even have two-factor authentication, which I have on my social media accounts, that I’m still sort of processing that. All right, so let’s turn it over to you guys. Who has a question for my esteemed panel?

[Audience member]: Private equity and their impact on health care.

Rovner: Funny, one of those things that I had written down but didn’t ask.

Sanger-Katz: I think this is a really interesting issue because we have seen a big growth in the investment of private equity into health care, where we’re seeing private equity investors purchasing more hospitals, in particular, purchasing more doctors’ practices, nursing homes. You kind of see this investment across the health care sector, and we’re just starting to get evidence about what it means. There’s not a lot of transparency currently. It’s actually pretty hard to figure out what private equity has bought and who owns what.

And then we really don’t know. I would say there’s just starting to be a little bit of evidence about quality declines in hospitals that are owned by private equity. But it’s complicated, is what I would say. And I think in the case of medical practices, again, we just don’t have strong evidence about it. So I think policymakers, there are some who are just kind of ideologically opposed to the idea of these big investors getting involved in health care. But I think there are many who are… feel a little hands-off, where they don’t really want to just go after this particular industry until we have stronger evidence that they are in fact bad.

Rovner: Oh, there’ve been some pretty horrendous cases of private equity buying up hospital groups, selling off the underlying real estate. So now that the… now the hospital is paying rent, and then the hospitals are going under. I mean, we’ve now seen this.

Sanger-Katz: Yeah, there’s… No, there’s… There have clearly been some examples of private equity investments in hospitals and in nursing homes that have led to really catastrophic results for those institutions and for patients at those places. But I think the broader question of whether private equity as a structure that owns health care entities is necessarily bad or good, I think that’s what we don’t know about.

Rovner: Yeah, I mean, there’s an argument that you can have the efficiencies of scale, and that there may be, and that they can bring some business acumen to this. There are certainly reasons that it made sense when it started. The question is what the private equity is in it for.

Is it there to try to support the organization? Or is it there to do what a lot of private equity has done, which is just sort of take the parts, pull as much value as you can out of them, and discard the rest, which doesn’t work very well in the health care system.

Sanger-Katz: I also think one thing that’s very hard in this issue — and I think in others that relate to changes in the business structure of health care — is that it’s, like, by the time we really know, it’s almost too late. There’s all of this incredible scholarship looking at the effects of hospital consolidation, that it’s pretty bad that when you have too much hospital concentration; particularly in individual markets, that prices go up, that quality goes down. It’s really clear. But by the time that research was done so many markets were already highly consolidated that there wasn’t a way to go back.

And so I think there’s a risk for private equity investment of something similar happening that when and if we find out that it’s bad, they will have already rolled up so much of medical practice and changed the way that those practices are run that there’s not going to be a rewind button. On the other hand, maybe it will turn out to be OK, or maybe it will turn out to be OK in certain parts of the health care system and not in others. And so there is, I think, a risk of over-regulating in the absence of evidence that it’s a problem.

Raman: Yeah. And I would just echo one thing that you said earlier is that about the exploratory stages. Everything that I can rack my brain and think of that Congress has done on this has been very much like, “Let’s have a discussion. Let’s bring in experts,” rather than like really proposing a lot of new things to change it. I mean, we’ve had some discussion in the past of just changing laws about physician-owned practices and things like that, but it hasn’t really gone anywhere. And some of the proponents of that are also leaving Congress after this election.

Rovner: And, of course, a lot of this is regulated at the state level anyway, which is part of the difficulty.

Sanger-Katz: And there is more action at the state level. There are a bunch of states that have passed laws that are requiring more transparency and oversight of private equity acquisitions in health care. That seems to be happening faster at the state level than at the federal level.

Raman: And so many times, it trickles from the state level to the federal level anyway, too.

Rovner: Maybe the states can figure out what to do.

Sanger-Katz: Yes.

Rovner: More questions.

[Audience member]: Oh, yeah. I have a question about access to health care. It seems that for the past few years, maybe since covid, almost everybody you talked to says, “I can’t get an appointment with a doctor.” They call, and it’s like six months or three months. And I’m curious as to what you think is going on because … in this regard.

Raman: I would say part of it is definitely a workforce issue. We definitely have more and more people that have been leaving due to age or burnout from the pandemic or from other issues. We’ve had more antagonism against different types of providers that there’ve been a slew of reasons that people have been leaving while there’s been a greater need for different types of providers. And so I think that is just part of it.

Rovner: I feel like some of this is the frog in the pot of water. This has been coming for a long time. There have been markets where people have… people unable to get in to see specialists. You break your leg, and they say, “We can see you in November.” And I’m not kidding. I mean, that’s literally what happens. And now we’re seeing it more with primary care.

I mean that the shortages that used to be in what we called underserved areas, that more and more of the country is becoming underserved. And I think because we don’t have a system. Because we’re all sort of looking at these distinct pieces, I think the health care workforce issue is going kind of under the radar when it very much shouldn’t be.

Sanger-Katz: There’s also, I think, quite a lot of regional variation in this problem. So I think there are some places where there’s really no problem at all and certain specialties where there’s no problem at all. And then there are other places where there really are not enough providers to go around. And rural areas have long had a problem attracting and retaining a strong health care workforce across the specialties.

And I think in certain urban areas, in certain neighborhoods, you see these problems, too. But I would say it’s probably not universal. You may be talking to a lot of people in one area or in a couple of areas who are having this problem. But, as Julie said, I think it is a problem. It’s a problem that we need to pay attention to. But I think it’s not a problem absolutely everywhere in the country right now.

Rovner: It is something that Congress… Part of this problem is because Congress, in 1997, when they did the Balanced Budget Act, wanted to do something about Medicare and graduate medical education. Meaning why is Medicare paying for all of the graduate medical education in the United States, which it basically was at that point? And so they put in a placeholder. They capped the number of residences, and they said, “We’re going to come back, and we’re going to put together an all-payer system next year.”

That’s literally what they said in 1997. It’s now 27 years later, and they never did it, and they never raised the cap on residencies. So now we’ve got all these new medical schools, which we definitely need, and we have all of these bright, young graduating M.D.s, and they don’t have residencies to go to because there are more graduating medical school seniors than there are residency slots. So that’s something we’re… that just has not come up really in the past 10 years or so. But that’s something that can only be fixed by Congress.

Raman: And I think even with addressing anything in that bubble we’ve had more difficulty of late when we were… as they were looking at the pediatric residency slots, that whole discussion got derailed over a back-and-forth between members of Congress over gender-affirming care.

And so we’re back again to some of these issues that things that have been easier to do in the past are suddenly much more difficult. And then some of these things are felt down the line, even if we are able to get so many more slots this year. I mean, it’s going to… it takes a while to broaden that pipeline, especially with these various specialized careers.

Rovner: Yeah, we’re on a trajectory for this to get worse before it gets better. There’s a question over here.

[Audience member]: Hi. Thanks so much. I feel like everybody’s talking about mental health in some way or another. And I’m curious, it doesn’t seem to be coming at the forefront in any of the election spaces. I’m curious for your thoughts.

Raman: I think it has come up some, but not as much as maybe in the past. It has been something that Biden has messaged on a lot. Whenever he does his State of the Union, mental health and substance use are always part of his bipartisan plan that he wants to get done with both sides. I think that there has been less of it more recently that I’ve seen that them campaigning on. I mean, we’ve done a little bit when it’s combined with something like gun violence or things like that where it’s tangentially mentioned.

But front and center, it hasn’t come up as much as it has in the past, at least from the top. I think it’s still definitely a huge issue from people from the administration. I mean, we hear from the surgeon general like time and time again, really focusing on youth mental health and social media and some of the things that he’s worried about there. But on the top-line level, I don’t know that it has come up as much there. It is definitely talked about a lot in Congress. But again, it’s one of those things where they bring things up, and it doesn’t always get all the way done, or it’s done piecemeal, and so …

Rovner: Or it gets hung up on a wedge issue.

Raman: Yep.

Sanger-Katz: Although I do think this is an issue where actually there is a fair amount of bipartisan agreement. And for that reason, there actually has been a fair amount of legislation that has passed in the last few cycles. I think it just doesn’t get the same amount of attention because there isn’t this hot fight over it. So you don’t see candidates running on it, or you don’t see people that…

There’s this political science theory called the Invisible Congress, which is that sometimes, actually, you want to have issues that people are not paying attention to because if they’re not as controversial, if they’re not as prominent in the political discourse, you can actually get more done. And infrastructure, I think, is a kind of classic example of that, of something like it’s not that controversial. Everybody wants something in their district. And so we see bipartisan cooperation; we got an infrastructure bill.

And mental health is kind of like that. We got some mental health investments that were part of the pandemic relief packages. There was some mental health investment that was part of the IRA, I believe, and there was a pretty big chunk of mental health legislation and funding that passed as part of the gun bill.

So I do think there’s, of course, more to do it as a huge problem. And I think there are probably more creative solutions even than the things that Congress has done. But I think just because you’re not seeing it in the election space doesn’t mean that there’s not policymaking that’s happening. I think there has been a fair amount.

Rovner: Yeah, it’s funny. This Congress has been sort of remarkably productive considering how dysfunctional it has been in public. But underneath, there actually has been a lot of lawmaking that’s gone on, bipartisan lawmaking. I mean, by definition, because the House is controlled by Republicans and the Senate by Democrats. And I think mental health is one of those issues that there is a lot of bipartisan cooperation on.

But I think there’s also a limit to what the federal government can do. I mean, there’s things that Congress could fix, like residency slots, but mental health is one of those things where they have to just sort of feed money into programs that happen. I think at the state and local level, there’s no federal… Well, there is a federal mental health program, but they’re overseeing grants and whatnot. I think we have time for maybe one more question.

[Audience member]: Hi. To your point of a lot of change happens at the regulatory level. In Medicaid one of the big avenues for that is 1115 waivers. And let’s take aside block granting or anything else for a minute. There’s been big bipartisan progress on, including social care and whole-person care models. This is not just a blue state issue. What might we expect from a Trump administration in terms of the direction of 1115s, which will have a huge effect on the kind of opportunity space in states for Medicaid? And maybe that we don’t know yet, but I’m curious. Maybe that 900-page document says something.

Sanger-Katz: Yeah, I think that’s an example of we don’t know yet because I think the personnel will really matter. From everything that I know about President Trump, I do not think that the details of Medicaid 1115 waiver policy are something that he gets up in the morning and thinks about or really cares that much about. And so I think …

Rovner: I’m not sure it’s even in Project 2025, is it?

Sanger-Katz: I think work requirements are, so that was something that they tried to do the last time. I think it’s possible that we would see those come back. But I think a lot really depends on who is in charge of CMS [Centers for Medicare & Medicaid Services] and Medicaid in the next Trump administration and what are their interests and commitments and what they’re going to say yes and no to from the states. And I don’t know who’s on the shortlist for those jobs, frankly. So I would just put that in a giant question-mark bin — with the possible exception of work requirements, which I think maybe we could see a second go at those.

Raman: I would also just point to his last few months in office when there were a lot of things that could have been changed had he been reelected; where they wanted to change Medicaid drug pricing. And then we had some things with block grants and various things that had we had a second Trump presidency we could have seen some of those waivers come to a fruition. So I could definitely see a push for more flexibility in asking states to come up with something new that could fall for under one of those umbrellas.

Rovner: Well, I know you guys have more questions, but we are out of time. If you enjoyed the podcast tonight, I hope you will subscribe. Listen to “What the Health?” every week. You can get it wherever you get your podcast. So good night and enjoy the rest of the festival. Thanks.

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The Host

Julie Rovner
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

A unanimous Supreme Court turned back a challenge to the FDA’s approval and rules for the abortion pill mifepristone, finding that the anti-abortion doctor group that sued lacked standing to do so. But abortion foes have other ways they intend to curtail availability of the pill, which is commonly used in medication abortions, which now make up nearly two-thirds of abortions in the U.S.

Meanwhile, the Biden administration is proposing regulations that would bar credit agencies from including medical debt on individual credit reports. And former President Donald Trump, signaling that drug prices remain a potent campaign issue, attempts to take credit for the $35-a-month cap on insulin for Medicare beneficiaries — which was backed and signed into law by Biden.

This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Rachana Pradhan of KFF Health News, and Emmarie Huetteman of KFF Health News.

Panelists

Anna Edney
Bloomberg

@annaedney

Read Anna's stories.

Emmarie Huetteman
KFF Health News

@emmarieDC

Read Emmarie's stories.

Rachana Pradhan
KFF Health News

@rachanadpradhan

Read Rachana's stories.

Among the takeaways from this week’s episode:

• All nine Supreme Court justices on June 13 rejected a challenge to the abortion pill mifepristone, ruling the plaintiffs did not have standing to sue. But that may not be the last word: The decision leaves open the possibility that different plaintiffs — including three states already part of the case — could raise a similar challenge in the future, and that the court could then vote to block access to the pill.
• As the presidential race heats up, President Joe Biden and former President Donald Trump are angling for health care voters. The Biden administration this week proposed eliminating all medical debt from Americans’ credit scores, which would expand on the previous, voluntary move by the major credit agencies to erase from credit reports medical bills under $500. Meanwhile, Trump continues to court vaccine skeptics and wrongly claimed credit for Medicare’s $35 monthly cap on insulin — enacted under a law backed and signed by Biden.
• Problems are compounding at the pharmacy counter. Pharmacists and drugmakers are reporting the highest numbers of drug shortages in more than 20 years. And independent pharmacists in particular say they are struggling to keep drugs on the shelves, pointing to a recent Biden administration policy change that reduces costs for seniors — but also cash flow for pharmacies.
• And the Southern Baptist Convention, the nation’s largest branch of Protestantism, voted this week to restrict the use of in vitro fertilization. As evidenced by recent flip-flopping stances on abortion, Republican candidates are feeling pressed to satisfy a wide range of perspectives within even their own party.

Also this week, Rovner interviews KFF president and CEO Drew Altman about KFF’s new “Health Policy 101” primer. You can learn more about it here.

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

Julie Rovner: HuffPost’s “How America’s Mental Health Crisis Became This Family’s Worst Nightmare,” by Jonathan Cohn.

Anna Edney: Stat News’ “Four Tops Singer’s Lawsuit Says He Visited ER for Chest Pain, Ended Up in Straitjacket,” by Tara Bannow.

Rachana Pradhan: The New York Times’ “Abortion Groups Say Tech Companies Suppress Posts and Accounts,” by Emily Schmall and Sapna Maheshwari.

Emmarie Huetteman: CBS News’ “As FDA Urges Crackdown on Bird Flu in Raw Milk, Some States Say Their Hands Are Tied,” by Alexander Tin.

Also mentioned on this week’s podcast:

• Bloomberg News’ “Dozens of CVS Generic Drug Recalls Expose Link to Tainted Factories,” by Anna Edney and Peter Robison.
• KFF Health News’ “Biden Plan To Save Medicare Patients Money on Drugs Risks Empty Shelves, Pharmacists Say,” by Susan Jaffe.
• KFF Health News’ “More States Legalize Sales of Unpasteurized Milk, Despite Public Health Warnings,” by Tony Leys.

click to open the transcript

Transcript: SCOTUS Rejects Abortion Pill Challenge — For Now

KFF Health News’ ‘What the Health?’ Episode Title: ‘SCOTUS Rejects Abortion Pill Challenge — For Now’Episode Number: 351Published: June 13, 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.] 

Mila Atmos: The future of America is in your hands. This is not a movie trailer and it’s not a political ad, but it is a call to action. I’m Mila Atmos and I’m passionate about unlocking the power of everyday citizens. On our podcast “Future Hindsight,” we take big ideas about civic life and democracy and turn them into action items for you and me. Every Thursday we talk to bold activists and civic innovators to help you understand your power and your power to change the status quo. Find us at futurehindsight.com or wherever you listen to podcasts.

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, June 13, at 10:30 a.m. As always, news happens fast and things might have changed by the time you hear this, so here we go.

We are joined today via video conference by Anna Edney of Bloomberg News.

Anna Edney: Hi there.

Rovner: Rachana Pradhan of KFF Health News.

Rachana Pradhan: Hello.

Rovner: And Emmarie Huetteman, also of KFF Health News.

Emmarie Huetteman: Good morning.

Rovner: Later in this episode we’ll have my interview with KFF President and CEO Drew Altman, who I honestly can’t believe hasn’t been on the podcast before. He is here to talk about “Health Policy 101,” which is KFF’s all-new, all-in-one introductory guide to health policy. But first, this week’s news.

So, as we tape, we have breaking news from the Supreme Court about that case challenging the abortion pill mifepristone. And you know how we always say you can’t predict what the court is going to do by listening to the oral arguments? Well, occasionally you can, and this was one of those times the court watchers were correct. The justices ruled unanimously that the anti-abortion doctors who brought the suit against the pill lack standing to sue. So the suit has been dismissed, wrote Justice [Brett] Kavanaugh, who wrote the unanimous opinion for the court: “A plaintiff’s desire to make a drug less available for others does not establish standing to sue.” So, might anybody have standing? Have we not maybe heard the end of this case?

Edney: Yeah, I think certainly there could be someone else who could decide to do that. I mean, just quickly looking around when this came out, it seems like maybe state AGs [attorneys general] could take this up, so it doesn’t seem like it’s the last of it. I also quickly saw a statement from Sen. [Bill] Cassidy, a Republican, who mentioned this wasn’t a ruling on the merits exactly of the case, but just that these doctors don’t have standing. So it does seem like there would be efforts to bring it back.

Rovner: This is not going to be the last challenge to the abortion pill.

Edney: Yeah.

Pradhan: Just looking in my inbox this morning after the decision, I mean it’s clear the anti-abortion groups are really not done yet. So I think there’s going to be a lot of pressure, of course, from them. It is an election year, so they’re trying to get, notch wins as far as races go, but also to get various AGs to keep going on this.

Rovner: And if you listen to last week’s podcast, there are three AGs who are already part of this case, so they may take it back with the district court judge in Texas. We shall see. Anyway, more Supreme Court decisions to come.

But moving on to campaign 2024 because, and this seems impossible, the first presidential debate is just two weeks away.President [Joe] Biden is still struggling to convince the public that he’s doing things that they support. Along those lines, this week the administration proposed rules that would ban medical debt from being included in calculating people’s credit scores. I thought that had happened already. What would this do that hasn’t already been done?

Huetteman: Well, last year the big credit agencies volunteered to cut medical debt that’s below $500 from people’s credit reports. Of course, there’s a lot of evidence that shows that that’s not really the way that people get hurt with their credit scores, they get hurt when they have big medical bills. So this addresses a major concern that a lot of Americans have with paying for health care in the United States.

I oversee our “Bill of the Month” project with NPR and I can say that a lot of Americans will pay their medical bills without question, even for fear of harm to their credit score, even if they think that their bill might be wrong. Also, it’s worth noting also that researchers have found that medical debt does not accurately predict whether an individual is credit-worthy, actually, which is unlike other kinds of debt that you’d find on credit scores.

Rovner: So yeah, not paying your car payment suggests what you might or might not be able to do with a mortgage or a credit card. But not paying your surprise medical bill, maybe not so much?

Huetteman: Yes, exactly. Really, we can all end up in the emergency room with a big bill. You don’t get a big bill just because you have trouble meeting your credit card bills or you have trouble meeting your car payments, for example.

Rovner: We’ll see if this one resonates with the public because a lot of the things that the administration has done have not. Meanwhile, President [Donald] Trump, who presided over one of the most rapid and successful vaccine development projects ever, for the covid vaccine, now seems to be moving more firmly into the anti-vax camp, and it’s not just apparently anti-covid vaccine. Trump said at a rally last month that he would strip federal funding from schools with vaccine mandates — any vaccines apparently, like measles and mumps and polio — and he says he would do it by executive order. No legislation required. This feels like it could have some pretty major consequences if he followed through on this. Anna, I see you nodding. You have a toddler.

Edney: Right, right. I was just thinking about that going into kindergarten, what that could mean, and there’s just so many … I mean, even kids don’t have to get chickenpox nowadays. That seems like a really great thing. I don’t know. I mean, I had chickenpox. I think that it could take us backwards, obviously, into a time that we’re seeing pockets of as measles crops up in certain places and things like that. I’d be curious. What I don’t know is how much federal funding supports a lot of these schools. I know there’s state funding, county funding, how much that’s actually taking away if it would change the minds of certain ones. But I guess if you’re in maybe a state that doesn’t like vaccines in the first place, it’s a free-for-all to go ahead and do that.

Pradhan: One of the questions I have, too, is through the CDC [Centers for Disease Control and Prevention] we have the Vaccines for Children Program, which provides free immunizations to children for a lot of these infectious diseases, for children who are either uninsured or underinsured or low-income. And so that’s been a really long-standing program and I’m very curious as to whether they would try to maybe reduce or eliminate a bunch of the vaccines that are provided through that, which obviously could affect a significant number of children nationwide.

Rovner: Yeah, it’s funny, the anti-vax movement has been around for, I don’t know, 20, 25 years; whenever that Lancet piece that later got rescinded came out that connected vaccines to autism. It seems it’s getting a boost and, yes, that’s an intended pun right now. I guess covid, and the doubts about covid, is pushing onto these other vaccines, too.

Edney: I think that we’ve certainly seen that. Before covid, at least my understanding of a lot of the concerns around the behavioral issues and autism linked to vaccines or things like that was more of the left-wing, maybe crunchier people who were seeing it as not wanting to put, in their words, poison in their bodies. But now we’re seeing this also right-wing opposition to it, and I think that’s certainly linked to covid. Any mandate at this point from the government is pushed back against more so than before.

Rovner: Well, we have lots of news this week on drugs and drug prices. Anna, you have quite the story about how trying to save money by buying generic might not always be the best move? As I describe it: the scary story of the week. Tell us about it.

Edney: Yes. Yeah, thank you. Yeah, I did this data dive looking into store-brand medication. So when you go into CVS or Walgreens, for example, you can see the Tylenol brand name there, but next to it you’ve got one that looks a lot like it, but it’s got CVS Health or Walgreens on the name and it costs usually a few dollars less. What I found is that of those store brands, CVS has a lot more recalls than the rest, even though they’re selling these same store-brand drugs. So they have two to three times more recalls than Walgreens and Walmart. And what’s happening is they are more often going to shady contract manufacturers to make their generic products that they’re selling over the counter. I found one that was making kids’ medication with contaminated water. And then the really disturbing one that was nasal sprays for babies on the same machines that this company was using to make pesticides. And just wrote about a whole litany of these kinds of companies that CVS is hiring at a higher rate than the other two — Walgreens and Walmart — that I was able to do the data dive on.

And interestingly, these store brands have a loophole, so they’re not responsible for the quality of those medications, even though their name’s on it. They can just walk away and say, “Well, we put it on the shelves. We agree with that, but it’s up to these companies that are making it to verify the quality.” And so, that’s usually not how this works. Even if there’s contract manufacturers, which a lot of drugmakers use, they usually have to also verify the quality. But store brands are considered just distributors, and so there’s this separation of who even owns the responsibility for this drug.

Pradhan: Yeah, I think a collective reaction reading this. I know, how many people did I text your story to Anna, saying, “Yikes! … FYI.”

Rovner: So on the one hand, you get what you pay for. On the other hand, price is not the only problem that we find with drugs. A new study from the University of Utah Drug Information Service just found that pharmacists are reporting the largest number of drugs in shortage since the turn of the century. And my colleague Susan Jaffe has a story on how some shortages are being exacerbated at the pharmacy level by a new Medicare rule that was intended to lower prices for patients at the counter.

Anna, how close are we to the point where the drug distribution system is just going to collapse in on itself? It does not seem to be working very well.

Edney: Yeah, it does feel that way because I always think of that example of the long balloon and when you squeeze it at one end the other end gets bigger. Because when you’re trying to help patients at the counter, somebody’s taking that hit, that money isn’t just appearing out of thin air in their pockets. So the pharmacists are saying — and particularly smaller pharmacies, but also some of the bigger ones — are saying the way that these drugs are now being reimbursed, how that’s working under this new effort, is they don’t have as much cash on hand, so they’re having trouble getting these big brand-name drugs. It was a really interesting story that Susan wrote. Just shows that you can’t fix one end of it, you need to fix the whole thing somehow. I don’t know how you do that.

And shortages are another issue just of other kinds, whether it’s quality issues or whether it’s the demand is growing for a lot of these drugs, and depending even on the time of year. So I think we’re all seeing it just appear to be disintegrating and hoping that there’s just no tragedy or big disaster where we really need to rely on it.

Rovner: Yeah, like, you know, another pandemic.

Edney: Exactly.

Rovner: There’s also some good news on the drug front. An FDA [Food and Drug Administration] advisory committee this week recommended approval for yet another potential Alzheimer’s drug, donanemab, I think I’m pronouncing that right. I guess we’ll learn more as we go on. The drug appears to have better evidence that it actually slows the progression of the disease without the risks of Aduhelm, the controversial drug approved by the FDA that’s been discontinued by its manufacturer. This would be the second promising drug to be approved following Leqembi last year. When we first started talking about Aduhelm — what was that, two years ago — we talked about how it could break Medicare financially because so many people would be eligible for such an expensive drug. So now we’re looking at maybe having two drugs like this and I don’t hear people talking about the potential costs anymore.

Is there a reason why or are we just worried about other things?

Edney: Well, I think there’s a benefit that they seem to have proven more than Aduhelm. But there’s also still a risk of brain swelling and bleeding, and that I’m sure would factor into someone’s decision of whether they want to try this. So maybe people aren’t exactly flocking in the same way to want to get these drugs. As they’re used more, maybe that changes and we see more of “Can you spot the swelling? Can you stop it?” And things like that. But I think that there just seems to be a lot of questions around them. Also, Aduhelm was the biggest one, which obviously Medicare didn’t cover, and then they’re not even trying to sell anymore. But I think that there’s just always questions about how they’re tested, how much benefit really there is. Is a few months worth that risk that you could have a major brain issue?

Rovner: While we are on the subject of drugs and drug prices, we have “This Week in Misinformation” from former President Trump, who as we all know, likes to take credit for things that are not his and deflect blame from things that are. Now in a post on his Truth Social platform, he says that he is the one who lowered insulin copayments to $35 a month, and that President Biden “had nothing to do with it.” Yes, the Trump administration did offer a voluntary $35 copayment program for Medicare Part D plans, but it was limited. It was time-limited and not all the plans adopted it. President Biden actually didn’t do the $35 copay either, but he did propose and sign the law that Congress passed that did it. It was part of the Inflation Reduction Act. Ironically, President Biden didn’t get all he wanted either. The intent was to limit insulin copayments for all patients, but so far, it’s only for those on Medicare. I would guess that Trump is saying this to try to neutralize one of the few issues that maybe is getting through to the public about something that President Biden did.

Pradhan: Well, I mean, I think even during President Trump’s first term, I mean lowering drug prices, he made it very clear that that was something that was important to him. He certainly wasn’t following the traditional or older Republican Party’s friendliness to the pharmaceutical industry. I mean, he was openly antagonizing them a lot, and so it’s certainly something that I think he understands resonates with people. And it’s a pocketbook issue similar to what’s going on on medical debt that we talked about earlier, right? These new regulations that are being proposed — they may not be finalized, we’ll have to see about that because of the timing — but these are things that are, I think at the end of the day, of course, are very relatable to people. Unlike, perhaps, abortion is a big campaign issue, but it’s not necessarily going to resonate with people in the same way and certainly not potentially men and women in the same way. But I think that there’s much more broad-based understanding of having to pay a lot for medications and potentially not being able to afford it. Obviously, insulin is probably the best poster child for a lot of reasons for that. So no surprise he wants to take credit for it, and also perhaps that it’s not really what happened, so …

Rovner: If nothing else, I think it signals that drug prices are still going to be a big issue in this campaign.

Pradhan: For sure. And I mean Joe Biden has made it very clear. I mean the Inflation Reduction Act of course included other measures to lower people’s out-of-pocket costs for drugs, which he’s very eagerly touting on the trail right now to shore up support.

Rovner: Let’s move on from drugs to abortion via the FDA spending bill on Capitol Hill this week. The annual appropriations bills are starting to move in House committees, which is notable itself because this is when they are supposed to start moving if they’re going to get done by Oct. 1, the start of the next fiscal year. We haven’t seen that in a long time. So last year Republicans got hung up because they wanted their leaders to attach all manner of policy riders to the spending bills, most of them aimed at abortion, which can’t get through the Senate. Well in a big shift, Republicans appear to be backing off of that, and the current version of the bill that funds the Department of Agriculture, as well as the FDA, does not include language trying to ban or further restrict the abortion pill mifepristone. Of course, that could still change, but my impression is that the new [House] Appropriations chairman, [Rep.] Tom Cole, who’s very much a pragmatist, wants to get his bills signed into law.

Pradhan: I do wonder, though, if because of the Supreme Court decision that just came out today, whether that will change the calculation, or at the very least, the pressure that he is under to include something in the FDA bill. But as you know, there’s plenty of time for abortion riders to make it in or out. I feel like this is, it’s like Groundhog Day. Usually something related to abortion policy will upend various pieces of legislation. So I’ll be curious to be on the lookout for that, whether it changes anything.

Rovner: Anna, were you surprised that they left it out, at least at the start?

Edney: Yeah, I think you’re just what we’ve seen with all of the rancor around abortion and abortion-related issues, I guess a little surprised. But also maybe it makes sense in just the sense that there are Republicans who are struggling with that issue and don’t want to have to keep talking about it or voting on it in the same way.

Rovner: Well, that leads right to my next subject, which is that the Senate is voting this afternoon, after we tape, on a bill that would guarantee access to IVF. Republicans are expected to block it as they did last week on the bill to guarantee access to contraception. But as of Wednesday, it’s going to be harder for Republicans to say they’re voting against the bill because no one is threatening to block IVF. That’s because the influential Southern Baptist Convention, one of the nation’s largest evangelical groups, voted, if not to ban IVF, at least to restrict the number of embryos that can be created and ban their destruction, which doctors say would make the treatments more expensive and less successful. It sounds like the rift among conservatives over contraception and IVF is a long way from getting settled here.

Huetteman: That certainly seems to be true. It’s also worth noting that there are a lot of influential members of Congress who are Baptist, of course, including House Speaker Mike Johnson. And I was refreshing my memory of the religious background of the current Congress with a Pew report: They say 67 members of this Congress are Baptist. Of course, Southern Baptist is the largest piece of that. And 148 are Catholic, which of course is another denomination that opposes IVF as well. So that’s a pretty big constituency that has their churches telling them that they oppose IVF and should, too.

Rovner: Yeah, everybody says they’re not coming for contraception, they’re not coming for IVF. I think we’re going to see a very spirited and continued debate over both of those things.

Well, speaking of the rift over reproductive health, former President Trump is struggling to please both sides and not really succeeding at it. He made a video address last week to the evangelical group, The Danbury Institute, which is a conservative subset of the aforementioned Southern Baptist Convention, in which former President Trump didn’t use the word abortion and skirted the issue. That prompted some grumbling from some of the attendees, reported Politico. Even as Democrats called him an anti-abortion radical for even speaking to the group, which has labeled abortion “child sacrifice.”

So far, Trump has gotten away with telling audiences what they want to hear, even if he contradicts himself regularly. But I feel like abortion is maybe the one issue where that’s not going to work.

Pradhan: Well, I think the struggle really is even if people are more forgiving of him saying different things, it puts a lot of down-ballot candidates in a really difficult position. And I know, Julie, you’d wanted to talk about this, but Republican candidates for U.S. Senate, I mean just how they have to thread the needle, and I don’t know that voters will be as forgiving about changes in their position. So I think they say it’s like, it’s not just about you. It’s like when two people get married, they’re like, “It’s not just about the two of you. It’s like your whole family.” This is like the family is your party and everyone down-ballot who has to now figure out what the best message is, and as we’ve seen, they’ve really struggled with “We’ve shifted now from being many candidates and Republican officeholders supporting basically near-total abortion bans, if not very early gestational limits, to the 15-week ban being a consensus position.” And now saying, well, Trump’s saying he’s not going to sign a national abortion ban, so let’s leave it to the states. I mean, it keeps changing, and I think obviously underscores the difficulty that they’re all having with this. So I don’t think it helps for him to be saying inconsistent things all the time because then these other candidates for office really struggle, I think, with explaining their positions also.

Rovner: So as I say every week, I’ve been covering abortion for a very long time, and before Roe [v. Wade] was overturned the general political rule is you could change positions on abortion once. If you were anti-abortion you could become pro-choice, and we’ve seen that among a lot of Democrats, Sen. [Bob] Casey in Pennsylvania, sort of a notable example. And if you supported abortion rights, you could become anti-abortion, which Trump kind of did when he was running the first time. Others have also as, there are … and again we’re seeing this more among Republicans, but not exclusively.

But people who try to change back usually get hammered. And as I say, Trump has violated every political rule about everything. So not counting him, I’m wondering about, as you say, Rachana, some of these Senate candidates, some of these down-ballot candidates who are struggling to really rationalize their current positions with maybe what they’d said before is something I think that bears watching over the next couple of months.

Huetteman: Absolutely. And we’re seeing candidates who will change their tone within weeks of saying something or practically days at this point. They’re really banking on our attention being pretty low as a public.

Rovner: Yeah. Although they may be right about that part.

Pradhan: Yeah, that’s true. And there’s a lot of time between now and November, but I think even the … just all the things, even this week of course, between now and November is an eternity. But we just talked about the Southern Baptist Convention stance on IVF. Of course, usually when these things happen, it prompts a lot of questions to lawmakers about whether they support that decision or not, whether they agree with it. And I think these court decisions … the Supreme Court, of course, will be out by the end of June, and so right now it might be fresh on people’s minds. But it’s hard to know whether September or October is the dominant or very prominent campaign issue in the same way.

Rovner: At the same time, we have a long way to go and a short way to go, so we will actually all be watching.

All right, well that is the news for this week. Now we will play my interview with Drew Altman and then we will come back and do our extra credits.

I am pleased to welcome to the podcast Drew Altman, president and CEO of KFF, and of course my boss. But lest you think that this is going to be a suck-up interview, you will see in a moment it’s also a shameless self-promotion interview. Drew, thank you so much for joining us.

Drew Altman: It’s great to be on “What the Health?” Thank you.

Rovner: I asked you here to talk about KFF’s new “Health Policy 101” project which launched last month, as a resource to help teach the basics of health policy. I know this is something you’ve been thinking about for a while. Tell us what the idea was and who’s the target audience here.

Altman: Well, since the Bronze Era, when I started KFF, faculty and students found their way to our stuff and they found it useful. It might’ve been a fact sheet about Medicaid or a policy brief about Medicare or a bunch of charts that we produced. But they’ve had to hunt and peck to find what they wanted and someone would find something on Medicaid or Medicare or the ACA [Affordable Care Act] or health care costs or women’s health policy or international comparisons or whatever it was. And for a very long time, I have wanted to organize our material about health policy for their world so that it was easy to find. It was one stop, and you could find all the basic materials that you wanted on the core stuff about health policy as a service to faculty and students interested in health policy because we don’t just analyze it and poll about it and report on it. We have a deep commitment. We really care about health policy and health policy education.

Rovner: You said those are the main topics covered. I assume that other topics could be added in the future? I mean, I could see a chapter on AI and health care.

Altman: Yes, and we’re starting with an introduction for me. There’s a chapter by Larry Levitt about challenges ahead. There’s a chapter by somebody named Julie Rovner on Congress and the agencies, who also wrote a book about all of that stuff, which is still available, folks.

Rovner: It desperately needs updating. So I’m pleased to be contributing to this.

Altman: But this is just the first year. And there were 13 chapters on the issues that I ticked off a moment ago and many more issues. And we’re starting the process of adding chapters. So the next chapter will probably be on LGBTQ issues, and then, though it’s not exactly the same thing as health policy, by popular demand, we will have a chapter on the basics of public health and what is the public health system, and spending on public health.

And I will admit, some of this also has origins in my own personal experience because before I was in government or in the nonprofit world or started and ran KFF, I was an academic at MIT [Massachusetts Institute of Technology] and I was fine when it came to big thoughts. And there I was and I’d written a book about health cost regulation. But what I didn’t know much about was how stuff really worked and the basics. And if I really needed to understand what was happening with regulation of private health insurance or the Medicaid program or the Medicare program, I didn’t really have any place to go to get basic information about the history of the program, or the details of the program, or a few charts that would give me the facts that I needed, or what are the current challenges. And when it really sunk in was when I left MIT and I went to work in what is now CMS [Centers for Medicare & Medicaid Services] and then was called the HCFA [Health Care Financing Administration], and boy on the first day did I realize what I did not know. It was only when I entered the real world of health policy that I understood how much I had to learn. So I wanted to bridge the two worlds a little bit by making available this basic “Health Policy 101.”

Rovner: I confess, I’m a little bit jealous that this hadn’t existed when I started to learn health policy because, like you, I had to ferret it all out, although thankfully KFF was there through most of it and I was able to find most of it along the way.

Altman: Exactly, and I think there’ll be other audiences for this because if you’re working on the Hill — but you don’t work full time on health — if you’re working in an association, if you’re working anywhere in the health care system, there’s lots of times when you really just need to understand. I just read about an 1115 waiver. What is that? Or what really is the difference between traditional Medicare and the Medicare Advantage plan? How is it that you get your drugs covered in the Medicare program? It seems to be lots of different ways. And just I’m confused. How does this actually work?

I’ll admit to you, also, I personally have an ulterior motive in all of this. And my ulterior motive is that it is my feeling now, and this has been a slowly creeping problem, that there isn’t enough what I would call health policy in health policy education. So that over time it has become more about what is fashionable now, which is delivery and quality and value.

And I won’t name names, but I spent a couple of days advising a health policy center at a renowned medical school about their curriculum in what they called health policy. And the draft of it had nothing in it that I recognized as health policy. Some of this is understandable. It’s because if you’re faculty with a disciplinary base — economics, political science, sociology, whatever — there’s no reason you would know a lot about what we recognize as the core of health policy. There has been a serious decline in faith in government, in young people taking jobs in certainly the federal government, but a little bit in state government as well. So the jobs now are all in the health care industry, they’re in tech, they’re in consulting firms. And so I think there’s just less of an incentive to learn a lot about Medicare, Medicaid, the ACA, the federal agencies, because you’re not going to go work in the federal agencies, at least as frequently as students did in my time. And so just to be blunt about it, I am, in my mind, trying to get more health policy back into health policy education.

Rovner: Well, as you know, I endorse that fully because that’s what we’re trying to do, too. One more question since I have you. I’ve been thinking about this a lot. When I started covering health policy shortly after you left HCFA, the big issue was people without insurance. And then throughout the early 2000s the big issue was spiraling costs. I feel like now the big issue is people who simply cannot navigate the system. The system has become so byzantine and complicated that, well, now there’s a “South Park” about it. I mean, it’s really to get even minor things dealt with is a major undertaking. I mean, what do you see as the biggest issue in policy for the next five or 10 years?

Altman: Well, I think the big issue for health care people used to be access to care. Now only about 8% of the population is uninsured. The big issue now is affordability, in my mind, and the struggles Americans are having paying their health care bills. It is an especially acute problem, virtually a crisis, for people with severe illnesses or people who are chronically ill. Fifty[%], 60% of those people really struggle to pay their medical bills. The crisis or the problem that isn’t discussed enough — because it isn’t a single problem it rears its head in so many ways — is the one you’re talking about: that is the complexity of the health care system. Just the sheer complexity of it; how difficult it is to navigate and to use for people who have insurance or don’t have insurance. Larry Levitt and I wrote a piece in JAMA about this, and we, all of us at KFF, are trying to focus more attention on that problem. Need to do more work on that problem and the many parts of it. It’s partly why we set up an entire program a couple of years ago on consumer and patient protection, where we intend to focus more on just this issue of the complexity of the system makes it hard to make it work for people. But especially for patients who are people who encounter the system because they need it.

Rovner: Well, we will both continue to try to keep explaining it as it keeps getting more byzantine. Drew Altman, thank you so much for joining us.

Altman: Thank you, Julie, very much.

Rovner: OK, we are back. It’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Emmarie, why don’t you go first this week?

Huetteman: Sure. My story comes from CBS [News]. The headline is “As FDA Urges Crackdown on Bird Flu in Raw Milk, Some States Say Their Hands Are Tied.” So the story says that there are three more states that have had their first reported cases of bird flu in the last month. And two of them don’t really have a way to conduct increased oversight of dairy cows and the industry that seems to be particularly having problems here. Wyoming and Iowa are those two states. Basically, these are states where raw milk is unregulated, so there’s no way for them to implement surveillance and restrictions on raw milk that might protect people from the fact that pasteurization appears to kill bird flu. But you don’t have pasteurization with raw milk, of course, that’s the definition.

Actually, this leads me to an extra, extra credit. KFF Health News’ Tony Leys wrote about the raw milk change in Iowa last year, and he was reporting on how Iowa only just changed their law, allowing legal sales of raw milk. And his story, among other things, pointed out that pasteurization helped rein in many serious illnesses in the past, including tuberculosis, typhoid, and scarlet fever. So unfortunately, this is a public health issue that’s been going on for a century or more, and we’ve got a method to deal with this, but not if you’re drinking raw milk. So that’s my story this week.

Rovner: Now people are going to drink raw milk and not get childhood vaccines. We’ll see how that goes. Sorry. Anna, you go next.

Edney: Yeah, mine is from Stat and it’s “Four Tops Singer’s Lawsuit Says He Visited ER for Chest Pain, Ended Up in Straitjacket.” It’s really scary, and maybe not totally surprising, unfortunately, that this is how an older Black man was treated when he went to the hospital. But this is Alexander Morris, a member of the Motown group The Four Tops. These are in the Rock & Roll Hall of Fame, The Four Tops, and he had chest pain and problems breathing and went to the hospital in Detroit and was immediately just assumed he was mentally ill, and he ended up quickly in a straitjacket. So he is suing this hospital. And I think he brought up in this article he’d seen people talk about driving while Black or walking while Black, and he essentially had become sick while Black. And he was able to prove he was a famous person and they took him out of the straitjacket. But how many other people haven’t had that ability, and just been assumed, because of the color of their skin, to not be having a serious health issue? So I think it’s worth a read.

Rovner: Yeah, it was quite a story. Rachana.

Pradhan: This week, I will take a story from The New York Times that is headlined “Abortion Groups Say Tech Companies Suppress Posts and Accounts.” It is basically an examination of how TikTok, Instagram, and others, how they moderate/remove content about abortion. What’s interesting about this is, so this is being told from the perspective of individuals who support access to abortion services. And it recounts some examples of Instagram suspending one group, it was called Mayday Health, which provides information about abortion pill access. There’s a telemedicine abortion service called Hey Jane, where TikTok briefly suspended them. What I thought was really interesting about this is anti-abortion groups have said for longer, actually, that technology companies have suppressed or censored information about crisis pregnancy centers, for example, that designed to dissuade women from having abortions. But I think it’s concerns about, broadly speaking, just what the policies are of some of these social media companies and how they decide what information is acceptable or not. And it details these examples of, again, women who support abortion access or posting TikToks that maybe spell abortion phonetically. Like “tion” is, instead of T-I-O-N, it’s S-H-U-N. Or they’ll put a zero instead of an O, and so it doesn’t get flagged in the same way. So yeah, definitely an interesting read.

Rovner: The fraughtness of social media moderation on this issue and many others. Well, my extra credit this week is from my fellow Michigan fan and sometime podcast guest Jonathan Cohn of HuffPost, and it’s called “How America’s Mental Health Crisis Became This Family’s Worst Nightmare.” And it’s basically the story of the entire mental health system in the United States over the last century, as told through the eyes of one middle-class American family, about one patient whose trip through the system came to a tragic end. Even if you think you know about this country’s failure to adequately treat people with mental illness, even if you do know about this country’s failures on mental health, you really do need to read this story. It is that good.

All right, 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 doing-double-duty editor this week, Emmarie Huetteman. As always, you can email us your comments or questions. We’re whatthehealth, all one word, @kff.org. Or you can still find me at X, I’m @jrovner. Anna?

Edney: @annaedney.

Rovner: Rachana?

Pradhan: I’m @rachanadpradhan on X.

Rovner: Emmarie?

Huetteman: I’m lurking on X @EmmarieDC.

Rovner: We will be back in your feed next week. Actually, we’ll be coming to you from Aspen next week. But until then, be healthy.

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But for the more than 6.5 million Americans who suffer from Alzheimer’s disease — and the people who support them — memory lapses are often the least of their problems. Many people with Alzheimer’s or other forms of dementia also experience mood and behavior symptoms ranging from anxiety and depression to violent outbursts and psychosis.

Family members, caregivers, and even some medical providers often dismiss these so-called neuropsychiatric symptoms as acting out, with behavior that’s within an individual’s control. Although these symptoms can be very disruptive and overwhelming, they aren’t the individual’s fault or an extension of their personality — they are another manifestation of the disease.

Read the rest…

The Host

Julie Rovner
KFF Health News

@jrovner

Read Julie's stories.

Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

With abortion shaping up as a key issue for the November elections, the movement that united to overturn Roe v. Wade is divided over going further, faster — including by punishing those who have abortions and banning contraception or IVF. Politicians who oppose abortion are already experiencing backlash in some states.

Meanwhile, bad actors are bilking the health system in various new ways, from switching people’s insurance plans without their consent to pocket additional commissions, to hacking the records of major health systems and demanding millions of dollars in ransom.

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

Panelists

Alice Miranda Ollstein
Politico

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Read Alice's stories.

Joanne Kenen
Johns Hopkins University and Politico

@JoanneKenen

Read Joanne's articles.

Rachel Roubein
The Washington Post

@rachel_roubein

Read Rachel's stories.

Among the takeaways from this week’s episode:

• It appears that abortion opponents are learning it’s a lot easier to agree on what you’re against than for. Now that the constitutional right to an abortion has been overturned, political leaders are contending with vocal groups that want to push further — such as by banning access to IVF or contraception.
• A Louisiana bill designating abortion pills as controlled substances targets people in the state, where abortion is banned, who are finding ways to get the drug. And abortion providers in Kansas are suing over a new law that requires patients to report their reasons for having an abortion. Such state laws have a cumulative chilling effect on abortion access.
• Some Republican lawmakers seem to be trying to dodge voter dissatisfaction with abortion restrictions in this election year. Sen. Ted Cruz of Texas and Sen. Katie Britt of Alabama introduced legislation to protect IVF by pulling Medicaid funding from states that ban the fertility procedure — but it has holes. And Gov. Larry Hogan of Maryland declared he is pro-choice, even though he mostly dodged the issue during his eight years as governor.
• Former President Donald Trump is in the news again for comments that seemed to leave the door open to restrictions on contraception — which may be the case, though he is known to make such vague policy suggestions. Trump’s policies as president did restrict access to contraception, and his allies have proposed going further.

Also this week, Rovner interviews Shefali Luthra of The 19th about her new book on abortion in post-Roe America, “Undue Burden.”

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

Julie Rovner: The 19th’s “What Happens to Clinics After a State Bans Abortion? They Fight To Survive,” by Shefali Luthra and Chabeli Carrazana. 

Alice Miranda Ollstein: Stat’s “How Doctors Are Pressuring Sickle Cell Patients Into Unwanted Sterilizations,” by Eric Boodman.  

Rachel Roubein: The Washington Post’s “What Science Tells Us About Biden, Trump and Evaluating an Aging Brain,” by Joel Achenbach and Mark Johnson.  

Joanne Kenen: ProPublica’s “Toxic Gaslighting: How 3M Executives Convinced a Scientist the Forever Chemicals She Found in Human Blood Were Safe,” by Sharon Lerner; and The Guardian’s “Microplastics Found in Every Human Testicle in Study,” by Damian Carrington. 

Also mentioned on this week’s podcast:

• NPR’s “Republicans Try To Soften Stance on Abortion as ‘Abolitionists’ Go Farther,” by Sarah McCammon.
• KFF Health News’ “Biden Leans Into Health Care, Asking Voters To Trust Him Over Trump,” by Phil Galewitz.
• KFF Health News’ “Exclusive: Senator Urges Biden Administration To Thwart Fraudulent Obamacare Enrollments,” by Julie Appleby.
• KFF Health News’ “KHN’s ‘What the Health?’: Un-Trumping the ACA,” featuring an interview with journalist Marshall Allen.

Click to open the Transcript

Transcript: Anti-Abortion Hard-Liners Speak Up

[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.] 

Mila Atmos: The future of America is in your hands. This is not a movie trailer, and it’s not a political ad, but it is a call to action. I’m Mila Atmos, and I’m passionate about unlocking the power of everyday citizens. On our podcast Future Hindsight, we take big ideas about civic life and democracy and turn them into action items for you and me. Every Thursday, we talk to bold activists and civic innovators to help you understand your power and your power to change the status quo. Find us at futurehindsight.com or wherever you listen to podcasts.

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, May 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. We are joined today via a video conference by Alice Miranda Ollstein of Politico.

Alice Miranda Ollstein: Hello.

Rovner: Rachel Roubein of The Washington Post.

Rachel Roubein: Hi, thanks for having me.

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 my interview with podcast panelist Shefali Luthra of The 19th. Shefali’s new book about abortion in the post-Roe [v. Wade] world, called “Undue Burden,” is out this week. But first, this week’s news. We’re going to start with abortion this week with a topic I’m calling “Abolitionists in Ascendance,” and a shoutout here to NPR’s Sarah McCammon with a great piece on this that we will link to in the show notes. It seems that while Republican politicians, at least at the federal level, are kind of going to ground on this issue, and we’ll talk more about that in a bit, those who would take the ban to the furthest by prosecuting women, and/or banning IVF and contraception, are raising their voices. How much of a split does this portend for what, until the overturn of Roe, had been a pretty unified movement? I mean they were all unified in “Let’s overturn Roe,” and now that Roe has gone, boy are they dividing.

Ollstein: Yeah, it’s a lot easier to agree on what you’re against than on what you’re for. We wrote about the split on IVF specifically a bit ago, and it is really interesting. A lot of anti-abortion advocates are disappointed in the Republican response and the Republican rush to say, “No, let’s leave IVF totally alone” because these groups think, some think it some should be banned, some think that there should be a lot of restrictions on the way it’s currently practiced. So not a total ban, but things like you can only produce a certain number of embryos, you can only implant a certain number of embryos, you can only create the ones you intend to implant, and so that would completely upend the way IVF is currently practiced in the U.S.

So, we know the anti-abortion movement is good at playing the long game, and so some of them have told me that they see this kind of like the campaign to overturn Roe v. Wade. They understand that Republicans are reacting for political reasons right now, and they are confident in winning them over for restrictions in the long term.

Rovner: I’ve been fascinated by, I would say, by things like Kristan Hawkins of Students for Life [of America] who’s been sort of the far-right fringe of the anti-abortion movement looking like she’s the moderate now with some of these people, and their discussions of “We should charge women with murder and have the death penalty if necessary.” Sorry, Rachel, you want to say something?

Roubein: This is something that Republicans, they don’t want to be asked about this on the campaign. The more hard-line abolitionist movement is something more mainstream groups have been taking a lot of pains to distance themselves and say that we don’t prosecute women, and essentially nobody wants to talk about this ahead of 2024. GOP doesn’t want to be seen as that party that’s going after that.

Kenen: And the divisions existed when Roe was still the law of the land, and we would all write about the divisions and what they were pushing for, and it was partly strategic. How far do you push? Do you push for legislation? Do you push for the courts? Do you push for 20 weeks for fetal pain? But it was like rape exceptions and under what terms and things like that. So it was sort of much later in pregnancy, and with more restrictions, and the fight was about exactly where do you draw that line. This abolition of all abortion under all circumstances, or personhood, only a couple of years ago, were the fringe. Personhood was sort of like, “Oh, they’re out there, no one will go for that.” And now I don’t think it’s the dominant voice. I don’t think we yet know what their dominant voice is, but it’s a player in this conversation.

At the same time, on the other side, the pro-abortion rights people, there’s polls showing us this many Americans support abortion, but it’s subtler too. Even if people support abortion rights, it doesn’t mean that they’re not, some subset are in favor of some restrictions, or where that’s going to settle. Right now, a 15-week ban, which would’ve seemed draconian a year or two ago, now seems like the moderate position. It has not shaken out, and …

Rovner: Well, let’s talk …

Kenen: It’s not going to shake out for some time.

Rovner: Let’s talk about a few specifics. The Louisiana State Legislature on Tuesday approved a bill that would put the drugs used in medication abortion, mifepristone and misoprostol, on the state’s list of controlled substances. This has gotten a lot of publicity. I’m wondering what the actual effect might be here though since abortion is already banned in Louisiana. Obviously, these drugs are used for other things, but they wouldn’t be unavailable. They would just be put in this category of dangerous drugs.

Ollstein: So, officials know that people in banned states, including Louisiana, are obtaining abortion pills from out of state, whether through telehealth from states with shield laws or through these gray-area groups overseas that are mailing pills to anyone no matter what state they live in or what restrictions are in place. So I think because it would be very difficult to actually enforce this law, short of going through people’s homes and their mail, this is just one more layer of a chilling effect and making people afraid to seek out those mail order services.

Rovner: So it’s more, again, for the appearance of it than the actuality of it.

Ollstein: It also sets up another state versus federal law clash, potentially. We’ve seen this playing out in courts in West Virginia and in North Carolina, basically. Can states restrict or even completely ban a medication that the FDA says is safe and effective? And that question is percolating in a few different courts right now.

Rovner: Including sort of the Supreme Court. We’re still waiting for their abortion pill decision that we expect now next month. Meanwhile, in Kansas, where voters approved a big abortion rights referendum in 2022 — remember, it was the first one of those — abortion providers are suing to stop a new state law enacted over the governor’s veto that would require them to report to the state women’s reasons for having an abortion. Now it’s not that hard to see how that information could be misused by people with other kinds of intents, right?

Ollstein: Well, it also brings up right to free speech issues, compelled speech. I think I’ve seen this pop up in abortion lawsuits even before Dobbs [v. Jackson Women’s Health Organization], this very issue because there have been instances where either doctors are required to give information that they say that they believe is medically inaccurate. That’s an issue in several states right now. And then this demanding information from patients. A lot of clinics that I’ve spoken to are so afraid of subpoenas from officials in-state, from out of state, that they intentionally don’t ask patients for certain kinds of data even though it would really help medically or organizationally for them to have that data. But they’re so afraid of it being seized, they figure well, they can’t seize it if they’re … doesn’t exist in the first place. And so I think this kind of law is in direct conflict with that.

Roubein: It also gets at the question of medical privacy that we’ve been seeing in the Biden administration’s efforts over HIPAA and protecting patients’ records and making it harder for state officials to attempt to seize.

Rovner: Yeah, this is clearly going to be a struggle in a lot of states where voters versus Republican legislatures, and we will sort of see how that all plays out. So even while this is going on in a bunch of the states, a lot of Republicans, including some who have been and remain strongly anti-abortion, are doing what I’m calling ducking-and-covering on a lot of these issues. Case in point, Texas Republican Sen. Ted Cruz and Alabama Republican Sen. Katie Britt this week introduced a bill they say would protect IVF, which is kind of ironic given that both of them voted against a bill to protect IVF back in, checking notes, February. What’s the difference here? What are these guys trying to do?

Kenen: Theirs is narrower. They say that the original bill, which was a Democratic bill, was larded with abortion rights kinds of things. I have not read the entire bill, I just read the summary of it. And in this one, if a state restricts someone who had — someone feel free to correct me if I am missing something here because I don’t have deep knowledge of this bill — but if a state does not protect IVF, they would lose their Medicaid payment. And I was not clear whether that meant every penny of Medicaid, including nursing homes, or if it’s a subsection of Medicaid, because it seems like a big can of worms.

Ollstein: Yeah, so the key difference in these bills is the word ban. The Republican bill says that if states ban IVF, then these penalties kick in for Medicaid, but they say that there can be “health and safety regulations,” and so that is very open to interpretation. That can include the things we talked about before about you can only produce a certain number of embryos, you can only implant a certain number of embryos, and you can’t discard them. And so even what Alabama did was not an outright ban. So even something like that that cut off services for lots of people wouldn’t be considered a ban under this Republican bill. So I think there’s sort of a semantic game going on here where restrictions would still be allowed if they were short of a blanket ban, whereas the democratic bill would also prevent restrictions.

Rovner: Well, and along those exact same lines, in Maryland, former two-term Republican governor Larry Hogan, who’s managed to dodge the abortion issue in his primary run to become the Senate nominee, now that he is the Republican candidate for the open Senate seat, has declared himself, his words, “pro-choice,” and says he would vote to restore Roe in the Senate if given the opportunity. But as I recall, and I live in Maryland, he vetoed a couple of bills to expand abortion rights in very blue Maryland. Is he going to be able to have this both ways? He seems to be doing the [Sen.] Susan Collins script where he gets to say he’s pro-choice, but he doesn’t necessarily have to vote for abortion rights bills.

Kenen: Hogan is a very popular moderate Republican governor in a Democratic state. He is a strong Senate candidate. His opponent, a Democrat, Angela Alsobrooks, has a stronger abortion rights record. I don’t think that’s going to be the decisive issue in Maryland. I think it may help him a little bit, but I think in Maryland, if the Senate was 55-45, a lot of Democrats like Hogan and might want another moderate Republican in the Senate. But given that this is going to be about control of the Senate, abortion will be a factor, I don’t think abortion is going to be the dominant factor in this particular race.

If she were to win and there’s two black women, I mean that would be the first time that two black women ever served in the Senate at once, and I think they would only be number three and number four in history. So race and Affirmative Action will be factors, but I think that Democrats who might otherwise lean toward him, because he was considered a good governor. He was well-liked. This is a 50-50ish Senate, and that’s the deciding thing for anyone who pays attention, which of course is a whole other can of worms because nobody really pays attention. They just do things.

Roubein: I think it’s also worth noting this tact to the left comes as Maryland voters will be voting on an abortion rights ballot measure in 2024. So that all sort of in context, we’ve seen what’s happened with the other abortion measures, abortion rights have won, so.

Rovner: And Maryland is a really blue state, so one would expect it …

Kenen: There’s no question that the Maryland …

Rovner: Yeah.

Kenen: I mean, and all of us would fall flat on our faces if the abortion measure fails in Maryland. But I believe this is the first one on the ballot alongside a presidential election, and some of them have been in special elections. It’s unclear the correlation between, you can vote for a Republican candidate and still vote for a pro-abortion rights initiative. We will learn a lot more about how that split happens in November. I mean, is Kansas going to go for Biden? Unlikely. But Kansas went really strong for abortion rights. If you’re not a single-issue voter, you can, in fact, have it both ways.

Rovner: Yes, and we are already seeing that in the polls. Well, of course then there is the king of trying to have it both ways: former President Trump. He is either considering restrictions on contraception, as he told an interviewer earlier this week, promising a proposal soon, or he will, all caps, as he put on Truth Social, never advocate imposing restrictions on birth control. So which is it?

Ollstein: So this came out of Trump’s verbal tick of saying “We’ll have a plan in a few weeks,” which he says about everything. But in this context it made it sound like he was leaving the door open to restrictions on contraception, which very well might be the case. So what my colleague and I wrote about is he says he would never restrict contraception. A lot of things he did in his first administration did restrict access to contraception. It was not a ban. Again, we’re getting back into the semantics of ban. It was not a ban, but his Title X rule led to a drop in hundreds of thousands of people accessing contraception. He allowed more kinds of employers to refuse to cover their employees’ contraception on their health plans, and the plans his allies are creating in this Project 2025 blueprint would reimpose those restrictions and go even further in different ways that would have the effect of restricting access to contraception. And so I think this is a good instance of look at what people do, not what they say.

Rovner: So now that we’re on the subject of campaign 2024, President Biden’s campaign launched a $14 million ad buy this week that includes the warning that if Trump becomes president again he’ll try to repeal the Affordable Care Act. Maybe health care will be an issue in this election after all? I don’t have a rooting interest one way or the other. I’m just curious to see how much of an issue health will be beyond reproductive rights.

Kenen: Well, as Alice just pointed out, Trump’s promised plans often do not materialize, and we are still waiting to see his replacement plan eight years later. I think he’s being told to sort of go slow on this. I mean, not that you can control what Trump says, but he didn’t run on health care until the end, in 2016. It was a close race, and he ran against Hillary Clinton, and it was the last 10 or so days that he really came down hard because it was right when ACA enrollment was about to begin and premiums came in and they were high. He pivoted. So is this going to be a health care election from day one? And I’m putting abortion aside for one second in terms of my definition of health care for this particular segment. Is it going to be a health care election in terms of ACA, Medicare, Medicaid? At this point, probably not. But is it going to emerge at various times by one or the other side in politically opportune ways? I would be surprised if Biden’s not raising it. The ACA is thriving under Biden.

Rovner: Well, he is. That’s the whole point. He just took out a $14 million ad buy.

Kenen: Right. But again, we don’t know. Is it a health care election or is it a couple ads? We don’t know. So yes, it’s going to be a health care election because all elections are health care elections. How much it’s defined by health care compared to immigration? No, at this point, that’s not what we’re expecting. Compared to the economy? No, at this point. But is it an issue for some voters? Yes. Is it going to be an issue more prominently depending on how other things play out? It’ll have its peaks. We just don’t know how consistent it’ll be.

Roubein: Biden would love to run on the Inflation Reduction Act and politically popular policies like allowing Medicare to negotiate drug prices. One of the problems of that is polls, including from KFF, has shown that the majority of voters don’t know about that. And some of these policies, the big ones, have not even gone into effect. CMS [Centers for Medicare & Medicaid Services] is going through the negotiation process, but that’s not going to hit people’s pocketbooks until after the election.

Kenen: The cliff for the ACA subsidies, which is in 2025, I mean I would imagine Democrats will be campaigning on, “We will extend the subsidies,” and again, in some places more than others, but that’s a time-sensitive big thing happening next year.

Rovner: But talk about an issue that people have no idea that’s coming. Well, meanwhile, for Trump, reproductive health isn’t the only issue where he’s doing a not-so-delicate dance. Apparently worried about Robert F. Kennedy Jr. stealing anti-vax [vaccine] votes from him, Trump is now calling RFK Jr. a fake anti-vaxxer. Except I’m old enough to remember when Trump bragged repeatedly about how fast his administration developed and brought the covid vaccine to market. That used to be one of his big selling points. Now he’s trying to be anti-vax, too?

Kenen: Not only did he brag about bringing it to the market. The way he used to talk about it, it was like he was there in his lab coat inventing it. Operation Warp Speed was a success. It got vaccines out in record time, way beyond what many people expected. Democrats gave him credit for that one policy in health care. He got a vaccine out and available in less than a year, and he got vaccinated and boasted about being vaccinated. He was open about it. Now we don’t know if he’s been boosted. He really backed off. As soon as somebody booed him, and it wasn’t a lot of boos, at one rally when he talked about vaccination and he got pushed back, that was the end.

Rovner: So, yeah, so I expect that to sort of continue on this election season, too.

Kenen: But we don’t expect RFK to flip.

Rovner: No, we do not. Right. Well, moving on to this weekend’s “Cyber Hacks,” a new feature, the fallout continues from the hack of Ascension [health care company]. That’s the Catholic hospital system with facilities in 19 states. In Michigan, patients have been unable to use hospital pharmacies and their doctors have been unable to send electronic prescriptions, so they’re having to write them out by hand. And in Indiana orders for tests and test results are being delayed by as much as a day for hospital patients. Not a great thing.

And just in time, or maybe a little late, the U.S. Department of Health and Human Services, through the newly created ARPA-H [Advanced Research Projects Agency for Health] that we have talked about, this week announced the launch of a new program to help hospitals make security patches and updates to their systems without taking them offline, which is obviously a major reason so many of these systems are so vulnerable to cyberhacking.

Of course, this announcement from HHS is just to solicit ideas for grants to help make that happen. So it’s going to be a while before we get any of these security changes. I’m wondering, how many systems are going to try to build a lot more redundancy into them? In the meantime, are we hearing anything about what they can do in the short term? It feels like the entire health care system is kind of a sitting duck for this group of cyberhackers who think they can get in easily and get ransom.

Kenen: There’s a reason they think that.

Rovner: They can.

Roubein: Thinking about hospitals and doctors using this manually, paper-based system and how that’s delaying getting your results and just there’s been these stories about patients. Like the anxiety that that’s understandably causing patients, and we’ll see sort of whether Congress can grapple with this, and there’s not really much legislation that’s going to move, so …

Kenen: But I was surprised that they were calling on ARPA-H. I mean, that’s supposed to be a biotech- curing-diseases thing, and none of the four of us are cybersecurity experts, and none of us really specialize in covering the electronic side of the digital side of health, but it just seems to me, I just thought that was an odd thing. First of all, some of these are just systems that haven’t been upgraded or individual clinicians who don’t upgrade or don’t do their double authorization. Some of it’s sort of cyberhygiene, and some of it’s obviously like the change thing. They’re really sophisticated criminals, but it’s not something that one would think you can’t get ahead of, right? They’re smart, good-guy technology people. It’s not like the bad guys are the only ones who understand technology. So why are the smart good guys not doing their job? And also, probably, health care systems have to have some kind of security checks on their own members to make sure they are following all the safety rules and some kind of consequences if you’re not, other than being embarrassed.

Rovner: I’ve just been sort of bemused by all of this, how both patients and providers complain loudly and frequently about the frustrations of some of these electronic record systems. And of course, in the places that they’re going down and they’ve had to go back to paper, people are like, “Please give us our electronic systems back.” So it doesn’t take long to get used to some of these things and be sorry when they’re gone, even if it’s only temporarily. It’s obviously been …

Kenen: But like what Rachel said, if you’re in the hospital, you’re sick, and do your clinicians need your lab results? Yes. I mean some of them are more important than others, and I would hope that hospitals are figuring out how to prioritize. But yeah, this is a crisis. If you’re in the hospital and they don’t know what’s wrong with you and they’re trying to figure out do you have X, Y, or Z, waiting until next week is not really a great idea.

Rovner: But it wasn’t that many years ago that their existence …

Kenen: Right, no, no, no.

Rovner: … did not involve …

Kenen: [inaudible 00:21:28].

Rovner: … electronic medical record.

Kenen: Right. Right.

Rovner: They knew how to get test results back and forth even if it was sending an intern to go fetch them. Finally, this week, we have some updates on some stories that we’ve talked about in earlier episodes. First, thanks in part to the excellent reporting of my colleague and sometime-pod-panelist Julie Appleby, the Senate Finance Committee Chairman Ron Wyden is demanding that HHS [U.S. Department of Health and Human Services] officials do more to rein in rogue insurance brokers who are reaping extra commissions by switching patients’ Affordable Care Act plans without their knowledge, often subjecting them to higher out-of-pocket costs and separating them from the providers that they’ve chosen. Sen. Wyden said he would introduce legislation to make such schemes a crime, but in the meantime he wants Biden officials to do more, given that they have received more than 90,000 complaints in the first quarter of 2024 alone about unauthorized switches and enrollments. Criminals go where the money is, right? You can either cyberhack or you can become a broker and switch people to ACA plans so you can get more commissions.

Kenen: I would think there could be a bipartisan, I mean it’s hard to get anything done in Congress. There’s no must-pass bills in the immediate future that are relevant. And the idea that a broker is secretly doing something that you don’t want them to do and that’s costing you money and making them money. I could see, those 90,000 people are from red and blue states and they vote, it’s going to affect constituents nationwide. Maybe they’ll do something. Maybe the industry can also… There is the National Association … I forgot the acronym, but there’s a broker’s organization, that there are probably things that they can also do to sanction. States can also do some things to brokers, but whether there’s a national solution or piecemeal, I don’t know, but it’s so outrageous that it’s not a right-left issue.

Rovner: Yes, one would think that there’ll be at least some kind of congressional action built into something …

Kenen: Something or other, right.

Rovner: … Congress that manages to do before the end of the year. Well, and in one of those seemingly rare cases where legislation actually does what it was intended to do, the White House this week announced that it has approved more than a million claims under the 2022 PACT Act, which made veterans injured as a result of exposure to burn pits and other toxic substances eligible for VA [Veterans Affairs] disability benefits. On the other hand, the VA is still working its way through another 3 million claims that have been submitted. I feel like even if it’s not very often, sometimes it’s worth noting that there are bipartisan things from Washington, D.C., that actually get passed and actually help the people that they’re supposed to help. It’s kind of sad that this is notable as an exception of something that happened and is working.

Roubein: In sort of the, I guess, Department of Unintended Side Effects here, my colleague Lisa Rein had a really interesting story out this morning that talked about the PACT Act, but basically that despite a federal law that prohibits charging veterans for help in applying for disability benefits, for-profit companies are making millions. She did a review of up to like a hundred unaccredited for-profit companies who have been charging veterans anywhere from like $5,000 to $20,000 for helping file disability claims because …

Rovner: That’s the theme of this week. Anyplace that there’s a lot of money in health care, there were people who will want to come in and take what’s not theirs. That’s where we will leave the news this week. Now we will play my interview with Shefali Luthra, then we’ll come back with our extra credits.

I am so pleased to welcome back to the podcast my former colleague and current “What The Health?” panelist Shefali Luthra. You haven’t heard from her in a while because she’s been working on her first book, called “Undue Burden,” that’s out this week. Shefali, great to see you.

Luthra: Thank you so much for having me Julie.

Rovner: So as the title suggests, “Undue Burden” is about the difficulties for both patients and providers in the wake of the overturn of Roe v. Wade. We talk so much about the politics of this issue, and so little about the real people who are affected. Why did you want to take this particular angle?

Luthra: To me, this is what makes this topic so important. Health care and abortion are really critical political issues. They sway elections. They are likely to be very consequential in this coming presidential election. But this matters to us as reporters and to us as people because of the life-or-death stakes and even beyond the life-or-death stakes, the stakes of how you choose to live your life and what it means to be pregnant and to be a parent. These are really difficult stories to tell because of the resources involved. And I wanted to write a book that just got at all of the different reasons why people pursue abortion and why they provide abortion and how that’s changed in the past two years. Because it felt to me like one of the few ways we could really understand just how seismic the implications of overturning Roe has been.

Rovner: And unlike those of us who talk to politicians all the time, you were really on the ground talking to patients and doctors, right?

Luthra: That was really, really important to the book. I spent a lot of time traveling the country, in clinics talking to people who were able to get abortions, who were unable to get abortions, and it was just really compelling for me to see how much access to care had the capacity to change their lives.

Rovner: So what kind of barriers then are we talking about that cropped up? And I guess it wasn’t even just the wake of the overturn of Roe. In Texas we had sort of a yearlong dry run.

Luthra: Exactly, and the book starts before Roe is overturned in Texas when the state enacted SB 8, the six-week abortion ban that effectively cut off access. And the first main character readers meet is this young girl named Tiffany, and she’s a teenager when she becomes pregnant, and she would love to get an abortion. But she is a minor. She lives very far from any abortion provider. She does not know how to self-manage an abortion. She does not know where to find pills. She has no connections into the health care system. She has no independent income. And she absolutely cannot travel anywhere for care. As a result, she has a child before she turns 18. And what this story highlights is that there are just so many barriers to getting an abortion. Many already existed: The incredible cost for procedure not covered by health insurance, the geographic distance, people already had to travel, the extra restrictions on minors.

But the overturning of Roe has amplified these, it is so expensive to get an abortion. It can be difficult to know you’re pregnant, especially if you are not trying to become pregnant. You have a very short time window. You may need to find childcare. You may need to find a car, get time off work, and bring all of these different forces together so that you are able to make a journey that can be days and pay for a trip that can cost thousands of dollars.

Rovner: One of the things that I think surprised me was that states that proclaimed themselves abortion “havens” actually did so little to help their clinics that predictably got swamped by out-of-state patients. Why do you think that was the case, and is it any better now?

Luthra: I think things have certainly changed. We have seen much more action in states, such as Illinois, where we see more people traveling there for care than anywhere else in the country. But it is worth going back to the summer that Roe was overturned. The governor promised to call a special session and put all these resources into making sure that Illinois could be a sanctuary. He never called that special session. And clinics felt like they were hanging out to dry, just waiting to get some support, and in the meanwhile, doing the absolute best they could.

One thing that I think this book really gets at is we are starting to see more efforts from these bluer states, the Illinois, the Californias, the New Yorks, and they talk a lot about wanting to be abortion havens, in part because it’s great politics if you’re a Democrat, but there’s only so much you can do. California has seen also quite a large increase in out-of-state patients. But I’ve spoken to so many people who just cannot conceivably go to California. They can barely go to Illinois. Making that journey when you are young, if you don’t have a lot of money, if you live in South Texas, if you live in Louisiana, it’s just not really feasible. And the places that are set up as these access points just can’t really fill in the gaps that they say they will.

Rovner: As you point out in the book, a lot of this was completely predictable. Was there something in your reporting that actually did surprise you?

Luthra: That’s a great question, and what did surprise me was in part something that we’ve begun to see borne out in the reporting, is there are very effective telemedicine strategies. We have begun to see physicians living in blue states, the New Yorks, Massachusetts, Californias, prescribing and mailing abortion pills to people in states with bans. This is pretty powerful. It has expanded access to a lot of people. What was really striking to me, though, even as I reported about the experiences of patients seeking care, is that while that has done so much to expand access in the face of abortion bans, it isn’t a solution that everyone can use. There were lots of people I met who did not want a medication abortion, who did not feel safe having pills mailed into their homes, or whose pregnancy complications and questions were just too complex to be solved by a virtual consult and then pills being mailed to them to take in the comfort of their house.

Rovner: Aren’t these difficulties exactly what the anti-abortion movement wanted? Didn’t they want clinics so swamped they couldn’t serve everybody who wanted to come, and abortion to be so difficult to get that women would end up carrying their pregnancies to term instead?

Luthra: Yes and no, I would argue. I think you are absolutely right that one of the primary goals of the anti-abortion movement was to make abortion unavailable, to make it harder to acquire, to have more people not get abortions and instead have children. But when I speak to folks in the anti-abortion movement, they are very troubled by how many people are traveling out of state to get care. They see those really long wait times in Kansas, in, until recently, Florida, in Illinois, in New Mexico, as a symptom of something that they need to address, which is that so many people are still finding a way to fight incredible odds to access abortion.

Rovner: Is there one thing that you hope people take away after they’re finished reading this?

Luthra: There are two things that I have spent a lot of time thinking about as I’ve reported this book. The first is just who gets abortions and under what circumstances. And so often in the national press, in national politics, we talk about these really extreme life-or-death cases. We talk about people who became septic and needed an abortion because their water broke early, or we talk about children who have been sexually assaulted and become pregnant. But we don’t talk about most people who get abortions; who are usually mothers, who are usually people of color, who are in their 20s and just know that they can’t be pregnant. I think those are really important stories to tell because they’re the true face of who is most affected by this, and it was important to me that this book include that.

The other thing that I have thought about so often in reporting this and writing this is abortion demands have an unequal impact. That is true if you are poor, if you are a person of color, if you live in a rural area, et cetera. You will in all likelihood see a greater effect. That said, the overturning of Roe v. Wade is so tremendous that it has affected people in every state. It affects you if you can get pregnant. It affects you if you want birth control. It affects you if you require reproductive health care in some form. This is just such a seismic change to our health care system that I really hope people who read this book understand that this is not a niche issue. This is something worthy of our collective attention and concern as journalists and as people.

Rovner: Shefali Luthra, thank you so much for this, and we will see you soon on the panel, right?

Luthra: Absolutely. Thank you, Julie. I’m so glad we got to do this.

Rovner: OK, we are back. It’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Joanne, why don’t you go first this week?

Kenen: This was a pair of articles, a long one and a shorter, related one. There’s an amazingly wonderful piece in ProPublica by Sharon Lerner, and it’s called “Toxic Gaslighting: How 3M Executives Convinced a Scientist the Forever Chemicals She Found in Human Blood Were Safe.” I’m going to come back and talk about it briefly in a second, but the related story was in The Guardian by Damian Carrington: “Microplastics Found in Every Human Testicle in Study.” Now, that was a small study, but there may be a link to the declining sperm count because of these forever chemicals.

The ProPublica story, it was a young woman scientist. She worked for 3M. They kept telling her her results was wrong, her machinery was dirty, over and over and over again until she questioned herself and her findings. She was supposed to be looking at the blood of 3M workers who were, it turned out, the company knew all this already and they were hiding it, and she compared the blood of the 3M workers to non-3M workers, and she found these plastic chemicals in everybody’s blood everywhere, and she was basically gaslit out of her job. She continued to work for 3M, but in a different capacity.

The article’s really scary about the impact for human health. It also has wonderfully interesting little nuggets throughout about how various 3M products were developed, some by accident. Something spilled on somebody’s sneaker and it didn’t stain it, and that’s how we got those sprays for our upholstery. Or somebody needed something to find the pages in their church hymnal, and that’s how we got Post-it notes. It’s a devastating but very readable, and it makes you angry.

Rovner: Yeah, I feel like there’s a lot more we’re going to have to say about forever chemicals going forward. Alice.

Ollstein: So I have a pretty depressing story from Stats. It’s called “How Doctors Are Pressuring Sickle Cell Patients Into Unwanted Sterilizations,” by Eric Boodman. And it is about people with sickle cell, and that is overwhelmingly black women, and they felt pressured to agree to be permanently sterilized when they were going to give birth because of the higher risks. And the doctors said, because we’re already doing a C-section and we’re already doing surgery on you, to not have to do an additional surgery with additional risks, they felt pressured to just sign that they could be sterilized right then and there and came to regret it later and really wanted more children. And so, this is an instance of people feeling coerced, and when people think about pro-choice or the choice debate about reproduction they mostly think about the right to an abortion. But I think that the right to have more children, if you want to, is the other side of that coin.

Rovner: It is. Rachel.

Roubein: My extra credit, it’s called “What Science Tells Us About Biden, Trump and Evaluating an Aging Brain,” by Joel Achenbach and Mark Johnson from The Washington Post. And basically, they kind of took a very science-based look at the 2024 election. They basically called it a crash course in gerontology because former President Donald Trump will be 78 years old. President Biden will be a couple weeks away from turning 82. And obviously that is getting a lot of attention on the campaign trail. They talked to medical and scientific experts who were essentially warning that news reports, political punditry about the candidates’ mental fitness, has essentially been marred by misinformation here about the aging process. One of the things they dived into was these gaffes or what the public sees as senior moments and what experts had told them is, that’s not necessarily a sign of dementia or predictive of cognitive decline. There need to be kind of further clinical evaluation for that. But there have been some calls for just how to kind of standardize and require a certain level of transparency for candidates in terms of disclosing their health information.

Rovner: Yes, which we’ve been talking about for a while, and will continue to. My extra credit this week is from our guest, Shefali Luthra, and her colleague at The 19th Chabeli Carrazana, and it’s called “What Happens to Clinics After a State Bans Abortion? They Fight To Survive.” And for all the talk about doctors and other staffers either moving out of or not moving into states with abortion bans, I think less has been written about entire enterprises that often provide far more than just abortion services having to shut down as well. We saw this in Texas in the mid-2010s, when a law that shut down many of the clinics there was struck down by the Supreme Court in 2016. But many of those clinics were unable to reopen. They just could not reassemble, basically, their leases and equipment and staff. The same could well happen in states that this November vote to reverse some of those bans. And it’s not just abortion, as we’ve discussed. When these clinics close, it often means less family planning, less STI [sexually transmitted infection] screening and other preventive services as well, so it’s definitely something to continue to watch.

Before we go this week, I want to note the passing of a health policy journalism giant with the death of Marshall Allen. Marshall, who worked tirelessly, first in Las Vegas and more recently at ProPublica, to expose some of the most unfair and infuriating parts of the U.S. health care system, was on the podcast in 2021 to talk about his book, “Never Pay the First Bill, and Other Ways to Fight the Health Care System and Win.” I will post a link to the interview in this week’s show notes. Condolences to Marshall’s friends and family.

OK, that is our show. 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. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, @jrovner. Joanne, where are you?

Kenen: We’re at Threads @JoanneKenen.

Rovner: Alice.

Ollstein: Still on X @AliceOllstein.

Rovner: Rachel.

Roubein: On X, @rachel_roubein.

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

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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

Public health officials are watching with concern since a strain of bird flu spread to dairy cows in at least nine states, and to at least one dairy worker. But in the wake of covid-19, many farmers are loath to let in health authorities for testing.

Meanwhile, another large health company — the Catholic hospital chain Ascension — has been targeted by a cyberattack, leading to serious problems at some facilities.

This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs Zhang of Stat, Alice Miranda Ollstein of Politico, and Sandhya Raman of CQ Roll Call.

Panelists

Rachel Cohrs Zhang
Stat News

@rachelcohrs

Read Rachel's stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories.

Sandhya Raman
CQ Roll Call

@SandhyaWrites

Read Sandhya's stories.

Among the takeaways from this week’s episode:

• Stumbles in the early response to bird flu bear an uncomfortable resemblance to the early days of covid, including the troubles protecting workers who could be exposed to the disease. Notably, the Department of Agriculture benefited from millions in covid relief funds designed to strengthen disease surveillance.
• Congress is working to extend coverage of telehealth care; the question is, how to pay for it? Lawmakers appear to have settled on a two-year agreement, though more on the extension — including how much it will cost — remains unknown.
• Speaking of telehealth, a new report shows about 20% of medication abortions are supervised via telehealth care. State-level restrictions are forcing those in need of abortion care to turn to options farther from home.
• And new reporting on Medicaid illuminates the number of people falling through the cracks of the government health system for low-income and disabled Americans — including how insurance companies benefit from individuals’ confusion over whether they have Medicaid coverage at all.

Also this week, Rovner interviews Atul Grover of the Association of American Medical Colleges about its recent analysis showing that graduating medical students are avoiding training in states with abortion bans and major restrictions.

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

Julie Rovner: NPR’s “Why Writing by Hand Beats Typing for Thinking and Learning,” by Jonathan Lambert.  

Alice Miranda Ollstein: Time’s “‘I Don’t Have Faith in Doctors Anymore.’ Women Say They Were Pressured Into Long-Term Birth Control,” by Alana Semuels.  

Rachel Cohrs Zhang: Stat’s “After Decades Fighting Big Tobacco, Cliff Douglas Now Leads a Foundation Funded by His Former Adversaries,” by Nicholas Florko.  

Sandhya Raman: The Baltimore Banner’s “People With Severe Mental Illness Are Stuck in Jail. Montgomery County Is the Epicenter of the Problem,” by Ben Conarck.  

Also mentioned on this week’s podcast:

• Stat’s “My Rendezvous With the Raw Milk Black Market: Quick, Easy, and Unchecked by the FDA,” by Nicholas Florko.
• The Stamford Advocate’s “Dan Haar: Hackers Stole a Disabled CT Couple’s SNAP Food Aid. Now They’re Out $1,373,” by Dan Haar.
• WKRN’s “‘Chaos’: Nurses, Visitors Describe Conditions Inside Ascension Hospitals After Cyberattack,” by Stephanie Langston.
• KFF Health News’ “Medicaid ‘Unwinding’ Decried as Biased Against Disabled People,” by Daniel Chang.
• KFF Health News’ “Why Medicaid’s ‘Undercount’ Problem Counts,” by Phil Galewitz.

Click to open the transcript

Transcript: Bird Flu Lands as the Next Public Health Challenge

[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.]

Mila Atmos: The future of America is in your hands.

This is not a movie trailer and it’s not a political ad, but it is a call to action. I’m Mila Atmos and I’m passionate about unlocking the power of everyday citizens. On our podcast “Future Hindsight,” we take big ideas about civic life and democracy and turn them into action items for you and me. Every Thursday we talk to bold activists and civic innovators to help you understand your power and your power to change the status quo. Find us at futurehindsight.com or wherever you listen to podcasts.

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, May 16, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this, so here we go.

We are joined today via video conference by Alice Miranda Ollstein of Politico.

Alice Miranda Ollstein: Hello.

Rovner: Rachel Cohrs Zhang of Stat News.

Rachel Cohrs Zhang: Hi, everybody.

Rovner: And we welcome back to the podcast following her sabbatical, Sandhya Raman of CQ Roll Call.

Sandhya Raman: Hi, everyone.

Rovner: Later in this episode we’ll have my interview with Atul Grover of the Association of American Medical Colleges. He’s the co-author of the analysis we talked about on last week’s episode about how graduating medical students are avoiding applying for residencies in states with abortion bans or severe restrictions. But first this week’s news.

Well, I have been trying to avoid it, but I guess we finally have to talk about bird flu, which I think we really need to start calling “cow flu.” I just hope we don’t have to call it the next pandemic. Seriously, scientists say they’ve never seen the H5N1 virus spread quite like this before, including to at least one farmworker, who luckily had a very mild case. And public health officials are, if not actively freaking out, at least expressing very serious concern.

On the one hand, the federal government is providing livestock farmers tens of thousands of dollars each to beef up their protective measures — yes, I did that on purpose — and test for the avian flu virus in their cows, which seems to be spreading rapidly. On the other hand, many farmers are resisting efforts to allow health officials to test their herds, and this is exactly the kind of thing at the federal level that touches off those intra-agency rivalries between FDA [Food and Drug Administration] and USDA [United States Department of Agriculture] and the CDC [Centers for Disease Control and Prevention].

Is this going to be the first test of how weak our public health sector has become in the wake of covid? And how worried should we be both about the bird flu and about the ability of government to do anything about it? Rachel, you wrote about this this week.

Cohrs Zhang: I did, yes. It is kind of wild to see a lot of these patterns play out yet again, as if we’ve learned nothing. We still have a lot of challenges between coordinating with state and local health officials and federal agencies like CDC. We’re still seeing authorities that are exactly the same between USDA and FDA. USDA actually got $300 million from covid relief bills to try to increase their surveillance for these kind of diseases that spread among animals, but people are worried it could all potentially jump to humans.

So I think there was a lot of hope that maybe we would learn some lessons and learn to respond better, but I think we have seen some hiccups and just these jurisdictional issues that have just continued to happen because Congress didn’t really address some of these larger authorities in any meaningful way.

Rovner: I think the thing that worries me the most is looking at the dairy farmers who don’t want to let inspectors onto their farms. That strikes me as something that could seriously hamper efforts to know how widely and how fast this is spreading.

Cohrs Zhang: It could. And USDA does have more authority than they have had in other foodborne disease outbreaks like E. coli or salmonella to get on these farms, according to the experts that I’ve talked to. But we do see sometimes federal agencies don’t always want to use their full statutory authority because then it creates conflict. And obviously USDA has this dual mission of both ensuring food safety and promoting agriculture. And I think that comes into conflict sometimes and USDA just hasn’t been willing to enforce anything mandatory on farms yet. They’ve been kind of trying to use the carrot instead of the stick approach so far. So we’ll see how that goes and how much information they’re able to obtain with the measures they’ve used so far.

Rovner: Alice, you want to add something.

Ollstein: Yeah, I mean, like Rachel said, it’s sort of Groundhog Day for some of the bigger missteps of covid: inadequate testing, inadequate PPE [personal protective equipment]. But it’s also like a scary repeat of some of the specifics of covid, which really hit agricultural workers really hard. And a lot of that wasn’t known at the time, but we know it now. And a lot of workers in these agricultural, meatpacking, and other sectors, were just really devastated and forced to keep working during the outbreak.

This sector in particular has been resistant to public health enforcement and we’re just seeing that repeat once again with a potentially more deadly virus should it make the jump to humans.

Rovner: Basically, from what they can tell, this virus is in a lot of milk. It seems that pasteurization can kill it, but is this maybe what will get people to stop drinking raw milk, which isn’t that safe anyway? And if you need to know why you shouldn’t drink raw milk, I will link to a highly informative and entertaining story by Rachel’s colleague Nick Florko about how easy it is to buy raw milk and how dangerous it can be. This is one of those things where the public looks at the public health and goes, “Yeah, nah.”

Ollstein: Right, yeah. I think, at least anecdotally, the raw milk seller that Nick bought from indicated that business is good for him, business is booming. A lot of the people that maybe weren’t so concerned about covid aren’t so concerned about bird flu, and I think that will continue to drink that. Again, we haven’t seen a lot of data about how exactly that works with bird flu fragments or virus fragments: whether it’s showing up in raw milk?; what happens when people drink it? There’s so many questions we have right now because I think the FDA has been focused on pasteurized milk because that’s what most people drink. But certainly in terms of concern with transitions into humans, I think that’s an area to watch.

Raman: One of the things that struck me was that one of the benefits from what the USDA and HHS [Department of Health and Human Services] were doing was the benefit for workers to get a swab test and do an interview so they can study more and gauge the situation.

If $75 is enough to incentivize people to take off work, to maybe have to do transportation, to do those other things. And if they’ll be able to get some of the data, just as Rachel was saying, to just kind of continue gauging the situation. So I think that’ll be interesting to see.

Because even with when we had covid, there were so many incentives that we did just for vaccines that we hoped would be successful for different populations and money and prizes and all sorts of things that didn’t necessarily move the needle.

Rovner: Although some did. And nice pun there.

All right, well, moving on to less potentially-end-of-the-world health news, Congress is grappling with whether and how to extend coverage of telehealth and, if so, how to pay for it. Telehealth, of course, was practically the only way to get nonemergency health care throughout most of the pandemic, and both patients and providers got used to it and even, dare I say, came to like it. But as a Politico story succinctly put it this week, telehealth “has the potential to reduce expenses but also lead to more visits, driving up costs.”

Rachel, you’ve been watching this also this week. Where are we on these competing telehealth bills?

Cohrs Zhang: Well, we have some news this morning. The [House Committee on] Energy and Commerce Health Subcommittee is planning to mark up their telehealth bill. And the underlying bill will be a permanent extension of some of these Medicare telehealth flexibilities that matter a lot to seniors. But they’re planning to amend it today, so that they’re proposing a two-year extension, which does fall more in line with what the Ways and Means Committee, which is kind of the counterpart that makes policy on health care, marked up …

Rovner: Yes, they shared jurisdiction over Medicare.

Cohrs Zhang: … unanimously passed. They shared, yes, but it is surprising and remarkable for them to come to an agreement this quickly on a two-year extension. Again, I think industry would’ve loved to see a little bit more certainty on this for what these authorities are going to look like, but I think it is just expensive. Again, when these bills pass out of committee, then we’ll actually get formal cost estimates for them, which will be helpful in informing what our end-of-the-year December package is going to look like on health care. But we are seeing some alignment now in the House on a two-year telehealth extension for some of these very impactful measures for Medicare patients.

Rovner: Congress potentially getting things done months before they actually have to! Dare we hope?

Meanwhile, bridging this week’s topics between telehealth and abortion, which we will get to next, a new report from the family planning group WeCount! finds that not only are medication abortions more than half of all abortions being performed these days, but telehealth medication abortions now make up 20% of all medication abortions.

Some of this increase obviously is the pandemic relaxation of in-person medication abortion rules by the FDA, as well as shield laws that attempt to protect providers in states where abortion is still legal, who prescribe the pills for patients in states where abortion is banned.

Still, I imagine this is making anti-abortion activists really, really frustrated because it is certainly compromising their ability to really stop abortions in these states with bans, right?

Ollstein: Well, I think for a while we’ve seen anti-abortion activists really targeting the two main routes for people who live in states with bans to still have an abortion. One is ordering pills and the other is traveling out of state. And so they are exploring different policies to cut off both. Obviously both are very hard to police, both logistically and legally. There’s been a lot of debate about how this would be enforced. You see Louisiana moving to make abortion pills a controlled substance and police it that way. These pills are used for more than just abortions, so there’s some health care implications to going down that route. They’re used in miscarriage management, they’re used for other things as well in health care. And then of course, the enforcement question. Short of going through everyone’s mail, which has obvious constitutional problems, how would you ever know? These pills are sent to people’s homes in discreet packaging.

What we’ve seen so far with anti-abortion laws and their enforcement is that just the chilling effect alone and the fear is often enough to deter people from using different methods. And so that could be the goal. But actually cutting off people from telehealth abortions that, like you said, like the report said, have become very, very widely used, seems challenging.

Raman: And I would say that that really underscores the importance of the case we’d heard this year from the Supreme Court, and that we will get a decision coming up about the regulation of medication abortions. And how the court lands on that could have a huge impact on the next steps for all of these. So it’s in flux regardless of what’s happening here.

Cohrs Zhang: I want to emphasize, too, that mail-order abortion pills have been sort of held up as this silver bullet for getting around bans. And for a lot of people, that seems to be the case. But I really hear from providers and from patients that this is not a solution for everyone. A lot of people don’t have internet access or don’t know how to navigate different websites to find a reliable source for the pills. Or they’re too scared to do so, scared by the threat of law enforcement or scared that they could purchase some sort of counterfeit that isn’t effective or harms them.

Some people, even when they’re eligible for a medication abortion, prefer surgical or procedural because with a medication you take it and then you have to wait a few weeks to find out if it worked. And so some people would rather go into the clinic, make sure it’s done, have that peace of mind and security.

Also, these pills are delivered to people’s homes. Some people, because of a domestic violence situation or because they’re a minor who’s still at home with their parents, they can’t have anything sent to their homes. There’s a lot of reasons why this isn’t a solution for everyone, that I’ve been hearing about, but it is a solution, it seems, for a lot of people.

Rovner: In other abortion news this week, Democrats in the Missouri state Senate this week broke the record for the longest filibuster in history in an effort to block anti-abortion forces from making it harder for voters to amend the state constitution.

Alice, this feels pretty familiar, like it’s just about what happened in Ohio, right? And I guess the filibuster is over, but so far they’ve managed to be successful. What’s happening in Missouri?

Ollstein: So Missouri Democrats, with their filibuster that lasted for days, managed to stop a vote for now on a measure that would’ve made ballot measures harder to pass, including the abortion rights ballot measure that’s expected this fall. It’s not over yet. They sort of kicked it back to committee, but there’s only basically a day left in the legislature session, and so stay tuned over the next day to see what happens.

But what Democrats are trying to do is prevent what happened in Ohio, which is setting up a summer special election on a provision that would make all ballot measures harder to pass in the future. In Ohio, they did hold that summer vote, and voters defeated it and then went on to pass an abortion rights measure. And so even if Republicans push this through, it can still be scuttled later. But there, Democrats are trying to nip it in the bud to make sure that doesn’t happen in the first place.

Rovner: I thought that was very well explained. Thank you very much.

And speaking of misleading ballot measures, next door in Nebraska — and I did have to look at a map to make sure that Nebraska and Missouri do have a border, they do — anti-abortion forces are pushing a ballot measure they’re advertising as enshrining abortion rights in the state constitution, but which would actually enshrine the state’s current 12-week ban.

We’re seeing more and more of this: anti-abortion forces trying to sort of confuse voters about what it is that they’re voting on.

Raman: I mean, I think that that has been something that we have been seeing a little bit more of this. They’ve been trying different tactics to see — the same metaphor of throwing spaghetti at the wall and seeing what sticks. So with Nebraska right now, the proposal is to ban abortions after the first trimester, except in the trio of cases: medical emergencies, rape, incest.

And so that’s definitely different than a lot of the other ballot measures that we’ve seen in the last few years in that it’s being kind of pitched as a little bit of a middle ground and it has the backing of the different anti-abortion groups. But at the same time, it would allow state legislature to put additional bans on top of that. This is just kind of like the mark in the constitution and it would already keep in place the bans that you have in place.

So it’s a little bit more difficult to comprehend, especially if you’re just kind of walking in and checking a box, since there’s more nuance to it than some of the other measures. And I think that a lot of that is definitely more happening in states like that and others.

Rovner: I feel like we’re learning a lot more about ballot measures and how they work. And while we’re in the Great Plains, there’s a wild story out of South Dakota this week about an actual scam related to signatures on petitions for abortion ballot measures. Somebody tease this one apart.

Ollstein: So in South Dakota, they’ve already submitted signatures to put an abortion rights measure on the November ballot. The state is, as happens in most states, going through those signatures to verify it. What’s different than most states is that the state released the names of some of the people who signed the petition, and that enabled these anti-abortion groups to look up all those people and start calling them, and to try to convince them to withdraw their signatures to deny this from going forward.

What happened is that, in doing so, these groups are accused of misrepresenting themselves and impersonating government officials in the way they said, “Hey, we’re the ballot integrity committee of the something, something, something.” And they said it in a way that made it sound like they were with the secretary of state’s office. So the secretary of state put out a press release condemning this and referring it to law enforcement.

The group has admitted to doing this and said it’s done nothing wrong, that technically it didn’t say anything untrue. Of course there’s lying versus misleading versus this versus that. It’s a bit complicated here.

So regardless, I am skeptical that enough people will bother to go through the process of withdrawing their signature to make a difference. It’s a lot more work to withdraw your signature than to sign in the first place. You have to go in person or mail something in. And so I am curious to see if, one, whether this is illegal, and two, whether it makes a difference on the ground.

Rovner: Well, at some point, I think by the end of the summer we’ll be able to make a comprehensive list of where there are going to be ballot measures and what they’re going to be. In the meantime, we shall keep watching.

Let’s move on to another continuing story: health system cyberhacks. This week’s victim is Ascension, a large Catholic system with hospitals in 19 states. And the hack, to quote the AP, “forced some of its 140 hospitals to divert ambulances, caused patients to postpone medical tests, and blocked online access to patient records.”

You would think in the wake of the Change Healthcare hack, big systems like Ascension would’ve taken steps to lock things down more, or is that just me?

Cohrs Zhang: We’re still using fax machines, Julie. What are your expectations here? So cyberattacks have been a theoretical concern of health systems for a long time. I mean, back in 2019, 2020, Congress was kind of sliding provisions into spending bills to help support health systems in upgrading their systems. But again, we’re just seeing the scale. And I think these stories that came out this week really illustrate the human impact of these cyberattacks. And people are waiting longer in an ambulance to get to the hospital.

I mean, that’s a really serious issue. And I’m hoping that health systems will start taking this seriously. But I think it’s just exposing yet another risk that the failure to upgrade these systems isn’t just an inconvenience for people actually using the system. It isn’t just a disservice to all kind of the power of health care data and patients’ information that they could be leveraging better. But it’s also a real medical concern with these attacks. So I am optimistic. We’ll see. Sometimes it takes these sort of events to force change.

Rovner: Well, just before we started to tape this morning, I saw a story out of Tennessee about one of the hospitals that’s being affected. And apparently it is. I believe the word “chaos” was used in the headline and the lead. I mean, these are really serious things. It’s not just what’s going on in the back room, it’s what’s going on with patient care.

In maybe the most depressing hacking story ever, in Connecticut criminals are hacking and stealing the value of people’s electronic food stamp debit card. The Stamford Advocate wrote about one older couple whose card has been now hacked five times and who are out nearly $1,400 they can’t get back because the state can only reimburse people for two hacks. I remember when electronic funds transfers were going to make our lives so much easier. They do seem to be making lives so much easier for criminals.

Finally this week, more on the mess that is the Medicaid unwinding, from two of my colleagues. One story by Daniel Chang is about how people with disabilities, who shouldn’t really have been impacted by the unwinding anyway, are losing critical home care services in all of the administrative confusion. This seems a lot like the cases of eligible children losing coverage because their parents were deemed to have too-high income, even though children have different eligibility criteria.

I know the Biden administration has been trying to soft-pedal its pushes to some of these states. Rachel, you were talking about the USDA trying not to push too hard, but it does seem like in Medicaid a lot of eligible people are falling between the cracks.

Raman: Yeah, I mean states, as we’ve seen, have been really trying to see how fast that they can go to kind of reverify this huge batch of folks because it will be a cost saver for them to have fewer folks on the rolls. But as you’re saying, that a lot of people are falling through the cracks, especially when it’s unintentionally getting pulled from the program like your colleague’s story. And people with a lot of chronic disabilities already qualify for Medicaid, don’t need to be reverified each time because they’re continually qualified for it. And so there are some cases that have been filed already by the National Health Law Program in Colorado, and [Washington,] D.C., and Texas. And so we’ll kind of see as time goes on, how those go and if there’s any changes made to stop that.

Rovner: Also on the Medicaid beat, my colleague Phil Galewitz has a story that’s kind of the opposite. According to a study in the policy journal Health Affairs, a third of those enrolled in Medicaid in 2022, didn’t even know it. That’s 26 million people. And 3 million people actually thought they were uninsured when they in fact had Medicaid. That not only meant lots of people who didn’t get needed health services because they thought they couldn’t afford them because they thought they didn’t have insurance, but also managed-care companies who got paid for these enrollees who never got any care, and conveniently never bothered to inform them that they were covered. Rachel, you had a comment about this?

Cohrs Zhang: I did, yes. One part I really liked about this story is how Phil highlighted that it’s in insurance companies’ best interests for these people not to know that they can get health care services. Because a lot of Medicaid, they’re getting a payment for each member, capitated payments. And so if people aren’t using it, then the insurance companies are making more money. And so I think there has been some more, I think, political conversation about the incentives that capitated payments create especially in the Medicaid population. And so I think that was certainly just a disservice. I mean, these people have been done a disservice by someone. And I think that it’s a really interesting question of who should have been reaching them. And we’ll just, I guess, never know how much care they could have gotten and how their lives could be different had they known.

Rovner: It’s funny, we’ve known for a long time when they do the uninsured statistics that people don’t always know what kind of insurance they have. And they’ll say when they started asking a follow-up question, the Census Bureau started asking a follow-up question about insurance, suddenly the number of uninsured went down. This is the first time I’ve seen a study like this though, where people actually had insurance but didn’t know it. And it’s really interesting. And you’re right, it has real policy ramifications.

All right, well that’s the news for this week. Before we get to our interview, Sandhya, you’ve been gone for the last couple of months on sabbatical. Tell us what you saw in Europe.

Raman: Yeah, so it’s good to be back. I was gone for six weeks mostly to France, improving my French to see how I could get better at that and hopefully use it in my reporting at some point. It was interesting because I was trying to tune out of the news a little bit and stay away from health care. And of course when you try to do that, it comes right back to you. So I would be in my French class and we’d do a practice, let’s read an article or learn a historical thing, and lo and behold, one of the examples was about abortion politics in France over the years.

It was interesting to have to explain to my classmates, “Yes, I’m very familiar with this topic, and how much do you want me to talk about how this is in my country? But let me make sure I know all of those words.” So it pops up even when you think you’re going to sneak away from it.

Rovner: Yes, and we’re very obviously U.S.-centric here, but when you go to another country you realize none of their health systems work that well either. So the frustration continues everywhere.

All right, that is the news for this week. Now we will play my interview with Atul Grover, then we will come back and do our extra credits.

I am so pleased to welcome to the podcast Dr. Atul Grover, executive director of the Association of American [Medical] Colleges’ Research and Action Institute. I bet you have a very long business card.

And I want to offer him a public apology for not having him on sooner. Atul is the co-author of the report we talked about on last week’s episode on how graduating medical students are less likely to apply for residency in states with abortion bans and restrictions. Welcome at last to “What the Health?”

Grover: Better late than never.

Rovner: So there seems to be some confusion, at least in social media land, about some of the numbers here. Tell us what your analysis found.

Grover: First, Julie, is there ever not confusion in social media land? The numbers basically bear out the same thing that we saw last year — making it a very short but real trend — which is that when we look at where new U.S. medical school graduates are applying for residencies, and they apply to any number of programs, what they’re doing, it appears, is selectively avoiding those states in which abortion is either completely banned or severely restricted. And that’s not just in reproductive health-heavy specialties like OB-GYN, but it seems to be across the board.

Rovner: Now, can you explain why all of the numbers seem to be going down? It’s not that the number of applicants are falling, it’s the number of applications.

Grover: There’s about 20,000 people that graduate from U.S. MD [medical degree] schools every year. There are another 15[,000] to 20,000 applicants for residency positions that are DO [doctor of osteopathic medicine] graduates domestically or international graduates. Could be U.S. citizens or foreign citizens.

But what we’ve tried to do for a number of years is encourage applicants to apply to a fewer number of residency programs because we found that they were out-applying, they were over-applying. Where we did some data analyses a couple of years back on diminishing returns where we said, “Look, once you apply to 15, 20, 30 programs, your likelihood of matching, I know you’re nervous, but the likelihood of matching is not going to go up. You’re going to do fine. You don’t need to apply to 60, 70, 80 programs.”

So the good news is we’re actually seeing those numbers come down by about, for U.S. medical grads, about 7% this year, which is really the first time that I can remember in the last 10 years that this has happened. So that is good news.

Rovner: And that was an explicit goal.

Grover: That was an explicit goal. We want to make this cheaper, easier, and more rational for applicants and for programs, as they have to screen people and figure out who really wants to come to their program.

So overall, we were really pleased to see that the average applicant, as they applied to programs, applied to a few less programs, which meant that in many cases they were maybe not applying to one or two states that the average applicant might’ve applied to last year. So on average, each state saw about a 10% decrease in the number of unique applicants. But that decrease was much higher when we looked at those states that had banned abortion or severely limited it.

Rovner: Eventually, all these residency positions fill though, right, because there are more applicants as you point out, more graduating medical students and incoming graduates from other countries than there are slots. So why should we care, if all of these programs are filling?

Grover: So, I think you should always care about the number of residency spots, and I know you have a long history here, as do I, in that that is the bottleneck where we have to deal with why we have physician shortages, or one of the reasons why across the board we just don’t train enough physicians.

We have increased the number of medical school spots. We have people that are graduating from DO schools, as I said, international graduates. More are applying every year than we have space for. Which means that, yes, right now every spot will fill, because if the alternative for somebody applying is, look, I either won’t get in and actually be able to train in my specialty of choice. Or, I may have to go to my third choice or 10th choice or 50th choice or 100th choice. I’d rather go to someplace than no place at all.

So yes, everything is filling, but our look at the U.S. MD seniors was in part because we believe that they are the most competitive applicants, and in some ways the most desirable applicants. They have a 95% success in the match year after year. And so we thought they would be the most sensitive to look at in terms of, hey, I’ve got a little more choice here. Maybe I won’t apply to that state where I don’t feel like I can practice medicine freely for my patients.

And I think that’s a potential problem for a lot of these states and a lot of these programs is, if the people who might’ve been applying if the laws were different, who happened to be a better match for your program, for your specialty and your community, aren’t choosing to apply there, yes, you can fill it, but maybe not with the ideal candidate. And I think that’s going to affect patients and populations and local communities in the years to come.

Rovner: When we saw the beginning of this trend last year most of the talk was about a potential shortage of OB-GYNs going forward, since physicians often stay in practice where it is that they do their residency. But now, as you mentioned, we’re seeing a decrease in applications and specialties across the board. Why would that be?

Grover: So this is an informed opinion as to why people across specialties are choosing not to apply to residencies in these states. We didn’t ask the specific people who are matching this past year, “Why did you choose to apply or not to apply to this state?”

So what we know, though, from asking questions in other surveys is that about 70% of all health professions and health profession students believe that abortion should be legal at some point during a pregnancy. If you look at some specialties like adolescent medicine, that number goes up to 96%. So No. 1, I think it’s a potential violation of what people believe should be some freedom between doctors and patients as to allowing them to have the full range of reproductive health care.

No. 2, I think the potential penalties and the laws are often viewed as being incredibly punitive and somewhat unclear. And as much as doctors hate getting sued, we really don’t want to be indicted. I know some people are fine getting indicted. We really don’t want to be indicted. And that has implications because if we’re indicted, if we’re convicted of any kind of criminal offense, we could lose our license and not be able to care for patients. And we have a long investment in trying to do so.

The third thing that I think is relevant is certainly some of the specialties we’re looking at are heavily populated by women physicians, so OB-GYN, pediatrics. But again, across the board, it’s 50% women. So I think for the women themselves that happen to be applying, there is this issue of, think about their ages, 26, 27, 28 to the mid-30s, for the most part, and there are outliers on either end. But for the most part, they are of reproductive age, and I think they want to have control over their own lives and their own health care, and make sure that all services are available to them and their families if they need it. And I think even if it’s not relevant to you as an individual, it probably is relevant to your spouse or partner or somebody else in your family. And I think that makes a huge difference when people make these choices.

Rovner: So in the end, assuming these trends continue, I mean there really is concern for what the health professional community will look like in some of these states, right?

Grover: Yeah, and I think one of the things that I tried to look at last year in an editorial for JAMA was trying to overlay the states that have already significant challenges in recruiting and retaining physicians. They tend to be a lot of the heavily rural states, Southern states, parts of the Midwest. You overlay that on a map of the 14 states now that have basically banned abortion, and there’s a pretty close match.

So I think it’s critically important for state, local officials, legislatures, governors to think about their own potential impact of passing these laws on something that they may think is critically important, which is recruiting and retaining health professionals. And as you said, about half of people who train in a state will end up staying there to practice.

And for these pipeline programs, I know places like Mississippi and Alabama will really try and recruit individuals from underserved communities, get them through high school, get them into college, get them to stay in the state for med school, stay in the state for residency. They’re 80% likely to stay in those states. You lose them at any point along the way and they’re a lot less likely to come back.

So without even telling these states, I can’t tell you what’s good for you, but you should at least figure out how to collect the data at a local level to understand the implications of your policies on the health of everybody in a state, not just women of reproductive age.

Rovner: And I assume that we’ll be hearing more about this.

Grover: I would think so, yes.

Rovner: And asking more students about it.

Grover: Yes, we will. And we get to administer something called the Graduation Questionnaire every year for all these MD students. One of the questions we just added, and hopefully we’ll have some data, my colleagues will have that by probably August or so, is asking them specifically: What role did laws around some of these social issues have in your choice of where to do your residency? And again, there is some overlap here of states that have restricted reproductive rights, transgender care, and some other issues that are probably all kind of mixed in.

Rovner: Great. We’ll have you back to talk about it then.

Grover: Great. And I’m happy to come back and talk about market consolidation, about life expectancy, the quality of U.S. health, or anything else you want.

Rovner: Atul Grover, thank you so much.

Grover: Thanks for having me.

Rovner: OK, we are back. It’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device.

Sandhya, why don’t you go ahead and go first this week?

Raman: Great. So my story is from Ben Conarck at The Baltimore Banner, and it’s called “People With Severe Mental Illness Are Stuck in Jail. Montgomery County Is the Epicenter of the Problem.”

This is a really sad and impactful story about Montgomery County, Maryland, which is just outside of  D.C., and how they are leading to this problem in this state. And many people are on the wait list for beds and psychiatric facilities, but they’re serving pretty short sentences of 90 days or less, and just a lot of the issues there. And just the problems for criminal defendants waiting in facilities for months on end for treatment.

Rovner: And I would add, because I live there, Montgomery County, Maryland, is one of the wealthiest counties in the country, and it’s kind of embarrassing that there are people who are not where they should be because they don’t have enough beds. Alice.

Ollstein: I have a piece from Time magazine called “‘I Don’t Have Faith in Doctors Anymore.’ Women Say They Were Pressured Into Long-Term Birth Control.” And it’s about something that I’ve been hearing about from providers for a bit now, which is that IUDs are this very effective form of birth control. It’s a device implanted in the uterus, and it was supposed to be this amazing way to help people avoid unwanted pregnancies. But as with many things, it is being used coercively, according to this report.

Because a physician has to implant it and remove it, people say that, one, they were pressured into having one often right after giving birth when they were sort of not in a place to make that kind of big decision. And then people who were given one struggled to have someone remove it when they wanted that done in the future.

And so I think it’s a good reminder that these tools are not inherently good or inherently bad. They can be used unethically or ethically by providers.

Rovner: And all reproductive health care is fraught. Rachel?

Cohrs Zhang: Yes. So Nick has been on quite the tear this week. My colleague Nick Florko at Stat and I wanted to highlight a profile that he wrote. The headline is, “After Decades Fighting Big Tobacco, Cliff Douglas Now Leads a Foundation Funded by His Former Adversaries.”

And I think it just has so much nuance into just a figure who fought Big Tobacco to bring to light what they were doing over decades. And now he’s chosen to take over this organization that had, in the past, been entirely funded by a tobacco company. And so I think it’s this really interesting … what we see all the time in Washington, how people contort themselves to make that transition into the private sector, or what they choose to do with their careers after public service. This is a nontraditional public service, obviously, being an advocate in this way. But I think it will be a really interesting dynamic to watch to see how much he chooses to change the direction of the organization, how long that arrangement lasts, if he chooses to do that.

I learned a lot reading this profile, and I think it’s even more rare to see people sit down for lengthy interviews for an old-fashioned profile. So I really enjoyed the piece.

Rovner: Full disclosure, I’ve known Cliff Douglas since the 1980s when he was just a young advocate starting out on his antismoking career. It really is good piece. I also thought Nick did a really good job.

Well, my story this week is from the NPR Shots blog. It’s by Jonathan Lambert and it’s called “Why Writing by Hand Beats Typing for Thinking and Learning.” And it made me feel much better for often being the only person in a room taking notes by hand in a notebook when everyone else is on their laptop. In fact, I can type as fast as anyone, and I can definitely type faster than I can write in longhand, but I actually find I take better notes if I have to boil down what I’m listening to. And it turns out there’s science that bears that out. Now, if only we could get the schools to go back to teaching cursive, but that’s a whole different issue.

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. And happy birthday today to half of my weekly live audience: Aspen the corgi turns 4 today.

As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X or Twitter, whatever you want to call it, @jrovner. Sandhya, where are you?

Raman: @SandhyaWrites.

Rovner: Alice.

Ollstein: @AliceOllstein.

Rovner: Rachel.

Cohrs Zhang: @rachelcohrs.

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

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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

A new analysis finds that graduating medical students were less likely to apply this year for residency training in states that ban or restrict abortion. That was true not only for aspiring OB-GYNs and others who regularly treat pregnant patients, but for all specialties.

Meanwhile, another study has found that more than 4 million children have been terminated from Medicaid or the Children’s Health Insurance Program since the federal government ended a covid-related provision barring such disenrollments. The study estimates about three-quarters of those children were still eligible and were kicked off for procedural reasons.

This week’s panelists are Julie Rovner of KFF Health News, Lauren Weber of The Washington Post, Joanne Kenen of the Johns Hopkins University schools of nursing and public health and Politico Magazine, and Anna Edney of Bloomberg News.

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Anna Edney
Bloomberg

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Read Anna's stories.

Joanne Kenen
Johns Hopkins University and Politico

@JoanneKenen

Read Joanne's articles.

Lauren Weber
The Washington Post

@LaurenWeberHP

Read Lauren's stories.

Among the takeaways from this week’s episode:

• More medical students are avoiding applying to residency programs in states with abortion restrictions. That could worsen access problems in areas that already don’t have enough doctors and other health providers in their communities.
• New threats to abortion care in the United States include not only state laws penalizing abortion pill possession and abortion travel, but also online misinformation campaigns — which are trying to discourage people from supporting abortion ballot measures by telling them lies about how their information might be used.
• The latest news is out on the fate of Medicare, and a pretty robust economy appears to have bought the program’s trust fund another five years. Still, its overall health depends on a long-term solution — and a long-term solution depends on Congress.
• In Medicaid expansion news, Mississippi lawmakers’ latest attempt to expand the program was unsuccessful, and a report shows two other nonexpansion states — Texas and Florida — account for about 40% of the 4 million kids who were dropped from Medicaid and CHIP last year. By not expanding Medicaid, holdout states say no to billions of federal dollars that could be used to cover health care for low-income residents.
• Finally, the bankruptcy of the hospital chain Steward Health Care tells a striking story of what happens when private equity invests in health care.

Also this week, Rovner interviews KFF Health News’ Katheryn Houghton, who reported and wrote the latest KFF Health News-NPR “Bill of the Month” feature, about a patient who went outside his insurance network for a surgery and thought he had covered all his bases. It turned out he hadn’t. If you have an outrageous or incomprehensible medical bill you’d like to share with us, you can do that here.

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

Julie Rovner: The Nation’s “The Abortion Pill Underground,” by Amy Littlefield.

Joanne Kenen: The New York Times’ “In Medicine, the Morally Unthinkable Too Easily Comes to Seem Normal,” by Carl Elliott.

Anna Edney: ProPublica’s “Facing Unchecked Syphilis Outbreak, Great Plains Tribes Sought Federal Help. Months Later, No One Has Responded,” by Anna Maria Barry-Jester.

Lauren Weber: Stat’s “NYU Professors Who Defended Vaping Didn’t Disclose Ties to Juul, Documents Show,” by Nicholas Florko.

Also mentioned on this week’s podcast:

• KFF Health News’ “Medical Residents Are Increasingly Avoiding States With Abortion Restrictions,” by Julie Rovner and Rachana Pradhan.
• CNBC’s “Abortion Bans Drive Away up to Half of Young Talent, New CNBC/Generation Lab Youth Survey Finds,” by Jason Gewirtz.
• The Washington Post’s “Texas Man Files Legal Action To Probe Ex-Partner’s Out-of-State Abortion,” by Caroline Kitchener.

Click to open the transcript

Transcript: Newly Minted Doctors Are Avoiding Abortion Ban States

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, May 9, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this, so here we go. We are joined today via video conference by Lauren Weber of The Washington Post.

Lauren Weber: Hello. Hello.

Rovner: Joanne Kenen of the Johns Hopkins University schools of public health and nursing and Politico Magazine.

Joanne Kenen: Hi, everybody.

Rovner: And Anna Edney of Bloomberg News.

Anna Edney: Hi there.

Rovner: Later in this episode we’ll have my interview with KFF Health News’ Katheryn Houghton, who reported and wrote the latest KFF Health News-NPR “Bill of the Month.” This month’s patient went out of network for surgery and thought he did everything right. Things went wrong anyway. But first, this week’s news. We are going to start again with abortion this week with a segment I’m calling, “The kids are all right, but they don’t want to settle in states with abortion bans.”

This morning we got the numbers from the Association of American Medical Colleges on the latest residency match. And while applications for residency positions were down in general — more on that in a minute — for the second year in a row, they were down considerably more in states with abortion bans, and to a lesser extent, in states with other abortion restrictions, like gestational limits. And it’s not just in OB-GYN and other specialties that interact regularly with pregnant people. It appears that graduating medical students are trying to avoid abortion ban states across the board. This could well play out in ways that have nothing to do with abortion but a lot more to do with the future of the medical workforce in some of those states.

Edney: I think that’s a really good point. We know that even on just a shortage of primary care physicians and if you’re in a rural area already and you aren’t getting enough of those coming — because you could end up dealing with these issues in primary care and ER care and many other sections where it’s not just dealing with pregnant women all the time, but a woman comes in because it’s the first place she can go when she’s miscarrying or something along those lines. So it could lower the workforce for everybody, not just pregnant women.

Rovner: A lot of these graduating medical students are of the age where they want to start their own families. If not them, they’re worried about their partners. Somebody also pointed out to me — this isn’t even in my story — that graduating medical students tend to wait longer to have their children, so they tend to be at higher risk when they are pregnant. So that’s another thing that makes them worry about being in states where if something goes wrong, they would have trouble getting emergency care.

Weber: I would just add, I mean, you know, a lot of these states also overlap with states that have severe health professional shortages as well. You know, my reporting in St. Louis for KFF Health News — we did a lot of work on how there are just huge physician shortages to start with. So the idea that you’re combining massive gaps in primary care or massive gaps in reproductive health deserts with folks that are going to choose not to go to these places is really a double whammy that I don’t necessarily think people fully grasp at this current point in time.

Rovner: I promised I would explain the reason that applications are down. This is something that’s happening on purpose. There are still more graduating medical students from MD programs and DO [Doctor of Osteopathy] programs and international medical graduates than there are residency slots, but graduating students had been applying to literally dozens and dozens of residencies to make sure they got matched somewhere, and they’re trying to deter that. So now I think students are applying to an average of 30 programs instead of an average of 60 programs.

That’s why it takes so long for them to crunch the numbers because everybody’s doing multiple applications in multiple states and it’s hard to sort the whole thing out. Of course, it may be that they don’t need all of those doctors. Because according to a separate survey from CNBC and Generation Lab, 62% of those surveyed said they probably wouldn’t or definitely wouldn’t live in a state that banned abortion. Seriously, at some point, these states are going to have to balance their state economies against their abortion positions. Now we’re talking about not just the medical workforce, but the entire workforce, at least for younger people.

Edney: Yeah. I was thinking about this recently because during the pandemic you had tech or Wall Street companies looking at Texas or Florida for where they wanted to move their headquarters or move a substantial amount of their company. And then when Dobbs [v. Jackson Women’s Health Organization] happened, how is the workforce going to play out? I’m curious what that ends up looking like because many of the people that might want to work for those companies might not want to live there in those states, and I think it could affect how the country is made up at some point. I think what’s still to play out is that over 60% that wouldn’t want to move to a state with abortion restrictions, whether that is something that plays out or whether some people say, “Well, that job’s really good, so maybe I do want to go make a lot more money in this place or whenever.” I’m curious how all of this I think, you know, over the next five years or something, plays out.

Rovner: Yeah. I mean, at some point, this something is better than nothing, that’s true of the residency numbers, too. If the only place you can match is in a state that you’d rather not go, I think most people would rather go somewhere than not be able to pursue their career, and I suspect that’s true for people in other lines of work as well. Well, meanwhile, anti-abortion states are continuing to push the envelope as far as they can. In Louisiana, legislation is moving, it passed the Senate already, to criminalize the act of ordering abortion pills from out of state. It’s scheduling mifepristone and misoprostol in the same category as opioids and other addictive drugs.

Simple possession of either abortion drug without a prescription could result in a $5,000 fine or five years in prison. And in a wild story out of Texas, the ex-partner of a woman who traveled to Colorado for an abortion is attempting to pursue wrongful death claims against anyone who helped her, by helping her with travel or providing money or anything else associated with the abortion. Both of these cases seem like they’re trying to more chill people from attempting to obtain abortions than they are really actually pursuing legal action, right?

Kenen: Well, in that case, he’s pursuing legal action. We don’t know how that’s playing out, but I mean, it’s this accumulation of barriers and threats and making it both more difficult and more risky to obtain an out-of-state abortion or obtain medication abortion in-state. But there’s a big thicket and a lot of it, because it’s in court and it takes years to straighten things out, we don’t know what the final landscape’s going to look like, but obviously the trend is toward greater restriction.

Rovner: And I would point out that the lawyer who’s representing the ex-partner who’s trying to find everyone involved with the ex-partner’s abortion is the lawyer who brought us SB 8 [Senate Bill 8] the law, the “bounty hunter law,” that makes it a crime for people to aid and abet somebody getting an abortion in Texas. Lauren.

Weber: Yeah. I just would add too that tactics like this, whether or not — however they do play out in court, they do have a deterrence effect, right? There’s no way to absolutely tell someone XYZ is legally safe or not. At the end of the day, that can lead to a heck of a lot of misinformation, misconceptions, and different life choices. So I mean, I think the different things that Joanne and Julie are describing lead to people making different choices as all this plays out.

Kenen: I think one of the stories that Julie shared this week — there was an interesting little aside about disinformation, which is the petition to get an abortion rights ballot initiative in, I think it was Missouri. And one of the things in that article was that the anti-abortion forces were telling people that if you sign this petition, you’re vulnerable to identity theft. Now, so that is not true, but it’s just like this misinformation world we’re living in is spilling over into things like, you know, democratic issues of, “Can you get something on the ballot in your state?” It may lose. Missouri is a very conservative state. I don’t know what the threshold is for passage there. I don’t know that it’s as high as the 60% in Florida. But who knows what’s going to happen?

Rovner: That story was interesting, though, because it was the anti-abortion groups were trying to get people not just to not sign the petition.

Kenen: Unsign.

Rovner: Right. They were trying to get people to take their signatures off. And when all was said and done, they had twice as many signatures as they needed to get it on the ballot, so it will be on the ballot. I don’t know either what the threshold is in Missouri ’cause they were playing with that. Lauren, do you know?

Weber: I don’t know what the threshold is, but I will say what I found interesting about that story was that they said they were going to activate the Catholic Church. And as someone who is Catholic and went to Mass during the Missouri eras of Todd Akin and the stem cell fights, activating the Catholic Church could be very effective on changing how the abortion ballot plays out because I’ve seen what that looks like. So I’ll be very curious to see how that plays out in the weeks and months to come.

Kenen: Right. States doing physician-assisted suicide, aid-in-dying bills, have also — people fighting them have activated the church and they’re quite effective.

Rovner: Yeah. But I think Ohio also activated the Catholic Church and it didn’t work out. So I mean, we obviously know from polling Catholics, they’re certainly in favor of contraception and more American Catholics are in favor of abortion rights than I think their priests would like to know, at least that’s what they tell pollsters.

Edney: I also think that activating the church, whatever church it is, is at least a above-the-board tactic where in a lot of ways you never know, but this was so scary because they’re really going out and, not assaulting, but like verbally trying to keep these people from even being able to get signatures, saying that why should we let people vote on something that’s bad for them. Like not giving the electorate the right to make their voices heard. It was pretty scary to see that because of things like Ohio and other abortion rights movements that won that this is what they’re resorting to to try to make sure Missouri goes a different way.

Rovner: Yeah. I think this is going to be a really interesting year to watch because there are so many of them. Well, in abortion travel news, a federal district judge in Alabama green-lighted a suit by abortion rights groups against the state’s attorney general, who was threatening to prosecute those who “aid and abet” Alabama residents trying to leave the state for an abortion. “The right to interstate travel is one of our most fundamental constitutional rights,” Judge Myron Thompson wrote. On the other hand, Idaho was in federal appeals court in Seattle this week arguing just the opposite. They want to have an injunction lifted on its law that would make it a crime to help a minor cross state lines for an abortion. So I guess this particular fight about whether states can have control over their residents’ trying to leave the state for reproductive health care is a fight that’s going to continue for a while.

Edney: I mean, I think that — and sure it’ll continue for a while — you know, my thought when hearing about these cases is sort of just like, I know people that, when there wasn’t really gambling in Maryland, that would get in the bus and the seniors would all go to Delaware and go to the casino and go gambling. Like, we do this all the time. We go to other states for other things — for alcohol, in some cases. It’s just interesting that now they’re trying to make sure that people can’t do that when it comes to women’s rights.

Rovner: Yeah. I know. I mean, there are lots of things that are legal in some states and not legal in others.

Edney: Right.

Rovner: This seems to be, again, pushing the envelope to places we have not yet seen. Well, moving on, it is May, which means it’s time for the annual report of the Medicare and Social Security trustees about the financial solvency of the trust funds, and the news is good, sort of. Medicare’s Hospital Insurance Trust Fund can now pay full benefits until 2036. That’s five years more than the trustees estimated last year, thanks largely to a strong economy, more people paying payroll taxes, and fewer people seeking expensive medical care. But of course, Washington being Washington, good news is also bad news because it makes it less likely that Congress will take on the distasteful task of figuring out how to keep the program solvent for the long term. Are we ever going to get to this or is Congress just going to kick the can down the road until it’s like next year that the trust fund’s going bankrupt?

Kenen: I mean, of all the can-kicking — you know, we’ve used that phrase about Congress frequently — this is the distillation of the essence of kicking the can when it comes to entitlements, right? Both Social Security and Medicare need congressional action to make them viable and sustainable and secure for decades, not years, and we don’t expect that to happen. I mean, even when things are less partisan than they are now, because obviously we’re in a hyperpartisan era, even when Washington functioned better, this was still a kick-the-can issue. Not only was it kick the can, but everybody fought over how to kick the can and where to kick the can and who could kick it furthest. So five extra years is a long time. I mean, it is. But again, the economy changes. Tax revenues change. It’s a cyclical economy. Next year, we could lose the five years or lose two years or gain one year. Who knows? But in terms of a sustained, bipartisan, sensible — no, I’m not holding my breath, because I would get very, very red, very fast.

Rovner: Yeah. And also, I mean, the thing about fixing both Medicare and Social Security is that somebody has to pay more. Either there will be fewer benefits or more taxes, or in the case of Medicare, providers will be paid less. So somebody ends up unhappy. Usually in these compromises, everybody ends up a little bit unhappy. That’s kind of the best possible world. Lauren, you wanted to add something?

Weber: Yeah. I mean, I just wanted to add that if it goes insolvent by 2036, it’s not looking very good for my ability to access these programs.

Kenen: But they always fix it. They always fix it. They just fix it at the last minute.

Weber: That’s true. I mean, I think that’s a fair point, but I do think overall, the concern, it does seem like something will have to change. I don’t think that when I — hope, God willing — live long enough to access this Medicare benefits, that I think they’ll look very different. Because when there is a compromise or there is something like this, there’s just no way the program can continue as it is, currently.

Kenen: The other thing though is this Medicare date probably means there’ll be less campaign. You know, it was beginning to bubble up a little bit on the presidential campaign. I mean, there were plenty of other health care issues to fight about, but it probably means that there’ll be a little bit of token talk about saving Medicare and so forth, but unlikely that there will become a really hot-button issue with either Trump or Biden putting out a detailed plan about it. There’ll be some verbal, “Yes, I’ll protect Medicare,” but I don’t think it’ll be elevated. If it was the other way, if it had lost five years or lost three years, then we would’ve had yet another Medicare election. I think probably we won’t.

Rovner: Yeah. I think that’s exactly right. If the insolvency date had gotten closer, it would’ve been a bigger issue.

Kenen: And remember that the trend toward Medicare Advantage, which is more than people had anticipated, I mean, it is revolutionizing what Medicare looks like. It’s more than half the people now. So there’s many, many sub-cans to kick on that, with private equity and access and prior authorization. I mean, there’s a million things going on there, and payment rates and everything, but that is a slow-motion, dramatic change to Med[icare], not so slow, but that is a dramatic change to Medicare.

Rovner: We’re figuring out how to do sort of a special episode just on Medicare Advantage because there’s so much there. But meanwhile, let’s catch up on Medicaid, ’cause it’s been a while. As one of my colleagues put it on Slack this week, it was a swing and a miss in Mississippi, where some pretty serious efforts to expand Medicaid came to naught as the legislature closed the books on its 2024 session last week. Mississippi is one of the 10 remaining states that have not expanded Medicaid under the Affordable Care Act, which could expand health coverage to an estimated 200,000 low-income residents there who lack it now. It feels like these last states, mostly in the South, are going to hold out as long as they can, even though they’re basically giving up a gigantic handout from the federal government.

Edney: It’s billions of dollars they’re leaving on the table and it doesn’t really make sense. This seemed to maybe come down to a work requirement. Maybe there was more there. It was more of a poison pill in that Senate bill instead, but it doesn’t seem to make sense. I mean, even one of the earlier bills the Senate in Mississippi had come up with would have left billions of dollars on the table as well. So I think the idea of this being the central part of Obamacare is still strong in some places.

Kenen: And it also is worth pointing out that these are states not just with the gap in coverage, but most of these states don’t have great health status. They have a lot of chronic disease, a lot of obesity, a lot of addiction, a lot of diabetes, etc. The se are not the healthiest states in the country. You’re not just leaving money on the table; you’re leaving an opportunity to get people care on the table and —

Rovner: And exacerbating health inequities that we already have.

Kenen: Yes. Yes. And when North Carolina decided to, which took many years of arguing about it — that’s a purple state; there were some people who thought it would be a domino: OK, North Carolina stopped holding out; the rest of the South will now. I, never having reported in North Carolina on that, you know, having spent time in the state, I never thought it was a domino. I thought it was just something that went on in North Carolina. Do I think eventually most or all of them will accept Medicaid? Yes. But, you know, we’ve mentioned this before: It took almost 20 years for the original Medicaid to go to all 50 states.

And it’s not just — because North Carolina is North Carolina and South Carolina is different. They have different dynamics. And it’s not over by any means, and there’s no … Mississippi got close. Are they going to pick up where they left off and sort it out next year? Who knows? There’s elections between now and then. We don’t know what the makeup and who is the driver of this, and which chamber there, and who’s retiring, and who’s going to get reelected. We just don’t know exactly. It’s not going to be a dramatic shift, but in these close fights, a couple of seats shifting in state government can change things.

Rovner: That’s what happened in Kansas, although Wyoming came close, I think it was a couple of years ago, and then there I haven’t seen any action either, so.

Kenen: You still hear talk about Wyoming considering it. Like, that’s not off the … I don’t think any of us would be totally shocked if Wyoming is the next one, but I mean it didn’t happen this year, so.

Rovner: Well the other continuing Medicaid story is the “unwinding,” dropping those from coverage who were kept on during the pandemic emergency by a federal requirement. A new report from the Georgetown Center for Children and Families finds that as of the end of 2023, the number of children covered by Medicaid or the Children’s Health Insurance Program was down by 10%, or about 4 million. Yet an estimated three-quarters of those kids are actually still eligible. They were struck from the rolls because of a breakdown in paperwork. Texas alone was responsible for more than a million of those disenrollments, a quarter of the total. Texas and Florida together accounted for nearly 40% of those dropped. And Texas and Florida are also the largest states that haven’t expanded Medicaid to the working poor. At some point the problem with the uninsured is going to be back on our radar, right? I mean, we haven’t talked about it for a while because we haven’t sort of needed to talk about it for a while because uninsurance rate has been the lowest it’s been since we’ve been keeping track.

Weber: I just can’t get over that three-quarters of kids lost their coverage due to paperwork issues. I mean, I know we talk about it many times on this podcast, but just to go back to it again: I miss mail. We all miss mail. I’m not someone also that’s moving frequently. That would make it easier to miss mail. I mean, that is just …

Kenen: You speak English.

Weber: Yeah, and I speak English. That is a wild stat, that 75% of these children lost this coverage because of paperwork issues. And as that report discusses, you know, some states did work to mitigate that and other states worked to not mitigate it. And I think that’s an important distinction to be clear about.

Rovner: And I will link to the report because the report shows the huge difference in states, the ones that sort of did it slowly and carefully. I think the part of it that made my hair stand on end was not so much the kids who came off because, you know, the whole family did, because the paperwork issues, but it’s the kids, particularly kids in CHIP who were still eligible when their parents aren’t. And there were some states that just struck families entirely because the parents were no longer eligible without realizing in their own state that parents’ eligibility and kids’ eligibility isn’t the same. And that apparently happened in a lot of cases. And I think the federal government tried to intercede in some of those because those were kids who, by definition of how these programs work, would still be eligible when their parents were not.

Kenen: The one thing it’s always good to remind people that, I mean, this is an extraordinary mess. I mean, it’s not the unwinding, it’s the unraveling. But unlike employer-sponsored insurance and the Obamacare exchanges, there’s no enrollment season for Medicaid. You can get in if you qual … so it can be the unwinding could be rewound. If a child gets sick and they are in an ER or they’re in a hospital or in a doctor’s or whatever, they can get back in quickly. It is a 365-day, always-open, for both Medicaid and CHIP in I believe every state. There may be an exception I’m not aware of, but I think it’s everywhere.

Rovner: I think it’s everywhere. I think it’s a requirement that it’s everywhere.

Kenen: I think it’s federal, right. So yes, it’s a mess, but unlike many messes in health care, it is a mess that can be improved. Although of course not everybody knows that and somebody will be afraid to go to the doctor ’cause they can’t pay, etc., etc. I’m not minimizing what a mess it is. But if you get word out, you can get word out to people that, you know, if you’re sick, go to the doctor. You’re still being taken care of.

Rovner: And also when people do go to the doctor, at the same time they’re told, uh-oh, your Medicaid’s been canceled, they can be reenrolled if they’re still eligible.

Kenen: Yeah, right. I mean, community health clinics know that. Hospitals know that. I don’t know that all private physicians’ offices know that, but …

Rovner: Although they should —

Kenen: They should.

Rovner: — because that’s how they’ll get paid.

Kenen: They should.

Rovner: So I suspect — providers have an incentive to know who’s eligible because otherwise they’re not going to get paid.

Kenen: So that should be the next public campaign. If you lost your Medicaid, here’s how you get it back. And we don’t see enough of that.

Rovner: Last week we talked about a lot of health-related regulations the Biden administration is trying to finalize. If it seems they’re all happening at once, there is an actual reason for that. It’s called the Congressional Review Act. Basically the CRA lets a new Congress and administration easily undo regulations put in place by an earlier administration towards the end of a presidential term. Basically that means any regulations the Biden administration doesn’t want easily overturned by the next Congress and president, should it return to Republican hands, those regulations need to be completed roughly by the end of this month. Towards that end, and as I said, speaking of looking at the problem of the uninsured, last week the administration finalized a rule that would give people here under DACA, that’s the Deferred Action for Childhood Arrivals immigration program, access to subsidized coverage under the Affordable Care Act.

These are about 100,000 so-called Dreamers, those who are not here legally but were brought over as children. In general, those who are not in the country legally are not able to access Affordable Care Act coverage. That was a gigantic fight when the Affordable Care Act was being passed. In some ways, though, I feel like this addition of Dreamers to the ACA is an acknowledgement that they’re not going to get full legal status anytime soon, which has also been a fight that’s been going on for years and years.

Kenen: Yes. And I was wondering, like, who’s going to sue to stop this or introduce legislation? I mean, somebody will do something. I’m not sure what yet. I mean, I would be surprised if nobody tries to block this because there’s obviously controversy about normalizing the status of the Dreamers or the DACA population and it’s been going on for years. We’ll see. I mean, it’s just another, I mean, immigration is such a flash point in this year’s election. Maybe people will say, “OK, this portion of the Dreamers has legal status and they can get health insurance” and people won’t fight about it. But usually nowadays people fight about — I mean, if the intersection of health care and immigration, I would think somebody will fight about it.

Rovner: Yeah. I would, too. And also, I mean obviously the people who are preventing legislation from getting through to legalize the Dreamers’ status, there seems to be, I believe, there is overwhelming support in both houses, but not quite enough to get it through. I suspect those people on the other side might not be very happy about this. Well, finally this week in business, or more specifically this week in private equity in health care, the multistate hospital chain Steward Health [Care] filed for bankruptcy this week, putting up for sale all 31 of its hospitals, which normally wouldn’t be really big news. Lots of hospitals are having trouble keeping their doors open. But in this case, we’re talking about a chain that was pretty large and stable until it was bought by Cerberus Capital Management, a private equity firm.

Cerberus sold off the land the hospitals were on, requiring them to pay rent to yet another company, and then Cerberus got out. The details of the many transactions that took place are still kind of murky, but it appears that many investors did quite well, including acquisitions of some private yachts, while the hospitals, well, did not do so well. This all has yet to play out fully. But this seems to be pretty much how private equity often works, right? They buy something, take the profit that they can, and leave the rest to the whims of the marketplace, or in this case billions of dollars in debt now owed by these hospitals.

Weber: Yeah. I mean, I think when you look at private equity the question is always when is the multipliers going to run out? Like, when are you going to run out of things to sell to get the multipliers out? And the question is, when you do this with health care, you know, we’ve seen some emerging research show that the patient outcomes for private equity-owned health care systems can be impacted by infection rates and so on. And I mean, I thought it was particularly interesting at the end of this Wall Street Journal story, they also noted how UnitedHealthcare, there is some investigations over —

Rovner: They’re tangentially involved.

Weber: They’re tangentially involved, but the government appeared — the story seems to allude to the government is interested in whether there’s some antitrust concerns on selling the doctors’ practices, which is obviously an ongoing issue as well as we talk about health care and acquisitions and consolidation in the country. So, 31 hospitals’ being insolvent is a lot of hospitals in a lot of states.

Rovner: Yeah. And I mean, the idea, I think, was that one of the ways they were going to pay off some of their debts was by selling the doctor practices to United. United, of course, now under the microscope for antitrust, might not be such an eager buyer, which leaves Steward holding the bag again with all of this debt. They owe literally billions of dollars to this company that now owns the land that their hospitals are on. It is quite the saga.

Kenen: It’s very complicated. I mean, I had to read everything more than once to understand it, and I’m not sure I totally understood all of it. It’s also sort of like the, you know, if you were writing, if you were teaching business school about what can go wrong when private equity buys a health system, this would be your final exam question. It is very complicated, extremely damaging, and the critics of PE in health care — I mean this is everything they warn about. And I would also, since all of us are journalists, I mean the same thing is going on with private equity in owning newspapers or newspaper chains: wreckage. Not everyone is a bad actor. There’s wreckage in health care and there’s wreckage in the media.

Rovner: Yeah. We will watch this one to see how it plays out. All right, that is this week’s news. Now we will play my “Bill of the Month” interview with Katheryn Houghton and then we will be back with our extra credits. I am pleased to welcome to the podcast my KFF Health News colleague, in person, here in our Washington, D.C., studio, Katheryn Houghton, who reported and wrote the latest KFF Health News-NPR “Bill of the Month.” It’s about an out-of-network surgery the patient knew would be expensive, but not how expensive it would be. Welcome, Katheryn.

Houghton: Hi.

Rovner: So tell us about this month’s patient, who he is, and what kind of treatment he got.

Houghton: So I spoke with Cass Smith-Collins. He’s a 52-year-old transgender man from Vegas, and he wanted to get surgery to match his chest to his gender identity, so he got top surgery.

Rovner: This was a planned surgery and he knew he was going to go out of network. So what kind of steps did he take in preparation to make sure that the surgery would be at least partially covered by his health insurance?

Houghton: Well, he actually took a really key step that some patients miss, and it’s making sure that you get prior authorization from insurance, so a letter from them saying we’re going to cover this. And he got that. He also talked with his surgeon beforehand, saying what do I need to do to make sure we can submit a claim with insurance? And he signed paperwork saying how that would happen.

Rovner: Then, as we say, the bill came. What went awry?

Houghton: Yeah. Or in this case the reimbursement didn’t come. For Cass’ case there are two key things that kind of went awry here. First off, covered doesn’t necessarily mean the entire bill. So what insurance says is a fair price is not going to match up with what the surgeon always says is a fair price. So when Cass saw that his procedure was covered, it didn’t say the entire amount. It didn’t say how much was covered. The second thing is that that provider agreement that he signed with the surgeon beforehand actually says you’re not guaranteed reimbursement. And that provider agreement also stated there are two different bills here. One is the cost that Cass paid up-front for his surgery, and the other was the bill submitted to insurance.

Rovner: And how much money are we actually talking about here?

Houghton: We’re talking about $14,000. And he expected to get about half of that back.

Rovner: Because he assumed that when he got to his out-of-network maximum the insurance would cover, right?

Houghton: Exactly.

Rovner: And that’s not what happened.

Houghton: Not at all.

Rovner: How much did the surgeon end up charging for the surgery and what did his insurance say about that?

Houghton: If you’re looking at both bills, the surgeon charged more than $120,000 for the surgery and insurance said ah, no, we’re not going to cover that. And it was a little over $4,000 that insurance said, this is the fair price.

Rovner: So that’s a big difference.

Houghton: A very big difference.

Rovner: Was Cass expected to pay the rest?

Houghton: He could have. The agreement that he signed actually said that he could be on the hook for whatever insurance didn’t cover. That being said, he didn’t get a bill this time around.

Rovner: So what eventually happened?

Houghton: So eventually, when KFF Health News started asking questions about this, insurance increased how much that they paid the provider. And with that increased reimbursement, which was $97,000, the provider gave Cass a reimbursement of about $7,000.

Rovner: So he ended up paying about $7,000 out-of-pocket.

Houghton: It was more towards the line of what he was expecting to pay for this.

Rovner: Right. I was just going to say that was about what his out-of-pocket maximum was. But in this case he was kind of just lucky, right?

Houghton: Yes. I mean the paperwork that he signed in advance — it was really confusing paperwork. We had several experts look over this and say, yeah, there are things in this we don’t fully understand what it means.

Rovner: What’s the takeaway here? A lot of people want to go to a particular provider who may be very good at what they do but don’t take insurance. Is there any way that he could have better prepared for this financially or that somebody looking at a similar kind of situation and doesn’t want to end up having someone say, oh, you owe us $80,000?

Houghton: Right. Yeah. So for this case it was really important for Cass to go to a surgeon that he felt like he could trust. And so if you do have that out-of-network provider, there are a few steps you can actually take. There’s still no guarantees, but there are steps. First off, patients should always ask their insurance company what covered actually means. Are you talking the entire bill here? Are you talking just a portion of it? Try to get that outlined. You can also ask your insurance company to spell out the dollar amount that they’re willing to pay for this. That’s a really helpful step. And lastly, on the provider side, you can also say, “Hey, whatever insurance deems as a fair payment, can we count that as the total bill?” You can always ask that. They’re not required, but it’s worth checking.

Rovner: Yeah. So at least you go in with your eyes open knowing what your maximum is going to be.

Houghton: Exactly. Especially if you’re paying out-of-pocket to begin with. You really want to know what is insurance reimbursing for this? What is the provider going to charge me more at the end of this?

Rovner: Well, I’m glad this one had a happy ending. Katheryn Houghton, thank you very much.

Houghton: Thank you so much.

Rovner: OK, we are back. It’s time for our “extra credit” segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Anna, why don’t you go first this week?

Edney: Sure. So mine is from ProPublica by Anna Maria Barry-Jester and it’s “Facing Unchecked Syphilis Outbreak, Great Plains Tribes Sought Federal Help. Months Later, No One Has Responded.” And I think we have even heard over the last few years the story of syphilis rates rising and in this specific look at the Great Plains, there are Native Americans there, that the syphilis rates are even worse. And this is resulting in deaths of babies, like wanted children. And it seems like the federal government has been pretty lackluster in its response, to put it mildly, sending a few CDC [Centers for Disease Control and Prevention] workers for a couple of weeks, and the tribes have been asking for basically a national emergency so they can get more help. And they’ve gone straight to HHS [Health and Human Services] Secretary [Xavier] Becerra, and at least in the last several weeks as this was being reported, they haven’t gotten any response or any help. So I think it’s an important story to spread far and wide.

Rovner: It is. Joanne?

Kenen: There was a very interesting op-ed in The New York Times this week by Dr. Carl Elliott, who is a physician and bioethicist at the University of Minnesota: “In Medicine, the Morally Unthinkable Too Easily Comes to Seem Normal.” It’s a little hard to summarize, but it’s very subtle. It’s the culture of medicine, of being a medical student or a resident, and the things you see, so much of what you see, shocks you anyway because it’s something you have to get used to. But there are outrages. He begins, the opening anecdote is a woman is unconscious and anesthetized before her surgery and the doctor in charge invites all the med students to come and like, “Oh, why don’t you come touch her cervix? She’ll never know. See what it’s like.”

And to that, to really the larger, even larger questions about how did Willowbrook [State School] survive for all those years? How did the Tuskegee studies go on for all those years? You know, at what point, what are the sort of cultural and peer pressure and dynamics of these outrages, big and large, becoming normalized? And, you know, as we know, like recently HHS just said you have to have a written consent for a pelvic exam, particularly if you’re going to be unconscious. But that’s only one example — it was a very disturbing piece actually.

Rovner: Yeah. It really was. Lauren?

Weber: I chose Nicholas Florko’s piece on how “NYU Professors Who Defended Vaping Didn’t Disclose Ties to Juul, Documents Show,” in Stat. Great piece. He dug through a bunch of the Juul legal documents that have been revealed to show how two prominent NYU public health professors were communicating with Juul about their comments in both a congressional hearing and then public comments to many, many journalists defending vaping and saying that, you know, it had public health benefits because it got people off of cigarettes. And it raises up a lot of thorny questions about conflict of interest. These public health officials say they were not paid by Juul, but they did accept dinners. And the question is, you know, a lot of the studies they submitted, one of them they even sent to Juul. It’s a lot of thorny questions about academic review and disclosures. It’s a great piece, too, and a warning for all journalists of who are you interviewing, what are their ties, and what are the disclosures that they may or may not be sharing? It was a great story.

Rovner: Yeah. Super thought-provoking. I will say, every time I speak — and we don’t take money for speaking — all of my speeches are for free. But I constantly, you know, they now have to fill out that, “Do you have any conflicts of interest?” And it’s like, no, I don’t take any money from any industry. But it’s all basically self-reported, and I think that’s one of the big problems with this whole issue. Well, my story this week is from The Nation. It’s by Amy Littlefield. It’s called “The Abortion Pill Underground.” And it’s not the first story like this, but it’s a very comprehensive look at the fight that’s shaping up between blue states that are passing shield laws to protect doctors who are providing abortion medication to patients in red states where, as we discussed earlier, prosecutors would like to reach back to punish those blue-state providers. It’s a fairly small group of providers operating in what is still a legally gray area.

As we mentioned, this is all still under — in court, in various places at various levels — but I do think it’s one of the next big battles that are shaping up in reproductive health. It’s a really good piece. 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 Twitter, @jrovner, or @julierovner at Bluesky and @julie.rovner at Threads. Joanne, are you hanging anywhere on social media?

Kenen: A little bit on Twitter @JoanneKenen, not even that much. But more on Threads @joannekenen1.

Rovner: Anna?

Edney: @annaedney on Twitter and @anna_edneyreports on Threads.

Rovner: Lauren?

Weber: Still only on Twitter, @LaurenWeberHP. HP is for health policy.

Rovner: Don’t apologize. You can find us all if you really want to. We will be back in your feed next week. Until then, be healthy.

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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

Some justices suggested the Supreme Court had said its piece on abortion law when it overturned Roe v. Wade in 2022. This term, however, the court has agreed to review another abortion case. At issue is whether a federal law requiring emergency care in hospitals overrides Idaho’s near-total abortion ban. A decision is expected by summer.

Meanwhile, the Centers for Medicare & Medicaid finalized the first-ever minimum staffing requirements for nursing homes participating in the programs. But the industry argues that there are not enough workers to hire to meet the standards.

This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of the Johns Hopkins University’s nursing and public health schools and Politico Magazine, Tami Luhby of CNN, and Alice Miranda Ollstein of Politico.

Panelists

Joanne Kenen
Johns Hopkins University and Politico

@JoanneKenen

Read Joanne's articles.

Tami Luhby
CNN

@Luhby

Read Tami's stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories.

Among the takeaways from this week’s episode:

• This week’s Supreme Court hearing on emergency abortion care in Idaho was the first challenge to a state’s abortion ban since the overturn of the constitutional right to an abortion. Unlike previous abortion cases, this one focused on the everyday impacts of bans on abortion care — cases in which pregnant patients experienced medical emergencies.
• Establishment medical groups and doctors themselves are getting more vocal and active as states set laws on abortion access. In a departure from earlier political moments, some major medical groups are campaigning on state ballot measures.
• Medicaid officials this week finalized new rules intended to more closely regulate managed-care plans that enroll Medicaid patients. The rules are intended to ensure, among other things, that patients have prompt access to needed primary care doctors and specialists.
• Also this week, the Federal Trade Commission voted to ban most “noncompete” clauses in employment contracts. Such language has become common in health care and prevents not just doctors but other health workers from changing jobs — often forcing those workers to move or commute to leave a position. Business interests are already suing to block the new rules, claiming they would be too expensive and risk the loss of proprietary information to competitors.
• The fallout from the cyberattack of Change Healthcare continues, as yet another group is demanding ransom from UnitedHealth Group, Change’s owner. UnitedHealth said in a statement this week that the records of “a substantial portion of America” may be involved in the breach.

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’ “Women Are Less Likely To Die When Treated by Female Doctors, Study Suggests,” by Liz Szabo.  

Alice Miranda Ollstein: States Newsroom’s “Loss of Federal Protection in Idaho Spurs Pregnant Patients To Plan for Emergency Air Transport,” by Kelcie Moseley-Morris.  

Tami Luhby: The Associated Press’ “Mississippi Lawmakers Haggle Over Possible Medicaid Expansion as Their Legislative Session Nears End,” by Emily Wagster Pettus.  

Joanne Kenen: States Newsroom’s “Missouri Prison Agency To Pay $60K for Sunshine Law Violations Over Inmate Death Records,” by Rudi Keller.  

Also mentioned on this week’s podcast:

• American Economic Review’s “Is There Too Little Antitrust Enforcement in the U.S. Hospital Sector?” by Zarek Brot-Goldberg, Zack Cooper, Stuart Craig, and Lev Klarnet.
• KFF Health News’ “Medical Providers Still Grappling With UnitedHealth Cyberattack: ‘More Devastating Than Covid,” by Samantha Liss.

CLICK TO OPEN THE TRANSCRIPT

Transcript: Abortion — Again — At the Supreme Court

[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, April 25, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this, so here we go.

We are joined today via video conference by Alice Miranda Ollstein of Politico.

Alice Miranda Ollstein: Hello.

Rovner: Tami Luhby of CNN.

Tami Luhby: Hello.

Rovner: And Joanne Kenen of the Johns Hopkins University schools of public health and nursing and Politico Magazine.

Joanne Kenen: Hi, everybody.

Rovner: No interview this week, but wow, tons of news, so we are going to get right to it. We will start at the Supreme Court, which yesterday heard oral arguments in a case out of Idaho over whether the federal Emergency Medical Treatment and Active Labor Act, or EMTALA, trumps Idaho’s almost complete abortion ban. This is the second abortion case the high court has heard in as many months and the first to actively challenge a state’s abortion ban since the overturn of Roe v. Wade in 2022. Last month’s case, for those who have forgotten already, was about the FDA approval of the abortion pill mifepristone. Alice, you and I both listened to these arguments. Did you hear any hints on which way the court might be leaning here?

Ollstein: The usual caveat that you can’t always tell by the questions they ask. Sometimes they play devil’s advocate or it’s not indicative of how they will rule on the case, but it did seem that at least a couple of the court’s conservatives were interested in really taking a tough look at Idaho’s argument. Obviously, some of the other conservatives were very much in support of Idaho’s argument that its doctors should not be compelled to perform abortions for patients experiencing a medical emergency. It really struck me from the arguments how much it focused on what’s actually going on on the ground.

That was a huge departure from a lot of other Supreme Court arguments and a lot of Supreme Court arguments on abortion where it’s a lot of hypotheticals and getting into the legal weeds. This was just like they were reading these concrete, reported stories of what’s been happening in Idaho and other states because of these abortion bans. People turned away while they were actively miscarrying, people being flown across state lines to receive timely care. I think whether that will make a difference that the justices are sort of being confronted with the concrete ramifications of the Dobbs [v. Jackson Women’s Health Organization] decision or not remains to be seen.

Rovner: I thought one of the things that it looked like very much like last month’s argument is that the women justices were very much about real details and talking about medical conditions, about ectopic pregnancies and premature rupture of membranes and things that none of the men mentioned at all. The men were sort of very legalistic and the women, including Amy Coney Barrett, who voted to overturn Roe v. Wade, were very much all about, as you said, what’s going on on the ground and what this distinction means. I mean, where we are is that Idaho has an exception in its abortion ban, but only for the life of the woman. Whereas EMTALA says you have to stabilize someone in an emergency situation and it’s been interpreted by the federal government to say sometimes that stabilization means terminating a pregnancy, as in the case of premature rupture of membranes or an ectopic pregnancy or a case where the woman is going to hemorrhage and is actively hemorrhaging.

That question of where that line is, between what’s an immediate threat to life and what’s just a threat to health or a threat to life soon, was the crux of this case. And it really does feel uncomfortably like we have nine Supreme Court justices making, really, medical decisions.

Ollstein: Yeah, it struck me how Amy Coney Barrett seemed to get pretty frustrated with Idaho’s attorney at a couple points. Idaho’s attorney was saying kind of, “Nothing to see here. There’s no problem. Since we allow lifesaving abortions and that’s what is required under EMTALA, there’s no conflict.” So Amy Coney Barrett was like, “Well, why are you here then? Why are you before us?” The reason is that they’re trying to get this lower-court injunction lifted even though it’s not in effect right now. The other point she got kinda testy was when Idaho was saying that their law is clear, doctors know what to do, and Amy Coney Barrett asked, “Well, couldn’t a prosecutor come in later and disagree and said, “Oh, you performed an abortion you said was to save someone’s life, but I don’t think it was necessary to save her life and I’m going to charge you criminally?” And the Idaho attorney conceded that that could happen.

So I think her vote could potentially be in play, but I don’t know if it’s going to be enough to overcome the court’s conservatives who are very skeptical that EMTALA should compel states to do anything.

Rovner: So the medical community has been quite outspoken in this case. The American Medical Association, American College of Obstetricians and Gynecologists and the American College of Emergency Physicians have all filed briefs saying the Idaho ban could require them to violate professional ethics, wrote the immediate president of the AMA, Jack Resnick, in an op-ed. “It is reckless for Idaho to tell emergency physicians that they must ignore their moral and ethical standards and stand by while a septic patient begins to lose kidney function or when a hemorrhaging patient faces only a 30% chance of death.” But I feel like the medical profession has long since lost control of the abortion issue. I mean, is there any chance here that they might prevail? I have to say this week I’ve gotten so many emails from so many doctor groups saying, “Oh my goodness, look what’s happening. They’re going to put us in this impossible situation.” To which I want my response to be, “Where have you been for the last 20 years?”

Ollstein: I mean, I think it is notable that these establishment medical groups are becoming more vocal. I mean, some might say better late than never, and I think in some instances they are having an impact at the state level. They have pushed some state legislatures to add or expand exemptions to abortion bans. But a lot of times Republican lawmakers have rejected calls from state medical associations to do that, and so I think filing amicus briefs is a way to have your say, lobbying at the state level is a way to have your say. Some doctors are even running for office specifically on this issue. And also, medical groups are campaigning hard on these state abortion referendums. I reported on doctor groups door-knocking in Ohio, for instance, before that referendum won big.

I think it’s really interesting to see the medical community get a lot more vocal on something they’ve either tried to stay out of or been vocal on the other side on in the past, but we’ll have to see how much impact that actually has.

Rovner: Well, one thing this case highlights is how pregnant women who experience complications that can threaten their health or future fertility, but are not immediately life-threatening, can end up in really terrible circumstances, as we heard in a number of anecdotes at the oral arguments. The Associated Press “FOIA’d”[requested Freedom of Information Act] EMTALA pregnancy complaint records from several states with abortion bans and found some pretty horrific examples, including one woman who miscarried in the emergency room lobby restroom after she was turned away from the registration desk. Another who was turned away and ended up giving birth in a car on the way to another hospital. That baby died. These are not people who go to the emergency room in search of abortions. They’re women who are trying to maintain pregnancies. Is the concept that people ending up in the most horrific situations are often those who most want children, is that finally getting through here?

Ollstein: What struck me most about that reporting is that the documents they got were just from the first few months after Roe v. Wade was overturned, so we have no idea what’s happening now. It could be better, it could be much worse, it could be the same. I think that lack of transparency makes this really hard to report on accurately. And the fact that it took The AP a year to even get those few heavily redacted documents speaks to the challenge here. We want an accurate picture of how these bans are impacting the provision of health care around the country, and it’s really hard to get.

Rovner: I know the Biden administration has been kind of trying to keep this quiet. I mean, not out there sort of blaring what’s happening. They’ve been sort of leaving that to the politics side and this is obviously the policy side. Obviously on the politics side, the Biden administration is getting bolder about using abortion as a campaign issue. The president himself gave a speech in Florida where a six-week ban is set to take effect next week and pinned all the abortion restrictions directly on former President Trump, who he pointed out has taken credit for them. Biden actually said the word abortion twice in that speech. I was listening very closely and went back and counted. I think that’s a first. They’re definitely stepping up the pressure politically, right?

Ollstein: Yes. The Biden campaign is leaning very hard on this. Even in states where it’s debatable whether they have a chance, like Florida, I think that there’s an interest, especially after seeing all of these referendums and ballot measures win big. It’s really shown Democrats that this is a very popular issue to run on, that they shouldn’t be afraid of it, that they should lean into it. I think you are seeing attempts to do that. It’s not always the language that the abortion rights advocacy community wants to hear, but it’s definitely more than we’ve heard from the Biden administration in the past.

I think you’re also seeing an attempt to sort of take the air out of Trump’s “Let’s leave it to states. I am reasonable and moderate” sort-of pitch. By highlighting what’s happening on the ground in certain states, it’s an attempt to say, “OK, you want to leave it to states? Then you own all of this. You own every woman being turned away from a hospital while she’s miscarrying. You own every instance of a ban going into effect and people having to travel across state lines,” et cetera. But whether just blaming Trump and arguing that he would be worse is enough versus saying what Biden would actually do and continue to do, I think that’s what we’ve heard people want to hear more of. Although there has been some action from the Biden administration recently.

Rovner: That was just going to be my next question. The one policy change the Biden administration did do this week was finalized a rule expanding the health records protections under HIPAA to abortion information. Why was this important? It sounds pretty nerdy.

Ollstein: This has been in the works for more than a year. A lot of people have been wondering why it’s been taking so long and worried that if it took even longer, it would be easier to get rid of it if a new administration takes over. But essentially this is to make it harder for states to reach across state lines to try to obtain information and use it to prosecute for having an abortion. It’s an attempt to better protect that data and so we heard a lot of praise after the announcement came out from abortion rights groups and some medical groups, and I would anticipate some groups on the right would sue. I’ve seen some complaints saying this will prevent law enforcement from investigating actual crimes against people, and so I expect to see some legal challenges soon.

Kenen: There are all sorts of efforts to stop both travel for abortion. There are also laws on books already, there have been for a number of years, about helping a minor cross state lines for abortion. There’s the attempts to stop the shipment of abortion pills from a legal state into a state that has a ban. There’s all sorts of things where, whether the intent is to actually prosecute a woman or a pregnant person, versus collecting evidence for some kind of larger crackdown or prosecution, this is potentially a piece … patient records are potentially a piece of that. We’ve talked a few weeks ago, maybe a month or two ago by now, about some Texas communities that wanted to say, “If you drive on the road in our town on the way to an abortion, we’re going to arrest you.” How they figure out logistically and practically … What are you going to do? Stop everybody on the road and give them a pregnancy test?

I mean, I don’t know how you enforce that, but just that these ideas are out there and on the books through this privacy shield. We have privacy under HIPAA, all of us, so to interpret it this way, or reinforce it depending on your political point of view, undermine excessively, whatever, but this is sort of pivotal because there’s so many ways these records could be used in various kinds of legislative and prosecutorial ways.

Rovner: As you point out, it’s not theoretical. We’ve seen attorneys general — Indiana and Kansas — and some other states, actually, and Texas say that they want to go after these records, so it’s not …

Kenen: Right and we’ve seen cases of the child rape victim and the prosecutor, what happened with the doctor, and so it’s not theoretical. It’s not widespread right now, but it’s not theoretical. Whether the pregnancy was planned and wanted or it was unplanned and ended up being wanted, going through a pregnancy loss is not just medically difficult, depending on when in pregnancy it occurs and under what circumstances. It can be medically quite complicated and it’s emotionally devastating. So to just get pulled into these political legal fights when you’ve already been bleeding in the parking lot or whatever, or having lost a pregnancy, it’s like you forget these are human beings. These are people going through medical crises.

Rovner: Indeed. Well, abortion is far from the only big health news this week. On Monday, the Biden administration finalized more long-awaited rules regarding staffing in nursing homes that participate in Medicare or Medicaid. Tami, what’s in these rules and why is the concept that nursing homes should have nurses on duty so controversial?

Luhby: It is very controversial and it’s also very consequential. So on Monday, as you said, the Biden administration finalized the first-ever minimum staffing rules at nursing homes involved in Medicare and Medicaid, and they say it’s crucial for patient safety and quality of care. It requires that all nursing homes provide a total of at least 3.48 hours of nursing care per resident per day, including defined periods of care from registered nurses and from nurses’ aides. Plus, nursing homes must have a registered nurse on-site at all times, which is different than the rules now. Now, CMS [Centers for Medicare & Medicaid Services] is giving the nursing homes some time to staff up. The mandate will be phased in over three years with rural communities having up to five years and they’re also giving temporary exemptions for facilities in areas with workforce shortages that demonstrate a good faith effort to hire. When I spoke to [Department of Health and Human Services] Secretary [Xavier] Becerra about the nursing home industry’s vocal concerns that this could cause a lot of nursing homes to close or limit admissions, he said, “Well, a business model that is based on understaffing is not a very good business model and is dangerous for patients.”

So, it’s going to be a heavy lift for nursing homes. According to HHS, 75% of them will have to hire staff, including 12,000 registered nurses and 77,000 aides. And also, 22% of them will need to hire registered nurses to meet the around-the-clock mandate. The nursing home operators, not surprisingly, have strongly pushed back on this rule even back when it was first proposed in September, saying that they’re already having staffing problems amid a nationwide shortage of nurses. The American Health Care Association called the mandate an unreasonable standard that only threatens to shut down more nursing homes, displace hundreds of thousands of residents, and restrict seniors’ access to care.

Rovner: We should point out the American Health Care Association is the lobbying group for nursing homes.

Luhby: Yes. What’s interesting also, though, is that on the other side, you have advocacy groups that are saying that it doesn’t go far enough and they’re citing a 2001 CMS study that found that nursing home residents need at least 4.1 hours of daily care. To add to all of this, if it’s not complicated and controversial enough, Congress is getting involved and is also split over the rules. Some lawmakers, like Sens. Elizabeth Warren and Bob Casey, generally support it, but nearly a hundred House members from both parties wrote to HHS Secretary Becerra expressing their concern that the mandate could lead to nursing home closures. And there’s a bipartisan Senate bill and a House Republican bill that would prohibit HHS from finalizing the rule. So we have time before this goes into effect. It goes into effect in phases, and we’ll see if lawmakers move to block the mandate or if the courts do, but it’s going to be interesting to watch how this plays out.

Rovner: Joanne wanted to add something.

Kenen: Well, first of all, as we say frequently, there’s always lawsuits. We have a health care/lawsuit system, so it’s not over. But I think the other thing is I think families who put a loved one in a nursing home don’t understand how little nursing, let alone doctoring, goes on. The name is “nursing” home and people expect there to be a nurse there, meaning a registered nurse. I think people often think there’s a doctor there, where the doctors are not there very much. That’s one reason the lack of medical care on-site, not only could there be emergencies, but I mean even things that could be treated in place if there is a physician. I mean, it’s just dial 911 and put them in an ambulance and send them to the hospital. And we do have this problem with hospital readmission, which is not just a cost problem and a regulatory problem, it’s really bad for patients to … the continuity of care is good and lack of continuity and handoffs and change, sending people back-and-forth is not good for them.

Obviously, there are times there’s an emergency and you need to send someone to a hospital, but not always. If there was a doctor or nurse, there’s some things that you don’t have to call 911 for. Because you don’t know or don’t learn about nursing homes until you have a relative there or until you’re a reporter who has to write about them. You don’t realize that they’re very custodial and there’s not a lot of taken care of in terms of getting assistance in bathing and walking and things like that. There’s less medical care, including nursing care, than people realize until your loved one is there. I mean, when I covered them the first time, I was really shocked. I mean, it’s 20 years ago the first time I wrote about it, but my assumption of what was there and what is actually there was a big gap.

Rovner: Tami.

Luhby: One thing also, though is … I mean, yes, that is definitely true about the medical care, but we’re also talking about just the care, not only the nursing. But that’s why so many aides need to be hired because you also have situations in nursing homes where people aren’t getting help to go to the bathroom, aren’t getting showered regularly, aren’t being watched. Maybe they’re trying to go to the bathroom themselves and they’re falling because they have to go. I mean, unfortunately, I’ve had experience with nursing homes with my family and I’ve seen this. But also I think it’s been pretty well reported in a lot of publications and studies and such. But there are a lot of problems in nursing homes, in general, and staffing.

Rovner: Well, just to talk about how long this is going on, former Sen. David Pryor died this week. When he was a House member, he rather famously went undercover at a nursing home to try and spotlight. That was when we first started to hear about some of the conditions in nursing homes. He was instrumental in doing the work that got the original federal nursing home standards passed in 1987, which was the first time I covered this issue, and even then there was a big fight in 1987 about should there be a staffing mandate? It’s like, hello, if we’re going to improve care in nursing homes, maybe we should make sure there are enough people to provide care. Even then the nursing home industry was saying, “But we have a shortage. We can’t hire enough people to actually do this if you give us a staffing mandate.” So literally, this has gone back-and-forth since 1987. And, as Joanne points out, it’s still in all likelihood not over, but one could sort of think, gee, they’ve had two generations now to come up with enough people to work in these nursing homes. Maybe Becerra is right. Maybe there’s something wrong with the business model?

Luhby: I was going to say, we know the business model is also moving more towards private equity, which is not necessarily going to be as concerned with the staffing levels. We know that the staffing levels … I think there’ve been studies that show that staffing levels are generally lower in investor-owned nursing homes. So there’s that.

Kenen: There’ve been a lot of demographic changes. I mean, you live longer, but you don’t always live healthier. We have families that are spread out. Not everybody’s living in the same town anymore. I mean, they haven’t for a number of decades now, but your daughter-in-law is 3,000 miles away. She can’t come to your house every day. At the same time, we do have a push and it’s not brand-new, it’s a number of years now, to do more home- and community-based care, but there are shortages and waiting lists and problems there, too. So there are a lot of people who need institutional care. Whether they wanted to have that or not, that’s where they go because either there’s not enough community support or they don’t have the family to fill in the gaps or they’re too medically complicated or whatever. Given the demographic trends and the degree of chronic disease and disability, this is not going away. It’s like Julie said, it’s way overdue. We need to figure it out. There are workforce shortages to train more CRNAs [certified registered nurse anesthetists] like the trained aides. It’s not a five-, six-year program. I mean, this can be done and is done somewhere in community colleges. You can do this. You can improve at all levels. You need more nurse RNs, nurses or advanced practice nurses, but you also need more of everything else. People who go to work in these jobs, by and large, do want to provide quality, compassionate care, and it’s hard to do if there are not enough of you.

Rovner: But they’re also super hard jobs and super stressful and super physically demanding.

Kenen: Hoisting and …

Rovner: Yeah, yeah. And not well-paid.

Kenen: Keeping track of a lot of stuff.

Rovner: Well, in a related move, the Biden administration this week also finalized rules that will attempt to make the quality of Medicaid managed-care plans more transparent. Among other things, the rules establish national wait time limits for certain types of medical care and require states to conduct secret shopper surveys of insurance provider networks to make sure there are enough practitioners available to serve the patient population. The administration says these rules are needed because so many Medicaid patients are now in managed care and regulations just haven’t kept up. Will these be enough to actually protect these often very vulnerable populations? I mean, obviously these people are not quite as vulnerable as people in nursing homes, but they’re kind of the next level down.

Kenen: Well, I think that we’ve seen a history of waves of regulation. Then whatever the status quo becomes, it doesn’t stay the status quo. Whether, as Tami mentioned, there’s more private equity or there’s monopolization and consolidation or just new state regulation. I mean, it’s not static. Do we know how this move is going to play out? No. Do we assume that the bad actors who don’t want to comply will find new ways of doing things that in five years we’ll have another set of regulations that we’ll be talking about? I mean, unfortunately, that’s the way things work. Some regulatory approaches or legal approaches work and others just sort of morph. There’s a lot of history of innovative great actors and lousy bad actors.

Rovner: I say it’s been a big week for federal regulation because we also have breaking news from the Federal Trade Commission, of all places. On Tuesday, the commissioners voted to finalize rules banning most noncompete clauses in employment contracts. At an event here at KFF, the FTC chair, Lina Kahn, said a surprisingly large number of comments about that proposed rule came from health care workers. Here’s a snippet from that conversation.

Lina Khan: There were a whole bunch of comments that said, “I signed this, but it’s not like I was exercising real choice. It felt coercive.” We also heard a lot about the effect of these noncompetes and the way that, especially in rural areas, if you want to switch employers and there’s really only one other option locally, if a noncompete is barring you from taking a job with that other hospital, practically to change jobs you have to leave the state. Right? And just how destructive and devastating that is for people and their families, especially if they’re choosing between staying in a job where the employer realizes that this is a captive employee and they don’t really have to compete in offering them better opportunities, better wages, and having to instead think about uprooting their family. We also heard from doctors who did not uproot their families, but instead just commuted hours and hours a day driving. People saying, “For five years I didn’t really see my kids at all awake, ever, because I was always on the road because of this noncompete.” So just really vivid stories from people.

Rovner: So even though the vote was less than 48 hours ago, the U.S. Chamber of Commerce has already filed suit to block the rules as have some smaller business groups. Why do businesses think they need to prevent workers from changing jobs near where they live? I mean, you could see it for people who’ve invented something. You don’t want them to walk out the door with proprietary secrets, but baristas at Starbucks and even nurses are not walking out with trade secrets.

Kenen: Well, I mean, this is common in doctors’ employment contracts, nurses, it’s everything. I think it’s partly because there are provider shortages in some places and they want to keep the workforce they have instead of having them be lured across town to a competitor where they could be paid more and then you have to pay even more to hire the next one. So that’s part of it. It’s economic. A lot of it’s economic. I mean, there’s some fear of patients going with a certain beloved provider, a doctor goes somewhere else. But I think it’s basically they don’t want churn. They don’t want to have to keep paying more. Somebody gets a job offer across the street and they don’t want to take it. They like where they are, but they’re going to ask for more money. It’s largely economic in a market where there’s scarcity of some specialties and certainly nursing. I mean, there’s questions about are there are not enough nurses? Or are we just putting them in the wrong places? But speaking generally, there’s a nursing shortage and physicians, we don’t have enough primary care providers. We certainly don’t have enough geriatricians. We don’t have enough mental health providers. We don’t have enough of a lot of things. This helps the employer, in this case, the health system, usually.

Rovner: I have to say it was only in the last couple of years that I even became aware there were noncompetes in health care. I mean, I knew about them for weathercasters on local stations. It’s like if you leave, you have to go to another station in another city. I had absolutely no idea that they were so common, as you point out, for so many economic reasons. Obviously this has also already been challenged in court, so we’ll have to see how that plays out.

Also this week on the antitrust front, we have a paper from three health economists published in the American Economic Review who calculated that if the Federal Trade Commission had been more aggressive about flagging and potentially blocking hospital mergers just between 2010 and 2015, health care prices could have been 5% lower. Researchers blame the FTC’s limited budget, but you have to wonder if that budget is limited because business has so much clout in Washington and really doesn’t want eager regulators snooping into their potentially anticompetitive practices. I mean, the FTC has been around for 120-some years now. Occasionally it tries to do big things like with these noncompetes, but mostly it doesn’t do as much as obviously economists and people who study it think that it could do. I mean, we certainly have problems with lack of competition in health care.

Ollstein: I think we have an unusually aggressive FTC right now, so it’ll be really interesting to see what they can accomplish in whatever time this administration has remaining to it, which remains to be seen. I have seen some more aggressive action from the agency in the past on things like payday lending and some of these other sort of maybe more fringy sectors of the economy. So to take on health care, which is so central and such a behemoth and, like you said, there’s so much political power behind it, as Joanne said, guarantee of lawsuits and coverage from us forever basically.

Kenen: The other point that’s worth making, I don’t think any of us have said this, it doesn’t apply to nonprofit hospitals or health systems, and that’s a lot of … market-dominant health care systems that are nonprofits, nominally their tax status is nonprofit. It’s a very confusing term to normal people, but these bans on noncompetes do not apply to the nonprofit sector, which is a lot of health care.

Rovner: Yet still it’s set off quite a conflagration since they passed this on Tuesday. Well, finally this week, speaking of big health care business, we are still seeing ramifications from that Change Healthcare hack back in February. While UnitedHealth Group, which owns Change, says things are approaching normality, that’s not the case for providers who still can’t submit bills or collect payments except doing it on paper. Meanwhile, in what’s going to be some kind of movie or miniseries someday, a second group is now demanding ransom after publishing some of the stolen data. If you’ve been following this story along with us, you’ll remember that United reportedly already paid a ransom of $22 million, except that it appears that the group that got that money stiffed the group that actually has control of the pirated data.

Oh, and buried in UnitedHealthcare’s news “update” posted on its website, it says protected health information, “which could cover a substantial proportion of people of America,” is involved in the hack. Can this get any worse?

Kenen: Snakes? I don’t think any of us journalists can quite comprehend. I mean, we understand intellectually, but I don’t think we understand what it’s like to be the billing clerk at a major practice right now trying to figure out what’s where and how to get paid and what it means for patients and what’s next. I mean, this is a tremendous hack, but it’s not the last.

Rovner: Yeah, and the idea that I think — what did they say? — 1 out of every 3 health care transactions goes through Change, I certainly wasn’t aware of. I think most reporters who are covering this weren’t aware of. I think certainly none of the public was aware of, that there’s that much of the money-changing that goes on from one, as we now know, vulnerable organization is a little bit scary.

Luhby: It shows the power of UnitedHealth[care] in the market. I mean, it’s the largest insurer and people think of it, “OK, I have insurance through it,” but they don’t realize all of the other tentacles that are attached.

Kenen: It also shows that there’s hack after hack after hack after hack. This company knew that they were big and powerful and central, and many of us never heard of them or barely knew what they were. But they knew what they were and despite all the warnings of the need for better and higher protection, cybersecurity protections, these things are going on still. I don’t have the technical expertise to know, well, OK, everybody’s doing everything they’re supposed to do as a health system, but the hackers are just always a step ahead. Or whether they’re really not doing everything they’re supposed to do and weak links in their own chains. Is it the diabolical geniuses? Or is it people still not taking this seriously enough?

Rovner: I will add that in our discussion with FTC Chair Lina Kahn, she did talk about cybersecurity as something that the FTC is going to be looking at in deciding whether there is unfair competition going on. Also, she has promised to come on the podcast, so hopefully we will get her in the next several weeks.

All right, that is the news for this week. 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. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Tami, you were the first in, why don’t you go first this week?

Luhby: Well, my extra credit is an AP story by Emily Wagster Pettus titled “Mississippi Lawmakers Haggle Over Possible Medicaid Expansion as Their Legislative Session Nears End.” This story brings us up to date on the negotiations between the House and Senate in Mississippi over expanding Medicaid. Just a quick refresher for listeners: Mississippi is one of 10 states that hasn’t expanded Medicaid yet, and this is the first time, and it’s really very consequential that the Republican-led legislature has seriously considered doing so. The problem is the House and Senate versions are very, very different. The House bill is more like a traditional Medicaid expansion, providing coverage for those earning up to 138% of the poverty level, although it would also try to institute a work requirement, and about 200,000 people would gain coverage. But the Senate version would only extend coverage to those earning up to 100% of the poverty level, which the Senate Medicaid committee chair thought would add about 40,000 to the program, and it would also come with a very strict work requirement.

So on Tuesday, lawmakers met to try to hash out a compromise. They did so in public. It was a public meeting recorded, which was very unusual, and apparently there were people waiting hours to get in. It was standing room only. The House offered a plan that would cover people earning up to 100% of the poverty level under Medicaid, while those earning between 100% and 138% would receive subsidies to buy insurance through the ACA exchange. But the Senate did not offer a proposal nor immediately respond to the one in the House. There are more meetings scheduled. I think there was another one yesterday. It remains to be seen what will happen, but the clock is ticking. The state legislature only is in session until May 5, and it doesn’t give them much time.

Another wrinkle is that it’s important to note that Gov. Tate Reeves, a Republican, has repeatedly voiced his opposition to Medicaid expansion in recent months and is likely to veto any bill. So if lawmakers do eventually agree on a compromise, they may very well also have to vote on whether to override the veto by the governor. This happened in Kansas in 2017 where the legislature did pass Medicaid expansion, Republican governor vetoed it, and the legislature was not able to override the veto and it never got that far again.

Rovner: So yes, we will keep our eyes on Mississippi. Thank you for the update. Alice, why don’t you go next?

Ollstein: I have a piece from States Newsroom related to the Supreme Court arguments on Idaho’s abortion ban and its impact on pregnant patients. The piece [“Loss of Federal Protection in Idaho Spurs Pregnant Patients To Plan for Emergency Air Transport”] is about the increase in patients being airlifted out of the state on these Life Flight [Network] emergency transports and the situation and doctors’ hesitancy to provide abortion care, even when they feel it’s medically necessary, is leading to this increase in flying patients to Oregon and Washington and Utah and neighboring states. It’s getting to the point where some doctors are even recommending people who are pregnant or planning to be pregnant purchase memberships in these flight companies, which normally is only recommended for people who do extreme outdoor sports who may need to be rescued or who ride motorcycles. So the fact that just being pregnant is becoming a category in which you are recommended to have this kind of insurance is pretty wild.

Rovner: Yeah. Welcome to 2024. Joanne.

Kenen: This is a piece from the Missouri Independent, which is also part of the States Newsroom, by Rudi Keller, and the headline is “Missouri Prison Agency To Pay $60K for Sunshine Law Violations Over Inmate Death Records.” That doesn’t sound quite as dramatic as this story really is. It’s about a mother who’s been trying to find out how her son was left unprotected, and he died by suicide, hanged himself in solitary confinement, when he had a history of mental illness. He was serving time for robbery. He wasn’t a murderer. I mean, he was obviously in prison. He had done something wrong, very wrong. He had had a 13-year sentence. But he had a history of mental illness. He had a history of past suicide attempts. He had been taken off some of his drugs, and she has been trying to find out what happened. But it’s not just her. There are other cases. The number of deaths in Missouri prisons has actually gone up in the last few years, even though the prison population itself has gone down. The headline is sort of the tip of a rather sad iceberg.

Rovner: Prison health care, I think, is something that people are starting to look at more closely, but there’s a lot of stories there to be done. Well, my story this week is from my friend and former colleague Liz Szabo, and it’s called “Women Are Less Likely To Die When Treated by Female Doctors, Study Suggests.” Now, this was a study of women on Medicare who were hospitalized, so not everybody, and the difference was small, but statistically significant. Those women treated by women doctors were slightly less likely to die in the ensuing 30 days than those treated by male doctors. It’s not entirely clear why, but at least part of it is that women tend to take other women’s problems more seriously, and women patients may be more likely to open up to other women doctors.

It’s another data point in trying to close the gap between women and men and the gap between people of color and white people when it comes to health care. So more studies to come.

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 to whatthehealth, all one word, @kff.org. Or you can still find me at X, I’m @jrovner. Joanne, where do you hang these days?

Kenen: Occasionally on X @JoanneKenen, but not very much, and on threads @joannekenen1.

Rovner: Tami?

Luhby: Best place is cnn.com.

Rovner: There you go. Alice?

Ollstein: @AliceOllstein on X, and @alicemiranda on Bluesky.

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

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Covering the American health care system means we tell some scary stories. This episode of “An Arm and a Leg” sounds like a real horror movie. 

It uses one of Hollywood’s favorite tropes: machines taking over. And the machines belong to the private health insurance company UnitedHealth Group. 

Host Dan Weissmann talks to Stat News reporter Bob Herman about his investigation into Medicare Advantage plans that use an algorithm to make decisions about patient care. The algorithm is owned by a subsidiary of UnitedHealth Group.

Herman tells Weissmann that some of UnitedHealth’s own employees say the algorithm creates a “moral crisis” in which care is unfairly denied.

Scary stuff! Such reporting even has caught the eye of powerful people in government, putting Medicare Advantage plans under scrutiny.

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Host and producer of "An Arm and a Leg." Previously, Dan was a staff reporter for Marketplace and Chicago's WBEZ. His work also appears on All Things Considered, Marketplace, the BBC, 99 Percent Invisible, and Reveal, from the Center for Investigative Reporting.

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Transcript: Son of Medicare: Attack of the Machines

Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Dan: Hey there–

So this is kind of a horror story. But it’s not quite the kind of story it might sound like at first.

Because at first, it might sound like a horror story about machines taking over, making all the decisions– and making terrible, horrifying choices. Very age-of-Artificial Intelligence.

But this is really a story about decisions made by people. For money.

It’s also kind of a twofer sequel– like those movies that pit two characters from earlier stories against each other. Like Godzilla vs King Kong, or Alien vs Predator.

Although in this case, I’ve gotta admit, the two monsters are not necessarily fighting each other.

Let’s get reacquainted with them. 

On one side, coming back from our very last episode, we’ve got Medicare Advantage: This is the version of Medicare that’s run by private insurance companies. 

It’s got a bright and appealing side, compared to the traditional Medicare program run by the federal government, because: It can cost a lot less, month to month — saving people money on premiums. And it often comes with extra benefits, like dental coverage, which traditional Medicare doesn’t offer. [I know.]

But Medicare Advantage can have a dark side, which is basically: Well, you end up dealing with private insurance companies for the rest of your life. You need something — a test, a procedure, whatever — they might decide not to cover it.

Which can be scary. 

Our other returning monster — am I really calling them a monster? — well, last time we talked about them, in 2023, we had an expert calling them a behemoth. That’s United HealthGroup. You might remember, they’re not only one of the biggest insurance companies 

— and maybe not-coincidentally the very biggest provider of Medicare Advantage plans —

they’ve also got a whole other business– under the umbrella name Optum. And Optum has spent the last bunch of years buying up a gazillion other health care companies of every kind. 

That includes medical practices — they employ more doctors than anyone else, by a huge margin. It includes surgery centers, and home-health companies, and every kind of middleman company you can imagine that works behind the scenes — and have their hands in a huge percentage of doctor bills and pharmacy visits. 

A few years ago, United bought a company called NaviHealth, which provides services to insurance companies that run Medicare Advantage plans. 

NaviHealth’s job is to decide how long someone needs to stay in a nursing home, like if you’re discharged from a hospital after surgery, but you’re not ready to go home yet.

And the horror story– the stories, as dug up by reporters — starts after United bought NaviHealth.

And according to their reports, it involves people getting kicked out of those nursing homes who aren’t ready to go home. 

People getting sent home who can’t walk up the stairs in their house. Who can’t walk at all. Who are on feeding tubes. People who NaviHealth’s own employees are saying, “Wait. This person isn’t ready to go home.”

But their new bosses have told them: You’re not really making these decisions anymore. 

This is where machines do enter the picture.

NaviHealth’s distinctive offering has always been its proprietary algorithm– an algorithm that makes predictions about how long any given patient might need to stay. 

Before United bought the company, that algorithm was used as a guide, a first-guess. Humans weighed in with their own judgment about what patients needed.

After United bought the company, people inside have told reporters, that changed: The new owners basically told their employees, If the algorithm says someone can go home after x days, that’s when we’re cutting them off.

 Like pretty much any horror movie, this story’s got people running around trying to tell everyone: HEY, WATCH OUT! THERE’S SOMETHING BIG AND DANGEROUS HAPPENING HERE.

And in this case, they’ve actually gotten the attention of some people who might have the power to do something about it. Now, what those people will do? We don’t know yet. 

And, by the way: Yes, I said at the end of our last episode that we’d be talking about Medicaid this time around. That’s coming! But for now, strap in for this one. 

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

So. I said that, like every horror movie, this one has people who are seeing what’s going on and are trying to warn everybody?

Like those movies, we’re gonna follow one of those people, watch them discover the problem, see how deep it goes, and start ringing alarm bells. Let’s meet our guy.

Bob Herman: My name is Bob Herman. I’m a reporter at STAT News

Dan: Stat is an amazing medical news publication. Bob covers the business of medicine there. Bob started working on this story in November 2022, after talking to a source who runs nursing homes. Bob’s source was complaining about Medicare Advantage. 

Bob Herman: There were a lot of payment denials. They just weren’t able to get paid. And just offhandedly, the source mentioned like, um, you know, and they’re attributing everything to this algorithm. This algorithm said, You know, only 17 days for our patients and then time’s up and I went running to Casey Ross 

Dan: Casey is a reporter at Stat who focuses on tech and AI in healthcare. Bob said, hey, what do you think of this? Wanna team up?

Bob Herman: And he was hooked.

Dan: They started talking to people who worked at nursing homes, talking to experts, and talking to families. And it was clear: They were onto something. 

Bob Herman: It took so many families by surprise to be like, what do you mean we’re going home? The, you know, my husband, my wife, my grandma, my grandpa, they can’t go to the bathroom on their own. Like, what do you? It was just, it was so confusing to people. It seemed like such a, a cold calculation,​

Dan: One person they ended up talking with was Gloria Bent. Her husband Gary was sent to a nursing home for rehab after brain surgery for cancer. He was weak. He couldn’t walk. And he had something called “left neglect”: His brain didn’t register that there was a left side of his body. Here’s Gloria testifying before a Senate committee about how — when Gary arrived at the nursing home — the first thing he got was a discharge date. That is…

Gloria Bent: Before the staff of the facility could even evaluate my husband or develop a plan of care, I was contacted by someone who identified themselves as my Navi Health Care Coordinator

Dan: Gloria says when she told the nursing home staff she’d heard from NaviHealth, they groaned. And told her what to expect. 

Gloria Bent: I was told that I had just entered a battlefield, that I could expect a series of notices of denial of Medicare payment accompanied by a discharge date that would be two days after I got that notice.

Dan: Yeah, they said she’d get two days notice. Gloria says the nursing home staff told her she’d have 24 hours to appeal each of those, but even if she won, the denials would keep coming. In fact, they said,

Gloria Bent: If we won a couple of appeals, then we could expect that the frequency with which these denials were going to come would increase.

Dan: All of which happened. NaviHealth started issuing denials July 15, 2022, after Gary had been at the home for a month.

Gloria appealed. She told senators what the doctor who evaluated the appeal found: Gary couldn’t  walk. He couldn’t even move — like from bed to a chair — without help from two people.. That reviewer took Gloria’s side.

Her husband’s next denial came a week after the first. Gloria won that appeal too. She says the reviewer noted that Gary needed maximum assistance with activities of daily living. 

The third denial came four days later, and this time Gloria lost. 

Gary came home in an ambulance: As Gloria testified, he couldn’t get into or out of a car without assistance from someone with special training. 

And when he got into the ambulance, he had a fever. The next morning, he wound up in another ambulance — headed to a hospital with meningitis. He lost a lot of the functioning he’d picked up at the nursing home. 

He died at home a few months later. When Gloria testified in the Senate, all of it was still fresh. She told them that as awful as Gary’s illness and decline had been, the fights with insurance were an added trauma.

Gloria Bent: This should not be happening to families and patients. It’s cruel. Our family continues to struggle with the question that I hear you asking today. Why are people who are looking at patients only on paper or through the lens of an algorithm

making decisions that deny the services judged necessary by health care providers who know their patients.

Dan: Bob Herman calls Gloria’s story heartbreaking, like so many others he’s seen. 

And his attention goes to one part of Gloria’s story beyond denial-by-algorithm. 

Because: It’s not just one denial. It’s that series of denials. You can appeal, but as Gloria testified, the denials speed up. And you have to win every single time. The company only has to win once. 

I mean, unless you’re ready to get a lawyer and take your chances in court– which, in addition to being a major undertaking, also means racking up nursing home bills and legal bills you may never get reimbursed for, while the court process plays out. 

Bob Herman: This appeal system is designed in such a way that people will give up. If you have a job, you know, even if you don’t, and you’re, and you’re also trying to take care of a family member, um, it’s a rigorous monotonous process that will chew people up and spit them out and then the people are inevitably going to give up. And I think in some ways insurers know that.

Dan: Going out on a limb to say: I think so too. So Bob and Casey’s first story on NaviHealth came out in March of 2023. They were the characters in the movie who go, “HEY, I THINK THERE’S SOMETHING REALLY BAD HAPPENING HERE.”

And people started paying attention. Like the U.S. Senate. which held that hearing where Gloria Bent told her story. 

And like the federal agency that runs Medicare — the Centers for Medicare and Medicaid Services, CMS. 

CMS finalized a rule that told insurers: You can’t deny care to people just from using an algorithm. 

And something else happened too: Bob and Casey started suddenly getting a lot MORE information. 

Bob Herman: We received so many responses from people and it just opened the floodgates for former employees, just patients and family members, just everyone across the board.

Dan: And not just former employees. Current employees. And what they learned was: There was absolutely a strategy at work in how this algorithm was being used. It was strategy some people on the inside didn’t feel good about. 

And this strategy got developed after United HealthGroup — and its subsidiary, Optum– bought NaviHealth in 2020. And here’s what NaviHealth employees started telling Casey and Bob about that strategy.

Bob Herman: For some of us, it’s creating this moral crisis. Like we know that we are having to listen to an algorithm to essentially kick someone out of a nursing home, even though we know that they can barely walk 20 feet.

Dan: What Bob and Casey learned from insiders– and how it connects to United’s role as a health care behemoth– that’s next.

This episode of An Arm and a Leg is produced in partnership with KFF Health News. That’s a nonprofit newsroom covering healthcare in America. Their reporters do amazing work, and I’m honored to work with them. We’ll have a little more about KFF Health News at the end of this episode.

So, NaviHealth — the company with the algorithm — got started in 2015.. And the idea behind it was to use data to get people home faster from nursing homes if they didn’t actually need to be there. 

Because there was a lot of evidence that some people were being kept longer than they needed. 

Bob Herman: There is some validity to the idea that there’s, there’s wasteful care in Medicare, like, you know, there’s been cases in the past proving that people stay in a nursing home for way longer than is necessary. And obviously there’s financial incentives for nursing homes to keep people as long as possible. 

Dan: Traditional Medicare does have limits on nursing home care — but if you need “post-acute care” — help getting back on your feet after leaving a hospital traditional Medicare pays in full for 20 days– pretty much no questions asked. One of the selling points of Medicare Advantage — like selling points to policy nerds and politicians — was that it could cut waste, by asking those kinds of questions. NaviHealth and its algorithm were designed to help Medicare Advantage plans ask those questions in a smart way. 

Bob Herman: There were… a lot of believers within NaviHealth that were like, okay, I think we’re doing the right thing. We’re trying to make sure people get home sooner because who doesn’t want to be at home.  

Dan: And as those employees told Bob and Casey: Before United and Optum came in, the algorithm had been there as a guide — a kind of first guess — but not the final word. 

NaviHealth has staff people who interact directly with patients. And back in the day, the pre-United day, Bob and Casey learned that those staff could make their own judgments. 

Which made sense, because the algorithm doesn’t know everything about any individual case. It’s just making predictions based on the data it has.

Bob Herman: And there was just, just this noticeable change after United and OptiMentor that it felt more rigid. There’s no more variation. 

Dan: If the algorithm says you go, you are pretty much going.

Bob Herman: United has said, no, that’s not the case, but obviously these documents and other communications that we’ve gotten kind of say otherwise.

Dan: Because these employees weren’t just talking. They were sharing. Internal memos. Emails. Training materials. All making clear: The company wanted people shipped out on the algorithm’s timetable. 

Bob Herman: Documents came in showing that like this was a pretty explicit strategy. You know, UnitedHealth was telling its employees. Listen, we have this algorithm. We think it’s really good. So when it tells you how many, how many days someone should be in a nursing home, stick to it.

Dan: Stick to it or maybe be fired. Bob and Casey got documents — employee performance goals– saying: How close you stick to the algorithm’s recommendations? That’s part of how we’re evaluating your job performance. 

Bob Herman: It’s okay. Algorithm said 17 days, you better not really go outside of that because your job is on the line. 

Dan: Here’s how closely people were expected to stick to it. In 2022, employee performance goals shared with STAT showed that workers were expected to keep actual time in nursing homes to within three percent of what the algorithm said it should be. Across the board.

So, say you had 10 patients, and the algorithm said they each should get 10 days. That’s 100 days. Your job was to make sure that the total actual days for those patients didn’t go past 103 days.

Then, in 2023, the expectations got more stringent: Stay within one percent of the algorithm’s predictions. 10 patients, the algorithm says 100 days total? Don’t let it get past a hundred and one. 

Bob Herman: Like that is, almost nothing. Like what, what, your hands are tied. If you’re that employee, what are you going to do? Are you going to get fired? Are you going to do what you’re told?

Dan: And one person who ended up talking, to did get fired. 

Bob Herman: Correct. Yes. Uh, Amber Lynch did get fired And what she said was what we had also heard just more broadly was it, it created this internal conflict, like, Oh my God, what I’m doing doesn’t feel right. 

Dan: Amber Lynch was a case manager. She told Bob and Casey about onepatient who couldn’t climb the stairs in his home after knee surgery. But the algorithm said he was ready. Amber’s supervisor said, “Have you asked the nursing home staff if they’ve tried to teach him butt bumping?” Amber grit her teeth and made the suggestion to the rehab director.

Amber Lynch: And she looked at me like I had two heads. She’s like, he is 78 years old. He’s not going to do that. He’s not safe to climb the stairs yet. He’s not doing it. We’re not going to have it butt bump the stairs.

Dan: Amber told Bob and Casey that when she got fired, it was partly for failing to hit the one percent target and partly for being late with paperwork– which she told Bob and Casey she fell behind because her caseload was so heavy.

She wasn’t the only one with that complaint. 

Bob and Casey’s story shows another NaviHealth case manager– not named in the story because they’re still on the job — in their home office, struggling to keep up. 

That week, they were supposed to work with 27 patients and their families. Gather documents, hold meetings. Another week, shortly before, they’d had 40 patients. 

“Do you think I was able to process everything correctly and call everyone correctly the way I was supposed to?” the case manager asked. “No. It’s impossible. No one can be that fast and that effective and capture all of the information that’s needed.”

Bob and Casey watched this case manager fill out a digital form, feeding the algorithm the information it asked for on a man in his 80s with heart failure, kidney disease, diabetes and trouble swallowing, who was recovering from a broken shoulder. 

A few minutes later, the computer spat out a number: 17 days. 

The case manager didn’t have a lot of time or leeway to argue, but they were skeptical that the algorithm could get that number exactly right based on only the data it had. 

And what data is the algorithm working with? What’s it comparing the data on any given patient TO? Bob Herman says that’s a big question.

Bob Herman: It’s something that for sure, like Casey and I, it’s been bothering us. Like, what, how is this whole system? Like, what is it based on? And we were never really given straight answers on that. NaviHealth and Optum and United have said it’s based on millions of patient records over time. The sources of that, it’s, it’s a little unclear, where all that’s coming from. 

Dan: Bob and Casey talked with an expert named Ziad Obermeyer, a professor at the University of California Berkeley School of Public Health, who is not anti-algorithm. He actually builds algorithmic tools for decision making in public health. 

AND he’s done research showing that some widely-used algorithms just scale up and automate things like racial bias.

He told Bob and Casey: Using an algorithm based on how long other, earlier patients have stayed in a nursing home — that’s not a great idea.

Because people get forced out of nursing homes, in his words, “because they can’t pay or because their insurance sucks.” He said, “So the algorightm is basically learning all the inequalities of our current system.”

And leaving aside that kind of bias, it seems unlikely to Bob that any algorithm could predict exactly what every single patient will need every single time. 

No matter how much data it’s got, it’s predicting from averages.

Bob Herman: It reminds me of, like, a basketball game where let’s say someone averages 27 points per game. They don’t have 27 points every single, the game they go out there. It just varies from time to time.

Dan: But the NaviHealth algorithm doesn’t have to be right every time for United to make money using it. 

Using it to make decisions can allow United to boost profits coming and going.

Bob Herman: United health and the other insurance companies that use Navi health. Are using this technology to more or less kick people out of nursing homes before they’re ready. And that is the claims denial side where it’s like, okay, let’s save as much money as we can instead of having to pay it to a nursing home.

Dan: And that’s just one side of it. The insurance side. Claims denial. But United isn’t just in the insurance business. 

United’s Optum side is in every other part of health care. 

Including — in the years since United took over NaviHealth — home health services. The kind of services you’re likely to need when you leave a nursing home.

In 2022, Optum bought one top home health company in what one trade publication called a “monster, jaw-dropping mega-deal” — more than 5 billion dollars. In 2023, Optum made a deal to buy a second mega-provider. 

Bob and Casey’s story says NaviHealth’s shortening nursing home stays is integral to United’s strategy for these acquisitions. It does seem to open up new opportunities.

Bob Herman: You’re out of the nursing home because our algorithm said so. Now we’re going to send you to a home health agency or we’re going to send some home health aides into your home. And by the way, we own them. 

Dan: Oh, right, because: If you’re in a Medicare Advantage plan, your insurer can tell you which providers are covered. 

Bob Herman: So the real question becomes, how much is United potentially paying itself?

Dan: That is: How much might United end up taking money out of one pocket — the health insurance side — and paying itself into another pocket, Optum’s home-health services?

We don’t know the answer to how much United is paying itself in this way, or hoping to. And United has said its insurance arm doesn’t favor its in-house businesses.

But it seems like a reasonable question to ask. Actually, it’s a question the feds seem to be asking.

Optum hasn’t wrapped up its purchase of that second home-health company yet, and in February 2024, the Wall Street Journal and other outlets reported that the U.S. Department of Justice had opened an anti-trust investigation. 

And you don’t have to be in a Medicare Advantage plan run by United to get kicked out of a nursing home on an algorithm’s say-so. 

Bob Herman says NaviHealth sells its algorithm-driven services to other big insurance companies 

He says, put together, the companies that use NaviHealth cover as many as  15 million people — about half of everybody in Medicare Advantage.

Bob Herman: Odds are, if you’re in a Medicare Advantage plan, there’s a, there’s a really good shot that your coverage policies, if you get really sick and need nursing home care, for example, or any kind of post acute care, an algorithm could be at play at some point.

Dan: This is the dark side of Medicare Advantage. 

Bob Herman: Everyone loves their Medicare Advantage plan when they first sign up, right? Because it’s offering all these bells and whistles. It’s, here’s a gym membership. It’s got dental and vision, which regular Medicare doesn’t have. And it’s also just, it’s, it’s cheaper. Like, if it’s just from a financial point of view, if, if you’re a low income senior, How do you turn it down? There’s, there’s so many plans that offer like free, there’s no monthly premiums in addition to all the bells and whistles. But Nobody understands the trade offs , When you’re signing up for Medicare and Medicare Advantage, you’re on the healthier side of, of being a senior, right?

Dan: And none of us can count on staying healthy forever. When you sign up for Medicare  you’re signing up your future self — whether that’s ten or twenty or more years out. That future you, might really need good medical care. 

And at that point, as we explained in our last episode, if Medicare Advantage isn’t working for you, you may not be able to get out of it.

Bob Herman: You could potentially not fully get the care that you need. We shouldn’t assume that, that this couldn’t happen to us because it can. 

Dan: So, yeah. Kind of a horror story. But: Unlike some horror movies, when Bob and Casey started publishing their stories, they started getting people’s attention.

We mentioned the new rules from the feds and the senate hearings after Bob and Casey’s first story in March 2023

Later in the year, when Bob and Casey published their story with documents and stories from inside NaviHealth, a class-action lawsuit got filed.

Since then, CMS has said it will step up audits under its new rules. 

Bob Herman: There was a memo that CMS sent out to Medicare advantage plans that said, Hey, listen, we’re telling you again, do not deny care solely on any AI or algorithms. Like just don’t do it. 

Dan: And in February 2024, the Senate held another hearing. 

Here’s Senator Elizabeth Warren at that hearing, saying these CMS rules aren’t enough. We need stronger guardrails.

Elizabeth Warren: Until CMS can verify that AI algorithms reliably adhere to Medicare coverage standards by law, then my view on this is CMS should prohibit insurance companies from using them in their MA plans for coverage decisions. They’ve got to prove they work before they put them in place.

Dan: So people — people with at least some power– are paying some attention. 

Bob Herman: I don’t think this is necessarily going to escape. Political scrutiny for a while. 

Dan: So, basically, the story isn’t over. 

This isn’t one of those horror movies where the monster’s been safely defeated at the end, and everybody just starts cleaning up the mess. And it’s not one where the monster is just on the loose, unleashing the apocalypse. 

Because it’s not a movie. There’s no ending. There’s just all of us trying to figure out what’s going on, and what we can maybe do about it.

One last thing: I got a lot of emails after our last episode, where we laid out a lot of information about Medicare Advantage and traditional Medicare. Most of it was along the lines of, Thank you! That was really helpful! Which made me feel really good.

And we got a couple notes about things we could have done better. Especially this: We said Traditional Medicare leaves you on the hook for 20 percent of everything, without an out of pocket limit. 

Which is true — but only for Medicare Part B: Doctor visits, outpatient surgeries and tests. Which can add up, for sure.

Medicare Part A — if you’re actually hospitalized — covers most services at 100 percent, after you meet the deductible. In 2024 that’s one thousand, six hundred thirty-two dollars. 

Thanks to Clarke Lancina for pointing that out. 

There have been a bunch of other, amazing notes in my inbox recently, and I want to say: Please keep them coming. 

If you go to arm and a leg show dot com, slash, contact, whatever you type there goes straight to my inbox. You can attach stuff too: documents… voice memos. 

Please let me hear from you. That’s arm and a leg show dot com, slash contact.

I’ll catch you in a few weeks. 

Till then, take care of yourself.

This episode of an arm and a leg was produced by me, Dan Weissmann, with help from Emily Pisacreta, and edited by Ellen Weiss. 

Adam Raymonda is our audio wizard. Our music is by Dave Weiner and blue dot sessions. Extra music in this episode from Epidemic Sound.

Gabrielle Healy is our managing editor for audience. She edits the first aid kit newsletter. 

Bea Bosco is our consulting director of operations. Sarah Ballama is our operations manager. 

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

Zach Dyer is senior audio producer at KFF Health News. He’s editorial liaison to this show. 

And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor, allowing us to accept tax exempt donations. You can learn more about INN at INN. org. 

Finally, thanks to everybody who supports this show financially– you can join in any time at arm and a leg show dot com, slash, support — and thanks for listening.

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

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

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

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The Host

Julie Rovner
KFF Health News

@jrovner

Read Julie's stories.

Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

Florida this week became a major focus for advocates on both main sides of the abortion debate. The Florida Supreme Court simultaneously ruled that the state’s 15-week ban, passed in 2022, can take effect immediately before a more sweeping, six-week ban replaces it in May and that voters can decide in November whether to create a state right to abortion.

Meanwhile, President Joe Biden, gearing up for the general election campaign, is highlighting his administration’s health accomplishments, including drug price negotiations for Medicare.

This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of the Johns Hopkins University schools of nursing and public health, Tami Luhby of CNN, and Lauren Weber of The Washington Post.

Panelists

Joanne Kenen
Johns Hopkins Bloomberg School of Public Health and Politico

@JoanneKenen

Read Joanne's articles.

Tami Luhby
CNN

@Luhby

Read Tami's stories.

Lauren Weber
The Washington Post

@LaurenWeberHP

Read Lauren's stories.

Among the takeaways from this week’s episode:

• The Florida Supreme Court’s decisions this week will affect abortion access not only in the state, but also throughout the region. Florida’s six-week ban, which takes effect on May 1, would leave North Carolina and Virginia as the only remaining Southern states offering the procedure beyond that point in pregnancy — and, in North Carolina, abortion is banned at 12 weeks after a woman’s last menstrual period.
• Since the U.S. Supreme Court overturned the constitutional right to an abortion in 2022, six states have voted on their own constitutional amendments related to abortion access. In every case, the side favoring abortion rights has won. But Florida’s measure this fall will appear on the ballot with the presidential race. Could the two contests, waged side by side, boost turnout and influence the results?
• Former President Donald Trump made many attempts during his term to undermine the Affordable Care Act, and this week the Biden administration reversed another one of those lingering attempts. Under a new regulation, the use of short-term insurance plans will be limited to four months — down from 36 months under Trump. The plans, which Biden officials call “junk plans” due to their limited benefits, will also be required to provide clearer explanations of coverage to consumers.
• In other Biden administration news, March has come and gone without the release of an anticipated ban on menthol flavoring in tobacco, and anti-tobacco groups are suing to force administration officials to finish the job. Menthol cigarettes are particularly popular in the Black community, and — like Trump’s decision as president to punt a ban on vaping to avoid alienating voters in 2020 — the Biden administration may be loath to raise the issue this year. Activists say, however, that it may be at the expense of Black lives.
• “This Week in Medical Misinformation” looks at an article from PolitiFact about the health misinformation that persists even with the pandemic mostly in the rearview mirror.

Also this week, Rovner interviews health care analyst Jeff Goldsmith about the growing size and influence of UnitedHealth Group in the wake of the Change Healthcare hack.

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

Julie Rovner: Politico’s “Republicans Are Rushing to Defend IVF. The Anti-Abortion Movement Hopes to Change Their Minds,” by Megan Messerly and Alice Miranda Ollstein.

Tami Luhby: The Washington Post’s “Biden Summons Bernie Sanders to Help Boost Drug-Price Campaign,” by Dan Diamond.

Lauren Weber: The Washington Post’s “Bird Flu Detected in Dairy Worker Who Had Contact With Infected Cattle in Texas,” by Lena H. Sun and Rachel Roubein.  

Joanne Kenen: The 19th’s “Survivors Sidelined: How Illinois’ Sexual Assault Survivor Law Allows Hospitals to Deny Care,” by Kate Martin, APM Reports.

Also mentioned on this week’s podcast:

• KFF Health News’ “ACA Plans Are Being Switched Without Enrollees’ OK,” by Julie Appleby.
• KFF Health News’ “Your Doctor or Your Insurer? Little-Known Rules May Ease the Choice in Medicare Advantage,” by Susan Jaffe.
• Health Affairs’ “Will the Change Healthcare Incident Change Health Care?” by Jeff C. Goldsmith.
• The Health Care Blog’s “Optum: Testing Time for an Invisible Empire,” by Jeff Goldsmith.

click to open the transcript

Transcript: Florida Limits Abortion — For Now

KFF Health News’ ‘What the Health?’Episode Title: Florida Limits Abortion — For NowEpisode Number: 341Published: April 4, 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 Thursday, April 4, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this, so here we go.

We are joined today via video conference by Tami Luhby of CNN.

Tami Luhby: Good morning.

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

Joanne Kenen: Hi, everybody.

Rovner: And Lauren Weber, the Washington Post.

Lauren Weber: Hello.

Rovner: Later in this episode, we’ll have an interview with Health Policy Analyst and Consultant Jeff Goldsmith about the continuing fallout from the Change Healthcare hack. But first, this week’s news. One of these weeks, we won’t have to lead with abortion news, but this is not that week. On Monday, the Florida Supreme Court ruled separately, but at the same time, that state voters could decide this November whether to make a right to abortion part of the state’s constitution and that the state’s constitution currently does not guarantee that right.

So the state’s 15-week abortion ban signed by Gov. Ron DeSantis in April of 2022 can take immediate effect. But wait, there’s more. First, the decision on the 15-week ban overruled years of precedent that Florida’s Constitution did, in fact, protect the right to abortion. And second, allowing the 15-week ban to take effect automatically triggers an even more sweeping six-week ban that Gov. DeSantis signed in 2023. That will take effect May 1. That’s the one he signed in the middle of the night without an audience people may remember. And this is going to affect far more people than just the population of Florida, right?

Kenen: The whole South. This is it. If you count the South as North Carolina and what we think of as the South, North Carolina is the only state that still has legal abortion, and that is only up to 12 weeks. And there are some conditions and hurdles, but you can still get an abortion in North Carolina.

But to get from a place, people were going to Florida, it’s easier to get from Alabama to Florida than it is from Alabama to even Charlotte. I think I read it’s a 17-hour drive from Florida or something like that. I don’t remember. It’s long. So it’s not just people who live within Florida, but people who live in 11 or 12 states in the American South have far fewer options.

Rovner: And even though the Florida ban feels less than a complete ban because it allows abortions up to six weeks, the fine print actually makes this one of the most restrictive bans in the country. It looks, in effect, like most people won’t be able to get abortions in Florida at all.

Weber: I would say that’s right, Julie. And just to reiterate what Joanne said, 80,000 women get abortions in Florida every year. That’s about one in 12 women in America that get abortions per year, and they will no longer have that kind of access because, at six weeks, a lot of women don’t know they’re pregnant. So, I mean, that’s a very restrictive abortion ban.

Rovner: Remember that six weeks isn’t really six weeks of having been pregnant. Six weeks is six weeks since your last menstrual period, which can be as little as two weeks in some cases.

Kenen: And I also think that even if you do know within six weeks, getting an appointment, given how few places there are in the entire South, even if you know and you get on the phone right away, can you get an appointment before your six weeks is an additional challenge because access is really limited …

Rovner: Right.

Kenen: … intentionally.

Rovner: Yes, and we’ve seen this with other six-week bans. We should point out that some people consider Virginia the South still, and you can go to Virginia, but that’s basically the last place that a good chunk of the country, geographically, if not population-wise, would need to turn to in order to get an abortion.

Well, if that’s not all confusing enough, even if voters do approve the ballot measure in November, the Florida Supreme Court suggested it could still strike down a right to abortion based on a majority of justices findings that the state’s constitution could include personhood rights for fetuses.

I’m having trouble wrapping my head around why the justices would allow a vote whose results they might then overturn. But I guess this is part of the continuing evolution, if you will, to use that word, of this concept of personhood for fetuses and embryos, and what has us talking about IVF, right?

Weber: Yeah, absolutely. I think, as many conservative Christian groups will say, this is the natural line that pro-life is. I mean, they argue, and while they’re pushing this view is not necessarily held by the majority of constituents, but this is their argument that a fetus, an embryo, such as one that could be used in IVF, is a person.

And so, I mean, I think that’s kind of the natural conclusion of pro-life ideology as we’re seeing it right now. And I think it will have a lot of political effects going forward because that IVF is obviously much more popular than abortion. I think we’ll see a lot of voting firepower potentially used on that.

Rovner: Well, I’m so glad you said that because I want to turn to politics. Some Democrats are suggesting that this could boost turnout for Democrats and help, if not put Florida in play for president, maybe the Democrat running to unseat Senator Rick Scott, the Republican.

On the other hand, while abortion ballot questions have done very well around the country, as we know, even in states redder than Florida, there is evidence that some Republicans vote for abortion rights measures and then turn around and vote at the same time for Republicans who would then vote to overturn them.

There are in fact Florida abortion rights advocates who don’t want Democrats to make this issue partisan because they want Republicans to come and vote for the ballot measure, which needs a 60% majority to pass, even if those Republicans then go on to vote for other Republicans. So, who really is helped by this entire mess, or is it impossible to tell at this point?

Weber: I think it’s impossible to tell, but I do think what is complicating is we haven’t seen the presidential race thrown into these abortion ballots. I mean, what we’re looking at is two candidates who potentially are facing a lot of low turnout due to lack of enthusiasm in their bases for both of them. And I am curious if the abortion ballot measures could have much more of an impact on the presidential race than maybe some of these other lower-office races that we’ve seen. I think that’s the main question that I guess we’ll see in November.

Rovner: As we have spoken about many times, President Biden is not super comfortable talking about this issue. He’s an 81-year-old Catholic. It does not come naturally to him to be in favor of abortion rights, which he now is. But Vice President Harris has been sent out. She’s sort of become the standard-bearer for this administration on reproductive health issues, and she’s been very active. And Joanne, you wanted to say something?

Kenen: There are a couple of points. In addition to the abortion ballot initiative. There’s also a marijuana legalization. I think we will see higher turnout and particularly among younger people who have been pretty disaffected this election. So that’s one, whether it affects the presidential race, whether it affects the Senate race. I mean, just as Democrats feel really strong about abortion, Republicans feel really strong about immigration. We don’t know what’s going to happen in November, but I do think this boosts turnout. The second thing to remember, though, is in terms of abortion ballot initiatives have passed every time they’ve come up since the fall of Roe [v. Wade].

This is a 60% threshold, and I do not believe that any state has reached that. I think the highest was about 57%. So even though it may get well over 50, it could get 59.9, the Florida ballot initiative needs 60%. That is a tall order. So you might end up seeing a big turnout, a big pro-abortion rights vote, maybe a big legal weed vote, and the abortion measure could still fail. But I do think it definitely changes the dynamics of Florida from the presidential race on down the ballot. I do think it is a different race than we would’ve seen beforehand.

Rovner: And I will point out, since she didn’t, that Joanne has spent time covering Florida and covering the politics in Florida. So you know where of you speak on this.

Kenen: Well, I lived there for a while, though it was a while ago. The state has, in fact, changed like everything else, including me, right? But I’m somewhat familiar with Florida. I was just there a few weeks ago in fact.

Rovner: And I want to underscore something that Lauren said, which is that we’ve seen all of these ballot measures since Roe was overturned, but we have not seen these ballot measures stacked on top of the presidential race. So I think that will be interesting to watch as we go forward this year.

Well, back here in D.C., the Biden administration issued a long-awaited rule reigning in the use of those short-term health plans that Democrats like to call junk insurance and that President Trump had expanded when he was in office. Tami, what is the new rule, and what will it do?

Luhby: Well, it’s actually curtailing the short-term plans and pretty much reversing the Trump administration rule. So it’s the latest move by the president to contrast his approach to health care with that of former President Donald Trump. Trump extended the duration of the short-term health insurance plans to just under a year and allowed them to be renewed for a total of 36 months. And it was seen as an effort to weaken the Affordable Care Act, draw out younger people, make it more difficult for the marketplace, probably send the older, sicker people there, which would raise premiums, basically cause more chaos in the marketplace.

Rovner: Yeah. And remind us why these plans can be problematic.

Luhby: I will tell you that the short-term plans do not have to adhere to Obamacare’s consumer protections, which is the big difference. For instance, they’re not required to provide comprehensive coverage, and they can discriminate against people with pre-existing conditions, charge them more, deny them, et cetera. As I’d said, the Trump administration heralded them as a cheaper alternative because since they can underwrite, they have typically cheaper premiums. But they also have very limited benefits, or they can have limited benefits depending on the patient or the consumer.

So the Biden rule, which was proposed last month as a series of actions aimed at lowering health care costs, limits the duration of new sales of these controversial plans to three months, with the option of renewal for a maximum of four months. So it’s going on these new plans from 36 months potentially to four months, which was the original idea of these plans because originally they were thought to be for people who might be switching jobs or have a temporary lapse in coverage. They were not intended to be a substitute for full insurance. And it also requires, notably, that the plans provide consumers with a clear explanation of their benefits and inform them of how to find more comprehensive coverage.

Rovner: And obviously this will continue to be controversial, but I think the Democrats, in general, who support the Affordable Care Act feel pretty strongly that this is something that’s going to help them. And as we talked about, we’re not sure yet how the administration is going to play the abortion issue in the campaign, but it is pretty clear that they are doubling down on health care.

One problem for the administration, as we have talked about, is that particularly on really popular things like Medicare drug price negotiations, lots of the public has no idea that that’s happened or if it’s happened that it’s because the Democrats did it. So, in part of an effort to overcome that, Biden invited Bernie Sanders to the White House this week. What was that about?

Luhby: Well, that’s my extra credit. Would you like me to discuss that now?

Rovner: Sure, let’s do that now.

Luhby: OK. So my extra credit is a Washington Post story titled “Biden Summons Bernie Sanders to Help Boost Drug-Price Campaign,” by Dan Diamond. And I have to admit, I hope I can do that here, that I am a fangirl of Dan Diamond’s stories, and even more so now because apparently, the Biden administration gave Dan a heads-up in advance, that since he published a pretty in-depth story an hour before the embargo lifted for the rest of us who were only given a few tidbits of information about what this meeting or what this speech was going to be about at the uncharacteristically late hour of 8:30 at night.

So Dan’s story looked at how the two former rivals, Joe Biden and [Sen.] Bernie Sanders, who were rivals in the 2020 Democratic presidential nomination, how they had very different views on how the nation’s health care system should operate and Dan’s story looked at how they were uniting to improve awareness of Biden’s efforts to lower drug prices and improve his chances in November. Biden invited Sanders to the White House to discuss the administration’s actions on drug prices, including the latest effort to reduce the out-of-pocket cost of inhalers, which really hasn’t gotten a lot of press.

Sanders brings his progressive credentials and his two-decade-plus track record of fighting for lower drug prices and, “naming and shaming individual pharmaceutical companies and executives.” He’s known to be pretty outspoken and fiery. So the story’s a good example of policy meets politics in an election year. It relays that most Americans still don’t know about the administration’s efforts despite the numerous speeches, news releases, and officials’ trips around the country, hence the need to tap Sanders, and it also provides a nice walk down memory lane, revisiting the duo’s battles in the 2020 primary as well as some of former President Trump’s drug price efforts.

Rovner: Yeah. And a little peek behind the journalistic curtain. I think we all got this sort of mysterious note from Sanders’ press people the night before saying, “If you’ll agree to our embargo, we’ll tell you about this secret thing that’s going to happen,” followed by an advisory from the White House saying that Bernie Sanders was coming to the White House to talk about drugs. [inaudible 00:13:30] …

Luhby: Right. And also, uncharacteristically, when I asked for a comment from Sanders directly, they said tomorrow, which is not like Sanders at all.

Kenen: Sanders and Biden were obviously opponents in the primary, but Sanders has really been very supportive of Biden. I think he’s really sort of highlighted the progressive things that Biden has done and stayed quiet about the more centrist things that Biden has done. He’s been a real ally, and he still has a lot of credibility, and I think they sort of like each other in a funny way. You can sort of see it, but that’s their issue.

Luhby: Biden has also been able to do things that other people have not been able to do with the congressional Democrats. Biden has been able to do things that congressional Democrats have tried to for years and have not been able to, and they may not be the extent to which the Democrats would like. If you remember the 2019 Medicare Drug Negotiation bill, I think, was 250 drugs a year. What ended up passing in the IRA [Inflation Reduction Act] was 10 drugs and ramping up, but at least it’s something.

Kenen: And it’s more than 20 years in the making. I mean, this goes way, way back.

Luhby: Mm-hmm.

Rovner: And I was going to underscore something that Joanne said earlier about Florida, which is that both sides are trying to gin up their base, and young people are really fond of Bernie Sanders in a lot of the things that he says, and this may be a way that Biden can ironically use the Medicare drug price negotiation issue to stir up his young person base to get them out to vote. So I was interested in the combination.

Kenen: So it’s Bernie Sanders and legal weed.

Rovner: That’s right. It’s Bernie Sanders and legal weed, at least in Florida.

Kenen: I’m not implying anything about Bernie Sanders’ use of it. It’s just the dynamic for the young voters.

Rovner: Yes. Things to draw young people out to the polls in November. Well, while the Biden administration is doing lots of things using its regulatory power, one thing it is not doing, at least not yet, is banning menthol flavoring in tobacco.

This is a regulation that’s now been sitting around for nearly two years and that officials had promised to finalize by the end of March, which of course was last week and which didn’t happen. So now three anti-tobacco groups have sued to try to force the regulation over the finish line. Somebody remind us why banning menthol is so very controversial.

Weber: It’s controversial in part because a lot of industry will say that banning menthol will lead to over-policing in Black communities. The jury is very much out on if that is an accurate representation or part of the cigarette playbook to keep cigarettes on the market. Look, a presidential election year and things to do with smoking is not new.

When I was at KFF Health News with Rachel Bluth back in the day, we wrote a story about how Trump postponed a vape ban to some extent because he was worried about vaping voters. So I mean, I think what you’re seeing is a pretty clear political calculus by the Biden folks to push this off into the new year, but as activists and public health advocates will say, it’s at the expense of, potentially, Black lives.

Rovner: That’s right.

Weber: So banning menthol cigarettes would really… what it would do is statistically save Black Americans who die from, predominantly from smoking these types of cigarettes. So it’s a pretty weighty decision to put off with a political calculus.

Rovner: He’s taking incoming from both sides. I mean, obviously, there are members of the Black community who say, as you point out, this could lead to an unnecessary crackdown on African American smokers who use menthol more statistically than anybody else does. Although, there’s some young people who use it too. On the other hand, you have people representing public health for the Black community saying, “We want you to ban this” because, as you point out, people are dying from smoking-related illnesses by using this product. So it’s a win-win, lose-lose here that is continuing on. We’ll be interested to see what, if the lawsuit can produce anything.

Well, speaking of things that are controversial, we also have Medicare Advantage. The private plan alternative to traditional Medicare now enrolls more than half of those in the program, many who like the extra benefits that often come with the plans and others who feel that they can’t afford traditional Medicare’s premiums and other cost-sharing. Except one reason those extra benefits exist is because the government is overpaying those Medicare Advantage plans. That’s a vestige of Republican plans to discourage enrollment in original Medicare that date back to the early part of this century.

So now taxpayers are footing more of the Medicare bill than they should. This week’s news is that the federal government is effectively trimming back some of those overpayments. And investors in the insurance companies, who make money from the overpayments, are going crazy. This is the subhead on a story from the Wall Street Journal, “Managed care stocks are set to fall due to disappointment with the government’s decision not to revise the 2025 Medicare payment proposal.” How is this ever going to get sorted out? Somebody always is going to be a loser in this game, either the patients or the insurance companies or the taxpayers. Everybody cannot win here.

Luhby: Right. And Humana got hit really hard when the rule came out because it is really focused on Medicare Advantage. So yeah, the insurers were hit, but as everything with the market, it’s not forever.

Rovner: I’m continually puzzled by … if the payments were equivalent, which was what they were originally supposed to be. Originally, originally back in the 1980s, insurance companies came to Congress and said, “We can provide managed care and Medicare cheaper, so you can pay us 95% of the average that you pay for a fee for service patient. We can make a profit on that.”

Well, that is long since gone. The question is how much more they will make. And as I point out, when they get overpaid, they do have to rebate those back effectively to the patients in terms of higher benefits. And that’s why many of them offer dental coverage and eyeglasses coverage and other types of, quote-unquote, extra benefits that Medicare doesn’t offer.

But also you get this lack of choice, and so we see when people try to leave these plans and go back to traditional Medicare, they can’t, which is only one of the sort of things that I think a lot of people don’t know about how Medicare Advantage works. Another place with an awful lot of small print.

Weber: It’s a lot of small print under a very good marketing name. The name itself implies that you’re making a better choice, but that isn’t necessarily what the small print would say.

Kenen: And there are people who are very satisfied with it and who get great care. I mean, it’s not monolithic. I mean, it is popular. It is growing and growing and growing. It’s partly economic, and there’s some plans that patients like, and there’s word of mouth or that were negotiated as part of union agreements and are actually pretty strong benefits. But they’re also people who are really encountering a lot of trouble with prior authorization, and limited networks, and your doctor’s no longer in it, et cetera, et cetera.

I think that those things, I actually checked with somebody about the provider networks, what we know about who’s dropping out, and I don’t think there’s really up-to-date data, but there is a perception, and you’re hearing it and seeing it online. But they do an incredible amount of marketing, an incredible amount of marketing. And if you’re in it and you like it and you save money and you’re getting great health care, terrific. You’re going to stay in it.

If you’re in it and you don’t like it and you’re not getting great health care and a lot of hassles or you can’t see the right doctors, it’s hard to get out and get back into it depending on what state you’re living … It’s not monolithic. But I think we might be between the financial pressures from the government and some of the debates about some of these things they’re doing there may be some reconsideration. But they have strong backers in Congress and not just Republicans.

Rovner: Oh, yeah. I mean, and as you point out, more than half of the people in Medicare are now on Medicare Advantage. I did want to sort of highlight my colleague Susan Jaffe, who has a story this week about the fact that patients can’t change plans in the middle of the year, but plans can drop providers in the middle of the year, so people may sign up for a health plan because their doctor or their hospital is in it and then suddenly find out mid-year that their doctor and their hospital is no longer in it.

There are occasionally, if you’re in the middle of treatment, there are opportunities sometimes to change, but often there aren’t. People do end up in these plans, and they can be happy for, basically, until they’re not, that there are trade-offs when you do it. And I think, as we point out, there’s so much marketing, and the marketing somehow doesn’t ever talk about the trade-offs that you make when you go into Medicare Advantage.

Luhby: Well, one also thing is that this is the peak 65 year, where the most baby boomers, and where are they coming from? They’re coming from private commercial insurance, so they’re familiar with it, and they were like, “Oh, OK, that’s seemingly very much like my employer plan. Sure, that sounds great. I know how to deal with that.” So that’s one of the things. And one cudgel that the insurers have is they say, “Oh, government, you’re going reduce our payments. We’re going to reduce the benefits and increase the premiums because we’re not going to have all of that extra government funding.” And that can scare the government because they don’t want the insurers to tell their patients, who are older patients who vote, “Oh, because of the government, we can no longer offer you all of these benefits, or we’ve had to raise your premium because of that.” So we’ll see if they actually do that.

Kenen: Joe Biden took away your gym, right?

Luhby: Exactly.

Rovner: [inaudible 00:22:11].

Luhby: And your dental benefits. So that’s always the threat that the insurers roll out. That’s the first thing that they say often, but we’ll see what happens. We don’t know yet until the fall, when enrollment starts, what will actually happen?

Rovner: We saw exactly that in the late ’90s after Congress balanced the budget. They took a big whack out of the payments for what was then, I think, called Medicare Plus Choice. It was the previous version of Medicare Advantage, and a lot of the companies just completely dropped out of the program. And a lot of the people, who as Joanne said, had been in those plants had been very happy, threw a fit and came to Congress to complain, and lo and behold, a lot of those payments got increased again. In fact, that was what led to the big increase in payments in 2003 was the huge cut that they made to payments, which drove a lot of the insurers out of the program. So we do know that the insurers will pack up and leave if they’re not paid what they consider to be enough to stay in the program.

Moving on. One of the things that Jeff Goldsmith talks about in this week’s interview is that our health system has become one of deep distrust between patients, providers, and insurers. Speaking of Medicare Advantage. That is sad and dysfunctional, except that sometimes there are good reasons for that distrust. One example comes this week from my KFF Health News colleague Julie Appleby. It seems that unscrupulous insurance brokers are disenrolling people in Obamacare plans from their health plans and putting them in different plans, which is unbeknownst to them until they find their doctor is no longer in their network or their drug isn’t covered.

The brokers who are doing this can earn bigger commissions. But patients can end up not just having to pay for their own medical care but owing the government money because suddenly they’re in plans getting subsidies that don’t match their incomes. It is a big mess. And it seems that the obvious solution, which would be making it harder for agents to access people’s enrollment information so they can switch them, would delay legitimate enrollment. It has to be easy for agents to basically manipulate people’s applications. So how do you guard against bad actors without inconveniencing everyone? This seems to be the question here and the question for Medicare Advantage, Lauren.

Weber: I was going to say, I mean, I think that’s the question Medicare itself has been dealing with for years. I mean, there’s a reason that many federal prosecutors call this a pay-and-chase situation in which there is rampant Medicare fraud. They prioritize the ease of patients accessing care to the disadvantage of some folks, or in this case, the American taxpayer, in this case, actual patients, being swindled.

But I don’t have an answer. I don’t think anyone really has an answer, considering we’re seeing things like the $2 billion catheter fraud that we’ve talked about here. So I think again, this is one of these things where the government’s been left a little flat-footed in trying to protect against bad actors.

Rovner: Yeah, well, the health sector is what a fifth of the economy now, so I guess it shouldn’t come as much of a surprise that you have not just bad actors, people who are making a lot of money from doing illegal things and find it to be worth their while and that some of them get caught, but presumably most of them don’t. I guess that’s what happens when you have that much money in one place, you need sort of better watchdogs. All right. Well, finally, this week in medical misinformation comes from PolitiFact in a story called “Four Years After Shelter-in-Place, Covid-19 Misinformation Persists.” That’s an understatement.

That last part was mine. At the top of the list says, “We have discussed before is growing resistance to vaccines in general, not just the covid vaccine,” which is not all that surprising considering how many people now believe fictitious stories about celebrities dropping dead immediately after receiving vaccines. There’s even a movie called “Died Suddenly.” Or that government leaders and the superrich orchestrated the pandemic. That’s another popular story that goes around. Or that Dr. Tony Fauci brought the virus to the United States a year before the pandemic. Lauren, health misinformation is your beat. Is it getting any better now that the pandemic is largely behind us, or is it just continuing unabated?

Weber: No, I would argue it’s possibly getting worse because the trust in institutions is at an all-time low. Social media has allowed for fire hose. I mean, it’s made everything … it’s made the public square that used to be more limited, all corners of the country.

I would say that misinformation has led to mistrust about basic medical things, including childhood vaccinations, but also other medical treatment and care. And I think you’re really seeing this kind of post-truth world post-covid, this distrust, this misinfo is going to continue for some time. And there’s too much to cover on my beat. There’s constantly stories around the bend, and I don’t expect that improving anytime soon.

Kenen: Every single time a celebrity, not just dies, because it’s always no matter what happens, it’s blamed on the covid vaccine, but also gets sick. I mean, Princess Kate. We don’t know everything about her health, but I mean, all of us know it wasn’t. Whatever it is, it’s not because the covid vaccine. But if you go online, you hear that that’s whatever she has it’s because she’s vaccinated.

And the other thing is it’s fed into this general vaccine mistrust. So when I wrote about the RSV vaccine, which we talked about a few weeks ago, it wasn’t so much that there’s a campaign against the RSV vaccine. There is somewhat of that. But it’s just this massive, “vaccines are bad.” So it’s spilling over into anything with a needle attached is part of this horrible plot to kill us all. So it’s just sort of this miasma of anti-vaccination that’s hovering over a lot of health care.

Rovner: Well, at the risk of getting a little too bleak, that will be the news for this week. Now, we will play my interview with Jeff Goldsmith, and then we’ll come back and do our extra credits. I am pleased to welcome back to the podcast Jeff Goldsmith, one of my favorite big-picture health system analysts. Jeff has been writing of late about the Change Healthcare hack and the growing size and influence of its owner, UnitedHealth Group, and what that means for the country’s entire health enterprise. Jeff, thanks for joining us again.

Jeff Goldsmith: You bet.

Rovner: So the lead of your latest piece gives a pretty vivid description of just how big United has become, and I just want to read it. “Years ago, the largest living thing in the world was thought to be the blue whale. Then someone discovered that the largest living thing in the world was actually the 106-acre, 47,000-tree Pando aspen grove in central Utah, which genetic testing revealed to be a single organism.

With its enormous network of underground roots and symbiotic relationship with a vast ecosystem of fungi, that aspen grove is a great metaphor for UnitedHealth Group. United, whose revenues amount to more than 8% of the U.S. health system, is the largest health care enterprise in the world.” Let’s pick up from there for people like me who haven’t been paying as much attention as maybe they should have, and still think that United is mainly a health insurance company. That is not true and hasn’t been for some time, has it?

Goldsmith: The difference between United and a health insurance company is that it also has $226 billion worth of care system revenues in it, some of which are services rendered to United and other, believe it or not, services rendered to United competitors. So, there isn’t anything remotely that size in the health insurance world. That $226 billion is more than double the size of Kaiser. Just to give you an idea of the scale.

Rovner: Which, of course, is the other companies that are both insurers and providers. That’s pretty much the only other really big one, right?

Goldsmith: Yes. I have a graphic in the piece that shows the Optum Health part, which is the care delivery part of Optum, is just about the same size as Kaiser, but it generates six and a half billion dollars in profit versus Kaiser’s $323 million. So it dwarfs Kaiser in terms of profitability even though it’s about the same size top line.

Rovner: So split it up for people who don’t know. What are sort of the main components that make up UnitedHealth Group?

Goldsmith: Well, there’s a very large health insurance business, $280 billion health insurance business. Then, there is a care system called Optum Health, which is about $95 billion. It has 90,000 affiliated or employed docs, a huge chain of MedExpress urgent care centers, surgery centers, a couple of very large home health care agencies. So that’s the care delivery part of United.

There’s Optum Insight, which is about $19 billion. That’s the part that Change Healthcare was inside of. It’s a business intelligence and corporate services business, and consulting business, that also manages care systems financials. And then, finally, there’s Optum Rx, which is about $116 billion, so a little bit more than half of Optum’s total, and that is a pharmacy benefit management company. Believe it or not, the third-largest one. So there are bigger pharmacy benefits management companies than Optum, but those are the three big pieces.

Rovner: I feel like this is almost as big as a lot of the government health programs, isn’t it?

Goldsmith: Yeah. I mean, I can’t remember top line how big the VA [Department of Veterans Affairs] is these days, but it’s VA scale, but it’s in a bunch of little pieces scattered all over the United States. I mean, that’s the big part of all of this. The care system is in at least 30 states. I have a map showing where some of the locations are. That map took me months to find. There isn’t a real registry of what the company owns, but it is a vast enterprise. And they’re great assets, if you’ll pardon a financial term for them.

Some of the finest risk-bearing multispecialty group practices in the United States are a part of Optum: Healthcare Partners based in Los Angeles; The Everett Clinic; the former Fallon Clinic, and Atrius in New England, which are the two finest risk-bearing, multispecialty physician groups in the Northeast. They weren’t dredging the bottom here at all. They got a tremendous number of high-quality groups that they’ve pulled together in the organization. The issue is it really an organization or is it a collection of assets that have been acquired at a very rapid pace over a period of the last 15 years.

Rovner: One of the things that I think the Change Healthcare hack proved for a lot of people is that nobody realized what a significant percentage of claims processing could go through one company. You have to wonder, have regulators, either at the state or federal level, kind of fallen down on this and sort of let this happen so that when somebody hacks into it, half the system seems to go down?

Goldsmith: The federal government challenged the Change acquisition and basically lost in court. They were unable to make the case. They were arguing that Change controlling all of these transactions of not only United but a lot of other insurers gave them access to information that enabled United to have some type of unfair competitive advantage. It was a difficult argument to make that didn’t make it. But the result of the Change acquisition was that about a third of the U.S. health system’s money flowed through one company’s leaky pipes.

And what we’re sort of learning as we learn more about Change is that there were something like a hundred separate programs inside Change, all of which somehow were vulnerable to this hack. And I think that’s one of the things that I think when [Sen.] Ron Wyden and [Sen.] Mark Warner get around to getting some facts about this, they’re going to wonder how did that happen. How could you have that many applications, that loosely tied together, that they were vulnerable to something like this?

And what my spies tell me is that a hacker, and it could have been a single hacker, not a country, but one guy was able to drop down into all of those data silos, vacuum out the data, and then delete the backups, so that United was basically left with no claims trail, no provider directories, nothing, and has had to reconstruct them; panicky reconstruction here in the last six weeks.

Rovner: Which I imagine is what’s taking so long for some of these providers to get back online.

Goldsmith: Julie, the part I don’t understand, is if it is true that that Change was processing a trillion and a half dollars worth of claims a year, a month interruption is $125 billion. That’s $125 billion that didn’t get paid to providers of care after the fact of them rendering the care. So the extent of the damage done by this is difficult to comprehend.

I mean, I have a lot of provider contacts and friends. Some of them, believe it or not, had no Change exposure at all because their main payers didn’t use Change. Some of them, it was all their payers used, and cash flow just ceased, and they had to go to the bank and borrow money to make their payrolls. None of this, for some reason, has made it in its full glory out into the press, and it isn’t that there aren’t incredibly high-quality business reporters in this field. There are.

Rovner: I know. I live in Maryland. I’ve driven over the Francis Scott Key Bridge in Baltimore. I know what it means. I mean, basically took apart the Baltimore Beltway. I mean, no longer goes in a circle. And I know how big the Port of Baltimore is, and I feel like everybody can understand that because it’s visceral. You can see it. There’s video of the bridge falling down. There isn’t video of somebody hacking into Change Healthcare and stopping a lot of the health system in its tracks.

Goldsmith: The metaphor that occurred to me, as you know, I’m a metaphor junkie, was actually Deepwater Horizon, and of course, we had a camera on that gushing well the whole time. This is like a gusher of red ink, a Deepwater Horizon-sized gusher of red ink that went on for a month. From what I’m able to understand, people are able to file the claims now. How many people have actually been paid for the month or six weeks’ worth of work they’ve done is elusive. And I still don’t have access to really good facts on how much of what they owed people they’ve actually paid.

I do know a lot of my investor analyst friends are waiting for United’s first-quarter financials to drop, which will probably show a four- or five-day drop in their medical loss ratio because of all the claims they were not able to pay, and therefore money was sitting in their coffers earning, what, 5% interest. That’s going to be kind of a festival when the first-quarter financials drop. And, of course, it isn’t just United, Humana, the Elevance, Cigna, all the rest of them. A lot of these folks use Change to process their claims. So there’s going to be a swollen offer here on the health insurance side from a month of not paying their bills.

Rovner: Well, is it the next Standard Oil? Is it going to have to be taken apart at some point?

Goldsmith: Yeah, but I mean, the question is, on what basis? Our health care system is so vast and fragmented, even a generous interpretation of antitrust laws, you’d have trouble finding a case. The Justice Department or FTC [Federal Trade Commission] is going to try again. But I’ll tell you, I think they’ve got their work cut out for them. I think the real issue isn’t anti-competitiveness, it’s a national security issue. If you have a third of the health systems dollars flowing through one company’s leaky pipes, that’s not an antitrust problem. It’s a national security problem, and I think there are some folks in the U.S. Senate that are righteously pissed about this.

There’s a lot of fact-finding that needs to happen here and a lot of work that needs to be done to make this system more secure. And I’ve also argued to make it simpler. Change was processing 15 billion transactions a year. That’s 44 transactions for every man, woman, and child in the country, and that was only a third of them. What are we doing with 100 billion transactions? What’s up with that? It beggars the imagination to believe that we to minutely manage every single one of those transactions. That is just an astonishing waste of money. It’s also an incredible insult to our care system. The assumption that there at any moment, every one of those folks could potentially be ripping us off, and we can’t have that.

Rovner: So we’re spending all of this money to try and not be ripped off for presumably less money.

Goldsmith: Hundreds of billions of dollars, but who’s counting?

Rovner: It’s kind of a depressing picture of what our health system is becoming, but I feel like it is kind of an apt picture for what our health system has become.

Goldsmith: It’s the level of mistrust. The idea that every one of his patients is trying to get a free lunch, and every doctor is trying to pad his income. We’ve built a system based on those twin assumptions. And when you think about them for a minute, they really are appalling assumptions. Most of what motivated me when I had cancer was fear.

I wasn’t trying to get stuff I wasn’t entitled to or didn’t need. I wanted to figure out a way to not be killed by the thing in my throat. And my doctors were motivated by a fear that if they let me go, maybe my heirs would sue them. I guess this idea that we are just helpless pawns of a behaviorist model of incentives, I think the economists ran wild with this thesis. And I think it’s given us a system that doesn’t work for anybody.

Rovner: Is there a way to fix it?

Goldsmith: I think we ought to cut the number of transactions in half. We ought to go and look at how many prior authorizations are really needed. Is this a model we really want to continue with, effectively universal surveillance of every clinical decision? We ought to be paying in bundles. We ought to pay our primary care physicians monthly for every patient that they see that’s a continuing patient and not chisel them over every single thing they do. We ought to pay for complex care in bundles where a cancer treatment is basically one transaction instead of hundreds.

I think we could get a long way to simplifying and reducing the absurd administrative overburden by doing those things. I also think that the idea that we have 1,100 health insurers. United’s the biggest, but it’s not by any means the only health insurer. There’s 1,100 rule sets that determine what data you need in order to pay a claim and whether a claim is justified or not. I think that’s a crazy level of variation. So I think we need to attack the variation. We’ve had health policy conversations about this for years and not done anything, and I think it’s really time to do it.

Rovner: Maybe this will give some incentive to some people to actually do something. Jeff Goldsmith, thank you so much.

Goldsmith: Julie. It’s good talking to you.

Rovner: OK. We are back, and time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Tami, you’ve already done yours this week. Lauren, why don’t you go next?

Weber: Yeah. I think we’re all keeping an eye on this in this podcast, but the title of this story is “Bird Flu Detected in Dairy Worker Who Had Contact With Infected Cattle in Texas,” which was written by my colleagues, Lena Sun and Rachel Roubein. Also, great pieces by Helen Branswell in the Texas Tribune on this as well.

But, essentially, just so listeners know, there has been a case of human bird flu detected, which is very concerning. As all of us on this podcast know, avian human flu is one of the worst-case scenarios in terms of a pathogen and infectiousness. As of right now, this is only one person. It seems to be isolated. We don’t know. We’ll see how this continues to mutate, but definitely something to keep an eye on for potential threat risk. TBD.

Rovner: Yeah. It is something I think that every health reporter is watching with some concern. Although, as you point out, we really don’t know very much yet. And so far, we have not seen. I think what the experts are watching for is human-to-human transmission, and we haven’t seen that yet.

Kenen: And this person seems to have a mild case, from the limited information we have, which is also a good sign for both that individual and everybody else in terms of spreadability.

Rovner: But we will continue to watch that space. Joanne.

Kenen: Well, you said enough bleak, but I’m afraid this is somewhat bleak. This is a piece by Kate Martin from APM Reports, which is part of American Public Media, and it was published in cooperation with The 19th, and the headline is “Survivors Sidelined: How Illinois’ Sexual Assault Survivor Law Allows Hospitals to Deny Care.” So there’s a very, very strong sort of everybody points to it as great law in Illinois saying that what kind of care hospitals have to provide to sexual assault victims and what kind of testing and counseling and everything. This whole series of services that legally they must do, and they’re not doing it. Even in cases of children being assaulted, they’re sending people 40 miles away, 80 miles away, 40 miles away. They’re not doing rape kits. They’re not connecting them to the counselors, et cetera. It is a pretty horrifying story. It begins with a story of a 4-year-old because they didn’t do what they were supposed to do. The father was the suspected perpetrator, and because the hospital didn’t do what they should have done he still has joint custody of this little girl.

Rovner: My story this week is from our podcast colleague, Alice [Miranda] Ollstein, and her Politico colleague, Megan Messerly, and it’s called “Republicans Are Rushing to Defend IVF. The Anti-Abortion Movement Hopes to Change Their Minds.” And it’s about the fact that while maybe not trying to outlaw IVF entirely, the anti-abortion movement does want to dramatically change how it’s practiced in the U.S.

For example, they would like to decrease the number of embryos that can be created and transplanted, both of which would likely make the already expensive treatment even more expensive still. Anti-abortion activists also would like to ban pre-implantation genetic testing so that, “Defective embryos can’t be discarded.” Except that couples with genes for deadly diseases often turn to IVF exactly because they don’t want to pass those diseases on to their children, and they would like to test them before they are implanted.

In other words, the anti-abortion movement may or may not be coming for contraception, but it definitely is coming for IVF. 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, @jrovner, or @julierovner at Bluesky and @julie.rovner at Threads. Tami, where can we find you?

Luhby: I’m at cnn.com.

Rovner: There you go. Joanne.

Kenen: @JoanneKenen on X, and @joannekenen1 on Threads. 

Rovner: Lauren.

Weber: @LaurenWeberHP on X

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

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En enero, Susanne Gilliam, de 67 años, estaba yendo a recoger el correo afuera de su casa cuando se cayó al resbalar sobre una capa de hielo negro.

Sintió una punzada de dolor en la rodilla y el tobillo de la pierna izquierda. Después de llamar a su marido por teléfono, logró regresar a su casa con dificultad.

Y así comenzó el vaivén interminable que tantas personas enfrentan cuando tienen que navegar el desorganizado sistema de salud de Estados Unidos.

El cirujano ortopédico de Gilliam, que la había tratado antes por problemas en la misma rodilla, la vio esa tarde pero le aclaró: “Yo no me ocupo de tobillos”.

La derivó a un especialista en tobillos que ordenó nuevas radiografías y una resonancia magnética. Gilliam pidió hacerse las pruebas en un hospital cerca de su casa en Sudbury, Massachusetts, que le resultaba más conveniente. Pero cuando llamó para pedir una cita, el hospital no tenía la orden del doctor, que finalmente llegó después de varias llamadas más.

Coordinar la atención que necesita para recuperarse, incluyendo sesiones de fisioterapia, se convirtió en un trabajo de medio tiempo para Gilliam. (Los terapeutas trabajan solo en una parte del cuerpo por sesión, y por lo tanto Gilliam requiere visitas separadas para su rodilla y su tobillo, varias veces a la semana).

“El peso de organizar todo lo que necesito es enorme”, dijo Gilliam. “Te queda una sensación de agotamiento físico y mental”.

En algunos casos, las deficiencias del sistema de salud son el precio que se paga por avances extraordinarios en el campo de la medicina. Pero también ponen en evidencia las incoherencias entre las capacidades de los adultos mayores y las demandas del sistema.

“La buena noticia es que sabemos mucho más y podemos hacer mucho más por las personas con distintas afecciones”, dijo Thomas H. Lee, director médico de Press Ganey, una consultoría que hace seguimiento de las experiencias de los pacientes con el sistema de salud. “La mala noticia es que el sistema se ha vuelto tremendamente complejo”.

Esto se agrava por las múltiples guías para tratar afecciones, la super especialización médica, y los incentivos financieros que hacen que los pacientes reciban cada vez más atención, dijo Ishani Ganguli, profesora asociada en la Escuela de Medicina de Harvard.

“No es raro que pacientes mayores tengan tres o más cardiólogos que les programan citas y pruebas regulares”, dijo. Si alguien tiene varios problemas de salud (por ejemplo, enfermedades cardíacas, diabetes y glaucoma), las interacciones con el sistema se multiplican.

Ganguli es la autora de un nuevo estudio que muestra que los pacientes de Medicare dedican aproximadamente tres semanas al año a hacerse pruebas médicas, ver a doctores, someterse a tratamientos o procedimientos médicos, buscar atención en salas de emergencia o pasar tiempo en el hospital o en centros de rehabilitación. (Los datos son de 2019, antes de la pandemia de covid, que alteró   los patrones de atención médica. Cada servicio recibido se contó como un día de contacto con el sistema de salud).

El estudio determinó que poco más de 1 de cada 10 personas mayores, incluyendo las que se estaban haciendo controles o recuperándose de enfermedades graves, pasaban más tiempo recibiendo atención médica: al menos 50 días al año.

“Hay aspectos de esto que son muy beneficiosos y valiosos para las personas, pero hay otros que son menos esenciales”, dijo Ganguli. “No hablamos lo suficiente sobre lo que les pedimos a los adultos mayores que hagan, y si tiene sentido”.

Victor Montori, profesor de medicina de la Clínica Mayo en Rochester, Minnesota, lleva muchos años advirtiendo sobre lo que llama la “carga de tratamiento” que enfrentan los pacientes.

Esto incluye el tiempo que dedican a recibir atención médica, programar citas, encontrar transporte para las visitas médicas, obtener y tomar medicamentos, comunicarse con las aseguradoras, pagar facturas médicas, monitorear su salud en casa y seguir consejos como cambios en la dieta.

Hace cuatro años, en un artículo titulado “¿Se siente mi paciente agobiado?”, Montori y sus colegas descubrieron que el 40% de los pacientes con enfermedades crónicas como asma, diabetes y trastornos neurológicos “sentían que su carga de tratamiento era insostenible”.

Cuando la carga de tratamiento es excesiva, las personas dejan de seguir las recomendaciones médicas y dicen que su calidad de vida empeora, según los investigadores. Los adultos mayores con múltiples afecciones médicas y bajo nivel de educación son especialmente vulnerables, ya que experimentan inseguridad económica y aislamiento social.

El uso cada vez más frecuente de sistemas telefónicos digitales y portales electrónicos para pacientes en los consultorios y la falta de tiempo por parte de los doctores profundizan las barreras. “Cada vez es más difícil para los pacientes acceder a doctores que puedan pasar tiempo con ellos, para ayudarlos a resolver problemas y responder sus preguntas”, dijo Montori.

Mientras tanto, los médicos rara vez preguntan a los pacientes sobre su capacidad para realizar las tareas que se les pide. “A menudo tenemos poca idea de qué tan compleja es la vida de nuestros pacientes”, escribieron médicos en un informe de 2022 sobre cómo reducir la carga de tratamiento.

Un ejemplo es lo que vivieron Jean Hartnett, de 53 años de Omaha, Nebraska, y sus ocho hermanos después que su madre de 88 años sufriera un derrame cerebral en febrero de 2021, mientras hacían compras en Walmart.

En ese momento, su madre estaba cuidando al padre de Hartnett, quien sufría de una enfermedad renal y necesitaba ayuda con las tareas diarias, como ducharse o ir al baño.

Durante el año posterior al derrame cerebral, los padres de Hartnett, ambos trabajadores agrícolas extremadamente independientes que vivían en Hubbard, Nebraska, sufrieron varios achaques y las crisis médicas se volvieron comunes.

Cuando un médico cambiaba el plan de atención de su mamá o su papá, eran necesarios nuevos medicamentos, suministros y equipos médicos, y programar nuevas sesiones de terapia ocupacional, física y del habla.

Ninguno de los padres podía quedarse solo si el otro necesitaba atención médica.

“No era inusual para mí estar llevando a uno de mis padres a su casa después del hospital o de la visita al médico y pasar una ambulancia o un familiar transportando al otro al doctor”, explicó Hartnett. “Se necesitaba muchísima coordinación”.

Hartnett se mudó a la casa de sus padres durante las últimas seis semanas de vida de su padre, cuando  los médicos decidieron que estaba demasiado débil como para someterse a diálisis. Falleció en marzo de 2022. Su madre murió meses después, en julio.

Entonces, ¿qué pueden hacer los adultos mayores y sus cuidadores y familiares para aliviar la carga de la atención médica?

Para empezar, es importante sincerarse  con el médico si el plan de tratamiento que recomienda no resulta factible, y explicarle por qué, dijo Elizabeth Rogers, profesora asistente de medicina interna en la Escuela de Medicina de la Universidad de Minnesota.

Recomendó preguntar sobre cuáles intervenciones serían las más importantes para mantenerse saludable y cuáles podrían ser prescindibles.

Los médicos pueden ajustar los planes, suspender los medicamentos que no producen beneficios significativos y programar visitas virtuales, en caso de que las personas puedan manejar la tecnología necesaria (muchos adultos mayores no pueden).

Pregunte también si un asistente de pacientes (también llamados navegadores) puede ayudarle a programar varias citas y exámenes en el mismo día, para minimizar la carga de ir y venir de los centros médicos. Estos profesionales también pueden ayudarlo a conectarse con recursos comunitarios, como servicios de transporte. (La mayoría de los centros médicos tienen personal de este tipo, pero los consultorios médicos no).

Si no entiende cómo hacer lo que su médico pide, pregunte: ¿Qué implicaría esto de mi parte? ¿Cuánto tiempo llevaría? ¿Qué necesitaré? Y pida materiales escritos, como guías de autocontrol del asma o la diabetes, que puedan ayudarle a comprender mejor los requisitos.

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

USE OUR CONTENT

This story can be republished for free (details).