KFF Health News held a web event Thursday that discussed how the lessons from the victory over smallpox could be applied to public health challenges today. The online conversation was led by Céline Gounder, physician-epidemiologist and host of “Eradicating Smallpox,” Season 2 of the Epidemic podcast.

Gounder was joined by:

Helene Gayle, a physician and epidemiologist, is president of Spelman College. She is a board member of the Bill & Melinda Gates Foundation and past director of the foundation’s HIV, tuberculosis, and reproductive health program. She spent two decades with the Centers for Disease Control and Prevention focusing primarily on HIV/AIDS prevention and global health.

William “Bill” Foege was a leader in the campaign to end smallpox during the 1970s. An epidemiologist and physician, Foege led the CDC from 1977 to 1983. He appears in the virtual learning series “Becoming Better Ancestors: Applying the Lessons Learned from Smallpox Eradication.” Foege is featured in Episode 2 of the “Eradicating Smallpox” docuseries.

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Transcript: Thinking Big in Public Health, Inspired by the End of Smallpox

Note: This transcript was generated by a third-party site and may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the web event. 

TRANSCRIPT  

[The video trailer for season 2 of the Epidemic podcast, “Eradicating Smallpox,” begins to play] 

Céline Gounder: Bangladesh 50 years ago, we were on the cusp of something big, something we had never done before. We were about to wipe smallpox off the planet. It’s one of humanity’s greatest triumphs. One public health has yet to repeat. I’m Dr. Celine Gounder. I’m a physician and epidemiologist. 

This season of Epidemic, we’re going to India and Bangladesh, where smallpox made its last stand, to understand how health workers beat the virus. The question I’m asking, “How can we dream big in public health again?” From KFF Health News and just human productions, Epidemic, eradicating smallpox. Listen wherever you get your podcasts. 

[Video trailer ends]  

Céline Gounder: Good morning everyone, and thanks for joining us today. I’m Dr. Celine Gounder. I’m editor-at-large for Public Health at KFF Health News and I’m the host of the Epidemic Podcast. In today’s conversation, we’re going to talk about lessons to be learned from the eradication of smallpox and how those can be applied to public health challenges today. The eradication of smallpox is one of humanity’s greatest triumphs. Many doctors and scientists thought it was impossible to eliminate a disease that had lasted for millennia and killed nearly one in three people infected. Smallpox remains the first and only human disease to be wiped out globally. 

Just a few logistical details before we get started. The briefing is being recorded and the link to the recorded version will be emailed to everyone later today. We also have ASL interpretation available. To access it, please click on the globe icon in your Zoom control panel and select ‘American Sign Language.’ A screen will appear and you will be able to view the interpreter. Questions should be entered using the Q&A function on Zoom and can be sent in during the discussion. 

I’d like to move forward with introducing our panelists today. Dr. Bill Foege is an epidemiologist and physician and was a leader in the campaign to end smallpox during the 1970s. Foege is featured in episode two of the Eradicating Smallpox docuseries, and he’s also featured in the Nine Lessons series produced by the Becoming Better Ancestors Project. The Nine Lessons, available at ninelessons.org, is a virtual learning series about how the lessons from smallpox eradication could be applied to COVID and other public health and societal challenges. 

Also, joining us today is Dr. Helene Gayle, who’s also an epidemiologist and physician. She’s the president of Spelman College. She’s also a board member of the Bill & Melinda Gates Foundation and past director of the Foundation’s program on HIV, Tuberculosis and reproductive health. She spent two decades with the Centers for Disease Control and Prevention, focusing primarily on HIV AIDS prevention and Global Health. 

So welcome and thank you for joining us today, Bill and Helene. I’d like to start with talking about some of the challenges we face in science communication. And as we’ve seen during the COVID pandemic, one of the big challenges is balancing reassurance with uncertainty. And before I ask you my questions, I’m going to play a clip of Dr. Tony Fauci speaking about this as part of the Nine Lessons series. So let’s give that a listen. 

[Video clip from the Nine Lessons series begins to play] 

Tony Fauci: If you have a static situation with nothing changing and you get one opinion one day, and then a week later you change, that’s flip-flopping. When you have a dynamic situation that’s evolving week to week and month to month, as a scientist, to be true to yourself and to be true to the discipline of science, you have to collect data as the situation evolves, which almost invariably will necessitate your changing policy, changing guidelines, changing opinion. And that’s exactly what happened with things like mask wearing. We didn’t know until weeks and weeks into the outbreak that a lot of the transmission was by people who were without symptoms. It was that that made the CDC and all of us say, “We really don’t need to be wearing masks.” As soon as we found out that, A, there was no shortage, B, we were getting good data, that outside of the hospital setting masks did work, and three, we found out that 50% of the infections were transmitted from someone who had no symptoms. When you put all those three things together, then the science tells us everybody should be wearing a mask. 

[Video clip ends]  

Céline Gounder: Bill, how did this play out in the smallpox eradication program, specifically this idea of scientific certainty, uncertainty, and science communication? 

Bill Foege: This is actually a balance that goes far beyond public health and medicine and almost everything we do. And on the one hand, you have to have enough certainty in order to get other people to follow you. There’s a book by Gary Wills on Leadership, and it’s entitled Certain Trumpets. He takes this from the Bible verse that says, “If you hear an uncertain trumpet, who would gird for battle?” 

So you have to have enough certainty. The other side of that though is Richard Feynman, the physicist who said, “Certainty is the Achilles heel of science.” If we believe something is true, we stop looking for other answers to why this is happening. And I think in smallpox, we always tried to present certainty in what we were doing. And all the time we worried about what could go wrong, what if we lose political support? I didn’t see HIV coming, but boy, if I had, that would’ve been a big problem to deal with. 

Céline Gounder: Helene, don’t you think public health officials should still be confident in expressing, particularly in an emergency, what we know and their recommendations for managing a public health crisis, and how do you balance that confidence and reassurance with the lack of certainty? 

Helene Gayle: So I think, and building on some of the things that Bill said, I think part of it is building the confidence in the communicator. And I think one of the things, and I point to Tony Fauci, is one of those people who I think Americans developed a sense of confidence with him because of his willingness and ability to say when we were wrong and what we know and when we knew it. And so I think recognizing that a lot of this is about building trust and building trust in the message as well as in the messenger. I think that’s where some of the ability to be confident, letting people know that you’re trying to give them the information as soon as you have it, but also being honest that this is evolving. 

A message is just a slice in time. And I think it’s important that we remember that we’re creating a narrative every time we open our mouths and thinking about what’s the narrative that we’re creating and being consistent in that narrative. So I think the consistency, building that trust, being able to say what you know and what you don’t know is what really I think builds the confidence in the messages. I think what we saw through this pandemic as well, the COVID pandemic as well as past, are people who are unwilling to admit what they know and what they don’t know, unwilling to go back and explain why we said something when we said it and why we’re making that explanation of why we’re now changing, as I think Tony Fauci did very clearly about mask wearing. 

So I think all of those things that really are about building trust and confidence are what can make us better in our communication as public health officials. 

Céline Gounder: So it still amazes me that the global health community decided to take on smallpox eradication. We often hear about sustainability, cost-effectiveness, those kinds of economic concepts. What does it mean, Helene, for a program to be sustainable? And when we say sustainable, for whom? 

Helene Gayle: Well, I think what we hope when we talk about sustainability is that efforts that are important for the short run can be sustained over the long run. And I think what we see so often in public health is that we have this massive surge of resources, personnel, effort, that then we let go of in between times. 

So each time we have a pandemic, we have to create this big surge all over again. What we need in public health is to be able to have that kind of long-term, sustainable approach, understanding that there will be times when we have to have those surges, but not letting everything go in between time. When you say for whom, it’s really about how do we create a system and have a system that is in place that gets us not only at the times of great need and crisis, but is there for the public’s health for the long-term. And that’s what I hope we can move to as we think about public health in America and around the world. 

Céline Gounder: Bill, does that sound like that’s a “sustainable goal” and should we be setting our public health goals based on what some think is sustainable or not? 

Bill Foege: Well, sustainability is a problem that I often had because people require evidence of sustainability before they’ll fund something, but you don’t know what is sustainable until you try and do it. One of the lessons that I learned in the seventies was, in this country, the appropriations for measles would go up when there were lots of measles cases and they would go down when cases were reduced. 

And inevitably, when they would go down, then the numbers had come up again. And so we had these variations. And we made a decision in the 1970s what would happen if we could interrupt transmission once, and that changes everything. Now the norm would be no transmission, and you could sustain the appropriations and it worked. We finally did that. So sustainability is something that bothers me. The pragmatists demand this, and I understand where they’re coming from, but there was a fellow by the name of Harlan Cleveland who was an American diplomat. He was our ambassador to NATO for many years. And late in his life, he became interested in global health and he was astonished at what happened with so few resources. And he came to the conclusion that global health workers are fueled on unwarranted optimism. And I like that phrase, because that is in fact what we do, is we become very optimistic and we make something happen that could not have been foreseen, that it would happen. 

Céline Gounder: So this also reminds me about a conversation we had on the podcast with, believe it or not, a science fiction writer. Her name is adrienne maree brown, and we spoke with her about how she imagines world’s, possibilities different from our own. So let’s hear a short clip of that now. 

Where do you find the inspiration to think up, to dream up the world’s that are so wildly different from our present reality? 

[Audio clip from episode 1 of the “Eradicating Smallpox” begins to play] 

adrienne maree brown: Saying that stuff is just the way it is. That’s one of the greatest ways that those who currently benefit from the way things are keep us from even imagining that things could be different. For centuries in this country, we were told that slavery was just the way things are and that it could never be any different. And yet there are people in those systems who said, “This isn’t right, this isn’t fair. Something else is actually possible.” 

So a lot of the work of radical imagination, for me, is the work of saying, can we imagine a world in which our lives actually matter and we structure our society around the care that we can give to each other, the care that we need. 

[Audio clip ends]  

Céline Gounder: Bill, you just talked about unwarranted optimism and you told me once, in fact, I think more than once to bet on the optimist. But to go back to what you were saying about the pragmatist, doesn’t it make more sense on some level to be pragmatic and realistic if you want to get things done? And how would realism have gotten in the way of efforts to eradicate smallpox? 

Bill Foege: Well, I think realism would have kept us from trying many things that we’ve tried. And the clip you just showed about an imagination that goes beyond realism is so important. If I would be director of CDC again, if I had a problem, I would try to get six comedians to come to CDC and I present them with the problem because they think in a different world than realism. And so I think it just makes sense to be unrealistic that we can do these things. 

Céline Gounder: Helene, what about you? How did you balance thinking big versus being pragmatic when you were leading public health programs over the course of your career? 

Helene Gayle: Well, I didn’t bring in comedians, but I think maybe I missed the boat on that. I love that idea. I like to think that I was able to combine the two. I think if you don’t think big, you will only achieve small progress. So I think you have to have big goals, but big goals can also be chunked into bite-sized pieces. So I think mixing the practical of what are the short-term games that are necessary to get to those big goals, both, give you a sense of what’s pragmatic and possible, but also keeps you inspired towards the bigger goal. 

I think it’s also the case in public health where oftentimes we are operating with very difficult political situations. And again, sometimes you have to be the realist and understand what the limits are, but at the same time not give up on what’s your ultimate goal, what’s your ultimate vision, and keeping that front and center, it’s incredibly important, particularly as we think about how we inspire, back to the unwarranted optimism, how we inspire public health workers to keep going. People don’t get inspired by the short term, “Did I get my stock in today?” They get inspired by, “I’m part of eradicating a disease or stopping a pandemic.” So I think we have to combine the two. 

Bill Foege: I might say that in India, we would have a meeting every month in the endemic states and go over what we had learned that month, and we would end the meeting by setting goals for the next month. We never once reached those goals until the last month. They were always beyond what we could do, but they gave us a vision of what we hoped we could do. 

Céline Gounder: So this also reminds me of another aspect of goal setting. In another episode of the podcast, we spoke with a global health expert, Dr. Madhu Pai at McGill University, and he pointed out that historically it’s been white men in Europe and in the United States who’ve really driven the agenda in global health. Here’s just a short clip from Madhu. 

[Audio clip from episode 2 of the “Eradicating Smallpox” begins to play] 

Madhukar Pai: We need to flip the switch and recenter global health away from this, what I call default settings in global health, to the front lines. People on the ground, people who are Black, indigenous, people who are in communities, people who are actually dealing with the disease burden, people who are dying off it, people who have actually lived experience of these diseases that we’re talking about, having them run it is the most radical way of re imagining and shifting power and global health. 

[Audio clip ends]  

Céline Gounder: So Bill, who set the smallpox eradication goals? Was this local or global experts or both? Was it local communities and how were those different perspectives weighed and balanced in the program? 

Bill Foege: Well, the global goal was set by WHO. It was originally conceived by the Soviet Union and presented to WHO, and it got only three votes the first time. Later, when the Soviet Union and the United States combined their efforts, they were able to convince the World Health Assembly and WHO took this on. So the global goal was set by WHO, but countries had the ability to say no. And Ethiopia went for a long time not becoming part of the program, they had other priorities. And these are legitimate priorities that World Bank once had a discussion on whether we should get into polio eradication or not. And I agreed to be part of the debate, even though I hate debates. I agreed to be part because I wanted to know what were the strongest arguments against polio eradication. And for me, there were two of them. 

One was that this would distract from other global health efforts. People would focus on this. But the other one came from an African leader who said, “This is neocolonialism. You’re telling us how to spend our money on a disease problem and not allowing us to make that decision.” My counter to that was, “I understand that, but I also understand when Gandhi said his idea of the golden rule was that he should not be able to enjoy what other people could not enjoy.” And so I said, “If I can enjoy the fact that my children, my grandchildren, and now my great-grandchildren are free of polio, I have an obligation as a parent to share that with everyone.” 

Céline Gounder: Helene, very often it’s scientific experts, physicians, epidemiologists who really lead the goal setting. Is there anything wrong with this technocratic approach to public health goal setting, and isn’t that just “following the science?” 

Helene Gayle: Well, it’s obviously following the science at a macro level, but I think, while it’s important to set these global goals and these big overarching goals, it’s also very important to listen to the people whose health we’re actually trying to have an impact on. And I can remember, during the HIV pandemic, where once people realized how important it was to mobilize resources, there was an unprecedented amount of resources available for HIV, and we got from several countries around the world, the pushback just as Bill was talking about, because they said, “Malaria is a bigger problem for me. We have more people who die from malaria, from measles, from other infectious diseases. So where are our resources for the things that are making the biggest difference for our people?” 

So I think it’s great to set the global goals and to be able to have these big overarching goals, but we can’t do that in the absence of also listening to the national and local needs and making sure that we’re thinking flexibly about how we use our resources so that what we do really meets the greatest needs of people on the ground. 

Céline Gounder: Bill, you once quoted Einstein to me who said, “Perfection of means and confusion of goals seem, in my opinion, to characterize our age.” So are government officials and public health leaders somehow confused about public health goals while being overly focused on perfecting public health tools? 

Bill Foege: I think so. You can’t stop scientists from trying to enlarge their area of knowledge. This is what scientists do. They try to figure out what is right and what is wrong. And so yes, we do confuse this. And it doesn’t matter whether you’re talking about a person, a state, a nation or the world, we devalue health until the day we lose it, and then suddenly it becomes so important. And so this idea of conveying what should happen ahead of time so we don’t lose health is problematic. But yes, it’s much easier to concentrate on the specifics and lose our sight of where we’re actually going with this. 

Céline Gounder: Can you just give an example of this attempt to perfect a public health tool? 

Bill Foege: Well, with vaccines, you see that people keep improving the vaccines, but don’t improve how to get them to everyone. The clip you showed on white people, mainly white men, making the decisions on global health in the past, is so true. And I’ve just finished reviewing the history of global health, and I think the one thing that was most destructive of global health was colonialism. Some people try to justify it on the basis of it brought new science and so forth, but just think of this country and the fact that colonialism killed off so many people that the slave trade became so important. 

And so today, we’re still operating with the effects of colonialism in this hemisphere. Not seeing the vision of the big goal and concentrating on small things, it’s easier for all of us to do. 

Céline Gounder: Helene, do you agree that public health officials are confused about the goals? And if so, why and how? 

Helene Gayle: Well, I think it’s hard to talk about public health officials as a monolith, and it’s part of the challenge, particularly in this country, is that we have such a disjointed public health system. And I think we would benefit from having a much different public health system, such that people can individualize their roles, what they want to focus on, et cetera. But at a national level, and I would argue even at the global level, that there is a system that is consistent about what’s most important and what’s most important to deliver on. 

So I do think that there’s a lot of inconsistency in our system. I think we have a fragmented public health system, and we would really benefit by having something that really had a much more of a network that is coordinated than what we have today. 

Céline Gounder: I just got back actually from vacation in Morocco and I happened to be staying in the Medina in Marrakesh the night of the earthquake. And it’s now been estimated that nearly 3,000 people have died in that earthquake or from that earthquake, to date. I felt it, but the building where I was staying sustained hardly any damage. And to date, I haven’t heard of any tourists or expats having been reported dead or seriously injured. Now, this was not an infectious disease outbreak, but it is a public health crisis of a kind, and some are more likely to be hurt and die than others. What does this tell us about, Bill, how to build resilience into the system and how was this done in the context of smallpox? 

Bill Foege: Well, the resilience is a difficult thing because we think locally. Well, wherever you are in the world, you’re both local and global. So I keep telling students, wherever you’re working, you’re working on global health. And so start thinking that way of how do we incorporate all these people. And see, you’re absolutely right. It doesn’t take an infectious disease. It takes a disaster to show what the social problems are that are causing this. Michael Osterholm once said, “One of the best fire departments we have is at the Minneapolis airport.” He said, “If we go 10 years or 15 years without a crash, no one will reduce their budget.” This is the kind of resilience that we need in public health. The last appropriations hearing that I had as director of CDC was chaired by Senator Hatfield from Oregon. He was the chair of the entire Appropriations Committee, but he asked permission, as a favor to me, to actually share this last one. 

He asked me a question that I was not expecting, which is the one you just asked. He asked, “If you were in charge, how would you improve the sustainability of public health?” And I told him that there were three things I would do. Number one, I would identify any program that has a positive benefit cost ratio, that is, for a dollar invested, you save more than a dollar, plus you improve health. Because if you don’t do that, you’re agreeing to spend money and have the disease both. And I said, “If you took these programs,” and I said, “In order to avoid infighting between the Congress and the executive branch, I put this totally in charge of Congress.” You decide when a program has a positive benefit cost ratio. And now it doesn’t compete with other things in the budget, it becomes something that’s an entitlement. We need this because it is cheaper and it improves health. 

Number two, I said, “I would index public health to healthcare expenditures, because the ratio of public health to healthcare keeps going down every year.” I said, “I would accept whatever it is right now and say we have to index our public health spending to that.” 

And the third, I would come up with mechanisms to improve and reward programs that benefit outcomes. Today, we benefit access and process, but not outcomes. And so, if we could benefit outcomes, it would change the way the insurance companies work and other programs work. So those three things I think would provide sustainability and public health we don’t have now. 

Céline Gounder: Helene, how was resilience built into the system in the context of HIV and or TB? 

Helene Gayle: I’ll answer that in a minute, but I just want to add on and taking from the example that you gave from Morocco that I think in many cases we’re talking about sustainability and resilience, but we’re also talking about equity. At the end of the day, the reason you probably were less likely to get impacted was you were probably staying in a building where the construction had been done in a way that it was as sustainable and not prone to the conditions of earthquake. And the people who are likely to have lost their lives were probably living in substandard building situations. So I think every time we think about sustainability and resilience, we also have to think about equity and are we making sure that the way in which we design our programs take equity into consideration, because that’s ultimately what is going to make populations and people have the kind of resilience that’s necessary. 

I think when I look at the programs like tuberculosis and HIV, I think what we tried to really do was to build up systems as we went along, because the best way to make sure that our efforts were sustainable and had resilience built into them was to actually build systems, not just focus on the program or the effort that we were doing. 

So in HIV, clearly when I look back on the public health infrastructure that was built, the human capacity that was developed as a result of HIV, that’s what starts building in resilience because you’re not just building for the HIV pandemic, but you’re really using those dollars in ways that can help to strengthen systems. And that’s what I think we have the kind of resilience and sustainability that we’re talking about. 

Céline Gounder: Lately, I’ve been thinking a lot about this concept of “Wicked problems.” And for people who are not familiar with this term, it goes back to the management literature several decades ago. And these are complicated, they’re messy, they’re context specific problems. People may not agree that there is a problem or what the problem is, they disagree on what caused it. And with wicked problems, there’s no one right solution, just some that might be less bad, might often create new problems. And so, these are very much about values and not just science. Bill, how would you apply this idea of wicked problems to public health challenges like smallpox or COVID? 

Bill Foege: Well, wicked problems turns out to be a good expression of, a great picture of this. And when I think of vaccines, for instance, in the beginning, in 1796 of the smallpox vaccine, and how they’ve improved in numbers and types, when I was born, my baby book shows I have got only two vaccinations. Children today will get 18 or 19 or 20 different vaccinations. And you look at the future of this, we now have two vaccines against cancer, one against liver cancer and one against cervical cancer. We’re going to see more vaccines against neoplasms. You look at the possibility of having vaccines in the future for certain heart diseases or even for addiction, alcoholism and drug addiction, and the possibilities are so great. And yet at the same time, we have more and more people who don’t trust science, don’t trust government, and they become anti-vaxxers. 

So this is the real challenge of vaccines. It will continue to be the foundation of global health, but we have to figure out how to get people incorporated in the solutions. Vashon Island in Puget Sound had a reputation for very low immunization uptake, and many of the people on the island were the hippies of the sixties and they didn’t trust government and so forth. The New York Times actually had a front page article on the rate of immunization in children, and I think about 19% were not being immunized. 

Now, they would not listen to the health officers of Seattle or anyone else of authority coming in, but two parents who had been Peace Corps volunteers started their own program of finding out from people what would it take for you to change your mind. What is it that you don’t know that you wish you knew? The vaccination rate decreased from 81%, or increased from 81% up to 88%, 89%. They were doing something at a grassroots level that we could not have done from the top down. And so, there are solutions to wicked problems, but they sure do require energy and organization and the ability to respect culture. 

Céline Gounder: Helene, is there a way we can better align people who have different sets of values around some of the same public health goals or strategies when it comes to some of these wicked problems, whether that is COVID or some of the other problems facing us today, whether it may be climate change or disinformation. Bill mentioned some of the challenges with anti-vaxxers and anti-science. 

Helene Gayle: Well, this is another time where I think we should bring in the comedians, but I do think, maybe not the comedians, but to take a point from what you were saying earlier, Bill, I do think looking at how do you find the common ground? And sometimes there’s only 5% of common ground, but you can start with that and continue to grow from there. I think oftentimes, we approach these things that are adversarial in a counter adversarial way. So if somebody’s hostile, we up the hostility, instead of thinking, “All right, where can we find common ground? What are the things that we all agree upon?” 

And sometimes it’s just the simple fact that we agree that saving lives is a high value and you can start from there and begin to develop the proof points that make nonbelievers believers. So I think we don’t do enough of thinking about where we find common ground, and instead, go to our corners and think by continuing to insist on what we believe and think that that’s what’s going to convince people, versus starting from where we all have a common belief and building from there. I don’t know any other way to do it. It’s not a magic bullet. It won’t work all the time. But I also think there has to be a point at which you recognize there are some people who you will never get on your side, and if you continue to try to wait for that to happen, you’ll get stuck and not move forward. 

So there’s always a certain point when you just need to keep moving forward, understanding that if you demonstrate effectiveness, that may be the most likely way of bringing others along. 

Bill Foege: When I’ve had an opportunity to meet with anti-vaxxers, I always start with the fact that I know no parent does this, withholding vaccines, to hurt their child. 

Helene Gayle: Exactly. 

Bill Foege: They do it only because they believe it’s the best thing for their child. And so if you can start there, you’re in a different position than if you just say, “Well, don’t you read the literature? Don’t you listen to…?” So I think understanding that there’s a reason why people feel this way is the beginning. 

Céline Gounder: So earlier we were talking a bit about public health tools and this desire to perfect public health tools, but at the same time, innovations in medical technology were in fact key to eradicating smallpox, especially a simple little tool called the bifurcated needle. Here’s a clip of some smallpox eradication workers discussing this tool from episode four of the podcast. 

In the early 1970s, smallpox was still stalking parts of South Asia. India had launched its eradication program more than a decade before, but public health workers couldn’t keep up with the virus. Enter the bifurcated needle. 

[Audio clip from episode 4 of the “Eradicating Smallpox” podcast begins to play] 

Tim Miner: It was a marvelous invention. In its simplicity, it looks like a little cocktail fork. 

Céline Gounder: You dip the prongs into a bit of vaccine. 

Tim Miner: And you would just prick the skin about 12 or 15 times until there was a little trace of blood, and then you’d take another one. 

Céline Gounder: It barely took 30 seconds to vaccinate someone. And it didn’t hurt. 

Yogesh Parashar: No. 

Céline Gounder: Well, it didn’t hurt too much. 

Yogesh Parashar: It was just like a pin prick rapidly done on your forearm. You had a huge supply with you and you just went about and dot, dot, dot, vaccinated people. Carry hundreds with you at one go. 

Tim Miner: And you could train somebody in a matter of minutes to do it. 

Céline Gounder: Easy to use, easy to clean, and a big improvement over the twisting teeth of the vaccine instrument health workers had to use before. The bifurcated needle was maybe two and a half, three inches long, small but sturdy enough for rough-and-tumble field work. 

Yogesh Parashar: It was made of steel, and it used to come in something that looked like a brick. It was just like one of those gold bricks that you see in the movies. 

Céline Gounder: And maybe worth its weight in gold. 

[Audio clip ends]  

Céline Gounder: So, Bill, public health officials say, in the context of COVID, that we now have the tools to diagnose and treat and prevent COVID, but are these tools enough for us to declare victory over COVID when not everyone has access to those tools? And in the context of smallpox, how did non-biomedical tools compliment biomedical innovations like the bifurcated needle? 

Bill Foege: Well, going back to what Helene said, we have to be thinking of this globally and everyone and realize that these tools for smallpox, that is the vaccine, at least some way of giving it, existed long before WHO decided to have a program. But the people that were getting smallpox were the ones who were disenfranchised. They were the ones who were unemployed, in poverty, who had bias, that sort of thing. And so, it was very important to include the non-technical things. And in smallpox, I can tell you that every school and every church and every chief of a village and every volunteer that became involved was part of the solution of this. 

Now, on the other hand, I can’t quite give up on smallpox eradication, even now, 40 plus years later. And I keep thinking of ways we could have improved. Nowadays, I would train dogs to pick up the scent of smallpox, because sometimes you would have beggar communities, people actually at the railroad station covered with a cloth with smallpox, but nobody knew that, but a dog would’ve picked that up right away. I’ve even come to the conclusion, if we were well enough organized, we could get rid of smallpox without vaccine and without the technical tools, the bifurcated needle, the jet injector and so forth. You would simply get people who are sick with smallpox and you would isolate them immediately and then you would follow all of their contacts. And the first symptom in a contact would get isolated and so on. And if you were organized well enough, you could get rid of smallpox without vaccine. So the tools are very important, but they’re not the last word. 

Céline Gounder: Well, and in fact, that’s the approach that was used for Ebola. And now we have a vaccine. But most of the Ebola control efforts during the West African epidemic were really about that, identifying and isolating. 

Helene, are we overly reliant on biomedical tools? And if we are overly reliant, should we pave the way for greater use of non-biomedical tools? 

Helene Gayle: Well, as we know, the social determinants of health contribute more to health status than access to healthcare itself. So access to healthcare, including all the biomedical advances is necessary but not sufficient. I think we have to continue to think about why do we have some of the gaps in health that we know already exists. We look at the COVID pandemic as an example, where we know that the populations that were at greatest risk outside of age are people who lived in houses that were overcrowded or who had jobs that put them at risk, low wage earners, et cetera. So I think we have to think about both things. And I think back to your earlier question that is about people’s trust and mistrust, part of the trust in people being willing to access some of our biomedical tools comes from feeling that the rest of their needs are also being taken care of. 

So if we just think of populations as we’ve got these great tools and we are going to give you these tools when your greatest challenge is whether or not you’re going to be able to feed your children at night or whether or not you’re going to have a roof over your head, you’re not going to be as eager and the uptake of our biomedical tools will not be as great. So I just think it’s about combining both and making sure that we’re thinking about some of these root causes that will also be part of helping to enhance, focusing on those will also be part of enhancing people’s trust and belief in some of the other approaches, that biomedical approaches that we know also make a huge difference. 

Céline Gounder: Public health is different from clinical medicine, in that it focuses on the public or the ‘we’ so to speak, while clinical medicine focuses on the ‘I’ or the patient. There seems to be very little appetite in this moment for thinking about the ‘we.’ 

Bill, is there anything wrong with that? And if so, how do we shift that perspective that thinking about ‘we’ and public health and beyond? 

Bill Foege: People often say clinical medicine deals with the numerator, the people that come to clinics and hospitals for care, while public health deals with the denominator. That’s simplistic because the denominator includes the numerator. And so, public health really is concentrated on everybody, on the ‘we’ and how to get everybody together on this. 

There are two things from history that always impressed me. Confucius was asked by a student once, “Could you tell us in one word how best to live?” And Confucius said, “Is not reciprocity that word.” And so, this is ‘we’ that everybody’s dealing with each other. And then Gandhi said, his idea of the golden rule was that he should not enjoy something not enjoyed by everyone, the ‘we.’ 

So we keep hearing this from the wise people of history to stop thinking about just ourselves. Gandhi also said, “We should seek interdependence with the same zeal that we seek self-reliance.” And then he added in a soft voice, “There is no alternative.” And this is true. There is no alternative. And we’ve just got to take that approach in school, that’s much of school is built around how to improve your self-reliance, how to develop, how get money in the future and so forth. And we have to figure out how to teach interdependence. 

Céline Gounder: Helene, should we be moving from an ‘I’ to a ‘we’ framing? And if so, how do we do that? 

Helene Gayle: I think we have to. I think we recognize, and when we have pandemics, it’s very obvious. You can’t just think about what’s happening to you as an individual without recognizing that if we don’t stem transmission for something like a COVID, all of us are at risk. 

So I think this sense of reciprocity is critical as we think about it. And it’s more broadly in our society. We can’t think that crime happens in one part of the city and it won’t also impact our economy, the economy of the city overall and ultimately impact other neighborhoods. I think we continue to think that we can wall off problems when we have to realize how interconnected we are, whether it’s health, whether it’s our economies, whether it’s the issue of climate change. I think as a species, we’re at a point where the ‘I’ thinking is having huge impacts for all of us. And unless we start having that ‘we’ mindset, we really are not going to be able to tackle some of these difficult wicked problems. 

Bill Foege: If I could add one thing that Will Durant once said, ‘We will never do things globally unless we fear an alien invasion.” And what we’ve come up with are surrogates for alien invasions. So we see nuclear weapons as threatening of all of us. So we think ‘we.’ But there are other things. Our synthetic biology might be another one of these. Climate change may be a third one. We have four or five things that could totally eliminate people and we should be thinking ‘we’ in order to solve those problems. 

Céline Gounder: So I’m now going to shift gears a little bit and take some of the questions our audience has been sending in. The first comes from Paurvi Bhatt who asks, “As we try to deal with new pandemics and eliminate older ones, how can we balance attention spans, science and safety in a world where “failing fast” and disruption define how we think about innovation?” 

Helene, do you want to take a stab at that one? 

Helene Gayle: Well, I just think we have to stay the course and continue to find ways. And we started out talking about health communications. I think we need to get better at our communications and in keeping people engaged in issues, because we are living in this 24/7 news cycle and a new issue coming up all the time. I think we as health professionals have an obligation to make sure that we are keeping these issues that are front and center in people’s minds and continuing to share what progress is happening. I think when people recognize there’s progress and you’re not just telling the same old story, I think you can keep people engaged, but I think it’s on us to do a better job in that regard. 

Céline Gounder: Bill? 

Bill Foege: I tell students now, and it took me a long time to reach this conclusion, that whenever they’re faced with these big problems, to think of three things. 

Number one, try to get the science right. We’ve talked about you can’t always do that and you have to apologize and go back, but try to get the science right. 

Number two, add art to the science. Will Durant says, “The first scientist that we know by name was Imhotep in Egypt, who was a physician and an artist and designed the step pyramid.” Because he said, “Then you get creative common sense at its best.” It was Huxley that says science is simply common sense at its best. So you get creative common sense at its best. 

And then I go back 700 years to Roger Bacon who did a report for the Pope. And he said, “One of the problems with science is it has no moral compass.” And so you have to develop scientists with a moral compass. And when you do this, now you have moral creative common sense at its best, and this is a great approach to wicked problems. 

Céline Gounder: Is public health science with a moral compass? 

Bill Foege: It’s supposed to be. And sometimes we see it drifting off, but in general, public health people have a social mind that they’re trying to do this with a moral compass, including everyone. 

Céline Gounder: Our next question comes from Merina Pradhan. Can you touch upon how the message needs to be as simple and brief as possible? Dr. Fauci’s message was very on point from a public health point of view, but how many in the general population would be able to assimilate that? Helene? 

Helene Gayle: I would just say we have to tailor the message to the audience. When I saw the background that Dr. Fauci was talking against, I think he was talking to an audience of people who could incorporate that message. I might be wrong, but I think regardless, the point is if you’re sitting and talking to a group of public health professionals, you have one message. If you’re talking to the general public, you have another. 

And I think it is true that we sometimes get confused with our own language because there’s so many nuances to public health that we put out these messages, that by the time we’re done, it’s hard to know. Do you believe yes, or do you believe no? So I agree. I think we have to keep it simple, but I think we also have to keep it truthful. And sometimes that’s a real challenge with the nuances of public health messaging. But I think again, tailoring it to the different audiences and recognizing that hopefully you have more than one bite at the apple, if you will, to make it short and concise, but then have other opportunities where you can explain it in greater detail. 

Céline Gounder: Bill, this question is for you, from Mark Rosenberg, one of the new epidemics is the public health crisis of gun violence, now the leading cause of death for children and teens in the United States. Are there lessons from the eradication of smallpox that could be applied to help solve this new epidemic? 

Bill Foege: I think all of the lessons from smallpox, knowing the truth, having coalitions, making sure that you progressing in the right way, having respect for culture, all of these things do apply. But I would end that answer, with becoming better ancestors, we’re saying that the ultimate expression of love from any of us is to become a better ancestor. And we certainly can do better on gun violence. And don’t put up with the discussion that says this is due to mental health problems and this and that, when other countries don’t have the same problem and they have just as much mental health problems as we do, but they don’t have the guns available. 

Céline Gounder: Helene, this is a question from Ayo Femi-Osinubi. “Bill mentions that we don’t know what is sustainable till we try. How would you approach sustainability for pandemic preparedness in the midst of trying to prioritize basic health service delivery?” 

Helene Gayle: Well, I think that the two aren’t necessarily in opposition. I think we need to have basic health services and building on basic services, making sure that we are thinking about how are those services available and sustainable so that when we have crises, public health crises, those systems are there and functional in a way that allows us to ramp up for public health emergencies. 

So I think those things are not in opposition. It’s what I was talking about earlier. I think we need a more clear and comprehensive public health system that doesn’t just get ramped up every time we have a crisis, that it’s there, that it’s stable, that we have the kind of workforce that we need, that we have the kind of tools that we need, and that those are in place and that we build upon those than the other services that are important for individual care. 

So again, I go back to a lot of this is about how we build systems that can be sustained and that are flexible and nimble so that they can respond when we have these public health crises. 

Céline Gounder: So one last question. I’m going to give this one to Bill from David Torres. “I teach my global health students about the history of smallpox eradication. Given the coercive nature of the final push to vaccinate some people for smallpox and today’s resistance to and mistrust of public health measures, including vaccination campaigns and masking for COVID, would the elimination of smallpox be conceivable today? And if so, how would it be accomplished?” 

Bill Foege: It would be very difficult today because of HIV and not knowing about immune systems, but you could still do it. The question about coercion, we hear this often, and most of this comes from one paper by Dr. Greenough, where he has interviewed people who worked on smallpox who used coercion. They would break into huts at 2:00 in the morning with the police officer to do that. None of that was necessary. 

And so particular people were so enthusiastic about smallpox eradication that they did this. But think about it for a moment. If you have a village with three people who have refused vaccination, if they get smallpox, everyone around them is already vaccinated. They’re the ones that suffer. You don’t have to go in and use coercion. And so, when I’ve talked to other people who worked in smallpox, they’re surprised that anyone used coercion. You don’t have to do that, and that’s part of respecting the culture, is that you find other ways to do this. 

Céline Gounder: Well, I really want to thank both of you, Bill and Helene for joining us today and for answering all of my questions, the audience’s questions. Between the two of you, you have over a century’s worth of wisdom in public health, and I always love hearing what you both have to say about these issues. 

I just want to remind the audience that a recording of the event will be posted online later today and that all registrants will be sent an email when the recording is available. Also, please check out the podcast, Epidemic. It’s available on Apple, Spotify, wherever you get your podcasts. Season two is the season on eradication of smallpox. And also check out the Nine Lessons at ninelessons.org. And thanks everyone for joining us today. 

Helene Gayle: Thank you. 

Bill Foege: Thank you. 

Season 2 of the ‘Epidemic’ Podcast Is ‘Eradicating Smallpox’

The eight-episode audio series “Eradicating Smallpox” documents one of humanity’s greatest public health triumphs.

By the late 1960s and early 1970s, smallpox was gone from most parts of the world. But in South Asia, the virus continued to kill. Public health heroes had to conquer social stigma, local politics, and more to wipe out the 3,000-year-old virus, an achievement many scientists thought was impossible.

Host Céline Gounder traveled to India and Bangladesh and brought back never-before-heard stories, many from public health workers whose voices have been missing in the coverage of the history of smallpox eradication. Gounder brings decades of experience working on tuberculosis and HIV in Brazil and South Africa; Ebola during the outbreak in Guinea, West Africa; and covid-19 in New York City at the height of the pandemic.

Season 2 of “Epidemic” is a co-production of KFF Health News and Just Human Productions.

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

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This story can be republished for free (details).

The Host

Emmarie Huetteman
KFF Health News

Emmarie Huetteman, associate Washington editor, previously spent more than a decade reporting on the federal government, most recently covering surprise medical bills, drug pricing reform, and other health policy debates in Washington and on the campaign trail.

The annual U.S. Census Bureau report this week revealed a drop in the uninsured rate last year as more working-age people obtained employer coverage. However, this year’s end of pandemic-era protections — which allowed many people to stay on Medicaid — is likely to have changed that picture quite a bit since. Meanwhile, reports show even many of those with insurance continue to struggle to afford their health care costs, and some providers are encouraging patients to take out loans that tack interest onto their medical debt.

Also, a mystery is unfolding in the federal budget: Why has recent Medicare spending per beneficiary leveled off? And the CDC recommends anyone who isat least 6 months old get the new covid booster.

This week’s panelists are Emmarie Huetteman of KFF Health News, Margot Sanger-Katz of The New York Times, Sarah Karlin-Smith of the Pink Sheet, and Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico.

Panelists

Sarah Karlin-Smith
Pink Sheet

@SarahKarlin

Read Sarah's stories

Joanne Kenen
Johns Hopkins Bloomberg School of Public Health and Politico

@JoanneKenen

Read Joanne's stories

Margot Sanger-Katz
The New York Times

@sangerkatz

Read Margot's stories

Among the takeaways from this week’s episode:

• The Census Bureau reported this week that the uninsured rate dropped to 10.8% in 2022, down from 11.6% in 2021, driven largely by a rise in employer-sponsored coverage. Since then, pandemic-era coverage protections have lapsed, though it remains to be seen exactly how many people could lose Medicaid coverage and stay uninsured.
• A concerning number of people who have insurance nonetheless struggle to afford their out-of-pocket costs. Medical debt is a common, escalating problem, exacerbated now as hospitals and other providers direct patients toward bank loans, credit cards, and other options that also saddle them with interest.
• Some state officials are worried that people who lose their Medicaid coverage could choose short-term health insurance plans with limited benefits — so-called junk plans — and find themselves owing more than they’d expect for future care.
• Meanwhile, a mystery is unfolding in the federal budget: After decades of warnings about runaway government spending, why has spending per Medicare beneficiary defied predictions and leveled off? At the same time, private insurance costs are increasing, with employer-sponsored plans expecting their largest increase in more than a decade.
• And the push for people to get the new covid booster is seeking to enshrine it in Americans’ annual preventive care regimen.

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

Emmarie Huetteman: KFF Health News’ “The Shrinking Number of Primary Care Physicians Is Reaching a Tipping Point,” by Elisabeth Rosenthal.

Sarah Karlin-Smith: MedPage Today’s “Rural Hospital Turns to GoFundMe to Stay Afloat,” by Kristina Fiore.

Joanne Kenen: ProPublica’s “How Columbia Ignored Women, Undermined Prosecutors and Protected a Predator for More Than 20 Years,” by Bianca Fortis and Laura Beil.

Margot Sanger-Katz: Congressional Budget Office’s “Raising the Excise Tax on Cigarettes: Effects on Health and the Federal Budget.”

Also mentioned in this week’s episode:

• U.S. Census Bureau’s “Health Insurance Coverage of U.S. Workers Increased in 2022,” by Rachel Lindstrom, Katherine Keisler-Starkey, and Lisa Bunch.
• The Commonwealth Fund’s “Can Older Adults with Employer Coverage Afford Their Health Care?” by Lauren A. Haynes and Sara R. Collins.
• KFF Health News’ “What One Lending Company’s Hospital Contracts Reveal About Financing Patient Debt,” by Noam N. Levey.
• The New York Times’ “A Huge Threat to the U.S. Budget Has Receded. And No One Is Sure Why,” by Margot Sanger-Katz, Alicia Parlapiano, and Josh Katz.
• The Wall Street Journal’s “Health-Insurance Costs Are Taking Biggest Jumps in Years,” by Anna Wilde Mathews.
• The New York Times’ “The N.Y.C. Neighborhood That’s Getting Even Thinner on Ozempic,” by Joseph Goldstein.

click to open the transcript

Transcript: Underinsured Is the New Uninsured

KFF Health News’ ‘What the Health?’

Episode Title: Underinsured Is the New Uninsured

Episode Number: 314

Published: Sept. 14, 2023

[Editor’s note: This transcript, generated using transcription software, has been edited for style and clarity.]

Emmarie Huetteman: Hello and welcome back to “What the Health?” I’m Emmarie Huetteman, a Washington editor for KFF Health News. I’m filling in for Julie [Rovner] this week, who’s on vacation. And I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Sept. 14, at 11 a.m. As always, news happens fast, and things might have changed by the time you hear this. So, here we go. We’re joined today by video conference by Margot Sanger-Katz of The New York Times.

Margot Sanger-Katz: Good morning, everybody.

Huetteman: Sarah Karlin-Smith of the Pink Sheet.

Sarah Karlin-Smith: Hi there.

Huetteman: And Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico.

Joanne Kenen: Hi, everybody.

Huetteman: No interview this week, so let’s get right to the news. The percentage of working-age adults with health insurance went up last year, according to the annual Census report out this week. As a result, the uninsured rate dropped to 10.8% in 2022. But lower uninsured rates may be obscuring another problem: the number of people who are underinsured and facing high out-of-pocket costs. The Commonwealth Fund released a report last month on how difficult it is for many older adults with employer coverage to afford care. And recent reporting here at KFF Health News has probed how medical providers are steering patients toward bank loans and credit cards that saddled them with interest on top of their medical debt. So, the number of people without insurance is dropping. But that doesn’t mean that health care is becoming more affordable. So what does it mean to be underinsured? Are the policy conversations that focus on the uninsured rate missing the mark?

Sanger-Katz: So, two things I would say. One is that I even think that the Census report on what’s happening with the uninsured is obscuring a different issue, which is that there’s been this artificial increase in the number of people who are enrolled in Medicaid as a result of this pandemic policy. So the Congress said to the states, if you want to get extra money for your Medicaid program through the public health emergency, then you can’t kick anyone out of Medicaid regardless of whether they are no longer eligible for the program. And that provision expired this spring. And so this is one of the big stories in health policy that’s happening this year. States are trying to figure out how to reevaluate all of these people who have been in their Medicaid program for all these years and determine who’s eligible and who’s not eligible. And there’s been quite a lot of very good reporting on what’s going on. And I think there’s a combination of people who are losing their Medicaid coverage because they really genuinely are no longer eligible for Medicaid. And there also appears to be quite a large number of people who are losing their Medicaid coverage for administrative hiccup reasons — because there’s some paperwork error, or because they moved and they didn’t get a letter, or some other glitch in the system. And so when I looked at these numbers on the uninsured rate, in some ways what it told us is we gave a whole bunch of people insurance through these public programs during the pandemic and that depressed the uninsured rate. But we know right now that millions of people have lost insurance, even in the last few months, with more to come later this year. And so I’m very interested in the next installment of the Census report when we get back to more or less a normal Medicaid system, how many people will be without insurance. So that’s just one thing. And then just to get to your question, I think having insurance does not always mean that you can actually afford to pay for the health care that you need. We’ve seen over the last few decades a shift towards higher-deductible health care plans where people have to pay more money out-of-pocket before their insurance kicks in. We’ve also seen other kinds of cost sharing increase, where people have to pay higher copayments or a percentage of the cost of their care. And we’ve also seen, particularly in the Obamacare exchanges, but also in the employer market, that there’s a lot of insurance that doesn’t include any kind of out-of-network benefit. So it means, you know, if you can go to a provider who is covered by your insurance, your insurance will pay for it. But if you can’t find someone who’s covered by your insurance, you could still get hit with a big bill. The sort of surprise bills of old are banned. But, you know, the doctor can tell you in advance, and you can go and get all these medical services and then end up with some big bills. So whether or not just having an insurance card is really enough to ensure that people have access to health care remains an open question. And I think we have seen a lot of evidence over recent years that even people with insurance encounter a lot of financial difficulties when they get sick and often incur quite a lot of debt despite having insurance that protects them from the unlimited costs that they might face if they were uninsured.

Huetteman: Joanne.

Kenen: I would say two big things. The uninsurance rate, which we all think is going to go up because of this Medicaid unwinding, it’s worth stopping and thinking about. It’s what? 7.9[%]? Was that the number?

Huetteman: It was 10.8, was the uninsured rate last year.

Sanger-Katz: It depends if you look at any time of the year or all of the year.

Kenen: Back when the ACA [Affordable Care Act] was passed, it was closer to something like 18. So in terms of really changing the magnitude of the uninsurance problem in America, the work isn’t done. But this is a really significant change. Secondly, some aspects of care are better — or within reach because the ACA made so many preventive and primary care services free. That, too, is a gain. Obviously, through the medical debt, which KFF [Health News] now has done a great job — oh, and believe me, and other reporters, you’ve done an amazing job, story after story. You know, the “Bill of the Month” series that you edited, it’s … but they’re not isolated cases. It’s not like, oh, this person ran into this, you know, cost buzz saw. There’s insane pricing issues! And out-of-pocket and, you know, deductibles and extras, and incredibly hard to sort out even if you are a sophisticated, insured consumer of health care. Pricing is a mess. There have been changes to the health care market, in terms of consolidation of ownership, more private equity, bigger entities that just have created … added a new dimension to this problem. So have we made gains? We’ve made really important gains. Under the original ACA passed under the Obama administration and the changes, the access and generosity of subsidy changes that the Biden administration has made, even though they’re time-limited, they have to be renewed. But, you know, are people still being completely hit over the head and every other body part by really expensive costs? Yes. That is still a heartbreaking and really serious problem. I mean, I can just give one tiny incident where somebody … I needed a routine imaging thing in network. The doctor in that hospital wasn’t reachable. I had my primary care person send in the order because she’s not part of that health care system. She’s in network. The imaging center is in network. The doctor who told me I needed this test is in network. But because the actual order came from somebody not in their hospital and in … on the Maryland side of the line, instead of the D.C. side of the line, the hospital imaging center decided it was going to be out of network. And because she’s not ours and wanted to charge me an insane amount of money. I sorted it out. But it took me an insane amount of time and I shouldn’t have needed to do that.

Huetteman: Yeah, that’s absolutely true.

Kenen: I could have paid it, if I had to.

Huetteman: Absolutely. And as you noted, I do edit the “Bill of the Month” series. And we see that with all kinds of patients, even the most enterprising patients can’t get an answer to simple questions like, is this in network or out of network? Why did I get this bill? And it’s asking way too much of most people to try and fit that into the rest of the things that they do every day. You know, Margot brought up the Medicaid unwinding. Well, let’s speaking of insurance, let’s catch up there for a moment because there was a little news this week. We’re keeping an eye on those efforts to strip ineligible beneficiaries from state Medicaid rolls since the covid-19 public health emergency ended. Now, some state officials are worried that people who lose coverage could opt to replace it with short-term insurance plans. You might know them as “junk plans.” They often come with lower price tags, but these short-term plans do not have to follow the Affordable Care Act’s rules about what to cover. And people in the plans have found themselves owing for care they thought would be covered. The Trump administration expanded these plans, but this summer the Biden administration proposed limiting them once more. Remind us: What changes has Biden proposed for so-called junk plans and for people who lose their coverage during the Medicaid unwinding? What other options are available to them?

Sanger-Katz: So the Biden administration’s proposal was to basically return these short-term plans to actual short-term coverage, which is what they were designed to do. Part of what the Trump administration did is they kept this category of short-term plans. But then they said basically, well, you can just keep them for several years. And so they really became a more affordable but less comprehensive substitute for ACA-compliant insurance. So the Biden administration just wants to kind of squish ’em back down and say, OK, you can have them for like a couple of months, but you can’t keep them forever. I will say that a lot of people who are losing their Medicaid coverage as a result of the unwinding are probably pretty low on the income scale, just as a result of them having qualified for Medicaid in the first place. And so a very large share of them are eligible for free or close-to-free health plans on the Obamacare exchanges. Those enhanced subsidies that Joanne mentioned, they’re temporary, but they’re there for a few years. They really make a big difference for exactly this population that’s losing Medicaid coverage. If you’re just over the poverty line, you can often get a free plan that’s a — this is very technical, but — it’s a silver plan with these cost-sharing wraparound benefits. And so you end up with a plan where you really don’t have to pay very much at the point of care. You don’t have to pay anything in a premium. So I think, in general, that is the most obvious answer for most of these people who are losing their Medicaid. But I think it is a challenge to navigate that system, for states to help steer people towards these other options, and for them to get enrolled in a timely way. Because, of course, Obamacare markets are not open all the time. They’re open during an open enrollment period or for a short period after you lose another type of coverage.

Huetteman: Absolutely. And a lot of these states actually have efforts that are normally focused on open enrollment right now. And some officials say that they are redirecting those efforts toward helping these folks who are losing their Medicaid coverage to find the options, like those exchange plans that are available for zero-dollar premiums or low premiums under the subsidies available.

Kenen: I have seen some online ads from HHS [the Department of Health and Human Services], saying, you know, “Did you lose your Medicaid?” and it’s state-specific — “Did you lose your Medicaid in Virginia?” I don’t live in Virginia, so I’m not sure why I’m getting it. My phone is telling me the Virginia one. But there is an HHS [ad], and it is saying if you lost your Medicaid, go to healthcare.gov, we can help. You know, we may be able to help you. So they are outreaching, although I’m afraid that somebody who actually lost it in Virginia might be getting an ad about Nebraska or whatever. I live close to Virginia. It’s close enough. But there is some effort to reach people in a plain English, accessible pop-up on your phone, or your web browser, kind of way. So I have seen that over the last few weeks because the special enrollment period, I mean, most people who are no longer eligible for Medicaid are eligible for something, and something other than a junk plan. Some of them have insurance at work now because the job market is better than it was in 2020, obviously. Many people will be eligible for these highly subsidized plans that Margot just talked about. Very few people should be left out in the cold, but there’s a lot of work to be done to make those connections.

Huetteman: Absolutely. Absolutely. And going back to the Census report for a second, it had noted that a big part of the increase in coverage came from employer-sponsored coverage among working-age adults, although we have, of course, seen those reports that say … and then they try to afford their health care costs. And it’s really difficult for a lot of them, even when they have that insurance, as we talked about. All right. So let’s move on. The New York Times is reporting a mystery unfolding in the federal budget. And I’d like to call it “The Case of Flat Medicare Spending.” After decades of warnings about runaway government spending, a recent Times analysis shows that spending per Medicare beneficiary has actually leveled off over more than a decade. Meanwhile, The Wall Street Journal reports that private health insurance costs are climbing. Next year, employer-sponsored plans could see their biggest cost increase in more than a decade, and that trend could continue. So what’s going on with insurance costs? Let’s start with Medicare. Margot, you were the lead reporter on the Times analysis. What explains this Medicare spending slowdown?

Sanger-Katz: So part of the reason why I have found it to be a somewhat enjoyable story is that I think there is a bit of a mystery. I talked to lots of people who have studied and written about this phenomenon over the years, and I think there was no one I talked to who said “I 100% understand what is going on here. And I can tell you, here’s the thing.” But there are a bunch of factors that I think a lot of people think are contributing, and I’ll just run through them quickly. One of them is Medicare is getting a little younger. The baby boomers are retiring generally, like, 65-year-olds are a little cheaper to take care of than 85-year-olds. So as the age mix gets younger, we’ve seen the average cost of taking care of someone in Medicare get a little smaller. That’s like the easiest one. I think another one is that Obamacare and other legislative changes that Congress has passed during this period have just mechanically reduced the amount of money that Medicare is spending. So the two most obvious ways are, in the Affordable Care Act, Congress took money away from Medicare Advantage plans, paid them a smaller premium for taking care of patients, and they also reduced the amount that hospitals get every year, as what’s called a productivity adjustment. So hospitals get a little raise on their pay rates every year. And the legislation tamped that down. There was also, some listeners may remember, the budget sequester that happened in 2011, 2012, where there was kind of a haircut that Medicare had to take across the board. So there have been these kind of legislative changes. They explain like a little bit of what is going on. And now I think the rest of it really has to do with the health care system itself. And part of that seems to be that this has been a period of relatively limited technological improvement. So, you know, for years medicine just kept getting better and better. We had these miracle cures, we had these amazing surgeries. We, you know, especially like in the area of cardiovascular disease, just enormous advances in recent decades where, you know, first bypass surgery and then stents and then, you know, drugs that could prevent heart attacks. And so I think, you know, health care spending kept climbing and climbing in part because there was better stuff to spend it on. It was expensive, but it really improved people’s health. And in recent years, there’s just been a little less of that. There have clearly been medical advances, particularly in the pharmaceutical space. You know, we have better treatments for cancer, for certain types of cancers, than we had before and for other important diseases. But these expensive innovations tend to affect smaller percentages of people. We haven’t had a lot of really big blockbusters that everyone in Medicare is taking. And so that seems to explain some of the slowdown. And then I think the last piece is, like, kind of the piece that’s the hardest to really explain or pin down, but it seems like there’s just something different that doctors and hospitals are doing. They’re getting more efficient. They’re not always buying the latest and greatest thing, if there’s not evidence to support it. They’re reducing their medical errors. And, you know, I think Obamacare probably gets a share of the credit here. It really created a lot of changes in the way we pay for medical care and in the Medicare program itself. And it created this innovation center that’s supposed to test out all of these different things. But I think also over the same period, we’ve seen the private sector make many of the same moves. You know, private insurers have gotten a little bit more stingy about covering new technologies without evidence. They’ve tended to pay physicians and hospitals in bundles, or paying them incentives for quality, not paying them for certain types of care that involve errors. And so a lot of people I talked to said that they think the medical system is reacting to all of the payers crunching down on them. And so they’re just not being quite as aggressive and they’re trying to think more about value, which I feel like is like kind of a lame buzzword that often doesn’t mean anything. But I think, you know, it’s a way of thinking about this change. And, you know, that’s the kind of thing, if culturally that endures, you know, could continue into the future. Whereas some of these other factors, like the demographics, the lack of technological development, those — the Obamacare, which was kind of a one-time legislative change, you know — those things may not continue into the future, which is why the fact that we’ve had 15 years of flat Medicare spending is no guarantee that Medicare spending won’t spike again in the future. And I think you were right to point to what’s happening in the private sector, because private sector insurance premiums also have been like a little bit on the flat side through this period. And I think there is potential for them to take off again.

Huetteman: Absolutely. And that’s what The Wall Street Journal’s reporting had just said, that the health care costs for coming into next year are climbing. Let’s talk about that for a minute. Why are private insurance costs rising as Medicare spending levels off? One of the things that I noticed is we talked about technological innovation. Pharmaceutical innovation seems to be one of the things that’s contributing to rising private health insurance costs and elsewhere, in particular, those weight-loss drugs I know.

Kenen: And the Alzheimer’s drugs.

Huetteman: And the Alzheimer’s drugs.

Kenen: Eventually they’ll become more widely available. Sarah knows way more than the rest of us.

Karlin-Smith: The Alzheimer’s drugs will probably be less of an issue for the private health insurance population. But certainly weight-loss drugs are something that private insurers are worried about what percentage of the population they will cover with these drugs. And I think insurance companies, they have to balance that … difficult balance between what percentage of the drug cost rate you put on patients and what do you build into premiums. And sometimes there’s only so much flexibility they can have there. So I think that’s a big reason for what you’re seeing here.

Huetteman: Yeah, absolutely.

Sanger-Katz: I think the weight-loss drugs are interesting because they kind of are, potentially, an example of the kind of technology that is both expensive and good for public health, right? So, you know, when we have all these improvements in cardiac disease, like, that was great. People didn’t have heart attacks. They didn’t have disability in old age. They lived longer lives. That was great. But it cost a ton of money. And I think because we have been going through this period in which costs have been kind of level, and there hasn’t been a lot of expensive breakthrough technology, we haven’t had to weigh those things against each other in the way that we might now, where we might have to say, OK, well, like, this is really expensive, but also, like, it has a lot of benefits. and how do we decide what the right cost benefit is as a society, as an employer, as a public insurance program? And I think we’re going to see a lot of payers and economists and other analysts really thinking hard about these trade-offs in a way that they, I think, haven’t really been forced to do very much in the last few years with … I mean, maybe with the possible exception of those breakthrough therapies for hepatitis C —also expensive, huge public health benefit. And it was a struggle for our system to figure out what to do with them.

Kenen: But, like the statins, which, you know, revolutionized heart health, these drugs that are useful for both diabetes and … weight loss, the demand of people who just want them because they want to lose those 20 pounds, insurers are not — Medicare at least is not — covering it. Insurers have some rules about “Are you pre-diabetic?” and etc., etc., but they cost a lot of money and a lot of people want to take them. So I think they’re clearly great for diabetes. They clearly are a whole new class of drugs that are going to do good things. We still don’t. … There’s still questions about who should be using them for the rest of their lives, for weight control, etc., etc. Yes, there are going to be benefits, but this era of … what is the typical cost per month, Sarah?

Karlin-Smith: The list price of these drugs are thousands of dollars per month. But I think to your point, Joanne, though, the trouble for insurance companies who are figuring out how to cover this is they’re starting to get more research that there are these actual health benefits outside of just weight loss. And once you start to say, you know, that these drugs help prevent heart attacks and have hard evidence of that, it becomes harder for them to deny coverage. I think to Margot’s point of the long-term benefits, you might see to health because of it, we get back to another issue in the U.S. health system is, which is these private health insurance companies might essentially basically be footing the bill for benefits that Medicare is going to reap, not necessarily the insurance companies, right? So if somebody, you know, doesn’t have a heart attack at 50 because they’re on these drugs, that’s great. But if the savings is actually going to Medicare down the line, you know, the private health insurer doesn’t see the benefit of that. And that’s where some of the tensions you get into it in terms of, like, how we cover these products and who we give them to.

Kenen: Because that trade-off: quality of life and longevity of life. That’s what health is about, right? I mean, is having people live healthy, good lives, and it costs money. But there’s this issue of the drug prices have gotten very high, and hepatitis C is a perfect example. I mean, now it’s like we were freaked out about $84,000 in, you know, 2013, 2015, whenever that came out. You know, now that looks quaint. But that price was still so high that we didn’t get it to people. We could have wiped out hepatitis C or come damn close to wiping out hepatitis C, but the price the drug was an obstacle. So we’re still, I mean, there’s a big White House initiative now, you know, there’s creative … the Louisiana model of, you know, what they call the Netflix model where, you know, you have a contract to buy a whole ton of it for less per unit. I mean, these are still questions. Yes. I mean, we all know that certain drugs make a big difference. But if they’re priced at a point where people who need them the most can’t get them, then you’re not seeing what they’re really invented for.

Sanger-Katz: Oh, I was just going to say, I think that part of what interests me about this particular class of drugs and the debates that we are likely to have about them, and there are, you know, the way that they’re going to be adopted into our health care system is that setting aside the diabetes indication for a moment, the idea of drugs that effectively treat obesity, I think obesity is a very stigmatized disease in our country. And in fact, Medicare has statutory language that says that Medicare cannot cover drugs for weight loss. So it would actually require an act of Congress for these drugs to be approved for that purpose in Medicare. And in Medicaid, in general, states are required to cover FDA-approved drugs. You know, they can put some limitations, but they’re supposed to cover them. Again, there is a special statutory exclusion for weight-loss drugs where the states really have discretion they don’t have for a cancer drug, for a drug for diabetes, a drug for other common diseases. And so I do think that, you know, a lot of this debate is colored by people’s prejudices against people who have obesity, and the way that our medical care system has thought about them and the treatment for their disease over time. And I’m curious about that aspect of it as well. I mean, of course, I think that Joanne is absolutely right that we do not know long term how these drugs are going to help people with obesity, whether it’s really going to reduce the burden of disease down the road for them, whether it’s going to have other health consequences in an enduring way. You know, I think there are unknowns, but I think if you take the most optimistic possible look at these drugs, that there’s quite a lot of evidence that they really do improve people’s health. And if we treat these drugs differently than we would an expensive drug for an infectious disease like hepatitis C or different from an expensive drug for cancer diseases that are less stigmatized, I think that would maybe be a little bit sad.

Karlin-Smith: I mean certainly the reason why the initial restrictions in Medicare and other programs are baked in goes back to stigma to some degree. But also, I mean … because they were thinking of these as weight-loss drugs and sort of vanity treatments people would only be using for vanity. And at that time, the drugs that were available did not work quite as well and had a lot of dangers and certainly did not show any of these other health benefits that we’re starting to see with this new class of medicine. So I think that would be the hope that, you know, as the science and the products shift, as well as our medical understanding around what causes obesity, what doesn’t cause obesity, how much of it is … right, again, just as medical as any other condition and not all about a person’s behavior. And I think we will see that the benefits of some of these drugs for certain people, in particular, are probably a lot bigger than maybe the benefits of certain cancer treatments that we pay a lot more money for. The challenge is going to be the amount of people and the amount of time they are going to be on these drugs, right? You know, if you’re talking about these hepatitis C drugs, I think one reason they didn’t shock the budgets in the way people were expecting, besides the fact that, unfortunately, we didn’t get them to everybody, is they’re actually really short-term cures, right? I think it’s like 10 weeks or something.

Kenen: Some are like eight.

Karlin-Smith: Right. Ballpark. And with the obesity drugs, what we know … these new drugs so far is that you seem like you have to consistently take them. Once you get off them, the weight comes back. And then the assumption would be you lose all those health benefits. So we’re talking about a high-cost drug on a chronic basis that our system can’t afford.

Kenen: Margot, do you know? I mean, my guess is that the ban on covering weight-loss drugs was written into MMA [the Medicare Modernization Act] in 2003. That’s my guess. I don’t know if anyone …

Sanger-Katz: That’s right. Yeah. It was part of the creation of the drug benefit program.

Kenen: So I think that you’re totally right that it’s what both of you said. You know, we tended to say it was someone’s fault, like they didn’t have enough willpower. Or they, you know, didn’t do what they were supposed to do. And there was stigma and we thought about it diffrently. I also think the science, you know, Sarah alluded to this, I think the science of obesity has really changed, that we didn’t talk about it — even though obesity experts — really didn’t talk about it as a disease a generation ago. We thought of it as maybe as a risk factor, but we didn’t think of it as a disease in and of itself. And we now do know that. So I think that the coverage issues are going to change. But what are the criteria? How fast do they change, for who do they change? Do you really want to put somebody on a drug because they want to lose 10 or 15 punds, which is … versus someone who really has struggled with weight and has physical risk factors because of it, including, you know, heart disease, diabetes, all these other things we know about. I mean, I just think we don’t know. I mean, there was a piece in the Times about the Upper East Side of Manhattan is like this beehive of people taking these weight loss drugs because they can afford it, but they’re also thinner than the rest of the population. So it becomes, you know, a luxury good or another disparity.

Sanger-Katz: If insurance won’t cover these drugs ,of course, rich people are going to take them more than people of limited means. Right? Like, I think you can only really test the hypothesis of, like, who are these drugs meant to reach once … if you have coverage for them, right? I thought that story was very good, and it did reveal something that’s happening. But I also thought … it felt like it was focusing on the idea that that rich people were taking these drugs just for vanity. And I think …

Kenen: Some of them, not all clearly some of them.

Sanger-Katz: Some of them are, of course. But I thought the thing that was less explored in that story is all of the people in poor neighborhoods of New York who were not accessing those drugs. Was it because they couldn’t find any way to get them?

Kenen: Right, and some of them were pre-diabetic. Some of them. I mean, the other thing is people who are overweight are often pre-diabetic. And that is an indication. I mean, you can … it’s in flux. It’s going to change over the coming months, you know, but what a cost and how those benefits paid off and who’s going to end up paying and where the cost shifting is going to come, because there is always cost shifting. We just don’t know yet. But these drugs are here to stay. And there are questions. There are a lot of questions. The mounting evidence is that they are going to be a benefit. It’s just, you know, what do we pay for them? Who gets them? How long do the people stay on them, etc., etc., etc.

Sanger-Katz: And just to come back to Emmarie’s first question, like, what is this going to mean for our insurance premiums, right? With something like 40% of adults in the United States have obesity. If we start to see more and more people taking these drugs to treat this disease, all of us are going to have to pay for that in some way. And, you know, that affects overall health care.

Huetteman: Absolutely. Well, let’s move to the week’s big covid news now. This week, the FDA approved a new booster, which comes amid an uptick in cases and concerns about a surge this fall and winter. Before the CDC made its recommendations, though, there was debate over whether the booster should be recommended only for a couple of higher-risk groups. So who does the CDC say should get the shot? And what’s the response been like from the health care community so far?

Karlin-Smith: So the CDC decided their advisers and the CDC themselves to recommend the shot for everybody. That really didn’t surprise me because I think that was the direction FDA wanted to go as well. I think the majority came down to the fact that a broad recommendation would be the best for health equity and actually ensuring the people we really want to get the shots get them. If you start siphoning off the population and so forth, it actually might prevent people that really should get the shots from getting it. I think the booster debate has actually been really similar since we started approving covid boosters, which is that the companies that provided for the boosters is not the same as the original data they presented to get the vaccines approved. So we don’t have as much understanding with the type of rigorous research some people would like to know: OK, what is the added benefit you’re getting from these boosters? We know they provide some added benefit of protection for infection, but that’s very short-lived. And then I think there’s … people have differences of opinions of how much added protection it’s giving you from severe disease and death. And so there are factions who argue, and I think Paul Offit has become one of the most known and vocal cheerleaders of this mindset, which is that, well, actually, if you’ve already had, you know, two, three, four shots, you’ve already had covid, you’re probably really well protected against the worst outcomes. And these shots are not really going to do that much to protect you from an infection. “So why take them anymore?” — essentially, is sort of his mindset. And there are people that disagree. I think the thing that probably might help change mindsets is, at least in this country, probably not going to happen, which is, you know, more rigorous outcomes research here. But I think the sentiment of the CDC and its advice has been, well, these shots are extremely low risk and there’s at least some added benefit. So for most people, the risk-benefit balance is: Get it. And if you make it kind of simple, if you say, OK, you know, everybody, it’s time to get your next covid booster, the feeling is that will get the most people in the U.S. to go out and do it. Unfortunately, most covid booster recommendations have been fairly broad — the last, at least, and that hasn’t translated. But we’ll see. This is actually the first time that everyone, except for babies under 6 months — because you can’t start your covid vaccination until then —everybody is really included in the booster recommendation at the same time. In previous rounds, particularly for younger kids, it was more staggered. So this will be the simplest recommendation we have yet.

Kenen: And that’s part of the public health strategy, is to not talk about it so much as boosters, just as an annual shot. The way you get an annual flu shot. I mean, most people don’t get them. But the idea is that to normalize this, you know, you get an annual flu shot, you get an annual covid shot, for certain age groups you get annual RSV now that’ll be available. But that’s not for everybody. I mean, I think they really want to make this simple. OK, it’s fall, get your covid shot. We don’t think uptake is going to be real high. It hasn’t been for boosters. But in terms of trying to change, this is just, you know, this is one of those things to add to your to-do list this year and to, sort of, less “pandemicize” it. I don’t think that’s a word. But, you know, everyone will forgive me. And more just, you know, OK, you know, this is one of the things you got to do in the fall. Maybe “pandemicize” is a word or maybe it should be.

Sanger-Katz: I like it. Maybe we should use it.

Huetteman: Pandemicize your care.

Kenen: Right. You know, it’s part of your preventive care and just … I mean, good luck trying to de-politicize it. But that’s part of it. I mean, the CDC director, Mandy Cohen, she wrote an op-ed this week and it was all about, you know, I’m a doctor, I’m the CDC director, and I’m a mom. And, you know, my family is going to get it. You know, Ashish Jha was tweeting about how he’s going to get it, his elderly parents are going to get theirs as soon as possible, etc., etc. So it’s not going to be … the hard-core people who really don’t want these shots and haven’t taken the shots and believe the shots cause more harm than good, etc. It won’t change a lot of their minds. But there are a lot of people who are uncertain in the middle and their minds can be changed. And they have … they were changed in the initial round of shots. So that’s who the messaging is … it’s sort of a reminder to people who take the shots and an invitation to those who … haven’t been getting boosted that just start doing this every year.

Karlin-Smith: And it is important to emphasize when the boosters have been tweaked and, you know, updated to try to match as close as they possibly can the current version of the virus. The virus has evolved and shifted a lot over time to the point where even these boosters, you know, they can’t quite keep up with the virus. But the idea is that we’re helping broaden everybody’s protection by keeping it as up to date with the science. So I think that’s an important element of that, that people don’t appreciate. They’re not just giving you the exact same shot over and over again. They’re trying to, like we do with the flu vaccine every year, be as close to what is circulating as possible.

Kenen: And there’s a new, new, new, new variant that looked very — do I have enough “news” in there? — that looked, and I don’t remember the initials; I can’t keep track — that is really quite different than the other ones. And there was a lot of initial concern that this vaccine would not work or that we wouldn’t … that our protection would not work against that. The follow-up research is much more reassuring that the fall shot will work against that. But that one really is different, and it’s got a lot of mutations. And, you know, we don’t know yet how … some of these things come and go pretty quickly. I mean, who remembers Mu? That one people were very worried about and it seemed quite dangerous and luckily it didn’t take root. You know, people don’t even know there was a Greek letter called Mu. M-u, not m-o-o, in case anyone’s wondering. If relatives ask me if they should take it, the two things that struck me in reading about it are, yes, it works against this new variant, and we’re not really sure what are the new, new, new, new, new, new, new, new ones. And also, I mean, there’s some research that it does protect against long covid. And I think that’s a big selling point for people. I think there are people who still, with reason, worry about long covid, and that vaccination does provide some protection against that as well.

Huetteman: That’s a great point. I mean, anecdotally, you talk to your friends who’ve had covid, there’s going to be at least a few of them who say they haven’t quite felt like themselves ever since they had covid. And I think that is one of the things that really motivates people who aren’t in those higher-risk categories, to think about whether they need the booster or not.

Kenen: Yeah, and also the myocarditis … Sarah, correct …  you follow this more closely than I do, so correct me if I’m wrong here, but I believe that they’re finding that the myocarditis risk in the newer formulations of the vaccine has dropped, that it is not as much of a concern for young men. And covid itself can cause myocarditis in some individuals. Did I get that right?

Karlin-Smith: Yeah, I think that that’s right. The general sense has been that the risk was more with the initial shots, and it seems to have gone down. I think that there are people that still worry about particular age groups of, like, young men in certain age groups, that maybe for them the benefit-risk balance with the myocarditis risk is, you know, might be a little bit different. And that’s where a lot of the pushback comes through. But right, like you said, there is a fairly high … there’s myocarditis risk from covid itself that needs to be balanced.

Huetteman: Well, OK. That’s this week’s news. Now we’ll take a quick break and then we’ll come back with extra credits.

Julie Rovner: Hey, “What the Health?” listeners, you already know that few things in health care are ever simple. So, if you like our show, I recommend you also listen to “Tradeoffs,” a podcast that goes even deeper into our costly, complicated, and often counterintuitive health care system. Hosted by longtime health care journalist and friend Dan Gorenstein, “Tradeoffs” digs into the evidence and research data behind health care policies and tells the stories of real people impacted by decisions made in C-suites, doctors’ offices, and even Congress. Subscribe wherever you listen to your podcasts.

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

Karlin-Smith: Sure. So I looked at a MedPage Today page by Kristina Fiore that talks about a GoFundMe campaign that was started by a small rural hospital in Pennsylvania. They’re trying to raise $1.5 million to basically keep the hospital open. It’s the only hospital in the county. It’s a small critical-access hospital. And I think people who follow health care and health policy in the U.S. are probably used to seeing GoFundMe campaigns for individual health care, as we talked about earlier in the episode, right? The unaffordability that can happen even for people with good insurance if you … depending on your medical situation. But this situation, I thought, was really unique, a whole hospital, which is, I guess, community-owned, and they’re essentially turning to the internet to try and stay open. And it touches on some of the payment differences in how rural hospitals make their money, or the payment rates they get reimbursed versus more urban hospitals. Other issues it brings up is just, you know, how do you keep an institution open that’s serving a relatively small population of people? So, you don’t necessarily want to have people going to the hospital, but they’re basically arguing that if we don’t get this amount of people in our ER per day, we can’t stay open. But then that means you don’t have an ER for anybody. And I think it’s just worth looking at, looking at the facts they put on their GoFundMe page, just thinking about, you know, what this says about various policies in the U.S. health system. And, unfortunately for them right now, they’re well short of their $1.5 billion goal.

Huetteman: Yeah, it’s amazing to see this get translated into an institution-saving effort as opposed to an individual-saving effort. Joanne, you want to go next?

Kenen: Sure. This is a story that it was by Bianca Fortis from ProPublica, Laura Biel, who wrote this for ProPublica and New York Magazine, and also Laura, who’s a friend of mine, also has a fabulous podcast called “Exposed.” And in this case, I want to mention the photographer, too, because if you click on this, it’s quite extraordinary visuals. Hannah Whitaker from New York Magazine. And the title is “How Columbia …” — and this is the university, not the country — “How Columbia Ignored Women, Undermined Prosecutors and Protected a Predator for More Than 20 Years.” This is an OB-GYN who was abusing his patients, and it’s hundreds, hundreds that have been identified and known. We knew about him because some of the patients had come forward, including Evelyn Wang, who was Andrew Wang — is Andrew Wang’s wife, the presidential candidate last cycle. But we didn’t know this. You know, first of all, it’s even bigger than we knew three years ago, and he has been prosecuted — finally. But it took 20 years. And this is really more of a story about how the medical system, the health care system, had warning after warning after warning after warning, and they didn’t do anything. And also, many of the people who tried to give the warnings, some of the employees, including the medical assistants, and the nurses, and the receptionists, knew what was going on. And they thought that they, as lower-level women going up against a white male doctor, wouldn’t be believed. And they didn’t even try. They just felt like he’s the guy, he’s the doctor. I’m the, you know, I’m the nurse. They won’t listen to me. So that was another subtheme that came out to me. I had known vaguely about this. It’s really long, and I read every word. It’s a really horrifying saga of an abdication of responsibility to women who were really harmed. Vulnerable women who were really harmed.

Huetteman: Yeah, it’s a really troubling story, but it’s an important piece of journalism. And I advise that people give it a little time. Margot, would you like to go next?

Sanger-Katz: Yeah. So this is a very nerdy, deep cut. I wanted to talk about a CBO [Congressional Budget Office] report from 2012 called “Raising the Excise Tax on Cigarettes: Effects on Health and the Federal Budget.” So when I published this article about how Medicare spending has sort of flattened out, we got so many reader comments and emails and tweets and several people asked, “Could it be that the decline in smoking has led to lower costs for Medicare?” And that caused me to do some reporting and to read this paper. And I think the finding, the sort of counterintuitive finding that I will tell you about in a minute, from the CBO really speaks to some of the discussion that we were having earlier about these obesity drugs, which is that there are many beneficial preventive therapies in health care that are great for people’s health. They make them healthier, they have happier lives, they live longer, they have less burden of disease, but they are not cost-effective in the sense that they reduce our total spending on health care. And the simplest way to think about this is that if everyone in America just died at age 65, Medicare’s budget would look amazing. You know, it would be great. We would save so much money if we could just kill everyone at age 65. But that’s not what the goal of Medicare is. It’s not to save the maximum amount of money. It’s to get a good value, to improve people’s life and health as much as possible for a good value. And so this report was looking at what would happen if we had a really effective policy to reduce smoking in the United States. They looked at a tax that they estimated would reduce the smoking rate by a further 5 percentage points. And what they found is that it would cost the government more money, that people would be healthier, they would live longer lives, more of them would spend more years in Medicare, and they would end up having some other health problem that was expensive that they weren’t going to have before. And also they would collect a lot of Social Security payments because they would live a lot longer. And so I found it so stunning because the economics of it, I think, make a lot of sense. And when you think about it, it’s true. But it does go to show how, I think, that sometimes when we, and when politicians, talk about preventive health care, they always talk about it like it’s a win-win. You know, this is going to be great for people and it’s going to save money. And I think that in health care, many times things that are good and beneficial improve health and they cost money and we have to decide if it’s worth it.

Huetteman: Absolutely. That’s great. Thank you. My extra credit this week comes from KFF Health News. Dr. Elisabeth Rosenthal, our senior contributing editor, writes: “The Shrinking Number of Primary Care Physicians Is Reaching a Tipping Point.” And we’ve seen some great coverage lately on the disappearance of the primary care doctor in this country. And Dr. Rosenthal also offers some solutions to this yawning gap in our health care system. She reports that the percent of U.S. doctors that have moved into primary care is now at about 25%, which is much lower than in previous decades. And one point she makes, in particular, about a problem that’s leading to this is the payment structure that we have in our country favors surgeries and procedures, of course, not diagnostic tests, preventative care, when it comes to reimbursing doctors. And of course, this lack of primary care doctors has implications for our overall health, both individually and as a country. So I recommend that you give that article a little bit of your time this week.

All right. That’s our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left a review; that helps other people find us, too. Special thanks, as always, to our amazing engineer, Francis Ying. And as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can tweet me. I’m @emmarieDC. Sarah?

Karlin-Smith: I’m @SarahKarlin.

Huetteman: Joanne?

Kenen: @JoanneKenen on Twitter, @joannekenen1 on Threads.

Huetteman: And Margot.

Sanger-Katz: @sangerkatz in all the places.

Huetteman: We’ll 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.

Congress returns from its August recess with a long list of things to do and not a lot of time to do them. The fiscal year ends Sept. 30, and it’s possible that lawmakers will fail to finish work not only on the annual appropriations bills, but also on any short-term spending bill to keep the government open.

Meanwhile, Medicare has announced the first 10 drugs whose prices will be negotiated under the Inflation Reduction Act of 2022. Exactly how the program will work remains a question, however. Even how the process will begin is uncertain, as drugmakers and other groups have filed lawsuits to stop it.

This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs of Stat, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico, and Alice Miranda Ollstein of Politico.

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Rachel Cohrs
Stat News

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Joanne Kenen
Johns Hopkins Bloomberg School of Public Health and Politico

@JoanneKenen

Read Joanne's stories

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories

Among the takeaways from this week’s episode:

• Hard-line Republicans are refusing to back even a temporary government spending bill, suggesting a government shutdown looms — with repercussions for health programs. While the Senate and House have come to intra-chamber agreements on subjects like community health center funding or even have passed spending bills, Congress as a whole has been unable to broker an overarching deal.
• A coalition of House Republicans is falsely claiming that global HIV/AIDS funding through PEPFAR promotes abortion and is battling efforts to extend the program’s funding. PEPFAR is a bipartisan effort spearheaded by then-President George W. Bush and credited with saving millions of lives.
• The PEPFAR fight underscores the dysfunction of the current Congress, which is struggling to fund even a highly regarded, lifesaving program. Another example is the months-long blockade of military promotions by a freshman Republican senator, Alabama’s Tommy Tuberville, a member of the Senate Armed Services Committee. His objections over an abortion-related Pentagon policy have placed him at odds with top military leaders, who recently warned that his heavy-handed approach is weakening military readiness.
• The Biden administration recently announced new staffing requirements for nursing homes, as a way to get more nurses into such facilities. But how long will compliance take, considering ongoing nursing shortages? And the drug industry is reacting to the news of which 10 drugs will be up first for Medicare negotiation, with much left to be sorted out.
• In abortion news, a Texas effort to block patients seeking abortions from using the state’s roads is spreading town to town — and, despite being dubiously enforceable, it could still have a chilling effect.

Also this week, Rovner interviews Meena Seshamani, who leads the federal Medicare program, about the plan to start negotiating drug prices.

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

Julie Rovner: JAMA Health Forum’s “Health Systems and Social Services — A Bridge Too Far?” by Sherry Glied and Thomas D’Aunno.

Alice Miranda Ollstein: The Washington Post’s “Heat’s Hidden Risk,” by Shannon Osaka, Erin Patrick O’Connor, and John Muyskens.

Rachel Cohrs: The Wall Street Journal’s “How Novartis’s CEO Learned From His Mistakes and Got Help From an Unlikely Quarter,” by Jared S. Hopkins.

Joanne Kenen: Politico’s “How to Wage War on Conspiracy Theories,” by Joanne Kenen, and “Court Revives Doctors’ Lawsuit Saying FDA Overstepped Its Authority With Anti-Ivermectin Campaign,” by Kevin McGill.

Also mentioned in this week’s episode:

• The Washington Post’s “Highways Are the Next Antiabortion Target. One Texas Town Is Resisting,” by Caroline Kitchener.
• KFF Health News’ “Biden Administration Proposes New Standards to Boost Nursing Home Staffing,” by Jordan Rau.
• Stat’s “The Curious Case of J&J’s Stelara, The Unluckiest Drug on Medicare’s List,” by Rachel Cohrs.

Click to open the transcript

Transcript: Welcome Back, Congress. Now Get to Work.

[Editor’s note: This transcript, generated using transcription software, has been edited for style and clarity.]

Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Sept. 7, 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 Rachel Cohrs of Stat News.

Rachel Cohrs: Good morning.

Rovner: Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico.

Joanne Kenen: Hi, everybody.

Rovner: And Alice Miranda Ollstein of Politico.

Alice Miranda Ollstein: Hello.

Rovner: Later in this episode, we’ll have an interview with Meena Seshamani, who runs the Medicare program for the federal government, with an update on the Medicare drug negotiation debate as, we’ll discuss, the first 10 drugs that will be subject to negotiation were announced last week. But first, this week’s news. So Labor Day is behind us, and Congress is back — sort of. The Senate is back. The House returns next week. And there are lots of questions to be answered this fall, starting with whether or not Congress can finish the annual spending bills before the start of fiscal 2024 on Oct. 1. Spoiler: They cannot. But there’s also a real question whether Congress can even pass a short-term bill to keep the government running while lawmakers continue to work on the rest of the appropriations. As of now, what do you guys think are the odds that we’re going to end up with some kind of government shutdown at the end of the month?

Ollstein: Well, it’s whether it happens at the end of the month or at the end of the year, really. Folks seem pretty convinced that it will happen at some point. It could be short-lived. But, yeah, like you said, you have some hard-line House Republicans who say they won’t support even a temporary stopgap bill without spending cuts, policy changes, without sort of extracting some of their demands from leadership. And you could work around that in the House by cobbling together a coalition of Republicans and Democrats. But that also puts [House Speaker Kevin] McCarthy’s leadership in jeopardy. And so, we’re having sort of the same dynamic play out that we saw earlier this year, trying to navigate between the hard-line House Republicans and, you know, the more vulnerable swing districts’ members. So it’s … tough.

Rovner: Yeah, it’s the Republicans from districts that [President Joe] Biden won … basically.

Ollstein: Yeah. And so you have this weird game of chicken right now where both the House and Senate are trying to pass whatever they can to give themselves more leverage in the ultimate House-Senate negotiations. They think, OK, if we pass five bills and they only pass one, you know, then we have the upper hand. So we’ll see where that goes.

Rovner: It’s funny, because the Senate has been a well-oiled machine this year on the spending bills, which is unusual. I was about to say I will point out that there are two women: the chairman and ranking member. But that’s actually also true in the House. We do have women running the appropriations process this year. But I was amused that Kevin McCarthy, sometime during August, a couple of weeks ago, said, you know, very confidently, well, we’ll pass a short-term spending bill. You know, we won’t let the government shut down. And by the next day, the hard-line Republicans, the right wing, were saying, yeah, no you won’t. You’re going to have to deal with us first. And, obviously, there’s lots of health stuff that’s going to get caught up in that. The end of the fiscal year also marks the end of funding authority for a number of prominent programs. This is not the same as the appropriations programs whose authorizations lapse can continue, although things can get complicated. PEPFAR, the two-decade-old bipartisan program that provides AIDS and HIV prevention and treatment around the world, is one of those programs that, at least as of now, looks pretty stuck. Alice, is there any movement on this? We’ve talked about it before.

Ollstein: Not yet. So the latest we know, and we got this last night, is that [Foreign Relations Committee] Chairman [Bob] Menendez in the Senate is floating a new compromise. Basically, supporters of PEPFAR have been pushing for the full five-year standard reauthorization. And a coalition of House Republicans who are claiming that PEPFAR money is going to abortion say they want no reauthorization at all. They just want the program to sort of limp along through appropriations. So between five years and zero, Menendez is now suggesting a three-year extension. There is a huge desire not to just have the one-year funding patch because that would kick all of this into the heat of the 2024 season. And if you think the debate is ugly now over abortion and federal spending, just wait until 2024.

Kenen: I mean, this … [unintelligible] money … it’s saved tens of millions of lives — and with bipartisan support in the past.

Rovner: It was a Republican initiative.

Kenen: Right. It was President Bush, George the second.

Rovner: George W. Bush. Yeah.

Kenen: And they’re not saying they’re actually going out and using the AIDS dollars to conduct, to actually do abortions. They’re saying that there’s, you know, they’re in the world of abortion and they’re promoting abortion, etc., etc. So the conversation gets really, really, really, really muddled. Under U.S. law, they cannot use U.S. dollars for abortion under the Hyde Amendment, you know, all sorts of other foreign policy rules. So it’s hard to overstate how important this program has been, particularly in Africa. It has saved millions and millions of lives. And I think Alice might have broken the story originally, but it got caught up in abortion politics, and it caught people by surprise. This is not something … everything in Washington gets caught up in politics, except this! So I think it’s been quite shocking to people. And it’s, I mean — life-and-death sounds like a, you know, it’s a Washington cliché — this is life-and-death.

Ollstein: Yeah, absolutely. And, you know, even though the program won’t shut down if they don’t manage to get a reauthorization through, you know, I talked to people who run PEPFAR services in other countries, and they said that, you know, having this year-to-year funding and instability and uncertainty — you know, they won’t be able to hire, they won’t be able to do long-term planning. They said this will really undermine the goal to eliminate HIV transmission by 2030.

Cohrs: Oh, I actually did just want to jump in about another Sept. 30 deadline, because there was a big development this week. I know we were just talking about long-term planning. There is funding for community health centers that’s expiring at the end of September as well. DSH cuts could go into effect for hospitals. We do this routine every so often, but the House is actually more in step than the Senate on this issue; they released — at least Republicans released — a draft legislation, where all three committees of jurisdiction are in agreement about how to proceed. There are some transparency measures in there.

Rovner: The three committees in the House.

Cohrs: In the House. Yes, yes, we’re talking about the House. Yeah. So, they have reconciled their differences here and are hoping to go to the floor this month. So, I think they are out of the gate first, certainly with some sort of longer-term solution here. Again, could get punted. But I think it is a pretty big development when we’re talking about these extenders that the industry cares about very much.

Kenen: Congress is so polarized that it can’t even do the things that it agrees on. And we have seen this before where CHIP [Children’s Health Insurance Program] got caught up a few years ago. Community health clinics have gotten caught right in that same bill, right? But, you know, we really have this situation where it’s so dysfunctional they can’t even move fully on things that everybody likes. And community health centers date back to the early ’60s. However, they got a really big expansion, again, under second President Bush. And they’re popular, and they serve a need, and everybody likes them.

Rovner: They got a bigger expansion under the Affordable Care Act.

Kenen: Right, but they, you know — but I think that the Bush years was like the biggest in many years. And then they got more. So again, I mean, are they going to shut their doors? No. Is it going to be a mess? It is already a mess. They can’t — they don’t know what’s coming next. That’s no way to run a railroad or a health clinic.

Rovner: All right, well, one more while we’re on the subject of abortion-related delays: Alabama Sen. Tommy Tuberville is still blocking Senate approval of routine military promotions to protest the Biden administration’s policy of allowing funding for servicewomen and military dependents to travel for abortions if they’re posted to states where it’s banned. Now, the secretaries of the Army, Navy, and Air Force are joining together to warn that Tuberville’s hold is threatening military readiness. Tuberville apparently went on Fox News last night and said he’s got more people who are coming to support him. Is there any end to this standoff in sight? I mean, people seem to be getting kind of upset about it. It’s been going on since, what, February?

Ollstein: Yeah, there is not yet an end in sight. So far, all of the attempts to pressure Tuberville to back down have only hardened his resolve, it seems, you know, and he’s gone beyond sort of his original statement of, you know, all of this is just to get rid of this policy that doesn’t pay for abortions; it just allows people to travel out of state if they’re stationed — they don’t get to choose where they’re stationed — if they’re stationed somewhere where abortion is not legal or accessible. And so now he’s making claims about other things in the military he considers too woke. He’s criticized some of these individual nominees themselves that he’s blocking, which was not sort of part of the original stand he took. And so, it’s tough, and there isn’t enough floor time to move all of these and go around him. And so this pressure campaign doesn’t seem to be really making any headway. So I don’t really see how this gets resolved at this point.

Kenen: Except that other Republicans are getting a little bit more public. I mean, they were sort of letting him run out for a while. And there’s more Republicans who are clearly getting enough of this. But I mean, unless McConnell can really get him to move — and we don’t know what’s gone on behind closed doors, but we’re certainly not seeing any sign of movement. In fact, as Alice said, he’s digging in more. I mean, like, Marines and woke are not the two words you usually hear in one sentence, but in his worldview, they are. So, I think it’s unprecedented. I mean, I don’t think anyone’s ever done this. It’s not like one or two people. It’s like the entire U.S. military command can’t move ahead.

Rovner: I’ve been doing this a very long time, and I don’t remember anything quite like this. Well, the one thing that we do expect to happen this fall is legislation on — and Rachel, you were referring to this already — sort of health care price transparency and PBMs, the pharmacy benefit managers. Where are we with that? They were supposed to work on it over the August break. Did they?

Cohrs: They were supposed to work on it. The House was clearly working on it and reconciling some of their differences. They’re planning to introduce legislative text on Friday. So, I think Democrats aren’t on board yet, so things could change from the draft they had been circulating early this week. But again, Republicans don’t really need Democrats to move forward, at least in the House. The Senate has been pretty quiet so far. Not to say that no work has gone on, but they certainly weren’t ready for the rollout in the same way that the House was. You know, I think there are still some big questions about, you know, what they’re planning to accomplish with insulin policy, how they’re planning to fit together this jigsaw puzzle of PBM transparency and reforms that have come out of different committees. And I think it’ll come down to [Senate Majority Leader] Sen. Schumer making some tough choices. And from my understanding, that hasn’t quite happened yet. But if the actual showdown happens November, December, they still have some time.

Rovner: Yeah. Now they’re not going out early. They’re clearly going to be fighting over the appropriation. So, the legislative committees have plenty of time to work on these other things. All right. Well, let’s turn to Medicaid for a moment. The quote-unquote “unwinding” continues as states move to redetermine who remains eligible for the program and who doesn’t following the pandemic pause. As predicted, it’s been a bit of a bumpy road. And now it seems a bunch of states have been incorrectly dropping children from Medicaid coverage because their parents are no longer eligible. That’s a problem because nationwide, income limits for children’s eligibility is higher than parents’. In some states, it is much higher. I remember after Hurricane Katrina, in Louisiana, parents were only eligible if they earned 15% of poverty. Somebody said 50, and the Medicaid director said, “No, 15, one-five.” Whereas kids are eligible to, I believe it’s 200% of poverty. And I think that’s a national level.

Kenen: Now, in some states it’s higher.

Rovner: Yes. But I say this is happening in a bunch of states because federal government won’t tell us how many or which ones. We do know it’s more than a dozen, but this is the second time the administration has admonished states for wrongly canceling Medicaid coverage. And they wouldn’t say which states were involved at that time either. Is this an effort to keep this as apolitical as possible, given that the states most likely to be doing this are red states who are trying to remove ineligible people from Medicaid as fast as they can, that they’re trying to sort of keep this from becoming a Republican versus Democrat thing.

Ollstein: It seems like, from what we’re hearing, that the administration is really wary of publicly picking a fight with these states. They want the states to work with them. And so, even if the states are going about this in a way they think is totally wrong, they don’t want to just put them publicly on blast, because they think that’ll make them, again, double down and refuse to work with the government at all. And so, they’re trying to maintain some veneer of cooperation. But at the same time, you’re having, you know, millions of people, including children, falling through the cracks. And so, you know, we have sort of this sternly-worded-letter approach and we’ll see if that accomplishes anything, and if not, you know, what measures can be taken. You know, the administration also created a way for states to hit pause on the process and take a little more time and do a little more verification of people’s eligibility. And some — a couple states — have taken advantage of that, and it’s been successful in, you know, having fewer people dropped for paperwork reasons, but it’s not really happening in the states where it sort of most needs to happen, according to experts.

Rovner: The administration has had fingers pointed at it, too, because apparently it approved some of these plans from the states that were going to look at total family income without realizing that, oh, that meant that kids who are still eligible could end up losing coverage because their parents are no longer eligible.

Kenen: Right. And I also read something yesterday that in some cases it’s sort of a technical issue rather than a “how much outreach and what your intentions are,” that it’s a programing issue, which is related to what Julie just said about the plan. So, it’s not that these states set about to drop these kids, and there may be some kind of goodwill to fix it, in which case you don’t want to get in — and I don’t know that it’s 100% red states either. So —

Rovner: No, that’s clear. We assume, because they’re the ones going fastest, but we do not know.

Kenen: Right, so that there seems to be some kind of — the way it was set up, technically, that can be remedied. And if it’s a technical fix as opposed to an ideological fight, you don’t really want to — you want to figure out how to reprogram the computer or whatever it is they have to do and then go back and catch the people that were lost. So, they’ve been pretty low-key about politicizing rewinding in general. But on the kids, I think they’re going to be even more — CHIP passed, another thing with bipartisan support that’s a mess. I mean, it seems to be the theme of the day. But, you know, CHIP was created on a bipartisan basis, and it’s always been sustained on a bipartisan basis. So, I think that the issue, I don’t know how technically easy it is to fix, but there’s a big difference in how the administration goes after someone that’s intentionally doing something versus someone who wrote their computer programmer set something up wrong.

Rovner: Well, we will definitely keep on this one.

Kenen: But it’s a big mess. It’s a lot of kids.

Rovner: It is a big mess. And let’s turn to the thing that is not bipartisan in Congress, and that is —

Kenen: That’ll be a bigger mess.

Rovner: — Medicare drug negotiations. Yes. While we were away, the federal government released its much-anticipated list of the 10 brand-name drugs that will be the first tranche up for potential price negotiation. I say potential, because the companies have the option of negotiating or not — sort of — and because there are now, I think, nine lawsuits challenging the entire program. My interview with Medicare administrator Meena Seshamani will get into the nuts and bolts of how the negotiation program is supposed to work. But Rachel, tell us a little bit about the drugs on the list and how their makers are trying to cancel this entire enterprise before it even begins.

Cohrs: Sure. So, a lot of these drugs that we’re seeing on the list are blood thinners. Some are diabetes medications. There are drugs for heart failure, rheumatoid arthritis, Crohn’s disease, and there’s also a cancer treatment, too. But I think overall, the drugs were chosen because they have high cost to Medicare. And it was —

Rovner: So that either could mean a lot of people use an inexpensive drug —

Cohrs: Yes.

Rovner: — or a few people use a very expensive drug.

Cohrs: Correct. And it was Wall Street’s favorite parlor game to try to guess what drugs were going to be on this list of 10 drugs that are going to be the guinea pigs to go through this program for the very first time. But it was interesting, because there were a few surprises. Medicare officials were using newer data than Wall Street analysts had access to. So, there were a couple drugs, especially further down on the list, that people used more in the period CMS [Centers for Medicare & Medicaid Services] was studying than had been used previously. So, we saw a couple very interesting instances of a drug being chosen for the list, even though it just kind of fell through the cracks. It was J&J’s [Johnson & Johnson’s] Stelara. It’s a Crohn’s disease treatment, and it does have competition coming in the market soon, but just because of a fluke of kind of when it was approved by the FDA, it just missed cutoffs for some of these exemptions and is now subject to some pretty significant discounts through the program.

Rovner: We’ll link to your very sad story about Stelara.

Cohrs: Sad for the company, but not sad for the patients who will hopefully be paying less for this medication. And there’s also the case of Astellas [Pharma Inc.], which makes a prostate cancer drug that’s very expensive. A lot of people expected that to be selected, but actually wasn’t. And Astellas had sued the Biden administration already before the list came out and then had to withdraw their lawsuit yesterday because their argument that they were going to be harmed by this legislation was made much weaker by the fact that they weren’t selected for this first year of the program. So, who knows? They could dust off their arguments a year from now or two years from now. But it was interesting to see kind of some of these surprises on the list. Again, there are still several, like you mentioned, outstanding lawsuits in several different jurisdictions. I think the main one that we’re watching is by the [U.S.] Chamber of Commerce, which requested a preliminary injunction by the end of this month. So, we’ll see if that comes through. But it is a very long road to 2026. There might be a new administration by then. So, I think there are still a lot of questions about whether this reaches the finish line. But I think it’s a very important step for CMS to get this list out there in the world.

Rovner: So, I spent some time digging in my notes from earlier years, and I dug up notes from an interview I did on Aug. 26 with a spokesperson from the drug industry about how the Medicare drug benefit, quote, “impact the ability of companies to research new medicines. And if that happens, the elderly would be the ones hurt the most.” That quote, by the way, was from Aug. 26 of 1987. Some things truly never change. But is this maybe, possibly, the beginning of the end of drugmakers being able to charge whatever they want in the United States? Because it’s the only country where they can.

Cohrs: Oh, they can still charge whatever they want. This law doesn’t change that. It just changes the fact that Medicare won’t be paying whatever drugmakers happen to charge for an unlimited amount of time. Like, they can still charge whatever they want to Medicare for as long as they can get on the market before they’re selected for this negotiation program. But certainly there could be significant cost — significant savings to Medicare, even if those prices are high. And it’s just kind of a measure that forces price reductions, even if the generic or biosimilar market isn’t functioning to lower those prices through competition.

Kenen: Right. And it’s only Medicare. So, people who are not on Medicare — insurance companies also negotiate prices, but they’re not the government. It’s different. But I mean, these drugs are not going to start being, you know, three bucks.

Rovner: But they may stop being 300,000.

Kenen: Well, we don’t know, because there are some people who think that if Medicare is paying less, they’re going to charge everybody else more. We just don’t know. We don’t know what their behavior is going to be. But no, this does not solve the question of affordability of medication in the United States.

Rovner: The drug companies certainly think it’s the camel’s nose under the tent.

Kenen: They have some medicine for camels’ noses that they can charge a lot of money for, I’m sure.

Rovner: I bet they do. While we are on the subject of things that I have covered since the 1980s, last week the Biden administration finally put out its regulation requiring that nursing homes be staffed 24/7/365 by, you know, an actual nurse. One of the first big reconciliation bills I covered was in 1987 — that was a big year for health policy — and it completely overhauled federal regulation of nursing homes, except for mandating staffing standards, because the nursing homes said they couldn’t afford it. Basically, that same fight has been going on ever since. Except now the industry also says there aren’t enough nurses to hire, even if they could afford it. Yet patient advocates say these admittedly low staffing ratios that the Biden administration has put out are still not enough. So, what happens now? Is this going to be like the prescription drug industry, where they’re going to try to sue their way out of it? Or is it going to be more like the hospital transparency, where they’re just not going to do it and say, “Come and get us”?

Kenen: My suspicion is litigation, but it’s too soon to know. I assume that either one of the nursing home chains — because there are some very big corporations that own a lot of nursing homes — there are several nursing home trade industry groups, for-profit, nonprofit. Does one owner — is in an area where there is a workforce shortage, because that does exist. I mean, I’d be surprised if we don’t see some litigation, because when don’t we see that? I mean, it’s rare. That’s the norm in health care, is somebody sues. Some of the workforce issues are real, but also this proposal doesn’t go into effect tomorrow. It’s not like — but I mean, there are issues of the nursing workforce. There are issues about not just the number of nurses, but do we have them in the right places doing the right jobs? It’s not just RNs [registered nurses]; there are also shortages of other direct care workers. I did a story a few months ago on this, and there are actually nursing homes that have closed entire wings because they don’t have enough staff, and those are some of the nonprofits. There are nursing issues.

Rovner: And a lot of nursing home staff got sick at the beginning of the covid pandemic, and many of them died before there were good treatments. I mean, it’s always been a very hard and not very well-paid job to care for people in nursing homes. And then it became a not very pleasant, not very well-paid, and very deadly job. So I don’t think that’s probably helping the recruitment of people to work in nursing.

Kenen: Right, but the issue — I think a lot of people, when you have your first family experience with a nursing home or, you know, or those of us reporters who hadn’t been familiar with them until we went and did some stories on them, I think people are surprised at how little nursing there actually is. It’s nurses’ aides; it’s, you know, what they used to call licensed practical nurses or nursing assistants; and CNAs, certified nursing assistants. They’re various; different states have different names. But these are not four-year RNs. The amount of actual nursing — forget doctors. I mean, there’s just not a lot of RNs in nursing homes. There’s not a lot of doctors who spend time in nursing homes. A lot of the care is done through people with less training. So, this is trying to get more nurses in nursing homes. And there’s been a lot of stories about inadequate care. KFF Health News — I think it was Jordan Rau who did them. There have been some good stories about particularly nights and weekends, just really nobody there. These are fragile people. And they wouldn’t be in a nursing home if they weren’t fragile people. There are a lot of horror stories. At the same time, there are some legitimate — How fast can you do this? And how well can you do it? And can you do it across the country? I mean, it’s going to take some working out, but I don’t think anybody thinks that nursing home care in this country is, you know, a paragon of what we want our elders to experience.

Rovner: And the nursing home industry points out, truthfully, that most nursing home payments now come from Medicaid, because even people who start out being able to afford it themselves often run out of money and then they end up — then they qualify for Medicaid. And Medicaid in many states doesn’t pay very much, doesn’t pay nursing homes very much. So it’s hard for these companies. We’re not even talking about the private equity companies. A lot of nursing homes operate on the financial edge. I mean, there are —our long-term care policy in this country is, you know, just: What happens, happens, and we’ll worry about it later. And this has been going on for 50 years. And now we have baby boomers retiring and getting older and needing nursing home care. And at some point, this is all going to come to a head. All right. Well, let us turn to abortion. This week marks the second anniversary of the Texas abortion ban, the so-called heartbeat bill, that bans most abortion and lets individuals sue other individuals for helping anyone getting an abortion, which the Supreme Court, if you’ll recall, allowed to take effect months before it formally overturned Roe v. Wade. And, I guess not surprisingly, Texas is still in the news about abortion. This time. The same people who brought us Texas SB 8, which is the heartbeat bill, are going town by town and trying to pass ordinances that make it illegal to use roads within that town’s borders to help anyone obtain an abortion. They’re calling it abortion “trafficking.” Now, it’s not only not clear to me whether a local ordinance can even impact a state or an interstate highway, which is what these laws are mostly aimed at; but how on earth would you enforce something like this, even if you want to?

Ollstein: So, my impression is that they do not want to. These are not meant to be practical. They are not meant to be enforced, because how would you do it other than implementing a very totalitarian checkpoint system? This is meant to —

Rovner: Yes, have you been drinking and are you on your way to get an abortion?

Ollstein: Right. Right, right, right. So, it seems like the main purpose is to have a chilling effect, which it very well could have, even if it doesn’t stand up in court. You know, you also have this situation that we’ve had play out in other ways, where people are challenging laws in courts for having a chilling effect, and courts are saying, look, you have to wait till you actually get prosecuted and challenge it, you know, do an as-applied challenge. If you can’t challenge unless there’s a prosecution but there’s no prosecutions, then you sort of just have it hanging over your head like a cloud.

Kenen: Like Alice said, there’s no way you could do this. Like, what do you do, stop every car and give every person a pregnancy test? Are you going to, like, have, you know, ultrasounds on the E-ZPass monitors? Like, you go through it, it checks your uterus. So, I mean, it’s just not — you can’t do this. But I think one of the things that was really interesting in one of the stories I read about it, I think it was in The Washington Post, was that when they interviewed people about it, they thought it was trafficking, like really trafficking, that there were pregnant woman being kidnapped and forced to have an abortion. So even if you’re pro-choice, you might say, “Oh, I’m against abortion trafficking. I mean, I don’t want anyone to be forced to have an abortion.” You know, so, it’s — the wording and the whole design of it is, they know what they’re doing. I mean, they want to create this confusion. They want to create a disincentive. There’s no way — you know, radar guns? I mean, it’s just, there’s no way of doing this. But it is part of the effort to clamp down even further on a state that has already really, really, really clamped down.

Rovner: Although, I mean, if one could sue and if one could then know about something that’s happening and then you could presumably take the person to court and say, I know you were pregnant and now you’re not, and somebody took you in a car to New Mexico or whatever …

Kenen: You can’t even prove — how do you prove that it wasn’t a miscarriage?

Rovner: That’s —

Kenen: Right? I mean …

Rovner: I’m not saying — I’m not talking about the burden of proof. I’m just saying in theory, somebody could try to have a case here. I mean, but we certainly know that Texas has done a very good job creating a chilling effect, because we still have this lawsuit from the women who were not seeking abortions, who had pregnancy complications and were unable to get health-saving and, in some cases, lifesaving care promptly. And that’s still being litigated. But meanwhile, we have, you know, just today a study out from the Guttmacher Institute that showed that despite how well these states that are banning abortion have done in banning abortion, there were presumably more abortions in the first half of 2023 than there were before these bans took effect, because women from ban states were going to states where it is not banned. And there has been, ironically, better access in those states where it is not banned. I can’t imagine that this is going to please the anti-abortion community. One would think it would make them double down, wouldn’t it?

Ollstein: We know that people are leaving their states to obtain an abortion. We also know that that’s not an option for a lot of people, and not just because a lot of people can’t afford it or they can’t take time off work, they can’t get child care — tons of reasons why somebody might not be able to travel out of state. They have a disability, they’re undocumented. We also have — it’s become easier and easier and easier to obtain abortion pills online through, you know, a variety of ways: individual doctors in more progressive states, big online pharmacies are engaged in this, overseas activist groups are engaged in this. And so, you know, that’s also become an option for a lot of people. And anti-abortion groups know that those are the two main methods. People are still continuing to have abortions. And so, they’re continuing to just throw out different ways to try to either, you know, deter people or actually block them from either of those paths.

Rovner: This fight will also continue on. So, that is this week’s news. Now we will play my interview with Meena Seshamani, and then we will come back and do our extra credits.

Hey, “What the Health?” listeners, you already know that few things in health care are ever simple. So, if you like our show, I recommend you also listen to “Tradeoffs,” a podcast that goes even deeper into our costly, complicated, and often counterintuitive health care system. Hosted by longtime health care journalist and friend Dan Gorenstein, “Tradeoffs” digs into the evidence and research data behind health care policies and tells the stories of real people impacted by decisions made in C-suites, doctors’ offices, and even Congress. Subscribe wherever you listen to your podcasts.

I am pleased to welcome back to the podcast Dr. Meena Seshamani, deputy administrator and director of the Center for Medicare at the Centers for Medicare & Medicaid Services. Meena was with us to talk generally about Medicare’s new prescription drug negotiation program earlier this summer. But now that the first 10 drugs subject to negotiation have been announced, we’re pleased to have her back. Welcome.

Meena Seshamani: Thank you for having me.

Rovner: So, remind our listeners, why hasn’t Medicare been able to negotiate drug prices until now — they negotiate prices of everything else — and what changed to make that happen?

Seshamani: That’s right. It was because of the Medicare law that Medicare did not have the ability to negotiate drugs. And thanks to the new drug law, the Inflation Reduction Act, now Medicare has the ability to negotiate the prices of the highest-cost drugs that don’t have competition. And that is part of the announcement that we had on what the first 10 drugs are that have been selected.

Rovner: So, as you say, last week, for the first time and in time for the Sept. 1 deadline, Medicare announced the list of the first 10 drugs that will be part of the first round of price negotiations. Why these 10 specifically? I imagine it’s not a coincidence that the list includes some of the drugs whose ads we see the most often on TV: drugs like Eliquis, Xarelto, and Jardiance, which I of course know how to pronounce because I see the ads all the time.

Seshamani: Well, the process of selection really was laid out in the drug law and also through the guidance that we put out that we had incorporated everybody’s comment for. So, what we did is we started with the, you know, over 7,500 drugs that are covered in the Part D Medicare prescription drug program. From there, we picked those drugs that had been on the market for seven years for a drug product or 11 years for a larger molecule or biologic product that did not have competition. And then from there, there are various exemptions and exclusions that, again, are laid out in the law: for example, drugs that have low Medicare spend, of less than $200 million; drugs that are plasma-derived products; certain orphan drugs. An orphan drug is a drug that is indicated for a rarer disease. So that, again, those specific criteria are laid out in the law and in our guidance. And then there were opportunities for manufacturers to apply, for example, for a small biotech exemption; if their drug was, you know, 80% of their, you know, Medicare Part D revenue, they could say, “Hey, I’m a small biotech.” Again, a lot of these criteria were laid out in the law. Or for a manufacturer of a biosimilar, which is kind of like a generic drug for one of these biologic drugs, they could say, “Hey, we have a biosimilar that’s going to be coming on the market, has a high likelihood of coming on the market, so you should delay negotiating” the brand, if you will, drug. So, again, all of these steps were laid out in the drug law, and those are the steps and criteria that we followed that came to that list of 10 drugs that we published.

Rovner: I did see the makers of one drug — and forgive me, I can’t remember which one it was — saying, “But our drug isn’t that expensive.” On the other hand, their drug is used by a lot of people on Medicare. So, it’s not just the list price of the drug, right? It’s how much it costs Medicare overall.

Seshamani: That’s right. The list is made up of those drugs that have the highest gross total cost to the program — so, price per unit times units of volume that is used.

Rovner: So, how does this negotiation process work? What happens now? Now we have this list of 10 drugs.

Seshamani: Yeah, a lot of this is also laid out in the law, and then we fleshed out further in our guidance. So, from the list of 10 drugs, on Oct. 1, manufacturers now have to decide if they want to participate in the negotiation program. It is a voluntary program. It is our hope that they will come to the table and want to negotiate, because I think we all have shared goals of improving access and affordability and really driving innovation for the cures and therapies that people need. So, Oct. 1, they sign agreements for the negotiation program if they decide to participate. And Oct. 2 is the deadline for gathering data. We put out what’s called an information collection request to say, this is the kind of data we’re thinking about collecting. We got lots of comments and incorporated that. So, that provides the framework for the data that we’re requesting both from the manufacturer of the selected drug, but also, there are aspects open to the public on, you know, how the drug benefits populations, for example. So that’s Oct. 2. Then we’re going to have patient-focused listening sessions, a session for each drug, for patients, their caregivers, you know, other advocates, to be able to share what they see as the benefits of the drugs that are selected. And, we will have meetings with each of the manufacturers. All of that information will come together in an initial offer that CMS will make Feb. 1, 2024, and that is a date that is stipulated in the law. The manufacturer then has about 30 days to evaluate that. If they like that offer, they can agree. If they want, they can make a counteroffer. From that counteroffer, CMS has the ability to agree or to say, “You know, we don’t agree, so let’s now have a series of negotiation meetings.” There can be up to three negotiation meetings that provides that back-and-forth, ultimately leading to an agreed-upon what’s called maximum fair price in the law. And those maximum fair prices are published by Sept. 1, 2024. Again, that Sept. 1 is stipulated in the law. And also as part of this process, CMS will publish a narrative about that negotiation process — you know, the data that was received, you know, the back-and-forth, and also we’ll publish ultimately the maximum fair prices that are agreed to.

Rovner: And does that maximum fair price just apply to Medicare?

Seshamani: The maximum fair price just applies to Medicare. The information will be available. I mean, we don’t have any authority. You know, the commercial sector, they do their own negotiations, and they will continue to do so. But part of this is an opportunity to really further the conversation about how drugs impact the lives of people. We have an opportunity now with some drugs that have been on the market for quite a while, right? Minimum of seven years or 11 years, to see how these drugs work in the real world, in people’s communities, so that we can incorporate that into what it is that we need and want for people to be healthy, to stay out of the hospital, to live meaningful lives. So it’s really an opportunity to further that conversation. And a lot of that data, a lot of those listening sessions, that will all go into our negotiation process and will be part of the narrative that we publish.

Rovner: And what happens if the drug company says either we don’t want to negotiate or we don’t like our final offer? If they say they don’t want to play, what happens?

Seshamani: Julie, I will say again, to start with, we are hopeful that the drug companies will come forward and will want to negotiate because, again, through many conversations that we have had, we do have shared goals of access and affordability and really driving innovation and procures and therapies that people need. And it is a choice for drug companies if they want to participate or not, as stipulated in the law. If a drug company decides not to sign, you know, the negotiation agreement, not to participate in negotiation, then we would refer them to the Department of Treasury for an excise tax. That excise tax is also described in the law. If a drug company has this excise tax applied, they can get out of paying the excise tax. If, No. 1, they decide to come to the table and negotiate, or No. 2, if they exit the Medicare and Medicaid market. So those are kind of their off-ramps, if you will, for that excise tax.

Rovner: So they don’t have to participate in the negotiation, but they also don’t have to participate in Medicare and Medicaid.

Seshamani: Correct.

Rovner: So I saw a lot of complaining last week with the first group of drugs that this is really only going to benefit the people on Medicare who take those drugs. But, in fact, if there really is a lot of money saved, the benefits could go well beyond this, right?

Seshamani: Yeah, I think two points. So, yes, this negotiation is for, you know, some of the highest-cost drugs to the Medicare program that don’t have competition. And the negotiated drug prices apply to the Medicare program. However, as we talked about, this really drives a conversation around drugs and really grounding this negotiation process in the clinical benefit that a drug provides. Considering things like if a drug is easier for someone to take and it’s easier for a caregiver, that can have tangible improvements to the health of the person they’re caring for, right? And I think we have that opportunity to really drive the conversation. And as we know in many aspects of health care, people look to Medicare to see what Medicare is doing. And also, the transparency around providing that narrative of the negotiation, publishing the maximum fair prices that are agreed to. That’s all data that anybody can use as they would like. And I think the second piece that’s important to remember is that negotiation is one very important piece of a very big change to Medicare prescription drug coverage. You know, alongside the $2,000 out-of-pocket tab that’s going to go into effect in 2025, the no-cost vaccines, $35 copay cap for insulin that have already gone into effect. So, really, it is part of a larger sea change in Medicare drug coverage that will help millions of people and their families. You know, I did a roundtable with seniors as we were rolling out the insulin copay cap. And one woman was telling me that she was providing money to her brother every month so that he could pay for his insulin on Medicare. So, really, I mean, this has tremendous impact not just for people on Medicare, but their families, their communities, and really furthers the conversation for the entire system.

Rovner: I was actually thinking of more nitty-gritty money, which is if you save money for Medicare, premiums will be lower for people who are getting drug coverage, and taxpayers will save money, too, right? I mean, this is not just for these people and their families.

Seshamani: Our priority is being able to reach agreement on a fair price for the people who rely on these medications for their lives and the American taxpayer in the Medicare program.

Rovner: I know you can’t comment on lawsuits, and there are many lawsuits already challenging this. But the drug companies, one of their major arguments is that if you limit what they can charge for their drugs, particularly in the United States, the last country where they can charge whatever they want for their drugs, they will not be able to afford to keep the pipeline going to discover more new, important drugs. This is an argument they’ve been making since, I told somebody earlier, since I covered this in the late 1980s. What is your response just to that argument?

Seshamani: Well, I think there were several articles, many articles were written about this on the day that the 10 selected drugs were published. They were published before the stock market opened. And there really was no impact on the stocks of the companies. There were many financial pieces written about this. So I think that is one indication of the fact that the pharmaceutical industry is strong, it is thriving, and it is designed to innovate. And what we’re hoping to do through this negotiation program is really reward the kinds of innovations that we all need, the cures and therapies that people need. Recently, the venture fund that backed Moderna invested in a new startup for small molecules. Bayer has recently invested a billion dollars in the U.S. So you see, the industry very much is thriving. That is what the stock market response also shows. And it’s also the way that we are approaching negotiation to make sure that we’re rewarding the kinds of innovations that people need.

Rovner: Well, Meena Seshamani, thank you so much. I hope we can come back to you as this negotiation process for the first time proceeds.

Seshamani: Absolutely. Thanks again, Julie.

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

Ollstein: Yeah, I picked a very sad story from The Washington Post about how people who have schizophrenia are a lot more vulnerable to extreme heat. And it’s rare to find one of these health care stories where you’re just astonished. You know, I had no idea about this. You know, it really walks through not only are people more vulnerable for mental health reasons, you know, it profiles this terrible story of a guy in Phoenix who wandered off into the desert and died because he was experiencing paranoid delusions. But also, just physically, people with schizophrenia have difficulty regulating their body temperature. A lot of medications people take make people more dehydrated, less able to cope. And just an astonishingly high percentage of people hospitalized and killed by extreme heat have these mental illnesses. Of course, they’re also more likely to have housing instability or be out on the street. So just a fascinating piece, and I hope it spurs cities to think of ways to address it. One other small thing I want to compliment is it just, technically, on this article online, they have a little widget where you can convert all of the temperatures cited in the lengthy story from Fahrenheit to Celsius. And I just really appreciated that for allowing, you know, no matter where you live, you sort of get what these high temperatures mean.

Rovner: Yeah, graphics can be really helpful sometimes. Rachel.

Cohrs: Yeah. So I chose a story in The Wall Street Journal and the headline is “How Novartis’s CEO Learned From His Mistakes and Got Help From an Unlikely Quarter,” by Jared S. Hopkins. And I think it was a really interesting and rare look inside one of these pharmaceutical companies. And Novartis hired a Wall Street analyst, Ronny Gal, to help advise them. And I think I had read his analysis before he crossed over to Novartis. So I think it was interesting to just hear how that has integrated into Novartis’ strategy and just how they’re changing their business. But I think as we’re, you know, having these conversations about drug pricing and how strategies are changing due to some of these policies, it is helpful to look at who these executives are listening to and what they’re prioritizing, whose voices in this decision-making process that really has impacts for so many people who are waiting for treatments. And I think there are tough choices that are made all the time. So I just thought it was very illuminating and helpful as we’re talking about how medicines get made in D.C.

Rovner: Yeah, maybe there will be a little more transparency to actually how the drug industry works. We will see. Joanne.

Kenen: With Julie’s permission, I have two that are both short and related. I wrote a piece for Politico Nightly called “How to Wage War on Conspiracy Theories,” and I liked it because it really linked political trends and disinformation and attempts to debunk, with very parallel things going on in the world of health care and efforts to the motivations and efforts to sow trust and what we do and do not know about how to debunk, which we’re not very good at yet. And then the classic example, of course, is the related AP story, which has a very long headline, so bear with me. It’s by Kevin McGill: “Court Revives Doctors’ Lawsuit Saying FDA Overstepped Its Authority With Anti-Ivermectin Campaign.” And, basically, it’s that the 5th Circuit, a conservative court that we’ve talked about before, is saying that the FDA is allowed to inform doctors, but it can’t advise doctors. And I’m not really sure what the difference is there, because if the FDA is informing doctors that ivermectin, we now know, does not work against covid, and it can in fact harm people, there’s ample data, that the FDA is not allowed to tell doctors not to use it. So the ivermectin campaign is a form of disinformation, or misinformation, whatever you want to call it, that at the very beginning, people had, you know, there were some test-tube experiments. We had nothing else. You can sort of see why people wanted … might have wanted to try it. But we have lots and lots and lots of good solid clinical research and human beings and, no, it does not cure covid. It does not improve covid. And it can be damaging. It’s for parasites, not viruses.

Rovner: It can cure worms. Well, I’m going to channel my inner Margot Sanger-Katz this week and choose a story from a medical journal, in this case the Journal of the American Medical Association. Its lead author is Sherry Glied, who’s dean of the NYU Robert F. Wagner Graduate School of Public Service and former assistant HHS [Department of Health and Human Services] secretary for planning and evaluation during the Obama administration — and I daresay one of the most respected health policy analysts anywhere. The piece is called “Health Systems and Social Services — A Bridge Too Far?” And it’s the first article I’ve seen that really does question whether what’s become dogma in health policy over the past decade that — tending to what are called social determinants of health, things like housing, education, and nutrition — can improve health as much as medical care can. Rather, argues Glied, quote, “There are fundamental mismatches between the priorities and capabilities of hospitals and health systems and the task of addressing social determinants of health,” and that, basically, medical providers should leave social services to those who are professional social service providers. That is obviously a gross oversimplification of the argument of the piece, however, but I found it really thought-provoking and really, for the first time, someone saying, maybe we shouldn’t be spending all of this health care money on social determinants of health. Maybe we should let social service money go to the social service determinants of health. Anyway, we will see if this is the start of a trend or just sort of one outlier voice. OK, that is our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks, as always, to our amazing engineer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can tweet me, or X me, or whatever. I’m still there @jrovner, also on Bluesky and Threads. Rachel?

Cohrs: I’m @rachelcohrs on X.

Rovner: Alice.

Ollstein: @AliceOllstein.

Rovner: Joanne.

Kenen: @JoanneKenen on Twitter, @joannekenen1 on Threads.

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.

In this special episode, host Julie Rovner, KFF Health News’ chief Washington correspondent, interviews three noted health policy experts.

Amy Finkelstein is a health economist at the Massachusetts Institute of Technology and co-author of “We’ve Got You Covered: Rebooting American Health Care,” which posits a new approach to universal health insurance. Sylvia Morris is a physician and one of the co-authors of “The Game Plan: A Woman’s Guide to Becoming a Doctor and Living a Life in Medicine,” in which five former medical school classmates share things they wish they had known earlier about how to thrive in what is still a male-dominated profession. And Michael LeNoir is a pediatrician, allergist, former broadcaster, and health educator in the San Francisco Bay Area who founded the African American Wellness Project, aimed at helping historically underserved African American patients better participate in their own care.

Click to open the transcript

Transcript: 3 Health Policy Experts You Should Know

[Editor’s note: This transcript, generated using transcription software, has been edited for style and clarity.]

Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News. Normally I’m joined by some of the best and smartest health reporters in Washington. But today we have a very special episode. Rather than our usual news wrap, we have three separate interviews I did earlier this month with three very interesting guests: author and health economist Amy Finkelstein, author and physician Sylvia Morris, and physician and medical educator Michael LeNoir. So let’s get right to it.

I am pleased to welcome to the podcast Amy Finkelstein, professor of economics at the Massachusetts Institute of Technology, noted health policy wonk, and one of my favorite people in health care. She’s got a new book, just out, called “We’ve Got You Covered: Rebooting American Health Care.” Amy Finkelstein, welcome to “What the Health?”

Amy Finkelstein: Thanks so much for having me on, Julie.

Rovner: So it’s been a minute since large-scale health system reform was on the national agenda — I think, even in the research community — which is in some ways odd because I don’t think there’s ever been as much unanimity that the health system is completely dysfunctional as there is right now. But I’m starting to see inklings of ideas bubbling up. I interviewed Kate Baicker, your former partner in research, a couple of months ago, and I don’t know if you saw it, but there’s a new Republican health reform plan just out from the Hoover Institution. Why is now the time to start talking about this again?

Finkelstein: I mean, I think the right question is why haven’t we been talking about it all along? I think it’s, unfortunately, always timely to talk about how to fix the incredibly rooted rot in our health care quote-unquote “system.”

Rovner: Why has it been so hard to reach any consensus about how health insurance should work? We don’t … I mean, we’re at a point even in the United States where we don’t all agree that everyone should have health insurance.

Finkelstein: So it’s a really good question. I think my co-author, Liran Einav, who’s my long-term collaborator, and I came to realize in writing this book is that we weren’t getting the right answers and consensus on them because we weren’t asking the right questions, both as researchers and in the public policy discourse. There’s a lot of discussion of “What do you think of single-payer?” or “Should we have a public option?” or “What about health savings accounts?” But what we came to realize, and it’s kind of idiotically obvious once we say it, but it still unfortunately bears saying: You can’t talk about the solution until you agree on what is the goal. What are we trying to do in health policy and health policy reform? And there are, of course, many admirable reasons to want health policy reform, or government intervention, more generally, in health policy. You can think, and this is what we’ve worked on for many years, that, you know, Adam Smith’s “invisible hand” doesn’t work that well in medical marketplace. You can be interested in making sure that we try to improve population health. You can think that health care is a human right. There are many possible reasons. What we came to realize in working on this book, and what then provided startling clarity and, hopefully, ultimately consensus on the solution, is that while all of these may be admirable goals, none of them are actually the problem that we have been trying but failing to solve with our health policy for the last 70-plus years. What becomes startlingly clear when you look at our history — and it’s the same in other countries as well, they’ve just succeeded more than we have — is that there is a very clear commitment, or a social contract, if you will, that we are committed that people should have access to essential medical care regardless of their ability to pay. Now, that may sound absurd in the only high-income country without universal health coverage, but as we discuss in our book, that represents our failure to fulfill that commitment, not its absence. And as we describe in great detail, it’s very clear from our history of policy attempts that there is a strong commitment to do this. This is not a liberal or a conservative perspective. It’s, as we discuss, an innate and in some sense psychological or moral impulse. And once you recognize this, as people have across the political spectrum, fundamentally we’re not going to ever consciously deny access to essential medical care for people who lack resources, and that an enormous number of our existing policies have been a backhanded, scrambling, not coherently planned attempt to get there. And I’m not just talking about the requirement that people can’t be turned away from the emergency room. If you look at all of these public policies we have to provide health insurance if you’re poor, if you’re young, if you’re old, if you’re disabled, if you’re a veteran, if you have specific diseases — there’s a program for low-income women with breast and cervical cancer. There’s a program for people with tuberculosis, for people with AIDS, for people with kidney failure. All of these arose out of particular political circumstances and salient moments where we felt compelled to act. It becomes very clear that we’re committed to doing this, and then a solution then becomes startlingly simple, once we agree. And, hopefully, if you don’t already, our book will convince you that whether or not you support this mission, it’s very clear it is the mission we’ve adopted as a society. Then the solution becomes startlingly simple.

Rovner: And the solution is …?

Finkelstein: Universal, automatic, basic coverage that’s free for everyone with the option — for those who want to and can afford it — to buy supplemental coverage. So the key is that the coverage be automatic, right? We’ve tried mandating that people have coverage … requiring it doesn’t make it so. In fact, a really sobering fact is that something like 6 out of 10 of the people who currently lack insurance actually are eligible for either free or heavily discounted coverage. They just don’t have it. And that’s because there’s a very, very complicated series of paths by which you can navigate coverage, depending, again, on your specific circumstances: age, income, disease, geography, disability, what have you. Once you have patches like this, you’ll always have gaps in the seam. So that’s why it has to be universal and automatic. We also argue that it has to be free, something that may get us kicked out of the economists’ club because, as economists for generations, we’ve preached that patients need some skin in the game, some copays and deductibles, so they don’t use more care than they actually really need. And in the context of universal coverage, we take that back. It was kind of a really sobering moment for us. We’ve written enormously on this issue in the past. We weren’t wrong about the facts. When people don’t have to pay for their medical care, they do use more of it. We stand by that research. And that of many other …

Rovner: This goes back to Rand in the 1970s, right?

Finkelstein: Exactly. And the Oregon Health Insurance Experiment, which I ran with Kate Baicker, whom you mentioned earlier. It’s just that the implications we drew from that we’re wrong — that if we actually are committed to providing a basic set of essential medical care for everyone, the problem is, even with very small copays, there will always be people who can’t afford the $5 prescription drug copay or the $20 doctor copay. And there’s actually terrific recent work by a group of economists — Tal Gross, Tim Layton, and Daniel Prinz — that show this quite convincingly. So what we’ve seen happen when we look at other high-income countries that have followed the advice of generations of economists going back, as you said, to Rand, and introduced or increased cost sharing in their universal basic coverage system to try to reduce expenses, it’s extraordinary. Time and time again, these countries introduced the copays with one hand and introduced the exceptions simultaneously with the other — exceptions for the old, the young, the poor, the sick, veterans, disabled. Sound familiar? It’s the U.S. health insurance in a microcosm applied to copays. And so what you see happen, for example, in the U.K., that was famously, you know, free at the point of service when it was started in 1948, but then, bowing to budgetary pressures and the advice of economists introduced, for example, a bunch of copays and prescription drugs. They then introduced all these exceptions. The end result is that currently 90% of prescriptions in the U.K. are actually exempted from these copays. So it’s not that copays don’t reduce health care spending. They do. That economic research is correct. It’s that they’re not going to do that when they don’t exist. All we do is add complexity with these patches. So that’s, I think, the part that we can get up and stand up and say and get a lot of cheers and applause. But I do want to be clear, it’s not all rainbows and unicorns. We do insist that this universal, automatic, free coverage be very basic. And that’s because our social contract is about providing essential medical care, not about the high-end experience that obviously everyone would like, if it were free. And so …

Rovner: And that’s exactly where you get into these fights about how — even, we’re seeing, you know, with birth control and pretty much any prescription drug — you have to offer one drug, but there are other drugs that might be more expensive, and insurance plans, trying to save money, don’t want to offer them. You can see already where the tension points are going to end up. Right?

Finkelstein: Exactly. And every other country has dealt with this, which is why we know it can be done. But they do one thing that is startlingly absent from U.S. health policy. Besides the universal coverage part, they also have a budget. And it’s kind of both incredibly banal and incredibly radical to say, “We should have a budget in our U.S. health care policy as well.” Everything else has a budget. When school districts make education policy, they do it given a budget and they decide how to make tough choices and allocate money across different types of programming. Or they decide to raise taxes, and go to the voters to raise taxes to fund more. We don’t have a budget for health care in the U.S. When people talk about the Medicare budget, they’re not actually talking about a budget in the sense that when I give my kids an allowance, that’s their budget, and they have to decide which toy to buy or which candy to purchase. When we talk about the Medicare budget, we just mean the amount we have spent or the amount that Medicare will spend. There’s no actual constraint, and that has to change. And only then can we have those tough conversations, as every other country does, about what’s going to be provided automatically and for free, and what’s obviously nice and desirable, but not actually part of essential medical care and our social contract to provide it.

Rovner: But, of course, the big response to this is going to be — and I’ve covered enough of these debates to know — you’re going to ruin innovation if we have a budget, if we limit what we can pay, the way every other country does, that we’re not going to have breakthrough drugs or breakthrough medical devices or breakthrough medical procedures, and we’re all going to be the worse for it.

Finkelstein: That, I think, is a very real concern, but it’s not a problem for us, because if that’s the concern, when the next administration adopts our policy, they can set a higher budget. Right? If we think that we want to induce innovation, and the way to do that is through higher prices for medical care, then we can decide to pay more for it — or we can decide, oh, my goodness, right, get it coming and going. On the other hand, we don’t want to raise taxes. We don’t want to spend even more of public money on health care. OK, well, then we’ll decide on less innovation. That’s in some sense separable from universal, automatic, basic free coverage. We can then decide what level we want to finance that at. And also, to be clear, we fully expect, in the context of our proposal, that about two-thirds of Americans would buy supplemental coverage that would get you access to things that aren’t covered by basic or greater choice of doctor or shorter wait times. And so that, again, might also — but that would be privately financed, not publicly financed — but that would also help with the innovation angle.

Rovner: And this is not a shocking thing. This is exactly how Switzerland works, right?

Finkelstein: Yeah, the somewhat sobering or, dare I say, humbling realization we came to is that, as I said, we very much thought about this — I guess, as academics — from first principles, you know, what is the objective that we’re trying to achieve it? And given that, how do we achieve it? But once we did that and we looked around the rest of the world — right? — it turns out that’s actually what every other high-income country has done, not just Switzerland, but all of them have some version. And they’re very different on the details, but some version of automatic, universal, basic coverage with the ability to then supplement if you want more. So, with many things when you do research on them and then you run into the man on the street and they say, “Isn’t this simple? Can’t we just do what every other country does?” When it comes to health care delivery and how to cut waste and overuse and deal with underuse in the health care system, the man on the street is, unfortunately, wrong. And we have a lot more work to do to figure out how we can get more bang for our health care buck. But it turns out they were right all along. And we, or I and my co-author and many other, I think, academic economists and policymakers, just didn’t realize it, that actually the coverage problem has a really, really simple solution. And that’s the key message of our book.

Rovner: So one of the things that’s stuck with me for 15 years now is a piece that Atul Gawande wrote in The New Yorker just before the debate on the Affordable Care Act about how, yes, every other country has this, but, in fact, every other country had some kind of event that triggered the need to create a system. You know, in England, it was coming out of World War II. Every country had some turning point. Is there going to be some turning point for the U.S. or are we just going to have to sort of knuckle under and do this?

Finkelstein: So we deliberately steer clear of the politics in most of the book because our view is the question you started with, like, “Why can’t we agree?” So let’s at least … can we agree on the solution before we figure out how to achieve it? But, of course, in the epilogue, we do discuss this, you know, how could we get there? And I guess the main lesson that we take away from our read of history is that universal health insurance was neither destined to happen in every other country, nor destined not to happen in the U.S. We talk about several incredibly near-misses in the U.S. Probably the closest we got was in the early 1970s, when both the Republican Nixon administration and the Democratic Congress under Kennedy had competing proposals for universal coverage on the table. They were actually arguing over whether there should be copays when there are different accounts of whether the Democrats got overly optimistic with Watergate looming and thought they could get more, or some senator got drunk and had a car accident and Ways and Means got derailed. But we had a near-miss there. But also, and to your point about the U.K., more soberingly, if you look at the history of other countries, it wasn’t easy there. I mean, the British Medical Association threatened to go on strike before the implementation of the National Health Service in 1948. So, despite that, you know, now it’s … the National Health Service is as popular as the British monarchy — or actually more popular, perhaps …

Rovner: [laughs] Probably more!

Finkelstein: … and is beloved by much of the British population. But if you look at the narrative that this was destined to come out of the postwar consensus, the Labour leader, [Aneurin “Nye”] Bevan, who was pushing for it on the eve of its enactment, described the Tories as, quote, “lower than vermin for their opposition to it.” I mean, it was just … and similarly in Canada, when Saskatchewan was the first province to get universal medical insurance, there the doctors did go on strike for over three weeks. So this idea that every other country just had their destiny, their moment, when it clearly came together, and we were destined not to have it? Neither seems to be an accurate reading of history.

Rovner: Well, it’s a wonderful read. And I’m sure we’ll come back and talk again as we dive back into this debate …

Finkelstein: I’d love to.

Rovner: … which I’m sure we’re about to do. Amy Finkelstein, thank you so much for joining us.

Finkelstein: Thank you so much for having me.

Rovner: Hey, “What the Health?” listeners. You already know that few things in health care are ever simple. So, if you like our show, I recommend you also listen to “Tradeoffs,” a podcast that goes even deeper into our costly, complicated, and often counterintuitive health care system. Hosted by longtime health care journalist and friend Dan Gorenstein, “Tradeoffs” digs into the evidence and research data behind health care policies and tells the stories of real people impacted by decisions made in C-suites, doctors’ offices, and even Congress. Subscribe wherever you listen to your podcasts.

Next, we have Sylvia Morris, one of a group of friends who are women physicians who want to make it easier for the next generation of women physicians.

I am pleased to welcome to the podcast Dr. Sylvia Morris. She’s an internist from Atlanta and one of five authors of a new book called “The Game Plan: A Woman’s Guide to Becoming a Doctor and Living a Life in Medicine.” Dr. Morris, welcome to “What the Health?”

Sylvia Morris: Thank you so much for having me.

Rovner: So why does there even need to be a book about being a woman in medicine? Aren’t medical schools more than half women students these days?

Morris: They are. But when you look at some of the specialties, and once you get out into practice, women leaders are still not as plentiful. They are not 50%. So, we just wanted to write from our perspective some tips and tools of the trade.

Rovner: So before we talk about the book, tell us about how you and your co-authors got together. It is rare to find a book that has five listed authors.

Morris: Exactly. So we actually went to med school together. We were classmates at Georgetown, and we met, I will say, in the early ’90s, shall we say? 1992, 1993. And after we finished med school, as well as training, we started doing girls’ trips. Our first one was, like, to Las Vegas and then subsequently have just really evolved. And probably 10 years ago, we were sitting around in Newport Beach and we thought, you know what? We should figure out something to do to really, to give back, but also to share information that we didn’t have. I am a first-generation physician. Several of my co-authors are as well. And it would have been nice for someone to say, “Hey, Doc, maybe you should think about this.” So that’s why we wrote the book.

Rovner: I noticed that, yeah, I mean, you start very much at the beginning — like, way before med school and go all the way through a career. I take it that was very intentional.

Morris: Yes, because I don’t think most people wake up and decide they’re going to be a doctor and then apply to medical school. And although we all have different journeys, some of us decided to become physicians later. Later, meaning in college. I was a kid that always wanted to be a doctor. So at 5, I would say “I want to be a doctor,” and here I am a physician. So we really wanted to highlight the different pathways to becoming a physician and just so that people can just … we’re going to peel the curtain back on what’s happening.

Rovner: I love how sort of list-forward this book is. Tell us the idea of actually making a game plan.

Morris: Well, we’re big “list people.” I think in med school, you kind of learn, well, what’s your to-do list for today? You need to check that CBC. Yeah, you know, you have to follow up on physical therapy, all of those things. So lists become a really inherent part of how we do business. And I think people understand the list, whether it’s a grocery shopping list. So we wanted to be prescriptive, not specific, meaning you must do X, but here are some of the things that you need to think about. And a list is very succinct, and everyone can get it.

Rovner: Which leads right into my next question. I love how this is such a nitty-gritty guide about all of the balancing that everybody in such a demanding profession of medicine, but particularly women, need to think about and do. What do you most wish that you had known when you were starting out that you’d like to spare your readers?

Morris: If I could go back to my 17-year-old self who was just dropped off at Berkeley, I really would say, “Enjoy the ride.” And that sounds so trite, because we get very caught up in “it has to be this way.” And quite honestly, things have not turned out how I thought they were going to turn out. Certainly, in many ways, much grander and beyond my wildest imagination. But you do have to be intentional about what you want. So I’ve been very clear about wanting to be a physician, and I’ve worked along that path. It is never a straight line. So just embrace the fact that there are going to be some ups and some downs, but keep in focus on the goal and persevere. I’d like to borrow the word from Associate Justice [Ketanji Brown] Jackson, how she talked about persevere.

Rovner: I noticed that there are a number of places where there are key decisions that need to be made. And I think, you know, you talk about being intentional. I think people don’t always think about them as they’re doing them, as in deciding where to go to medical school, where to do a residency, what specialty to choose, what type of practice to participate in. The five of you are all in different specialties in different sort of practice modalities, right?

Morris: Yes, we are. And I think that that really adds to the richness of the book. And again, there’s no one way to get to your goal. But we have the benefit of being able to sort of bounce ideas off of each other. So if we are looking for a new job or kind of a career pivot, then we have someone to reach out to to say, “Hey. You did this. What are your thoughts? What should I look out for?”

Rovner: How important is it to have a support system? I mean, obviously, you talk about family and kids, but, I mean, to have a support system of friends and colleagues and people you can actually share stresses and successes with, that others will understand.

Morris: It is so important to know that you are not alone. There’s nothing new under the sun. So if you are going through something where we suffer in silence and isolation, that’s when bad things happen. So having a trusted group of friends, and whether it’s one person or three people — I’m lucky to have at least four people in my life that I can be candid and vulnerable with. It makes all the difference in the world. My mom died when I was in medical school, and having the support of my colleagues, my friends, to say, “Hey, yeah, you can keep going. You can do this.” That’s important. And there are some very low periods in residency, just because you’re tired all of the time. So having a group, whether it’s one or three or four, then please, have friends.

Rovner: I’m curious that while you are all African American women, you don’t really have a separate section on navigating medicine as members of an underrepresented group. Is that for another book entirely? Was there a specific reason that you didn’t do that?

Morris: I think certainly when people see us on the cover, then you’d realize, “Oh, they are women of African descent.” And I also think that because … women are still underrepresented in medicine, in particular in leadership, that we wanted to make sure we reached the broadest audience. And quite truthfully, our message works for not only women, but also works for men, it works for people of color. We just really wanted to say, “Hey, these are the things that we can think about when you are applying to medical school and as you embark on your career.” But I like the idea of a second book.

Rovner: Actually, that’s my … my next question is, what do you hope that men get out of this? Because, you know, flipping through, it’s a really good guide, not just to being a woman in medicine, but to being anyone in medicine or really anyone in a very time-demanding profession.

Morris: Yes, the word “ally” is kind of overused now, but I think that it gives the men in our lives, whether they be our partners and husbands, our fathers — I have a favorite uncle, Uncle William — to have an inkling of what’s happening and how to best support us. So I think that there’s just some valuable pearls.

Rovner: Well, thank you very much. It is a really eye-opening guide. Dr. Sylvia Morris, thank you for joining us.

Morris: Thank you.

Rovner: Finally for this special episode, here’s my chat with Michael LeNoir, a physician who spent much of his career trying to improve the health of African American patients.

We are pleased to welcome to the podcast Dr. Michael LeNoir, an allergist and pediatrician who spent the last 4½ decades serving patients in the East Bay of San Francisco and working to improve health equity nationwide. He’s a former president of the National Medical Association, which represents African American physicians and patients, and a founder of the African American Wellness Project, a nonprofit that grew out of the realization of just how large and persistent health disparities are for people of color. Dr. LeNoir, welcome to “What the Health?”

Michael LeNoir: Well, thank you so much.

Rovner: Health disparities and health equity have become, if you will, trendy research topics in the past couple of years in the health policy community because we know that people of color have worse health outcomes in general than white people, regardless of income. But this is hardly a new problem. When did it become obvious to you that, despite other civil rights advances, the health system is still not serving the Black community equally?

LeNoir: Well, I think it goes back to, actually, 2002, when as a doctor in a community that had people of color, physicians of color, I recognized that there was a difference in how African Americans were treated both professionally and personally. And it was such a stark difference. So I gathered together most of the Black health leaders in the Bay Area, some running hospitals, some running programs, two were directors of health, some Congress people, and some local politicians. And there were about 30 people in the room. And I … go around the room and asked, give me one instance where the health system that you engaged in treated you disrespectfully or you didn’t get information, or you felt abandoned without advocates. And we weren’t four people in when some people started crying about experiences that they’d all had. Now, I knew they had these experiences because of that as a doctor. You know, I’m in the doctor’s lounge as a consultant in allergy and immunology. I see the differences in how Black people were treated as opposed to whites. And I see the respect that was given to white physicians that was not given to Black physicians. So at that point, I decided, you know, there’s something upside down in this health system. The concept is that health is supposed to take care of you from the top down. Either your insurance company is supposed to take care of you, or the feds, or somebody. But my feeling was, you know, for African Americans the health system was not going to change unless we changed it from the bottom up. And so that’s when we started the African American Wellness Project to educate African Americans how to deal with some of the aspects of early detection, disease prevention, exercise, and things like that. But more importantly, what to happen when you have a problem, when you engage with the system. What tools do you need? What resources do you need? How do you get the best possible outcomes?

Rovner: So just this month, the Centers for Disease Control and Prevention released a survey that found that 1 in 5 women reported being mistreated by medical professionals during pregnancy or delivery. For Black women, it was closer to 1 in 3. This is clearly some sort of systemic problem even in addition to racism, isn’t it? The health system is not functioning well.

LeNoir: We did a piece on this yesterday because it’s pretty clear that this has been a problem as long as I’ve been a physician. Where it’s really a problem is the increasing incidence of maternal mortality among Black women. And so now we know that there’s something going on that’s not being taken care of. There’s one classic video that we show when we talk about this subject. It was a Black physician in Illinois who was in a small Illinois town, was in the intensive care unit, and could not get the care that she needed when she had covid respiratory issues. And so what happened was she was broadcasting from the ICU about what was being given to her, what was being talked to her about, what was not being done. And her care … when her symptoms were ignored, how they delayed in doing stuff. And she died four days after she did this video. But, you know, we’re not surprised. I mean, I see these studies of Black people don’t like the health care system. You know, Kaiser Foundation [KFF] must have spent, I don’t know how many dollars, looking at a study we did five years ago. On every study I’ve seen, Black people are not happy with the health care system. They had 12,000 people. We had 400. But the conclusions are the same. And it’s not so much because of the availability or the capacity of the health care system to close the gap on the health of Blacks and others in this society. It has a lot to do with unconscious bias and the fact that the system doesn’t recognize itself. And no matter how much you call attention to it, it continues year after year, decade after decade.

Rovner: Is there anything we can do about unconscious bias? I mean, now we all know it’s there, but that doesn’t seem to get around to fixing it.

LeNoir: There’s several things that have been talked about: change in medical schools and showing them more positive images so that when they come out of medical school, then the only patients that we see are poor, Black, uneducated, you know, down and out, because those are the ones that go to the VA hospital or the public hospitals. So that’s one thing. And the other thing is a Black person should call it out when they see it. That’s the big thing. And I think we’re much too docile in the health care system. Here’s what I always would feel is that if we get as mad about health care that is disrespectful and unequal as we do when someone cuts in front of us in the Safeway line, we wouldn’t have that problem.

Rovner: Seriously, I mean, so you think people really just need to speak up more?

LeNoir: Absolutely. And in the piece that we did yesterday, the piece was entitled “Health Care System Not Equal,” don’t put up with it.

Rovner: What can Black doctors do and how do we get more of them? I know that’s a big piece of this is that people don’t feel represented within the health care provider community.

LeNoir: Well, unfortunately, we know and probably you kno, and probably most patients know, that a good doctor may not be the smartest person in a medical school. They may have a variety of different prejudices and a variety of different talents or a variety of different capacity to engage patients in a positive way. But our medical system and our system that screens students for medical school really kinda looks more at analytics. I mean, what kind of grades you make, what your SATs look like, what kind of symbolic social things did you do in order to get into medical school? And so, consequently, that shuts out a lot of students at a very early place in the system. A Black student often goes into the system determined to be a doctor, but he doesn’t have those resources, those networks, those connections. So he bombs out in junior college. I can remember I had a unique educational experience. I went to a college-educated … well, middle school in Cincinnati. It’s called Walnut Hills High School No. 3. [To get in] you took a test, and my dad was a YMCA executive. So we moved to Dallas, Texas, which was completely segregated. So I recognized immediately when I got there that the learning experience was different, but the education was not. Because I learned as a Black student in an environment that was college preparatory that … I didn’t have many allies in that many networks. And my parents, like so many Black parents, said, there’s no excuses. You can’t … don’t be coming on with the excuse of discrimination, when we were facing it every day. And more than that, on the positive side, we’re not being encouraged like the white students were. When I got to Dallas, you know, we didn’t have all the books, we didn’t have all the stuff, but the teachers knew I had talent, and they pushed me and pushed me, pushed me. So when I went off to a university by choice — could have gone to Stanford, all these other places — that I had the talent. Whereas back in my high school there were students as good as I was as students. And then they went off to the University of Texas, where I ultimately transferred, which didn’t seem to be a big deal for me because I thought Howard actually was harder. But they go to the University of Texas, they were from a segregated school, and then by themselves and they bomb out … and so consequently they don’t get to realize the bigger part of themselves. So getting back to this question that you asked five minutes ago. The reason is that the parameters to choose people for medical school need to start earlier, and they need to encourage Blacks, especially Black males of talent, so they can then go on and do some things that are necessary to get into medical school.

Rovner: Yeah, I’ve seen some programs that are trying to recruit kids as young as 11 or 12 to gauge interest in going into a medical career.

LeNoir: Yeah, well, I think that’s, you know, that’s so unnecessary. But it’s a game. I mean, who is it … the doctor … your old Dr. So-and-So didn’t go to Harvard. So the talents to be a good doctor, you know, I don’t know whether you feel this way. I don’t think you can teach judgment by the time somebody gets out of high school. You know, physicians, the first thing I think that you have to have is good judgment, and good judgment can be sometimes assessed on the MCAT and these other things that they use to prioritize things for that.

Rovner: I know the Association of American Medical Colleges is very concerned about the Supreme Court decision that came down earlier this year banning affirmative action. Are you also worried about what that might mean for medical school admissions?

LeNoir: Well, you have to realize that in California, we’ve been dealing with this since the Bakke decision, so we’ve not been able … and I served on medical school committees. I served on the University of California-San Diego, and one year here at UC-San Francisco, kinda chaired the clinical faculty, so had the chance to kind of get engaged in policy here. And what we found out was that you can’t change that. You have to change the system itself.

Rovner: Yeah, I mean, how worried are you, obviously in California, I guess, things have gone OK, but it’s going to be a big change at a lot of other medical schools about how they’re going to go about admitting their next classes and trying to at least further more culturally diverse classes of medical students.

LeNoir: Well, you know, California’s not done OK. I mean the percentage of California students — I believe diversity in California is probably 50% less than it was in the days when we had more liberal affirmative action guidelines. And so in those days, we were reporting 24, 25 Black students in these classes. That’s not happening anymore. So … I do worry. I mean, the reality is right in front of us. And I think that some schools … not necessarily the schools themselves, but the politicians that supervise these schools that have oversight over these schools are going to use this as a weapon. I know that already many of the attorney generals have sent letters to the university saying, look, I don’t care what you do, it’s not going to happen anymore. And the first persons to leave jobs now are diversity. Good jobs in diversity management … those jobs are disappearing almost as we speak.

Rovner: So if you could do just one thing that would help the system along to make things a little bit less unequal, what would it be?

LeNoir: I think it would be making certain that the system has the tools to detect two types of unconscious bias: this personal unconscious bias on the part of providers, but this institutional unconscious bias. And I think we have to attack that first. Institutions don’t look at African Americans the same way. And here’s … let me give you an example of what that falls out to. Let’s look at the statistics on vaccinations in ethnic groups. The impression is that Black people didn’t get vaccinated. But at the end of the day, if you looked at the numbers, we were vaccinated pretty much about the same level as the rest of America. But when we got ready to look at this, what we found out is hesitancy was based upon the fact that Black people did not trust the system. And institutions are expected to come out, here you are, you know, you’re part of an institution. You see a different doctor every week. And they come out to tell you you’re supposed to do your shots and stuff like that. Then Black people don’t believe that. They don’t go, they don’t go with that. And so consequently, at the end of the day, once the information came out and people got a chance to look at it, we started getting vaccinations at the same rate. But the people who are asking us to trust them had never attempted institutionally to obtain our trust. And so I think under those circumstances, that’s one of the reasons, that’s one of the things we most have to attack is institutional unconscious bias, institutional racism that’s covered over by the fact that we’re taking care of the poor. You know, we do all these things here and there, but poor people have opinions, too. And if we expect to change the system where everybody is treated equally, we have to look at what the institutional policies, or the institutional character or personality that results in the kinds of outcomes that we see in hospitals. And then we start looking at providers and other people. And they have to start engaging in this community now. There’ll be another pandemic, you know that. I know that. Probably this summer, this winter, things are going to … Look, what have doctors done? What have institutions done to gain the trust of the populations they serve? Probably nothing.

Rovner: Well, we’ve seen, you know, one of the things the pandemic has shown us is that now all Americans don’t trust institutions anymore. Is there maybe even a way to help everyone gain more trust? I mean, I guess it’s becoming much more obvious to at least the public health community that much of the public in general is distrustful of public health advice, of medical advice, of expertise in general.

LeNoir: Oh, yeah, there’s no question. This is not a unique problem among African Americans. I mean, it’s hard to trust a system where you have a problem and your doctor refers you somewhere and your next appointment is four months away. And here’s what the tragedy is: Nobody in Washington is talking about changing the system. I can remember the big furor over what were we going to do? Are we going to do single-payer? Are we going to do this? At least there was a dialog. Have you heard a dialog in Washington about changing this awful health care system that denies people access, overcharges them, and then is not blamed for the outcomes? I haven’t seen any of that. I haven’t seen anybody talk about health care at the national level. We used to do pieces, I remember years ago when I worked for CBS Radio, I tried to get a curriculum for hypertension, diabetes. Now you barely see anything on health except violence, and you don’t see too many pieces that people could use for health education. So I think the system is really broken and nobody’s … I don’t see any, even in the discussions last night [during the first Republican presidential primary debate], health never came up. You know, Ukraine, but not the health care system, which is really cheating us all.

Rovner: Yeah, I know. I mean, we’re … an entire Republican debate, and there was not a single mention of the Affordable Care Act or anything else that Republicans might want to do to fix a health care system that I think even Republican voters know is broken.

LeNoir: Yeah, I think that [Donald] Trump has sucked all the oxygen out of the room. And they’re not talking policy very much at all. I mean, even the undertones of the policy discussions have Trump all over it. So I think we’re in a very bad place, but I hate to see that escalating discussion on how to change the health care system, not just for the good of the poor people and Black people, I don’t think white people are really particularly excited about the system, and that dialog is not taking place.

Rovner: Is there anything you can offer that’s at all optimistic about this?

LeNoir: Well, no. No, I really can’t. As a doctor, I can tell you. Here’s the expanding issue. It just seems now that the solution to all the health problems that we have are the social determinants of health. I mean, you know, income and poverty and food, you know, issues and employment, all of that, they all contribute definitely to health outcomes. And so until we change those, then obviously the system, they say, will not change. Every chronic disease that I’ve looked at over the last 10 or 15 years, and especially recently, what Black people don’t do as well, it’s not because they don’t get into the system at the right time. They may even have early disease detection. It’s because they are not treated the same way. So if you look at statistics, all Black women have more deaths from breast cancer, our Black children have more asthma. It’s not because they don’t enter the system. It’s how they’re treated when they get into the system. So then going back to what we can do, we have to arm the patient, Black or white, to understand what you need to do to get the most effective outcomes. How do you select your primary care doctor? It’s critically important to everything that happens to you. How you’re able to challenge the system with a second opinion when you want that. To have an advocate, if you go into the hospital, not your brother or sister, but somebody who knows something about health care. So what we’re trying to do with the African American Wellness Project is to do that. We talk about early detection. Here’s the other problem with this. Now, I’d rather have penicillin than get rid of poverty or to get everybody a job. And in the New England Journal probably maybe a week ago, there was an editorial about how we as physicians should be able to manage the other elements, the social determinant elements, as part of our visits. Now I’ve barely got enough time to see the patients that I have. Now I’m supposed to get somebody food, a job and all that … but I’m not saying that that doesn’t need to change. It does. But if every solution to the problem of health equity is the social determinants like I’m seeing, then I mean, we might not get penicillin, but we may get somebody a job. But I think that that that process is important. It is important. But if you look at studies that at the VA, especially with men with prostate cancer, or if you have prostate cancer and … everything’s done exactly the same: early detection, the PSAs, the biopsy, the identification — the prostate is done not by biopsy, but by MRI — and they treat it the same, Black people do better. And the same thing is true with breast cancer and other chronic diseases. All these studies. You can go to PubMed, and you look at all these studies and you see every study talks about that, that the reason that they’re not doing as well, is because of the social determinants of health. Now, I mean, I appreciate that, but I’m not going to wait for everybody to get a job before I try to get a stent put in my artery, or I try to get some concern for my position. So to go back to your question again that you asked me five minutes ago, is that we need to talk to people about the system they face, and they need to go into it with less naivete and more organization. And that’s what we try to do with the African American Wellness [Project]. We try to provide you with that information and the tools that you need when you need to go into the system. If you need to know what questions to ask … we’ll tell you how to do that. One of the things I found out is I engage social media as a way to talk to people, because I’ve always used traditional media and, boy, I recognize now that you have to do it a little differently. You can’t do it exactly the same way. And so I just think we have to prepare people and we have to tell them the things that they need to do to recognize and understand before they enter the system. Until we start to get more serious in this country, about that dialog on our health care system, I think the individual is the only way we can approach it.

Rovner: Dr. LeNoir, thank you. Thank you so much for all of what you’re doing and thank you for joining us today.

LeNoir: Thank you for having me.

Rovner: OK, that’s our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks, as always to our amazing engineer, Francis Ying. And also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can tweet me or X me or whatever. I’m still @jrovner, also on Bluesky and Threads. I hope you enjoyed this special episode. We’ll be back with our regular podcast panel after Labor Day. Until then, be healthy.

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But a research study the Centers for Medicare & Medicaid Services commissioned to identify the appropriate level of staffing made no specific recommendations and analyzed only staffing levels lower than what the previous major federal evaluation had considered best, according to a copy of the study reviewed Monday by KFF Health News. Instead, the new study said there was no single staffing level that would guarantee quality care, although the report estimated that higher staffing levels would lead to fewer hospitalizations and emergency room visits, faster care, and fewer failures to provide care.

Patient advocates said the report was the latest sign that the administration would fall short of its pledge to establish robust staffing levels to protect the 1.2 million Americans in skilled nursing facilities. Already, the administration is six months behind its self-imposed deadline of February to propose new rules. Those proposals, which have not been released, have been under evaluation since May by the Office of Management and Budget. The study, dated June 2023, has not been formally released either, but a copy was posted on the CMS website. It was taken down shortly after KFF Health News published this article.

“It’s honestly heartbreaking,” said Richard Mollot, executive director of the Long Term Care Community Coalition, a nonprofit that advocates for nursing home patients in New York state. “I just don’t see how this doesn’t ultimately put more residents at risk of neglect and abuse. Putting the government’s imprimatur on a standard that is patently unsafe is going to make it much more difficult for surveyors to hold facilities accountable for the harm caused by understaffing nursing homes.”

For months, the nursing home industry has been lobbying strenuously against a uniform ratio of patients to nurses and aides. “What is clear as you look across the country is every nursing home is unique and a one-size-fits-all approach does not work,” said Holly Harmon, senior vice president of quality, regulatory, and clinical services at the American Health Care Association, an industry trade group.

Nursing home groups have emphasized the widespread difficulty in finding workers willing to fill existing certified nursing assistant jobs, which are often grueling and pay less than what workers can make at retail stores. Homes say their licensed nurses are often drawn away by other jobs, such as better-paying hospital positions. “The workforce challenges are real,” said Katie Smith Sloan, president and CEO of LeadingAge, an association that represents nonprofit nursing homes.

The industry has also argued that if the government wants it to hire more workers it needs to increase the payments it makes through state Medicaid programs, which are the largest payor for nursing home care. Advocates and some researchers have argued that nursing homes, particularly for-profit ones, can afford to pay employees more and hire additional staff if they forsake some of the profits they give investors.

“Certainly, facilities haven’t put all the dollars back into direct care over the years,” said David Grabowski, a professor of health care policy at Harvard Medical School. “But for certain facilities, it’s going to be a big lift to pay for” higher staffing levels, he said in an interview last week.

In a written statement to KFF Health News, Jonathan Blum, CMS’ principal deputy administrator and chief operating officer, said the study had been posted in error. “CMS is committed to holding nursing homes accountable for protecting the health and safety of all residents, and adequate staffing is critical to this effort,” he said. “CMS’s proposal is being developed using a rigorous process that draws on a wide range of source information, including extensive input from residents and their families, workers, administrators, experts, and other stakeholders. Our focus is on advancing implementable solutions that promote safe, quality care for residents.” Blum’s statement called the study a “draft,” although nothing in the 478-page study indicated it was preliminary.

The study has been widely anticipated, both because of the central role the administration said it would play in its policy and because the last major CMS study, conducted in 2001, had concluded that nursing home care improves as staffing increases up to the level of about one worker for every six residents. The formal metric for that staffing level was 4.1 staff hours per resident per day, which is calculated by dividing the number of total hours worked by nurses and aides on duty daily by the number of residents present each day.

CMS never adopted that staffing ratio and instead gave each nursing home discretion to determine a reasonable staffing level. Regulators rarely cite nursing homes for insufficient staffing, even though independent researchers have concluded low staffing is the root of many nursing home injuries. Too few nurse aides, for instance, often means immobile residents are not repositioned in bed, causing bedsores that can lead to infection. Low staffing also is often responsible for indignities residents face, such as being left in soiled bedsheets for hours.

The new research was conducted by Abt Associates, a regular contractor for CMS that also performed the 2001 study. But the report, in an implicit disagreement with its predecessor, concluded there was “no obvious plateau at which quality and safety are maximized or ‘cliff’ below which quality and safety steeply decline.” Abt referred questions about the study to CMS.

The study evaluated four minimum staffing levels, all of which were below the 4.1 daily staff hours that the prior study had identified as ideal. The highest was 3.88 daily staff hours. At that level, the study estimated 0.6% of residents would get delayed care and 0.002% would not get needed care. It also said that staffing level would result in 12,100 fewer hospitalizations of Medicare residents and 14,800 fewer emergency room visits. The report said three-quarters of nursing homes would need to add staff to meet that level and that it would cost $5.3 billion extra each year.

The lowest staffing level the report analyzed was 3.3 daily staffing hours. At that level, the report said, 3.3% of residents would get delayed care and 0.04% would not get needed care. That level would reduce hospitalizations of Medicare residents by 5,800 and lead to 4,500 fewer emergency room visits. More than half of nursing homes would have to increase staff levels to meet that ratio, the report said, and it would cost $1.5 billion more each year.

Charlene Harrington, a professor emeritus of nursing at the University of California-San Francisco, said CMS “sabotaged” the push for sufficiently high staffing through the instructions it gave its contractor. “Every threshold they looked at was below 4.1,” she said. “How can that possibly be a decent study? It’s just unacceptable.”

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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Every person who agreed to get the smallpox vaccination was a potential outbreak averted, so the team was determined to vaccinate as many people as possible. 

The duo leaned on each other, sometimes literally, as they traversed the country’s rugged and watery geography. Khan, whom Miner sometimes referred to as “little brother,” used his local knowledge to help the team navigate both the cultural and physical landscape. When crossing rickety bamboo bridges, he would hold Miner’s hand and help him across. “We didn’t let him fall,” chuckled Khan. 

Episode 4 of “Eradicating Smallpox” explores what it took to bring care directly to people where they were. 

To conclude the episode, host Céline Gounder speaks with public health advocate Joe Osmundson about his work to help coordinate a culturally appropriate response to mpox in New York City during the summer of 2022. “The model that we’re trying to build is a mobile unit that delivers all sorts of sexual and primary health care opportunities. They’re opportunities!” exclaimed Osmundson.

The Host:

Céline Gounder
Senior fellow & editor-at-large for public health, KFF Health News

@celinegounder

Read Céline's stories

Céline is senior fellow and editor-at-large for public health with KFF Health News. She is an infectious diseases physician and epidemiologist. She was an assistant commissioner of health in New York City. Between 1998 and 2012, she studied tuberculosis and HIV in South Africa, Lesotho, Malawi, Ethiopia, and Brazil. Gounder also served on the Biden-Harris Transition COVID-19 Advisory Board. 

In Conversation with Céline Gounder:

Joe Osmundson 
Public health advocate and clinical assistant professor of biology at New York University

@reluctantlyjoe

Voices from the Episode:

Tim Miner
Former World Health Organization smallpox eradication program worker in Bangladesh

Shahidul Haq Khan
Former World Health Organization smallpox eradication program worker in Bangladesh

Click to open the transcript

Transcript: Speedboat Epidemiology

Podcast Transcript 

Epidemic: “Eradicating Smallpox” 

Season 2, Episode 4: Speedboat Epidemiology 

Air date: Aug. 29, 2023 

Editor’s note: If you are able, we encourage you to listen to the audio of “Epidemic,” which includes emotion and emphasis not found in the transcript. This transcript, generated using transcription software, has been edited for style and clarity. Please use the transcript as a tool but check the corresponding audio before quoting the podcast. 

TRANSCRIPT 

Céline Gounder: In the early 1970s, smallpox was still stalking parts of South Asia. India had launched its eradication program more than a decade before, but public health workers couldn’t keep up with the virus. 

Enter … the bifurcated needle. 

[Metallic ding sound] 

[Light instrumental music begins playing] 

Tim Miner: It was a marvelous invention in its simplicity. It looks like a little cocktail fork. 

Céline Gounder: You dip the prongs into a bit of vaccine … 

Tim Miner: And you would just prick the skin about 12 or 15 times until there was a little trace of blood and then you’d take another one. 

Céline Gounder: It barely took 30 seconds to vaccinate someone. 

And it didn’t hurt. 

Yogesh Parashar: No. 

Céline Gounder: Well … it didn’t hurt too much. 

Yogesh Parashar: It was just like a pinprick, rapidly done on your forearm. You had a huge supply with you and you just went about and — dot, dot, dot — vaccinated people, carry hundreds with you at one go. 

Tim Miner: And you could train somebody in a matter of minutes to do it. 

Céline Gounder: Easy to use. Easy to clean. And a big improvement over the twisting teeth of the vaccine instrument health workers had to use before. 

The bifurcated needle was maybe 2 and a half, 3 inches long. 

Small, but sturdy enough for rough-and-tumble fieldwork. 

Yogesh Parashar: It was made of steel. And it used to come in something that looked like a brick. It was just like one of those gold bricks that you see in the movies. 

Céline Gounder: And maybe worth its weight in gold. 

[Light instrumental music fades to silence] 

Céline Gounder: That “cocktail fork” was among the pioneering innovations that helped public health workers wipe out a centuries-old virus. 

Tim Miner: You had the bifurcated needle, you had the sterile water, and you had the freeze-dried vaccine, and you could mix them up and off you’d go. 

Céline Gounder: Ah, but getting there wasn’t always that easy. 

I’m Dr. Céline Gounder, and this is “Epidemic.” 

[Epidemic theme music plays] 

Céline Gounder: On this episode, we’re exploring what it took to deliver the smallpox vaccine to the people — and all the remaining places — that needed it most. 

In South Asia, Bangladesh was a major battleground in the campaign to stop smallpox. 

We spoke with a man who helped lead an eradication team there. 

Shahidul Haq Khan: My name is MD Shahidul Haq Khan. 

Céline Gounder: For our interview, Shahidul Haq Khan invited me to his home in Barishal. That’s in south-central Bangladesh. We sat at a table in the courtyard, and his granddaughter, Kashfia, who looked like she was around 10 years old, stood close by … 

Céline Gounder: Kashfia. So nice to meet you, Kashfia. I’m Céline. 

Kashfia: Hello. 

Céline Gounder: Hello. [Céline chuckles.] Are you going to listen to us? 

Céline Gounder: Kashfia wanted to hear her granddad’s stories, and I got the impression that was also important to Shahidul. 

As the two of us did our best to communicate through a translator — with neighbors, chickens, and street noise all around — Shahidul wanted me to understand why he was speaking with me and the significance of the smallpox campaign. 

Shahidul Haq Khan: [Shahidul speaking in Bengali] 

English translation: The purpose of saying these things is that we needed all this effort. We put a lot of hard work and effort behind smallpox eradication. 

Céline Gounder: Very hard work. You must be very proud of what you helped accomplish. 

Shahidul Haq Khan: [Shahidul speaking in Bengali] 

English translation: Yes, of course. Of course, I can say that we’re proud to say that we’ve eliminated smallpox from this country. 

Céline Gounder: The job was to hunt down smallpox — and stop it — in a country packed with people, crisscrossed by rivers, edged with mangrove forests, and dotted with remote lowland river islands. 

[Rain sounds fade in] 

Céline Gounder: And there were the monsoons. It rained A LOT. 

[Bouncy, upbeat music begins playing softly in the background] 

[Rain sounds fades out] 

Tim Miner: Uh, well, we got wet. [Tim chuckles.] To state the obvious. 

Céline Gounder: That’s Tim Miner. He was an officer with the World Health Organization in Bangladesh. 

Tim Miner: My legal name is Howard Miner, but I was the third Howard, so I got nicknamed Tim. 

Céline Gounder: Shahidul and Tim worked together for several months in 1974. 

The public health strategy was called “search and containment,” and a big part of that meant figuring out how to get the vaccine from one community to the next. 

Tim Miner: And occasionally you have to park your motorcycle, take your shoes and socks off, and walk across a leech-infested paddy field to get to the next case. 

Céline Gounder: The work depended on local knowledge, and Shahidul was the local knowledge. 

He was the lead Bangladeshi member on the eradication team, and when they arrived at a village that had a suspected case of smallpox, often Shahidul went in first, with Tim a few steps behind …  

Tim Miner: Someone would bring out some chairs. And sometimes we would have tea and biscuits. Or, if they didn’t have tea and biscuits, then somebody would climb up and get a coconut and chop off the top and watch me drink it and dribble the coconut milk all over myself, and everybody had a good time.  

Shahidul Haq Khan: [Shahidul speaking in Bengali] 

English translation: Dr. Miner called me “little brother.” I was younger then. How old was I? 21 or 22 years old. 

Tim Miner: He referred to me as “Dr. Miner,” even though I’m not a … a physician. That’s how he referred to me. 

Céline Gounder: Shahidul had been working in public health before he joined the smallpox effort. He offered guidance on culture — and occasionally gave Tim a hand on rickety bamboo bridges. 

Shahidul Haq Khan: [Shahidul speaking in Bengali] 

English translation: Most of the time, I escorted him across the bamboo bridge. I took his bag and held his hand and helped him across. 

Tim Miner: You learn to walk and not look down and just, uh, you know, hang onto the poles. And, fortunately, I never fell in. 

Shahidul Haq Khan: [Shahidul speaking in Bengali] 

English translation: We didn’t let him fall. 

[Bouncy, upbeat music fades out] 

Céline Gounder: The team was based on a hospital ship, called the Niramoy. It had all the basics: a couple of cabins, a space to perform surgery, plus a few comforts, like a generator they’d turn on in the morning for showers, a cook who picked up fresh fish at the market every day. 

Tim Miner: I would have a doodh cha, a tea with milk, and a kacha morich pyaz — scrambled eggs with, uh, chiles. 

Céline Gounder: The hospital ship hauled supplies from port to port. And everywhere they went, they towed a speedboat along with them. 

Tim Miner: We would receive reports of cases and we would get down from the ship in our speedboat, and the speedboat driver would take us as far as the boat could go. And we would walk, do the investigation, and find out who the contacts were and vaccinate the village and surrounding areas. 

Céline Gounder: Tim calls it “speedboat epidemiology.” The work required a willingness to go wherever and everywhere the virus took up residence. By and large, people welcomed them and were glad to get the vaccine. 

Tim Miner: They know about smallpox. They’ve been dealing with it, you know, all of their lives. And they have lost family members to the disease. 

Céline Gounder: Still, the task was huge: to find and vaccinate every person with smallpox — and all the people that person had come in contact with. 

[Subtle music begins playing] 

Céline Gounder: In modern-day public health, the work gets done with cellphones and spreadsheets, maybe social media. In Bangladesh in 1974, they had none of that. 

Shahidul and Tim had the speedboat, motorbikes, and their feet to cover a territory that took them all the way down to the coast. 

Tim Miner: First there’s Barishal … 

Shahidul Haq Khan: Latachapli … 

Tim Miner: … then there’s Faridpur … 

Shahidul Haq Khan: … Dankupara … 

Tim Miner: … then there’s Patuakhali. 

Shahidul Haq Khan: … and Kuakata. 

Céline Gounder: People were constantly on the move — maybe for seasonal work or better opportunities. That made contact tracing tricky. During one investigation, Tim identified a man who’d been exposed to the virus, but he’d left the region for Dhaka. 

The capital was densely populated — a city of 2 million in 1974. And smallpox was highly contagious. So Tim called a colleague — on the shortwave radio — to see if he could track down the man in Dhaka. 

[Ambient Dhaka street noises play in the background] 

Tim Miner: Well, it’s not just a street address or a ZIP code or anything like that, as you can well imagine. He lived in a basti, or a slum. And I described it as best I could. You know, ‘You enter by the big tree and turn left at the tea stall and walk the path and then start calling out for the family name.’ 

Céline Gounder: They found the guy! And vaccinated him. Tim says the man had smallpox, but the virus hadn’t quite erupted yet, so it was a pretty mild case. 

Tim Miner: Because of his immunization. It is somewhat miraculous, the needle in the haystack. 

[Music fades out] 

Céline Gounder: In Bangladesh, people weren’t likely to just show up to a local clinic to get the vaccine, so the team took the vaccine to the people. 

At its best, public health follows and bends to the rhythm of the culture. For example, after Ramadan, as Muslims began to break the fast for Eid … 

Tim Miner: Where people go back to their villages and visit and bring presents and gifts and food. 

[Ambient sounds of the water from a port in Bangladesh play] 

Céline Gounder: The team went to ports where steamer ships departed, asking in Bengali if travelers had come in contact with anyone with the disease’s distinctive pustules. 

Tim Miner: Guṭibasanta, uh, basanta rōgī. 

Céline Gounder: Which means “smallpox patient.” 

Tim Miner: Have you seen any guṭibasanta and basanta rōgī? 

Céline Gounder: Tim says he relied on his team to figure out how best to make the person in front of them comfortable. 

Tim Miner: ‘What would you do? What do you think should be done in this case?’ And I don’t think this is done often enough. It was a real partnership. It was real working together. 

Céline Gounder: Well, a partnership, yes. But Shahidul Haq Khan says the search-and-containment program was pretty strict. His work was meticulously checked and checked again. 

Remember, he was maybe 21 or 22 years old, with a big responsibility on his shoulders, and Tim Miner was a tough boss. 

Shahidul Haq Khan: [Shahidul speaking in Bengali] 

English translation: At any cost, we had to vaccinate all. There was no other way. 

Céline Gounder: Sometimes Shahidul had to return to the same home over and over — or hang out, if the man of the house was still in the fields working. 

Shahidul Haq Khan: [Shahidul speaking in Bengali] 

English translation: We had to wait until they returned. 

Shahidul Haq Khan: [Shahidul speaking in Bengali] 

English translation: Otherwise, Dr. Miner would again take us back there, no matter how late. [Shahidul laughs] 

Céline Gounder: One evening, Shahidul returned to the hospital ship after a day of door-to-door canvassing, and had to give a not-so-great report to Tim. 

[Tense music begins playing] 

Shahidul Haq Khan: [Shahidul speaking in Bengali] … a pregnant, uh, … 

English translation: I couldn’t vaccinate a pregnant woman in Dankupara. This was the first time that I couldn’t vaccinate someone. 

Shahidul Haq Khan: [Shahidul speaking in Bengali] 

English translation: I couldn’t convince her at all. He immediately told us to pack up. He stopped the work and said, “Let’s go.” 

Shahidul Haq Khan: [Shahidul speaking in Bengali] 

English translation: Immediately. At that very moment. 

Tim Miner: We were working basically 24/7, if need be. 

Céline Gounder: The team headed to the speedboat. It was late. And it was freezing. Shahidul remembers the bite of the cold air as they blasted across the water toward the woman’s village. 

Tim Miner: I fully understand, understood why this woman hesitated to be vaccinated. She was expecting a child and she didn’t want to do anything to jeopardize her life or the life of the unborn child. So, we were very gentle in talking with her and answering her questions. It was time well spent. 

Céline Gounder: The woman agreed to take the vaccine. 

Shahidul Haq Khan: [Shahidul speaking in Bengali] 

English translation: That day was one of the most memorable of my life. 

[Music fades to silence] 

Céline Gounder: Many on the team considered their outreach to women fundamental to success in South Asia, because … women talk. 

What they say, what they believe, echoes. 

Tim Miner: They get together, they do the laundry, they do the cooking, they share good times and bad times. This woman who was vaccinated probably showed her vaccination either in her family or in the village. And that’s the importance of getting one person, especially a pregnant woman who will tell others about immunization. 

Céline Gounder: Public health workers trying to end smallpox across South Asia mostly had the same tools — the vaccine, that bifurcated needle, and a strategy — on paper. But squashing the virus required tactics specific to each community: its needs, its culture, its worries … and its terrain. 

[Staccato music begins playing] 

Céline Gounder: Smallpox eradication workers went to great lengths to meet people where they were. 

But Joe Osmundson, who’s a public health advocate in New York City, told me that’s not an approach we see nearly enough in public health today. 

Joe Osmundson: Céline, it’s not your first time at the rodeo. [Celine laughs] Um, it’s like, we’ve all been through this again and again and again. 

We know what the problems are and yet we seem reluctant to actually do the right thing, which is to build processes that meet people where they’re at. 

Céline Gounder: After the break, more on what it looks like to bring public health directly to those who need it most. 

[Music fades to silence] 

Céline Gounder: Mpox, formerly known as monkeypox, is a highly contagious virus. Last summer, mpox cases spiked around the world, spreading quickly, predominantly among men who have sex with men. Mpox spreads through physical contact. It causes a painful blistering rash and, in extreme cases, it can be deadly. 

My colleague Joe Osmundson acted as a community liaison for the New York City Department of Health to help coordinate a culturally appropriate response to mpox. 

Joe Osmundson: I’m a microbiologist by training, but I also just do tons of advocacy and activism as a queer person who believes in equal access to the best biomedicine available. 

Céline Gounder: As mpox cases were increasing, we knew we needed to vaccinate those at highest risk as quickly as possible. Joe’s plan? Mobile vans to quickly bring mpox vaccines to places where high-risk people already were. 

Joe Osmundson: Our idea was to go to commercial sex venues, because commercial sex venues self-select for people with a large number of sexual partners. And if you give them the best possible immunity, that protects not just the people at the party but all the other people in the larger sexual network that they connect with. 

Céline Gounder: What is a commercial sex venue? 

Joe Osmundson: It’s basically a nonhousehold space where people gather for sex. 

When you have public venues where people gather, you have the opportunity to meet them where they’re at, to provide education, to provide condoms, to provide access to HIV testing and access to health care. 

So many queer people don’t have affirming doctors, don’t feel comfortable asking about sexual health with their physicians. So, you can put a van outside with affirming physicians and actually provide that preventative care that actually stops the infection. 

Céline Gounder: Did you run into any obstacles in doing this outreach? Setting up the mobile vans …? 

Joe Osmundson: So, there is a huge amount of mistrust in this community for city officials, for good reason. For many decades there was a group inside the New York City Department of Health that had undercover people who would go to these parties and find violations and close them down. So really it was only me and a couple other people doing outreach on-site. 

Céline Gounder: How did it work, what was the scene like, and what was your role in that? 

Joe Osmundson: Yeah, so, when I was there, I would go inside the club and, you know, there’s a little line, an area where people get dressed or undressed, and I would just hang out there and people would have a lot of questions. 

So, because, again, they perceived me as being, like, a part of their community, it was very easy to talk to people and just ask, you know, “Hey, have you had your vaccine yet? Have you had both doses?” If not, you know, it’ll take 15 minutes. I can walk you down to the van and get you that dose tonight. 

Céline Gounder: Were these mobile vaccination vans successful? 

Joe Osmundson: We find them to be massively successful. Once the city was able to get the vans there, people were so grateful to be able to get a shot on-site. 

We were giving 60, 80 doses per event — when the event might only have 140 people — so we were vaccinating 60% of these parties. 

That’s the other magic of the mobile units, was that you had people queer people talking to queer people, and even queer people of color talking to queer people of color and offering the care in terms that that community knows how to respond to and also just has more inherent trust with. 

Céline Gounder: But, at the same time, in New York City, mpox vaccination rates have been disproportionately low in Black communities. 

Joe Osmundson: Mm-hmm. 

Céline Gounder: As well as Hispanic communities. 

What could public health leaders have done from the start to ensure more equitable vaccine distribution, and what should they be doing now? 

Joe Osmundson: Yeah. It was a remarkable sort of mistake that, not just New York, but many cities made where they said we’ll build the foundation and then worry about equity later, because this is an emergency. 

So we’ll open up a brick-and-mortar in Chelsea, and then we’ll get the vaccine vans up at, you know, Brooklyn Pride, a Bronx health clinic. You know, we’ll do that later. 

We know that if you don’t do equity as the foundation, you will be chasing disparities. 

Céline Gounder: What can we say about who’s been vaccinated and who remains unvaccinated? 

Joe Osmundson: Black people are undervaccinated. They also have a higher rate of advanced HIV infection, and mpox plus advanced HIV means really severe disease and even death. Ninety percent of mpox deaths have been in Black people, Black queer people with advanced HIV. 

And we need something brand-new because we’ve been failing these folks for years. They have so many horrific experiences with their health care providers, or they don’t have insurance, or they’re underemployed, or they live super far from the nearest health care clinic. 

When people have difficulties accessing care, it spreads to every disease state, from HIV to mpox to primary care, etc. 

Céline Gounder: How can we apply this model of health outreach beyond mpox? 

Joe Osmundson: The model that we’re trying to build is a mobile unit that delivers all sorts of sexual and primary health care opportunities. They are opportunities! You know? If someone’s getting a covid vaccine, give them a flu vaccine at the same time. The literature shows that these interventions work. 

Céline Gounder: What else is there beyond vans? Are there other strategies when it comes to reaching people where they are that we haven’t employed that we should be thinking about? 

Joe Osmundson: We have affirming clinicians, affirming Black queer clinicians all over this city. Their expertise should be fostered. 

For years there’s been this model of health officials talking to community. And that’s outreach. And we aren’t done with that. 

We have experts, we have clinicians, we have epidemiologists, we have scientists who are in the community who know the science just as well as health officials. And communication needs to go two ways. 

Céline Gounder: That was Joe Osmundson, a microbiologist at New York University and the author of the book “Virology.” 

Joe Osmundson: The sexiest public health outreach worker of all time! [Laughter] A face made for radio. [Laughter] 

[“Epidemic” theme music begins playing] 

Céline Gounder: Next time on “Epidemic” … 

Larry Brilliant: Your company is sending death all over the world. You’re the greatest exporter of smallpox in history … You’ve got to stop this. 

Céline Gounder: “Eradicating Smallpox,” our latest season of “Epidemic,” is a co-production of KFF Health News and Just Human Productions. 

Additional support provided by the Sloan Foundation. 

This episode was produced by Taylor Cook, Zach Dyer, and me. 

Redwan Ahmed was our translator and local reporting partner in Bangladesh. 

Managing editor Taunya English was scriptwriter for the episode — with help from Stephanie O’Neill. 

Oona Tempest is our graphics and photo editor. 

The show was engineered by Justin Gerrish. 

Voice acting by Pinaki Kar. 

We had extra editing help from Simone Popperl. 

Music in this episode is from the Blue Dot Sessions and Soundstripe. 

We’re powered and distributed by Simplecast. 

If you enjoyed the show, please tell a friend. And leave us a review on Apple Podcasts. It helps more people find the show. 

Follow KFF Health News on Twitter, Instagram, and TikTok. 

And find me on Twitter @celinegounder. On our socials, there’s more about the ideas we’re exploring on the podcasts. And subscribe to our newsletters at kffhealthnews.org so you’ll never miss what’s new and important in American health care, health policy, and public health news. 

I’m Dr. Céline Gounder. Thanks for listening to “Epidemic.” 

[“Epidemic” theme fades out] 

Credits

Taunya English
Managing editor

@TaunyaEnglish

Taunya is senior editor for broadcast innovation with KFF Health News, where she leads enterprise audio projects.

Zach Dyer
Senior producer

@zkdyer

Zach is senior producer for audio with KFF Health News, where he supervises all levels of podcast production.

Taylor Cook
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@taylormcook7

Taylor is associate audio producer for Season 2 of Epidemic. She researches, writes, and fact-checks scripts for the podcast.

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Oona is a digital producer and illustrator with KFF Health News. She researched, sourced, and curated the images for the season.

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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.

For the first time since 2004, it appears health insurance coverage will not be a central issue in the presidential campaign, at least judging from the first GOP candidate debate in Milwaukee Wednesday night. The eight candidates who shared the stage (not including absent front-runner Donald Trump) had major disagreements over how far to extend abortion restrictions, but there was not even a mention of the Affordable Care Act, which Republicans have tried unsuccessfully to repeal since it was passed in 2010.

Meanwhile, a new poll from KFF finds that health misinformation is not only rampant but that significant minorities of the public believe things that are false, such as that more people have died from the covid vaccine than from the covid-19 virus.

This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico, Victoria Knight of Axios, and Margot Sanger-Katz of The New York Times.

Panelists

Joanne Kenen
Johns Hopkins Bloomberg School of Public Health and Politico

@JoanneKenen

Read Joanne's stories

Victoria Knight
Axios

@victoriaregisk

Read Victoria's stories

Margot Sanger-Katz
The New York Times

@sangerkatz

Read Margot's stories

Among the takeaways from this week’s episode:

• The first Republican presidential debate of the 2024 cycle included a spirited back-and-forth about abortion, but little else about health care — and that wasn’t a surprise. During the primary, Republican presidential candidates don’t really want to talk about health insurance and health care. It’s not a high priority for their base.
• The candidates were badly split on abortion between those who feel decisions should be left to the states and those who support a national ban of some sort. Former Vice President Mike Pence took a strong position favoring a national ban. The rest revealed some public disagreement over leaving the question completely to states to decide or advancing a uniform national policy.
• Earlier this summer, Stanford University’s Hoover Institute unveiled a new, conservative, free-market health care proposal. It is the latest sign that Republicans have moved past the idea of repealing and replacing Obamacare and have shifted to trying to calibrate and adjust it to make health insurance a more market-based system. The fact that such plans are more incremental makes them seem more possible. Republicans would still like to see things like association health plans and other “consumer-directed” insurance options. Focusing on health care cost transparency could also offer an opportunity for a bipartisan moment.
• In a lawsuit filed this week in U.S. District Court in Jacksonville, two Florida families allege their Medicaid coverage was terminated by the state without proper notice or opportunity to appeal. It seems to be the first such legal case to emerge since the Medicaid “unwinding” began in April. During covid, Medicaid beneficiaries did not have to go through any kind of renewal process. That protection has now ended. So far, the result is that an estimated 5 million people have lost their coverage, many because of paperwork issues, as states reassess the eligibility of everyone on their rolls. It seems likely that more pushback like this is to come.
• A new survey released by KFF this week on medical misinformation found that the pandemic seems to have accelerated the trend of people not trusting public health and other institutions. It’s not just health care. It’s a distrust of expertise. In addition, it showed that though there are people on both ends — the extremes — there is also a muddled middle.
• Legislation in Texas that was recently signed into law by Republican Gov. Greg Abbott hasn’t gotten a lot of notice. But maybe it should, because it softens some of the state’s anti-abortion restrictions. Its focus is on care for pregnant patients; it gives doctors some leeway to provide abortion when a patient’s water breaks too early and for ectopic pregnancies; and it was drafted without including the word “abortion.” It bears notice because it may offer a path for other states that have adopted strict bans and abortion limits to follow.

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

Julie Rovner: KFF Health News’ “Doctors and Patients Try to Shame Insurers Online to Reverse Prior Authorization Denials,” by Lauren Sausser.

Margot Sanger-Katz: KFF Health News’ “Life in a Rural ‘Ambulance Desert’ Means Sometimes Help Isn’t on the Way,” by Taylor Sisk.

Joanne Kenen: The Atlantic’s “A Simple Marketing Technique Could Make America Healthier,” by Lola Butcher.

Victoria Knight: The New York Times’ “The Next Frontier for Corporate Benefits: Menopause,” by Alisha Haridasani Gupta.

Also mentioned in this week’s episode:

• NPR’s “Two Families Sue Florida for Being Kicked off Medicaid in ‘Unwinding’ Process,” by Selena Simmons-Duffin
• NPR’s “Texas Has Quietly Changed Its Abortion Law,” by Selena Simmons-Duffin.
• KFF’s “Poll: Most Americans Encounter Health Misinformation, and Most Aren’t Sure Whether It’s True or False.”

Click to open the transcript

Transcript: A Not-So-Health-y GOP Debate

[Editor’s note: This transcript, generated using transcription software, has been edited for style and clarity.]

Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News. And I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Aug. 24, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So, here we go. We are joined today via video conference by Margot Sanger-Katz of The New York Times.

Margot Sanger-Katz: Good morning.

Rovner: Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico.

Joanne Kenen: Hi, everybody.

Rovner: And Victoria Knight of Axios News.

Victoria Knight: Hello, everyone.

Rovner: No interview this week, but we’ll have an entire interview episode next week. More on that later. First, we will get to this week’s news. Well, Wednesday night saw the first Republican presidential debate of the 2024 cycle, minus front-runner Donald Trump, in what could only be called a melee, on Fox News Channel. And while there was a spirited debate about abortion, which we’ll get to in a minute, I didn’t hear a single word about anything else health-related — not Medicare or Medicaid, nor any mention of the Affordable Care Act. Was anybody surprised by that? For the record, I wasn’t. I wasn’t really expecting anything except abortion.

Kenen: Well, somebody, I think it was [former New Jersey Gov. Chris] Christie actually pointed out that nobody was talking about it.

Knight: Mike Pence. It was [former Vice President] Mike Pence, actually.

Kenen: Oh, Pence. OK. “Nobody’s talking about Medicare and Social Security.” And then he didn’t talk about it, and nobody mentioned the ACA.

Rovner: Is the ACA really gone as a Republican issue, for this cycle, do we think?

Kenen: Well, I think it’s become, like, a guerrilla warfare. Like, they’re still trying to undermine it. They’re not trying to repeal it, but they’re looking at its sort of soft underbelly, so to speak, and trying to figure out where they can put more market forces on, which we can sort of come back to later. But they spent 10 years trying to repeal it, and they just figured out what they’ve got to do now is pretend it’s not there. Right now, abortion is their topic.

Rovner: Well, let us turn to that.

Sanger-Katz: Yeah, I was just going to say that we’ve been seeing this happen a little bit over the last couple of cycles. In the 2020 race — I went through the transcripts of all of the speakers during the Republican National Convention and was really staggered by how few mentions of Obamacare there were relative to the way that the issue had been discussed in the past. But I think — just a note, that this is the Republican debate. Republicans don’t really want to be talking about health insurance and health care, because they don’t really have affirmative plans to put forward and because I think that they see that there are some real political liabilities in staking out a strong position on these issues. But in a general election, I think it will be impossible for them to avoid it, because, I think, Joe Biden has a lot of things that he wants to say. I think he is very committed to, in particular, broadcasting that he wants to protect Medicare. I think he’s quite proud of the expansions that he’s made of the Affordable Care Act. And so, this is a little bit of a weird moment in the race because, you know, we really only have one party that’s having a primary, and its leading candidate is not participating in the debates. And so, I think these candidates are trying to focus elsewhere. But it is — I will say, as someone who’s covered a couple of these now — it is a weird experience to have health care and health policy feel like a second-tier issue, because it was so central — Obamacare, in particular — was just so central to so many of these election cycles and such an animating and unifying issue among Republican voters, that this kind of post-failure-of “repeal and replace” era feels very different.

Kenen: One really quick thing is, they’re going to hit Biden on inflation. Economically, it’s his most vulnerable point, and health care costs are a burden. And I was a little surprised, without going into Obamacare and repeal and all that stuff, they mentioned the price of food, the price of gas, they mentioned interest rates and housing. It would have been really easy, and I expect that at some point they will start doing it, to talk about the cost of health care, because Biden’s done a huge amount on coverage and making insurance more affordable and accessible. But the cost of health care, as we all know, is still high in America.

Rovner: And at very least, the cost of prescription drugs, which has been a bipartisan issue going back many, many years. All right. Well, the one health issue that, not surprisingly, did get a lot of attention last night was abortion. With the exception of Mike Pence, who has been an anti-abortion absolutist for his entire tenure in Congress, as governor of Indiana, and as vice president, everyone else looked pretty uncomfortable trying to walk the line between the very anti-abortion base of the party and the recognition that anti-abortion absolutism has been a losing electoral strategy since the Supreme Court overturned Roe last year. What does this portend for the rest of the presidential race and for the rest of the down-ballot next year? Rather than trying to bury the fact that they all disagree, they all just publicly disagreed?

Knight: And I think they also, like, if you listened, [former U.S. ambassador to the United Nations] Nikki Haley kind of skirted around how she would address it. She talked about some other things, like contraception and saying that there just weren’t enough votes in the Senate to pass any kind of national abortion ban. [Florida Gov.] Ron DeSantis also, similarly, said he was proud of his six-week bill but didn’t quite want to answer about a national abortion ban. There were the few that did say, like, Hey, we’re into that. And some said, You know, it needs to go back to the states. So there definitely was kind of this slew of reactions on the stage, which I think just shows that the Republican Party is figuring out what message, and they don’t have a unified one on abortion, for sure.

Rovner: I do want to talk about Nikki Haley for a second, because this is what she’s been saying for a long time that she thinks that there’s a middle ground on abortion. And, you know, bless her heart. I’ve been covering this for almost 40 years and there has never been a middle ground. And she says, well, everybody should be for contraception. Well, guess what? There’s a lot of anti-abortion stalwarts who think that many forms of contraception are abortion. So there isn’t even a consensus on contraception. Might she be able to convince people that there could be a middle ground here?

Sanger-Katz: Oh, what I found sort of interesting about her answers: I think on their face they were kind of evasive. They were like, I don’t need to answer this question because there’s not a political consensus to do these things. But I do think it was sort of revealing of where the political consensus is and isn’t that I think she’s right. Like, realistically, there aren’t the votes to totally ban abortion; there aren’t the votes to renew the Roe standard. And I think she was in some ways very honestly articulating the bind that Republicans find themselves in, where they, and I think a lot of their voters, have these very strong pro-life values. At the same time, they recognize that getting into discussions about total abortion bans gives no favors politically and also isn’t going to happen in the near future. So, I felt like, as a journalist, you know, thinking about how I would feel having asked her that question, I felt very dissatisfied by her answer, because she really didn’t answer what she would like to do. But I do think she channeled the internal debate that all these candidates are facing, which is, like, is it worth it to go all the way out there with a policy that I know will alienate a lot of American voters when I know that it cannot be achieved?

Rovner: I was actually glad that she said that because I’ve been saying the opposite is true also — everybody says, well, why didn’t, you know, Congress enshrine abortion rights when they could have? The fact is, they never could have. There have never been 60 votes in the Senate for either side of this debate. That’s why they tried early after Roe to do national bans and then a constitutional amendment. They could never get enough votes. And they tried to do the Freedom of Choice Act and other abortion rights bills, and they couldn’t get those through either. And this is where I get to remind everybody, for the 11,000th time, the family planning law, the Title X, the federal Family Planning [Services and Public Research] Act, hasn’t been reauthorized since 1984 because neither side has been able to muster the votes even to do that. Sorry, Joanne, you wanted to say something.

Kenen: No, I thought Haley’s response on abortion was actually really pretty interesting on two points, right? She didn’t technically answer the question, but she also said this question is a fantasy — you know, face it. And, you know, she said that, and then she mentioned the word contraception. She did not dwell on it. She sort of said it sort of quickly. She missed an opportunity, maybe, just for one or two more sentences. You know, she said we need to make sure that contraception … she’s the only woman on that stage. She’s a mother; she’s got two kids. And, you know, there is uncertainty. After Dobbs there were advocacy groups saying, you know, they’re going to ban contraception tomorrow, and that didn’t happen. And we still don’t know how that fight will play out and what types of contraception will be debated. But I noticed that she said that on a stage full of Republicans, and I noticed that nobody else — all men — didn’t pick up on it.

Rovner: The big divide seemed to be, do you want to leave it completely to the states or do you want to have some kind of national floor of a ban? And they seemed, yeah —

Kenen: Yeah, and the moderators didn’t pick up on that. I mean, there was such a huge brouhaha on the stage. You know, the moderators had a lot of trouble moderating last night. It wouldn’t have been easy for them to get off of abortion and follow up on contraception. But I thought it was just sort of an interesting thing that she noted it.

Sanger-Katz: I will say also, and I agree with Julie: With the possible exception of Mike Pence, even the candidates that were endorsing some kind of national abortion policy, we’re talking about a 15-week gestational limit. There really wasn’t anyone who was coming out and saying, “Let’s ban all abortions. Let’s even go to six weeks,” which many of the states, including Florida, have done. So I do think, again, like, even the candidates that were more willing to take an aggressive stand on whether the federal government should get involved in this issue were moderating the position that you might have expected for them before Dobbs.

Kenen: But even 15 weeks shows how the parameters of this conversation have changed, because what the Republicans had been doing pre-Dobbs was 20 weeks, with their so-called fetal-pain bills. So 15 weeks, which would have sounded extremely radical two years ago — compared to six weeks, 15 sounds like, oh, you know, this huge opportunity for the pro-choice people. And it is another sign of how this space has shrunk.

Sanger-Katz: Yeah, no, I don’t mean that it’s a huge opportunity for the pro-choice people, but I think it reflects that even the candidates who were willing to go the most out on the limb in wanting to enforce a national abortion restriction understand the politics do not permit them to openly advocate going all the way towards a full ban.

Rovner: While we are on the subject of Republicans and health, there actually is a new Republican plan to overhaul the health system. Sort of. It’s from the Hoover Institution at Stanford, from which a lot of conservative policy proposals emanate. And it’s premised on the concept that consumers should have better control of the money spent on their health care and a better idea of what things cost. Now, this has basically been the theme of Republican health plans for as long as I can remember. And the lead author of this plan is Lanhee Chen, who worked for Republicans in the Senate and then led presidential candidate Mitt Romney’s policy shop, and whose name has been on a lot of conservative proposals. But I find this one notable more for its timing. Republicans, as we mentioned, appear to have internalized the idea that the only thing they can agree on when it comes to health care is that they don’t like the Affordable Care Act. Is that changing or is this just sort of hope from the Republican side of the policy wonk shop?

Sanger-Katz: I think this is connected to the discussion that we had about the debate, but it feels to me like we are in a bit of a post Obamacare era where the fights about “Are we going to continue to have Obamacare or not?” have sort of faded from the mainstream of the discussion. But there’s still plenty of discussion to be had about the details. The Democrats clearly want to expand Obamacare in various ways. Some of those they have done in a temporary fashion. Others are still on the wish list. And I think this feels very much like the kind of calibration adjustment, you know, small changes, tinkers on the Republican side to try to make the health insurance market a little bit more market-based. But this is not a big overhaul kind of plan. This is not a repeal-and-replace plan. This is not a plan that is changing the basic architecture of how most Americans get their insurance and how it is paid for. This is a plan that is making small changes to the regulation of insurance and to the way that the federal government finances certain types of insurance. That said, I think the fact that it’s more incremental makes it feel like these are things that are more likely to potentially happen because they feel like there are things that you could do without having a huge disruptive effect and a big political backlash and that you could maybe develop some political consensus around.

Rovner: It does, although I do feel like, you know, this is a very 2005 plan. This is the kind of thing that we would have seen 15 years ago. But as Democrats have gotten the Affordable Care Act and discovered that the details make it difficult, Republicans have actually gotten a lot on the transparency side and, you know, helping people understand what things cost. And that hasn’t worked very well either. So there’s a long way to go, I think, on both sides to actually make some of these things work. Victoria, did you want to add something?

Knight: Yeah, I’ve been talking to Republicans a lot, trying to figure out like what is their next go-to going to be. And I think they’re pretty understanding that ACA is set in place, but they still don’t want to give up that there are alternative types of health insurance that they want to put out there. And I think that seems that’s kind of what they realize they can accomplish if they get another Republican president and they’re going to try to do association health plans again. They’re going to try to expand some of these what they call health reimbursement arrangements, things like that, to just like kind of try to add some other types of health insurance options, because I think they know that ACA is just too entrenched and that there’s not much else they can do outside of that. And then, yeah, I think focus a little more on the transparency and cost because they know that’s a winning message and that is the one thing in Congress right now on the health care end that seems to have bipartisan momentum for the most part.

Rovner: Yeah, I think you’re absolutely right. Well, another issue that could have come up in last night’s debate but didn’t was the unwinding of Medicaid coverage from the pandemic. The news this week is that the first lawsuit has been filed accusing a state of mistreating Medicaid beneficiaries. The suit filed against Florida by the National Health Law Program and other groups is on behalf of two kids, one with a disability, and a mom who recently gave birth. All would seem to still be eligible, and the mom says she was never told how to contest the eligibility determination that she was no longer eligible, and that she was cut off when she tried to call and complain. State officials say their materials have been approved by the Centers for Medicare & Medicaid Services, which they have, and that Florida, in fact, has a lower procedural disenrollment rate than the average state, which is also true. But with 5 million people already having been dropped from Medicaid, I imagine we’re going to start to see a little more pushback from advocacy groups about people who are, in all likelihood, still eligible and have been wrongly dropped. I’m actually a little surprised that it took this long.

Kenen: Many of the people who have been dropped, if they’re still eligible, they can get recertified. I mean, there’s no open enrollment season for Medicaid. If you’re Medicaid-eligible, you’re Medicaid-eligible. The issue is, obviously, she didn’t understand this. It’s not being communicated well. If you show up at the hospital, they can enroll you. But people who are afraid that they aren’t covered anymore may be afraid of going to the hospital even if they need to. So there’s all sorts of bad things that happen. In some of these cases, there are simple solutions if the person walks in the door and asks for help. But there are barriers to walking in the door and asking for help.

Rovner: I was going to say one of the plaintiffs in this lawsuit is a child with a disease …

Kenen: Cystic fibrosis.

Rovner: Right. That needs expensive drugs and had not been able to get her drugs because she had been cut off of Medicaid. So there’s clearly stuff going on here. It’s probably true that Florida is better than the average state, which means that the average state is probably not doing that well at a lot of these things. And I think we’re just starting to see, you know, it’s sort of mind-numbing to say, oh, 5 million people have been separated from their health insurance. And again, we have no idea how many of those have gotten other health insurance, how many of those don’t even know and won’t know until they show up to get health care and find out they’re no longer covered. And how many people have been told they’re no longer covered but can’t figure out how to complain and get back on?

Sanger-Katz: And it’s this very extreme thing that’s happening right now. But it is, in many ways, the normal system on steroids. You know, if you’ve been covering Medicaid for any period of time, as all of us have, like, people get disenrolled all of the time from Medicaid for these administrative reasons, because of some weird hiccup in the system, they move, their income didn’t match in some database. This is a problem that a lot of states face because they have financial incentives often to drop people off of Medicaid because they have to pay a portion of the cost of providing health care. And a lot of them have rickety systems, and they’re dealing with a population that often has unstable housing or complicated lives that make it hard for them to do a lot of paperwork and respond to letters in a timely way. And so part of the way that I’ve been thinking about this unwinding is that there’s a particular thing that’s happening now, and I think there’s a lot of scrutiny on it, appropriately. And I think that there should be to make sure that the states are not cutting any corners. But I also think in some ways it’s sort of like a way of pressure-testing the normal system and reminding us of all of the people who slip through the cracks in normal times and will continue to do so after this unwinding is over. And these stories in Florida, to me, do not feel that dissimilar from the kinds of stories that I have heard from patients and advocates in states long before this happened.

Rovner: Yeah, I think you’re right. It’s just shining a light on what happens. I mean, it was the oddity that they were … states were not allowed to redetermine eligibility during the pandemic because normally states are required to redetermine eligibility at least once a year. And I think some do it twice a year. So it’s, you know, these redeterminations happen. They just don’t happen all in a huge pile the way they’re happening now. And I think that’s the concern.

Sanger-Katz: And it also, I think, really shines a light on the way that Medicaid is structured, where the Affordable Care Act simplified it quite a lot because, [for example], you’re in an expansion state and you earn less than a certain amount of money, then you can get Medicaid. But there are all of these categories of eligibility where, you know, you have to be pregnant, you have to be the parent of a child of a certain age. You have to demonstrate that you have a certain disability. And I think [it] is a reminder that this is a pretty complicated safety net, Medicaid. You know, there’s lots of things that beneficiaries have to prove to states in order to stay eligible. And there’s lots of things, honestly, you know, if states really want to make sure that they are reserving resources for the people who need them, that they do need to be checking on. And so I think we’re all just sort of seeing that this is a messy, complicated process. And I think we’re also seeing that there are these gaps and holes in who Medicaid covers. And it’s not the case that we have a perfect and seamless system of universal coverage in this country. We have this patchwork and people do fall between the cracks.

Kenen: And this is one of the most vulnerable populations, obviously. Some of the elderly are also very vulnerable, but these are people who may not speak either English or Spanish. They don’t have access to computers necessarily. I mean, we’re giving the least assistance to the population that needs the most assistance. And, you know, I mean, I think if Biden wanted to be really savvy about fixing it, he’d come out with some slogan about “Instead of Medicare unwinding, it’s time to have Medicare rewinding,” or something like that, because they’re going to have to figure … I mean, they have taken some steps, but it’s a huge mess, and the uninsurance rate is going to go up, and hospitals are going to have patients that are no longer covered, and it’s not going to be good for either the health care system or certainly the people who rely on Medicaid.

Rovner: I think it’s noteworthy how much the administration has been trying not to politicize this, that apparently, you know, we keep hearing that they won’t even tell us which states, although you can … people can sort of start to figure it out. But, you know, states that are having a more difficult time keeping eligible people on the rolls, shall we say, when the administration could have … I mean, they could be trumpeting, you know, which states are doing badly and trying to shame them. And they are rather very purposely not doing that. So I do think that there’s at least an attempt to keep this as collegial, if you will, as possible in a presidential election year. So my colleagues here at KFF have a depressing, but I guess not all that surprising, poll out this week about medical misinformation and how much of the public believes things that simply aren’t true — like that more people died from the covid vaccine than covid itself, or that ivermectin is a useful treatment for the virus. It’s not. It’s for parasites. And the survey didn’t just ask about covid. People have been exposed to, and a significant percentage believe, things like that it’s harder to get pregnant if you’ve been on birth control and stop. It isn’t. Or that people who keep guns in their house are less likely to be killed by a gun than those who don’t. They’re not. But what’s really depressing is the fact that the pandemic seems to have accelerated an already spiraling trend in distrust of public institutions in general: government, local and national media, and social media. Are we ever going to be able to start to get that back? I mean, you know, we talk about the woes with public health, but this goes a lot deeper than that, doesn’t it?

Kenen: And it’s not just health care. When you look at historical metrics about trust — which I’ve had to for a course I teach — we were never a very trusting society, it turns out. We’ve had large sectors of the population haven’t been trusting of many institutions and sectors of society for decades. We’re just not too huggy in this country. It’s gotten way worse. And what you said is right, but it’s broad. It’s not just doctors. It’s not just vaccines, it’s expertise. This distrust is really corrosive. But of all the things in that survey, one that really blew me away was we’re like, what, 13 years since Obamacare was passed? Only 7% or 8% — “only,” I should say only in quotes, you know — only 7% or 8% still thought there were death panels, but something like 70% wasn’t sure if there were death panels. Like, has anyone known anyone who went before a death panel? Since 2010? And yet 70% — I mean, I may be a little off, I didn’t write it down — but it’s something like 70% weren’t sure. And that is a mind-blowing number. It just says, you know, they weren’t ready to come out and say, yes, there are death panels. But that meant that a lot of Democrats also weren’t sure if there were death panels There are no death panels.

Knight: I was just gonna say, I also thought it was interesting that it showed people do use social media to get a lot of their information, but then they also don’t trust the information that they get on there. So it’s kind of like, yeah …

Rovner: And they’re right not to!

Knight: Yeah, they’re absolutely right not to. But then it’s also like, well, they’re then just not getting health information at all, or if they’re getting it, they just don’t trust it. So just showcasing how difficult it is to fill that void of health information, like, people just aren’t getting it or don’t trust it.

Rovner: I feel like some of this is social literacy. I mean, you know, we talk about health literacy and things that people can understand, but, you know, people don’t understand the way journalism works, the difference between the national news and what you see on Facebook. And I think that’s, Joanne, going back to your point about people not trusting expertise, it’s also not being able to figure out what expertise is and who has expertise. I mean, that’s really sort of the bottom line of all this, isn’t it?

Kenen: Well, I mean, I was doing some research — I can’t remember the exact details, this was something I read several months ago — but there was one survey maybe a couple of years ago where the majority of people said they don’t trust the news they read, but they’re still getting their news from something that they don’t trust. So it sounds sort of funny, but it’s actually not. I mean, it’s really a crisis of people don’t know what to believe. The uncertainty is corrosive, and it’s health care and politics, this widening chasm of people with alternative sets of facts — or alternative worldviews, anyway. So it’s not good. I mean, it was a really good survey, it was a really interesting survey, but some of it wasn’t so surprising. I mean, that there’s still people who, like, the fertility issues and the vaccines. You can sort of understand why those have lingered in the environment we’re in. I had actually had a conversation the other day with a political scientist who had studied the death panel rumors 10 years ago. And I said, what about now? And, you know, he was sort of … he hadn’t looked at it and he was sort of saying, well, you know, there aren’t any. And people have probably figured that out by now. Well, no. I have to email him the study, right?

Sanger-Katz: Anytime that I read a study like this, I am also reminded — and I think it is useful for all of us to be reminded of this and probably most people who are listening to the podcast — that the average American is just not as tuned in on the news and on the Washington debate and on the minutia of public policy, as all of us are. So, you know, and I think that that is part of the reason why you see so many people not sure about these things. It’s clearly the case that they are being exposed to bad information and that is contributing to their uncertainty. And I think the rise of misinformation about both health policy and about actual, you know, health care, in the case of covid, is a bad and relatively newer phenomenon. But I also think a lot of people just aren’t paying that close attention, you know, and it’s good to be reminded of that.

Kenen: The book I just read that I referred to — it’s by an MIT political scientist named Adam Berinsky, and it’s called “Political Rumors.” And it just came out, and he was talking about exactly that, that we’re all exposed to misinformation. We can’t avoid it. It’s everywhere. And that for people who aren’t as engaged with day-to-day politics, they end up uncertain. That’s this messy middle, which they also use in the KFF survey. They came up with a very similar conclusion about the “muddled middle,” I think was the phrase they used. And what this political scientist said to me the other day was that, you know, pollsters tend to not look at the “I don’t know, I’m uncertain, no opinion.” They sort of shunt them aside and they look at the “yes” or “no” people. And he was saying, no, no, no, you know, this is the population we really need to pay attention to, the “Uncertains” because they’re probably the ones you can reach more. And in the real world, we saw that with vaccination, right? I mean, in the primary series — I mean, booster takeup was low — but in the primary when there was a lot of uncertainty about the vaccines, the people who said “no way I am ever going to get the vaccine” — I mean, KFF was surveying this every month — most of them didn’t. You know, a few on the margins did, but most of them who were really militantly against the vaccine didn’t take it. The ones who were “I don’t know” and “I’m a little scared” and “I’m waiting and seeing” … a lot of them did take it. They were reached. And that’s sort of an important lesson to shift the focus as we deal with distrust, as we deal with disinformation and we deal with messaging, which is good, and truth-building and confidence-building, it is that muddled middle that’s going to have to be more of a target than we have traditionally thought.

Rovner: Well, in the interest of actually giving good information, we have a couple of updates on the reproductive health front. For those of you keeping score, abortion bans took effect this week in South Carolina and Indiana after long drawn-out court battles. Meanwhile, in Texas, an update to our continuing discussion of women with pregnancy complications who’ve been unable to get care because doctors fear running afoul of that state’s ban, a couple of weeks ago, reports Selena Simmons-Duffin at NPR, Texas Gov. Greg Abbott very quietly signed a law that created a couple of exceptions to the ban for ectopic pregnancies and premature rupture of membranes, both of which are life-threatening to the pregnant woman, but just not necessarily immediately life-threatening. I had not heard a word about this change in the law until I saw Selena’s story. Had any of you?

Kenen: In fact, it should have come up because of this court case in Texas about, you know, a broader health exception — it’s not even “health,” it’s life-threatening. It’s like, at what point do you get sick enough that your life is in danger as opposed to, you know, should you be treating that woman before … you see what direction it’s going, and you don’t let them go to the brink of death? I mean, that was the court case and Abbott fought that. But yeah, it was interesting.

Rovner: It was a really interesting story that was also, you know, pushed by a state legislator who was trying very hard not to … never to say the word abortion and to just make sure that, you know, this was about health care and not abortion. It’s an interesting story, we will link to it.

Sanger-Katz: I wonder if other states will do this as well. It seems like, as we’ve discussed, you know, abortion bans are not as popular as I think many Republican politicians thought they would [be]. And I do think that these cases of women who face really terrible health crises and are unable to get treated are contributing to the public’s dislike of these policies. And on the one hand, I think that there is a strong dislike of exceptions among people who support abortion bans because they don’t want the loopholes to get so big that the actual policy becomes meaningless. On the other hand, it seems like there is a real incentive for them in trying to fix these obvious problems, because I think it contributes to bad outcomes for women and children. And I think it also contributes to political distaste for the abortion ban itself.

Kenen: But it’s very hard to legislate every possible medical problem …  I mean, what Texas did in this case was they legislated two particular medical problems. And some states … they have the ectopic — I mean, ectopic is not … there’s no stretch of the imagination that that’s viable. Right? The only thing that happens with an ectopic pregnancy is it either disintegrates or it hemorrhages. I mean, the woman is going to have a problem, but making a list of “you get this condition, you can have a medical emergency abortion, but if you have that condition and your state legislator didn’t happen to think about it, then you can’t.” I mean, the larger issue is: How do you balance the legal restrictions and medical judgments? And that’s … I don’t think any state that has a ban has completely figured that out.

Rovner: Right. And we’re back to legislators practicing medicine, which is something that I think the public does seem to find distasteful.

Sanger-Katz: I mean, I don’t think that this solves the problem at all, but I think it does show a surprising responsiveness to the particular bad outcomes that are getting the most publicity and a sort of new flexibility among the legislators who support these abortion bans. So it’s interesting.

Rovner: All right. Meanwhile, another shocking story about pregnant women being treated badly. The Centers for Disease Control and Prevention reported this week that a survey conducted this April found that 1 in 5 women reported being mistreated by medical professionals during pregnancy or delivery. For women of color, the rate was even higher: more than 1 in 4. Mistreatment included things like getting no response to calls for help, being yelled at or scolded, and feeling coerced into accepting or rejecting certain types of treatment. We know a lot of cases where women in labor or after birth reported problems that went ignored. Among the most notable, of course, was tennis legend Serena Williams, who gave birth to her second child this week after almost not surviving the birth of her first. We’re hearing so much about the high maternal mortality rate in the U.S. What is it going to take to change this? This isn’t something that can be solved by throwing more money at it. This has got to be sort of a change in culture, doesn’t it?

Kenen: No. I mean, it’s … if someone who’s just given birth, particularly if it’s the first time and you don’t know what’s normal and what’s not and what’s dangerous and what’s not dangerous, and, you know, it’s a trauma to your body. I mean, you know, I had a very much-wanted child, but labor is tough, right? I always say that evolution should have given us a zipper. But the philosophy should be, if someone who’s just been through this physical and emotional ordeal, has discomfort or a question or a fear, that you respect it and that you calm it down, you don’t dismiss it or yell at somebody. When you’re pregnant, you read all these books and you go to Lamaze workshops and you learn all this stuff about labor and delivery. You learn nothing about what happens right after. And it’s actually quite uncomfortable. And no one had ever told me what to expect. And I didn’t know. And I always, like, when younger women are having babies, I let them know that, you know, talk to your doctor or learn about this or be prepared for this, because that is a really vulnerable point. And that this survey — and it’s more Black and poor women, and Latina women in this survey, it’s not that … it’s disproportionate like everything else in health care — they’re being disrespected and not listened to. And some of them are going to have bad medical outcomes because of that.

Rovner: As we are seeing. All right. Well, that is this week’s news now. We will take a quick break. Then we will come back and do our extra credit.

Hey, “What the Health?” listeners: You already know that few things in health care are ever simple. So if you like our show, I recommend you also listen to “Tradeoffs,” a podcast that goes even deeper into our costly, complicated, and often counterintuitive health care system. Hosted by longtime health journalist and my friend Dan Gorenstein, “Tradeoffs” digs into the evidence and research data behind health care policies and tells the stories of real people impacted by decisions made in C-suites, doctors’ offices, and even Congress. Subscribe wherever you get your podcasts.

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

Knight: So my extra credit is from The New York Times, and the story is called “The Next Frontier for Corporate Benefits: Menopause.” It basically details how a lot of companies are realizing that, you know, as more women get into leadership positions, high-level leadership, executive positions, they’re in their 40s, late 40s, early 50s, that’s when menopause or perimenopause starts happening. And that’s something that can last for a while. I didn’t realize the stories, that it can last almost 10 years sometimes. And so it was talking about how, you know, it affects women for a long period of time. It can also affect their productivity in the workplace and their comfort and being able to accomplish things. And so they were realizing, you know, we kind of need to do something to help these women stay in these positions. And there was actually an interesting tidbit at the very end where it was talking about some companies may even be, like, legally compelled to make accommodations. And that’s due to the new Pregnant Workers Fairness Act, which says that employers have to provide accommodations for people experiencing pregnancy but also related medical conditions. They’re saying menopause could be included in that. And just some of the benefits some of these companies were offering were access to virtual specialists, but they were talking about, like, if they need to do other things like cooling rooms and stuff like that. So I thought it was kind of interesting. And another employer benefit that maybe some employers are thinking about adding.

Kenen: I think all offices should have, like, little nap cubicles and man-woman, pregnant-not pregnant. And, you know, just like “life is rough.” [laughter]

Knight: I agree.

Kenen: Just a little corner!

Rovner: Joanne, why don’t you go next?

Kenen: Mine is from The Atlantic. It’s by Lola Butcher. And it is “A Simple Marketing Technique Could Make America Healthier.” And it’s basically talking about how some medical practices are doing what we in the news business and the tech industry knows of as “A-B testing.” You know, a tech company may try a big button or a little button and see which one consumers like. Newsrooms change headlines— headline A, headline B and see which one draws more readers — and that hospitals and medical practices have been trying to do. In some cases, it’s text messaging two different kinds of reminders to figure out, you know … one example was the message with something like 78 characters got women to book a mammogram, but a message with 155 characters did not. Two text messages were better than one for booking children’s vaccines. So some people are very excited about this. It’s getting people to do preventive care and routine care. And some people think this is just not the problem with health care, that it’s way deeper and more systemic and that this isn’t really going to move the needle. But it was an interesting piece.

Rovner: Any little thing helps.

Kenen: Right. This was an interesting piece.

Rovner: Margot.

Sanger-Katz: I wanted to talk about an article in KFF Health News from Taylor Sisk. The headline is “Life in a Rural ‘Ambulance Desert’ Means Sometimes Help Isn’t on the Way,” and it’s a really interesting exploration of some of the challenges of ambulance care in rural areas, which is a topic that is near and dear to my heart. Because when I was a reporter in New Hampshire covering rural health care delivery, I spent the better part of a year writing about ambulance services and the challenges there. And I think this story is highlighting a real challenge for people in these communities. And I think it’s also really a reminder that the ambulance system is this weird, off-to-the-side part of our health care system that I think is often not well integrated and not well thought of. It tends to be regulated as transportation, not as health care. It tends to be provided by local governments or by contractors hired by local governments as opposed to health care institutions. It tends to have a lot of difficulty with billing a very high degree of surprise billing for its patients, and also just a real lack of health services research about best practices for how fast ambulances should arrive, what level of care they should provide to people, and on and on. And I just think that it’s good that she’s highlighted this issue. And also, I think it is a reminder to me that ambulances are probably worth a little bit more attention from reporters overall.

Rovner: Well, my story is also something that’s near and dear to my heart because I’ve been covering it for a long time. It’s from my KFF Health News colleague Lauren Sausser. It’s called “Doctors and Patients Try to Shame Insurers Online to Reverse Prior Authorization Denials.” And it is a wonderful 2023 update to a fight that Joanne and I have been covering since, what, the late 1990s. It even includes comments from Dr. Linda Peeno, who testified about inappropriate insurance company care denials to Congress in 1996. I was actually at that hearing. The twist, of course, now is that while people who were wrongly denied care at the turn of the century needed to catch the attention of a journalist or picket in front of the insurance company’s headquarters. Today, an outrage post on Instagram or TikTok or X can often get things turned around much faster. On the other hand, it’s depressing that after more than a quarter of a century, patients are still being caught in the middle of appropriateness fights between doctors and insurance companies. Maybe prior authorization will be the next surprise medical bill fight in Congress. We shall see. All right. That is our show for the week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks, as always, to our amazing engineer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can tweet me or X me or whatever. I’m @jrovner, also on Bluesky and Threads. Joanne?

Kenen: I am also on Twitter, @JoanneKenen; and I’m on Threads, @joannekenen1; and Bluesky, JoanneKenen.

Rovner: Margot.

Sanger-Katz: I’m @sangerkatz.

Rovner: Victoria.

Knight: I’m @victoriaregisk on X and Threads.

Rovner: Well, we’re going to take a week off from the news next week, but watch your feed for a special episode. We will be back with our panel after Labor Day. Until then, be healthy.

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

A divided three-judge federal appeals court panel has ruled that a lower court was wrong to try to reverse entirely the FDA’s approval of the abortion drug mifepristone. The panel did find, however, that the agency violated regulatory rules in making the drug more easily available and that those rules should be rolled back. In practice, nothing changes immediately, because the Supreme Court has blocked the lower court’s order that the drug effectively be removed from the U.S. market — for now.

The case is pivotal for the future of reproductive health, as the pill is part of a regimen that is now the most common way American women terminate early pregnancies and is also widely used by doctors to manage miscarriages.

Meanwhile, as President Joe Biden’s Inflation Reduction Act turns one, Medicare officials are preparing to unveil which 10 drugs will be the first to face price negotiation under the new law.

This week’s panelists are Julie Rovner of KFF Health News, Shefali Luthra of The 19th, Sarah Karlin-Smith of the Pink Sheet, and Alice Miranda Ollstein of Politico.

Panelists

Shefali Luthra
The 19th

@shefalil

Read Shefali's stories

Sarah Karlin-Smith
Pink Sheet

@SarahKarlin

Read Sarah's stories

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories

Among the takeaways from this week’s episode:

• Wednesday’s federal appeals court decision siding with conservative medical groups challenging mifepristone regulations has perhaps the biggest implications for the drug’s distribution via telemedicine, which has been key to securing abortion access for people in areas where abortion is unavailable.
• The ongoing legal threat to mifepristone is reverberating through the drug industry, as drugmakers worry challenges to the FDA’s scientific authority could cause serious problems for future drug development — especially in an industry that takes big financial risks on getting products approved.
• Texas is suing Planned Parenthood over past Medicaid payments made to the program, charging that the health organization “defrauded” the state, even though the claims were made while a court had specifically allowed Planned Parenthood to remain in the program. Still, the lawsuit emphasizes just how far Texas has gone, and will go, to maintain the legal authority to not support Planned Parenthood, even in its non-abortion work.
• The federal government is expected to release the list of 10 pharmaceuticals subject to Medicare price negotiations by Sept. 1. The drugs’ identities are the subject of much educated speculation, as Congress laid out in the law how drugs qualify for consideration — though even stakeholders in the drug industry are wondering which specific drugs will be up for discussion.
• A national survey of pharmacists finds drug shortages are widespread and leading to rationing at the pharmacy level. A lack of incentives to produce generic drugs is complicating supply-chain problems, leaving fewer options when there are manufacturing or other types of issues with a particular drugmaker.

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

Julie Rovner: Time’s “She Wasn’t Able to Get an Abortion. Now She’s a Mom. Soon She’ll Start 7th Grade,” by Charlotte Alter.

Sarah Karlin-Smith: MIT Technology Review’s “Microplastics Are Everywhere. What Does That Mean for Our Immune Systems”? by Jessica Hamzelou.

Shefali Luthra: The Atlantic’s “Right Price, Wrong Politics,” by Annie Lowrey.

Alice Miranda Ollstein: Politico’s “We’re on the Cusp of Another Psychedelic Era. But This Time Washington Is Along for the Ride,” by Erin Schumaker and Katherine Ellen Foley.

Also mentioned in this week’s episode:

• States Newsroom/The Georgia Recorder’s “Study Cited by Texas Judge in Abortion-Pill Case Under Investigation,” by Sofia Resnick.
• Stat’s “From Drug Shortages to High Prices, U.S. System’s Shortcomings Have Deep Roots,” by Matthew Herper.

Click to open the transcript

Transcript: Abortion Pill’s Legal Limbo Continues

KFF Health News’ ‘What the Health?’

Episode Title: Abortion Pill’s Legal Limbo Continues

Episode Number: 310

Published: Aug. 17, 2023

Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News. And I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Aug. 17, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So here we go. We are joined today via video conference by Alice Miranda Ollstein of Politico.

Alice Miranda Ollstein: Good morning.

Rovner: Sarah Karlin-Smith of the Pink Sheet.

Sarah Karlin-Smith: Hi, everybody.

Rovner: And Shefali Luthra of The 19th.

Shefali Luthra: Hello.

Rovner: So, no interview this week but plenty of news, particularly for the middle of August, so we will get right to it. The breaking news this week is about abortion and about a Texas abortion case, because 2023. Technically, this news is out of New Orleans, where on Wednesday a three-judge panel of the 5th Circuit federal Court of Appeals upheld, in part, a lower-court decision from Texas that found that the FDA was wrong to approve the abortion pill mifepristone back in the year 2000. Before we get any further in this discussion, we should point out that this decision does not impact the immediate availability of abortion pills. The Supreme Court earlier this spring issued a stay of the lower-court ruling, meaning nothing will change until the full outcome of the case is determined, presumably by the Supreme Court at some point, probably next year. But, Alice, remind us of what this case was about and then what the decision means.

Ollstein: Yeah. So this case is: A coalition of different anti-abortion medical groups that formed last year, specifically formed in the district that a very conservative judge was in charge of down in Texas, brought the case there. And they are going after both the original FDA approval of mifepristone more than two decades ago and a bunch of decisions the agency has made since then to make the pills easier for patients to obtain, like allowing mail delivery, like allowing their use longer into pregnancy than before — 10 weeks versus seven weeks — allowing nonphysicians to prescribe the pills, a bunch of different things.

Rovner: And allowing for a lower dose of the pill actually.

Ollstein: Yes, yes.

Rovner: Which is going to get significant in a second. Go ahead.

Ollstein: Definitely. We should talk about the labeling chaos that could result from this. But so basically, the lower-court judge went all in, agreed with everything they said, essentially, and more or less ordered a national ban. That got stayed. It remains stayed for now, but the 5th Circuit has now weighed in and endorsed some but not all of those arguments. They said, look, the statute of limitations has passed us by on challenging the original FDA approval of the drugs, but they sided with the groups in ordering FDA to get rid of all of those other subsequent decisions. And so this, if upheld by the Supreme Court — we know the Biden administration is already planning to appeal — would really put the pills out of reach for a lot of people. So, it would be a sharp curtailment, but not the total ban the groups were seeking.

Rovner: Yeah, Shefali, and this was obviously what the appeals court had been leaning towards anyway. We know that because that was what they had done before the Supreme Court overruled it. And certainly we know that Justice [Samuel] Alito and I believe Justice [Clarence] Thomas would also do this. So, there’s every reason to believe that this could well be the final outcome. What would it mean? So, the pill would still be approved, but only in the form it was allowed to be distributed before 2016?

Luthra: Precisely, which would be quite significant. You mentioned, right, the need to relabel pills based on the different formulation. We would have pills technically only approved up until seven weeks of pregnancy, although doctors could prescribe them off-label, through 12 weeks in all likelihood. But the telemedicine implications are probably some of the biggest, especially in states where they’ve seen large numbers of out-of-state patients coming for abortion care, right, because they’re near states with bans. Those clinics have really relied on telemedicine because it means they can see more people, and it’s quite safe, right? It’s endorsed by the World Health Organization. You don’t need someone to come in for two, in some cases three visits to get a couple of pills and take them at home. And to lose that would really just cut capacity and make abortions, which are already very difficult to obtain, even in states where it’s legal but there just aren’t as many clinics — like a Kansas, a New Mexico, etc. — if not impossible, very nearly so, just because the math doesn’t work in terms of providers versus patients in need.

Rovner: And the piece of this that I really don’t understand, and I read through the entire decision yesterday afternoon, was they said that the plaintiffs in the case cannot challenge the approval of the generic version of the drug, which was approved in 2019. But of course, the generic version of the drug was approved under the then-rules that that are now going to be rolled back. So you would — would you have a case for the brand name and the generic would have different labeling requirements? It seems very confusing.

Luthra: I think there are a lot of questions that are still open about what this means, right, not only for mifepristone but just for the precedents of FDA approval of medications at large, especially as we’ve seen so many more FDA-approved drugs become more politicized. And, I mean, that’s one of the reasons that so many medical groups have expressed deep concern about this case. It just opens a tremendous can of worms looking well beyond abortion and puts us in pretty uncharted territory for what comes next.

Rovner: And the drug industry is kind of freaked out. Sarah, I guess you could talk to this. I mean, the reliability of FDA approval is now called into question if anybody can basically go to court and say, “Nope, FDA, you shouldn’t have done that,” and possibly win, right?

Karlin-Smith: Right. I mean, they don’t want the scientific sort of authority of the FDA questioned. And I think, you know, like a lot of hot-button political issues where there’s maybe not a good side for them to be on, the pharmaceutical companies tend to try and stay out of abortion politics as much as they can. But some executives and so forth did join amicus briefs in this case because they are concerned about the precedent of FDA approval decisions being able to be challenged in court. And if nothing else, I think drug companies really, and any business to an extent, relies on, like, certainty. And so just having the loss of that certainty that an FDA decision really means, what it means is problematic for them. But I think also these are companies that sort of are based in science and medicine and would definitely prefer to have the assurance that those are the people that approved their drugs and kind of give that seal of approval and it means what it says.

Rovner: Yeah, and the drug industry, I think more than many others, which depends on long shots a lot. I mean, there’s just a lot of dry holes in the drug industry; you spent a lot of time and a lot of money on a drug that ends up not going anywhere. So if you spend a lot of time and a lot of money on a drug that does what it’s supposed to do and gets approved, I think that that could certainly dampen the enthusiasm if then a court could come and say, “Oops, nope.”

Karlin-Smith: And the reputation we talk a lot about, like drug pricing, on this show — the reputation of the FDA and the perceived quality and trustworthiness of its decisions is kind of why the drug companies can charge, to some degree, the prices they charge for their medicines versus, say, you know, we compare it to the supplement industry, which is very loosely regulated, and their claims are not really backed up in the same way by science and medicine. And you can buy those for much cheaper at the store. So their whole business model is really threatened by this.

Rovner: Yeah.

Ollstein: And I think it’s worth noting that one of the three judges on the panel wanted to go further and fully strip FDA approval from the drug, but he was overruled by his other two colleagues. But still, he wrote that dissenting opinion. And that could come into play if and when the Supreme Court takes this up.

Rovner: And he, of course, raised the specter of the Comstock Act, that 1800s-era anti-vice law that apparently some anti-abortion groups are hoping to sort of bring back into the 21st century — Are we in the 22nd century? I’m losing track — and try to figure out if you can just make all of this illegal.

Ollstein: Yes. Judge [James] Ho, who was appointed by [then-President Donald] Trump to the 5th Circuit, and his opinion went a lot further than his colleagues’ in embracing the arguments made by the challengers. So how much influence that has on the process going forward will be really interesting. You know, the Comstock Act has to do with things sent through the mail, and the concern from a lot of legal experts and medical groups is that the interpretation that Judge Ho and these groups are making could mean that sending anything that could potentially be used for an abortion, even if it’s medical equipment that’s also used for other things, could be in jeopardy. And this would be mail delivery. Even sending something to a state where abortion is protected by law could be challenged under this federal rule. And so, we’re definitely in a “throw things at the wall and see what sticks” kind of era. And this is one of the things they’re throwing at the wall.

Rovner: Yeah, just because nothing changes for now doesn’t mean that nothing is going to change. And we will obviously keep a very close eye on this. So last week we talked about a controversy surrounding one of the scientific studies that [District] Judge [Matthew] Kacsmaryk, the lower-court judge, relied on in his ruling. The study was by the Charlotte Lozier Institute. It found that women who had medical abortions were more likely to go to a hospital emergency room within 30 days than women who had surgical procedures. And we talked about how that paper is currently under review by the publisher of the journal the paper appeared in. During the discussion, I apparently misspoke about the paper’s findings, suggesting that it was just the raw number of ER visits that rose along with increased use of medication abortion rather than the rate of the visits. But nonetheless, this study is very much an outlier in three decades of research into the safety of the drug. And I say three decades because it was available in Europe many years before it was available in the United States. And the drug has otherwise been found to have very few serious complications, right?

Luthra: Right. I think you’re absolutely correct, Julie. The study remains an outlier. There remain serious methodological questions about how it came to its findings. And we have an incredibly rich body of research that continues to grow, that shows exactly what you said, which is that the complication rate for medication abortions remains incredibly low. Most people do not require follow-up medical care, especially not in an emergency room. And the reliance on that study in particular was quite striking because of what an outlier it is in the larger medical body of research.

Rovner: And it didn’t actually come up in the appeals court ruling, although they did say, and fair point, they acknowledged that the complication, the serious complication rate, is very low. But if it’s being used by a lot of people and we now know that medication abortion is more than half of all abortions, a very small percentage of a whole lot of people is still a fair number of people. Whether that is enough people to actually create the kind of havoc in emergency rooms that’s been suggested is a different question. But I think that the appeals court justices were fairly careful in the way they worded that. So the mifepristone ruling was not the only news this week about a Texas abortion case. Another Texas abortion case in front of Judge Kacsmaryk in fact: He held a hearing earlier this week in a case brought by the state of Texas to require Planned Parenthood to pay back more than a billion dollars in Medicaid reimbursements, not for abortions, but for family planning and other medical services covered by Medicaid. This one is a weird case even by Texas standards, right?

Ollstein: Yeah, and I’ll say that they’re suing them for more than a billion dollars, but they were only paid by Medicaid in the lower millions. You know, 17-ish million is what Planned Parenthood told me. So, the 1.8 billion is for penalties and damages. They’re accusing them of defrauding the state. So, there has been a many-years’ fight over Planned Parenthood’s participation in Medicaid in Texas specifically, also in other states. Planned Parenthood says that, you know, because lower courts for years blocked the state’s attempt to kick them out of Medicaid, they were perfectly allowed to continue providing nonabortion services, like contraception, tests, whatever, and be reimbursed for that. And the state coming back later and saying that they knowingly defrauded the Medicaid program, they see it as a political attack on them and their ability to keep providing services in the state.

Rovner: There was a court stay on Texas’ desire to kick them out of the Medicaid program, right, so at least at the time it was legal for them to bill Medicaid, and Texas paid the Medicaid claims that they billed, right?

Luthra: I think it’s also helpful to situate this in just a really long history of Texas doing whatever it can to get Planned Parenthood away from government dollars, including turning down millions in federal funding, starting their own state health program for reproductive health, just so that they could have the legal authority to not include Planned Parenthood. This is not really new, but it just is so striking because of the money at stake, because of sort of the tactics, and because of the implications in a world where Planned Parenthood isn’t even providing abortions in Texas anymore.

Rovner: This goes back probably before some of you guys were born, the efforts to sort of defund Planned Parenthood from state and federal dollars, even in states where Planned Parenthood never provided abortions. And there are a number of states where they never provided abortions. But there is a line in the Medicaid statute itself about free choice of providers for patients, and that’s what has been relied on. Lower courts have relied on that for years and years. Congress tried to change it and couldn’t. Texas is actually, I think, the first state that’s ever successfully gotten a court ruling that said they can cut Planned Parenthood out of their Medicaid program. So, it was not odd for Planned Parenthood, while this litigation was going on, to say, “We’re just going to continue to provide women who come to us with family planning and other health care services that we’ve been providing under Medicaid for generations.” But now we’ll see what Judge Kacsmaryk has to say. And then I imagine this will get appealed and we will see where this one ends up, too. Well, finally this week in reproductive health, the American College of Obstetricians and Gynecologists announced the introduction of an online abortion training program, which has been a year in the making, that will give all OB-GYN residents, even in states with abortion bans, access to at least the basics in abortion care and in caring for early pregnancy loss, which is all often the same care. But I have to wonder whether this is going to make students any more willing to do their residencies in states that effectively restrict the rights to practice medicine according to evidence-based standards. I know we’ve talked about this before, but we’re looking at what could be a serious shortage of just women’s reproductive health care in general in abortion ban states, right, if the supply of students wanting to go there to do their residencies and hence stay on afterwards is going to start to dry up?

Ollstein: I mean, it’s already happening for sure. Applications are going down in these ban states. And, you know, when I saw the online curriculum, that’s better than nothing. But all the medical students and residents I’ve spoken to really stress that, in order to be trained and, for some specialties, board-certified, you need practical experience; you need to personally participate in many, many, many abortions to be fully qualified as a physician. And they really stress that the more you do, the more different complications you’re able to observe. And if you only do a few or none and just do online curriculum, you’re not going to be really prepared for a miscarriage situation or any of the many things that could come up in the future. And these could be life-or-death moments. And so to not have people trained and ready to respond in certain states where it’s already hard to recruit people because of, you know, it’s just seen as a less desirable place to be, this is yet another factor. On top of that, you have state attorneys general who have been very litigious and threatening to providers. And so, I’m hearing that that fear is making people not want to practice in particular states.

Luthra: And I think another factor that we don’t often sort of say out loud, but that’s really relevant when it comes to OB-GYNs in training, is that the majority of OB-GYNs are women. And given the age of when people finish medical school, etc., many of them are pursuing residency when they’re at a stage in their life where they might consider getting pregnant, which means that the risks are not just professional or educational; in many cases they are quite personal, and that’s a factor that many people are considering as well.

Rovner: And even the male OB-GYNs in training, many of them are married to women and, again, same age, thinking about, it’s time to start a family. Also, it’s not just the residents themselves, but the residents’ families. I’ve seen that sort of from both sides. We should point out, I mean, there are training programs now and they’re obviously — you know, it’s only been a year, so it’s hard to sort of create these things out of whole cloth — but where residents can travel to other states to get some hands-on experience and training that they want. But again, one of the things we forget sometimes about residents is they don’t earn a lot of money and it’s a disruption. I mean, it’s hard enough to move to a place to do your residency; to then have to sort of pick up and move someplace else for a couple of months to do a rotation is not terribly convenient either. So this is obviously still all being sorted out. But the education of sort of the next generation of reproductive health providers is definitely under question here, right?

Ollstein: And it’s not just the time needed; it’s often the money, because if these people are doing their residency at a public university hospital in a ban state, that public university hospital, under the state law, is afraid to give any money to support them going to another state for training. And so often people either have to apply for grants from foundations to cover that expense or even pay out of their own pockets. So, it’s a real heavy lift.

Rovner: It is. Well, in other news, and there is other news this week, President [Joe] Biden is taking a victory lap as the Inflation Reduction Act, that omnibus health-slash-energy-slash-tax bill, turns 1. But the fate of the highest-profile health policy in that law, calling for Medicare to negotiate the prices of some very expensive drugs, is still in some doubt, as drugmakers sue to try to block the program. Sarah, where is this, and when do we expect to get that list of the first 10 drugs the government wants to negotiate the price of? That’s due soon, right?

Karlin-Smith: Right. So the list is due by Sept. 1 at the latest. So that is a week, I think, from this Friday, or no, a little bit longer than that. But the expectation, I think, is we may get it before Sept. 1, because that’s the Friday before Labor Day weekend.

Rovner: Oh, I don’t know. They love to drop stuff the Friday before Labor Day.

Karlin-Smith: Sometimes they do, and sometimes they also want to take a break too. So, we’re expecting that list of 10 drugs, which would be — their negotiated prices would go into effect in 2026. There’s lots of reasonably well-educated guesses of what those drugs are, because the law sort of lays out how they select them and we have a general sense of how much money is spent on certain drugs in the U.S. and so forth. But Medicare has the most up-to-date data. So, there are still companies that kind of have a sense of, “Oh, I might be on the edge,” depending on how their sales have been in Medicare the past few years. So, people are really curious.

Rovner: Coincidentally or not so coincidentally, I’ve seen some of the speculation, and it is all of the drugs that you see all of those ads for, if you watch, if you still watch, you know, commercial television, on the news or on cable TV. I mean, there are so many ads, and it’s like, surprise, these are all the drugs that are on the likely list that Medicare is going to want to do something about the price of. I assume that is not a coincidence. I’m being snide.

Karlin-Smith: I think some of it is, right, to qualify for the list, you have to be in sort of the top spending categories. And part of that means you’re most likely to have to treat large populations of people. So when you get to drugs like that, like anticoagulants — I think there’s a few expected to be up there — blood thinners, some anti-diabetic medicines, trying to think of some of the other examples. These are kind of mass-market drugs that a lot of people, particularly in the Medicare population, need these medicines. Some cancer medicines, anti-inflammatory drugs. So, it’s not particularly surprising that you would see advertisements for them. And in a lot of cases, too, these are drugs that have some amount of brand competition for them. So, there are two newer blood thinners that might be on there. So, you know, that tends to lead to advertisement when there’s competition in a space. Same for the diabetes medicines and the anti-inflammatories; there’s a lot of expensive biologics in that space that compete.

Rovner: Well, when I’m in charge of the FDA, they’re not going to be able to use, like, songs from the ’60s and ’70s anymore, because that just makes me crazy. Well, meanwhile, in something related to this, drug shortages seem to be getting worse. There’s a new survey from the American Society of Health-System Pharmacists that found that 99% of the 1,100 hospital pharmacists that responded said they were currently managing drug shortages, and one-third said those shortages are forcing them to ration, delay, or cancel treatment. And these aren’t minor drugs. They include cancer chemotherapies, anesthesia drugs, other things that can be difficult to get but important when you need them. Sarah, is this a manufacturing problem, or a marketing problem, or both? I mean, why are drug shortages so much worse now? It’s not all supply chain, is it?

Karlin-Smith: There’s some supply chain, and I think there’s still some supply chain issues that started during covid that are still impacting people. There are manufacturing concerns, depending on the company. You know, drug shortages have gotten a lot of attention recently, but really for probably the past decade or so that I’ve been covering the drug industry and following shortages, the reasons have tended to be the same: They tend to be older, sterile, injectable drugs that are harder to make. But yet, because they have gone generic, the prices have gone down so low that players tend to leave. So only a few players stay in the market because of the pricing situation. So then if they have any manufacturing problem, it can very easily lead to a shortage. Generic companies argue that, you know, there’s just not a lot of incentive for them to invest in redundancy or certain even manufacturing capabilities that might help prevent shortages. So, for better or worse, there really hasn’t been a lot of change in the reasons for these shortages over the years; it’s just that they keep happening.

Rovner: Yeah, well, it’s funny. Matthew Herper over at Stat News has kind of a provocative piece about all of this, suggesting, as you say, that the shortages right now are, in large part, due to the incentives to find the cheapest generics, but that this new Medicare negotiation process — which includes a different clock; it will be based on time on the market rather than time under patent — could encourage drugmakers to do the opposite thing, to sit on new drugs until they can test for all possible uses because they don’t want to bring them to market until they think they can make the most money, because that’s going to determine how long before there can be competition. I mean, is this ever really going to work, being a purely capitalist market?

Karlin-Smith: I mean, there are definitely people, you know, in the shortage space that have argued that some of the current shortages make a good case for public manufacturing of drugs. And actually, it might surprise some people, but the U.S. has engaged in the past in public manufacturing. There are some efforts going on now, like in California; they’re looking into some public manufacturing. So that’s on the generic side. On some of the other situations that Matthew Herper is describing with the IRA, it’s a bit more complicated because essentially the IRA does give companies some amount of time on the market without negotiation. But a lot of drugs, they have all these multiple indications. And so companies are just trying to figure out potentially how they can game their products to make the most amount of money before they’re subject to negotiation. And I know Medicare is quite aware of some of this stuff and is thinking about how they can set up their regulations to protect against that. But not everything is within their control. So we’ll see what happens, because there is concern, you know, particularly I think in the orphan or rare disease space, that a company may delay getting a rare disease indication based on when they think they might get subject to drug negotiations.

Rovner: Every time you think, Oh, they can just lower the price of drugs, it’s super, super complicated. All right. Well, finally this week, there’s something I’ve been trying to get to for a couple of weeks: Before Congress left for the August recess, it passed, on a bipartisan vote, a bill that could finally dethrone UNOS, the United Network for Organ Sharing. UNOS has been the outside organization handling the collection and distribution of human organs for transplant since the federal government began the federal transplant program in 1984. Over the years, UNOS has been roundly criticized for its handling, or mishandling, of the system. But the legislation that originally created the federal organ transplant program had been interpreted not to allow anyone else to compete for the contract to run the network. So, this legislation changes that, for the first time letting other entities see if they can do a better job so maybe fewer people will die waiting for transplanted organs. This feels a lot more important than the attention that it got, I think because there was so much else happening as Congress was leaving town. Or does it feel important to me because I spent so many years and so many hours watching Congress fight over this?

Karlin-Smith: I think it is important. There’s certainly been a lot of big exposés of problems in the system over the years. And there’s also been a lot of, when I’ve covered this more closely in the past, like, tensions between different parts of the country in sort of figuring out how organs are allocated and which parts of regions get impacted or not. So there has always been, like, political dynamics here. I think the underlying thing to watch with this overhaul is that part of what goes on here is we just don’t have enough organs for the number of people that need it. So, you can certainly make improvements and make sure that all the organs we have get to people and get done in the fairest way possible, because there have been lots of concerns around equity issues, particularly that Black people and other people of different ethnicities have not been, you know, getting the organs they deserve. But the question becomes, you know, can anybody do anything about a shortage of organs, and how do you really handle that? I think there’s always going to be tensions on this topic if you don’t have enough organs.

Rovner: Yeah, these were the ultimate formula fights, if you will. You know, it’s usually over money. In the ’90s and early 2000s, it was literally over organs, over, you know, how far you could ship donated organs and whether the large transplant centers should keep more because they do more organ transplants and therefore are more likely to have success. And boy, this fight has been going on for a very long time, but this is at least a step, I think, towards resolving it. All right. Well, that is this week’s news. We will take a quick break and then we will come back and do our extra credit. Hey, “What the Health?” listeners, you already know that few things in health care are ever simple. So, if you like our show, I recommend you also listen to “Tradeoffs,” a podcast that goes even deeper into our costly, complicated, and often counterintuitive health care system, hosted by longtime health care journalist and friend Dan Gorenstein. “Tradeoffs” digs into the evidence and research data behind health care policies and tells the stories of real people impacted by decisions made in C-suites, doctor’s offices, and even Congress. You can subscribe to “Tradeoffs” wherever you get your podcasts. OK, we are back and it’s time for our extra credit segment. That’s when we each recommend a story we read this week we think you should read too. As always, don’t worry if you miss it; we will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Shefali, why don’t you go first this week?

Luthra: My piece is from The Atlantic, by Annie Lowrey. The headline is “Right Price, Wrong Politics.” It is incredibly smart. It is about how there is all this conversation about people wanting to move to states where they have access to health care protected, whether that is abortion or gender-affirming care, etc., etc. There is one problem, which is that those states are largely ones where it is much more expensive to live, because of housing prices. And if you want to live in a place where you can afford a home, those are often the states with restrictions on health care. I love this piece. I think there is so much conversation about, Why don’t people simply move to a place where state laws reflect what they would like? And the answer is it’s really not attainable for most people. And I think she does a great job of explaining why that is and putting it in the context of policy choices and not just sort of individual human elements.

Rovner: I was super jealous of this piece. It was like, Oh, yeah, of course. Alice.

Ollstein: I chose a piece by a couple of my colleagues, and it’s called “We’re on the Cusp of Another Psychedelic Era. But This Time Washington Is Along for the Ride.” And it’s about how much bipartisan support there is in Congress right now for making psychedelics more available as medicine to treat things like PTSD [post-traumatic stress disorder] or depression. There are just a lot more clinical trials going on right now and just support for making them available through the VA [Department of Veterans Affairs] as sort of a test of how a broader population might respond. You know, we’re talking about things like psilocybin, things like ketamine, things like ecstasy, that have shown a lot of promise in having a therapeutic benefit for mental health conditions that have resisted other forms of treatment. So, fascinating stuff.

Rovner: It is. Sarah.

Karlin-Smith: I took a look at a piece in MIT Tech Review called “Microplastics Are Everywhere. What Does That Mean for Our Immune Systems?” And it just does a good job of helping you understand what the research has shown about how these very tiny particles may impact your immune cells and then impact our ability to fight off diseases and maybe even lead to more challenges with antibiotics and antibiotic resistance. And I’ve been fascinated by all the coverage of this, because this — huge problem and, you know, they talk about them being in our air and in the deepest part of the ocean. And, you know, it’s just one of those things that we have to kind of grapple with as a society, like health, economic consequences, and so forth. So, it’s worth looking at.

Rovner: More things to keep us awake at night.

Karlin-Smith: Exactly.

Karlin-Smith: A list of more things to keep us awake at night. My story this week is one of the most talked about on social media. It’s from Time, and it’s called “She Wasn’t Able to Get an Abortion. Now She’s a Mom. Soon She’ll Start 7th Grade,” by Charlotte Alter. And as the headline indicates, it’s kind of a gutting piece about a 12-year-old in Mississippi who was raped in her own yard, was too scared to tell anyone, and ended up having a baby at age 13. It’s another story about all those things that are, quote, “made up,” or not supposed to happen. Except they did. She might have been eligible for a rape exception, except there are no abortion providers left in the state, and her mother didn’t know that rape exceptions were a possibility. In the end, the closest place for her to have gotten an abortion was Chicago, which was too far and too expensive for her family. So now she has a son while she’s going to middle school. I’m sure we will see more of these as time progresses. All right. That is our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us too. Special thanks, as always, to our amazing engineer, Francis Ying. And as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can tweet me or X me or whatever. I’m still there, @jrovner, also on Bluesky and Threads. Shefali?

Luthra: I’m @shefalil.

Rovner: Alice.

Ollstein: @AliceOllstein.

Rovner: Sarah.

Karlin-Smith: I’m @SarahKarlin or @sarahkarlin-smith.

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

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

Ohio voters — in a rare August election — turned out in unexpectedly high numbers to defeat a ballot measure that would have made it harder to pass an abortion-rights constitutional amendment on the ballot in November. The election was almost a year to the day after Kansas voters also stunned observers by supporting abortion rights in a ballot measure.

Meanwhile, the percentage of Americans without health insurance dropped to an all-time low of 7.7% in early 2023, reported the Department of Health and Human Services. But that’s not likely to continue, as states boot from the Medicaid program millions of people who received coverage under special eligibility rules during the pandemic.

This week’s panelists are Julie Rovner of KFF Health News, Emmarie Huetteman of KFF Health News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico, and Rachel Roubein of The Washington Post.

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Emmarie Huetteman
KFF Health News

@emmarieDC

Read Emmarie's stories

Joanne Kenen
Johns Hopkins Bloomberg School of Public Health and Politico

@JoanneKenen

Read Joanne's stories

Rachel Roubein
The Washington Post

@rachel_roubein

Read Rachel's stories

Among the takeaways from this week’s episode:

• It should not have come as much of a surprise that Ohio voters sided with abortion-rights advocates. Abortion rights so far have prevailed in every state that has considered a related ballot measure since the Supreme Court overturned Roe v. Wade, including in politically conservative states like Kentucky and Montana.
• Moderate Republicans and independents joined Democrats in defeating the Ohio ballot question. Opponents of the measure — which would have increased the threshold of votes needed to approve state constitutional amendments to 60% from a simple majority — had not only cited its ramifications for the upcoming vote on statewide abortion access, but also for other issues, like raising the minimum wage.
• A Texas case about exceptions under the state’s abortion ban awaits the input of the state’s Supreme Court. But the painful personal experiences shared by the plaintiffs — notable in part because such private stories were once scarce in public discourse — pressed abortion opponents to address the consequences for women, not fetuses.
• The uninsured rate hit a record low earlier this year, a milestone that has since been washed away by states’ efforts to strip newly ineligible Medicaid beneficiaries from their rolls as the covid-19 public health emergency ended.
• The promise of diabetes drugs to assist in weight loss has attracted plenty of attention, yet with their high price tags and coverage issues, one thorny obstacle to access remains: How could we, individually and as a society, afford this?
• Lawmakers are asking more questions about the nature of nonprofit, or tax-exempt, hospitals and the care they provide to their communities. But they still face an uphill battle in challenging the powerful hospital industry.

Also this week, Rovner interviews Kate McEvoy, executive director of the National Association of Medicaid Directors, about how the “Medicaid unwinding” is going as millions have their eligibility for coverage rechecked.

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

Julie Rovner: KFF Health News’ “How the Texas Trial Changed the Story of Abortion Rights in America,” by Sarah Varney.

Joanne Kenen: Fox News’ “Male Health Care Leaders Complete ‘Simulated Breastfeeding Challenge’ at Texas Hospital: ‘Huge Eye-Opener’,” by Melissa Rudy.

Rachel Roubein: Stat’s “From Windows to Wall Art, Hospitals Use Virtual Reality to Design More Inclusive Rooms for Kids,” by Mohana Ravindranath.

Emmarie Huetteman: KFF Health News’ “The NIH Ices a Research Project. Is It Self-Censorship?” by Darius Tahir.

Also mentioned in this week’s episode:

• Politico’s “Abortion Rights Won Big in Ohio. Here’s Why It Wasn’t Particularly Close,” by Madison Fernandez, Alice Miranda Ollstein, and Zach Montellaro.
• KFF Health News’ “Seeking Medicare Coverage for Weight Loss Drugs, Pharma Giant Courts Black Influencers,” by Rachana Pradhan.
• Stat’s “Alarmed by Popularity of Ozempic and Wegovy, Insurers Wage Multi-Front Battle,” by Elaine Chen.

click to open the transcript

Transcript: On Abortion Rights, Ohio Is the New Kansas

KFF Health News’ ‘What the Health?’Episode Title: On Abortion Rights, Ohio Is the New KansasEpisode Number: 309Published: Aug. 10, 2023

[Editor’s note: This transcript, generated using transcription software, has been edited for style and clarity.]

Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping a day early this week, on Wednesday, Aug. 9, at 3:30 p.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. We are joined today via video conference by Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico.

Joanne Kenen: Hey, everybody.

Rovner: Rachel Roubein of The Washington Post.

Rachel Roubein: Hi, everybody.

Rovner: And my colleague and editor here at KFF Health News Emmarie Huetteman.

Emmarie Huetteman: Hey, everyone. Glad to be here.

Rovner: So later in this episode, we’ll have my interview with Kate McEvoy, executive director of the National Association of Medicaid Directors. She’s got her pulse on how that big post-public health emergency “Medicaid unwinding” is going. And she’ll share some of that with us. But first, this week’s news. I guess the biggest news of the week is out of Ohio, which, in almost a rerun of what happened in Kansas almost exactly a year ago, voters soundly defeated a ballot issue that would have made it harder for other voters this fall to reverse the legislature’s strict abortion ban. If you’re having trouble following that, so did they in Ohio. [laughs] This time, the fact that the abortion rights side won wasn’t as much of a surprise because every statewide abortion ballot question has gone for the abortion rights side since Roe v. Wade was overturned last year. What do we take away from Ohio? Other than it looked a lot like … the split looked a lot like Kansas. It was almost 60-40.

Kenen: It shows that there’s a coalition around this issue that is bigger than Democrat or Republican. Ohio was the classic swing state that has turned into a conservative Republican-voting state — not on this issue. This was clearly independents, moderate Republicans joined Democrats to … 60-40, roughly, is a pretty big win. Yes, we’ve seen it in other states. It’s still a pretty big win.

Roubein: I agree. And I think one of my colleagues, Patrick Marley, and I spent some time just driving around and traveling Ohio in July. And one of the things that we did find is that — this ballot measure to increase the threshold for constitutional amendments is 60% — it had in some, in many, ways turned into a proxy war over abortion. But, in some ways, both sides also didn’t talk about abortion when they were, you know, canvassing different voters. You know, they use different tools in the toolbox. I was following around someone from Ohio Right to Life and, you know, he very much said, “Abortion is the major issue to me.” But, you know, they tried to kind of bring together the side that supported this. Other issues like legalizing marijuana and raising the minimum wage, and, you know, the abortion rights side was very much a part of, you know, the opposition here. But when some canvassers went out — my colleague Patrick had traveled and followed some, and some, you know, kind of focused on other issues like, you know, voters having a voice in policy and keeping a simple majority rule.

Rovner: Yeah, I think it’s important — for those who have not been following this as closely as we have — what the ballot measure was was to make future ballot measures — and they said they were not going to have them in August anymore, which, this was the last one — in order to amend the constitution by referendum, you would need a 60% majority rather than a 50% majority. And just coincidentally, there is an abortion ballot measure on Ohio’s ballot for November, and it’s polling at about 58%. But, yes, this would have applied to everything, and it was defeated.

Kenen: And it’s part of a larger trend. It began before the overturning of Roe v. Wade. Over the last couple of years, you’ve seen conservative states move to tighten these rules for ballot initiatives. And that’s because more liberal positions have been winning. I mean, Medicaid, the Medicaid expansion on the ballot, has won, and won big. Only one was even close …

Rovner: In very red states!

Kenen: They often won very big in a number of very, very conservative states, places like Idaho and Nebraska. So, you know, there’s always been … the conventional wisdom is that, you know, the political parties are more extreme than many voters, that the Democratic Party is for the left and the Republican Party is for the right. And there are a lot of people who identify with one party or the other but aren’t … who are more moderate or, in this case, more liberal on Medicaid. And Medicaid … what was it, seven states? I think it’s seven. Seven really conservative states. And then the abortion has won in every single state. And there’s a little bit of conversation and it’s … very early. And I don’t know if it’s going to go anywhere, but if I’ve heard it and written a bit about it, conservative lawmakers have heard about it, too, which is there are groups interested in trying to get some gun safety initiatives on ballots. So that’s complicated. And it may not happen. But they’re seeing, I mean, that’s the classic example of both a criminal justice and a public health issue — so we can talk about it — a classic example where the country is much more in the center.

Rovner: Well, let us move to Texas, because that’s where we always end up when we talk about abortion. You may remember that lawsuit where several women who nearly died from pregnancy complications sued the state to clarify when medical personnel are able to intercede without being subjected to fines and/or jail sentences. Well, the women won, at least for a couple of days. A Texas district judge who heard the case ruled in their favor, temporarily blocking the Texas ban for women with pregnancy complications. But then the state appealed, and a Texas appeals court blocked the lower-court judge’s blocking of part of the ban. If you didn’t follow that, it just means that legally nothing has changed in Texas. And now the case goes to the Texas Supreme Court, which has a conservative majority. So we pretty much know what’s going to happen. But whether these women ultimately win or lose their case may not be the most important thing. And, to explain why I’m going to do my extra credit early this week. It’s by my KFF Health News colleague Sarah Varney. It’s called “How the Texas Trial Changed the Story of Abortion Rights in America.” She writes that this trial was particularly significant because it put abortion foes on the defensive by graphically depicting harm to women of abortion bans — rather than to fetuses. And it’s also about the power of people publicly telling their stories. I’ve done a lot of stories over the years about women whose very wanted pregnancies went very wrong, very late. And, I have to tell you, it’s been hard to find these women. And when you find them, it’s been really hard to get them to talk to a journalist. So, the fact that we’re seeing more and more people actually come out publicly, you know, may do for this issue what, you know, perhaps what gay rights, you know, what people coming out as gay did for gay marriage? I don’t know. What do you guys think?

Kenen: Well, I think these stories have been really compelling, but they’re also, they’re the most dramatic and maybe easiest to push back. But it’s, you know, there’s a whole lot of other reasons women want abortions. And the focus — and it’s life and death, so the focus, quite rightfully, has to be on these really extreme cases. But that’s not … it’s still in some ways shifting attention from the larger political discussion about choice and rights. But, clearly, some of these states, we’ve seen so many stories of women who, their lives are at stake, their doctors know it, and they just don’t think they have the legal power; they’re afraid of the consequences if they’re second-guessed. There are tremendous financial and imprisonment [risks] for a doctor who is deemed to have done an unnecessary abortion. And this idea that’s taken hold … among some conservatives is that there’s never a need for a medical abortion. And that’s just not true.

Rovner: And yet, I mean, what this trial and a lot of things in Sarah’s piece too point out is that that line between miscarriage and abortion is really kind of fuzzy in a lot of cases. You know, if you go to the hospital with a miscarriage and they’re going to say, “Well, did you initiate this miscarriage?” And we’ve seen women thrown in jail before for losing pregnancies, with them saying, “You know, you threw yourself down the stairs to end this pregnancy.” That actually happened, I think it was in Indiana. So this is —

Kenen: And miscarriage is very common.

Rovner: That was what I was saying.

Kenen: Early miscarriage is very common. Very, very common.

Huetteman: One of the things that’s so striking about the past year, since Dobbs overturned Roe v. Wade ,is that we’ve seen this kind of national education about what pregnancy is and how dangerous it can be and how care needs to really be flexible to meet those sorts of challenges. And this actually got me thinking about something that another familiar voice on this podcast, Alice Miranda Ollstein, and some colleagues wrote this morning about the Ohio outcome, which is they pointed out that the anti-abortion movement really hasn’t evolved in terms of the arguments that they’re making in the past year about why abortion should continue to be less and less available. Meanwhile, we’ve got these, like, really incredible, really emotional, moving stories from women who have experienced this firsthand. And that’s a hard message to overcome when you’re trying to reach voters in particular.

Rovner: And it’s interesting; both sides like to take — you know, they all go to the hardest cases. So, for years and years, the anti-abortion side has, you know, has gone to the hardest cases. And that’s why they talk about abortion in the ninth month up till birth, which isn’t a thing, but they talk about it. And you know, now the abortion rights side has some hard cases now that abortions are harder to get. Well, while we are on the subject of Texas lawsuits, States Newsroom — and thank you for sending this my way, Joanne — has a story reporting that the publisher of the scientific paper that both the lower court judge and the appeals court judges used to conclude that the abortion drug mifepristone causes frequent complications — it does not — is being reviewed for potential scientific misconduct. The paper comes from the Charlotte Lozier Institute, which is the research arm of the anti-abortion group the Susan B. Anthony List. Sage, which is the publisher of the journal that the paper appeared in, has posted something called an expression of concern, saying that the publisher and editor, quote, “were alerted to potential issues regarding the representation of data in the article and author conflicts of interest. SAGE has contacted the authors of this article and an investigation is underway.” This was sort of a whistleblower by a pharmacist who looked at the way the data in this paper was put together and says, “No, that’s really very misleading.” I don’t think I’ve ever seen this, though; I’ve never seen a scientific paper that’s now being questioned for its political bent, a peer-reviewed scientific paper. I mean, this could change a lot of things, couldn’t it?

Kenen: Well, not if people decide that they still think it’s true. I mean, look at — you know, the vaccine autism paper was retracted. That wasn’t initially political. It’s become more political over the years; it wasn’t political at the time. That was retracted. And people have been jumping up and down screaming, “It was retracted! It was retracted!” And, you know, millions of people still believe it. So, I mean, legally, I’m not sure how much it changes. I mean, I thought we had all heard that there were flaws in this study. This article was good because I hadn’t been aware of how deeply flawed and in all the many ways it was flawed. And also the whistleblower yarn was interesting. I’m not sure how much it changes anything.

Rovner: Well, I’m thinking not in terms of this case. And by the way, I think we didn’t say this, that the study was of emergency room visits by women who’d had either surgical or medical abortions. And the contention was that medical abortions were more dangerous than surgical abortions because more women ended up in the emergency room. But as several people have pointed out, more people ended up in the emergency room after medical abortions because there have been so many more medical abortions over the years. I mean, you don’t actually have to be a data scientist to see some of the problems.

Kenen: Right. And some of them also weren’t that — really, were nervous, and they didn’t know what was normal and they went to the ER because they were scared and they really were safe. They were not — they didn’t need — you know, they just weren’t sure how much pain and discomfort or bleeding you’re supposed to have. And they went and they were reassured and were sent home. So it’s not even that they really had a medical emergency or that they were harmed.

Rovner: Or that they had a complication.

Kenen: Right. There were many flaws pointed out with this research.

Rovner: But my broader question is, I mean, if people are going to start questioning the politics of scientific papers, I mean, I could see the other side going after this.

Kenen: Well, there’s climate science, too, that’s bad. I mean, I don’t think this is actually unique. I think it’s egregious. But there were studies minimizing the risk of smoking, which was also a political business, commercial. Climate is certainly political. I mean, I think this is sort of the most politicized and most acute example, but I don’t think it’s the only one.

Roubein: And I think, Julie, as you’d mentioned, I think when [U.S. District Judge] Matthew Kacsmaryk in Texas came down with his decision — you know, for instance, there are media outlets — that my colleagues at the Post did a story just kind of unpacking some of the kind of flaws and some of the studies that were used to make, you know, a court decision.

Rovner: Yeah, to give the judge what he assumes to be evidence that this is a dangerous drug. So it’s — yeah.

Kenen: Which he came in believing, we know, from the profiles of him and his background.

Rovner: Right. All right, well, let us move on. The official Census Bureau estimate of how many people lack health insurance won’t be out until next month. But the Department of Health and Human Services is out with a report based on that other big federal population survey that shows the uninsured rate early this year was at its lowest level since records started being kept, which I think was in the 1980s: 7.7%. Now, that’s clearly going to be the high point for the fewest number of people uninsured, at least for a while, because clearly not all of the millions of people who are losing or about to lose their Medicaid coverage are going to end up with other insurance. But I remember — Joanne, you will, too — when the rate was closer to 18% … was a huge news story, and the thing that triggered the whole health reform debate in the first place. I’m surprised that there’s been so little attention paid to this.

Kenen: Because, you know … [unintelligible] … it’s so yesterday. And also, as you alluded to, you know, we’re in the middle of the Medicaid unwinding. So the numbers are going up again now. And we don’t know. We know that it’s a couple of million people. I think 3 million might be the last —

Rovner: I think it’s 4 [million], it’s up to 4.

Kenen: Four, OK. And some of them will get covered again and some of them will find other sources of coverage. But right now, there’s an uptick, not a downtick.

Roubein: And I think when you look at just, like, estimates of what the insured and the uninsured rates would be in 2030, like, the CMS’ [Centers for Medicare & Medicaid Services] analysis, one of the other questions is, you know, whether the enhanced Obamacare subsidies continue past 2025. So there’s Medicaid and then there’s also some other kind of question marks and cliffs coming up on how and whether it will fluctuate.

Rovner: No, it’s worth watching. And remember, when the census numbers come out, those will be for 2022. Well, moving on, we have two stories this week looking at the potential cost of those breakthrough obesity drugs, but through two very different lenses. One is from my KFF Health News colleague Rachana Pradhan, details how the makers of the current “it” drug, Ozempic, which is Novo Nordisk, in an effort to get the votes to lift the Medicare payment ban on weight loss drugs, is quietly contributing large amounts of money to groups like the Congressional Black Caucus Foundation and the Congressional Hispanic Caucus Institute. It’s sort of a backdoor lobbying that’s pretty age-old, but that doesn’t mean it doesn’t work. The other story, by Elaine Chen at Stat, looks at how health insurers are pushing back hard against the off-label use of diabetes medications that also work to help people lose weight. They’re doing things like allowing the more expensive weight loss drugs only if people have tried and failed other methods or disallowing them if the other methods had been slightly successful. So, if you take a lesser drug and you lose enough weight, they won’t let you take the better drug because, look, you lost weight on the other drug. We’ve talked about this, obviously, before: These drugs, on the one hand, have the potential to make a lot of people both healthier and happier. There’s a study out this week that shows that Mounjaro, the Eli Lilly drug, actually reduces heart disease by 20%.

Kenen: In people who have heart disease.

Rovner: Right, in people who have heart disease.

Kenen: It’s not lowering everybody’s risk.

Rovner: But still, I mean, everybody’s — well, I mean, there are medical indications for using these drugs for weight loss. But if everybody who wants them could get them, it would literally break the bank. Nobody can afford to give everybody who’s eligible for these drugs these drugs. Is the winner here going to be the side with the most effective lobbying, or is that too cynical?

Huetteman: Isn’t that always the winner? Speaking of cynical.

Rovner: Yeah, in health care.

Kenen: Well, I mean, I also think there’s questions about, like, these drugs clearly are really wonderful for people who they were designed for; you don’t have to be on insulin. They’re having not just weight loss and diabetes. There are apparently cardiac and other — you know, these are probably really good drugs. But there are a lot of people who do not have diabetes or heart disease who want them because they want to lose 20 pounds. And some of them are being told you have to take it for the rest of your life. I mean, I just know this anecdotally, and I’m sure we all know it anecdotally.

Rovner: Right. It’s like statins.

Kenen: Yes.

Rovner: Or blood pressure medication. If you stop taking your blood pressure medication, your blood pressure goes back up.

Kenen: Right. So, I mean, should the goal for the weight loss be, “OK, this is going to help you take off that weight and then you’re going to have to maintain it through diet and exercise and healthy lifestyle,” blah, blah, blah, which is hard for people. We know that. Or are we putting healthy people on a really expensive drug that changes an awful lot of things about their body indefinitely? We don’t have safety data for lifelong use in otherwise healthy people. So, you know, I’m always a little worried because even the best clinical trial is small compared to the entire — it’s small and it’s time-limited. And maybe these drugs are going to turn out to be absolutely phenomenal and we’re going to all live another 20 healthy years. But maybe not, you know. Or maybe they’re going to be really great for a certain subpopulation, but, you know, we’re not going to want to put it in the water supply. So, I still think that there’s this sort of pell-mell rush. And I think it’s partly because there’s a lot of money at stake. And it’s also, like, most people who are overweight have tried to lose it, and it’s very difficult to lose and maintain weight. So, you know, people want an easier way to do it. And I think the other thing is right now it’s an injection. There are side effects for some people on discomfort. There probably will be an oral version, a pill, sometime fairly soon, which will open — you know, there are people who don’t want to take a shot who would take a pill. It also means you might be able to tell — I mean, I don’t know the science of the pills, but it would make sense to me that you could take a lower dose, you know, maybe ease into it without the side effects, or could you stay on it longer with fewer problems? I mean, we’re just the very beginning of this, but it’s a huge amount of money.

Rovner: Yeah. You could see — I mean, my big question, though, is why can’t we force the drugmakers to lower the price? That would, if not solve the problem, make it a lot better. I mean, really, we’re going to have to wait until there is generic competition?

Kenen: It’s not just this.

Rovner: Yeah.

Kenen: I mean, it’s all sorts of cancer treatments and it’s hepatitis treatments. And it’s, I mean, there’s a lot of expensive drugs out there. So, this one just has a lot of demand because it makes you skinny.

Rovner: Well, that was the thing. We went through this with the hepatitis C drugs, which were really super expensive. It’s much more like that.

Kenen: Well, they seemed super expensive at the time —

Rovner: Not so much anymore.

Kenen: — but maybe for a thousand dollars, in retrospect.

Rovner: All right. Well, let’s move on. So, speaking of powerful lobbies, let’s talk about hospitals. Iowa Republican Sen. Chuck Grassley and Massachusetts Democrat Elizabeth Warren — now, there is an unlikely couple — are among those asking the IRS to more carefully examine tax-exempt hospitals to make sure they’re actually benefiting the community in exchange for not paying taxes, which is supposed to be the deal. Now, Sen. Grassley has been on this particular hobbyhorse for many, many years, I think probably more than 20, but not much ever seems to come of this. I can’t tell you how many workshops I’ve been to on, you know, how to measure community benefits that tax-exempt hospitals are providing. Any inkling that this time is going to be any different?

Roubein: Well, hospitals don’t tend to be sort of the losers. They try and kind of frame themselves as, like, “We’re your sort of friendly neighborhood hospital,” and every — I mean, every congressman, most congressmen have, you know, hospitals in their district. So they they get lobbied a lot, though, you know — I mean, this is a different issue, but particularly on the House side, hospitals are facing site-neutral payments, which if that actually went through Congress would be a loss. So yeah, but lawmakers have found it in general hard to take on the hospital industry.

Rovner: Yeah, very much so.

Kenen: Yeah. I mean, I think that we think of nonprofits and for-profits as, they’re different, but they’re not as different as we think they are, in that, you know, nonprofits are getting a tax break and they have to reinvest their profits. But it doesn’t mean they’re not making a lot of money. Some of them are. I mean, some of them have, you know, we’ve all walked into fancy nonprofits with, you know, fancy art and marble floors and so on and so forth. And we’ve all been in nonprofits that are barely keeping their doors open. So it’s your tax status. It’s not really, you know, your ethical status or the quality of care. I mean, there’s good nonprofits, there’s good for-profits. You know, this whole thing is like, if I were a hospital, I would be getting this huge tax break, and what am I doing to deserve it? And that’s the question.

Rovner: And I think the argument is, you know, that the 7.7% uninsured we were talking about, that hospitals are supposed to be providing care as part of their community benefit that the federal government now is ending up paying for. I think that’s sort of the frustration. If nonprofit hospitals were doing what they were supposed to do, it would cost federal and state governments less money, which always surprises me because this is not gone after more. I mean, Grassley has spent his whole career working on various types of government fraud. So this is totally in line for him. But it’s never just seemed to be a big priority for any administration.

Huetteman: There’s a little bit of an X factor here. Look at the fact that Grassley and Warren are talking about this publicly now. Maybe I’m just really optimistic from all the journalism we’ve been doing about projects like “Bill of the Month.” But the reality is that a lot of people are now seeing reporting that’s showing to them what nonprofit hospitals are actually doing when it comes to pursuing patients who don’t pay bills. And what it means to have community benefit comes into question a lot when you talk about wage garnishment, suing patients who are low-income for their medical debt. These are things that journalists have uncovered over and over again, happening at — ding, ding, ding — nonprofit hospitals. It’s harder to argue that hospitals are just doing their best for people when you have these stories of poor people who are losing their homes over unpaid medical bills, for instance. And I think that right now, when we’re in this political moment where health care costs are so, so potent to people and so important, I mean, could we see that this will actually be more effective, that we’re heading towards something that’s more effective? Maybe.

Rovner: Well, repeats the journalist, as we all are, the power of storytelling. Definitely the public is primed. I imagine that’s why they’re doing it now. We’ll see what comes of it.

Kenen: think the public is primed for bad practices. I’m not sure how many patients understand if the hospital they go to is a nonprofit or a for-profit. I think the public understands that everything in health care costs too much and that there are bad actors and greed. There’s a difference between profit and greed, and I think many people would say that we’re now in an era of greed. And not everybody in the health care sector — before anybody calls us up and shouts, “Not everybody who provides care is greedy” — but we’ve seen, you know, it is clearly out there. You know, you had Zeke Emanuel on a couple of weeks ago. Remember what he said, that, you know, 10 years ago, some people still liked their health care and now nobody likes their health care, rich or poor.

Rovner: Yeah, he’s right. All right. Well, that is this week’s news. Now, we’ll play my interview with Kate McEvoy of the National Association of Medicaid Directors about how the Medicaid unwinding is going. And one note before you listen: Kate frequently refers to the federal CMCS, which is not a misspeak; it stands for the Center for Medicaid and CHIP Services, which is the branch of CMS, the Centers for Medicare & Medicaid Services, that deals with Medicaid. So, here’s the interview:

I am pleased to welcome to the podcast Kate McEvoy, executive director of the National Association of Medicaid Directors, which is pretty much exactly what the name says, a group where state Medicaid officials can share information and ideas. Kate, welcome to “What the Health?”

Kate McEvoy: Good afternoon. Thanks for having me.

Rovner: Obviously, the Medicaid unwinding, which we have talked about a lot on the podcast, is Topic A for your members right now. Remind us again which Medicaid recipients are having their coverage eligibility rechecked? It’s not just those in the expansion group from the Affordable Care Act, right?

McEvoy: It’s not, no. Each and every person served by the country nationwide has to be reevaluated from an eligibility standpoint this year.

Rovner: What do we know about how it’s going? We’re seeing lots of reports that suggest the vast majority of people losing coverage are for paperwork reasons, not because they’ve been found to be no longer eligible. I know you recently surveyed your members. What are they telling you about this?

McEvoy: So, I first want to say this is an unprecedented task and it’s obviously historically significant for everyone served by the program. The volume of the work, and also the complexity, makes it a challenging task for all states and territories. But what we are seeing to date is a few things. First, we have seen an incredible effort on the part of states and territories to saturate really every means of communicating with their membership, really getting out that message around connecting with the programs, especially if an individual has moved during the period of the pandemic, which is very typical for people served by Medicaid. So that saturation of messaging and use of new means of connecting with people, like texting, really does represent a tremendous advance for the Medicaid program that has traditionally relied on a lot of complex, formal, legal notices to people. So that seems like a very positive thing. What we are seeing, and this is not unexpected, is that, you know, for reasons related to complex life circumstances and competing considerations, many people are not responding to those notices, no matter how we are transmitting those messages. And so that is a piece that is of great interest and concern to all of us, notably Medicaid directors wanting to make sure that eligible folks do not lose coverage simply because they are not responsive to the requests for more information. So we’re at a point where we’re beyond that initial push around messaging and now are really focused on means of protecting people who remain eligible, either through automatic review of their eligibility — the ex parte process — or by restoring them through such means as reconsideration. That’s really the main focus right now.

Rovner: And there’s that 90-day reconsideration window. Is that … how does that work?

McEvoy: So the federal law gives this period of 90 days to families and children within which they can be renewed with very little effort, essentially removing the responsibility to complete a new application. We also have long-standing help to people called “presumptive eligibility.” So if someone goes to a federally qualified health center or, more unfortunately, goes to the hospital, many of those types of providers can restore someone’s eligibility. So those are important protective pieces. We also know from the survey that you mentioned of our membership that many states and territories are extending those reconsideration protections to all coverage groups — also including older adults and people with disabilities.

Rovner: So are there any states that are doing anything that’s different and innovative? I remember when CHIP [the federal Children’s Health Insurance Program] was being stood up — and boy, that was a long time ago, like 1999 — South Carolina put flyers in pizza boxes, and some other state put flyers in sneaker boxes for back-to-school stuff. Are there better ways to maybe get ahold of these people?

McEvoy: So I think the answer is: a lot of different channels. Our colleagues in Louisiana have a partnership with Family Dollar stores to essentially feature this information on receipts. There’s a lot of work at pharmacy counters. Some of the big chain pharmacies have QR codes and other means of prompting people around their Medicaid eligibility. There’s going to be a big push for the back-to-school effort. And I think CMS and states are really interested, particularly in ensuring that children do not lose coverage even if their parents have regained employment and they’re no longer eligible. Another thing that’s going on is a lot of innovation in the means of enabling access to information. So many states have put in place personal apps through which people can track their own eligibility. There’s interest and some uptake of the so-called pizza-tracker function — so you can kind of see where you’re situated in that pipeline — and also a lot of use of automation to help call people back if they’re trying to get to state call centers. So really, all of those types of strategies … we’re seeing a huge amount of effort across the country.

Rovner: How’s the cooperation going with the Department of Health and Human Services? I know that … they seem to be not happy with some states. Are they being helpful, in general?

McEvoy: They’re being extraordinarily helpful. I would say that we often talk about Medicaid representing a federal-state equity partnership, and we’ve seen that manifest from the beginning of the first notice of the certainty around the start of the unwinding. CMCS has consistently offered guidance to states. They work with states using a mitigation approach as opposed to moving rapidly to compliance. We feel mitigation is the best way of essentially working out the strategies that are going to best protect continuing eligibility for people at the state level. And we really appreciate CMS’ efforts on that. We understand they do have to ensure accountability across the country, and we’re mutually committed to that.

Rovner: You better explain mitigation strategies.

McEvoy: Yeah, so this is a year where we are calling the question on eligibility standards that help ensure that the pathway to Medicaid coverage is a smooth one, and also that there is continuity of coverage. So, for any state that wasn’t yet meeting all those standards, CMCS essentially entered into an agreement with the state or territory to say, here is how you will get there. And that could have involved some means of improving the automatic renewals for Medicaid. It could have meant relying on an integrated eligibility processes. There are a lot of different tools and strategies that were put in place, but essentially that is a path to every state and territory coming into full compliance.

Rovner: Is there anything unexpected that’s happening? I know so much of this was predicted, and it was predicted that the states that went first that, you know, were really in a hurry to get extra people off of their rolls seem to be doing just that: getting extra people off of their rolls. Are you surprised at the differences among states?

McEvoy: I think that there have definitely been differences among states in terms of the tools they have used from a system standpoint, but I don’t see any differences in terms of retention of eligible people. That remains a shared goal across the entire country. And again, this is a watershed point where we have the opportunity to bring everyone to the same standards, ongoing, so that we help to prevent some of the heartache of the eligibility process for folks ongoing.

Rovner: Anything else I didn’t ask?

McEvoy: Well, I think that piece around the reconsideration period is particularly important. We are struck by there being probably less literacy around that option, and that’s something we want to continue to promote. The other piece I’d wind up by saying is that the Medicaid program is always available for people who are eligible. So in the worst-case scenario in which an otherwise eligible person loses coverage, they can always come back and be covered. This is in contrast to private insurance that may have an annual open enrollment period. Medicaid, as you know, is available on a rolling basis, and we want to keep reinforcing that theme so that no one goes with a gap in coverage.

Rovner: Kate McEvoy, thank you very much. And I hope we can call you back in a couple of months.

McEvoy: I would be very happy to hear from you.

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

Huetteman: My story this week comes from KFF Health News, my colleague Darius Tahir. He has a story called “The NIH Ices a Research Project. Is It Self-Censorship?” Now, the story talks about the fact that the former head of NIH Francis Collins, was, as he was leaving, announcing an effort to study health communications. And we’re talking about not just doctor-to-patient communications, but actually also how mass communications impact American health. But as Darius found out, the acting director quietly ended the program as NIH was preparing to open its grant applications. And officials who spoke with us said that they think political pressure over misinformation is to blame. Now, we don’t have to look too far for examples of conservative pressure over misinformation and information these days. In particular, there’s a notable one from just last month out of a Louisiana court, the federal court decision that blocked government officials from communicating with social media companies. You really don’t have to look too far to see that there’s a chilling effect on information. And we’re talking about the NIH was going to study or rather fund studies into communication and information. Not misinformation, information: how people get information about their health. So it’s a pretty interesting example and a really great story worth your read.

Rovner: And I’ve done nothing but preach about public health communication for three years now.

Kenen: It’s a very good story.

Rovner: Yeah, it was a really good story. Rachel, you’re next.

Roubein: All right. This story is called “From Windows to Wall Art, Hospitals Use Virtual Reality to Design More Inclusive Rooms for Kids,” by Stat News, by Mohana Ravindranath. And I thought this story was really interesting because she kind of dived into what Mohana called “a budding movement to make architecture more inclusive” for the people and patients who are spending a lot, a lot of time in hospital walls. And what some researchers are doing is using virtual reality to essentially gauge how comfortable children who are patients are in hospital rooms. And she talked to researchers at Berkeley who were using these, like, virtual reality headsets to kind of study and explore mocked-up hospital rooms. And, I didn’t know a ton about this field. I mean, apparently it’s not new, but it’s this kind of growing sort of movement to make patients more comfortable in the space that they’re inhabiting for perhaps long periods of time.

Rovner: I went to a conference on architecture, hospital architecture, making it more patient-centered, 10 years ago. But my favorite thing that I still remember from that is they talked about putting art on the ceiling because people are either in bed or they’re in gurneys. They’re looking up at the ceiling a lot. And ceilings are scary in hospitals. So that was one of the things that I took away from that. OK, Joanne, now it’s your turn.

Kenen: OK. This is from Fox News. And yes, you did hear that right. It’s by Melissa Rudy, and the headline is “Male Health Care Leaders Complete ‘Simulated Breastfeeding Challenge’ at Texas Hospital: ‘Huge Eye-Opener’.” So at Covenant Health, they had a bunch of high-level guys in suits pretend they were nursing and/or pumping mothers, and they had to nurse every three hours for 20 minutes at a time. And they found it was quite difficult and quite cumbersome and they didn’t have enough privacy. And as one of them said, “There was no way to multitask.” But trust me, if you have two kids, you have to figure that out, too. So it was a really good story.

Rovner: Some of these things that we feel like should be required everywhere, but it was a great read; it was a really good story. OK, that is our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us too. Special thanks this week to Zach Dyer, sitting in for the indefatigable Francis Ying. And as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can tweet me or X me or whatever; I’m @jrovner. And also on Bluesky and Threads. Rachel?

Roubein: @rachel_roubein — that’s on Twitter.

Rovner: Joanne.

Kenen: In most places I’m @JoanneKenen. On Threads, I’m @joannekenen1.

Rovner: Emmarie.

Huetteman: And I am @emmarieDC.

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

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

Congress has left for its annual August recess, but lawmakers have a long to-do list waiting when they return — and only a handful of legislative days to fund the government before the Oct. 1 start of the new fiscal year.

Meanwhile, Republican presidential candidates who are not named Donald J. Trump are preparing for their first televised debate and making interesting promises about health care.

This week’s panelists are Julie Rovner of KFF Health News, Alice Miranda Ollstein of Politico, Sandhya Raman of CQ Roll Call, and Lauren Weber of The Washington Post.

Panelists

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories

Sandhya Raman
CQ Roll Call

@SandhyaWrites

Read Sandhya's stories

Lauren Weber
The Washington Post

@LaurenWeberHP

Read Lauren's stories

Among the takeaways from this week’s episode:

• Work has paused on Capitol Hill. Among other items of unfinished business, lawmakers returning next month will have to pass at least a short-term spending bill — or soon face a government shutdown with implications for health programs and much, much more. Authorizations are also on the agenda, with programs like community health centers on the line. But the path to passage winds through a social issues minefield, owing to conservative House Republicans who have inserted measures targeting abortion access and gender-affirming care for transgender people.
• Access to women’s health care in the United States is worsening, with maternal health deserts popping up around the nation even in the years before the overturn of Roe v. Wade. Some states in particular have seen a huge decline in the number of maternal health providers, including the closures of obstetric wards. The fact that more people are living in counties with no maternal health providers is troubling news for a nation experiencing a maternal mortality crisis.
• State medical boards across the country have disciplined fewer than two dozen providers reported for spreading covid-19 misinformation, according to a new investigation by The Washington Post. The paucity of punishments demonstrates how ill-equipped such boards are to address the serious problem of health misinformation.
• On the 2024 presidential campaign trail, Republican candidates like Gov. Ron DeSantis of Florida are signaling that re-litigating the covid pandemic is part of their playbook — but do voters still care that strongly about vaccine mandates and business shutdowns?
• And the National Institutes of Health has moved to officially study long covid, a little-understood condition that impacts the lives of many Americans.

Also this week, Rovner interviews KFF Health News senior correspondent Phil Galewitz, who reported the latest KFF Health News-NPR “Bill of the Month” installment, about how a bill that should never have been sent created headaches for one patient. If you have an outrageous medical bill you’d like to share with us, you can do that here.

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

Julie Rovner: Stat’s “Henrietta Lacks Settlement Hailed by Experts as Step Toward Correcting Medicine’s Racist History,” by Annalisa Merelli.

Alice Miranda Ollstein: The Tampa Bay Times’ “Florida Veered From Norms to Strip Transgender Care From Medicaid, Records Show,” by Emily L. Mahoney and Romy Ellenbogen.

Sandhya Raman: KFF Health News’ “Black Women Weigh Emerging Risks of ‘Creamy Crack’ Hair Straighteners,” by Ronnie Cohen.

Lauren Weber: Politico’s “CDC Investigators Find More TB Infections Linked to Bone Graft Materials,” by Alice Miranda Ollstein and Lauren Gardner.

Also mentioned in this week’s episode:

• The Washington Post’s “Doctors Who Put Lives at Risk With Covid Misinformation Rarely Punished,” by Lena H. Sun, Lauren Weber, and Hayden Godfrey.
• Roll Call’s “Health Deadlines Pile Up as Congress Adjourns for August,” by Lauren Clason, Ariel Cohen, Jessie Hellmann, and Sandhya Raman.
• Slate’s “How Meta Created a Wild West for Abortion Misinformation,” by Jennifer Neda John.
• Politico’s “‘It’s a Crisis’: Maternal Health Care Disappears for Millions,” by Alice Miranda Ollstein and Megan Messerly.

click to open the transcript

Transcript: Congress Is Out. The Presidential Campaign Is In.

KFF Health News’ ‘What the Health?’Episode Title: Congress Is Out. The Presidential Campaign Is In.Episode Number: 308Published: Aug. 3, 2023

[Editor’s note: This transcript, generated using transcription software, has been edited for style and clarity.]

Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Aug. 3, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. We are joined today via video conference by Alice Ollstein, of Politico.

Ollstein: Good morning.

Rovner: Lauren Weber, The Washington Post.

Lauren Weber: Hello, hello.

Rovner: And Sandhya Raman, of CQ Roll Call.

Sandhya Raman: Good morning.

Rovner: Later in this episode we’ll have my interview with my KFF Health News colleague Phil Galewitz, who wrote the latest “Bill of the Month” for KFF Health News and NPR. This month’s patient never should have gotten a bill for his care, but he and his family ended up with a giant mess nonetheless. But first, this week’s news. It is officially August. Congress is gone until September, which makes it a good time to take stock of what has and hasn’t been accomplished on the health agenda and what might feasibly get done this fall, which is always shorter than you think. The biggest outstanding issue, literally and figuratively, is the spending bill for the Department of Health and Human Services. When Congress comes back, members theoretically only have 11 legislative days before Oct. 1, when the new fiscal year begins. And if Congress doesn’t complete work on the spending bill, which has yet to come to the House or Senate floor or even get out of the House Appropriations Committee, a lot of Health and Human Services programs could shut down unless Congress passes a temporary bill to keep them open. Sandhya, right now everything kind of points to an Oct. 1 shutdown, or am I missing something?

Raman: Yeah, I think at this point we’re looking at either a shutdown or just, like, a continuing resolution, just kicking the can a little bit down the road and giving them some more time. So right before Congress left, the Senate did advance, in the Appropriations Committee, their spending bill for [the departments of] Labor, HHS, and Education. And that means that all 12 of theirs have gotten at least that far, through the Senate Appropriations Committee, but they would still need to come to the floor, and it doesn’t mean that the House is going to agree to any of that. And the House is a lot further behind in that the only markup they’ve had on the HHS bill is on the subcommittee level. It’s not even at the House Appropriations level. And you can kind of see the tea leaves in that they were trying to get the agriculture bill done before they left, which has all the FDA money in it, and they didn’t end up bringing it to the floor because they didn’t think they would have the votes to pass it. So I think that we’re going to need some time, given that I don’t think that, even though the Senate bills have been bipartisan so far, that they’re going to be eager to jump on those.

Rovner: Every year when there’s a change in leadership in either the House or the Senate, they vow, “This is the year we’re not going to do a big omnibus spending bill. We’re going to do all 12 appropriations separately, and we’re going to run them through the House and the Senate floors, and we’re going to have a conference.” And it hasn’t happened in more than 20 years now. And there’s clearly no reason to think it’s going to happen this year, right?

Ollstein: And one of the biggest sticking points: There are the fights that happen every single year over things like the Hyde Amendment, which prevents federal spending on abortion, but that has spread to almost every single appropriations bill. There are anti-abortion budget riders. There are anti-trans health care budget riders. There are all kinds of things tucked in there that Democrats say they will oppose and that the Senate bills don’t have. But, you know, you have this disconnect where there are plenty of House members who would be completely fine with a shutdown; they’ve said publicly that they think that would not be so bad.

Rovner: You have to say it wouldn’t be as bad as letting the debt ceiling get breached.

Ollstein: Right, right, right, right. Whereas Democrats are very much saying it would be horrible to have a shutdown. And so I was talking to some Democratic House members who say that people are really torn between the pressure to make a deal to keep the government open and the pressure to oppose all of these conservative budget riders. And that tension is going to really come into play in the fall.

Rovner: Yeah. Alice, you wrote a wonderful story on all the abortion fights in all these different bills, and I just had sort of deja vu to the ’90s. If you were following abortion, you had to keep track of obviously the ag bill with FDA in it, HHS bill, and the Department of Justice bill because of abortion in prisons, and the defense bill because of, you know, abortions for servicewomen. I mean, we basically had some kind of abortion fight in more than half of the appropriations bills. So we’re coming back to that right now. Well, there are also lots of programs whose authorizations expire Oct. 1. That’s not the same as the appropriations bills that we’ve just been talking about. Without appropriations, programs have to shut down, at least temporarily. Authorizations, though, can lapse as long as the programs are funded through the appropriations. But it’s still nice to, you know, get your work done on time. Some of the big programs Congress is working on include renewing authority for community health centers, for pandemic preparedness programs, for a big group of graduate medical education programs. What’s the fall outlook for those authorizations?

Raman: So I think part of it is tied into what we see with appropriations, because a lot of these programs — even if they come to an agreement, it’s likely to ride on whatever big spending bill we have next, whether that’s a continuing resolution, whether that’s an omnibus or anything like that. So if we end up seeing some sort of continuing resolution, which is looking likely, a lot of these are going to be short-term, maybe extended if they have an agreement there, which is what they traditionally do, and then something longer — the next vehicle that pops up, the next one, or sometimes they even get a one-year, even if there is agreement, just because this is what Congress does. So some of them, I think, are looking more promising than others. We’ve seen things kind of happen with some of the graduate medical education, the [National] Health Service Corps, like those have kind of come to some sort of agreement, but —

Rovner: And those are typically bipartisan programs.

Raman: Yeah, but then others are not as far along and will take time. I mean, the process to even do like the SUPPORT [for Patients and Communities] Act, which was a 2018 law that had a bunch of different opioid provisions in it, that was bipartisan, got through: I mean, we’ve been marked up in [the] Energy and Commerce [Committee] in the House, and the Senate has not done a markup; they just have a bill that has come out so far. And so getting that done before the Sept. 30 deadline is tricky. There are some that are a little bit more partisan that I think would be more difficult to get done. I mean, the Children’s Hospitals Graduate Medical Education has been a little bit derailed over, like, political back-and-forth over policies for transgender children. And so I think even some things that have been more easy to get across the finish line in the past are having factors that are weighing them down. So a lot of these are a question mark. Yeah.

Rovner: So that was originally a Republican program. I remember when it was created because Medicare funds most of the graduate medical education, but obviously there’s not a lot of Medicare beneficiaries who are children, so they had been left out and this is their own program. But I always get at this point to share my favorite piece of trivia about authorizations versus appropriations, which is that the federal family planning program, Title X [“ten”], has not been reauthorized since 1984. Congress has tried any number of times and has failed. It continues to get funded, but it has literally been operating without authorization for all of those years. Well, one more important authorization that’s not part of the Department of Health and Human Services but is part of health care is PEPFAR [the United States President’s Emergency Plan for AIDS Relief], the very successful international AIDS and HIV program begun under President George W. Bush 20 years ago this year. But this time around, the bipartisanly popular program is hung up over — what else? — abortion. Alice, you wrote about this. I mean, PEPFAR, this is really a Republican-backed program.

Ollstein: Yes. It was created by George W. Bush and has had bipartisan support for most of its life. It’s credited with saving the lives of tens of millions of people. Few programs can say that, of any kind. And millions of people are depending on it right now for access to medications around the world. So Republicans are saying that they won’t support reauthorizing it but they will keep it funded through appropriations, just like you were talking about, keep it sort of limping along on a one-year budget, with language restoring the Trump-era restrictions on the program. So, of course, for the entirety of the program, money has not gone to providing abortions, but this expands that and says money can’t go to any organization that, you know, uses other money to provide abortions or even an organization that gives money to another organization and that subsequent organization does abortions. And so this really has been tough for the program in the last few years. And independent experts are telling me that not reauthorizing it, yes, it wouldn’t shut down the program, but they worry it would send a signal to other countries that this is not something the U.S. is really invested in going forward and it would lead other people to cutting their contributions.

Rovner: Yeah, I mean, in addition to saving millions of lives or tens of millions of lives, this has been an important piece of international diplomacy, particularly in Africa, right?

Ollstein: Right. And that was the point Sen. [Bob] Menendez [(D-N.J.)], who had wanted a full five-year reauthorization attached to the NDAA [National Defense Authorization Act], which he said his Republican colleagues killed — he made that exact point.

Rovner: The defense authorization bill.

Ollstein: Exactly, yes. They were trying that as a workaround to get it reauthorized. And it didn’t work because of GOP opposition. But Menendez was saying, you know, this will only empower countries like China that have been trying to make inroads in Africa with philanthropic work and reduce the influence of the U.S. The geopolitics are definitely on people’s mind as well as the basic humanitarian value.

Rovner: So it’s going to be a busy fall. Well, while we are on the subject of reproductive health, the problem of getting maternal health care here in the U.S. is growing, according to a new study from the March of Dimes. We are the country that already has the worst record for maternal mortality in the developed world. Yay, us. How much worse has it gotten?

Ollstein: It’s gotten a lot worse. So in just one year, between 2019 and 2020, there was a 4% decline in the number of hospitals that have birthing services, OB [obstetrics] wards. And 4% may not sound like a lot, but it’s not evenly distributed; that’s just the national average. Some states had a nearly 25% decline. And like you said, you know, we’re already doing so much worse than other countries with maternal mortality. And this just means millions of more people than before are living in a county that has zero hospitals, zero OB-GYNs, zero maternal health care providers — and then a lot of those same places, these same states and counties, also have really high rates of chronic health conditions that are contributors to maternal mortality. And so all of this is coming as births are expected to go up because of abortion bans. This data was from before Dobbs [v. Jackson Women’s Health Organization, the 2022 Supreme Court ruling overturning the nationwide right to abortion], so we don’t know yet what’s going to happen, but the expectation is that births will go up. And at the same time, there’s just fewer care providers to meet that need.

Rovner: And we also know that in the states with bans, we’re starting to see providers either leave or not go there to train in the first place, which is just going to make the whole thing worse. This week the action is going on in a couple of Midwestern states, Indiana and Ohio, I guess both of which have bans, and one of which is in force and one of which isn’t. Where are we with Indiana and Ohio? I know it changes from hour to hour.

Ollstein: So Ohio’s ban is still enjoined, so that means abortion is still legal in Ohio. The development was about this upcoming vote, and there are two upcoming votes. This is kind of wonky, but the upcoming vote that’s happening in less than a week is whether to make ballot initiatives in general harder to pass, to raise the threshold from 50 to 60%. And that’s explicitly intended to thwart the fall vote on legalizing abortion in the state and putting something in the state constitution that supports it.

Rovner: Which, coincidentally, polls show has about like 56, 57% support, right? So 60% would make it more likely to fail.

Ollstein: Right. Right. That’s coming up. But for now, because of a court injunction, abortion remains legal and the ban is not enforced.

Rovner: And Indiana, which had a very stringent ban that was about to go into effect?

Ollstein: Sandhya, do you want to?

Raman: Oh, yeah. I was just going to add to Ohio first that, as of this morning, the voter turnout for the Ohio election next week is super high. It was, like, over 380,000 people have already cast their ballot, and that was higher than, I guess, you know, when they had, like, [a] competitive Senate primary before. And so it will definitely be something to watch. I mean, we don’t know if the voter turnout is high one way or the other, but I just thought that was really interesting. But with Indiana, their abortion ban was supposed to take effect on Tuesday and then it was halted by another lawsuit, and they were the state that was the first one to pass a post-Dobbs, new abortion ban last year. So it’s, like, another sticking point in that a lot of the bans that have gone into effect are older laws or things that have been unblocked in court.

Rovner: So, yes, it really does depend on the day. I guess I read that a bunch of clinics that had been providing abortion have stopped, even though the ban is, at least for the moment, on hold. So rather typically around the country, you literally have to go day by day to figure out what is allowed and what is not. All right. Well, let us turn now to a segment I’m calling “Myths and Disinformation” this week. Lauren, I was so glad you could join us this week because you and a couple of your colleagues at the Post have a new investigation into how doctors who were peddling bad and often dangerous information during the pandemic were called to account. Spoiler: Not a lot of them were, right?

Weber: Yeah, I was going to say spoiler alert that not a lot of them were called to account. So essentially my colleagues Lena Sun, Hayden Godfrey, and I reviewed the records from all 50 states’ various medical boards, both MD boards and osteopathic boards, to see who actually had been punished for spreading covid misinformation or for practicing in a way that is misinformation-related. And despite discovering from our various records requests over hundreds of complaints for doctors that asked patients to remove masks or told them the vaccines were full of metal or told them not to get a vaccine or a various number of the —or prescribed ivermectin or hydroxychloroquine — only 20 doctors have been disciplined, and we are three and a half years into covid. And you know, what our investigation found is something that everyone on this panel has known for quite some time. But state medical boards are historically weak, underfunded, and are very ill-equipped in the social media age, where misinformation is a deluge, to really step into that breach. And what our investigation essentially found is that they’ve really failed to stop doctors that are spreading misinformation or, you know, prescribing drugs that are not deemed the consensus around the standard of care.

Rovner: So everybody says, oh, well, this is up to medical boards in every state, and they keep doctors honest and keep them on the straight and narrow and sanction them when they do wrong things. That’s not been true for a long time. And I guess now it’s still not true, right?

Weber: Yeah, exactly. And it’s really interesting. And this came up, too, in the case in Idaho for abortion, you see a lot of misinformation folks cite free speech in their ability to practice medicine. It’s actually — you know, it makes it difficult to discipline people because it is being able to prescribe things off-label, or your medical judgment is not something people — medical boards are loath to discipline over, and for good reason. You understand why that may be, but in the case of covid, where this has continued and, you know, treatments like hydroxychloroquine or ivermectin have been deemed outside of the standard of care, it is very surprising that we’ve seen such a low number of disciplinary actions taken. It really goes to show that the boards are not equipped to kind of step into this breach as misinformation has flooded the zone.

Rovner: Well, meanwhile, abortion rights groups are getting frustrated with Meta, Facebook’s parent company, over its inconsistent moderation of information about abortion and reproductive health. It reminds me of some years ago when public libraries would try to limit internet search terms to keep people away from online porn but ended up barring people from searching about breast cancer because it had the word “breast” in it. So this isn’t something that’s new. In fact, going back decades, anti-abortion groups used to advertise their crisis pregnancy centers, which don’t offer abortion but sound like they do, in the yellow pages of the phone book. And kids, ask your parents what a Yellow Pages was. But social media algorithms have the ability to determine what information a lot more people see or don’t see. This one looks pretty hard to resolve. I know that, unlike Twitter, Facebook is trying here, but this is going to be difficult, yes?

Weber: Yeah, I would say it’s a really hard — you know, it’s interesting that the article in particular that you’re talking about, there were two different camps opposed that were saying abortion is killing the unborn child versus you’re killing people if they have an abortion. And both of those got sanctioned by Facebook because it had the word kill in it. And so what we’re going to see is how they come down on this information. But in a world where you see misinformation — in [Judge Matthew] Kacsmaryk’s circuit [district] court ruling, you know, it’s kind of hard to see how this is going to be resolved by Facebook. I do not envy them in this task. I don’t really know how you would come down on this and how you would comprehensively evaluate all of these posts in a fair manner that is respective of free speech. And like you said, Julie, you know, a lot of times it leads to unintended consequences when you try and restrict posts like this on all sides. And there are some smart people that are trying to advise in the correct way, but we’ll see what happens.

Rovner: Yeah, it is not easy. Speaking of mis- and disinformation and real information, we’re going to move to the campaign trail, because it’s only August of an odd-numbered year but the 2024 presidential campaign is in full swing, with the first Republican candidate debate later this month. And while health care, specifically the desire to repeal the Affordable Care Act, is far from the rallying cry for Republicans that it has been in the last couple of presidential campaigns, we are seeing some interesting stances and comments from candidates who are not named Donald Trump. We will start with the candidate who’s running second in the Republican primary polls. That would be Florida Gov. Ron DeSantis, whose campaign launch has been anything but smooth. DeSantis, perhaps looking for some publicity, raised some eyebrows last week when he suggested on a conservative podcast that, if elected, he might install Democratic presidential candidate and known anti-vaxxer Robert F. Kennedy Jr. at the CDC [Centers for Disease Control and Prevention] or the FDA. DeSantis has been trying to stake out kind of a middle ground on his vaccine position. He’s not outright anti-vax, but he doesn’t support mandates and he’s kind of hot and cold on supporting vaccines in general. I don’t see how this would actually win him love on either side. I mean, he actually said that they would sic RFK Jr. on the CDC or the FDA.

Weber: I got to say, I find it fascinating. I mean, look, RFK Jr. has a cult following. And I think if anything, it speaks to the fact that Republicans are very much anti-vaccine mandate, anti-government shutdown, all things that RFK says all the time. And DeSantis did walk it back and said he would put him on a committee because, you know, we wouldn’t want a Democrat actually running these things. But I think really what this episode shows is the salience that words like the CDC, and we’ll talk later about the FDA — you know, the American voting public cares about these things now. They know what these agencies are, and they have strong feelings. They blame them for pandemic policies. And I think it just goes to show that relitigating the pandemic and different people’s versions of how they believe the pandemic went is really going to be a constant in this political run-up to 2024.

Ollstein: While I agree with that, I also think it is maybe not as salient as DeSantis was hoping it would be. I mean, he really has formed his candidacy on his governorship during the pandemic, and it doesn’t seem to be breaking through. He’s still just miles and miles and miles behind Trump. And depending on the polls, some of these people with way less of a platform than the governor of Florida are doing quite well. And so I think that people do have strong feelings about vaccine mandates and mask mandates and school closures and all of that, but not nearly as strong as a year ago. So I think that he maybe isn’t getting the juice from saying a lot of these things that he was hoping he would.

Rovner: Well, speaking of candidates who have less of a platform and yet seem to be making inroads — long shot but picking-up-momentum candidate Vivek Ramaswamy, who actually does know something about health policy, as the founder of a biotech firm, has vowed to, quote, “expose and [to] ultimately gut” the FDA. Now, he is a former libertarian rapper, so it is not a shock that he opposes most federal regulatory entities. But I wonder how even Republican voters would feel about actually gutting the FDA. It’s one thing — Alice, you were talking about feelings about the pandemic, but the FDA obviously does a lot more things than just deal with masks and covid vaccines. I mean, is there really a Republican constituency for wiping out the federal regulatory mechanism?

Ollstein: I mean, there at least seems to be at the state level in some states. We’ve talked so much about how GOP lawmakers have voted to roll back public health powers in a bunch of states because of covid. But it’s set to have implications way beyond covid and limit public health workers’ ability to respond to foodborne outbreaks and other things — things in the water, things in the air. So you could see that skepticism and desire to strip the government of its public health powers at the federal level as well.

Rovner: And, Lauren, you’ve been looking at this at the state level, too, right, sort of the slow decline of trust in public health, or maybe not-so-slow decline of trust in public health.

Weber: Yeah. I mean, you know, I found this February, 30 states have passed laws that have rolled back public health powers. There’s litigation at the federal level that has really stripped a lot of executive power for the public health system. As we know, public health leaders on the ground have resigned, quit, or been fired in droves due to political pushback. There’s a lot of concern among the public health community and the folks that I talk to constantly that we have seen just a massive hollowing-out of the workforce that will be impossible to replace. And so I think you’re seeing, you know, kind of as we’ve talked about, how I think this is a talking point among Republican candidates, to kind of bash these government agencies because it’s something that is appealing to people that are irritated over these deals.

Raman: Like, if you look at his comments about this, does this really hold up to the scrutiny? I mean, FDA is not the one that would mandate vaccines, mandate mask-wearing. They don’t set prices. None of that is under their jurisdiction. And, you know, you can assume that he knows this given his background, but I think it just kind of goes with some of his other comments about, you know, defunding a lot of the other agencies that he’s made. So I think some of this also just banks on people maybe not knowing, you know, what falls under what bucket. And it just might be an easy punching bag to lump it in together if the people aren’t aware of what falls under CDC versus FDA or any other agency or state-level.

Rovner: And he’s one of those people that just seems very sure of himself, even when what he’s saying isn’t necessarily true. And the very-sure-of-himself part seems to appeal to voters. But I want to go back to DeSantis just one more time. But before we’re done, speaking of trying to have it both ways, DeSantis stepped into a bees’ nest on abortion, of all things. This is the governor who signed a six-week abortion ban bill in Florida, but he kind of hemmed and hawed about saying whether he would support a national abortion ban. So that won him a firm rebuke from the Susan B Anthony List, which is a pretty powerful political arm of conservative Republicans. Does DeSantis really think he can sustain a position like this, where you can really say, “We only want states to deal with this and we don’t really want it to be at the federal government”? I mean, that was sort of the Supreme Court’s argument. But I think that there’s a lot of grassroots Republicans who would like to not have to fight this state by state and would like to see a national ban.

Ollstein: Yes, the major anti-abortion groups have said that that, you know, “leave it to the states” is not an answer they will accept and they will continue to put the pressure on candidates. Their argument is that, you know, because of things like the appropriations process and because of things like access via Medicaid — [that] is a fight and access in prisons is a fight and access for — you know, their argument is the federal government is already involved in abortion, so you should support the federal government getting involved in banning abortion.

Rovner: Which is kind of true. I mean, the part about the federal government already being heavily involved in abortion.

Ollstein: Sure. Do with that what you will. But candidates keep falling into this same trap. I mean, you had Nikki Haley, who is not polling very well at the moment — she held a whole event with Susan B. Anthony List that they hyped, and she said she would lay out her plan for abortion and there were, like, no specifics whatsoever. And then the group said, “Oh, she assured us she supports a national ban,” but then she said she didn’t. And this is going to continue to be a fight. I think really Mike Pence is the one who is most firm in saying, “Yeah, I support a national ban.”

Rovner: Yeah, and he’s been consistent his entire career, when he was in the House and when he was governor.

Ollstein: He is also not polling very well, I will note.

Rovner: Yes, that’s true. Fair point. We will obviously continue to talk about things on the campaign trail as we move along the campaign trail. Well, finally this week, I want to talk about covid, which we haven’t done for a while. It is still around, and cases, while still low, are on the upswing at the moment. But the news this week is that after almost three years, the National Institutes of Health is finally acting on directions from Congress to get moving on efforts to study and treat so-called long covid, which as many as 10% of patients end up with after having the virus. The long covid community, which could be several million people, have been agitating for scientists to take their symptoms more seriously and do more work in the research realm. Now, NIH has finally created an Office of Long COVID [Research and Practice], albeit with only two full-time staffers to start with. It’s also started enrolling an estimated 24,000 people in several clinical trials to test things like a longer course of the drug Paxlovid. But patient groups say it’s still way too little for what’s a serious and growing more widespread ailment. Why is this all taking so long? I mean, we have a Democratic administration. One would think that they would be anxious to do this.

Weber: I mean, I think if you look at it, there was over a billion dollars allocated to this. I mean, I don’t know why it’s taking so long, Julie. I think a lot of advocates are asking the same question and really beating the drum around that — and especially if you look at things that are named Operation Warp Speed or, you know, other covid treatments, vaccine, other things that were able to move at a much quicker pace and get done in a much quicker time frame — I think there’s a lot of agitation among what could be a very large group of people that their concerns and quality of life and some of these horrible symptoms are not being addressed. And as you noted, I think it’s very fascinating there are only two full-time staffers. I’ll be curious to see if this continues to change, but historically, it hasn’t been very promising.

Rovner: This is not new that Congress will direct, particularly the NIH, to study something that NIH just doesn’t seem prepared to study. Of course, as we know, there’s no NIH director at the moment. We’ve talked about the fact that nominee is being blocked by Democrat Bernie Sanders. But still, I mean, this is something — and I think Congress wants NIH to do because so many of their constituents are coming to them and saying, “We have this problem; please go out and study it.” And yet the federal scientists don’t seem to know really what to do.

Weber: Well, and there was a congressman, I don’t remember his name, but someone on this panel probably does, who said he was retiring because he has long covid, and I think he has colleagues that also have long covid. So, I mean, I think that probably helped get them a fair amount of cash. But as you said, the delivery mechanism on getting clinical trials rolling has really not been there.

Rovner: Well, we will keep an eye on this, too. That is this week’s news. Now we will play my interview with KFF Health News’ Phil Galewitz, and then we will come back with our extra credits. We are pleased to welcome back to the podcast my colleague Phil Galewitz, who reported and wrote the latest KFF Health News-NPR “Bill of the Month” story. Phil, thanks for being here.

Phil Galewitz: Nice to be back.

Rovner: So, this month’s patient was well covered by insurance and, to cut to the chase, shouldn’t have paid anything for a surgery he had in 2021. Tell us who he is and what kind of care he got.

Galewitz: Thomas Greene had complications from diabetes, and he had to get some clogged arteries cleared out in his leg to treat something called peripheral artery disease. So he went to the hospital in 2021 for the procedure. He recovered pretty well. He had some other health issues, but he recovered fine from the procedure. The issue then came when the bills started coming in.

Rovner: And Mr. Greene has both Medicare and a supplemental Medigap policy, which should have brought his out-of-pocket cost to zero. But that’s not what happened. What did happen?

Galewitz: Yes, the Greenes, because of their good insurance, were used to whenever they got health care, that they did not have any out-of-pocket expenses. But this time, about a year later, or over a year, after the procedure, they suddenly started getting some letters from collection agencies who were looking to collect bills for about $3,000 for anesthesia.

Rovner: So, just the anesthesia part.

Galewitz: It was just the anesthesia. The hospital was fine. The surgeon who did the procedure was fine, but the anesthesiologist, who they were not even familiar with, started sending them bills through a collection agency, and they were perplexed about what was going on. And they tried to reach out and call and find out what was happening, why they were getting bills. And they said they were getting a runaround and couldn’t really get a clear answer.

Rovner: They went for help, too, and the people who were helping them had trouble getting answers.

Galewitz: Yes. They went to some organizations within Pennsylvania that specialize in helping seniors with their medical bills, and even them couldn’t get any clear answers. And then thankfully, they kept pushing and kept pushing, and they were able to get another advocacy group to work on their behalf, who talked to this organization called the North American Partners in Anesthesia, which is a large anesthesia group, to stop sending them bills, and thankfully, the bills have stopped coming. They did not pay anything, but they were worried about that this was going to affect your credit.

Rovner: So what did happen? How did they end up with these bills that they shouldn’t have had?

Galewitz: It’s still a mystery. North American would not talk to us, KFF Health News, to give us answers, and they don’t really have a clear answer. By law, providers are supposed to bill Medicare within one year to have their claims paid. In this case, the records that the Greenes have show that the bills to the claims to Medicare were sent in after a year, and that because of that, Medicare clearly marked down and said these bills are after a year, we’re not paying anything, and the patient owes zero. And when a patient gets a notice from Medicare saying, “You owe zero,” that’s supposed to be it. You don’t owe anything. No matter what letters you get from the provider, you’re not supposed to pay anything. But in this case the provider continued to bill and continued to send collection agencies after the patient. And they were perplexed.

Rovner: And just to be clear, when they billed this supplemental policy, the supplemental policy has to deny it if Medicare denied it, right?

Galewitz: Right. Humana was their supplemental provider, and that was actually the answer from Humana. If Medicare is not covering it, then we’re not going to cover it.

Rovner: So, in the meantime, even if you get one of these bills and you know that you don’t owe anything but there are collection letters coming, you do need to do something, right?

Galewitz: Yes. You should open your mail. The Greenes did say at one point they think they may have gotten some letters earlier from the anesthesia group and they may not have opened them. Because they didn’t expect any bills, they didn’t open them. The lesson is open your mail. Even if you think you shouldn’t get any bill, you should at least know ahead of time that you may be able to stave off problems down the road. So always open your mail, and then you may be able to handle the problem earlier on. So they may have stopped some of the collections. But again, they were covered. They reached out. They tried to do everything that they can within their realm, and they struggled. They’re feeling OK now. They never got a letter from North American saying, “Hey, we apologize,” or, “You’re in the clear.” They’ve just stopped getting bills. And it’s been since last year that they’ve gotten a bill, so they feel like they should be OK.

Rovner: And just the one little quirk also of this story is that it looked like the anesthesia group overbilled, right?

Galewitz: There was a question on the bills, on the claims, that it appeared that an anesthesiologist and a nurse anesthetist both billed Medicare for the exact same time, though it could be that maybe there was both, that one assisted the other. This was not a complex procedure. So there were questions about that. But it would be unusual that they would both bill for the exact same time period. And so there’s a question if they were double billing; it could not have been. North American would not answer our question.

Rovner: Well, so we have discovered another thing that, even if you don’t necessarily get answers, it appears that they got their problem solved, right?

Galewitz: Yes.

Rovner: OK. Phil, Galewitz, thank you very much.

Galewitz: Thank you.

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

Ollstein: Sure. Staying on the DeSantis train, I have a piece from the Tampa Bay Times called “Florida Veered From Norms to Strip Transgender Care From Medicaid, Records Show.” And this came out of a lawsuit that was challenging the state’s decision to strip Medicaid coverage of gender-affirming care, not just for children, but for adults as well. So what came out in discovery in the lawsuit was that the state did just all of these really unusual things. And the judge thought it showed a political motivation rather than, you know, a serious health care motivation for doing this. They paid all of these outside contractors with dubious backgrounds to be part of this effort. They came up with a slogan for the report, which is completely unusual. And the reporters found that staffers who supported defunding gender-affirming care got huge raises, and people who were not supportive of it did not. So, really good accountability reporting, and it seems to have played out in court as well.

Rovner: Yeah, quite a story. Sandhya.

Raman: My extra credit this week is called “Black Women Weigh Emerging Risks of ‘Creamy Crack’ Hair Straighteners.” And it’s from Ronnie Cohen for KFF Health News and on BET. The story takes a look at the messaging and awareness related to increasing health risks that people are worried about related to relaxers or, you know, chemically straightened hair. And it’s something that is especially popular among Black women. I think it was really interesting that only about half of states have anti-hair-discrimination laws, and so a lot of women might be more eager to get their hair chemically straightened for various reasons, workplace or things like that. And there’s not a ton of research.

Rovner: Right. It’s not just that they think it looks better.

Raman: No, no. And there’s not a ton of research on the cancer risk, but personal care products like hair relaxers don’t have the same kind of approval process through the FDA as food and drugs. So, it just takes a look at some of the different things there and what different providers are kind of considering and watching out for.

Rovner: Yeah, it’s really kind of scary. Lauren.

Weber: I actually flagged one of Alice’s stories, which is, “CDC Investigators Find More TB Infections Linked to Bone Graft Materials,” and it details how a bunch of patients have tested positive for tuberculosis after receiving bone grafts. And one of them has died. And there’s 36 more that are being treated for tuberculosis. And I find this fascinating because I find the coverage of tuberculosis in this country totally not where it should be. I mean, TB is — there are a lot of cases in the U.S. It’s a highly infectious — I mean, not a lot; there’s like 10,000 — but there’s a lot more than people realize. And it can be latent and lie in wait and, you know, to have some sort of medical procedure and then find out that whatever was implanted in you has given you a very dangerous, highly infectious disease that could result in you having to quarantine for months, depending on what it is, is really alarming. And there’s a lot of accountability follow-up questions on this for the FDA, these bone graft companies. And it gets at, do we want to gut the FDA, that is hopefully trying to stop things like this, even if it’s not preventing it here? It just leads to a lot of accountability questions that I think are quite fascinating.

Rovner: Yeah, a lot a lot of things that people have not thought about. Well, my story this week is from Stat, but it’s not so much a story as it is an event. Aug. 1 would have been the 103rd birthday of Henrietta Lacks, who longtime listeners to the podcast will remember we talked about a few years back when the book about her life, “The Immortal Life of Henrietta Lacks,” was made into a movie. For those of you without such long memories, Henrietta Lacks was an African American woman from Baltimore who was admitted to Johns Hopkins Hospital for cervical cancer in 1951. She died later that year at age 31. But the doctors who treated her also harvested cells without her knowledge or permission that turned out to be the first-ever self-perpetuating cell line. So HeLa cells, as they are called, for Henrietta Lacks, have been used in more than 75,000 different studies since then and have led to the development of such breakthroughs as the polio vaccine, treatments for cancer, and even the mapping of the human genome. While Hopkins has given the cells away for free to researchers, many of the companies that have used them have developed products that have made them, the companies, very rich. But until this week, no one in Henrietta Lacks’ family ever profited from the enormous contribution that she made to medical science. This week, the family’s lawyers reached a confidential but presumably significant settlement with one of those companies, Thermo Fisher, which makes a wide range of scientific supplies. But this is not just about justice for the family of Henrietta Lacks; it’s about starting to recognize and atone for unethical medical research over many, many years, particularly on African Americans. A good birthday present indeed. OK, that is our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us too. Special thanks, as always, to our producer, Francis Ying. Also as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can still tweet me. I’m @jrovner. Sandhya.

Raman: I’m @SandhyaWrites.

Rovner: Lauren.

Weber: @LaurenWeberHP.

Rovner: Alice.

Ollstein: @AliceOllstein.

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

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