The Host

Julie Rovner
KFF Health News

@jrovner

Read Julie's stories.

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

The partisan fight in Congress over how to raise the nation’s debt ceiling to prevent a default has accelerated, as the U.S. Treasury predicted the borrowing limit could be reached as soon as June 1. On the table, potentially, are large cuts to federal spending programs, including major health programs.

Meanwhile, legislators in two conservative states, South Carolina and Nebraska, narrowly declined to pass very strict abortion bans, as some Republicans are apparently getting cold feet about the impact on care for pregnant women in their states.

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

Panelists

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories

Rachel Cohrs
Stat News

@rachelcohrs

Read Rachel's stories

Joanne Kenen
Johns Hopkins Bloomberg School of Public Health and Politico

@JoanneKenen

Read Joanne's stories

Among the takeaways from this week’s episode:

• The United States is approaching its debt limit — much sooner than expected. And it is unclear how, or if, lawmakers can resolve their differences over the budget before the nation defaults on its debts. Details of the hastily constructed House Republican proposal are coming to light, including apparently inadvertent potential cuts to veterans’ benefits and a lack of exemptions protecting those who are disabled from losing Medicaid and nutrition benefits under proposed work requirements.
• A seemingly routine markup of a key Senate drug pricing package devolved this week as it became clear the committee’s leadership team, under Sen. Bernie Sanders (I-Vt.), had not completed its due diligence to ensure members were informed and on board with the legislation. The Senate Health, Education, Labor and Pensions Committee plans to revisit the package next week, hoping to send it to the full Senate for a vote.
• In more abortion news, Republican lawmakers in North Carolina have agreed on a new, 12-week ban, which would further cut already bare-bones access to the procedure in the South. And federal investigations into two hospitals that refused emergency care to a pregnant woman in distress are raising the prospect of yet another abortion-related showdown over states’ rights before the Supreme Court.
• The number of deaths from covid-19 continues to dwindle. The public health emergency expires next week, and mask mandates are being dropped by health care facilities. There continue to be issues tallying cases and guiding prevention efforts. What’s clear is the coronavirus is not now and may never be gone, but things are getting better from a public health standpoint.
• The surgeon general has issued recommendations to combat the growing public health crisis of loneliness. Structural problems that contribute, like the lack of paid leave and few communal gathering spaces, may be ripe for government intervention. But while health experts frame loneliness as a societal-level problem, the federal government’s advice largely targets individual behaviors.

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

Julie Rovner: The Washington Post’s “Dog-Walking Injuries May Be More Common Than You Think,” by Lindsey Bever.

Joanne Kenen: The Atlantic’s “There Is No Stopping the Allergy Apocalypse,” by Yasmin Tayag.

Rachel Cohrs: ProPublica’s “This Pharmacist Said Prisoners Wouldn’t Feel Pain During Lethal Injection. Then Some Shook and Gasped for Air,” by Lauren Gill and Daniel Moritz-Rabson.

Alice Miranda Ollstein: The Wall Street Journal’s “Patients Lose Access to Free Medicines Amid Spat Between Drugmakers, Health Plans,” by Peter Loftus and Joseph Walker.

Also mentioned in this week’s episode:

• The New York Times’ “Surgeon General: We Have Become a Lonely Nation. It’s Time to Fix That,” by Vivek H. Murthy.
• “What the Health?” podcast, July 7, 2022: “A Chat With the Surgeon General on Health Worker Burnout.”
• KFF Health News’ “After Idaho’s Strict Abortion Ban, OB-GYNs Stage a Quick Exodus,” by Sarah Varney.
• Politico’s “‘You Can’t Hide Things’: Feinstein, Old Age and Removing Senators,” by Joanne Kenen.

Click to open the transcript

Transcript: Health Programs Are at Risk as Debt Ceiling Cave-In Looms

KFF Health News’ ‘What the Health?’

Episode Title: Health Programs Are at Risk as Debt Ceiling Cave-In Looms

Episode Number: 296

Published: May 4, 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 at KFF Health News. And I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, May 4, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So here we go. We are joined today via video conference by Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico.

Joanne Kenen: Hey, everybody.

Rovner: Rachel Cohrs of Stat News.

Rachel Cohrs: Good morning.

Rovner: And Alice Miranda Ollstein of Politico.

Ollstein: Hello.

Rovner: So plenty of news this week. We’re going to dive right in. We’re going to start again this week with the nation’s debt limit, which Treasury Secretary Janet Yellen warned this week could be reached as soon as June 1. That’s a lot earlier than I think most people had been banking on. And if Congress doesn’t act to raise it by then, the U.S. could default on its debts for the first time in history. Do we have any feel yet for how this gets untangled now that we know — I think there are, what, eight days left where both the House and the Senate will be in session?

Ollstein: You said it caught all of us by surprise. It seems to have caught lawmakers by surprise as well. They seem to have thought they had a lot more time to fight and blow smoke at one another, and they really don’t. And there has not been a clear path forward. There are efforts to get Mitch McConnell more involved. He has sort of said, “Ah, you people figure this out. You know, whatever House Republicans and the White House can agree on, the Senate will pass.” And he’s been trying to stay out of it. But now both Republicans and Democrats want him to weigh in. He’s seen as maybe a little more reasonable than some of the House Republicans to some of the players, and so —

Rovner: He may be one of the few Republicans who understands that it would be very, very bad to default.

Ollstein: Right. You have a lot of House Republicans saying it wouldn’t be so bad — the tough medicine for Washington spending, etc. So, you know, if I were to bet money, which I wouldn’t, I would bet on some sort of short-term punt; I mean, we’re really coming up to the deadline, and that’s what Congress loves to do.

Rovner: Yeah, I do too.

Kenen: I agree with Alice. You know, I think if the deadline had been a couple of months from now — they really didn’t want to do a punt. I mean, I think they wanted to walk up to the cliff and cut some kind of deal at the last hour. But I think this caught everybody off guard, including possibly Janet Yellen. So I think it’s much more likely there’ll be a short-term postponement. I think the Democrats would like to tie it to the regular budget talks for the end of the fiscal year. I’m not sure the Republicans will consider September 30 short-term. It might be shorter than that. Of course, we could have another one. But I think Alice’s instincts are right here.

Rovner: Yeah, I do too. I mean, the best thing Congress does is kick the can down the road. They do it every year with all kinds of things. Sorry, Rachel, I interrupted you.

Cohrs: Oh, no, that’s all right. I was just going to flag that the date to watch next week is May 9, when I think they’re all supposed to kind of get in a room together and start this conversation. So I think we’ll hopefully have a readout. I don’t know that they’re going to solve everything in that meeting, but we’ll at least get a sense of where everyone’s coming from and just how acrimonious things really are. So, yeah, those will kick off in earnest.

Rovner: Yeah. Well, one thing the Democrats are talking about is a discharge petition in the House, which is a rarely successful but not all that little-used way to bring a bill to the floor over the objections of the party in charge. Is there any chance that this is going to work this time?

Kenen: That’s one reason the Republicans might not want an extension, because they probably couldn’t do it in the next two or three weeks. There’s a slight chance they could do it in early to mid-June. The Democrats need five Republicans to sign on to that. I would think that if any Republicans are willing to sign on to that, they’re not going to say it in public, so we won’t know who they are, but the chances of it working improve if there’s an extension; the chances of it working are still not great, but I don’t think it’s impossible. I do not think it’s impossible, because there are Republicans who understand that defaulting is not a good idea.

Rovner: This has been painted this week as, Oh, this is a secret idea. It’s like, it’s not, but the actual discharge petition, you get to sign it not anonymously, but no one knows who’s signing on. It’s not like co-sponsoring a regular bill.

Kenen: But stuff gets out. I mean, there’s no such thing as a secret on the Hill.

Rovner: But technically, when you sign it, it’s not an obvious public thing that you’re supporting it, so we will — we’ll have to see. Well, we know that Republicans are demanding deep, in some cases very deep, cuts to federal spending with their bill to raise the debt ceiling. We’re finding out just how deep some of the cuts would be. One possible piece of fallout I think Republicans didn’t bargain for: They say they intended to exempt veterans from the cuts, but apparently the bill doesn’t actually do that, which has already prompted cries of outrage from very powerful veterans groups. This is the danger of these really broadly written bills, right, is that you can sort of actually accidentally end up sweeping in things you didn’t mean to.

Cohrs: Right. Well, this bill came together very quickly, and Kevin McCarthy was dealing with a lot of competing factions and trying to make everyone happy on issues like energy credits, that kind of thing. And obviously this didn’t get attention before. And I think that that’s just kind of a symptom that isn’t infrequent in Washington, where things come together really quickly, and sometimes there are some unintended consequences, but I think that’s one of the functions of kind of the news cycle in Washington especially, is to bring attention to some of these things before they become law. So the rhetoric has been very fiery, but again, there’s a possibility that it could be worked out at a later date if for some reason the final deal ends up looking something like the Republican bill, which is not necessarily the case.

Rovner: Once upon a time — and we’ll talk about this next — we had something called regular order, where bills went through the committee process, there was a committee report, and people had time to look at them before they came to the floor. And now it’s sort of like a fish. If you leave it out too long, it’s going to start to smell. So you got to catch it and pass it right away. Well, before we get to that, another change that those people who wrote the Republican bill probably didn’t intend: The requirement for states to institute work requirements for those who get Medicaid and/or food stamps — something that states cannot opt out of, we are told — does not include exemptions for people with disabilities. In other words, they would be required to work if they are of the age. Even those who’ve been getting, you know, disability benefits for years would have to be recertified as quote “unfit to work” by a doctor, or else they would have their benefits terminated. I would imagine that states would be among those joining the uproar with this. They have enough to do with redeterminations right now from people who got on Medicaid during the pandemic. The last thing they need is to have to basically redetermine every single person who’s already been determined to have a disability.

Kenen: And it’s a burden for the disabled too, even if the states are willing to do it. Bureaucracies are hard to deal with, and people would get lost in the shuffle. There’s absolutely no question that disabled people would get lost in the shuffle given the system they’ve set up.

Ollstein: Yes, this is a perfect example of how people fall through the cracks, and especially because a lot of the mechanisms that states set up to do this, we’ve seen, are not fully accessible for people with disabilities. Some of them have audio-only options. Some of them have online-only options. It’s very hard for people to — even if they know about it, which they might not — to navigate this and become certified. And so there is a fair amount of data out there that the projected savings from policies like work requirements don’t come from more people working; they come from people getting kicked off the rolls who maybe shouldn’t be, should be fully eligible for benefits.

Kenen: And it’s not just physical disability. I mean, there’s all sorts of developmental disabilities — people who really aren’t going to be able to navigate the system. It’s just — it may not be what they intended, it may be what they intended, who knows. But it’s not a viable approach.

Rovner: Yeah. Meanwhile, even if the Democrats could sneak a bill out of the House with a little bit of moderate Republican support, there’s no guarantee it could get through the Senate, where West Virginia’s Joe Manchin says he supports at least some budget cuts and work requirements and where the absence of California’s Dianne Feinstein, who is 89 and has been away from Washington since February, trying to recover from a case of shingles, has loomed large in a body where the elected majority only has 51 votes. Joanne, you wrote about the sticky problem of senators of an advanced age. Feinstein is far from the first, but is there anything that can be done about this when, you know, one of our older senators is out for a long time?

Kenen: There is no institutional solution to an incapacitated senator. And in addition to the magazine piece I wrote about this yesterday for Politico Magazine, I also wrote about last night in Politico Nightly sort of going back to the history until the 1940s. I mean, there have been people, a handful, but people out for like three or four years. The only tool is an expulsion vote, and that is not used. You need two-thirds vote, and you can’t get that. It was used during the Civil War, where there were I think it was 14 senators from Confederate states who didn’t sort of get that they were supposed to leave once the Civil War started, so they got expelled. Other than that, there’s only been one case, and it was for treason, in the 1790s. So they’re not going to start expelling senators who have strokes or who have dementia or who have other ailments. That’s just not going to happen. But that means they’re stuck with them. And it’s not just Feinstein. I mean, there have been other impaired senators, and there will be more impaired senators in the future. There’s no equivalent to the 25th Amendment, for which the vice president and the cabinet can remove a president. The Senate has no mechanism other than behind-the-scenes cajoling. And, you know, we have seen Dianne Feinstein — she didn’t even announce she wasn’t running for reelection until other people announced they were running for her seat. But it’s like 50-50 Senate — if it’s 47-53 and one is sick, it doesn’t matter so much. If it’s 50-50 or 51-49, it matters a lot.

Rovner: Yeah, and that’s what I was going to say. I mean, you and I remember when Tim Johnson from South Dakota had, what was it, an aneurysm?

Kenen: I think he had a stroke, right?

Rovner: Yeah. It took him a year to come back, which he did eventually.

Kenen: Well, we both covered Strom Thurmond, who, you know, was clearly not —

Rovner: —he was not all there —

Kenen: — situational awareness for quite a few years. I mean, it was very clear, you know, as I mention in this story, that, you know, instead of the staff following his orders, he was following the staff’s orders and he was not cognizant of Senate proceedings or what was going on.

Rovner: Yeah, that’s for sure.

Kenen: But there also are some who are really fine. I mean, we know some who are 80, 88 — you know, in their 80s who are totally alert. And so an age cutoff is also problematic. That doesn’t work either.

Rovner: Right. Ted Kennedy was, you know, right there until he wasn’t. So I’m amazed at the at how some of these 80-something-year-old senators have more energy than I do. Well, elsewhere on Capitol Hill, we talked about the bipartisan drug price bill last week in the Senate that was supposed to be marked up and sent to the floor this week, which did not happen. Rachel, how did what should have been a fairly routine committee vote get so messed up?

Cohrs: Yeah, it was a — it was a meltdown. We haven’t seen something like this in quite a — a couple of years, I think, on the Hill, where Chairman Bernie Sanders’ first major, you know, health care markup. And I think it just became clear that they had not done due diligence down the dais and had buy-in on these bills, but also the amendment process, which sounds like a procedural complaint but it really — there were some substantive changes in these amendments, and it was obvious from the markup that senators were confused about who supported what and what could get the support of the caucus. And those conversations in the Lamar Alexander, you know, iteration of this committee happened before. So I think it, you know, was a lesson certainly for everyone that there does need to be — I don’t know, it’s hard to draw the line between kind of regular order, where every senator can offer an amendment, and what passes. And it’s just another symptom of that issue in Congress where even sometimes popular things that an individual senator might support — they could pass on their own — that throwing off the dynamics of packages that they’re trying to put together. So I think they are hoping to give it another shot next week after a hearing with executives from insulin manufacturers and pharmacy benefit managers. But it was pretty embarrassing this week.

Rovner: Yeah. I was going to say, I mean normally these things are negotiated out behind the scenes so by the time you actually — if you’re going to have a markup; sometimes markups get canceled at the last minute because they haven’t been able to work things out behind the scenes. Correct me if I’m wrong, but Bernie Sanders has not been chairman before of a major legislative committee, right? He was chairman of the Budget Committee, but they don’t do this kind of take up a bill and make amendments.

Kenen: I don’t remember, but he was a lead author of the bipartisan veterans bill. So he has — it’s probably his biggest legislative achievement in the Senate. And that was a major bipartisan bill. So he does know how these things work.

Rovner: Right. He knows how to negotiate.

Kenen: It just didn’t work.

Rovner: Yeah, I think this came as a surprise — a committee like this that’s really busy with legislation and that does legislation that frequently gets amended and changed before it goes to the floor. I am told he was indeed chairman of Veterans’ Affairs, but they don’t do as much legislation as the HELP Committee. I think this was perhaps his first outing. Maybe he learned some important lessons about how this committee actually works and how it should go on. All right. Rachel, you said that there’s going to be a hearing and then they’re going to try this markup again. So we’ll see if they get through this in the May work period, as they call it.

Kenen: Maybe they’ll come out holding hands.

Rovner: I want to turn to abortion. It seems that maybe, possibly, the tide in states is turning against passage of the broadest possible bans. In the same day last week we saw sweeping abortion restrictions turned back, though barely, by lawmakers in both South Carolina and Nebraska. And in North Carolina, where Republicans just got a supermajority big enough to override the state’s Democratic governor’s veto, lawmakers are now looking at a 12-week ban rather than the six-week or total ban that was expected. Alice, is this a trend or kind of an anomaly?

Ollstein: Every state is different, and you still have folks pushing for total or near-total bans in a lot of states. And I will say that in North Carolina specifically, a 12-week ban will have a big impact, because that is the state where a lot of people throughout the entire South are going right now, so they’re getting incoming folks from Texas, Oklahoma, Alabama, Louisiana. So it’s one of the sort of last havens in the entire southeast area, and so even a restriction to 12 weeks, you know, we know that the vast majority of abortions happen before that point, but with fewer and fewer places for people to go, wait times are longer, people are pushed later into pregnancy who want to terminate a pregnancy sooner. And so it could be a big deal. This has also been kind of a crazy saga in North Carolina, with a single lawmaker switching parties and that being what is likely to enable this to pass.

Rovner: Yeah, a Democrat turned Republican for reasons that I think have not been made totally clear yet, but giving the Republicans this veto-proof majority.

Kenen: They’ve got the veto-proof majority. I did read one report saying there was one vote in question. It might be this lawmaker who turned, whether she’s for 12-week or whether she’s for 15 or 20 or whatever else. So it’ll certainly pass. I don’t have firsthand knowledge of this, but I did read one story that said there’s some question about they might be one short of the veto-proof majority. So we’ll just have to wait and see.

Rovner: Yeah, North Carolina is obviously a state that’s continuing. So my colleague and sometime podcast panelist Sarah Varney has a story this week out of Idaho, where doctors who treat pregnant women are leaving the state and hospitals are closing maternity wards because they can no longer staff them. It’s a very good story, but what grabbed me most was a line from an Idaho state representative who voted for the ban, Republican Mark Sauter. He told Sarah, quote, “he hadn’t thought very much about the state abortion ban other than I’m a pro-life guy and I ran that way.” He said it wasn’t until he had dinner with the wife of a hospital emergency room doctor that he realized what the ban was doing to doctors and hospitals in the state and to pregnant women who were not trying to have abortions. Are we starting to see more of that, Alice? I’ve seen, you know, a few Republicans here and there saying that — now that they’re seeing what’s playing out — they’re not so sure these really dramatic bans are the way to go.

Ollstein: Yeah, I will say we are seeing more and more of that. I’ve done some reporting on Tennessee, where some of the Republicans who voted for the state’s near-total ban are expressing regret and saying that there have been unintended consequences for people in obstetric emergency situations. You know, they said they didn’t realize how this would be a chilling effect on doctors providing care in more than just so-called elective abortion situations. But it does seem that those Republicans who are speaking out in that way are still in the majority. The party overall is still pushing for these restrictions. They’re also accusing medical groups of misinterpreting them. So we are seeing this play out. For instance, you know, in Tennessee, there was a push to include more exceptions in the ban, alter enforcement so that doctors wouldn’t be afraid to perform care in emergency situations, and a lot of that was rejected. What they ended up passing didn’t go as far as what the medical groups say is needed to protect pregnant people.

Rovner: It’s important to point out that the groups on the other side, the anti-abortion groups, have not backed off. They are still — and these are the groups that have supported most of these pro-life Republicans who are in these state legislatures. So were they to, you know, even support more exemptions that would, you know, turn them against important supporters that they have, so I think it’s this —

Ollstein: —right—

Rovner: —sort of balancing act going on.

Ollstein: Plus, we’ve seen even in the states that have exemptions, people are not able to use them in a lot of circumstances. That’s why you have a lot of pro-abortion rights groups, including medical groups, saying exemptions may give the appearance of being more compassionate but are not really navigable in practice.

Rovner: Right. I mean, we’ve had all these stories every week of how near death does a pregnant woman have to be before doctors are not afraid to treat her because they will be dragged into court or put in jail?

Ollstein: Right.

Rovner: So this continues. Well, the other big story of the week has to do with exactly that. The federal Department of Health and Human Services has opened an investigation into two hospitals, one each in Missouri and Kansas, that federal officials say violated the federal emergency medical care law by refusing to perform an abortion on a woman in medical distress. If the hospitals don’t prove that they will comply with the law, they could face fines or worse, be banned from participation in Medicare and Medicaid. I can’t help but think this is the kind of fight that’s going to end up at the Supreme Court, right? I mean, this whole, if you have a state law that conflicts with federal law, what do you do?

Ollstein: Yeah, we’re seeing that both in the EMTALA space [Emergency Medical Treatment and Labor Act] and in the drug space. We’re seeing a lot of state-federal conflicts being tested in court, sort of for the first time in the abortion question. So we also, in addition to these new federal actions, you know, we still have cases playing out related to abortion and emergency care in a few other states. So I think this will continue, and I think that you’re really seeing that exactly the letter of the law is one thing, and the chilling effect is another thing. And how doctors point out if a lot of these state abortion bans are structured around what’s called an affirmative defense, which means that doctors have to cross their fingers and provide the care and know that if they get sued, they can mount a defense that, you know, this was necessary to save someone’s life. Now, doctors point out that a lot of people are not willing to do that and a lot of people are afraid to do that; they don’t have the resources to do it. Plus, in the medical space, when you apply for licenses or things in the future, it doesn’t just say, “Were you ever convicted of something?” It says, “Were you ever charged with something?” So even if the charges are dropped, it still remains on their record forever.

Rovner: Yeah, and they have malpractice premiums. I mean, there’s a whole lot of things that this will impact. Well, I want to talk about covid, because we haven’t talked about covid in a couple of weeks. It is still with us. Ask people who went to the big CDC conference last week; I think they’ve had, what, 35 cases out of that conference? Yet the public health emergency officially ends on May 11, which will trigger all manner of changes. We’re already seeing states disenrolling people for Medicaid now that they’re allowed to redetermine eligibility again, including some people who say they’re still eligible, as we talked about a little bit earlier. We’re also seeing vaccine mandates lifted. Does this mean that the pandemic is really over? It obviously is a major signal, right, even if covid is still around?

Kenen: It means it’s legally over. It doesn’t mean it’s biologically over. But it is clearly better. I mean, will we have more surges next winter or over some kind of holiday gathering? You know, it’s not gone and it’s probably never going to be gone. However, we also don’t know how many cases there really are because not everybody tests or they don’t realize that cold is covid or they test at home and don’t report it. So the caseload is murky, but we sure note that the death toll is the lowest it’s been in two years, and I think it’s under 200 a day — and I’d have to double check that — but it’s really dropped and it’s continuing to drop. So even though there’s concern about whether we still need some of these protections, and I personally think we do need some of them in some places, the bottom line is, are people dying the way they were dying? No. That is — you know, I’ve watched that death toll drop over the last couple of weeks; it’s consistent and it’s significant. And so we should all be grateful for that. But whether it stays low without some of these measures and access to testing and access to shots and — and people are confused, you know, like, Oh, the shots aren’t going to be free or they are going to be free or I don’t need one. I mean, that whole murkiness on the part of the public — I mean, I have friends who are quite well aware of things. I mean, I have friends who just got covid the other day and, you know, said, “Well, you know, I’m not going to — I’m not really, really sick, so I don’t need Paxlovid.” And I said, “You know, you really need to call your doctor and talk about that.” So her doctor gave her Paxlovid — so she actually had a risk factor, so, two risk factors. So it’s not over, but we also have to acknowledge that it’s better than many people thought it would be by May 2023.

Rovner: Yeah, I know. I mean, the big complaints I’m seeing are people with chronic illnesses who worry that masks are no longer required in health care facilities, and that that seems to upset them.

Kenen: I mean, I think if you were to ask a doctor, I would hope that you could ask your doctor to put on a mask in a certain situation. And that doesn’t work in a hospital where lots of people around, but the doctors I’ve been to recently have also worn masks and —

Rovner: Yeah, mine too.

Kenen: Luckily, we do know now that if you wear a good mask, an N95, properly, it is not perfect, but you still can protect yourself by wearing a mask. You know, I take public transport and I wear masks in public transport, and I still avoid certain settings, and I worry more about the people who are at risk and they don’t understand that the shots are still free; they don’t know how to get medication; they don’t — there’s just a lot of stuff out there that we have communicated so poorly. And the lack of a public health emergency, with both the resources and the messaging — I worry about that.

Rovner: And as we pointed out, people losing their health insurance, whether, you know —

Kenen: That’s a whole other —

Rovner: Yeah, rightly or not. I mean, you know, whether they’re no longer eligible.

Kenen: Most are, but they’re still, you know — falling through the cracks is a major theme in American health care.

Rovner: It is. Well, finally this week, the U.S. surgeon general, Vivek Murthy, wants us to be less lonely. Really. The health effects of loneliness have been a signature issue for Dr. Murthy. We talked about it at some length in a podcast last summer. I will be sure to add the link to that in the show notes. But now, instead of just describing how loneliness is bad for your health — and trust me, loneliness is bad for your health — the surgeon general’s office has issued a new bulletin with how Americans can make themselves less lonely. It’s not exactly rocket science. It recommends spending more time in person with friends and less time online. But does highlighting the issue make it easier to deal with? I mean, this is not one of the traditional public health issues that we’ve talked about over the years.

Ollstein: I’m very interested to see where this conversation goes, because it’s already sort of feeling like a lot of other public health conversations in the U.S. in that they describe this huge, existential, population-level problem, but the solutions pushed are very individual and very like, you have to change your lifestyle, you have to log off, you have to join more community groups. And it’s like, if this is a massive societal problem, shouldn’t there be bigger, broader policy responses?

Kenen: You can’t mandate someone going out for coffee —

Ollstein: —exactly—

Kenen: —three times a week. I mean, this one —

Ollstein: Exactly. You can’t boostrap loneliness.

Kenen: This one, I think — I think it validates people’s feelings. I mean, I think people who are feeling isolated —I mean, we had loneliness before the pandemic, but the pandemic has changed how we live and how we socialize. And if — I think it’s sort of telling people, you know, if you’re feeling this way, it is real and it’s common, and other people are feeling that way, too, so pick up the phone. And maybe those of us who are more extroverted will reach out to people we know who are more isolated. So, I mean, I’m not sure what HHS or the surgeon general can do to make people spend time with one another.

Ollstein: Well, there are structural factors in loneliness. There are economic factors. There is, you know, a lack of paid time off. There are a lack of public spaces where people can gather, you know, in a safe and pleasant way. You know, other countries do tons of things. You know, there are programs in other countries that encourage teens, that finance and support teens forming garage bands, in Scandinavian countries. I mean, there are there are policy responses, and maybe some of them are already being tried out at like the city level in a lot of places. But I’m not hearing a lot other than telling people to make individual life changes, which may not be possible.

Rovner: But although I was going to point out that one of the reasons that this is becoming a bigger issue is that the number of Americans living alone has gone up. You know, and again, Joanne, this was way before the pandemic, but it’s more likely — people are more in a position to be lonely, basically. I mean, it’s going to affect a larger part of the population, so —

Kenen: And some of the things that Alice suggested are policies that are being worked on because of, you know, social determinants and other things: recreation, housing. Those things are happening at both the state and federal level. So they would help loneliness, but I don’t think you’re going to see them branded as a loneliness — national loneliness program. But, you know, the demographics of this country — you know, families are scattered. Zoom is great, you know, but Zoom isn’t real life. And there are more people who are single, there are more people who are widowed, there are more people who never married, there are more people who are divorced, the elderly cohort. Many people live alone, and teens and kids have had a hard time in the last couple years. So I think on one level it’s easy for people to make fun of it because, you know, we’re coming out of this pandemic and the surgeon general’s talking about loneliness. On the other hand, there are millions or tens of millions of people who are lonely. And I think this does sort of help people understand that there are things to be done about it that — I don’t think individual action is always a bad thing. I mean, encouraging people to think about the people in their lives who might be lonely is probably a good thing. It’s social cohesion. I mean, Republicans can make that case, right, that we have to, you know, everybody needs to pick up a telephone or go for a walk and knock on a door.

Rovner: Yeah, they do. I mean, Republicans are big on doing things at the community level. That’s the idea, is let’s have government at the lowest level possible. Well, this will be an interesting issue to watch and see if it catches on more with the public health community. All right. That is this week’s news. Now it is 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 KFF Health News and in our show notes on your phone or other mobile device. Rachel, why don’t you go first this week?

Cohrs: My story is in ProPublica and the headline is “This Pharmacist Said Prisoners Wouldn’t Feel Pain During Lethal Injection. Then Some Shook and Gasped for Air,” by Lauren Gill and Daniel Moritz-Rabson. And I think it’s just a story about this ongoing issue of expert testimony in criminal justice settings. And obviously these are really important questions about medications that, you know, are used for lethal injections and how they work and just how, you know, people are responding to them in the moment. And I mean, it’s just such an important issue that gets overlooked in the pharmaceutical space sometimes. And yeah, I think it’s just something that is very sobering, and it’s just a really important read.

Rovner: Yeah. I mean, there’s been a lot about doctors and the ethics of participating in these. This is the first time I’ve seen a story about pharmacists. Joanne?

Kenen: Well, I saw this one in The Atlantic. It’s by Yasmin Tayag, and I couldn’t resist the headline: “There Is No Stopping the Allergy Apocalypse.” Basically, because of climate change, allergies are getting worse. If you have allergies, you already know that. If you think you don’t have allergies, you’re probably wrong; you’re probably about to get them. They take a little while to show up. So it’s not in one region; it’s everywhere. So, you know, we’re all going to be wheezing, coughing, sneezing, sniffling a lot more than we’re used to, including if you were not previously a wheezer, cougher, or sniffler.

Rovner: Oh, I can’t wait. Alice.

Ollstein: So I have a piece from The Wall Street Journal called “Patients Lose Access to Free Medicines Amid Spat Between Drugmakers, Health Plans,” by Peter Loftus and Joseph Walker. And it is some really tragic stories about folks who are seeing their monthly costs for medications they depend on to live shoot up. In one instance in the story, what he has to pay per month shot up from 15 to more than 12,000. And so you have the drugmakers, the insurance companies, and the middlemen pointing fingers at each other and saying, you know, “This is your fault, this is your fault, this is your fault.” And meanwhile, patients are suffering. So, really interesting story, hope it leads to some action to help folks.

Rovner: I was going to say, maybe the HELP Committee will get its act together, because it’s trying to work on this.

Ollstein: Yeah.

Rovner: Well, my story is from The Washington Post, and it’s called “Dog-Walking Injuries May Be More Common Than You Think,” by Lindsey Bever. And it’s about a study from Johns Hopkins, including your colleagues, Joanne, that found that nearly half a million people were treated in U.S. emergency rooms for an injury sustained while walking a dog on a leash. Not surprisingly, most were women and older adults, who are most likely to be pulled down by a very strong dog. The three most diagnosed injuries were finger fractures, traumatic brain injuries, and shoulder injuries. As a part-time dog trainer in my other life, here are my two biggest tips, other than training your dog to walk politely on a leash: Don’t use retractable leashes; they can actually cut off a finger if it gets caught in one. And never wrap the leash around your hand or your wrist. So that is my medical advice for this week. And that is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us too. Special thanks, as always, to our ever-patient producer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can tweet me, as long as Twitter’s still there. I’m @jrovner. Joanne?

Kenen: @JoanneKenen.

Rovner: Alice.

Ollstein: @AliceOllstein.

Rovner: Rachel.

Cohrs: @rachelcohrs.

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

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Olivia Scholes, de 28 años, de Vancouver, British Columbia, tiene síndrome de ovario poliquístico o SOP. Es una de cada 10 mujeres a nivel mundial a las que se les diagnostica esta afección hormonal, que puede causar múltiples quistes ováricos, infertilidad, aumento de peso y otros problemas.

Después de su diagnóstico hace 10 años, Scholes controló su afección en parte tratando de consumir, o evitar, ciertos alimentos y bebidas. Pero a veces, transferir lo que sabía que tenía que hacer a sus platillos diarios era complicado y requería de tiempo.

“El hecho de tener esa información no significa que planee mis comidas con esa información todo el tiempo”, dijo Scholes.

Scholes estaba navegando por TikTok cuando vio un video que explicaba cómo se usaba ChatGPT para crear un plan detallado de nutrición y entrenamiento.

Ese video la interesó a ver si chatbot, un programa de inteligencia artificial entrenado para ofrecer respuestas detalladas, podría brindarle opciones de comidas adaptadas al SOP.

El control del peso y de la insulina puede ayudar a reducir el impacto de la afección. Debido a que muchas personas con SOP experimentan resistencia a la insulina, controlar sus niveles a través de la dieta es uno de los mejores pasos que se puede tomar.

Scholes comenzó preguntando a ChatGPT si sabía cuáles eran los mejores alimentos para las personas con síndrome de ovario poliquístico y resistencia a la insulina, y el chatbot le proporcionó una lista. Luego preguntó si el sistema podría darle un plan de dos semanas, con tres comidas al día, dos refrigerios y postres sin edulcorantes artificiales.

En cuestión de segundos, Scholes tenía una lista de alimentos, que luego le pidió a ChatGPT que la convirtiera en una lista de compras.

Scholes dijo que, al transformar la información en comidas planificadas, el chatbot  le facilitó la compra de ingredientes para una variedad de menús.

“La gran ayuda de ChatGPT no solo fue que tomó la información que ya conocía; puso esa información en un espacio tangible para mí”, dijo Scholes.

ChatGPT, desarrollada por la empresa OpenAI, se lanzó públicamente en noviembre y llegó a 100 millones de usuarios activos en enero, lo que la convirtió en la aplicación para consumidores de más rápido crecimiento en la historia.

ChatGPT está entrenada en una gran cantidad de texto de una variedad de fuentes, como Wikipedia, libros, artículos de noticias y revistas científicas. El chatbot avanzado de inteligencia artificial (IA) permite a los usuarios ingresar un mensaje de texto y recibir un resultado generado de manera inteligente, que además, permite iniciar una conversación.

Otros chatbots, como el chat de Google Bard y Bing AI, también de Microsoft, son similares a ChatGPT y pueden planificar comidas.

Algunos profesionales de salud y bienestar dicen que la capacidad de ChatGPT para tener conversaciones puede ser útil para generar planes de comidas e ideas para personas que tienen objetivos de salud y necesidades nutricionales específicas.

Scholes compartió su experiencia usando ChatGPT en un video de TikTok. Ese video ahora tiene más de 1.3 millones de visitas y una sección de comentarios colmada de preguntas sobre su experiencia.

En febrero, Jamie Askey, de Lufkin, Texas, hizo un video de TikTok explicando cómo usar ChatGPT para generar planes gratis de comidas y listas de compras que cumplan con los objetivos de calorías y macronutrientes: los nutrientes que el cuerpo necesita, como grasas, carbohidratos y proteínas.

Askey ha hecho muchos videos desde principios de 2021 dando consejos de salud, desde recetas fáciles para preparar comidas hasta consejos sobre cómo dejar de comer compulsivamente.

Su video ahora tiene más de 13,000 visitas en TikTok, con gente agradecida por los consejos.

“Lo mejor de este sitio web es que es muy conversacional”, dijo Askey sobre ChatGPT.

A diferencia de Google y otros motores de búsqueda, los usuarios no tienen que buscar un tema a la vez. El formato de diálogo hace posible que ChatGPT siga una instrucción, brinde una respuesta detallada y responda a preguntas de seguimiento.

Los usuarios interesados en generar opciones de comidas pueden decirle a ChatGPT “Quiero que actúes como nutricionista” o “Quiero que me hagas un plan de nutrición saludable”. El chatbot luego responderá con preguntas aclaratorias para ayudar a generar un plan de comidas apropiado. Es posible que el usuario deba proporcionar información adicional, como su altura, peso, restricciones dietéticas y objetivos.

Askey, quien es enfermera y entrenadora certificada en macronutrición, advierte que las personas con enfermedades crónicas deben ser evaluadas por un profesional antes de usar un chatbot para planificar comidas.

“Las posibilidades son infinitas cuando le preguntas a esta máquina”, dijo Askey. “Pero tienes que pensar que no siempre es blanco y negro. Hay áreas grises y ahí es donde entra en juego el historial de salud. Ahí es donde entra en juego el historial de dietas”.

Los usuarios de ChatGPT están entusiasmados con las capacidades del programa y con la idea de que podría simplificar las tareas cotidianas.

Pero el chatbot no está exento de fallas. Un problema: los datos de entrenamiento de ChatGPT están actualizados hasta 2021, lo que significa que parte de la información que proporciona puede estar desactualizada. Para la planificación de comidas y la nutrición, el programa no puede obtener las últimas pautas de salud y bienestar, lo que puede ser particularmente problemático para las personas con ciertas afecciones de salud.

El modelo también puede generar información incorrecta, proporcionando respuestas incorrectas o malinterpretando lo que pregunta el usuario. Cuando Scholes le pidió al chatbot las comidas para dos semanas, el chatbot se detuvo en el día ocho.

Algunos usuarios también han expresado su preocupación por fallas y sesgos dentro de la tecnología que pueden afectar negativamente los tipos de respuestas que genera. En diciembre de 2022, Steven T. Piantadosi, profesor asociado de Psicología en la Universidad de California-Berkeley, publicó una cadena de Twitter que destacaba los sesgos.

OpenAI, la empresa de investigación de inteligencia artificial detrás de ChatGPT, ha reconocido el potencial de sesgo dentro de la IA. Dijo en un blog en febrero que muchas personas están ” preocupadas por los sesgos en el diseño y el impacto de los sistemas de IA”.

En esa publicación, la compañía también describió algunos de los pasos que está tomando para eliminarlos.

Scholes se pregunta si los prejuicios existentes contra ciertos tipos de personas podrían afectar sus resultados.

“Si ChatGPT se basa en algún tipo de material fóbico contra las personas con sobrepeso, y yo busco material dirigido a mujeres gordas que lidian con problemas de gordura y SOP, ¿qué tipo de sesgos ya están integrados en ese sistema?”

Para cualquiera que esté considerando usar ChatGPT para generar un plan de comidas con metas de salud, Askey recomendó siempre verificar. “La IA no es una persona”, dijo. “Entonces, siempre tienes que verificar”.

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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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.

If Congress fails to raise the nation’s debt ceiling in the next few months, the U.S. could default on its debt for the first time in history. Republicans in Congress, however, say they won’t agree to pay the nation’s bills unless Democrats and President Joe Biden agree to deep cuts to health and other programs. Among the proposals in a bill House Republicans passed April 26 is the imposition of new work requirements for adults who receive Medicaid.

Meanwhile, many of the states passing restrictions on abortion are also passing bills to restrict the ability of trans people to get health care. The two movements — both largely aimed at conservative evangelicals, a key GOP constituency — have much in common.

This week’s panelists are Julie Rovner of KFF Health News, Jessie Hellmann of CQ Roll Call, Shefali Luthra of The 19th, and Sarah Karlin-Smith of the Pink Sheet.

Panelists

Jessie Hellmann
CQ Roll Call

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Shefali Luthra
The 19th

@Shefalil

Read Shefali's stories

Sarah Karlin-Smith
Pink Sheet

@SarahKarlin

Read Sarah's stories

Among the takeaways from this week’s episode:

• The Republican-controlled House’s proposal to raise the debt ceiling contains enough politically poisonous measures that the plan is a non-starter in the Senate. They include substantial funding cuts to major federal health programs, including the FDA and the National Institutes of Health — cuts that would force the federal government to cut back on grants and other funding.
• The proposal would also impose work requirements on adults enrolled in Medicaid — which covers low-income and disabled Americans, as well as pregnant women — and in the Supplemental Nutrition Assistance Program, which helps needy families buy food. Under the plan, the government would save money by cutting the number of people helped. But most beneficiaries cannot work or already do so. Experience shows the change would mostly affect people who struggle to report their work hours through what can be complicated online portals.
• Multiple congressional committees have released plans to fight high drug costs, promoting efforts to explore how pharmacy benefit managers make decisions about cost and access, as well as to encourage access to cheaper, generic drugs on the market. And during congressional testimony this week, the administrator of the Centers for Medicare & Medicaid Services, Chiquita Brooks-LaSure, said the agency would no longer issue warnings to hospitals that fail to comply with a law that requires them to post their prices, but instead would move directly to fining the holdouts.
• Also in news about cost-cutting legislation, a plan to address an expensive glitch in Medicare payments to hospital outpatient centers and physician offices is gaining steam on Capitol Hill. Hospital consolidation has helped increase costs in the health care system, and lawmakers are eager to keep health spending under control. But the hospital industry is ramping up advertising to make sure lawmakers think twice before legislating.
• In abortion news, it will likely be at least a year before the Supreme Court rules on whether the abortion pill mifepristone should remain accessible. Some justices suggested in last summer’s Dobbs decision, which overturned abortion rights, that they would leave further abortion questions to the states, yet the nation is finding that overturning a half-century of legal precedent is messy, to say the least. Meanwhile, reporting and polling are revealing just how difficult it is for doctors in states with abortion bans to determine what constitutes a “medical emergency” worthy of intervention, with a grim consensus emerging that apparently means “when a woman is near death.”

Also this week, Rovner interviews Renuka Rayasam, who wrote the latest KFF Health News-NPR “Bill of the Month” feature, about a pregnant woman experiencing a dangerous complication who was asked to pay $15,000 upfront to see one of the few specialists who could help her. If you have an outrageous or exorbitant medical bill you want to share with us, you can do that here.

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

Julie Rovner: The Nation’s “The Poison Pill in the Mifepristone Lawsuit That Could Trigger a National Abortion Ban,” by Amy Littlefield.

Shefali Luthra: The Washington Post’s “The Conservative Campaign to Rewrite Child Labor Laws,” by Jacob Bogage and María Luisa Paúl.

Jessie Hellmann: Politico’s “Gun Violence Is Actually Worse in Red States. It’s Not Even Close,” by Colin Woodard.

Sarah Karlin-Smith: The Wall Street Journal’s “Weight-Loss Drugmakers Lobby for Medicare Coverage,” by Liz Essley Whyte.

Also mentioned in this week’s episode:

• In Oklahoma, a Woman Was Told to Wait Until She’s ‘Crashing’ for Abortion Care,” by Selena Simmons-Duffin.
• Anti-Trans Bills Have Doubled Since 2022. Our Map Shows Where States Stand,” by Annys Shin, N. Kirkpatrick, and Anne Branigin.

click to open the transcript

Transcript: Dancing Under the Debt Ceiling

KFF Health News’ ‘What the Health?’

Episode Title: Dancing Under the Debt Ceiling

Episode Number: 295

Published: April 27, 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 at KFF Health News. And I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, April 27, at 10 a.m. As always, news happens fast — really fast this week — and things might have changed by the time you hear this. So here we go. We are joined today via video conference by Jessie Hellmann of CQ Roll Call.

Jessie Hellmann: Good morning.

Rovner: Sarah Karlin-Smith, the Pink Sheet.

Sarah Karlin-Smith: Hi, everybody.

Rovner: And Shefali Luthra of The 19th.

Shefali Luthra: Hello.

Rovner: Later in this episode, we’ll have our KFF Health News-NPR “Bill of the Month” interview with Renuka Rayasam. This month’s patient had a happy ending medically, but a not-so-happy ending financially. But first, the news. We’re going to start this week with the budget and, to be specific, the nation’s debt ceiling, which will put the U.S. in default if it’s not raised sometime in the next several weeks, not to panic anyone. House Republicans, who have maintained all along that they won’t allow the debt ceiling to be raised unless they get spending cuts in return, managed to pass — barely — a bill that would raise the debt ceiling enough to get to roughly the middle of next year. It has no chance in the Senate, but it’s now the Republicans’ official negotiating position, so we should talk about what’s in it. It starts with a giant cut to discretionary spending programs. In health care that includes things like the National Institutes of Health, most public health programs, and the parts of the FDA that aren’t funded by user fees. I mean, these are big cuts, yes?

Hellmann: Yeah, it’s about a 14% cut to some of these programs. It’s kind of hard to know exactly what that would mean. But yeah, it’s a big cut and there would have to be, like, a lot of changes made, especially to a lot of health care programs, because that’s where a lot of spending happens.

Rovner: Yeah, I mean, sometimes they’ll agree on cuts and it’ll be like a 1% across the board, which itself can be a lot of money. But I mean, these are, these are sort of really deep cuts that would seriously hinder the ability of these programs to function, right?

Karlin-Smith: NIH for a number of years was operating on only getting budget increases that were not keeping up kind of with inflation and so forth. And they just finally, over the last few years, got back on track. Even though their budget seemed like it was going up, really, if you adjusted for inflation, it had been going down. And then when you have an agency like FDA, which, the line is always that they do an incredible amount of work on really a shoestring budget for the amount they regulate, so they never get — NIH sometimes gets, you know, that bipartisan popularity and does get those bigger increases back, and they never really get those big increases, so I think it would be harder for them also to get that back later on if they did get such big cuts.

Hellmann: There are like also a lot of health programs that just operate on flat funding from year to year, like Title X.

Rovner: Yeah, the family planning program.

Hellmann: And so obviously, like HHS said last year, We are only able to fund a certain number of providers, like, less than previously, because of inflation, and stuff like that. So obviously if you take a 14% cut to that, it would make it even harder.

Rovner: All right. Another major proposal in the package would institute or expand work requirements for people on food stamps and on Medicaid. Now, we’ve had work rules for people on welfare since the 1990s, but most people on Medicaid and food stamps, for that matter, either already work or can’t work for some reason. Why are the Republicans so excited about expanding or instituting work requirements?

Hellmann: I think there are a few reasons. No. 1, it’s a big money saver. The CBO [Congressional Budget Office] came out with their analysis this week showing that it would save the federal government about $109 billion. A lot of that would be shifted to the states because the way the bill is written, states would still be allowed to cover these individuals if they can’t prove that they’re working. But they’d have to pick up the costs themselves, which, I’ve seen experts questioning if that would really happen, even in states like, you know, New York and California, who probably wouldn’t want these people to lose coverage. But I think an argument that you hear a lot too, especially during the Trump administration when they were really pushing these, is they say that work is what provides fulfillment and dignity to people. Former CMS [Centers for Medicare & Medicaid Services] administrator Seema Verma talked about this a lot. The argument I heard a lot on the Hill this week is that Medicaid and other — SNAP [Supplemental Nutrition Assistance Program], TANF [Temporary Assistance for Needy Families], programs like that — trap people in poverty and that work requirements will kind of give them an incentive to get jobs. But as you said, like, it wouldn’t apply to most — you know, most people are already working. And most people who lost coverage under some of the previous iterations of this just didn’t know about it or they were unable to complete the reporting requirements.

Rovner: And to be clear, the CBO estimate is not so much because people would work and they wouldn’t need it anymore. It’s because people are likely to lose their coverage because they can’t meet the bureaucratic requirements to prove that they’re working. Shefali, you’re nodding. We’ve seen this before, right?

Luthra: I was just thinking, I mean, the savings, yes, they come from people losing their health insurance. That’s very obvious. Of course, you save money when you pay for fewer people’s coverage. And you’re absolutely right: “This will motivate people to work” argument has always been a little bit — complicated is a generous word. I think you could even say it’s a bit thin just because people do already work.

Rovner: And they — many of them work, they don’t earn enough money, really, to bring them out of poverty. And they don’t have jobs that offer health insurance. That’s the only way they’re going to get health insurance. All right. Well, where do we go from here with the debt ceiling? So now we’ve got this Republican plan that says work — everybody has to work and prove that they work and we’re going to cut all these programs — and the Democrats saying this is not a discussion for the debt ceiling, this is a separate discussion that should happen down the road on the budget. Is there any sign that either side is going to give here?

Hellmann: It doesn’t seem like it. Democrats have been saying, like, this is a non-starter. The president has been saying, like, we’re not going to negotiate on this; we want a clean increase in the debt ceiling, and we can talk about some of these other proposals that you want to pursue later. But right now, it seems like both sides are kind of at a standstill. And I think Republicans see, like, passing this bill yesterday as a way to kind of strengthen their hand and show that they can get all on the same page. But I just do not see the Senate entertaining a 14% cut or, like, Medicaid work requirements or any of this stuff that is just kind of extremely toxic, even to some, like, moderate Democrats over there.

Rovner: Yeah, I think this is going to go on for a while. Well, so at this high level, we’ve got this huge partisan fight going on. But interestingly, this week elsewhere on Capitol Hill things seem surprisingly almost bipartisan, dare I say. Starting in the Senate, the chairman and the ranking member of the Health, Education, Labor and Pensions Committee, Democrat Bernie Sanders and Republican Bill Cassidy, announced that they’ve reached agreement on a series of bills aimed at reining in prescription drug costs for consumers, including one to more closely regulate pharmacy benefit managers and others to further promote the availability of generic drugs. Sarah, we’ve talked about the target on the backs of PBMs this year. What would this bill do and what are the chances of it becoming law?

Karlin-Smith: So this bill does three things: One is transparency. They want to pull back the cover and get more data and information from PBMs so that they can better understand how they’re working. So I think the idea would then be to take future policy action, because one of the criticisms of this industry is it’s so opaque it’s hard to know if they’re really doing the right thing in terms of serving their customers and trying to save money and drug prices as they say they are. The other thing is it would basically require a lot of the fees and rebates PBMs get on drug prices to be given back directly to the health plan, which is sort of interesting because the drug industry has argued that money should be given more directly to patients who are paying for those drugs. And when that has scored by the CBO, that often costs money because that leads to PBMs using less money to lower people’s premiums, and premiums are subsidized from the government. So I’m curious if the reason why they designed the bill this way is to sort of get around that, although then I’m not sure exactly if you get the same individual … [unintelligible] … level benefit from it. And then the third thing they do is they want to eliminate spread pricing, which is where — this is really a pharmacy issue — where PBMs basically reimburse pharmacies less than they’re charging the health plans and, you know, their customers for the drug and kind of pocketing the difference. So I think, from what I’m seeing on the Hill, there’s a ton of momentum to tackle PBMs. And like you said, it’s bipartisan. Whether it’s this bill or which particular bills it’s hard to know, because Senate Finance Committee is sort of working on their own plan. A number of committees in the House are looking at it, other parts of the Senate. So to me, it seems like there’s reasonable odds that something gets done maybe this spring or summer on PBMs. But it’s hard to know, like, the exact shape of the final legislation. It’s pretty early at this point to figure out exactly how it all, you know, teases out.

Rovner: We have seen in the past things that are very bipartisan get stuck nonetheless. Well, across the Capitol, meanwhile, the House Energy and Commerce Committee is also looking at bipartisan issues in health care, including — as they are in the Senate — how to increase price transparency and competition, which also, I hasten to add, includes regulating PBMs. But, Jessie, there was some actual news out of the hearing at Energy and Commerce from Chiquita Brooks-LaSure, who runs the federal Medicare and Medicaid programs. What did she say?

Hellmann: So they’ve instituted two fines against hospitals that haven’t been complying with the price transparency requirements. So I think that brings the number of hospitals that they’ve fined to, like, less than five. Please fact-check that, but I’m pretty sure that I can count it on one hand.

Rovner: One hand. They have, they have actually fined a small number of hospitals under the requirement. Yeah. I mean, we’ve known — we’ve talked about this for a while, that these rules have been in effect since the beginning of 2022, right? And a lot of hospitals have just been not doing it or they’re supposed to be showing their prices in a consumer-understandable way. And a lot of them just haven’t been. And I assume CMS is not happy with this.

Hellmann: Yeah, so Brooks-LaSure said yesterday that CMS is no longer going to issue warnings for hospitals that aren’t making a good-faith effort to comply with these rules. Instead, they’ll move straight to what’s called the corrective action phase, where basically hospitals are supposed to, like, say what they’re going to do to comply with these. And after that, they could get penalized. So we’ll see if that actually encourages hospitals to comply. One of the fines that they issued is like $100,000. And so I think some hospitals are viewing this, you know, as a cost of doing business because they think it would cost them more to comply with the price transparency rules than it would to not comply with them.

Rovner: So transparency here is still a work in progress. There’s also a fight in the House over the very wonky-sounding site-neutral payment policy in Medicare, which, like the surprise bill legislation from a few years back, is not so much a partisan disagreement as a fight between various sectors in the health care system. Can you explain what this is and what the fight’s about?

Hellmann: So basically hospital outpatient departments or, like, physician offices owned by hospitals get paid more than, like, independent physician’s offices for providing things like X-rays or drug administration and stuff like that. And so this is —

Rovner: But the same care. I mean, if you get it in a hospital outpatient or a doctor’s office, the hospital outpatient clinic gets paid more.

Hellmann: Yeah. And there’s not much evidence that shows that the care is any different or the quality is better in a hospital. And so this has kind of been something that’s been getting a lot of attention this year as people are looking for ways to reduce Medicare spending. It would save billions of dollars over 10 years, I think one think tank estimated about 150 billion over 10 years. It’s getting a lot of bipartisan interest, especially as we talk more about consolidation in hospitals, you know, buying up these physician practices, kind of rebranding them and saying, OK, this is outpatient department now, we get paid more for this. There are fewer independent physician’s offices than there used to be, and members have taken a really big interest in how consolidation increases health care prices, especially from hospitals. So it does seem like something that could pass. I will say that there is a lot of heat coming from the hospital industry. They released an ad on Friday last week warning about Medicare cuts, so, they usually do whenever anyone talks about anything that could hurt their bottom lines. Very generalist ad and kind of those “Mediscare” ads that we’ve been talking about. So it’ll be interesting to see if members can withstand the heat from such a powerful lobbying force.

Rovner: As we like to say, there’s a hospital in every single district, and most of them give money to members of Congress, so anything that has the objection of the hospital industry has an uphill battle. So we’ll see how this one plays out. Let us turn to abortion. The fate of the abortion pill mifepristone is still unclear, although the Supreme Court did prevent even a temporary suspension of its approval, as a lower court would have done. Now the case is back at the 5th Circuit Court of Appeals, which has swiftly scheduled a hearing for May 17. But it still could be months or even years before we know how this is going to come out, right, Shefali?

Luthra: It absolutely could be. So the fastest that we could expect to see this case before the Supreme Court again, just — what from folks I’ve talked to is, I mean, we have this hearing May 17, depending on how quickly the 5th Circuit rules, depending on how they rule, there is a chance that we could see if we get, for instance, an unfriendly ruling toward mifepristone, the federal government could appeal to the Supreme Court this summer. We could see if the Supreme Court is willing to take the case. The earliest that means that they would hear it would be this fall, with a decision in the spring a year from now, but that would be quite fast. I think what’s striking about it is that we may all recall last year, when the Supreme Court issued its decision in the Dobbs case, they said this will put the issue of abortion back in the hands of the states, out of the judiciary, we will no longer be involved. And anyone at the time could have told you there’s no way that this would happen because it is too complicated of an issue, when you undo 50 years of precedent, to assume there will be no more legal questions. And here we are. Those critics have been proven right, because who could have seen that, once again, we’d have the courts being asked to step in and answer more questions about what it means when a 50-year right is suddenly gone?

Rovner: Indeed. And of course, we have the … [unintelligible] … This is going to be my next question, about whether this really is all going to be at the state level or it’s going to be at the state and the federal level. So as red states are rushing to pass as many restrictions as they can, some Republicans seem to be recognizing that their party is veering into dangerously unpopular territory, as others insist on pressing on. We saw a great example of this over the weekend. Former vice president and longtime anti-abortion activist Mike Pence formally split on the issue with former President Trump, with Pence calling for a federal ban and not just leaving the issue to the states. Nikki Haley, the former governor of South Carolina and the lone woman in the Republican field so far, managed to anger both sides with the speech she made at the headquarters of the hard-line anti-abortion group the Susan B. Anthony List. Haley’s staff had suggested ahead of time that she would try to lay out a middle ground, but she said almost nothing specific, which managed to irritate both full abortion abolitionists and those who support more restrained action. Is this going to be a full-fledged war in the Republican Party?

Luthra: I think it has to be. I mean, the anti-abortion group is still very powerful in the Republican Party. If you would like to win the nomination, you would like their support. That is why we know that Ron DeSantis pursued a six-week ban in Florida despite it being incredibly unpopular, despite it now alienating many people who would be his donors. This is just too important of a constituency to annoy. But unfortunately, you can’t really compromise on national abortion policy if you’re running for president. A national ban, no matter what week you pick, it’s not a good sound bite. We saw what happened last year when Sen. Lindsey Graham put forth his national 15-week ban: Virtually no other even Republicans wanted to endorse that, because it’s a toxic word to say, especially in this post-Dobbs environment, especially now that we have all of this polling, including NPR polling from yesterday, that showed us that abortion bans remain quite unpopular and that people don’t trust Republicans largely on this issue. I think this is going to be incredibly interesting because we are going to eventually have to see Nikki Haley take a stance. We will have to see Donald Trump, I think, frankly, be a bit more committal than he has been, because meanwhile, he has lately told people publicly that he would not issue any federal policy, would leave this up to the states, we also know that he has said different things in other conversations. And at some point those conflicts are going to come to a head. And what Republicans realize is that their party’s stance and the stance they need to take to maintain favor with this important group is just not a winning issue for most voters. People don’t want abortion banned.

Rovner: Yeah, it’s a real problem. And Republicans are seeing they have no idea how to sort of get out of this box canyon, if you will. Well, back in the states, things seem to be getting even more restrictive. In Oklahoma this week NPR has another of those wrenching stories about pregnant women unable to get emergency health care. This time, a woman, a mom of three kids already with a nonviable and cancerous pregnancy who was told literally to wait in the hospital parking lot until she was close enough to death to obtain needed care. And that case turned out not to be an outlier. A quote-unquote “secret shopper” survey of hospitals in Oklahoma found that a majority of the 34 hospitals contacted could not articulate what their policy was in case of pregnancy complications or how they would determine if the pregnant person’s life was actually in danger. I can’t imagine Oklahoma is the only state where this is the case. We have a lot of these bans and no idea where sort of the lines are, even if they have exceptions.

Luthra: We know that this is not isolated to Oklahoma. There is a lawsuit in Texas right now with a group of women suing the state because they could not access care that would save their lives. One of those plaintiffs testified in Congress about this yesterday. Doctors in virtually every state with an abortion ban have said that they do not know what the medical exceptions really are in practice other than that they have to wait until people are on death’s door because there isn’t — medical emergency isn’t really a technical term. These bills, now laws, were written without the expertise of actual physicians or clinicians because they were never really supposed to take effect. This really has been just another example of a way that the dog chased the car and now the dog has the car.

Rovner: And the dog has no idea what to do with the car. Well, meanwhile, in Iowa, the attorney general has paused the state’s policy of paying for abortions as well as emergency contraception for rape victims. This is where I get to rant briefly that emergency contraception and the abortion pill are totally different, that emergency contraception does not cause abortion — it only delays ovulation after unprotected sex and thus is endorsed for rape victims in Catholic health facilities across Europe. OK, end of rant. I expect we’re going to see more of this from officials in red states, though, right, with going — not just going after abortions, but going after things that are not abortion, like emergency contraception.

Luthra: And I mean, if we look at what many of the hard-line anti-abortion groups advocate, they don’t just want to get rid of abortion. They specifically name many forms of hormonal contraception, but specifically the emergency contraception Plan B, and they oppose IUDs [intrauterine devices]. It would just be so, so surprising if those were not next targets for Republican states.

Rovner: So abortion isn’t the only culture war issue being fought out in state legislatures. There’s also a parallel effort in lots of red states to curtail the ability of trans people, mostly but not solely teenagers, to get treatment or, in some cases, to merely live their lives. According to The Washington Post, as of the middle of this month, state legislators have introduced more than 400 anti-trans bills just since January. That’s more than the previous four years combined. Nearly 30 of them have become law. Now, I remember in the early aughts when anti-gay and particularly anti-gay marriage bills were the hot items in red states. Today, with some notable exceptions, gay marriage is as routine as any other marriage. Is it possible that all these attacks on trans people, by making them more visible, could have the same effect? In other words, could this have the opposite effect as the people who are pushing it intended? Or am I just looking for a silver lining here?

Luthra: I think it’s too soon to say. There isn’t incredible polling on this issue, but we do know that in general, like, this is not an issue that even Republicans pick their candidates for. It’s not like they are driven to the ballot box because they hate trans people this much. I wouldn’t at all be surprised if there is a backlash, just because what we are hearing is so, frankly, horrific. What I have been really struck by, in addition to the parallels to anti-gay marriage, have been the ways in which restrictions on access to health care for trans people really do parallel attacks to abortion in particular, thinking about, for instance, passing laws that restrict access to care for minors, passing laws that restrict Medicaid from paying for care, that restrict how insurance covers for care. It’s almost spooky how similar these are, because people often think minors are easier to access first. People often think health insurance is an easier, sort of almost niche issue to go for first. And what we don’t often see until afterward is that these state-by-state laws have made care largely inaccessible. The other thing that I think about all the time is that these are obviously, in both cases, forms of health care restriction that are largely opposed by the medical community, that are often crafted without the input of actual medical expertise, and that target health care that does feel incredibly difficult to extricate from the patient’s gender.

Rovner: Yeah. The other thing is that people are going from state to state, just like with abortion. In order to get health care, they’re having to cross state lines and in some cases move. I mean, we’re starting to see this.

Luthra: The high-profile example being Dwyane Wade, formerly of the Miami Heat, moving away from Florida because of his child.

Karlin-Smith: The other thing, Julie, you were saying in terms of how optimistic to be, in terms of maybe the other side of this issue sort of pushing back and overcoming it, is that Politico had this good story this week about doctors in states where this care is perfectly legal and permissible but they’re getting so many threats and essentially their health care facilities feel that they’re so much in danger that they are concerned about how to safely provide and help these people that they do want to help and give care, while also not putting their families and so forth in danger, which perhaps also has a parallel to some of how there’s tons of, like, constant protests outside abortion clinics. And people have volunteered for years just to kind of escort people so they can safely feel comfortable getting there, which of course is, you know, can be very traumatic to patients trying to get care.

Rovner: Yeah, the parallels are really striking. So we will watch that space too. All right. That is the news for this week. Now, we will play my “Bill of the Month” interview with Renuka Rayasam. Then we will come back and share our extra credit. We are pleased to welcome to the podcast Renuka Rayasam, who reported and wrote the latest KFF Health News-NPR “Bill of the Month” story. Renu, welcome to “What the Health?”

Renuka Rayasam: Thanks, Julie. Thanks for having me.

Rovner: So this month’s patient was pregnant with twins when she experienced a complication. Tell us who she is, where she’s from, and what happened.

Rayasam: Sure. Sara Walsh was 24 weeks pregnant with twins — it was Labor Day weekend in 2021 — and she started to feel something was off. She had spent a long time waiting to have a pregnancy that made it this far — eight years, she told me. But instead of feeling excited, she started to feel really nervous and she knew something was off. And so on Tuesday, she went to her regular doctor. And then on Wednesday, after that Labor Day, she went to her maternal fetal specialist, who diagnosed her with a pretty rare pregnancy complication that can occur when you have twins, when you have multiple fetuses that share blood unevenly through the same placenta. And it’s called twin-to-twin transfusion syndrome. And, you know — and this was Wednesday — she went into the office in the morning and she waited a long time for the doctor to kind of come back with the results, she and her husband, and just kind of spent the morning sort of back-and-forth between her maternal fetal specialist and her OB-GYN. And they told her she needed to get treatment immediately, that if she didn’t have treatment that she could lose one or both twins, she herself could even die. She needed to keep her fluid intake low. So they referred her to a specialist about four hours away from where she was. She was in Winter Haven, Florida, and they referred her to a specialist near Miami. And the specialist there apparently does not contract with any private insurance. And so that afternoon, hours after her diagnosis, she was packing her bags; she was getting ready to go, figuring out a place to stay, a hotel room and all that. And she gets a call from the billing office of this specialist in Coral Gables, Florida, near Miami. And they said, “Listen, we don’t contract with private insurance. You have to pay upfront for the pre surgical consultation for the surgery and then the post-surgical consult. And you need to have that money before you show up tomorrow in our office at 8 a.m.”

Rovner: And how much money was it?

Rayasam: About $15,000 in total for the consultations and the surgery itself. She told me she burst into tears. She didn’t want to lose these twins. She wasn’t given any option of shopping around for another provider. And she spent some time trying to figure out what to do. She couldn’t get a medical credit card because I guess there’s a 24-hour waiting period and she didn’t have that long. And so finally, her mother let her borrow her credit card. She checked into a hotel at midnight and at 8 a.m. the next morning she handed over her credit card and her mother’s credit card before she could have the procedure — before she could even see the doctor, I should say.

Rovner: And the outcome was medically good, right?

Rayasam: Yeah. The provider who did her surgery is a pioneer in this field. And that was why those doctors sent Sara to this provider, Dr. Ruben Quintero. He came up with this staging system that helps assess the symptom’s severity and even pioneered the treatment for it. But he sort of used all that to kind of say, OK, you have to pay me; I’m not even going to deal with insurance in this case. And so that afternoon, it was that Thursday, the day after she was diagnosed, she had a procedure, it went well, she had a couple of follow-ups in the following weeks. And then five weeks later, she delivered premature but otherwise healthy twin girls.

Rovner: So is that even legal for a doctor to say, “I’m not even going to look at you unless you pay me some five-figure amount”?

Rayasam: Generally, no. We have the federal No Surprises Act, as you know, and that’s meant to do away with surprise billing. But that was really designed for kind of inadvertent medical bills or surprises. Things get really complicated when there’s this appearance of choice where, you know, she had time to call the insurer, she had time to call the provider. It wasn’t as if she was unconscious and sort of rushed to the nearest doctor. Technically, she had a choice here. She could have chosen not to get the procedure. She could have gone to a different state. But obviously, those are not real choices in her situation when she needed the procedure so urgently. And so in those cases, you know, the billing experts I spoke with said this is a real loophole in federal billing legislation and state surprise billing legislation because the bill wasn’t a surprise. She knew how much to expect upfront. And that’s what makes this situation tricky.

Rovner: And she knew that the doctor wasn’t in network.

Rayasam: Absolutely. She knew the doctor wasn’t in network, and she knew how much she had to pay, and she willingly forked over the money, of course, as anyone would have in that situation or tried to in that situation.

Rovner: So after the fact, she went back to her insurance company to see if they could work something out, since it was pretty much the only place she could have gone at that point to get the treatment. But that didn’t go so well.

Rayasam: That didn’t go so well, and it’s one complication in this story that I myself don’t know what to make of, but the provider does not contract with any insurer, I should say. But he did take her insurance card and — or, the billing person did — and they say that they bill as a courtesy to the patient. So they file the paperwork for the patient. They say, “OK, your insurer will reimburse you. We’re going to provide all the paperwork.” In Sara’s case, it took a long time for this doctor and his practice to get Blue Cross Blue Shield the paperwork they needed to kind of pay for her claim. And in addition to that, they didn’t really send over the right paperwork right away. So it took a long time. And eventually she got only $1,200 back and she ended up paying far more than that out-of-pocket.

Rovner: And of course, the next obvious question is, doesn’t her insurance have an out-of-pocket maximum? How did she ever end up spending this much?

Rayasam: That’s a great question. We reached out to her insurer, and they didn’t really give us much of an explanation, but they, you know, on their billing statements and what they said to her was, “Hey, you went willingly out of network; this doesn’t qualify you for those out-of-pocket maximums.” They didn’t give us an explanation as to why. This seems to be a classic case of where those maximums should apply. But like I said, I think, you know, she had very little recourse. She tried to appeal the bills. She’s, you know, been on the phone with her insurer multiple times. The thing that makes this story more complicated is that it’s such a rare procedure and there aren’t that many providers in the country that even perform this procedure. So at first she was having to struggle with billing codes and all that with her insurance, so a lot of the people she was dealing with on the insurance side were really confused. It wasn’t something that they had a playbook for, knew what to do with, and that’s what made this a little bit more complicated.

Rovner: So what’s the takeaway here? I mean, obviously this was a rare complication, but if you multiply the number of rare complications of different things, you’re talking about a lot of people. Is there any way to get around this? I mean, it sounds like she did everything she could have in this case.

Rayasam: She did. In this case, it turns out there was another provider in Florida. There was no way for her to know that. Neither her OB-GYN nor the maternal fetal specialist told her about this other provider. I found out about it. I called around and did the reporter thing. And there are now four providers in Florida that will treat this. But of course, you know, if I was a patient, I wouldn’t shop around and risk my pregnancy either. So it’s unfortunate, in this case, there’s not much a person can do other than make sure that they’re keeping all the paperwork. And, you know, one thing that one of the billing experts I spoke with told me is that when you pay upfront, it makes things a lot harder. And in this case, like I said, she didn’t have a choice. But if there’s ever a way to get the bill on the back end, then there’s more of an incentive for the provider and the insurer to work together to get paid. But once the provider was paid, the insurer is not going to rush to reimburse the patient.

Rovner: And the provider is not going to rush to help the insurer figure out what to do. Ah well, another cautionary tale. Renu Rayasam, thank you so much.

Rayasam: Thank you.

Rovner: 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 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. Sarah, why don’t you go first this week?

Karlin-Smith: Sure. I took a look at a story in The Wall Street Journal, “Weight-Loss Drugmakers Lobby for Medicare Coverage. Adding Ozempic, Mounjaro to federal plans could stoke sales.” It really documents well sort of the range of lobbying organizations and groups and where they’re sort of putting money to try and get Medicare to shift its policies and cover treatments for obesity, which was something that in the early creations of Part D was banned. And I think largely at that time it was because weight loss was seen as more of a cosmetic treatment than something that impacted health in the same way we appreciate now.

Rovner: And also, there wasn’t anything that worked.

Karlin-Smith: Right. The things that prior to this, the things that were available at different times were not very effective and in some cases turned out to be fairly unsafe. And of course, now we have treatments that seem to work very well for a number of people, but there’s a fear of just how much money it would cost Medicare. So the other interesting thing in this story is they talk about some lawmakers in Congress thinking about ways to maybe narrowly start opening the floodgates to access by potentially maybe limiting it to people with certain BMIs [body mass indexes] or things like that to maybe not have the initial cost hit they might be concerned about with it.

Rovner: And of course, whether Medicare covers something is going to be a big factor in whether private insurance covers something. So it’s not just the Medicare population I think we’re talking about here.

Karlin-Smith: Right. There’s already I know lobbying going on around that. My colleague wrote a story a few weeks ago about Cigna sort of pushing back about having those drugs be included potentially in, like, the essential health benefits of the ACA [Affordable Care Act]. So it’s going to be, yeah, a broader issue than just Medicare.

Rovner: Yeah, it’s a lot. I mean, I remember when the hepatitis C drugs came out and we were all so, you know, “Oh my God, how much this is going to cost, but it cures hepatitis C.” But I mean, that’s not nearly as many people as we’re talking about here. Jessie, why don’t you go next?

Hellmann: My stories from Politico. It’s called “Gun Violence Is Actually Worse in Red States. It’s Not Even Close.” It takes a weird twist that I was not expecting. Basically, the premise is about how gun deaths are actually higher in areas like Texas and Florida. They have higher per capita firearm deaths, despite messaging from some Republican governors that it’s actually, like, you know, cities like Chicago and New York that are like war zones, I think it’s the former president said. The author kind of makes an interesting argument I didn’t see coming about how he thinks who colonized these areas plays into kind of like the culture. And he argues that Puritans like had more self-restraint for the common good. And so areas like that have less firearm deaths where, you know, the Deep South people were — had like a belief in defending their honor, the honor of their families. So they were kind of more likely to take up arms. Not sure how I feel about this argument, but I thought it was an interesting story and an interesting argument, so —

Rovner: It is. It’s a really good story. Shefali.

Luthra: My story is from The Washington Post. It is called “The Conservative Campaign to Rewrite Child Labor Laws.” It’s a really great look at this Florida-based group called the Foundation for Government Accountability, which, despite its innocuous-sounding name, is trying to help states make it easier to employ children. This is really striking because we have seen, in states like Arkansas, efforts to make it easier to employ people younger than 16 in some cases, which is just really interesting to watch in these states that talk about protecting children and protecting life to, to then make it easier to, to employ kids.

Rovner: And in dangerous profess — in dangerous jobs sometimes. I mean, we’re not talking about flipping burgers.

Luthra: No, no. We’re talking about working in, like, in meat plants, for instance. But I think what’s also interesting is that this same organization that has made it easier to employ children has also tried to fight things like anti-poverty and try to fight things like Medicaid expansion, which is just sort of, if you’re thinking about it from an access-to-health standpoint, like, anti-poverty programs and Medicaid are shown to make people healthier. It’s sort of a really interesting look into a worldview that in many ways uses one kind of language but then advance the policy agenda that takes us in a different direction.

Rovner: Maybe we should go back to to Jessie’s story and depend on who settled that part of the country. We shall see. Speaking of history, my story’s from The Nation, and it’s called “The Poison Pill in the Mifepristone Lawsuit That Could Trigger a National Abortion Ban,” by Amy Littlefield. And it’s about the Comstock Act, which is a law from the Victorian era — it was passed in 1873 — that banned the mailing of, quote, “lewd materials,” including articles about abortion or contraception. A lot has been written about the Comstock Act of late because it was used to justify part of the opinion in the original mifepristone case out of Amarillo. But what this article makes clear is that reviving the law is actually a carefully calculated strategy to make abortion illegal everywhere. So this is not something that just popped up in this case. It’s a really interesting read. OK, that is our show. As always. if you enjoyed 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 ever-patient producer, Francis Ying. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can tweet me, at least for now. I’m @jrovner. Sarah?

Karlin-Smith: I’m @SarahKarlin.

Rovner: Jessie.

Hellmann: @jessiehellmann.

Rovner: Shefali.

Luthra: @Shefalil.

Rovner: 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 KHN’s 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.

Several states have begun the herculean task of redetermining how many of an estimated 85 million Americans currently receiving health coverage through the Medicaid program are still eligible. To receive federal covid-19 relief funds, states were required to keep enrollees covered during the pandemic. As many as 15 million people could be struck from the program’s rolls — many of whom are still eligible, or are eligible for other programs and need to be steered to them.

Meanwhile, the trustees of the Medicare program report that its Hospital Insurance Trust Fund should remain solvent until 2031, three years longer than it projected last year. That allows lawmakers to continue to put off what are likely to be politically unpleasant decisions, although they will eventually have to deal with Medicare’s underlying financial woes (and those of Social Security).

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Amy Goldstein of The Washington Post, and Rachel Roubein of The Washington Post.

Panelists

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories

Amy Goldstein
The Washington Post

@goldsteinamy

Read Amy's Stories

Rachel Roubein
The Washington Post

@rachel_roubein

Read Rachel's stories

Among the takeaways from this week’s episode:

• The Medicaid “unwinding” is likely to strip health coverage not just from millions of people who are no longer eligible for the program, but also from millions of people who still are. States are supposed to take their time reevaluating eligibility, but some are rushing to disenroll people.
• Another complication in an already complicated task is that many Medicaid workers hired during the pandemic have never actually redetermined Medicaid eligibility for anyone, because states had been required to keep people who qualified on the program.
• Grimly, some of the extra years of solvency gained in the Medicare Hospital Insurance Trust Fund are a result of pandemic deaths in the 65-and-older population.
• The Department of Health and Human Services has issued payment rules for Medicare Advantage Plans for 2024. The agency ended up conceding at least somewhat to private plans that for years have been receiving more than they should have from the U.S. Treasury. The new rules will work to shrink those overpayments going forward, but not try to recoup those from years past.
• The situation with “first-dollar coverage” of preventive services by commercial health plans is becoming a bit clearer following last week’s decision in Texas that part of the Affordable Care Act’s preventive services mandate is unconstitutional. Judge Reed O’Connor (who in 2018 ruled the entire health law unconstitutional) issued a nationwide stay on coverage requirements from the U.S. Preventive Services Task Force, saying it is a volunteer organization not subject to the oversight of the Health and Human Services secretary. The federal government is already appealing that ruling.
• But O’Connor’s decision is not quite as sweeping as first thought. He banned required coverage only of the task force’s recommendations made after March 23, 2010 — the day the ACA was signed into law. Earlier recommendations stand. O’Connor also did not strike preventive services recommended by the Health Resources and Services Administration and the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices, since those agencies are overseen by an official appointed by the president and confirmed by the Senate.
• In abortion news, the liberal candidate for a Supreme Court seat in Wisconsin, Janet Protasiewicz, defeated her conservative opponent to switch the majority on the court from 4-3 conservative to 4-3 liberal. That ideological shift is likely to preserve abortion rights in the state, and possibly stem the ability of the GOP legislature to continue to draw maps that favor Republicans.
• Meanwhile, states in the South are continuing to pull back on abortion access. The Florida legislature is moving rapidly on a bill that would ban the procedure after six weeks of pregnancy, while in North Carolina, a single legislator’s switch from Democrat to Republican has given the latter a supermajority in the legislature large enough to override any veto of the Democratic governor, Roy Cooper.

Also this week, Rovner interviews Daniel Chang, who reported and wrote the latest KHN-NPR “Bill of the Month” feature about a child who had a medical bill sent to collections before he started to learn to read. If you have an outrageous or exorbitant medical bill you want 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: New York Magazine’s “The Shared Anti-Trans and Anti-Abortion Playbook,” by Irin Carmon.

Alice Miranda Ollstein: The Los Angeles Times’ “Horrifying Stories of Women Chased Down by the LAPD Abortion Squad Before Roe vs. Wade,” by Brittny Mejia.

Rachel Roubein: KHN’s “‘Hard to Get Sober Young’: Inside One of the Country’s Few Recovery High Schools,” by Stephanie Daniel of KUNC.

Amy Goldstein: The Washington Post’s “After Decades Under a Virus’s Shadow, He Now Lives Free of HIV,” by Mark Johnson.

Also mentioned in this week’s podcast:

• Stat’s “Denied by AI: How Medicare Advantage Plans Use Algorithms to Cut Off Care for Seniors in Need,” by Casey Ross and Bob Herman.
• ProPublica’s “How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them,” by Patrick Rucker, Maya Miller, and David Armstrong.
• The Atlantic’s “There’s No Such Thing as a Casual Interaction With Your Doctor Anymore,” by Zoya Qureshi.
• Politico’s “Democrats Want to Restore Roe. They’re Divided on Whether to Go Even Further,” by Alice Miranda Ollstein and Megan Messerly.

Click to Open the Transcript

Transcript: The ‘Unwinding’ of Medicaid

KHN’s ‘What the Health?’Episode Title: The ‘Unwinding’ of MedicaidEpisode Number: 292Published: April 6, 2023

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

Julie Rovner: Hello and welcome back to KHN’s “What the Health?” I’m Julie Rovner, chief Washington correspondent at Kaiser Health News. And I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, April 6, 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: Rachel Roubein of The Washington Post.

Rachel Roubein: Good morning.

Rovner: And we welcome back to the podcast, after a bit of a break, Amy Goldstein, also of The Washington Post.

Amy Goldstein: Good to be back.

Rovner: Later in this episode, we will have the latest KHN-NPR “Bill of the Month” interview, with my colleague Daniel Chang. This month’s patient had a medical bill sent to collections before he was old enough to read. Impressive. But first, this week’s news. We’re going to start this week with Medicaid. During the pandemic, as most health policy nerds know, the federal government required states to keep anyone who qualified for the Medicaid program on the rolls, even if they became ineligible. But as of April 1, last week, states were free to start, quote, “unwinding” that Medicaid coverage. Now, states are facing the daunting task of determining who’s still eligible for the program and who can be removed and how those who are losing that Medicaid coverage can be steered to other programs, which they might be eligible. This is, to quote then-Vice President Biden when the ACA got passed, a BFD. So, what are some of the potential problems here? We’re talking about a lot of people, right, Amy? You wrote about this.

Goldstein: We are talking about a lot of people. It’s unclear how many people are going to lose Medicaid. But if you go by the Biden administration’s estimates, they’re thinking perhaps 15 million people out of 85 million people who are on Medicaid. So that’s a lot of low-income people who could end up without insurance or scrambling to see if they can find other insurance if they know to do that. And obviously, Medicaid is a joint federal-state enterprise, and states are the ones that carry it out. States set their eligibility rules to a large extent, and states have each had to write and submit to the federal government a plan for how they’re going to go about this unwinding. And the issue is that, with so many different plans, there are some things that CMS, Centers for Medicare & Medicaid Services, want states to do — for instance, to try as much as possible to check whether people are eligible by trying to match up with other records, say, from food stamps or wage records that the states might have.

Rovner: So basically, don’t count on them responding to a letter that says you need to reestablish your eligibility for this program.

Goldstein: Exactly. But how assertively states are going to 1) do that, and secondly, how hard they’re going to try to reach people in how many different ways — time will tell.

Rovner: Yeah, I’ve noticed. I mean, some states are doing things like sending out special colored envelopes. It’s Easter week; we’ve got robin’s-egg blue envelopes. I think that was Massachusetts. Somebody’s sending out pink envelopes and magenta envelopes. But, you know, Alice, you covered when they were doing the Medicaid work requirements, and Arkansas discovered that the problem wasn’t so much that people weren’t working; it’s that people literally had trouble navigating the reporting system. And that’s kind of what we’re looking at writ large here, right?

Ollstein: Yeah. And the people who are most likely to be flagged for removal, they could be very low income. They could have unstable housing, move around a lot, stay with family. They might not receive mail at the address that was on file a few years ago. They might not have reliable phone or internet access to be reachable in those ways. So, as Amy said, it really makes a difference how much and what kind of an effort states make to let people know this is even happening. Because as we saw with work requirements and even just, like, the regular pre-pandemic periodic Medicaid eligibility checks, people fall through the cracks all of the time for reasons that are not their fault at all. And so, with this all happening at once, with so many more people than normal, the risk of that just grows.

Goldstein: And if I could just throw in one more complicating factor: If you think about what’s happened to workforces over the pandemic, a lot of the Medicaid agencies in the states have lost workers, and there are shortages in a lot of places. And people who’ve been hired in the last couple years have never had to do renewals or, as the lexicon goes, redeterminations before. So what’s going on inside the places where these decisions are going to have to get made for all these people is a bit of a problem in many, many states.

Roubein: I think how I’ve been sort of thinking about it in my mind is there’s 1) that issue of ensuring people who are still eligible don’t lose coverage. And then there’s the other issue of people who aren’t eligible for Medicaid anymore, but having states and navigators and groups help them find coverage elsewhere, whether that’s on the exchange, or some people might actually be now eligible for employer insurance. And some of that breakdown from that 15 million from that Department of Health and Human Services report — they had projected 6.8 million will lose Medicaid coverage despite being still eligible and that roughly 8.2 million people expected to leave the program because they’re no longer eligible for the program.

Rovner: And before somebody writes me and asks … [unintelligible] … I know states weren’t absolutely required to keep these people on the rolls, but they were required to keep these people on the rolls if they wanted the extra pandemic money. So every state did it. So every state basically has this task ahead of them to try to figure out how it works, and we shall keep tabs on this. I want to turn to Medicare. Last week, we got the annual report of Medicare’s trustees, which found, a little unexpectedly I think, that the program’s Hospital Insurance Trust Fund should continue to be able to pay all of its bills until 2031. That’s three years longer than it was projected to last year. Kind of grimly, apparently some of the improvement is due to many older people on Medicare dying during the covid pandemic. But this also does take some pressure off of lawmakers to fix what ails Medicare financially, right? They tend to only act when it’s within this four- or five-year window.

Ollstein: I would say yes and no. I haven’t seen a huge shift in the talk on Capitol Hill in response to this report. It’s only pushing back the deadline a few years. And it’s true, Congress only acts when there’s an imminent crisis and sometimes not even then. But I think the people really saying, “Hey, we need to do something,” are not going to stop saying that because of this.

Rovner: I’m going to put that on a T-shirt: Congress only acts when there’s an imminent crisis and sometimes not even then.

Roubein: Oh, yeah. I mean, I think that’s frustrated budget experts because Congress isn’t particularly doing anything in terms of financial solvency. And I mean, it’s really political, as we’ve seen — Biden during his State of the Union and how he got Republicans to talk about basically his ad-libbed Medicare conversation. But it’s kind of this tradition.

Rovner: “We’re not going to touch Medicare or Social Security.”

Roubein: Yeah. Off the table, this kind of tradition of “Mediscare.” No one wants to kind of be putting their foot out there with a proposal that would change Medicare.

Goldstein: This looming insolvency of Medicare is not at all a new problem. And ducking the problem is not a new phenomenon. Julie, you may remember, along with me, in the late 1990s, as a result of the big Balanced Budget Act of 1997 — this goes back a way — Congress created a bipartisan commission on the future of Medicare, and it was led by members of Congress. It was a big deal, it got a lot of attention, and it tried for many, many, many months to map out the future of Medicaid. And in the final analysis, it just dissolved in disagreements.

Rovner: Yeah, Medicare, not Medicaid,

Goldstein: Yes, Medicare.

Rovner: They did recommend a drug benefit that did eventually come to pass, but —

Goldstein: That’s right. But that was not the solvency solution.

Rovner: No, it was not. And I will say, my bookcase here at home is littered with reports of these various commissions that Congress punted to. It’s like, well, you guys solve it. And of course, no one ever has. We are still at this. But obviously this year, Rachel — you kind of hinted at this — some of this is going to come to a head because it’s part of the debt ceiling debate, that Congress is going to have to do something about the debt ceiling, lest the U.S. actually default on its debt. Republicans want to have spending cuts as part of this. They had said they wanted to do something about Medicare as part of this. Is there any update on that debate? We still seem to be in the “after you, Alphonse” portion of this, with both Biden saying he’s ready to talk to the Republicans and Republicans saying they’re ready to talk to Biden and nobody really talking to each other yet.

Roubein: Yeah, I mean, I think both sides are pretty dug in here at the moment. McCarthy a month or two ago had said no cuts to Medicare and Social Security. And Kevin McCarthy, I think it was the end of last month, had demanded a meeting with Biden. And then, you know, kind of the Biden team came back and said, “OK, well, we put out a budget. So, you know, Republicans need to produce their budget document.” And, you know, that’s kind of the political argument that we’ve been hearing for a little while here.

Rovner: Well, to paraphrase Alice, this crisis is about to get imminent, but not quite.

Goldstein: Before we leave Medicare, let me just make a couple more points. One is that this affects hospital care. So it’s not all parts of Medicare. And when the insolvency date comes — as you say, now projected to be 2031 — it’s not as if the program is going to be unable to pay any of its bills. This year its trustees said that it’s going to be able to pay 89% of the hospital benefits to which Medicare are entitled. The other point is, I mean, there’s a long-standing reason why politicians have been reluctant to fix something despite the many, many, many years of cries of, “We better fix it soon because it’s going to be harder to fix the longer we wait.” And that is that, older Americans — I mean, to state the obvious — are a very active voting bloc and they do not like the prospect of federal benefits being eroded. So there is politics behind why both parties have been reticent.

Rovner: Yes, there’s four ways to make Medicare solvent. You can pay providers less, which is what they usually end up doing, and they fight back. You can make the benefits less, either by having people wait longer to get on them or having to pay more for them. Or you can require the taxpayers to pay more money. So everything is kind of unpleasant here. And I think that’s why Congress would just as soon not do this. But while we still have Medicare teed up, we talked at some length a few weeks ago about Medicare Advantage plans, the private alternative to the government fee-for-service Medicare, and how those plans are technically being overpaid, which has prompted quite the TV advertising campaign from the plans, which I suspect very few people understand. There’s just all these sort of old people saying, “They’re going to cut our Medicare.” So the Department of Health and Human Services finally issued its Medicare Advantage payment rule for next year, and it appears to split the difference, stopping plans from continuing to overstate how sick their patients are, which is what’s responsible for a lot of the overpayments. But it limits the ability of the government to look back to recoup some of those overpayments that have been made. Is that basically a one-sentence explanation of what they’ve done here?

Roubein: The industry waged a pretty fierce battle here, but they phased in their plan. So essentially the Centers for Medicare & Medicaid Services had proposed switching to a more updated coding system, which included eliminating approximately 2,000 codes. And insurers claimed that this could lead to substantial pay cuts. The administration fiercely disputed that. But they did, as you say, kind of split the difference, in terms of saying, “OK, well, we’re going to phase in these changes over three years,” which CMS officials and other experts have said is something that they kind of tend to do when there is controversial policy.

Rovner: Right. When they don’t want to irritate anybody too much, although I did notice that there’s also some rules about deceptive advertising for Medicare Advantage plans. So maybe it’ll make me stop screaming at the TV when these ads come on. Moving along, last week we were able to bring you the breaking news about the preventive care ruling out of Texas from federal District Judge Reed O’Connor. What else have we learned since those first breaking hours? I know the decision doesn’t cover preventive care recommended by groups that report directly to someone in the federal government who is appointed by the president and confirmed by the Senate — at least it doesn’t at the moment. But it only limits preventive care that’s recommended by the U.S. Preventive Services Task Force. But it could still be expanded at the appeals level, right?

Goldstein: That’s right. This affects a lot of people: everybody with private health insurance, which is estimated by federal health officials to be about 150 million people. It’s not killing all free preventive services. It’s ending the mandate that they’re provided at no cost to consumers for those preventive services that the U.S. Preventive Services Task Force has either defined or updated since the Affordable Care Act was passed in 2010. So that leaves intact a few important categories of things: 1) earlier preventive services, like mammograms, which were required to be covered for free before, are still intact. It also leaves intact services that are required by two different parts of HHS. Within HRSA [Health Resources and Services Administration], they have jurisdiction over women’s health services, so that’s why things like contraception are not touched by — at the moment, as you say — by this court ruling. And similarly, an advisory body to the CDC, which has jurisdiction over vaccinations, whether it’s childhood vaccinations, covid vaccinations — so those aren’t touched. But what’s happened in the past week is, predictably, the day after Judge O’Connor — who, as I’m sure you discussed last week, was the same judge who a few years ago held that the entire ACA was unconstitutional and was ultimately overruled by the Supreme Court — anyhow, O’Connor last week said this applies nationwide, not just to places where the plaintiffs are. And the next day, the Biden administration, the Justice Department, very quickly filed a notice of appeal. It was one paragraph. It wasn’t laying out the appeal, but it was getting on the record that the administration is going to appeal to the 5th Circuit Court of Appeals, which is a conservative circuit based in New Orleans that hasn’t been entirely friendly to the ACA in the past. What the administration did not yet do is say that it wants to stay the judge’s ruling, but it’s very likely that that’s going to be requested as well.

Rovner: Even if the judge’s ruling doesn’t get stayed, it’s likely to have very little immediate impact, right? Because insurance contracts are already kind of set for the year. If insurers wanted to stop covering this — and they’re probably not going to stop covering it — but if they wanted to make it — institute copays or say this is part of your deductible — they’re likely not to do that until the next plan year, right? Alice, I see you nodding.

Ollstein: Yeah, but that isn’t uniform. So the folks I talked to said that, while most plans are baked in for the year and what we really should be looking for is when the new 2024 things start coming out in the summer into the fall, that’s what we should be watching in terms of, you know, what could change there. But that isn’t uniform. It’s possible that some plans could change earlier. There are all different kinds of possibilities, but I was kind of surprised to see the Biden administration not rush to file an appeal right away. They filed a notice of appeal, but they haven’t actually filed the appeal yet or asked for the stay, but I think that is stemming from this not being seen as an imminent threat to people’s health coverage. The piece of it I’ve really been interested in is the impact on HIV and STDs, because, like Amy said, a lot of the basic cancer screenings and other things will continue to be protected in some form because they were recommended prior to 2010. But a lot of the STD and HIV stuff is a lot more recent, so it’s a lot more vulnerable to being rolled back, and plans and employers — for a lot of these things — covering preventive services for free with no out-of-pocket costs is good; it’s really cheap to cover and it prevents a lot of expensive care down the road. But that’s sort of less true with some of these things. PrEP, the HIV prevention drug, is really expensive. A lot of the lab costs for STD testing are still expensive. And so you could see folks’ plans and employers wanting to save money by shifting some of those costs to patients. And public health experts are worried about that.

Rovner: I think another quirk of this that we didn’t realize right away is what the decision says is that it only affects USPSTF rulings that were made after the date that the Affordable Care Act was signed, March 23, 2010. But what that ends up doing is leaving in effect prior recommendations that are not necessarily up to date. So you could end up rolling back to things that medical experts no longer think is the appropriate interval or type of preventive service being required. And then, of course, you have the insurers who are going to be required to put out their bids for next year in the coming months. Now, this is not the first time insurers have had to stab in the dark at what they think the rules are going to be and how much they’re going to want to charge for that. So we’re having yet another round of insurers kind of having to throw their hands out and throw darts against the wall, right?

Goldstein: Yes. And this — Alice mentioned employers are a big constituency in this. There is some survey evidence, I mean not terribly systematic survey evidence, but a little bit of survey evidence that was done last fall with this case pending, that showed that most insurers, a high, high proportion of insurers, wanted to keep these benefits. So that may influence, as you’re saying, Julie, what the bids come in looking like while this is all still kind of murky.

Rovner: Yeah, we know it’s popular and we know in most cases it’s relatively cheap. So one would assume that this decision might not have too much impact, although as I sort of alluded to, and I haven’t heard whether this is happening yet, the plaintiffs could also appeal because they didn’t get everything they wanted. They also wanted to have the women’s health stuff out of HRSA and the immunization stuff out of CDC stayed as, you know — or the requirements gotten rid of, and the judge did not do that. So one presumes they could also appeal and we would see what happens at the 5th Circuit Court of Appeals. But I think everybody assumes at this point that it’s going to end up at the Supreme Court, yes? I see nods all around. Oh, boy. I can’t wait. All right. Well, let’s turn to abortion. The big abortion news this week comes from Wisconsin in a race for state Supreme Court, of all things, which was supposed to be nonpartisan or technically was nonpartisan. Still, the strong showing by the judge who was associated with the liberal side of the ledger could have some major impact, right? This was expected to be a very close race, and it really wasn’t.

Ollstein: No, it wasn’t close at all. The progressive candidate really took it away, and the campaign really heavily focused on abortion. This is because the state’s ban, which has been in place, you know, since long before Roe was enacted, is likely to come before the court. But the implications go way beyond that. This could change how the legislature makeup is in the future because of challenges to the gerrymandered state maps. That could, you know, open the door to Medicaid expansion and all kinds of other things, you know, related to abortion, related to all kinds of things. Because right now, you know, you have a Democratic governor who is on his second term who can’t really do very much because of the state legislature. So this could have tons and tons of repercussions going forward in Wisconsin.

Rovner: And we should point out, because I meant to say, this election flipped the state Supreme Court from 4-3 conservative to 4-3 liberal.

Roubein: It was really interesting because you saw the liberal candidate, Janet Protasiewicz, really leaning into abortion rights. And, you know, obviously she’s a judge, but in multiple ads from her campaign it said, you know, women should have the freedom to make their own decisions on abortion. That was a quote from the ads. And now, you know, kind of, she was … [unintelligible] … from the other side, like, can she be impartial when she rules? And, you know, she said like, “No, I have not promised any of these major groups, Emily’s List, etc., that are backing me, how I will rule.” But, you know, we did see the judge, as she called it, her personal beliefs and be really open about that.

Rovner: And her opponent was also pretty open about it, too. He was a very conservative guy who was pretty much promising to go down the line with what the conservatives wanted. Alice, you were about to say something.

Ollstein: Yeah, well, it’s been fascinating now that we’re a day out from the election results. There is sort of a freakout going on on the right about it and about what it means for abortion specifically. And you’re seeing a lot of very prominent people on the right publicly saying, “We have a message on abortion that voters don’t like and we need to change it right now.” People are saying that the right needs to moderate and stop pushing for near-total bans with no exceptions, which is going on in a lot of states right now. That debate was already happening on the right, but I think this just pours fuel on it. I think with the Florida governor about to be confronted with whether or not to sign a six-week ban, this really is going to squeeze a lot of people.

Rovner: Yes, I feel very smug about my extra credit story from last week, which was the Rebecca Traister long read in New York Magazine about how Democrats have underestimated how winning an issue abortion may be. And I saw her sort of also smugly tweeting late Tuesday night. It’s like, “See, I’m telling you this.” While the Upper Midwest may be getting more supportive of abortion rights, also this week Michigan Governor Gretchen Whitmer formally signed the repeal of the state’s nearly hundred-year-old pre-Roe ban. But in the South, the trend is going the other way, as you mentioned, Alice. Florida’s legislature is moving quickly on a six-week abortion ban, while in North Carolina a Democratic state legislator who ran on abortion rights is switching parties, giving the Republicans there a supermajority that will let them override the Democratic governor’s vetoes. Are we looking at, fairly imminent, abortion being unavailable throughout the South?

Roubein: I think Florida, North Carolina, Nebraska is also considering a similar limit — were all states that in the two months after Roe v. Wade was overturned — were states that saw an increase in abortions. I think North Carolina is particularly interesting because in early February all the Democrats had signed on to a bill to codify Roe v. Wade. But I was reporting at the time with my colleague Caroline Kitchener on this, and she talked to one of the Democrats there, who said, well — after he signed on to it — like, “Well, that doesn’t preclude me from voting for abortion restrictions.” He had said this is, quote, “This is still the first quarter.” So I think even before we saw the state Democrat switch to Republican, you know, what happened in North Carolina where there is a Democratic governor was an open question even beforehand.

Rovner: Yeah, this reminds me of Virginia trying to expand Medicaid, and there’s constantly this sort of one member, another member. I mean, it literally didn’t happen until the last vote allowed it to happen, I think.

Ollstein: Yeah. I mean, this also really puts a spotlight on the tactic of doing a ballot referendum on abortion, because —

Rovner: That was my next question, Alice.

Ollstein: Ta-da.

Rovner: Tell us about your story about that.

Ollstein: The relation to this is, yes, you have a lot of Republican lawmakers and some Democrats, or some former Democrats, as we’ve seen, who are moving very aggressively to continue to pass abortion restrictions, whether it’s total bans or something short of that. But the referendums often show that that doesn’t necessarily reflect all of the Republican electorate, which is not always aligned with their representatives on this issue. And based on the results of the six referendums last year in which the pro-abortion-rights side won all six out of six, folks are hoping to get that going in more states this year, and it’s already underway — not as much in the South, and not every state can do a referendum legally. It varies state to state what the rules are, but where it’s possible, people are trying to do it. My story this week reported on an internal fight on the left about how to go about it. So most of the referendums that are moving forward in these red and purple states right now, trying to get on the ballot in the next few years, say that basically they would only restore the protections of Roe v. Wade, so only protect abortion up to the point of fetal viability. And you have a lot of folks — you know, medical groups, activists — saying, Why are we doing that? Why are we sort of pre-compromising? We keep seeing over and over at the ballot box this is a winning issue; why aren’t we being bold? Like the right is going for total bans. Why aren’t we going for total legalization? But the folks who want the viability limit in there are saying, Look, we want to put something forward that we know is going to pass. We’ve done research and focus groups and polling. You know, this is the way we think is smartest to go. Plus, you know, the vast majority of abortions take place prior to viability anyways. And right now we have no abortion at all. So isn’t legalizing most better than nothing? And so it’s a really interesting debate.

Rovner: It’s literally the mirror image of the debate that’s going on on the right, which has been happening over the years. It’s just that it’s all kind of, you know — now that we’re in this sort of odd place — it’s all magnified. So, you know, the right is trying to decide between do we restrict abortion a little or do we just allow, you know, the end of Roe v. Wade and states to make up their mind? Or do we go for a national ban? Where the left is saying, do we just want to bring things back to where they were when we had Roe, or do we want to go further and allow and basically have public funding and sort of other things to assure what they call reproductive justice? So obviously, this fight is going to continue on both sides.

Goldstein: Let me just say that this tension between the electorate and lawmakers in fairly conservative states is a real echo of what has happened over the years with Medicaid expansion, when there have been several states in which legislators were really dug in that they weren’t going to expand Medicaid under the ACA, and public ballot initiative and it expanded. So it’s sort of turning to the exact same tactic.

Rovner: That’s right. And again, in a lot of these Republican states, the voters were very happy to expand Medicaid. So that, yes, we’ve seen this particular book before. Well, before we go, there were a couple of stories that got kicked over from last week when we had our breaking news. But I really wanted to mention about artificial intelligence in health care or at least in health insurance. One story from ProPublica details how the health insurance giant Cigna is using an algorithm to reject thousands of claims for care that’s kind of between cheap and very expensive, and then letting medical director physicians basically batch-approve those rejections on the theory, likely correct, that even if most of the care is medically appropriate, most people won’t bother to appeal a bill of just a couple of hundred dollars and will just pay it. The other story, from Stat News, is kind of strikingly similar. It’s about a Medicare Advantage plan that’s using AI to pinpoint the exact moment it can stop paying for some care, particularly expensive care, in a hospital or nursing home. Now, it would appear that the Medicare Advantage case is more egregious because it seeks to actually cut off care, where Cigna is just denying payment after the fact. But it seemed to make it pretty clear that while a) it might improve care and save money, sometimes it’s just saving money for people other than the patients, right? That’s what it certainly looks like in these cases.

Ollstein: I mean, as we’ve seen with other uses of algorithms, algorithms reflect the values of the people creating the algorithms. And you say, “Oh, it’s a robot, it’s completely impartial.” Why are there racial discrimination implications then? But we do keep seeing this and it’s like, it was created by humans, it’s going to have human failings and require oversight and accountability mechanisms.

Rovner: Yeah. And finally, one more story from the “be careful what you wish for.” There’s a story in The Atlantic this month about the downside of telehealth that at least some of us saw coming. Now that doctors can charge for and be reimbursed for virtual care by video, more and more doctors are starting to charge for other forms of communication that used to be free, like telephone calls and emails. Now, lawyers have long charged for phone calls advising clients. I always kind of wondered why doctors didn’t. I guess I have my answer now. Is this another case of anything — that any technology that’s good is probably also going to have its downsides?

Goldstein: Well, it’s also a reflection that fewer and fewer doctors work on their own. They’re working for health systems that have the bottom line in mind, which is not to say they only have the bottom line in mind, but they’re less autonomous in terms of their pricing policies.

Rovner: And yeah, are being asked to see more patients, so it takes more time to actually, you know — one of the interesting things in this in the story was that a phone call may only be five minutes for you, but it’s probably 20 minutes for your doctor who has to go make a notation in your chart and maybe call in a prescription. And it’s more than just the quick phone call for the doctor. I think this is something that used to be a courtesy and now it’s just a charge. All right, well, that is this week’s news. Now we will play my “Bill of the Month” interview with Daniel Chang and then we’ll come back with our extra credit. We are pleased to welcome to the podcast Daniel Chang, who reported and wrote the latest KHN-NPR “Bill of the Month.” Daniel, welcome to “What the Health?”

Daniel Chang: Hi, Julie. I’m glad to be here.

Rovner: So this month’s patient wasn’t even old enough for kindergarten when he got a medical bill sent to collection for care he didn’t even receive. Who is this kid? Why did he need medical care? And this is very impressive, I’ve got to say.

Chang: So, at the time — this happened last Memorial Day weekend — Keeling McLin was his name, and he was 4 years old. And according to his mom, Sara McLin, who’s a dentist in central Florida, she had just finished cooking something on the stove and Keeling had gotten up to get something. And on his way down he put his hand on the hot stove. That was pretty painful, from what she described. And so she took him to the emergency room for care.

Rovner: First she took him to urgent care, right?

Chang: Well, it was a stand-alone emergency room, so it’s one of those hybrid ones, I guess you might call it. No inpatient, of course.

Rovner: And therein is about to be our problem. So Mom did everything right here, right? She made sure that she went to a facility in her network, and then they sent her off to another hospital. But the problem is, where is the first visit, right?

Chang: Correct. The first visit was a problem. It was part of the HCA system. And they didn’t have, I guess, the resources there to treat Keeling’s burn. So they referred him to a HCA hospital with a burn center, which was about a 90-minute drive away from the stand-alone ER.

Rovner: And they managed to deal with the burn, right? The kid’s OK.

Chang: They did. He’s OK. It turned out to be not as bad as suspected. And Sara McLin told me that they drained his blisters, wrapped his hand, and sent her home with instructions on how to care for it. And she didn’t think about it again.

Rovner: Until she got the bill.

Chang: Exactly.

Rovner: This gets pretty Kafkaesque, doesn’t it? What were the bills here?

Chang: So, the first bill that she received was from the physician provider group; Envision Healthcare employed the physician in the stand-alone emergency room. That bill was for about $72. She called her insurer, which was UnitedHealthcare, and they told her that — essentially not to worry about it. And the bill itself is labeled as a surprise out-of-network bill, although when I reached out to Envision Healthcare, they said that it was not, it was part of her cost sharing. In any case, that bill didn’t cause her any problems. Shortly after that, she got a bill from the stand-alone emergency room, and this bill was considerably higher, although her share was about $129. But the reason that she was a little confused about this is because she said that the physician at the stand-alone emergency room told her, “You know what, this won’t even count as a visit because we can’t do anything for him.” So she left with that thought. And later on she said she wished she had gotten that in writing, but that was the problem bill.

Rovner: Yes. So what eventually happened?

Chang: So what eventually happened is that the bill was in Keeling’s name and it did not include his mom or his dad on there. It was just simply to Keeling. And for reasons that HCA didn’t explain, and we can’t explain, Envision got his insurance information correct, but HCA had him as an uninsured person responsible for his own bills. And it’s odd because his date of birth is on that bill. And you would think that somewhere along the line someone would catch that. But they didn’t. And so what happened is that Sara fell into this sort of twilight zone where she couldn’t speak to anyone about the bill because it wasn’t in her name. And so, according to her conversations with folks at HCA and later at Medicredit, they couldn’t talk to her because her name wasn’t on the bill. So this was the one thing that she was trying to get resolved. And she tried for months and got nowhere, which is when she reached out to us.

Rovner: And as you point out, that Medicredit is the collections agency, right? This 5-year-old’s bill got sent to collections.

Chang: That’s correct. That just kind of compounded the frustration because Sara had worked for a couple of months to get HCA to add her name onto the bill. And she had even written them a letter, she says, and they told her they were going to do it and she was waiting for the bill. But then the next letter she got was from the collection agency, for the same amount and with the same problem. Her name wasn’t on the bill. So when she called the collection agency to try to dispute the bill, they told her, “Sorry, we can’t talk to you. You’re not the authorized representative on this bill.”

Rovner: It feels like the biggest problem here is not so much that mistakes happen. They do. Obviously, they’ve happened a lot in our “Bill of the Month” series. But they are so very hard to fix — I mean, even when you say, “Look, this is a 5-year-old.”

Chang: I agree. It sounded so frustrating. And I think, ultimately, of course, that’s why she reached out to us. But she tried repeatedly and not only did she tell me this, but the bills that she provided to us had a lot of her handwritten notes in the margins and the dates that she had spoken to individuals. And it just — it’s really hard. None of the experts that we spoke with could understand why HCA couldn’t just simply fix this before they sent it to collections. And HCA acknowledged the error, and they apologized to her. And they ultimately canceled the debt. But the system clearly doesn’t seem to work in favor of patients when you have these sort of odd complications that really they didn’t have anything to do with what she owed or what they said she owed; it was all a matter of identification.

Rovner: So is there anything she could have done differently? I’m not saying, you know — she obviously couldn’t prevent the mistake from being made. But was there some better way for her to try to navigate this?

Chang: You know, neither the insurer or the providers gave us an explanation of what she could have done differently or what individuals who find themselves in a similar position could do. And so I think she did everything that she reasonably could, short of perhaps hiring an attorney? I’m not sure; maybe that would have worked, but you shouldn’t have to go to that length and that cost just to get your name on your minor child’s bill so that you can take care of it and speak to the people who say you owe them the money. It’s just — it’s crazy.

Rovner: And she’s a dentist, so she’s a health care professional. She obviously had some, you know, knowledge of the system and how it works. And even she had trouble —

Chang: That’s correct.

Rovner: — getting it done. So I guess basically the lesson is, watch your bills closely and be ready to take action.

Chang: And potentially, when I think about this situation, ensuring perhaps that the stand-alone ER had all of the information, but I can also see where she was told that, “Look, this doesn’t even count as a visit. We couldn’t treat him here. You’ve got to take him to the burn center. We won’t count this as a visit.” I think she left comfortable in that knowledge, only to realize later that, oops, it wasn’t that way. Yeah.

Rovner: Get it all in writing.

Chang: Yes.

Rovner: Daniel Chang, thank you so much.

Chang: You’re very welcome. Thanks for having me on.

Rovner: 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 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 khn.org and in our show notes on your phone or other mobile device. Alice, why don’t you go first this week?

Ollstein: Sure. So I picked a really fascinating history piece from the LA Times by Brittny Mejia, and it’s about what law enforcement’s role was pre-Roe v. Wade in cracking down on illegal abortions. All abortions were illegal. And it just really vividly describes how cops would conduct raids on doctors who were operating clandestinely and performing abortions, you know, the tactics they would use. It was just really fascinating. And so I think it’s worth resurfacing this history, thinking, OK, so abortion is illegal again; what does enforcement look like? What could enforcement look like? And this is a very disturbing picture of what it used to look like.

Rovner: Amy, you have a story that’s kind of related to Alice’s story, also looking at history, but updated.

Goldstein: That’s right. I chose a story by my colleague at the Post, Marc Johnson, with the headline, “After Decades Under a Virus’s Shadow, He Now Lives Free of HIV.” And it’s an interview with one of only five people in the world who’ve had stem cell transplants that have cured them of cancer but also gotten rid of any evidence of HIV in their bodies. And it’s not a hugely long story, but it’s just a beautiful trajectory reminding us of what the early bad world of AIDS was, with this individual’s friends dying all around him in San Francisco, to the decades when he was on a lot of AIDS drugs, and suddenly being unexpectedly liberated from all that. It’s a good read.

Rovner: Yeah, it is. Rachel.

Roubein: My extra credit is titled “‘Hard to Get Sober Young’: Inside One of the Country’s Few Recovery High Schools,” by Stephanie Daniel of KUNC. And basically it takes the reader inside a Denver recovery high school, which mixes high school education with treatment for drug and alcohol addiction. And so this high school in Colorado — it’s one of 43 nationwide, and she kind of details the history of recovery high schools, which, the first one opened up in Silver Spring, Maryland, in 1979. And she also kind of goes through what I thought was interesting, which was kind of, the challenges of recovery high schools, most being publicly funded charter or alternative schools, and they have a higher ratio of mental health and recovery personnel, so there’s really not a ton of them nationwide.

Rovner: I had never heard of them until I saw this story. It was really interesting. Well, for the second week in a row, my story is from New York Magazine. It’s by Irin Carmon, and it’s called “The Shared Anti-Trans and Anti-Abortion Playbook.” And she points out that not only are there many of the same people fighting abortion who are also fighting trans health care, but there’s also a similarly long-term strategy, as Irin wrote. They’re focusing on youth first, because they understand that it’s much harder to convince the public to restrict the lives of adults. As someone who’s spent years covering the fight over whether or not teen girls should be able to access sex education, birth control, or abortion, it does feel familiar. 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 ever-patient producer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can tweet me. I’m @jrovner. Rachel?

Roubein: @rachel_roubein.

Rovner: Alice?

Ollstein: @AliceOllstein.

Rovner: Amy?

Goldstein: @goldsteinamy.

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

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“It was a time of a lot of learning, turnaround, and pivoting for me, because we weren’t necessarily expecting that kind of life change,” she said.

Ferrell Ortiz would have liked a little more guidance to navigate the application process for Medicaid. She was inundated with forms. She spent days on end on the phone trying to figure out what was covered and where she could go to get care.

“Sometimes the representative that I would speak to wouldn’t know the answer,” she said. “I would have to wait for a follow-up and hope that they actually did follow up with me. More than 476,000 pregnant Texans are currently navigating that fragmented, bureaucratic system to find care. Medicaid provides coverage for about half of all births in the state — but many people lose eligibility not long after giving birth.

Many pregnant people rely on Medicaid coverage to get access to anything from prenatal appointments to prenatal vitamins, and then postpartum follow-up. Pregnancy-related Medicaid in Texas is available to individuals who make under $2,243 a month. But that coverage ends two months after childbirth — and advocates and researchers say that strict cutoff contributes to rates of maternal mortality and morbidity in the state that are higher than the national average.

They support a bill moving through the Texas legislature that would extend pregnancy Medicaid coverage for a full 12 months postpartum.

Texas is one of 11 states that has chosen not to expand Medicaid to its population of uninsured adults — a benefit offered under the Affordable Care Act, with 90% of the cost paid for by the federal government. That leaves more than 770,000 Texans in a coverage gap — they don’t have job-based insurance nor do they qualify for subsidized coverage on healthcare.gov, the federal insurance marketplace. In 2021, 23% of women ages 19-64 were uninsured in Texas.

Pregnancy Medicaid helps fill the gap, temporarily. Of the nearly half a million Texans currently enrolled in the program, the majority are Hispanic women ages 19-29.

Texans living in the state without legal permission and lawfully present immigrants are not eligible, though they can get different coverage that ends immediately when a pregnancy does. In states where the Medicaid expansion has been adopted, coverage is available to all adults with incomes below 138% of the federal poverty level. For a family of three, that means an income of about $34,300 a year.

In Texas, childless adults don’t qualify for Medicaid at all. Parents can be eligible for Medicaid if they’re taking care of a child who receives Medicaid, but the income limits are low. To qualify, a three-person household with two parents can’t make more than $251 a month.

For Ferrell Ortiz, the hospitals and clinics that accepted Medicaid near her Dallas neighborhood felt “uncomfortable, uninviting,” she said. “A space that wasn’t meant for me” is how she described those facilities.

Later she learned that Medicaid would pay for her to give birth at an enrolled birthing center.

“I went to Lovers Lane Birth Center in Richardson,” she said. “I’m so grateful that I found them because they were able to connect me to other resources that the Medicaid office wasn’t.”

Ferrell Ortiz found a welcoming and supportive birth team, but the Medicaid coverage ended two months after her daughter arrived. She said losing insurance when her baby was so young was stressful. “The two-months window just puts more pressure on women to wrap up things in a messy and not necessarily beneficial way,” she said.

In the 2021 legislative session, Republican Gov. Greg Abbott signed a bill extending pregnancy Medicaid coverage from two months to six months postpartum, pending federal approval.

Last August, The Texas Tribune reported that extension request had initially failed to get federal approval, but that the Centers for Medicare & Medicaid Services had followed up the next day with a statement saying the request was still under review. The Tribune reported at the time that some state legislators believed the initial application was not approved “because of language that could be construed to exclude pregnant women who have abortions, including medically necessary abortions.”The state’s application to extend postpartum coverage to a total of six months is still under review.

The state’s Maternal Mortality and Morbidity Review Committee is tasked with producing statewide data reports on causes of maternal deaths and intervention strategies. Members of that committee, along with advocates and legislators, are hoping this year’s legislative session extends pregnancy Medicaid to 12 months postpartum.

Kari White, an associate professor at the University of Texas-Austin, said the bureaucratic challenges Ferrell Ortiz experienced are common for pregnant Texans on Medicaid.

“People are either having to wait until their condition gets worse, they forgo care, or they may have to pay out-of-pocket,” White said. “There are people who are dying following their pregnancy for reasons that are related to having been pregnant, and almost all of them are preventable.”

In Texas, maternal health care and Pregnancy Medicaid coverage “is a big patchwork with some big missing holes in the quilt,” White said. She is also lead investigator with the Texas Policy Evaluation Project (TxPEP), a group that evaluates the effects of reproductive health policies in the state. A March 2022 TxPEP study surveyed close to 1,500 pregnant Texans on public insurance. It found that “insurance churn” — when people lose health insurance in the months after giving birth — led to worse health outcomes and problems accessing postpartum care.

Chronic disease accounted for almost 20% of pregnancy-related deaths in Texas in 2019, according to a partial cohort review from the Texas Maternal Mortality and Morbidity Review Committee’s report. Chronic disease includes conditions such as high blood pressure and diabetes. The report determined at least 52 deaths were related to pregnancy in Texas during 2019. Serious bleeding (obstetric hemorrhage) and mental health issues were leading causes of death.

“This is one of the more extreme consequences of the lack of health care,” White said.

Black Texans, who make up close to 20% of pregnancy Medicaid recipients, are also more than twice as likely to die from a pregnancy-related cause than their white counterparts, a statistic that has held true for close to 10 years with little change, according to the MMMRC report.

Stark disparities such as that can be traced to systemic issues, including the lack of diversity in medical providers; socioeconomic barriers for Black women such as cost, transportation, lack of child care and poor communication with providers; and shortcomings in medical education and providers’ implicit biases — which can “impact clinicians’ ability to listen to Black people’s experiences and treat them as equal partners in decision-making about their own care and treatment options,” according to a recent survey.

Diana Forester, director of health policy for the statewide organization Texans Care for Children, said Medicaid coverage for pregnant people is a “golden window” to get care.

“It’s the chance to have access to health care to address issues that maybe have been building for a while, those kinds of things that left unaddressed build into something that would need surgery or more intensive intervention later on,” she said. “It just feels like that should be something that’s accessible to everyone when they need it.”

Extending health coverage for pregnant people, she said, is “the difference between having a chance at a healthy pregnancy versus not.”

As of February, 30 states have adopted a 12-month postpartum coverage extension so far, according to a KFF report, with eight states planning to implement an extension.

“We’re behind,” Forester said of Texas. “We’re so behind at this point.”

Many versions of bills that would extend pregnancy Medicaid coverage to 12 months have been filed in the legislature this year, including House Bill 12 and Senate Bill 73. Forester said she feels “cautiously optimistic.”

“I think there’s still going to be a few little legislative issues or land mines that we have to navigate,” she said. “But I feel like the momentum is there.”

Ferrell Ortiz’s daughter turns 5 this year. Amelie is artistic, bright, and vocal in her beliefs. When Ferrell Ortiz thinks back on being pregnant, she remembers how hard a year it was, but also how much she learned about herself.

“Giving birth was the hardest experience that my body has physically ever been through,” she said. “It was a really profound moment in my health history — just knowing that I was able to make it through that time, and that it could even be enjoyable — and so special, obviously, because look what the world has for it.”

She just wishes people, especially people of color giving birth, could get the health support they need during a vulnerable time.

“If I was able to talk to people in the legislature about extending Medicaid coverage, I would say to do that,” she said. “It’s an investment in the people who are raising our future and completely worth it.”

This story is part of a partnership that includes KERA, NPR, and KHN.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Julie Rovner is chief Washington correspondent and host of KHN’s 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.

Opponents of the Affordable Care Act may have stopped trying to overturn the entire law in court, but they have not stopped challenging pieces of it — and they have found an ally in Fort Worth, Texas: U.S. District Judge Reed O’Connor. In 2018, O’Connor held that the entire ACA was unconstitutional — a ruling eventually overturned by the Supreme Court. Now the judge has found that part of the law’s requirement for insurers to cover preventive care without copays violates a federal religious freedom law.

In a boost for the health law, though, North Carolina has become the 40th state to expand the Medicaid program to lower-income people who were previously ineligible. Even though the federal government will pay 90% of the cost of expansion, a broad swath of states — mostly in the South — have resisted widening eligibility for the program.

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

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Among the takeaways from this week’s episode:

• Thursday’s decision out of Texas affects health plans nationwide and is expected to disrupt the health insurance market, which for years has provided preventive care without cost sharing under the ACA. Even if the decision survives a likely appeal, insurers could continue offering the popular, generally not-so-costly benefits, but they would no longer be required to do so.
• The decision, which found that the U.S. Preventive Services Task Force cannot mandate coverage requirements, hinges on religious freedom objections to plans covering PrEP, the HIV medication, alongside other preventive care.
• Speaking of the ACA, this week North Carolina became the latest state to expand Medicaid coverage under the health law, which will render an estimated 600,000 residents newly eligible for the program. The development comes amid reports about hospitals struggling to cover uncompensated care, particularly in the 10 states that have resisted expanding Medicaid.
• Pushback against Medicaid expansion has contributed over the years to a yawning coverage divide between politically “blue” and “red” states, with liberal-leaning states pushing to cover more services and people, while conservative-leaning states home in on policies that limit coverage, like work requirements.
• On the abortion front, state attorneys general are challenging the FDA’s authority on the abortion pill — not only in Texas, but also in Washington state, where Democratic state officials are fighting the FDA’s existing restrictions on prescribing and dispensing the drug. The Biden administration has adopted a similar argument as it has in the Texas case challenging the agency’s original approval of the abortion pill: Let the FDA do its job and impose restrictions it deems appropriate, the administration says.
• The FDA is poised to make a long-awaited decision on an over-the-counter birth control pill, an option already available in other countries. One key unknown, though, is whether the agency would impose age restrictions on access to it.
• And as of this week, 160 Defense Department promotions have stalled over one Republican senator’s objections to a Pentagon policy regarding federal payments to service members traveling to obtain abortions.

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

Julie Rovner: New York Magazine/The Cut’s “Abortion Wins Elections: The Fight to Make Reproductive Rights the Centerpiece of the Democratic Party’s 2024 Agenda,” by Rebecca Traister.

Alice Miranda Ollstein: Stat’s “How the Drug Industry Uses Fear of Fentanyl to Extract More Profit From Naloxone,” by Lev Facher.

Rachel Cohrs: The Washington Post’s “These Women Survived Combat. Then They Had to Fight for Health Care,” by Hope Hodge Seck.

Sandhya Raman: Capital B’s “What the Covid-19 Pandemic and Mpox Outbreak Taught Us About Reducing Health Disparities,” by Margo Snipe and Kenya Hunter.

Also mentioned in this week’s podcast:

• The New York Times’ “‘We’re Going Away’: A State’s Choice to Forgo Medicaid Funds Is Killing Hospitals,” by Sharon LaFraniere.
• KHN’s “Fresh Produce Is an Increasingly Popular Prescription for Chronically Ill Patients,” by Carly Graf.
• California Healthline’s “Prescription for Housing? California Wants Medicaid to Cover 6 Months of Rent,” by Angela Hart.

click to open the transcript

Transcript: A Judicial Body Blow to the ACA

KHN’s ‘What the Health?’Episode Title: A Judicial Body Blow to the ACAEpisode Number: 291Published: March 30, 2023

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

Julie Rovner: Hello and welcome back to KHN’s “What the Health?” I’m Julie Rovner, chief Washington correspondent at Kaiser Health News. And I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, March 30, at 11 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. Today we are joined via video conference by Alice Miranda Ollstein of Politico.

Alice Miranda Ollstein: Good morning.

Rovner: Sandhya Raman of CQ Roll Call.

Sandhya Raman: Good morning.

Rovner: And happy birthday to you.

Raman: Thank you.

Rovner: And Rachel Cohrs of Stat News.

Rachel Cohrs: Hi, everybody.

Rovner: We’ve got breaking news, so we will get right to it. In Texas, we’ve got a major decision from a federal judge with national implications. No, not the abortion pill case — that is still out there. This time, Judge Reed O’Connor has ruled that the Affordable Care Act can’t require coverage of preventive services recommended by the [U.S.] Preventive Services Task Force because the PSTF, as an independent advisory board, can’t legally mandate anything. This case was specifically — although it was about a lot of things — but it was mostly about employers who didn’t want to cover preexposure prophylaxis [PrEP] for people at high risk of HIV because it violated their religious beliefs. And if the name Reed O’Connor sounds familiar, that’s because he’s the same judge who ruled in 2018 that the entire Affordable Care Act was unconstitutional, a finding that wasn’t formally overturned until it got to the Supreme Court. Alice, you’ve been following this case. What happens now?

Ollstein: I’m expecting the Biden administration to appeal at lightning speed, although that appeal will go to the 5th Circuit, which is very right-leaning. It’s ruled to chip away at the Affordable Care Act in the past. So who really knows what will happen there? But yeah, this is really huge. This is saying that this board that has decided what services insurance companies have to cover for free, with no cost sharing, going all the way back to 2010 is not constitutional, and thus what they say can’t be enforced. And so this throws the insurance market into a bit of chaos.

Rovner: Yeah, although one would think that it wouldn’t affect this year’s policies — I mean, for people who are going to be worried that all of a sudden, you know, oh my God, I scheduled my mammogram and now my insurer might not pay for it. It’s not going to be that immediate, right?

Ollstein: We’re not expecting that. I mean, we’re expecting the Biden administration to ask for courts to stay the impact of the ruling until further arguments and appeals can be made. But we really don’t know at this point. And I will say, you know, I’ve seen some misinformation out there about how the ruling deals with contraception. They do not block the contraception mandate. That is related to this case, but the court did not accept that part of the challengers’ claims.

Rovner: Yeah, we should say there are a bunch of different claims and the judge only accepted a couple of them. It could have been even broader. But, you know, unlike the previous Affordable Care Act cases, this one doesn’t threaten the entire law, but it does threaten one of the law’s most popular pieces, those requirements that plans cover preventive care that’s been shown to be cost-effective. This could be an uncomfortable case for the Supreme Court, assuming it gets there, couldn’t it?

Cohrs: It could be an uncomfortable case for the Supreme Court, but it’s also uncomfortable for insurers, too, who’ve promised this. People have come to expect it. And if it is cost-effective, I mean, certainly there may be plans that, you know, make choices to restrict coverage or impose some cost sharing. If this stands, if this is applied nationwide — again, very big ifs at this point — but if these really are cost-effective, then it’s kind of an open question what insurers will choose to do, because obviously they want people to enroll in their plans as well.

Rovner: Yeah, I was going to say, I could see insurers sort of deciding as a group that we’re going to keep providing this stuff, as you say, Rachel, because they want, you know, they want to attract customers, because for the most part it’s not that expensive. I mean, obviously, you know, things like colonoscopies can run into the thousands of dollars, but a lot of these things are, if not de minimis, then just not very expensive. And, as I mentioned, they’re very popular. So it’s possible that, even though they may strike down the mandate, there won’t be as much of an impact from this as some people are saying. But, as Alice points out, we don’t really know anything at this point.

Ollstein: And I think some of the concern is the kind of risk-pool sorting we used to see, you know. So the challengers said that their right to purchase insurance that doesn’t cover certain things was being infringed upon. And so if insurers start to create separate plans, some of which cover all kinds of preventive care, including sexual health care, and separate ones that don’t, and people who don’t think they need a lot of stuff, you know, sort themselves into some plans and not others, you can see that reflected in premiums that could lead to some of the major pre-ACA problems we used to see.

Rovner: If the idea that somebody doesn’t like something and therefore can’t buy something without it, you can see that leading to all kinds of problems down the line about people saying, well, “I don’t like that drugstores sell condoms, so therefore I should be able to go to a drugstore that doesn’t sell condoms,” although that’s not a mandate. But you can see that this could stretch very far with people’s religious beliefs. And indeed, the basis of this claim is that this violated the Religious Freedom Restoration Act. That’s one of the things that Judge O’Connor found, and that could be taken to quite the extreme, I imagine.

Ollstein: Right. I mean, they weren’t required to actually purchase PrEP. They weren’t required to use it. They weren’t required to prescribe it. Just the insurance company was required to cover it along with everything else they cover. And the folks said even purchasing insurance that had that as one of the things it could conceivably cover violated their religious rights.

Rovner: Yes. And this goes back to the contraceptive cases, where the religious organization said that, you know, by having birth control in their plans, it made them complicit in something that they thought was a sin. And that’s exactly what’s being stressed here, even among the individual plaintiffs: that having to buy insurance that has these benefits, even if they don’t use them, makes them complicit in, basically, sex outside of marriage. I mean, that’s what’s in the decision. It’s quite a reach. I’ll be interested to see, as this goes up, what people think of it. So, before we got Judge O’Connor’s opinion, what I thought would be the biggest news of the week comes from North Carolina, which on Monday became the 40th state to expand Medicaid under the Affordable Care Act, to cover people with incomes up to 138% of poverty. That’s about $20,000 in 2023. Well, it’s almost there. The newly eligible 600,000 people won’t be able to sign up until the legislature approves a budget, which is likely later this spring. North Carolina expanding the program leaves only a swath of states across the South, including Florida, Georgia, and Texas, and a couple in the Great Plains as still holding out on a 90% federal match. Is anyone else on the horizon or is this going to be it for a while?

Raman: I think one thing to note about how this is happening is that North Carolina was able to do this finally through the legislature after like a yearslong process. And it has been increasingly rare for this to happen through the legislature. The last time was Virginia, in 2018, but every other state that has done it in recent years has all been through ballot initiative and going that route. And the 10 holdouts that we have, you know, we have Republican-controlled legislatures who’ve been pretty against doing this. So I think if any of those states were to be able to do that at this point that haven’t been tempted by, you know, any of the incentives … [unintelligible] … get a higher match rate or anything like that, it would have to be through the ballot, which is already a difficult process, can take years. There have been various roadblocks to push back and even some of the states in the past that have been able to get it through ballot initiative — some of the legislatures afterwards have tried to like push back on it — when we saw with Utah a few years ago, where even if the voters had voted that they wanted to expand, they wanted to kind of pull it back.

Rovner: We thought in Maine, where the governor blocked it until basically he was out of office.

Raman: Yeah.

Ollstein: And in Missouri, where they just refused to fund it.

Raman: Yeah, so I think that’ll be definitely something to watch with how the budget goes in the next few months. But I guess, at least with North Carolina, this was something that was bipartisan. It was spearheaded in the legislature by Republicans, so I think they might not have the same issues there than Missouri, but it’s a tough haul to get the remaining 10 at this point after this many years.

Rovner: Yeah, I feel like North Carolina is much more like Virginia, which is that, finally, after a lot of wearing down, the Republican legislature and the Democratic governor were able to come to some kind of agreement. That’s what happened in Virginia. And that seems to be what’s happened here in North Carolina. Meanwhile, in those 10 states, hospitals which end up providing free care to people who can’t pay aren’t doing so well. In Florida, the state’s hospital association has been all but begging the state government to expand Medicaid pretty much since it was available to them, which is now going on 13 years. According to the American Hospital Association, 74% of rural hospital closures around the country took place in states that have not expanded Medicaid or where expansion had been in place for less than a year. And the New York Times has a story this week about the toll that that lack of insurance is taking — I’m sorry — and the New York Times has a story this week about the toll that lack of insurance for the working poor is taking there, not just on the state’s hospitals, but on the health of the state’s population. Lawmakers in these states are very happy to take federal money for all manner of things. What is it about this Medicaid expansion that’s making them say, “No, no, no”?

Raman: This was something that came up this week in the House. Appropriations’ Labor, HHS, Education Subcommittee had a hearing this week specifically on rural communities and some of the issues they face. And Medicaid expansion obviously did come up with some of the witnesses and some of the lawmakers as something that would be helpful given the number of hospital closures they’ve seen, and there might only be one health care facility for miles or in a county, and just how it would be helping them to kind of relieve paying for the uncompensated care that they’re already dealing with, you know, highlighted a number of the issues there. So it’s something that comes up, but I think one of the pushbacks that we saw was, you know, again, that it is a) tied to the Affordable Care Act, which has been such a partisan back-and-forth since its inception, and then b) just the messaging has always been about the cost. I mean, even if the general consensus is that it does save money over time for taking care of that care, something that came up was why states get more of a reimbursement for expansion than they do for traditional Medicaid. That was brought up a couple times, things like that. And so I think it’s hard to get some of those folks on board just because of how partisan it has become.

Rovner: Yeah, I remember I watched the hearing in Wyoming on this last year. They didn’t want to do it, it seemed, more for ideology. I mean, a lot of states that are doing this, you know, you can levy a tax on hospitals and nursing homes, who are happy to pay the tax because they’re now getting paid for these patients who couldn’t pay. And the state’s really not out-of-pocket, as it were, at all. But and yet, as we point out, these last 10 states, including some of the really big ones, have yet to actually succumb to this. Well, while we are talking about Medicaid, there have been a couple of interesting stories from my KHN colleagues in the past few weeks about so-called social determinants of health, those not strictly medical interventions that have a big impact on how sick or healthy people are. In California, Democratic Gov. Gavin Newsom wants to use Medicaid to pay for six months of rent or temporary housing for homeless people. And in Montana, health professionals can now prescribe vouchers for fruit and vegetables for patients with little access to fresh food. Is this the wave of the future, or will those who want to shrink rather than expand the welfare state and government in general roll programs like these back?

Cohrs: I think there certainly is a trend, a lot of momentum behind the idea of food as medicine and, you know, moving away and exploring some of these non-medication treatments or some of these underlying reasons why people do have health issues. I think certainly support for the Medicaid program is going to be a hot-button issue in D.C. over the next few months, but there is a lot that states can do on their own as well. And I know states have, you know, programs to kind of cover people that fall between the cracks of traditional insurance programs. California has a robust program for that, the local levels as well. So I think there may be ways to get around that, even if we do see some more restrictions. And again, the administration is Democratic at this point, so I think they may be friendlier to some of these innovations than prior ones, and that could change at any time. But this certainly isn’t something that’s going to go away.

Rovner: I wonder if we’re going to end up with blue states having all of these more robust pro — I mean, we already have blue states with more robust programs, but blue states having these more inclusive programs and red states not. Alice, you’re nodding.

Ollstein: Absolutely. And that’s been the trend for a while, but it could even accelerate now, I think, and you’re seeing that on both sides, with blue states looking to cover more and more things; also looking to cover more and more people, including undocumented people. That’s another trend in Medicaid. At the same time, you have red states that have long explored how to cover fewer and fewer, you know, trying to change the income eligibility threshold for expanded Medicaid, trying to do work requirements, trying to do, like, other restrictions. And so I think the patchwork and the divide is only going to continue.

Rovner: Well, moving on to abortion this week, we are still waiting, as I said, for that other decision out of Texas that could impact the future of the abortion pill mifepristone. But Alice, there’s another case at the other end of the country that could have something to say about the Texas case. What’s going on in Washington state?

Ollstein: This one has really flown under the radar. So this is an interesting situation where the same — a lot of the same Democratic attorneys general who were siding with the Biden administration in the Texas case are challenging the Biden administration in a different case in Washington state, basically saying that the remaining federal restrictions on abortion pills — mainly that providers have to get certified in order to prescribe the drugs or dispense them — saying that that should be tossed out, that it’s not supported by medicine and science. And so it’s interesting because you have the Biden administration fighting back against an effort to make the pills more accessible, which is not what a lot of people expect. It goes sort of against their rhetoric in recent months; they’ve talked about wanting to make the pills more accessible and they’re opposing an effort that would do that. But it is somewhat consistent with their position in the Texas case, which is, they’re saying, “Look, this is the FDA’s job. Let the FDA do its job. The FDA has a process, came up with these rules, got rid of some, kept others, and you outside folks don’t have the right to challenge and overturn it.”

Rovner: So what happens if the judges in both of these cases find for the plaintiffs, which would be kind of, but not completely, conflicting?

Ollstein: Yeah, so the Washington state case could just apply to the dozen states that are part of the challenge. And so you could have, again, more of a patchwork in which the abortion pills become even more accessible in those blue states and even less accessible in other states. You could also have these competing rulings that ultimately trigger Supreme Court review.

Rovner: Yeah, it’s not exactly a circuit split because it wouldn’t be opposite decisions on the same case; they’re different cases here. But as you point out, it’s really a case challenging the authority of the FDA to do what the FDA does. So it’s going to be really interesting to watch how this all plays out. While the future of mifepristone remains in doubt, the FDA is going to consider making at least one birth control pill over the counter. We know that morning-after pills, which are high doses of regular birth control pills, are already available without a prescription. So why hasn’t there been an over-the-counter birth control pill until now?

Ollstein: Everything concerning birth control, emergency contraception, abortion, it just — these fights drag on for years and years and years. So finally, we seem to be on the cusp of having a decision on this. It’s expected, from most people I’ve talked to, that they will approve this over-the-counter birth control. There’s a lot of data from around the world. A lot of other countries already have this. And one key unknown is whether the FDA will maintain an age restriction on it. A lot of progressive advocates do not want an age restriction because they think that this is important to help teens prevent unwanted pregnancies. And I think that’s going to be a big piece of the fight that I’m watching.

Rovner: And oh, my goodness, it was that age restriction that held up the over-the-counter morning-after pill for years. That was like a 13-year process to get that over the counter. It went on and on and on, and I covered it. All right. Well, there is abortion-related action on Capitol Hill too this week. We’ve got a potential abortion standoff brewing in the Senate over reproductive health policy at the Department of Defense. Who wants to talk about that one?

Raman: This one has been, I think, really interesting, since we’re all health reporters. And it’s been really something that I think my defense colleagues have been following so closely. But we have Senator Tuberville, who’s been holding up military nominations because the Pentagon has a policy that allows, you know, service members leave for reproductive care and it covers travel to seek an abortion. And so —

Rovner: Although it still doesn’t pay for the abortion.

Raman: It does not pay for the abortions. It’s for the travel. And so I know that my colleagues have looked at this and how this point, like, both sides have been getting a little frustrated, you know, with even some senators saying, “Hey, I agree that I don’t like this policy, but you need to find another way,” because as of earlier this week 160 promotions have been stalled. And so it’s just been kind of ramping up and holding up a lot of folks for kind of an unusual method.

Rovner: Yeah, and the defense secretary saying, I mean, this threatens national security because these are promotions — are important promotions. Flag officers, these are not, you know, just sort of — they’re routine, but they’re, you know, but if they don’t happen, if they get stalled, it’s a problem. In all of my years of seeing anti-abortion senators hold up things, this is not one I have seen before. It’s at least — it’s sort of new and imaginative, and I guess we will see how that plays out. Back in the states, though, it seems that the efforts to restrict reproductive rights are getting very extreme, very fast. Yes, the Oklahoma Supreme Court ruled earlier this month that a pregnant woman does have a right to an abortion when continuing the pregnancy threatens her life. But four of the nine justices there didn’t even want to go that far, suggesting that the legislature has the right to basically require saving the fetus even at the cost of the pregnant person’s life. In Texas, a lawsuit in which the ex-husband is suing the friend of his ex-wife for the wrongful death of his child for helping her get abortion medication is setting the stage for the so-called personhood debate: the idea that a new person with full legal right is created upon fertilization of an egg by sperm. Over the past few decades, several states have rejected personhood ballot measures as a bridge too far. But it feels like all bets are off now. I mean, it’s sort of like a race to see who can be the most extreme state.

Ollstein: I think the trends are revealing some interesting things. I mean, one, anti-abortion folks are well aware that people are still getting abortions, mainly in one of two ways: either traveling out of state or ordering pills online and taking them at home, both of which are very difficult to enforce and stop. And so there’s just a lot of, like, throwing spaghetti against the wall and seeing what sticks, in terms of, can we actually criminalize either of those things? If so, how is it enforced, or does it even need to be enforced? Or is just the fear and the chilling effect enough? I mean, we definitely see that. We definitely see medical providers holding off on doing even perfectly legal things because of fear and the chilling effect. And so there’s just a lot of experimentation at the state level right now.

Rovner: Yeah, I forgot to mention Idaho, where the legislature introduced a bill that would make it a crime — that creates abortion trafficking as a crime — for someone to take a minor, it’s not really across state lines, because the state can’t do that, so it’s like taking the minor to the border in an effort to cross state lines to get an abortion. There was, for many years in the late 1990s and early 2000s, something called the Child Custody Protection Act in Congress, because they needed that for the interstate part of it, that would make it a crime to take a minor across state lines in violation of the home state’s parental involvement laws. It passed both the House and the Senate at various times. It never became law. It’s been introduced recently, but nobody’s tried to take it up recently. I wouldn’t be surprised to see that come back up, too. But it really does seem that every day there’s another bill in another state legislature that says — after all the claims of the anti-abortion movement for decades, that we don’t want to punish the women, we only want to punish the providers — that’s gone out the window, right?

Raman: I guess I would add that, you know, we’re seeing a lot of this activity now. But something that I keep in mind is that a) it’s gotten a lot harder to know what’s going to, you know, using the spaghetti metaphor that Alice did, like what will stick. So there’s just a lot more flurry of action. And then I feel like I see increasingly, you know, people, since they don’t know that, just like fixating a lot on various things, just because you don’t know. I think, you know, even a few years ago, there were a lot of things that would have one sponsor or two sponsors and have no chance of going anywhere, as most bills introduced anywhere do. But now, a) a lot of these things are moving very, very quickly in the legislature, and b) since we don’t know, it’s hard to know where to kind of focus, even to some of the experts that I’ve talked to, where it’s just, “We’re not sure.” So just be aware of all of these things in various places because of kind of that uncertainty.

Rovner: Yeah, I know I’m generally loath to talk about bills that got introduced either in Congress or in state legislatures, because I think it unnecessarily creates expectations that for the most part don’t happen. But as both of you say, some of these things are happening so fast that, if you mention them one week, they’re law by the next week. So we will see as this continues to move quickly. All right. That’s the news for this week. Now it is 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 khn.org and in our show notes on your phone or other mobile device. Rachel, why don’t you go first this week?

Cohrs: All right. So my story is from the Washington Post, and the headline is “These Women Survived Combat. Then They Had to Fight for Health Care,” by Hope Hodge Seck. And I thought it was just a really great feature on this very niche issue. And I think veterans’ kind of health care overall just doesn’t get as much coverage as it should, and —

Rovner: Particularly women’s veteran’s health care.

Cohrs: Exactly. Yes. And so these women were essentially going into combat situations to help relations with women in very conservative cultures, and they were exposed to the grenade blasts and a lot of these combat situations. But then their health care coverage upon returning wasn’t covered. And there is kind of a new bill with some momentum behind it that is trying to plug that loophole. So, yeah, I thought it was a very great feature on an issue that’s undercovered.

Rovner: Yeah, this was something I knew nothing about until I read this story. Alice?

Ollstein: I chose a piece by Rachel’s colleague at Stat, Lev Facher, called “How the Drug Industry Uses Fear of Fentanyl to Extract More Profit From Naloxone.” And this is really timely, with the approval this week of over-the-counter opioid-overdose-reverse medication. And basically it’s about how these drug companies are coming up with new forms of the drug, really huge doses, new delivery forms, injectables, and nasal sprays, and stuff that are not really justified by science and are sort of just an opportunity for more profit because the basic form of the drug that works extremely well and is very affordable, they are basically hyping the fear of fentanyl to try to push these stronger products they’re coming up with. And the fear is that municipal governments that have limited resources are going to spend their money on those not really justified new forms and get fewer medication for everyone than just using the basic stuff that we know works.

Rovner: Indeed. Sandhya?

Raman: My extra credit is from Margo Snipe and Kenya Hunter at Capital B, and it’s called “What the Covid-19 Pandemic and Mpox Outbreak Taught Us About Reducing Health Disparities.” And I thought this was an interesting look that they did, highlighting how, you know, there’s been a lot more talk about the various health inequities among, you know, racial and ethnic and sexual minority communities after these two pandemics have started. And they look at how some of the targeted efforts have narrowed some of the gaps in things like vaccines, but just how some of these lessons can be used to address other health disparities, you know, things like community outreach and expanding types of screenings and how many languages public health information is translated into and things like that. So, it’s a good read.

Rovner: Well, my extra credit this week is a long read, a very long read, by Rebecca Traister in New York Magazine, called “Abortion Wins Elections: The Fight to Make Reproductive Rights the Centerpiece of the Democratic Party’s 2024 Agenda.” And while I’m not sure I’m buying everything that she’s selling here, this is an incredibly thorough and interesting look at the past, present, and possibly future of the abortion rights movement at the national, state, and local levels. If you are truly interested in this subject, it’s well worth the half hour or so of your time that it takes to get through the entire thing. It’s a really, really good piece. OK, that is our show for this week. As always, if you enjoyed 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 ever-patient producer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can tweet me still. I’m @jrovner. Alice?

Ollstein: @AliceOllstein.

Rovner: Rachel?

Cohrs: @rachelcohrs.

Rovner: Sandhya?

Raman: @SandhyaWrites.

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 KHN’s 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.

Medicare Advantage, the private-sector alternative to original Medicare, now enrolls nearly half of all Medicare beneficiaries. But it remains controversial because — while most of its subscribers like the extra benefits many plans provide — the program frequently costs the federal government more than if those seniors remained in the fully public program. That controversy is becoming political, as the Biden administration tries to rein in some of those payments without being accused of “cutting” Medicare.

Meanwhile, President Joe Biden has signed a bill to declassify U.S. intelligence about the possible origin of covid-19 in China. And new evidence has emerged potentially linking the virus to raccoon dogs at an animal market in Wuhan, where the virus reportedly first took hold.

This week’s panelists are Julie Rovner of KHN, Margot Sanger-Katz of The New York Times, Jessie Hellmann of CQ Roll Call, and Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico.

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Jessie Hellmann
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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 Biden administration recently changed the formula used to calculate how much the federal government pays private Medicare Advantage plans to care for patients with serious conditions, amid allegations that many of the health plans overcharge or even defraud the government. Major insurers are making no secret about how lucrative the program can be: Humana recently said it would leave the commercial insurance market and focus on government-funded programs, like its booming Medicare Advantage plans.
• The formula change is intended to rein in excess spending on Medicare — a huge, costly program at risk of insolvency — yet it has triggered a lobbying blitz, including a vigorous letter-writing campaign in support of the popular Medicare Advantage program. On Capitol Hill, though, party leaders have not stepped up to defend private insurers as aggressively as they have in the past. But the 2024 campaign season could hear the parties trading accusations over whether Biden cut Medicare or, conversely, protected it.
• The latest maternal mortality rates released by the Centers for Disease Control and Prevention show the problem continued to worsen during the pandemic. Many states have extended Medicaid coverage for a full year after women give birth, in an effort to improve care during that higher-risk period. But other problems limit access to postpartum care. During the pandemic, some women did not get prenatal care. And after the fall of Roe v. Wade, some states are having trouble securing providers — including one rural Idaho hospital, which announced it will stop delivering babies.
• The federal government will soon declassify intelligence related to the origins of the covid pandemic. In the United States, the fight over what started the pandemic has largely morphed into an issue of political identity, with Republicans favoring the notion that a Chinese lab leak started the global health crisis that killed millions, while Democrats are more likely to believe it was animal transmission tied to a wet market.
• And in drug price news, Sanofi has become the third major insulin maker (of three) to announce it will reduce the price on some of its insulin products ahead of a U.S. government policy change next year that could have cost the company.

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

Julie Rovner: Vice News’ “Inside the Private Group Where Parents Give Ivermectin to Kids With Autism,” by David Gilbert

Jessie Hellmann: The Washington Post’s “Senior Care Is Crushingly Expensive. Boomers Aren’t Ready,” by Christopher Rowland

Joanne Kenen: The New Yorker’s “Will the Ozempic Era Change How We Think About Being Fat and Being Thin?” by Jia Tolentino

Margot Sanger-Katz: Slate’s “You Know What? I’m Not Doing This Anymore,” by Sophie Novack

Also mentioned on this week’s podcast:

• Coverage by KHN’s Fred Schulte on Medicare Advantage: https://khn.org/news/author/fred-schulte/
• The New York Times’ “Biden Plan to Cut Billions in Medicare Fraud Ignites Lobbying Frenzy,” by Reed Abelson and Margot Sanger-Katz
• The CDC’s “Maternal Mortality Rates in the United States, 2021,” by Donna L. Hoyert

Click to open the transcript

Transcript: The Policy, and Politics, of Medicare Advantage

KHN’s ‘What the Health?’Episode Title: The Policy, and Politics, of Medicare AdvantageEpisode Number: 290Published: March 23, 2023

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

Julie Rovner: Hello and welcome back to KHN’s “What the Health?” I’m Julie Rovner, chief Washington correspondent at Kaiser Health News. And I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, March 23, at 10:30 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. Today we are joined via video conference by Margot Sanger-Katz of The New York Times.

Margot Sanger-Katz: Good morning, everybody.

Rovner: Jessie Hellmann of CQ Roll Call.

Jessie Hellmann: Hello.

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

Joanne Kenen: Hi, everybody.

Rovner: So a happy 13th birthday to the Affordable Care Act, which President Obama signed just a couple of hundred feet from where I am sitting now. But there’s lots of other health news, so we’re going to dive right in. I want to start this week with Medicare Advantage, the private Medicare alternative that now enrolls more than half of all Medicare beneficiaries. If you watch cable TV or pretty much any TV at all, you have likely seen the dueling ads. They’re part of a multimillion-dollar lobbying campaign, like this ad from the Better Medicare Alliance, made up of mostly Medicare Advantage insurers.

Excerpt from ad set in a bowling alley:Bowler 1: They might cut Medicare Advantage.Bowler 2: C’mon!Bowler 1: They’re talking about it in Washington.Bowler 2: Cut Medicare Advantage? Higher premiums? With inflation already so high?Bowler 3: That’s nuts!

Rovner: Or this one from the consumer advocacy group Protect Our Care.

Excerpt from ad: Insurance companies are lying to America’s seniors about cuts to Medicare Advantage benefits. Experts agree what they are saying is just plain false. Health insurance companies are simply trying to stop cuts to their sky-high profits, CEO salaries, and bonuses.

Rovner: I swear, Margot, I pulled the clip from that first ad before you also used it in your excellent story published Wednesday. So — and I know this is a hugely complicated issue that we’re going to try to take apart at least a little bit — but, who’s right here? Those who are saying that Medicare Advantage is about to be cut or those who were saying not really.

Sanger-Katz: I think actually they are both a little bit right. The Biden administration has made a very technical change to the formula that pays these private plans extra money when they sign up patients who have serious medical diagnoses. And this is, of course, a response to an earlier problem. It used to be Medicare Advantage plans — those are the private plans that are an alternative to the government Medicare program. It used to be that they just got a flat fee for everyone that they signed up. That was about what it costs on average to take care of someone in Medicare. And what happened is that the plans then had a huge incentive to only sign up healthy people. And so that’s what they tried to do. And they marketed to healthy people by doing things like including gym benefits in the health insurance plan or this famous, and perhaps apocryphal, example of, you know, locating the enrollment office on the third story of a building with no elevators so only people who could get up the stairs would be able to sign up for the plan. And so, there was this policy response where it said, well, you know, sicker people are more expensive to take care of, and we want these plans to not just be cherry-picking all of the healthiest people. And so they created this system that basically pays extra to the plans. If you have congestive heart failure, if you have cancer, or if you have diabetes, then your health plan gets, like, a little bonus. But what we have seen over the course of the life of this program is that this has created enormous incentives for the plans to diagnose their customers with as many diseases as possible, regardless of the strength of the evidence that they have. And there is a whole industry of data-mining operations that go through people’s medical records, of home health agencies that go into people’s homes just to diagnose them with more illnesses. And there are just absolutely widespread — from, like, every possible authoritative source that you can think of — allegations of overcharging of the federal government through this program and also of fraud. Not every insurance plan in the country in this program has been accused of fraud, but quite a lot of them have, including most of the largest players. And they are facing lawsuits in federal court for basically scamming Medicare by saying that their people are too sick.

Rovner: So I want to go back to the beginning or, really, the middle. Medicare has offered beneficiaries the option of enrolling in a private managed-care plan instead of what’s known as traditional Medicare, where patients can go to just about any doctor or hospital, pretty much from the inception of the program and pretty broadly since the Reagan administration in the early 1980s. They were originally called Medicare risk plans. Health plans almost exclusively, HMOs, said they could provide the same care more efficiently by, quote, “managing care,” and could still make a profit even if the government paid them 5% less than the average patient in traditional Medicare in that area. So it was a good deal all around. The plans were making money. The government was saving money. Yeah, that was a very long time ago. Since then, Congress has significantly raised what it pays the plans with the stipulation that they use the excess funds to either reduce premiums or add benefits, mostly dental, vision, and hearing care. Still, however, a lot of insurers are, to use a technical term, raking it in. In fact, Humana last month announced that it was going to pull out of the commercial insurance market in order to concentrate on its much more lucrative Medicare Advantage business. So, how are these companies both providing more benefits and making big profits? I know that fraud is part of it. Jessie, where’s all this money coming from?

Hellmann: Like Margot said … I think a lot of it has to do with the upcoding that they do. They’re just able to find all of these diagnoses from their enrollees, either through chart reviews … some have done home health visits where they send in people to interview patients and ask about their health history without really providing any care. So that’s another way. And it’s just become, like, a really lucrative business practice for them. But like Margot said, they’ve just been facing more and more scrutiny and lawsuits over the way that they do this.

Rovner: They deny care, too, right? That has been a long-standing issue that people who go into these plans and then get sick sometimes have trouble getting the care that they need.

Hellmann: Medicare Advantage plans do something called prior authorization, where they require providers submit requests for something to be covered before they’ll pay for it. They do this with a lot of more costly things, like imaging or like nursing home stays, which are obviously very expensive. And so if they can deny these claims and maybe get a beneficiary to do something that is cheaper before moving onto these more costly things, then that obviously saves some money. But that’s something else that the Biden administration has been looking more closely at. They’ve proposed a few rules that would just say that Medicare Advantage plans have to cover things that are covered by Medicare. They can’t just deny care for something based on their own proprietary models of deciding whether something is medically necessary or not.

Kenen: It’s complicated because sometimes there are patients that ask for things that they actually don’t need. You know, something they have seen on TV or they heard their neighbor had or whatever, and that [there’s] actually something more conservative [that can be done]. Back surgery is the famous example. You know, sometimes physical therapy and other treatments will do better than an $80,000 back surgery. But there’s a difference between saying, “Let’s try something else first,” and times when somebody is really sick and needs an expensive drug, they may have already tried a cheaper drug in another health plan the year before. It’s very hard to untangle, you know, when “no” is appropriate because we have overtreatment in this country. But the problem here is that sometimes “no” it’s completely inappropriate, and the insurer is not paying for something that the patient expected to get when they signed up for a health plan to take care of their health.

Rovner: And we should point out this is true in all managed-care plans, not just in Medicare Advantage plans.

Kenen: Yes.

Rovner: So before we move on, I want to give a shoutout to my KHN colleague Fred Schulte, who has been on the Medicare Advantage fraud trail like a dog with a bone for more than a decade now. We will link to some of his award-winning work in our show notes. Anyway, now the Biden administration, Margot, as you said, is trying to crack down on the, if not outright fraud, at least the manipulation of payments, which will also, at the same time, save the Medicare trust fund a lot of money. In the past, though, even small changes to Medicare Advantage, because it is so popular, have been met with a lot of pushback from members of Congress in both parties. But that’s not really happening this time, is it?

Sanger-Katz: Yeah, This has, I think, been the biggest surprise and the most interesting part of reporting on this story. Historically, Medicare Advantage is about half of Medicare’s enrollment, as in these plans. If you survey seniors who have these plans, they tell you that they really love them. And notwithstanding all the stuff we just talked about, I think they are popular by most people who use them. In part, it’s because they get these extra benefits. They have lower premiums. You know, they get some goodies that they wouldn’t get with regular Medicare. And in Congress, the preponderance of members of Congress have signed letters indicating that they support, I think, what they call a stable policy-and-rate environment for the plan. So last year, 80% of members of the House of Representatives signed such a letter. That’s just, I mean, you don’t see 80% of members of the House of Representatives agreeing on practically anything — and a majority of senators as well. And I think everyone’s expectation, including me, is that when these people signed this letter and said, you know, this is important and my constituents care about it, that they would have the back of the plans and that it would be hard for regulators to be aggressive in trying to change anything about this program because there would be such a big political outcry. And, in fact, what’s happened is they have really started cracking down. They started with some of these smaller regulations. And then the one that they did, it was kind of hidden in a technical way, but it had a really big impact. They changed this whole formula and they basically said, hey, plans, like, you can no longer get these extra payments for a lot of the diseases that they were very commonly making money for diagnosing people for. And all of a sudden, you know, this support on the Hill just kind of dissolved. And that is very much in the face of this huge lobbying effort. You know, Julie, you mentioned the television commercials, but the plans also mobilize their customers to call their members of Congress to contact the White House. Something like 142,000 calls and letters have been submitted to members of Congress and the White House. The proposal itself, there’s the formal comment process — in a normal year [it] gets like a couple of hundred comments, mostly from various stakeholders in the Medicare system. This year there was an organized letter-writing campaign and 15,000 comments were submitted on this rate notice. So we just see this environment in which the public has been activated. Lobbyists are going crazy. The CEO of United[Healthcare], the largest health insurer in the country, was making the rounds on the Hill, talking to members of Congress. And yet … and yet there’s really no one in Congress who’s standing up and screaming and yelling about how terrible this is. I mean, I shouldn’t say no one. There are a few individual members of Congress, Republicans, who have been highly critical of this and who have pointed out that this move is potentially inconsistent with President [Joe] Biden’s promise to never cut Medicare, which is a key campaign message for him going into his reelection. But the leaders in Congress, the heads of committees, the really prominent members, and certainly leading Democrats have not said those kinds of things. There were letters that came out very late in the process, really in the last week or so, from Republicans in House and Senate committees of jurisdiction that you might have expected to be these angry, partisan, like, “how dare you do this to Medicare Advantage?” kind of letters. And they were not those kinds of letters. They weren’t critical, but they were very polite and they were very technical. They’re, like, could you please answer the following 10 very technical questions about this tiny little detail of the formula? So it’s clear … they are concerned and they are providing oversight. And I don’t think that they are enthusiastically embracing these changes. But at the same time, I think they are not carrying water for the insurance industry and making it very politically difficult for the Biden administration to make these changes.

Rovner: I feel like the Humana announcement actually sent quite a message that says, wow, we can make a lot more money from Medicare than we can make from the commercial market.

Kenen: Well, I think that’s true. I mean, one reason so many seniors are in Medicare Advantage, and do like it, is that they get an incredible deluge of marketing. I mean, the companies went in here, they saw that it was a business opportunity. They have marketed themselves very aggressively. People get dozens and dozens of letters saying, “Apply for this plan” or “We’ll give you this. We’ll give you that.” So the market is there. But I also think there’s a political dynamic that’s bubbled up recently that’s different. There’s been a fight every year about Medicare Advantage payments. It hasn’t been as grassroots; it hasn’t gotten as much attention. But there’s been a fight. I mean, every year the administration puts out their formula. Every year the industry fights it back. You know, there’s some kind of compromise. The industry doesn’t get hit as much as it would have. It’s part of the game, right? I mean, that’s how payment rules are made in Washington. But something has changed here that Biden quite successfully, at the State of the Union, really put the Republicans on the hot seat in terms of protecting Medicare and Social Security. And they’ve flipped it. Because the Republicans are better at language. You know, if this was a Republican rule, they would be calling it the “Protect America’s Seniors From Fraudulent Insurers” rule. You know … the Democrats just don’t do that.

Rovner: We should point out that it was the Republicans who named it Medicare Advantage — renamed the whole Medicare private plan program.

Kenen: Right. But just as … Biden’s politically great moment at the State of the Union making the Republicans promise not to touch Medicare, the Republicans have flipped it, because now they’re accusing Biden of attacking Medicare in a different way. And, you know, Medicare was this hot political issue in campaigns in the late Nineties and the early 2000s. It was replaced by a 10- to 15-year fight about what became the Affordable Care Act and repealing it and all that. And then there was this political vacuum in 2022, and in 2020, after the Republicans failed to repeal the ACA, we sort of had a — not health slogan-free, but it was on the back burner and …

Rovner: We had a reset. Well, we did have a pandemic.

Kenen: We had the pandemic, but — and that was politicized — but the traditional health care fight is reemerging. The traditional partisan health care fight is … both sides have accused the other over the year of “Mediscare.” This is the platform for that fight that I think we will continue to see going into 2024. I mean, it will evolve. I mean, this particular rule will get settled. But, you know, you’re sort of seeing who is the champion of Medicare, which Republicans, years ago, when Paul Ryan, when he was the budget chair of the House and the speaker of the House, he really wanted to significantly transform Medicare in ways that made it very different than the Medicare as it existed for them, Republicans, who are “saving Medicare.” For the Democrats, it was “Republicans are privatizing and destroying Medicare.” This is just Chapter 9,000. It’ll morph again between now and November 2024, but it’s begun.

Sanger-Katz: I think the politics of this are interesting and I think kind of unsettled. I’m very curious to see how this plays out in the campaigns. I do think that there is an available argument for Republicans to make that this change, which does take money out of the pockets of these plans and which potentially could mean that beneficiaries are going to end up with a little bit less generosity, because when those plans make less money, maybe they’re not going to give you as many extra goodies or lower your premium by as much. We don’t know that, but it’s certainly possible.

Rovner: In 1997, they cut payments for what was then Medicare Plus Choice, I think, Medicare Part C. And that’s exactly what happened. They cut all the extra benefits and people threw a fit, and they ended up having to put a lot of the money back.

Sanger-Katz: But in the Affordable Care Act, they cut a lot of the money and the benefits just kept growing. So we don’t know how the plans are going to absorb this change. But anyway, I think there is this available attack line for Republicans. Biden said he’s not going to cut Medicare. Look what he did. He’s cut Medicare. He’s taken all this money out of Medicare and it’s causing your premiums to go up. On the other hand, I do think there is this opportunity for Biden to say, “We reduced fraud; we improved the health of the Medicare trust fund.” And I think a lot of Republicans are actually committed to both of those things. I think they care about program integrity. They care about the fiscal future of the program. And so it’s all just a little bit scrambled. This almost feels more like something you might see in a Republican administration than a Democratic one.

Rovner: I was just saying, Jessie, is there any inclination on the Hill to do anything about this, or do you think they’re just going to either talk about it or not talk about it, as it were?

Hellmann: I haven’t heard anything about any potential action on the Hill. There’s just been letters sent asking questions, or some Republicans have sent letters saying, “We don’t like this.” But I don’t know that there’s enough support in both the Senate and the House to override this. And they are talking more about, like, the health of the Medicare trust fund. And some of the rules proposed by the administration could help strengthen that a little bit. It’s not going to solve all of its problems. But to go in and meddle with what the administration is doing to help the trust fund a little bit, while Congress is having more and more debates about helping the trust fund, I don’t know if that would be a good look.

Kenen: You could still have a policy compromise on, like, anti-fraud policy and still have a political fight. “We saved it!” “No, we saved it!” Oh, they … it’s way too soon to know what issues are going to dominate 2024 and what issues attract sustained attention from a public that doesn’t sustain attention to much of anything anymore. But right now, this is certainly a trial balloon for 2024. And I can see it. I can see that. I can see working out some kind of compromise on the actual technical issues and still having a political fight.

Rovner: Well, we’re going to move on because we’re clearly not gonna settle this today. But I hope people at least got a flavor for really how complicated this is, both, you know, technically and politically. I want to turn to something else that’s complicated: That’s reproductive health. And by that I mean much more than abortion and birth control. A new study from the Centers for Disease Control and Prevention finds that maternal mortality, the death rate for people when they are giving birth or in the weeks immediately after, rose by more than a third in 2021 compared to 2020. And African American women, even those with higher incomes, were 2½ times more likely to die during or just after childbirth than white women. Certainly, the pandemic had something to do with this. It disrupted medical care for just about everybody, and pregnant women who got covid had a higher risk of severe illness or death. But this is really just a continuation of a trend that’s been troubling health experts for several years now. Joanne, you’re our public health expert here. Why has this been so difficult to address?

Kenen: I mean, I think some of it is the two things that Julie said for 2020. I mean, you know, there was all this fear that the vaccines could hurt pregnant women. Actually, it was covid that hurt pregnant women and their babies. So, hopefully, we’re over the worst of that. And people weren’t going in for good prenatal care. So that was a factor. But this is a really sustained problem, and we’ve begun to take some steps. Most states are now extending Medicaid coverage postpartum for six months or a year under Medicaid. I think that when many of us, including me, when I first heard about these problems with maternal mortality, I was thinking about giving birth. I was thinking about hemorrhage and things that happen in the delivery room or right after, when, in fact, it’s really the full year after. There is high risk for everything. And that’s where a lot of the disparities in our system … the states that don’t have Medicaid, the states that  …

Rovner: Didn’t expand Medicaid.

Kenen: … didn’t extend Medicaid, you know, or there aren’t … most of them are now expanding it for women in this category, or beginning to. So that might help. I mean, the disparities throughout the health care system, this is not just an income thing. In all economic strata, the racial disparities in maternal mortality exist. And then I just found out something recently that really shocked me. I’ve done some work over the past six months writing about domestic violence as a public health problem, and I’ve moderated two panels, just like in the last 10 days on it. And most states do not count homicide, suicide, and overdose as part of the maternal mortality figures. So if you think these figures are bad, it’s way worse, because pregnancy and postpartum are all so high risk for all of those things. But since the OB-GYNs actually review these maternal mortality cases, they’re not reviewing those other three categories. So as bad as it is, it shocked me to realize what we’re looking at and being horrified by isn’t even the full picture.

Rovner: Wow. So, well, here’s where reproductive health writ large and abortion policy cross in ways that may be unexpected to lawmakers who voted for their states’ bans, but not to anybody who’s studied health policy. In Idaho, a rural hospital has announced it will no longer deliver babies, forcing women seeking labor and delivery care to travel nearly 50 miles. Why? Because the hospital, Bonner General Health in Sandpoint, says it cannot keep enough health professionals, both OB-GYNs and pediatricians, to safely run a maternity ward. Why not? Well, Idaho’s, quote, “legal and political climate,” says the hospital from its press release, quote: “The Idaho legislature continues to introduce and pass bills that criminalize physicians for medical care nationally recognized as the standard of care.” Margot, your extra credit this week is about something similar, but in Texas. So why don’t you do it now?

Sanger-Katz: Yes, I wanted to recommend this article from Sophie Novak in Slate called “You Know What? I’m Not Doing This Anymore.” And her piece profiles a whole bunch of nurses and doctors who work in OB-GYN care in Texas who are quitting or leaving or who are considering not taking jobs that they might otherwise have taken. And I think we don’t have real data on these trends, and I’m always a little bit worried about these kinds of stories that, you know, you can always find five or six or seven or 10 doctors who are unhappy or who say that they might quit. There was a lot of those stories, like, when Obamacare passed, all these doctors are going to retire early because they don’t like the rules. I think that turned out to be more marginal than we might have expected based on that coverage. But I still think that this story is telling these stories of these providers, and I think it’s pointing to something that is a real risk and is potentially a real trend, which is if you are someone who is in the business of caring for women through pregnancy and childbirth, and you feel like you cannot do the things that you were trained to do, that there is potential criminal liability for you in providing the care that your patients need, if you’re having to watch your patients suffer through needless harm or medical risk because you can’t provide an abortion when one is medically indicated without facing that kind of legal risk. I do think that there is a real risk that these people are not going to want to practice in those states. They would rather go to a place where they have a little bit more autonomy and a little bit less concern about prosecution. And what that means is that the women left behind in these states, however you feel about abortion, may not have access to as many health care providers, and they are going to continue to have pregnancies and births and need that kind of support. And I think that is a very interesting and troubling dynamic that I think could have very large reverberations and could, of course, make the trends that Joanne was just talking about, you know, even more concerning and lead to even more disparities. Because, of course, it is a lot of the states that are banning abortion are states that have these kind of poor, minority communities who are already facing a lot of the maternal mortality. We see in the existing data it’s increasing in a kind of across-the-board way, but there are some places where it’s worse than other places. And a lot of the worst places for maternal and fetal mortality are these same places that are banning abortion and where they may be at risk of losing some of the providers that can help ameliorate the problem.

Rovner: And it’s not just losing the providers, it’s replacing the providers who do get old enough and retire or who leave, because we’re seeing medical students, fourth-year medical students, say they’re loath to apply for residencies in some of these states, partly because they’re worried about their training, but partly because, you know, if they’re women, they may need this care at some point or they may have family members who will come with them who need this care at some point. And because, for the most part, where you do your residency tends to be where you end up practicing. So, I mean, we didn’t see it so much in this year’s match, but I’m wondering whether this is going to be an issue, too. There’s some big, important academic training centers in some of these states with bans. I’m thinking, you know, Vanderbilt comes to mind immediately in Tennessee. I think this is another thing that was perhaps unexpected, although if you thought about it hard, you could have predicted it.

Kenen: I mean, pregnancy is complicated. A century ago, women commonly died in pregnancy. And we live in an era where it’s safer than it had been, but we forget it can still be risky. And wanted pregnancies, very much wanted pregnancies, can go wrong. And I’ve experienced … I mean, I have two kids, but I experienced that, and I needed emergency medical care and I was able to get it. I needed emergency medical care more than once, and I was able to get it.

Rovner: And I remember visiting you when you were on bed rest.

Kenen: Right? It was one of my few fun nights on bed rest, when Julie and Joanne Silberner brought me dinner. We had a picnic, right? In bed, right? But, you know, I never had to deal with anything except the grief of losing a pregnancy. So, you know, it was a very much wanted pregnancy, and I didn’t have to worry about anything being withheld from me. I had a lot of things go wrong a lot of times. But, you know, I was really lucky to end up with the family I have. When I read these stories, and I go back and think, what if I had to deal with infection? What if I couldn’t get that care? And we’re just not thinking this assumption, by mostly male lawmakers, that it’s not a huge medical thing. Pregnancy changes your body, everything about your body, it’s not just cosmetic. There are lots and lots of risk factors, before and after. That [has] sort of just been glossed over as, oh, it’s not a problem. And it is a problem. And one reason we’re going to see this shift in medical practice is because they understand it’s a problem. I mean, you read these stories about these doctors, and we’ve talked about them every week, and our listeners have heard them and read them, about doctors who are watching a patient with a serious infection, until she is getting close enough to die that they can treat her, but not so close to dying that they lose her. And you hear the anguish.

Rovner: That’s why I was so taken by that line in the press release from the hospital in Idaho, which is that doctors don’t want to possibly be criminalized for what is considered the standard of care. They’re being asked to basically choose between perhaps getting sued or put in jail and what they vowed to do to care for their patients. And it’s really hard. It’s not really that much of a surprise that people are going to leave or not go there. All right. Well, we will definitely come back to this, too. I want to talk about covid briefly. Jessie, the president signed the bill passed by Congress to declassify intelligence on the origin of covid. Do we have any idea when that’s going to happen? How soon? And do we get to see this, too? Or just the members of Congress?

Hellmann: The director of national intelligence is supposed to declassify this information 90 days after the law is passed. After that, I’m not entirely sure if it’s just for Congress or it’s for the public, to be honest.

Rovner: We will see. I was amused that, right after this happened — because now we have all this talk that, you know, “Oh, absolutely” or not, absolutely it was a lab leak, but “more likely it was a lab leak.” Now we have new evidence suggesting that it may, in fact, have started in the Wuhan wet market, after all, jumping from something called raccoon dogs? Now, I consider myself something of an animal expert here. I have never heard of a raccoon dog.

Sanger-Katz: They’re really cute. I was enjoying looking at all the photographs of them.

Rovner: Are we going to now go back to the “OK, maybe it really did come from the market”? I-I-I …

Kenen: What I’m about to say is an oversimplification, but if you’re a Republican, you think it’s a lab leak. And if you’re a Democrat, you think it’s a raccoon dog. And that is an oversimplification. And one of the things that drives me crazy is that the potential for lab leaks exists and lab safety is an issue that should be bipartisan. There have been lab leaks in the U.S., there have been lab leaks elsewhere in the world. And that doesn’t mean this came from a lab leak, but lab leaks are a thing. And we want to make them not a thing. But again, there are many lessons we should be able to take from the pandemic; that’s one of them. Like, OK, maybe this wasn’t a lab leak, maybe this was the Wuhan animal market, but let’s take this as a moment to think about how we can protect ourselves from a future lab leak. You know, we may never conclusively know. Even the raccoon dog thing is still a theory. I mean, there’s evidence behind that theory, but the scientific establishment has not said, OK, this is it. There’s still debate. The science world tends to think it’s zoonotic, that it’s from an animal, but it’s not over yet. And again, the politicization is preventing good public policy.

Rovner: If only someone could turn that fight into something. And as I quoted Michael Osterholm last week as saying, “It doesn’t matter which one it was, because we have to be ready for both of them in a future pandemic.”

Kenen: Exactly. And we’ll probably have both. I mean, we may not have a pandemic from a lab leak, but is it possible that somebody, somewhere, or some community will be hurt from a lab leak? Yes, it is. And we need to mitigate that. Is it possible we have another zoonotic infection? I mean, there’s two Marburg outbreaks in Africa right now. I mean, that’s from animals. And there’s two of them going on. It’s an obscure disease. It’s worse than Ebola. It doesn’t spread as fast, but we have zoonotic infections way more often than the average American realizes.

Sanger-Katz: And also just one more thing, which is we still had and have a global pandemic that has caused enormous suffering and death and fear around the world. And in some ways, I feel like this obsession with like whose fault it is is a distraction from what can we do to prevent such a thing from happening in the future and really looking at, like, what was done appropriately and inappropriately in terms of the covid response? Pinning this down seems … it seems academically interesting to me. It seems useful to know. I think, as you guys have said, you’ve got to be ready for both things anyway. But it also feels like a little bit of a sideshow sometimes when the reality is: Covid came for us. It wasn’t a near-miss where looking at the origin is the whole story. It’s also everything that came afterwards is really important, too.

Rovner: Yes, absolutely. Well, finally this week, one more update. On last week’s podcast,while we were discussing Novo Nordisk following Eli Lilly’s lead in announcing insulin price cuts, I wondered aloud how long it would be before the third company in the triumvirate that controls most of the diabetes drug market, Sanofi, would follow suit. As it turned out, the answer was a couple of hours. In a press release that came out Thursday afternoon, Sanofi said it would cut the price of its most popular insulin product by 78% and ensure that people with health insurance pay no more than $35 a month for their insulin. But I’m thinking this fight is not completely over; now that the three big companies have voluntarily said we’ll lower our prices on some of our insulins, Congress is still going to want to do something about this, right?

Hellmann: Yeah. Sen. [Chuck] Schumer said last week that he still wants Congress to address this issue. He still wants to cap the cost of insulin because, like you said, there are still insulin products that some of these companies offer that don’t fall under these announcements.

Rovner: Drug prices will continue to be a top-of-mind issue, I suspect. All right. Well, that’s as much news as we have time for this week. Now it is 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 khn.org and in our show notes on your phone or other mobile device. Margot, you’ve already done yours. Joanne, why don’t you go next?

Kenen: It’s a piece in The New Yorker, and I’m not sure how she pronounces her name. I think it’s Jia Tolentino. If any of you know, please correct me. But the story is called “Will the Ozempic Era Change How We Think About Being Fat and Being Thin?” I mean, this is a diabetes drug that is being used off-label for weight loss, quite widely to the point that there’s a shortage for people who have diabetes; they are having trouble getting it. It does help people lose weight and it’s become very much in demand because it does help you lose weight. And there are a few others in this class. So, the question she poses: This is a metabolic disorder, it’s not just a willpower issue, and will this help us get to that point? … It was a really good, interesting article, and I still ended up with a lot of questions about long-term safety, about do you have to take it forever and how much, and what happens if you don’t? It’s treating obesity rather than thinking about how to prevent obesity, which is a better — you know, too late for some millions of Americans, but there is generations to come. So but it was an interesting, provocative landscape piece.

Hellmann: My story is from The Washington Post. It’s called “Senior Care Is Crushingly Expensive. Boomers Aren’t Ready.” It’s just a story about how expensive long-term care could be, especially if you need really specialized care. One of the people interviewed for this story would have to pay about $72,000 a year to stay in an assisted-living facility. This person has Alzheimer’s and so they just need a little more help than someone else might. And they talk a lot about how Medicaid will cover some of this care, but only if you spend all of your life savings. And obviously, Medicare doesn’t really cover stays in assisted-living facilities either. I know we talked in email about how perennial this issue is. It’s something that was an issue 20 years ago. People are warning: We need to fix this problem.

Rovner: More than that. When I first joined CQ in 1986, it was the first big story I wrote, about what are we going to do about long-term care for the baby boomers? Here we are almost 40 years later, still talking about the same thing.

Hellmann: Yeah, I guess the answer is nothing.

Rovner: Not much has happened.

Kenen: Yeah, what’s happened is we’ve shifted more and more of it onto families.

Rovner: Yeah, that’s true.

Kenen: More complicated care for longer.

Rovner: My extra credit this week is a truly terrifying piece from Vice News called “Inside the Private Group Where Parents Give Ivermectin to Kids With Autism,” by David Gilbert. And the headline says most of it. What it doesn’t say is that when you give horse wormer to kids — and this group actually advises the use of the paste that’s given to horses — they’re going to have adverse reactions. The kids, not the horses, including headaches, stomachaches, blurry vision, and more. But the administrators of this group insist that the side effects aren’t because the children are being administered something that can kill people in the wrong dosages, but because the medication is, quote, “working.” They also say it can cure a whole host of other disorders from Down syndrome to alopecia. It is quite the story. You really do need to read it.

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 ever-patient producer, Francis Ying. As always, you can email us your comments or questions. We’re at whatthehealth — all one word — at kff.org. Or you can tweet me. I am @jrovner. Margot?

Sanger-Katz: @sangerkatz

Rovner: Jessie.

Hellmann: @jessiehellmann

Rovner: Joanne.

Kenen: @JoanneKenen

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 KHN’s 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.

This week, the eyes of the nation are on Texas, where a federal judge who formerly worked for a conservative Christian advocacy group is set to decide whether the abortion pill mifepristone can stay on the market. Mifepristone is half of a two-pill regimen that now accounts for more than half of the abortions in the United States.

Meanwhile, Novo Nordisk, another of the three large drug companies that dominate the market for diabetes treatments, has announced it will cut the price of many of its insulin products. Eli Lilly announced its cuts early this month. But the push for more affordable insulin from activists and members of Congress is not the only reason for the change: Because of quirks in the way the drug market works, cutting prices could actually save the companies money in the long run.

This week’s panelists are Julie Rovner of KHN, Jessie Hellmann of CQ Roll Call, Sarah Karlin-Smith of the Pink Sheet, and Alice Miranda Ollstein of Politico.

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Sarah Karlin-Smith
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Alice Miranda Ollstein
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Among the takeaways from this week’s episode:

• The federal judge examining the decades-old approval of mifepristone could issue a decision at any time after a hearing largely behind closed doors, during which he appeared open to restricting access to the drug.
• Democratic governors seek to counter the chill of Republican states’ warnings to pharmacies about distributing mifepristone, and a separate lawsuit in Texas seeks to set a precedent for punishing people who aren’t medical providers for assisting someone in obtaining an abortion.
• In pandemic news, Congress is moving forward with legislation that would force the Biden administration to declassify intelligence related to the origins of covid-19, while the editor of Cochrane Reviews posted a clarification of its recently published masking study, noting it is “inaccurate” to say it found that masks are not effective.
• Top federal health officials sent an unusual letter to Florida’s surgeon general, warning that his embrace of vaccination misinformation is harmful, even deadly, to Americans. While covid vaccines come with some risk of negative health effects, contracting covid carries a higher risk of poor outcomes.
• Novo Nordisk’s announcement that it will cut insulin prices puts pressure on Sanofi, the remaining insulin maker that has yet to adjust its prices.
• The Veterans Health Administration will cover Leqembi, a new Alzheimer’s drug. The decision comes as Medicare considers whether it will also cover the drug. Experts caution that new drugs shaking up the weight-loss market could prove costly for Medicare.
• Washington is eyeing changes to federal rules that would affect the practice of medicine. One change would force health plans to speed up “prior authorization” decisions by health insurers and increase transparency around denials, which supporters say would help patients better access needed care. Another proposal would ban noncompete clauses in contracts, including in health care. Arguments for and against the change both cite the issue of physician burnout — though they disagree on whether the ban would make the problem better or worse.

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

Julie Rovner: “Tradeoffs” podcast’s “The Conservative Clash Over Abortion Bans,” by Alice Miranda Ollstein and Dan Gorenstein

Alice Miranda Ollstein: Politico’s “Sharpton Dodges the Spotlight on Latest Push to Ban Menthol Cigarettes,” by Julia Marsh

Sarah Karlin-Smith: Allure’s “With New Legislation, You Can Expect More Recalls to Hit the Beauty Industry,” by Elizabeth Siegel and Deanna Pai

Jessie Hellmann: The New York Times’ “Opioid Settlement Hinders Patients’ Access to a Wide Array of Drugs,” by Christina Jewett and Ellen Gabler

Also mentioned in this week’s podcast:

• CQ Roll Call’s “Noncompete Rule Puts Doctors, Hospitals at Odds,” by Jessie Hellmann
• Cochrane’s “Statement on ‘Physical Interventions to Interrupt or Reduce the Spread of Respiratory Viruses’ Review,” by Karla Soares-Weiser, editor-in-chief
• The “Osterholm Update” podcast’s “Truth in the Midst of Political Theater,” by Michael Osterholm and Chris Dall
• Stat’s “Denied by AI: How Medicare Advantage Plans Use Algorithms to Cut Off Care for Seniors in Need,” by Casey Ross and Bob Herman

click to open the transcript

Transcript: Judging the Abortion Pill

KHN’s ‘What the Health?’Episode Title: Judging the Abortion PillEpisode Number: 289Published: March 16, 2023

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

Julie Rovner: Hello and welcome back to KHN’s “What the Health?” I’m Julie Rovner, chief Washington correspondent at Kaiser Health News. And I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, March 16, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. We are joined today via video conference by Alice Miranda Ollstein of Politico.

Alice Miranda Ollstein: Good morning.

Rovner: Jessie Hellmann of CQ Roll Call.

Jessie Hellmann: Hello.

Rovner: And Sarah Karlin-Smith the Pink Sheet.

Sarah Karlin-Smith: Hi, Julie.

Rovner: So, we have more than enough news. Let us get right to it. We will start this week with abortion. And, of course, that means we will start in Texas. On Wednesday, federal District Judge Matthew Kacsmaryk held a four-hour hearing in Amarillo on a lawsuit charging that the FDA wrongly approved the abortion pill mifepristone back in the year 2000 and that he, Judge Kacsmaryk, should substitute his legal judgment for the FDA’s medical judgment and order the FDA to take it off the market. What was said at the hearing? Well, we don’t really know because only 18 reporters were allowed in. They weren’t allowed to take any electronic devices in with them. And there’s no audio and no transcript. But, Alice, I know you’ve been trying to follow this from afar, like I have. What do we know about what happened and when might we expect a ruling?

Ollstein: So we can expect a ruling literally at any time. Hopefully not while we are taping right now. The judge did say that he would rule as soon as possible, although with four hours of oral arguments to sift through, that could take a bit of time. I always bank on a Friday evening news dump, because that’s when it tends to happen.

Rovner: I keep reminding people that’s when the ACA [Affordable Care Act] ruling came down.

Ollstein: Exactly.

Rovner: Came down on the Friday before Christmas at 7:30 at night.

Ollstein: Exactly. Thankfully, some great reporters were able to make it and provided us with some updates about this. It was really fascinating. The judge definitely, as we anticipated from his record of working for conservative, explicitly anti-abortion organizations before he was confirmed to this judgeship, he did seem open to taking the steps that the challengers were asking for in restricting access to this medication. I think the question really is whether he is going to go for a full ban or — what a lot of the questions during oral arguments centered around — was around rolling back more recent FDA rules that allowed people to get the pills by telemedicine, by mail delivery. And so there is some question as to … if going all the way back to a 20-year-old FDA approval and overturning it is a bridge too far. Maybe these more recent agency rules are sort of more justifiable in having the court go after them. So, we’re all just on high, high alert, refreshing pages over here.

Rovner: Yeah. Once again, remind us of why this could have national impact, this one judge in Amarillo, Texas?

Ollstein: Yeah. So these anti-abortion medical groups incorporated in Amarillo specifically so that they could get in front of this judge who has a record of being an abortion opponent. And so this is an example of “judge shopping,” which is an increasingly common practice. So this could have national implications because it’s going after the federal regulations around these pills. Really, this will mainly impact blue and purple states, where the pills are still legal and still used today. A bunch of states have already banned them and put restrictions on all forms of abortion or just the pills. And so this really will squeeze states where their use is protected.

Rovner: And I think abortion rights organizations are freaked out because everybody thinks, well, it’s just one judge. You’ll go up to the next level and you’ll get it, you know, you’ll get it stayed. Except in this case, the next level is the 5th Circuit Court of Appeals, which is just as conservative. And we seem to do a lot of anti-abortion rulings. And then if you go above the 5th Circuit Court of Appeals, you’re at the Supreme Court, which just overturned Roe v. Wade. So if this judge rules for the plaintiffs in this case, there’s not a lot of hope, I guess, from the abortion rights side that anything could be overturned, right?

Ollstein: It also gets into really interesting stuff about what is on the labels of these different drugs. Pro-abortion rights and other medical groups have been pushing the FDA to officially add miscarriage management to the label of mifepristone, so that if it is banned in this case, people can still access it for that. That has not happened. It is used for miscarriage management off-label. That is the real risk of people losing access; they’re not just for abortion. Again, there are two pills that have been used for abortions together for the past 20 years, and the other one, misoprostol, there could be restrictions put on it through this case, but because it officially is labeled and marketed for non-abortion purposes, it’s harder to ban.

Rovner: It’s a stomach ulcer drug.

Ollstein: Exactly.

Rovner: All right. Well, assuming that the pill is not pulled from the market, the squabble over whether pharmacies will stock it continues. As we discussed at some length last week, Walgreens caved to threats of prosecution from Republican attorneys general and waffled on whether they’ll sell the pills, even in some states where abortion remains legal. Now, a group of Democratic governors are not so subtly urging seven other national pharmacy chains to pay no attention to those Republican attorneys general threats. Have we heard from any of the other pharmacy chains about whether they will or won’t sell mifepristone in the wake of Walgreens getting raked over the coals by both sides?

Ollstein: Total radio silence. And I think that the backlash to Walgreens is the reason for that. I think they saw what happened. They saw Walgreens getting really slammed from both sides. You know, you have anti-abortion folks slamming Walgreens for saying they’ll sell the pills anywhere in the country. And you have pro-abortion rights people mad at Walgreens for saying that they won’t sell them in some places. So it’s kind of a no-win situation. And the other pharmacies, I’m sure, are looking at that and saying, why would we stick our necks out getting certification from the drugmakers to sell the pills in the first place? It’s going to still take a while and who knows what could happen by the? And so why would we prematurely come out and say what we’re doing when we have no idea?

Rovner: Yeah, and I remind people for the millionth time that it’s not that Walgreens was going to stop selling them. None of the pharmacies have started selling them yet because it was only in January that FDA said for the first time that they could, which, as Alice points out, may be one of the things that this judge in Texas rolls back, if he doesn’t try to roll back the entire approval of the pill. One more on abortion: Also in Texas, the ex-husband of a woman who got an abortion last summer is suing three of her friends for, quote, “wrongful death” for allegedly helping her obtain abortion medication. His evidence largely comes from screenshots from a group chat, raising more calls for better privacy protections for electronic information. Meanwhile, it’s not even totally clear that the abortion was illegal last July, because there was some legal back and forth about whether Texas’ trigger law abortion ban was actually triggered when Roe was overturned the month before. If the ex-husband wins this suit, though, I’m wondering how much of a reaction there is going to be to nonmedical providers being found liable for damages. He’s suing them for $1,000,000. We keep hearing about this, but to my knowledge, it hasn’t actually happened yet, that nobody’s been convicted, I don’t think anywhere of, you know, abetting someone having an abortion, particularly a nonmedical provider.

Karlin-Smith: And then I mean, it seems like, again, it’s designed to have these chilling effects on people and get people to think twice before they do things they otherwise would. And I know this story raises the issue of whether there’ll be more pressure on tech companies to encrypt all data and messages, which would be interesting to see, you know, how companies react going forward. But we already know that …

Rovner: How the tech companies react.

Karlin-Smith: Right. I think we already have seen that doctors who take oaths and hold certain ethical standards to protect people’s health and life have felt like they’ve been put in very challenging situations between the law and what the best care they normally provide for their patients with abortion. So if doctors feel this way, if regular people feel like they’re also going to be on the hook for something, I would be more concerned, in the sense that regular people would feel even less protected. The medical providers, which tend to work for companies that have, you know, lawyers to help them guide them through their decision-making. And, you know, they have various types of insurance as well to help them through this stuff. So it does seem like it could have a big chilling effect if this ex-husband wins in any way.

Rovner: Yes. I mean, the point here is to just further isolate women who are pregnant and don’t want to be, for whatever reason, from reaching out, not just to medical providers, but to their friends, or at least, I guess, reaching out in some way other than in person. We will see how this one plays out. All right. Well, let’s talk about covid, which we haven’t done for a while. First, the reignited fight over the lab leak versus wet-market-origin theory. I have studiously tried to steer away from this because the one thing just about every expert agrees on is that we will probably never know for sure where covid-19 came from. And to quote Michael Osterholm, the esteemed epidemiologist at the University of Minnesota, we have to be prepared for the future for both events: another spillover event and for the lab leak. Still, the House moved forward with a bill this week, already passed by the Senate the week before, to require the declassification of some intelligence related to covid’s origins. Jessie, you covered it. What would the bill do? And is … do we think the president is going to sign this?

Hellmann: So the president hasn’t said yet if he will veto it, but if he does, it would be his first time vetoing something, if I’m not mistaken. So it could be a bad look if he does decide to make that decision. It passed the House 419 to 0. There were 16 non-voting members. It passed the Senate unanimously a few weeks ago, so I can’t imagine that he would veto it. And, basically, what the bill does, it would require the director of national intelligence to declassify information on covid-19 origins within 90 days and send the declassified report to Congress. It’s not clear how much that will illuminate. There’s so many questions about this. The intelligence community is still pretty divided on this issue, despite the Department of Energy, intelligence community saying a few weeks ago that they think it could have arose from a lab leak, though they said that with low confidence. So, it’s not really clear what information we’ll get from this.

Rovner: And this is just basically Congress saying, well, we don’t know, but we want to know what you know.

Hellmann: Yeah.

Rovner: Is that basically where we are?

Hellmann: Exactly. And there’s also, like, a lot of hearings going on right now in Congress where they’re starting to bring people and talk about this. And I think last week, or was it this week, a select committee had a closed meeting with the Department of Energy about their report. So there’s definitely a lot of interest in this.

Rovner: We will definitely see how this plays out. Well, another thing, we are still fighting about, three years in, the efficacy of masks. A couple of weeks ago, the gold-standard scientific organization, the Cochrane Review[s], put out a meta-analysis of mask studies conducted over the years that concluded there was not sufficient evidence to demonstrate that masks help stop the spread of respiratory illnesses. Well, as so often happens with conditional findings like those, mask opponents immediately trumpeted that the study shows that masks don’t work, which is not what the study showed. Now, in a fairly rare step, the editor of the Cochrane Review herself has posted a clarification of the summary of the study, which we will post in the show notes, but I will quote from it: “Commentators have claimed that a recently updated Cochrane Review shows that, quote, ‘Masks don’t work,’ quote, which is an inaccurate and misleading interpretation.” So what’s that line again? A lie travels around the world before the truth can even get out of bed. Is that where we are with masks now? We’ve gotten to the point where there’s this huge belief that masks don’t work. And the fact is, like the origin of covid, we don’t actually know.

Karlin-Smith: I think that the “don’t actually know” is maybe not the best way to put it. There are things we do know, and that’s some of what, you know, has tried to be clarified in the past week or so from this, although there is that ultimate question of: Is it too little, too late, and are people already sort of set in their views? And that’s the sort of thing for different types of researchers to figure out in terms of how you convince people of various evidence and stuff. But, you know, I think one line that stuck out to me is, in The New York Times piece, trying to dissect the nuance of this review. And it is really nuanced and you really have to appreciate those nuances. You know, they say is what we learn from the Cochrane Review is that particularly before the pandemic, distributing masks didn’t lead people to wear them. And thus, if a mask is going to work, but you don’t wear it, it’s not going to work. And you know, people who have been sort of anti-mask to some degree have said, well, but that does show masks don’t work, because if we can’t get people to wear masks, what does it matter? Of course, for people that want to wear a mask or, you know, are comfortable wearing a mask, there’s also plenty of evidence that shows well-fitting, quality masks will block covid. So you shouldn’t think on an individual level, “Let me throw away my N95. It’s not doing me any good.” It certainly is doing you good. And we have, you know, laboratory research and other research to prove that. So, you know, The New York Times did a really good job of dissecting what was really studied, how much was studied, pre-covid, post-covid, what they looked at, and to try and help people understand where we’re at, which is definitely, again, that there can be benefits to wearing masks. There are differences in population benefits versus individual benefits. And when you think about the population benefits, too, sometimes I think you also have to think about even small, subtle benefits on a population level can make a big difference. So even if mask-wearing isn’t the be-all and end-all some people maybe want you to think about, but it helps lower transmission and lowers cases on a population level, you know, that can translate to hundreds of thousands or even millions less cases, which can then lead, you know, to whatever corresponding number of deaths. So I think it’s also thinking about that, you know, something doesn’t have to be 100% effective in stopping transmission to be really valuable on a societal level.

Rovner: They could have summarized it as “Masks don’t work if people don’t wear them, and it’s hard to get people to wear them.” That would have been accurate. Right?

Karlin-Smith: But the other question is: How do we figure out how to get people to wear them if they do work?

Rovner: Well, but that’s not what this study was about.

Karlin-Smith: Right.

Ollstein: I found this whole reaction really depressing. And it’s been huge on Capitol Hill. It’s been coming up at all of these hearings with Republican members citing this and flatly declaring that it shows that masks don’t work, using it to go after officials like CDC Director [Rochelle] Walensky and excoriate her for recommending masks. And it just feels like we’ve learned nothing. Like Sarah was saying, we have not learned the difference between individual and population-level benefits. Everything is so black and white. Either something is completely effective or completely ineffective. There’s no nuance around reducing risk, and everyone keeps talking about how the next pandemic is inevitable. And it just feels like we absolutely have not learned anything from this one.

Rovner: Yeah, if you’d asked me three years ago where we would be in three years, this is not the place I would have predicted. Speaking of covid misinformation, this week the directors of the Food and Drug Administration and the Centers for Disease Control and Prevention took the rare step of writing a joint letter to Florida Surgeon General Joseph Ladapo — I assume that’s how he pronounces his name — warning that his claims that the covid vaccine is causing an upswing in adverse events are, quote, “incorrect, misleading and could be harmful to the American public.” Sarah, I’ve never seen a joint letter from the FDA and the CDC, certainly not to a state official. I mean, they must have been very unhappy about this.

Karlin-Smith: Yeah, I think it was a unique step. But also, Robert Califf at the FDA has made going after what he calls, you know, scientific misinformation, a key part of his commissionership. He often makes the claim that he feels like misinformation is what is killing so many Americans. So it wasn’t surprising in the sense that he felt the need to publicly respond in this way, particularly when you have an individual of such high stature in the state making claims that he feels are potentially dangerous to people. And a lot of what the Florida surgeon general said, again, has a little nugget of truth, but has largely been debunked in the way he’s framing it. So, yes, we do know there is some risk of these myocarditis, these negative heart effects from these covid mRNA vaccines. But we also know that getting covid actually poses a higher risk of these heart events. So it’s a trade-off that most people argue you would prefer to go with the vaccine than that. And so, the fact that, you know, you have such a high-level health official in a state perpetuating anti-vaccine sentiments, I think is why you see Califf and Walensky really feeling like they had to respond, though I’m a little bit perplexed as to why they decided to do it at this particular moment. But I think it’s because he actually addressed them first with a letter. But, you know, this surgeon general has been doing this for a while now.

Rovner: He’s been the surgeon general for a while, and he’s been saying things outside the mainstream, shall we say, for a while. Well, I want to turn to drug prices because there’s a lot of news there, too. Another one of the big three diabetes drugmakers, Novo Nordisk, has followed Eli Lilly’s lead in announcing it will slash the cost of many of its insulin products by up to 75%. First question, how much pressure will this put on Sanofi, the last of the drug companies that dominate the diabetes drug market? Are they almost inevitably going to follow?

Karlin-Smith: I think most people think it is inevitable, although maybe not for the reasons we’re all thinking. Some of it is just that peer pressure. But a big thing that sort of comes out in this: Sean Dickson, to give him credit, at West Health was sort of the first person I saw point this out. There’s changes in the law related to Medicaid rebates and what these companies will essentially, you know, the discounts they have to give Medicaid coming up, that when you raise your prices faster than inflation, because these insulin products have had their prices raised so much over the years, they were going to have to start owing the government money soon for their drugs instead of the government reimbursing them. So that’s seen as really probably one of the key reasons why these changes are happening when they’re happening, which is not to, like, take any credit away from all the advocates who have pushed for lower insulin prices over the years. Certainly, this law and regulation that was passed was designed, in fact, to motivate companies to do this. So, you know, there’s a cynical way of looking at it, and there’s another way of working at it. But, you know, I do think most people expect Sanofi to follow through, particularly if they think it’s going to impact their formulary placement, in terms of how they compete with these products. But then also just, you know, from a PR perspective, it’s not going to look good for them to be that last holdout.

Rovner: But this sort of leads to my next question. I haven’t seen anybody mention this yet, but I can’t help but think that particularly Lilly and Novo Nordisk are happy to cut the prices on insulin and get lots of good press, as you point out, because both of them are sitting on giant blockbuster drugs to treat obesity. Novo already has FDA approval for Wegovy, which is the same drug as its diabetes drug Ozempic, just in a larger dose. While Lilly already has the diabetes drug Mounjaro, whose clinical trials for obesity have shown it may be even more effective than Wegovy in helping people lose weight. Am I missing something here, or are these companies about to make a killing on other drugs?

Karlin-Smith: No, I mean, that’s one point. And I think, you know, Novo Nordisk is more reliant on insulin and diabetes products in general than Eli Lilly and Sanofi, which have broader profiles. But one thing to note is most of the insulin drugs that are getting list price cuts are older insulin. So, you know, Novo Nordisk notably did not cut the price of one of their newer insulins … in their announcement this week. So again, you have to look at which particular products they’re cutting and why. But there’s big concern about how the use of some of these diabetes medicines to treat obesity will impact budgets because such a large percentage of the U.S. population is overweight.

Rovner: You’re just getting to my next question.

Karlin-Smith: That’s what … I assumed you were thinking of this Medicare issue. Right now Medicare does not cover drugs for weight loss, but the thought process is, if they change that, because these drugs are much more effective than prior weight loss drugs have been, you know how will Medicare pay for these? So that’s another big drug pricing debate coming down the pike.

Rovner: I was just going to say, I mean, this is the thing that I’ve been thinking about, you know, and I guess the complication with Medicare … there’s a piece in the New England Journal of Medicine this week by a bunch of drug price researchers that said, well, maybe the cost-benefit for Medicare wouldn’t be quite as good as it would be for the younger population, because obesity is not such a factor for shortening your life if you’re over 65 than if you’re under 65. But as others point out, it’s unlikely that private insurers are going to start covering this medication if Medicare doesn’t. So you’ve got this sort of place where you’ve got these very promising drugs that are currently very expensive, many in the neighborhood of $1,300 a month, which is not what most people can afford, if insurance isn’t covering it. But the promise of working … and you’ve got all these rich people buying it from heaven-knows-what doctor. So there is actually a shortage. But this is expensive enough that if they can’t push the price down, it has the potential to really impact the entire cost of the health care system. Right?

Karlin-Smith: Right. I’ve seen people writing about this the way we were talking about the Alzheimer’s drugs if Medicare was decided to cover it for all patients who qualify for Alzheimer’s, some of the drugs that came out, how they would essentially have to raise premiums and the implications there. They remind me also of, a number of years ago now, when some new cholesterol-lowering medicines came out that were really pricey. And what would happen to Medicare if they got prescribed and used widely? That, of course, didn’t happen. In part, perhaps, because payers curtail these to some degree. This is going to become a really interesting public discussion because the costs issue, but it’s also sort of about how we think about obesity and weight loss. And for a long time, there’s been sort of a stigma attached to weight loss and weight loss products and people not thinking about it as a medical condition, something where you really need to try other things before you get a medicine or get a medical procedure. It’s sort of a personal failure, a cosmetic issue, issues of self-control … and the fact that these drugs are much more successful than previous weight loss medicines, which tended to not help people lose very much weight and had a lot more side effects, some of them were fairly dangerous.

Rovner: And got pulled off the market.

Karlin-Smith: Right.

Ollstein: For killing people.

Karlin-Smith: You’re going to confront a lot of issues head-on in figuring out how to deal with this, because it’s not just about price. It’s sort of thinking about what we consider a disease and what we’re willing to treat as a medical condition.

Rovner: Yeah, I think this is going to be a really big debate going forward. Well, you mentioned Alzheimer’s. And speaking of Alzheimer’s, the Veterans [Health] Administration has announced that it will offer patients with Alzheimer’s disease, that newest Alzheimer’s drug, Leqembi, is that how you pronounce it? It received accelerated approval from the FDA in January. That means more evidence needs to be presented to assure its safety and efficacy. Sarah, is this drug really better/safer than Aduhelm, which it’s a chemical cousin of, right? And that’s the one that we had all the fighting over last year. So what do we think Medicare is going to do with this drug?

Karlin-Smith: So we do have some evidence that this drug does seem to be an improvement over Aduhelm, even though Leqembi only got an accelerated approval so far from the FDA. FDA is already evaluating the drug for full approval because in that interim between when they filed the accelerated approval, they actually pretty much wrapped up a Phase 3 clinical trial that looked at outcomes and did show some benefit on cognition and so forth. There’s certainly a debate out there as to how meaningful that benefit was, but they have shown a hard clinical benefit in trials, not just changed a laboratory marker that is predictive of Alzheimer’s. So that is significant for the company. But it’s just that FDA and then I think CMS hasn’t really considered that further data yet. And so I think there is a good chance that if FDA grants the drug full approval, which I think is pretty likely, will reconsider it, and they maybe were just sort of buying them some time because, again, it is going to be a bit of a challenge to figure out how to operationalize this. The VA, if you compare to Medicare, I was looking yesterday, you know, the VA probably has a few hundred thousand people that might qualify for this drug versus Medicare potentially has upwards of 6 million or so forth. So the different budget process and the VA also has more ability to negotiate drug prices with the company than Medicare does right now for this particular product.

Rovner: So very first-world problems. We finally have drugs to treat things that we’ve been trying to treat effectively for a long time, except that we can’t afford them. So we’re going to … I imagine this debate is going to also continue. Well, finally this week, I wanted to talk briefly about the practice of medicine and the role of the federal government, even though that’s sort of what we’ve been talking about this entire time. Jessie, you wrote about the Biden administration’s rules barring noncompete clauses in employment this week. Obviously, this is something that transcends health care. Apparently, even Starbucks doesn’t want its trained baristas going to work for local competitors. But how does this affect health care?

Hellmann: Yeah, so from what I’ve heard, noncompetes are really rampant in the health care. Especially between physicians and group practices in hospitals. So I’ve seen a lot of doctors submitting comments to the FTC telling them, and some of these is begging them to finalize this rule. There have been … the American Academy of Family Physicians has come out really strongly in favor of the rule. Basically, the argument is that it contributes to burnout, when doctors can’t leave jobs they’re unhappy in. And it also contributes to workforce shortages. If you’re in a noncompete agreement saying that you can’t work at a competitor within a 10- or 20-mile radius and you’re really unhappy in your job, but you might feel compelled to just go work somewhere else. On the other side, you have the American Hospital Association coming out really forcefully against this rule, which is not a good sign and, obviously, very powerful in Washington. And they’re kind of using the covid pandemic as the impetus to try to block this, arguing that providers are really burned out right now. People are leaving the workforce. We really can’t afford to lose people at this time to competitors, and this will make it harder for us to retain and recruit workers. Both sides are making the same arguments in different ways.

Rovner: We’ll wait on these rules. Well, the other big intra-health care dispute that federal officials are being asked to weigh in on is prior authorization. That’s when insurers make it cumbersome for patients to get care their doctors want them to have. The idea is to prevent doctors from providing unnecessary or unnecessarily expensive care. But doctors say it just throws up barriers that make it harder even to get fairly typical care and puts patients at risk by delaying their treatment. I honestly thought this got taken care of in the Affordable Care Act, which incorporated the provisions of the patients’ bill of rights that Congress had been arguing about for the entire decade leading up to the ACA. But now the Biden administration has proposed rules that would require insurers to at least respond faster to prior authorization requests, although that wouldn’t start until 2026. This is actually one of the American Medical Association’s top issues. Is this just another example of people who are not doctors trying to practice medicine, i.e., the insurance companies, and does the federal government really have a role in all of this?

Karlin-Smith: I think this is a tough issue because usually the insurance companies do have doctors that are trying to make these decisions. What you see are doctors actually in medical practice, not an insurance company, complaining about as they’re often not the peers that they say they are. So, you know, you might have a cardiologist making a decision regarding a prior authorization that relates to something in the orthopedic field. So there’s questions about whether the people that really have enough knowledge are making the calls.

Rovner: Or, God forbid, they have nurses making these calls, too.

Karlin-Smith: But it’s one of these issues that’s really tough because there is a sort of in some cases, I think, a need and a reason to have prior authorization. And it can be useful because not all doctors are willing to, you know, maybe try the cheapest alternative for patients when one does exist. There are some, you know, to use the term, sort of, “quacks” out there that sometimes recommend things that the medical establishment overall would agree you shouldn’t be using on patients. But it’s just that the way this is, like, in the real world, it’s sort of gotten out of control, I guess, in some ways. The best way … where legitimate medical care is being denied, patients are going through prior authorization for refills of prescription drugs they clearly have benefited from and have been on for years. So it’s a tricky situation because there is certainly, for the government, an economic reason to have some degree of prior authorization. It’s just figuring out how to get the good out of it, where it actually can benefit and help, even both protect patients financially and medically without hurting patients, and particularly patients that don’t understand how to navigate the system and push back against bad decisions on prior auth.

Hellmann: There is also a really interesting story in Stat this week about the role of artificial intelligence and algorithms in making some of these decisions. So I do have questions about that. It does seem like I have been hearing more and more from doctors lately about how burdensome prior auth has been. I did a story a few months ago about prior authorization requirements for opioid treatment programs, and providers are saying it takes a long time to get approval. Sometimes you get denials for seemingly no reason, like people who need opioid treatment. Some of these people are really vulnerable, and once you decide you need care, you kind of want to get them at that moment. And they might not want to go through an appeals process. And that’s something that the administration has acknowledged is an issue, too. They say that they’re going to look at it.

Rovner: I remember when most of the health beat was actually refereeing these disputes between pieces of the medical establishment, so … there are other things that the administration is busy with in the health care realm. Well, that is the news for this week. Now it is time for our extra-credit segment — that’s where 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 khn.org and in our show notes on your phone or other mobile device. Sarah, why don’t you go first this week?

Karlin-Smith: I took a look at a story in Allure magazine: “With New Legislation, You Can Expect More Recalls to Hit the Beauty Industry.” And it’s a good explainer on modernizations to FDA’s regulations of cosmetics that passed in the end of the year in Congress. It’s the first overhaul since World War II. They say it gives the FDA some pretty big new authorities, like they can mandate the recall of a beauty product if it’s contaminated. Before they basically just had to beg companies to voluntarily do that, which in many cases companies don’t want products that might harm people to be on the market. But sometimes for whatever reason, they might not move as you want. And so it’s important for FDA to have that authority. You know, it also will do things like disclose common allergens to protect people, gives FDA a lot of new funding to help implement this. You know, I think it’s a pretty big consumer bill and it was kind of like an interesting thing to look at a different part of health policy we don’t often talk about. One thing that the story brings up that’ll be interesting to see and I know has been sort of a tension with leading up to whether this law would ever get passed, was how small companies will be able to handle this, and will it put basically small beauty out of business over big companies that know how to handle FDA and its regulations? So we’ll look to see what happens to your smaller cosmetic brands moving forward.

Rovner: Indeed. Jessie.

Hellmann: My extra credit is a story from The New York Times called “Opioid Settlement Hinders Patients’ Access to a Wide Array of Drugs.” And this is an angle I hadn’t really thought about: That $21 billion opioid settlement came with an agreement that distributors place stricter limits on drug suppliers to individual pharmacies and scrutinized their dispensing activity. But it doesn’t just apply to opioids. It applies to all controlled substances. So we’re seeing medications like Xanax and Adderall get caught up in this. And pharmacies are saying, like, it’s making it hard for them to fill prescriptions for patients and some of whom have had them for a really long time. And I don’t know, like, if anyone else has heard about the Adderall shortage — I don’t know if you would classify this as a shortage — but it’s an angle that I hadn’t really thought of. Like, it might not just be supply-chain issues.

Rovner: Yeah, I’ve heard about the Adderall shortage. I mean, I think there’s been a lot of coverage of that. So, yeah, I thought that was a really interesting story, too. Alice.

Ollstein: Yes. I chose a story by my colleagues up in New York, my colleague Julia Marsh, which is about the debate in New York over a flavored-cigarette ban and how it is dividing the civil rights community. And so, you have some civil rights leaders saying that we should ban menthol cigarettes because they have caused a lot of health harms to the Black community. They have long been marketed in ways that target the Black community. They’re in some ways more addictive than non-flavored tobacco. So they’re in support of this ban. And then you have Al Sharpton and some other civil rights leaders on the other side warning that such a ban and the enforcement of such a ban will lead to more police interaction with the Black community, more targeting, and potentially more deaths, which is what we’ve seen in the past. And so a fascinating piece about some …

Rovner: Deaths from law enforcement. Not from cigarettes.

Ollstein: Exactly. Well, yes, it’s kind of “damned if you do, damned if you don’t” on this issue. But a fascinating look at this and what could be a preview as the debates around this at the national level ramp up. So we’ve already seen this happen in California and some other states. Now, the debate is really hot in New York, but it could indicate some of the arguments we might hear if it really moves forward at the national level.

Rovner: Well, my extra credit this week is the latest episode of our competitor podcast “Tradeoffs,” which you really should also listen to regularly, by the way. It’s called “The Conservative Clash Over Abortion Bans,” and it’s actually by Alice here. And it’s a really close look at those exceptions to abortion bans, like for life or health. That’s something that we’ve talked about quite a bit here, except this looks at it from the viewpoint of how it’s dividing the anti-abortion community, which is really interesting. So, super helpful. Everybody listen to it. Thank you, Alice. 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 ever-patient producer, Francis Ying. As always, you can email us your comments or questions. We’re at whatthehealth — all one word — @kff.org. Or you can tweet me. I’m @jrovner. Alice?

Ollstein: @AliceOllstein

Rovner: Sarah?

Karlin-Smith: @SarahKarlin

Rovner: Jessie.

Hellmann: @jessiehellmann

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

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El segundo embarazo de Tamara Etienne estuvo lleno de riesgos y preocupaciones desde el principio, exacerbado porque ya había sufrido un aborto espontáneo.

Como maestra de tercer grado en una escuela pública del condado de Miami-Dade, pasaba todo el día parada. Le pesaban las preocupaciones financieras, incluso teniendo seguro de salud y algo de licencia paga.

Y, como mujer negra, toda una vida de racismo la volvió desconfiada de las reacciones impredecibles en la vida diaria. Estaba agotada por el trato despectivo y desigual en el trabajo. Justamente el tipo de estrés que puede liberar cortisol, que, según estudios, aumenta el riesgo de parto prematuro.

“Lo experimento todo el tiempo, no camino sola, o lo hago con alguien a quien debo proteger. Sí, el nivel de cortisol en mi cuerpo es incontable”, expresó.

A los dos meses de embarazo, las náuseas implacables cesaron de repente. “Empecé a sentir que mis síntomas de embarazo estaban desapareciendo”, dijo. Entonces comenzó un extraño dolor de espalda.

Etienne y su esposo corrieron a la sala de emergencias, donde confirmaron que corría un grave riesgo de aborto espontáneo. Una cascada de intervenciones médicas —inyecciones de progesterona, monitoreo fetal en el hogar y reposo en cama— salvó a la niña, que nació a las 37 semanas.

Las mujeres en Estados Unidos tienen más probabilidades de dar a luz prematuramente que las de la mayoría de los países desarrollados. Esto coincide con tasas más altas de mortalidad materno infantil, miles de millones de gastos en cuidado intensivo y a menudo una vida de discapacidad para los prematuros que sobreviven.

Aproximadamente uno de cada 10 nacimientos vivos en 2021 ocurrió antes de las 37 semanas de gestación, según un informe de March of Dimes publicado en 2022. En comparación, investigaciones recientes citan tasas de nacimientos prematuros del 7,4% en Inglaterra y Gales, del 6% en Francia y del 5,8% en Suecia.

En su informe, March of Dimes encontró que las tasas de nacimientos prematuros aumentaron en casi todos los estados de 2020 a 2021. Vermont, con una tasa del 8%, tuvo la calificación más alta del país: una “A-”. Los resultados más sombríos se concentraron en los estados del sur, que obtuvieron calificaciones equivalentes a una “F”, con tasas de nacimientos prematuros del 11,5% o más.

Mississippi (15 %), Louisiana (13,5 %) y Alabama (13,1 %) fueron los estados con peor desempeño. El informe encontró que, en 2021, el 10,9% de los nacidos vivos en Florida fueron partos prematuros, por lo que obtuvo una “D”.

Desde que la Corte Suprema anulara Roe vs. Wade, muchos especialistas temen que la incidencia de nacimientos prematuros se dispare. El aborto ahora está prohibido en al menos 13 estados y estrictamente restringido en otros 12: los estados que restringen el aborto tienen menos proveedores de atención materna, según un reciente análisis de Commonwealth Fund.

Eso incluye Florida, donde los legisladores republicanos han promulgado leyes contra el aborto, incluida la prohibición de realizarlo después de las 15 semanas de gestación.

Florida es uno de los estados menos generosos cuando se trata de seguro médico público. Aproximadamente una de cada 6 mujeres en edad fértil no tiene seguro, lo que dificulta mantener un embarazo saludable. Las mujeres de Florida tienen el doble de probabilidades de morir por causas relacionadas con el embarazo y el parto que las de California.

“Me quita el sueño”, dijo la doctora Elvire Jacques, especialista en medicina materno-fetal del Memorial Hospital en Miramar, Florida.

Jacques explicó que las causas de los partos prematuros son variadas. Alrededor del 25% se inducen médicamente, por condiciones como la preeclampsia. Pero la investigación sugiere que muchos más tendrían sus raíces en una misteriosa constelación de condiciones fisiológicas.

“Es muy difícil identificar que una paciente tendrá un parto prematuro”, dijo Jacques. “Pero sí puedes identificar los factores estresantes en sus embarazos”.

Los médicos dicen que aproximadamente la mitad de todos los nacimientos prematuros debido a factores sociales, económicos y ambientales, y al acceso inadecuado a la atención médica prenatal, se pueden prevenir.

En el Memorial Hospital en Miramar, parte de un gran sistema de atención médica pública, Jacques recibe embarazos de alto riesgo referidos por otros obstetras del sur de Florida.

En la primera cita les pregunta: ¿Con quién vives? ¿Donde duermes? ¿Tienes adicciones? ¿Dónde trabajas? “Si no supiera que trabajan en una fábrica paradas cómo les podría recomendar que usaran medias de compresión para prevenir coágulos de sangre?”.

Jacques instó al gerente de una tienda a que permitiera a su empleada embarazada trabajar sentada. Persuadió a un imán para que le concediera a una futura mamá con diabetes un aplazamiento del ayuno religioso.

Debido a que la diabetes es un factor de riesgo importante, a menudo habla con los pacientes sobre cómo comer de manera saludable. Les pregunta: “De los alimentos que estamos discutiendo, ¿cuál crees que puedes pagar?”.

El acceso a una atención asequible separa a Florida de estados como California y Massachusetts, que tienen licencia familiar paga y bajas tasas de residentes sin seguro; y a Estados Unidos de otros países, dicen expertos en políticas de salud.

En países con atención médica socializada, “las mujeres no tienen que preocuparse por el costo financiero de la atención”, apuntó la doctora Delisa Skeete-Henry, jefa del departamento de obstetricia y ginecología de Broward Health en Fort Lauderdale. Y tienen licencias por maternidad pagas.

Sin embargo, a medida que aumentan los nacimientos prematuros en Estados Unidos, la riqueza no garantiza mejores resultados.

Nuevas investigaciones revelan que, sorprendentemente, en todos los niveles de ingresos, las mujeres negras y sus bebés experimentan resultados de parto mucho peores que sus contrapartes blancas. En otras palabras, todos los recursos que ofrece la riqueza no protegen a las mujeres negras ni a sus bebés de complicaciones prematuras, según el estudio, publicado por la Oficina Nacional de Investigación Económica.

Jamarah Amani es testigo de esto como directora ejecutiva de Southern Birth Justice Network y defensora de la atención de parteras y doulas en el sur de Florida. A medida que evalúa nuevos pacientes, busca pistas sobre los riesgos de nacimiento en los antecedentes familiares, análisis de laboratorio y ecografías. Y se centra en el estrés relacionado con el trabajo, las relaciones, la comida, la familia y el racismo.

“Las mujeres negras que trabajan en ambientes de alto estrés, incluso si no tienen problemas económicos, pueden enfrentar un parto prematuro”, dijo.

Recientemente, cuando una paciente mostró signos de trabajo de parto prematuro, Amani descubrió que su factura de electricidad estaba vencida, y que la empresa amenazaba con cortar el servicio. Amani encontró una organización que pagó la deuda.

De los seis embarazos de Tamara Etienne, dos terminaron en aborto espontáneo y cuatro fueron de riesgo de parto prematuro. Harta de la avalancha de intervenciones médicas, encontró una doula y una partera locales que la ayudaron en el nacimiento de sus dos hijos más pequeños.

“Pudieron guiarme a través de formas saludables y naturales para mitigar todas esas complicaciones”, dijo.

Sus propias experiencias con el embarazo dejaron un profundo impacto en Etienne. Desde entonces, ella misma se ha convertido en una doula.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Julie Rovner is chief Washington correspondent and host of KHN’s 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.

President Joe Biden’s fiscal 2024 budget proposal includes new policies and funding boosts for many of the Democratic Party’s important constituencies, including advocates for people with disabilities and reproductive rights. It also proposes ways to shore up Medicare’s dwindling Hospital Insurance Trust Fund without cutting benefits, basically daring Republicans to match him on the politically potent issue.

Meanwhile, five women in Texas who were denied abortions when their pregnancies threatened their lives or the viability of the fetuses they were carrying are suing the state. They charge that the language of Texas’ abortion ban makes it impossible for doctors to provide needed care without fear of enormous fines or prison sentences.

This week’s panelists are Julie Rovner of KHN, Shefali Luthra of The 19th, Victoria Knight of Axios, and Margot Sanger-Katz of The New York Times.

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Shefali Luthra
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Margot Sanger-Katz
The New York Times

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Among the takeaways from this week’s episode:

• Biden’s budget manages to toe the line between preserving Medicare and keeping the Medicare trust fund solvent while advancing progressive policies. Republicans have yet to propose a budget, but it seems likely any GOP plan would lean heavily on cuts to Medicaid and subsidies provided under the Affordable Care Act. Democrats will fight both of those.
• Even though the president’s budget includes something of a Democratic “wish list” of social policy priorities, the proposals are less sweeping than those made last year. Rather, many — such as extending to private insurance the $35 monthly Medicare cost cap for insulin — build on achievements already realized. That puts new focus on things the president has accomplished.
• Walgreens, the nation’s second-largest pharmacy chain, is caught up in the abortion wars. In January, the chain said it would apply for certification from the FDA to sell the abortion pill mifepristone in states where abortion is legal. However, last week, under threats from Republican attorneys general in states where abortion is still legal, the chain wavered on whether it would seek to sell the pill there or not, which caused a backlash from both abortion rights proponents and opponents.
• The five women suing Texas after being denied abortions amid dangerous pregnancy complications are not asking for the state’s ban to be lifted. Rather, they’re seeking clarification about who qualifies for exceptions to the ban, so doctors and hospitals can provide needed care without fear of prosecution.
• Although anti-abortion groups have for decades insisted that those who have abortions should not be prosecuted, bills introduced in several state legislatures would do exactly that. In South Carolina, those who have abortions could even be subject to the death penalty. So far none of these bills have passed, but the wave of measures could herald a major policy change.

Also this week, Rovner interviews Harris Meyer, who reported and wrote the two latest KHN-NPR “Bill of the Month” features. Both were about families facing unexpected bills after childbirth. If you have an outrageous or exorbitant medical bill you want 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: KHN’s “Girls in Texas Could Get Birth Control at Federal Clinics, Until a Christian Father Objected,” by Sarah Varney

Shefali Luthra: The 19th’s “Language for Treating Childhood Obesity Carries Its Own Health Risks to Kids, Experts Say,” by Jennifer Gerson

Victoria Knight: KHN’s “After People on Medicaid Die, Some States Aggressively Seek Repayment From Their Estates,” by Tony Leys

Margot Sanger-Katz: ProPublica’s “How Obamacare Enabled a Multibillion-Dollar Christian Health Care Cash Grab,” by J. David McSwane and Ryan Gabrielson

Also mentioned in this week’s podcast:

• The New York Times’ “The Programs You’d Have to Cut to Balance the Budget,” by Alicia Parlapiano, Margot Sanger-Katz, and Josh Katz

Click to open the transcript

Transcript: Biden Budget Touches All the Bases

KHN’s “What the Health?”Episode Title: Biden Budget Touches All the BasesEpisode Number: 288Published: March 10, 2023

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

Julie Rovner: Hello and welcome back to KHN’s “What the Health?” I’m Julie Rovner, chief Washington correspondent at Kaiser Health News. And I’m joined by some of the best and smartest health reporters in Washington. We are taping this week on Friday, March 10, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. Today we are joined via video conference by Shefali Luthra of The 19th.

Shefali Luthra: Hello.

Rovner: Victoria Knight of Axios News.

Victoria Knight: Hi. Good morning.

Rovner: And Margot Sanger Katz of The New York Times.

Margot Sanger Katz: Hello, everybody.

Rovner: Later in this episode we’ll have my “Bill of the Month” interview with Harris Meyer. It’s a twofer this time: two successive bills from two different families related to having a baby. But first, this week’s news. We are taping on Friday this week because President [Joe] Biden released his budget Thursday afternoon, and it felt weird to have a news podcast without talking about the budget. And yes, like most presidential budgets since the 1980s, this one is, quote-unquote, “dead on arrival” on Capitol Hill. But one thing the president’s budget does is provide a pretty-detailed look at the administration’s priorities and policy initiatives. Which health program stuck out to you as getting a publicity, if not an actual funding, boost in this document? Victoria, you were looking at the budget.

Knight: Yeah. My colleagues at Axios and I spent several hours yesterday morning going through the budget. I think it was really interesting because I think he was trying to toe the line between “we want to save Medicare, make sure it stays solvent,” but also “we want to push some more progressive ideas as well.” So there’s kind of both things in there. Some obvious things: He wants to permanently extend the enhanced tax credits for the ACA [Affordable Care Act] — so, make permanent those subsidies. Those expire, currently, at the end of 2025. He also wanted to do something called Medicaid-like coverage for eligible people in states that haven’t expanded Medicaid. And then he also wants to expand the number of drugs to be negotiated under the IRA [Inflation Reduction Act] and also move up the timeline a little bit. So, just an example: It’s supposed to be 10 drugs to be negotiated in 2026. And now he wants to do 20. Something also really interesting: [He] wants to do like a Netflix-like subscription service for hepatitis C to basically eradicate hepatitis C within the U.S.

Rovner: I thought that was maybe the most interesting thing in this budget because it’s something that we just hadn’t heard of before.

Knight: Yeah.

Rovner: That, basically, I mean, these hepatitis C drugs were really expensive when they first came out and there was concern that Medicaid programs, in particular, were going to have trouble paying for them because many of the people who have hepatitis C are intravenous drug users, and they’re more likely to get hepatitis C — or people in prison. Lots of people on Medicaid who have hepatitis C. And this would basically be a way to pay in advance for the drugs. Is that essentially what they would do?

Knight: Yeah. And I think it’s also interesting that it at least has one Republican senator — Bill Cassidy is super into this idea. He did something similar in Louisiana. I’m not sure there’s other Republicans that are on board for that, but I thought that was really interesting. You know, of course, he was talking about extending the $35 insulin cap to the commercial market. There’s some other stuff about behavioral health, pandemic preparedness. One other thing Shefali will appreciate also, he proposed increasing Title X family planning funding by almost 80% from 2023 levels, which I think — Shefali, maybe you know — [is] one of the highest increases they’ve ever proposed, in a while at least.

Luthra: Yeah, the family planning clinics, interest groups, etc., were very, very happy about this proposal, even if they know it will not become reality. I think their sense was this was a commitment that would be really transformative for them, especially now, when they are so tightly funded.

Rovner: I did notice that for a president who has not technically said that he’s running again, some of these targeted increases were for some of the very important interest groups who have been kind of, I won’t say whining, but complaining. You know, Title X had not gotten big increases since Biden became president. There’s an initiative for more money for home- and community-based care in Medicaid, which is something, again, there’s an active constituency for in the Democratic Party; the “Cancer Moonshot,” you know, which has obviously been something near and dear to President Biden’s heart; also more money … also, the [American] Cancer Society sent out a lot of emails yesterday saying, yay, thanks for proposing this big budget increase. So there does certainly seem to be a lot of touching of the important constituencies, perhaps in anticipation of reelection campaign?

[Three panelists chime in at once.]

Luthra: Julie, you forgot …

Sanger-Katz: I would say …

Knight: And I think he did … Go, Margot!

Rovner: One at a time! [laughing all around] Margot, you go first.

Sanger-Katz: I would say so. And I would also just point out that the Medicare policies in the bill were previewed by the White House a couple of days before the budget release, and they were, like, the main thing. This is what they were leading with. The president had an op-ed in The New York Times describing his Medicare policies, and they put out a fact sheet with a lot of the Medicare policies. And I think it really reflects this notion that improving the solvency of Medicare and also committing to not really cutting the core services of Medicare, that this is a very key political message that the president cares about, that the president wants to run on, and that he thinks is a very useful contrast with what some Republicans have proposed in the past and what he imagines they might want to propose as House Republicans get ready to release their own budget, which faces some difficult constraints because Speaker [Kevin] McCarthy has promised certain members that the budget that they will pass will be a balanced budget. And that’s quite hard to do without touching the big health care programs.

Rovner: Yeah. Republicans have not promised not to touch Medicaid, which now the president has been very careful to say, “It’s not just Medicare and Social Security. I’m not going to let you cut Medicare, the Affordable Care Act either.” All right, Victoria, you wanted to say something?

Knight: I think — it was also interesting that, I do think, the president did want to push forward some of the more progressive policies that … the progressive base care about, such as doing more negotiating of drugs; something Sen. Bernie Sanders (I-Vt.) has talked a lot about is the community health centers program; expanding Medicaid, home- and community-based services; … and the insulin price cap — things that I think the progressive base cares about as well. So I feel like, as you’re saying, that interest groups, but also the different bases and also the groups that care about reproductive health care, they want him to do something after Roe v. Wade. So it definitely was, like, this huge list of trying to cater to everyone.

Rovner: It’s kind of a Democratic wish list.

Sanger-Katz: At the same time, though, I think he did leave out some of the things that were part of the Build Back Better package. In the previous budgets, the president had gone even bigger on things that the progressive base wanted. And you can see a lot of things in this budget where he’s ticking those boxes, as you say. And I think a lot of policies that he has proposed in the past that he wasn’t able to get through the last Congress — but not all. It does seem like this budget is a little more focused on being able to reduce the deficit a little bit less on this very expansive notion of a robust federal government that is spending money to improve people’s lives in quite as many ways as the message that he has been proposing in his previous budgets. You can see, again, I think this is a pivot towards campaign mode, towards his assessment of the current political moment, growing concerns about the deficit and about inflation.

Rovner: But also, as you mentioned, Margot, they put out the Medicare part of this in advance, mainly because I feel like the Medicare part of the budget is not so much a part of, you know, the statement of the budget as it is a negotiating position for this whole fight we’re going to have over the debt ceiling in a couple of months, where the Republicans are going to want to demand cuts to programs basically in exchange for not letting the U.S. default on its debts. And what the president has managed to do here is say, “We’re going to lower the price of prescription drugs more, we’re going to tax the rich more. And those two things are going to a) reduce the deficit some and b) shore up the Medicare trust fund. So you can’t accuse me of not dealing with the impending problem of Medicare.” How much of a box does that actually put Republicans in when we start to get to these negotiations?

Sanger-Katz: I don’t know how much of a box it really puts them in for a couple of reasons. One is that some of what he’s proposing is really kind of an accounting gimmick. He’s taking money that is already flowing into the federal budget, that is already part of the dollars and cents of our deficit, and he’s just redirecting them from the general fund into the Medicare trust fund. So it is true that these proposals would extend the solvency of the Medicare Hospital Insurance Trust Fund, which is projected to run into some financial trouble in the coming decade. But it is not true that, like, all of the things that he’s proposing are actually new money. Some of it just comes out of other parts of the budget. It doesn’t change the deficit.

Rovner: So I will point out that that is a time honored way of extending the solvency of trusts.

Sanger-Katz: Oh, sure. I’m not saying that Biden is alone in doing that. But I just think there’s kind of three things he’s doing in this proposal. One of them is not deficit reduction. It’s just kind of moving money around. One is this drug price reduction proposal where he’s trying to get more savings by going more aggressively after more drugs. I think that is a place where he can put Republicans in a box a little bit. They’ve come out in opposition to the drug price negotiation provisions that were part of the Inflation Reduction Act that they passed last year. But those policies are super popular. The public really supports them. They feel like the pharmaceutical companies make too much money. They think that Medicare should be able to negotiate. So I think that’s a very politically shrewd decision that I think does demand potentially a response from Republicans as a possibility for deficit reduction. But then the third thing that he did is he really just raised taxes. You know, these are taxes on the rich; as Biden has been promising all along, he’s not going to raise taxes for people earning under $400,000 a year. So they’ve increased these payroll taxes, they’ve increased some investment taxes. There was kind of a loophole, a category of businesses that were not subject to that tax in the past. And, you know, I think those are basically nonstarters with Republicans. And when Republicans talk about deficit reduction, they often are very, very focused on cutting spending that the federal government does. They are much less interested in increasing taxes. And I do think that the fact that Biden led with this proposal, that he’s so comfortable talking about raising taxes as a core part of his platform, is a sign that the politics of tax cuts have changed a little bit, that that is … if you’re just taxing the rich, it seems like the public will accept that. Democrats seem actually excited about that in certain cases. But I still think tax increases are a hard political row to hoe. I think that it is not something that probably appeals to many Republican politicians. And I also think it’s probably not something that appeals to many Republican voters, either. So I don’t know that it really puts Republicans in a box in a meaningful way because they don’t feel any tension where their supporters will want them to do this thing.

Rovner: Obviously, this is a big fight yet to come. Victoria, you wanted to say something.

Knight: Yeah. I just want to add one thing. We did have, like, the first indicator: The House Freedom Caucus had a press conference this morning, and they didn’t give a lot of details, but they did say they want to restore Clinton-era work requirements for welfare programs. So they didn’t specify Medicaid, but it seems pretty likely that’s probably what they’re talking about. My colleagues and I did talk to some Republicans last week that were indicating they did want work requirements for Medicaid. So I think that seems like the very first. There’s going to be three different groups within the House Republican caucus that are going to release budgets: the Budget Committee, the House Freedom Caucus, the Republican Study Committee. So I think we are going to start seeing the outlines of what they want to do very soon. But that was kind of the first one coming out this morning, so …

Rovner: Yes, underscoring the fact that the Republicans don’t agree on what they want to do …

Knight: No.

Rovner: … which is why we haven’t seen their budget yet.

Knight: Exactly.

Rovner: Although I will point out President Biden’s budget was a month late, too.

Sanger-Katz: Can I just say one thing about the Republican budget? Because I actually spent a lot of time looking at various budget proposals and trying to examine this goal that the Republicans have of balancing the budget. Just like: How hard is it to balance the budget? And it turns out that it’s extremely hard. It’s sort of hard in a normal year. But in this post-covid era, when spending has been so elevated for so long, balancing the budget within a decade is just really, really, really hard. If you do it without raising taxes, which Republicans say they don’t want to raise taxes; if you do it without cutting defense spending, which Republicans say they don’t want to cut defense spending; if you do it without cutting Medicare or Social Security, which recently McCarthy has said he does not want to do — you end up just … this is just the basic math … having to cut everything else by 70%. That’s 7-0%. That is not the kind of cut that you can achieve even by imposing a work requirement on Medicaid, a work requirement on food stamps, and other kinds of policies that Republicans have proposed in the past. That is like deeply, deeply reducing the role of the federal government, you know, cutting Medicaid in more than half. Larry Levitt [KFF’s executive vice president for health policy] pointed out earlier this week reducing Medicaid spending by 70% probably means 50 million fewer people would have Medicaid coverage. And that’s just Medicaid. You’re talking about basically everything that the government does — environmental protection, law enforcement, military pensions, just about any program that you can think about in the government that’s not Medicare, Social Security, or direct defense spending. Seventy percent cut is quite hard to do. And so I am very curious to see what these budgets look like. I can tell you, having looked at some of the previous Republican proposals, that those all relied on some reductions to Medicare and Social Security because those programs represent such a large percentage of federal spending that if you don’t cut those at all, there’s just not a lot of dollars left. And in my reporting on this question, it does seem like one thing that the Republican Budget Committee is very likely to do is to use very aggressive assumptions about the economic growth that their policies will unleash. And so the idea is that if the economy grows by so much, then tax revenue, what increase all by itself, because people will be earning more money, and so that will enable them to balance the budget in 10 years without having to actually reduce the deficit by as much as independent scorekeepers like the Congressional Budget Office think would be necessary.

Rovner: Although I would point out that every time we’ve had one of these big tax cuts that Republicans say it’s going to grow the economy enough to pay for it, it has not grown the economy enough to pay for it.

Sanger-Katz: Indeed! You know, cutting everything that the government does by 70% probably actually would have a negative impact on the economy. People would be losing money. They would be losing their government jobs. These would be very large economic impacts that probably most economists do not think would lead to economic growth.

Rovner: Yeah, well, we will see. I will put, Margot, the nice story you did with your colleagues demonstrating all of this in chart form in the show notes. OK. Let us turn to abortion. We will start with Walgreens, poor Walgreens, caught in the maw of the abortion wars. In January, the FDA said that brick-and-mortar pharmacies for the first time could start dispensing the abortion pill, mifepristone, whose distribution had been tightly regulated since it was first approved more than 20 years ago. Almost immediately, both CVS and Walgreens, the country’s largest and second-largest pharmacy chains, announced they would apply for FDA certification to distribute the pills in states where abortion is still legal. Then, last month, 20 Republican state attorneys general, including at least four in states where abortion is still legal, warned CVS and Walgreens that if they send the pills by mail, they could be in violation of the 1873 Comstock Act, which we have talked about here before, which prohibited the mailing of items considered, air quotes, “obscene,” which at the time included information about birth control. Cut to last week when Walgreens appeared to cave to the pressure and the threat of legal action, saying it would not sell the pill in states where it’s illegal, not actually naming those states. Then, after a huge backlash, it tried to walk back its position a little, mostly leaving lots of questions. Shefali, what is your take on what Walgreens is and isn’t going to do now vis-a-vis mifepristone? They’ve kind of said both things.

Luthra: I think there’s a lot of layers here, but I want to go back to January for a moment, when we got that news from Walgreens and CVS so quickly that they would participate in providing mifepristone. Frankly, a lot of these folks that I spoke to were very surprised that [the pharmacies] reacted so quickly because carrying mifepristone in stock opens you up to really intense harassment, boycotts, protests from the anti-abortion movement. And we did see right away many of the premier anti-abortion movements calling for boycotts of Walgreens and CVS, for protests, etc. They have been organizing protests outside pharmacies right now. And there has been pressure from the beginning from governors like [Florida] Gov. Ron DeSantis instructing pharmacies not to stock the press down. The fact that Walgreens ultimately has caved in these states with hostile governments wasn’t surprising. If anything, it was surprising that it took quite so long. I am incredibly curious to see what happens with CVS and Rite Aid, the other two pharmacies that are now getting caught in the crosshairs, facing really intense pressure from lawmakers and politicians who support abortion access and also those who don’t. We saw in New York this week, the governor and the attorney general called on pharmacies to continue carrying mifepristone. Frankly, I’m skeptical that that really matters because there is no reason not to carry mifepristone in New York, a state where the government is very friendly to abortion.

Rovner: And we should point out, because this is my biggest frustration: Nobody’s actually doing it yet because nobody’s gotten certified yet.

Luthra: Correct.

Rovner: They’re not — all these headlines that said, “Walgreens is going to stop doing this.” It’s like, no, they’re going to not start doing this. Sorry.

Luthra: And we have no idea when they will get certified how long it would take. We have no idea, frankly, if mifepristone will still be able to be distributed in the country at that point, because we are still waiting on the ruling from this judge in Texas. We simply have so many open questions. And at this point, this really is more of an avenue for people to make statements about how they feel about abortion access, than it is actually affecting people’s ability to get care. The other statement grandstanding that I have been really struck by is what we’ve seen from the California governor, Gavin Newsom, who really does love to talk a lot about his pro-abortion rights bona fides, even if those statements don’t translate much into actual impact or policy. And what we saw this week was his promise that California wouldn’t do business with Walgreens if they wouldn’t stock mifepristone.

Rovner: And this is not just an idle threat in California, right? There’s a huge contract that he now says he’s not going to renew.

Luthra: So there is a contract. But friend of the podcast and former KHNer Sydney Lumpkin found the contract that Newsom was referring to. You would think it would be a significant amount of money, given how much attention it has gotten. It is a $54 million contract over five years. When you look at the overall market cap of Walgreens, a $30 billion company, it’s not clear exactly how meaningful that actually is compared to the pressure they are facing from lawsuits and the very powerful anti-abortion movement.

Rovner: So, and what … I mean, you referred to this, but what are we thinking that CVS and Rite Aid are going to do — having seen Walgreens literally put through the wringer here on this issue?

Luthra: I think that’s a really good question. I — I mean, coming into this week — had assumed that they would follow the path of Walgreens and do the exact same thing, right? Stock mifepristone, provide it with a doctor’s prescription in states where they are protected and face no legal risks, but perhaps not do so in those states where a) mifepristone is banned, as they have said they would not do. And also in states where, like Kansas, for instance, abortion is legal, but you have a very anti-abortion attorney general. It is quite interesting that they have not said either way what they will do beyond just, well we won’t do it in states where it’s illegal.

Rovner: Yeah, if I was advising CVS at this point, I would tell them to not say a word to anybody until some of this shakes out.

Luthra: Exactly.

Rovner: All right. Well, let us move on to Texas, where there is always abortion news. As Shefali mentioned, we have not had the decision yet on that abortion pill case out of Amarillo, but both sides are still going at it on other issues. Remember all those stories we’ve been chronicling about women with wanted pregnancies gone wrong who couldn’t get medical care until they were literally at death’s door or they went to another state? Well, five of them are suing the state of Texas, saying they should have been allowed to terminate their pregnancies under existing exceptions to the abortion bans, except that doctors and hospitals have been unwilling to risk giant fines and even jail time. The five women — some of whom are still pregnant, some of whom are not — want the state, whose officials continue to claim that these women were eligible for abortions in Texas if their lives were truly at risk, they want the state to clarify those exceptions even more. Is there any chance this happens? They’re not asking for the bans to be lifted. I mean, this is a kind of a unique lawsuit that we’ve not seen before because we’ve not seen that many women in this situation before.

Luthra: I think this is a pretty smart approach. I wouldn’t be surprised if it has better odds of success than, as you mentioned, a request to fully overturn Texas’ abortion bans because the exceptions are really unclear. Doctors do not feel safe talking about abortion, even in cases where it is likely that it would be very beneficial for the pregnant person, for a fetus that has really minimal chance of survival upon birth. One thing that Nancy Northup, the head of CRR [the Center for Reproductive Rights], said to me when I asked her is, depending on how this case goes, it is not at all unlikely that we see similar lawsuits filed in other states with abortion bans with similarly vague “life of the parent” exceptions that are, in reality, impossible to enforce. I think this is going to be the beginning of a very robust series of legal challenges to state abortion bans. And we’ll see better success for abortion rights lawyers in some states than in others — really depending on the makeup of these different states’ supreme courts.

Rovner: Yeah, I mean, it’s funny because over the years I’ve heard obviously lots of warning about this possibility, both from the Center for Reproductive Rights, which, as you say, is pushing this case, and other groups. But nobody could sue because nobody had standing, because it hadn’t happened. It was all theoretical. Well, now it’s happened and we have people to whom it is not theoretical, who are able to go to court and say, hey, this happened to us and it violated our rights and you need to do something about it.

Luthra: And I do want to add just one thing. I mean, it’s — I think we can’t understate just what these people have been through, the women who are suing Texas. I was just really struck by one woman who flew from Texas to Colorado for an abortion that she couldn’t get in state, paid extra for a seat by the airplane in case she went into labor on the flight, and said that she still has PTSD to this day from having to travel while afraid that she might go into labor and could die from it. Like, what these people are going through right now is just … it’s really difficult for us to imagine. And I think we’re just going to hear so many more stories that are really troubling about people whose lives have been so deeply put at risk, and they’re unable to get the care their doctors want to provide.

Rovner: Right. And I say for the 11th time, these are not women who got pregnant by accident and don’t wish to be pregnant. Many of these are women who’ve been through infertility treatment and were desperately anxious to be pregnant, were thrilled when they got pregnant, but whose pregnancy took a bad turn either for the fetus or, in some cases, one of the fetuses of twins, or in some cases the pregnant person themselves. Well, meanwhile, the Texas Republican legislature has been busy proposing even more abortion restrictions. Last week, we talked about a bill that would ban websites that include information about how to get abortion pills and punish internet providers who don’t block those sites. This week, we have a bill giving state officials the upper hand in prosecuting abortion cases in parts of the state where local Democratic prosecutors have suggested they don’t plan to zealously pursue such cases. Another bill would create a special prosecutor whose job would be, among other things, to pursue violations of the state’s abortion bans. Why is Texas such a hotbed of this?

Luthra: It’s always Texas. Texas is the biggest state in the country to have banned abortion, right? Most of the people who are traveling out of state — well, maybe not most, but the plurality — are Texans, because just so many people live there. And if we think about it, Roe v. Wade, as a case, it came from Texas. SB 8, the first law that allowed a state to circumvent Roe and ban abortions [at] anything after six weeks, that was a Texas law. This is a place where lawmakers really believe that they can be a fertile testing ground for the future of abortion restrictions. Between them and Missouri, I think, that is where we will see the bulk of innovative new ways to further restrict access.

Rovner: Well, speaking of big states that are banning or thinking about banning abortion, you wrote about Florida this week, which already has a ban on abortions after 15 weeks [and is] now considering a ban after six weeks. Florida is kind of a pivotal state in all this, right?

Luthra: Florida, third-biggest state in the country. And if we look at the map of the U.S. South and particularly the Southeast, Florida is just critical. Between Florida and North Carolina, that is where people across the region are going for abortions. And Florida has more than 60 clinics compared to, you know, around a dozen in North Carolina. If abortion there is banned after six weeks, there will be thousands of people who are displaced. They will probably have to go to North Carolina, while abortion is legal there, to Virginia and then to Illinois. And that is just really too far for so many people to travel. There just aren’t realistic options once you take Florida off the map.

Rovner: Well, finally, a bill has been introduced in the South Carolina legislature that could potentially subject patients who get abortions to the death penalty. Now, I am old enough to remember last year, when anti-abortion groups insisted they didn’t want to punish women who had abortions, just those who provide or facilitate them. I guess that’s not the case anymore.

Luthra: And I think we need to see where this bill goes. It is not the only state, either, where we are seeing legislation proposed that would treat abortion as murder or as homicide. There was a bill in Louisiana just last summer that failed on that front. But we have seen bills introduced in Tennessee, in Georgia, in so many others that I cannot remember now. But it’s a long list. I think what’s interesting is, so far, none of these bills have actually moved forward. And it’s still obviously early in the session. But what I’m curious about is, is this chipping away at the resistance toward these kinds of really strict abortion bans? And is this the first step in a multiyear effort to redirect who is punished for getting an abortion to switch from the doctors, the health care providers, to the pregnant people themselves, which has always been sort of this Rubicon the movement has been afraid to cross.

Rovner: Yeah, I remember in 2016 Chris Matthews was interviewing then-candidate Donald Trump and sort of got Donald Trump to say, you know, yes, the woman should be punished. And the anti-abortion movement came at him, like, no, no, no, that’s not what we say. That’s not what we want. And now it’s, you know, seven, eight years later and that’s not necessarily what people are saying. So, we will see how that goes. OK. That’s the news for this week. Now, we will play my “Bill of the Month” interview with Harris Meyer and then we’ll come back and do her extra credits.

We are pleased to welcome to the podcast Harris Meyer, who reported and wrote the last two KHN-NPR “Bill of the Month” stories, which are kind of related. Harris, welcome to “What the Health?”

Harris Meyer: Thanks very much, Julie.

Rovner: So, both of these bills have to do with something very common and very treacherous to your financial health: having a baby. Let’s start with baby No. 1, a now-3-year-old named Joey Trumble. Where is she from? Why was she in the hospital for 36 days?

Meyer: Joey was born prematurely in December 2019. Her mother, Brenna Kearney, is a writer in Chicago, and she was diagnosed with preeclampsia, and her doctors ordered her hospitalized at Northwestern. And then she developed a worse form of preeclampsia called HELLP syndrome. But anyway, the baby was born healthy but premature. And the baby, Joey, was treated at Northwestern Prentice, but without the knowledge of the parents the doctors who were treating her came over from next door from Lurie Children’s, and her hospital, Northwestern, was in network for her health plan. But Lurie Children’s doctors were out of network. They did not know that. So after her baby was sent home — it had about a month, 36 days, of hospitalization — the family got a bill of about $12,000, which was unexpected.

Rovner: That’s right. And we should point out that the baby was covered, right, under the mother’s health insurance.

Meyer: Correct.

Rovner: And yet they still got a bill for $12,000.

Meyer: That’s right. The hospitalization was covered. And, to their surprise, the doctors, the neonatologist from Lurie who treated the baby, were not covered in network. And so Brenna spent the next year contesting these charges. And they were never told that the doctors were out of the network. But she had found out that there was a 2011 Illinois law, which was in effect, which prohibited this kind of out-of-network billing for neonatology services.

Rovner: That’s right. And we should point out that this was before the federal No Surprises Act took effect, because this was late 2019.

Meyer: Correct.

Rovner: But there was a state law that should have applied.

Meyer: There was a state law. Illinois was a pioneer in this. So she cited that law to Blue Cross Blue Shield Illinois and to Lurie Children’s, and they said they knew nothing about it. So the bill was sent to collections about a year later, and she was able to get Blue Cross, finally, and, a year after the birth, to cover the Lurie doctor charges fully. However, in December, three years after she gave birth, she finds out she’s being billed again, after she thought the whole ordeal was over — many years after. And she finds out that Blue Cross of Illinois had taken the money back and now Lurie was coming after her and her husband again for the out-of-network charges. And that’s when she came to Kaiser Health News, and I made calls to Lurie, to Blue Cross of Illinois, and to Northwestern. And after my calls, Lurie agreed to drop the charges. But now a state senator, the Illinois Department of Insurance, and the Illinois attorney general are looking into this to see if there was a long pattern of violations by Lurie of this 2011 state law. And Brenna actually has been contacted now by three other women who experienced similar out-of-network bills from Lurie. So we’ll see what happens with that.

Rovner: So sort of a happy ending to that one. Let’s move to baby No. 2, or, more accurately, his mother. Who is she and what happened to her?

Meyer: OK. This was last June. Danielle Laskey is a school nurse, an RN, in Seattle. She was on vacation with the family. And at 26 weeks pregnant she felt that her water broke. Her doctors in Seattle ordered her to come back and said, you’d better come in. And her doctors were at Swedish Maternal & Fetal Specialty Center in Seattle, which was in network for her Blue Shield health plan. And when she got there, they said, yes, your water broke. You were at risk for the same complication from your first pregnancy three years ago. We want you to go to Swedish Medical Center across the street immediately, and we want you to stay there until you give birth, and we’ll monitor you. So she was in the hospital for seven weeks until she gave birth in August of last year.

Rovner: Oh, so just for context, Swedish is one of the big hospitals in Seattle, right?

Meyer: Yes, absolutely. And it’s one of the specialty facilities for this particular uncommon complication, which is called placenta accreta. Anyway, she was there for seven weeks. And again, she and her husband were not told that the hospital was out of network. But it turns out that Swedish, even though her doctors were — her Swedish doctors were in network for her health plan, it turns out that Swedish Medical Center was out of network, and she found out. Then the baby was born. The baby was in the hospital, the baby boy, for about a month. And then, meanwhile, after the baby was born, she experienced symptoms again, and she was rehospitalized for a day to have this placenta condition treated. Both those hospitalizations — you know, she and her husband, who’s a psychiatrist, thought they were emergencies. The doctors regarded them as emergencies. But yet afterward, the Regence Blue Shield and Swedish decided they were not emergencies. And so, guess what? The family was hit with over $100,000 in out-of-network bills for the two Swedish hospitalizations.

Rovner: And this was after the federal law took effect, right? This was last year.

Meyer: The federal law and a Washington state law were both in effect at that point, which say that you cannot apply out-of-network charges in an emergency situation. So, at first, Blue Shield said that it was not an emergency and it didn’t come under the law. And Swedish Medical Center was going to take the family to collections. The family appealed to Regence Blue Shield. Regence in January granted the appeal for the first hospitalization, erasing $100,000 or so of the charges. But the second hospitalization, $15,000 bill, was still in effect. And then they contacted Kaiser Health News. I contacted Regence Blue Shield and Swedish, and then the charges were dropped for the second hospitalization.

Rovner: Amazing how that happens.

Meyer: Yeah, well, it’s not a solution. So the twist on this one is that Regence Blue Shield said we decided it was an emergency and that it wasn’t proper that the doctors were in network but the hospital wasn’t, so we’re going to consider this an in network and erase the charges. But they said Regence Blue Shield had a contract with Swedish, which made Swedish a quote-unquote “participating provider”; therefore, the federal and state laws do not apply to that situation, and the hospital was allowed to charge the out-of-network charge. We’re going to erase it for this case, but the law does not apply to that situation.

Rovner: I confess, if I’m in a hospital and they say they’re a participating provider, I’m going to assume that means they’re in network. And in this case, it doesn’t, right?

Meyer: Right. It’s a very strange twist that my experts had never encountered before. I took the issue to the federal agency CMS, which administers the No Surprises Act, and they said that they’re going to look into this and HHS, Treasury Department, and Department of Labor are all going to have to look into this to see if this could be fixed through an agency guidance or whether this would require a congressional action to fix this apparent loophole in the law.

Rovner: Creativity. So what’s the takeaway here for both women and particularly for pregnant women who know at some point they’re likely to be in the hospital? You can’t ask every single person who touches you whether they’re in your network. And isn’t that what state and the federal law are supposed to guard against? These are the exact things that we assumed would be taken care of. Right?

Meyer: Right. Well, first of all, the family, the patient, and their loved ones need to ask the hospital and the insurer to tell them their rights under the No Surprises Act and make sure that both the insurer and the provider are following the letter of those federal and state laws. Second, if they do get, God forbid, a out-of-network bill, they need to immediately appeal that to the insurance company, and there’s a two-level appeal process. The second level, they get an independent review. And then, at the same time, they need to file a report or a complaint with the state attorney general’s office, the state department of insurance, and maybe even contact state legislators. There also are private agencies or private companies with nurses and lawyers, etc., that will help families, for a fee, address issues like this. Hopefully it shouldn’t require that, but sometimes it may. And of course, then there’s Kaiser Health News. You can file your “Bill of the Month” complaint through the portal, which we can’t deal with hundreds of thousands of cases, obviously.

Rovner: But we can help at least a few. And Harris Meyer, you helped two. So thank you very much. And thank you for joining us.

Meyer: Thank you, Julie.

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

Knight: My extra credit is called “They Could Lose the House — to Medicaid,” by Tony Leys, and it is published on NPR but is a KHN story. It’s about a family in Iowa who found out, after the mother in the family died, that they could lose their house because she was getting services through Medicaid. She had dementia, and so she needed really intensive at-home family care. Then after she died, they got a letter from the Iowa Department of Human Services — just a month after she died, so not long after — saying that the state was trying to recoup the money that they had spent on her care. So it was almost over $200,000 that they were asking for. And what was really upsetting is this family home was going to be the inheritance for the daughter. And so now they’re kind of like, what are we going to do? Thankfully, they don’t have to do anything with the house until something happens to the father. So it’s not gone immediately. But this is basically something that some states do. It’s called estate recovery programs. And if people use Medicaid in those states, the states have the ability to come back later … whether it’s, like, a house or they can ask for funds that these families used for Medicaid. So it’s really illuminating. I had no idea this was something that happened, and it varies by state to state. But in Iowa, this is something that they kind of pursue very aggressively.

Rovner: I remember when Congress made this a possibility, I think it was back in 1995. It’s been around, the possibility of states recouping Medicaid money for a long time. But as you point out, not all states do it. And it’s usually a surprise when states do do it. People still really don’t know about it. Shefali.

Luthra: So my story is from my 19th colleague, Jennifer Gerson. The headline is “Language for Treating Childhood Obesity Carries Its Own Health Risks to Kids, Experts Say.” And what Jen did, which I think is really smart and important, is she looked at the new clinical guidelines we got from the American Academy of Pediatrics. And those were meant to improve how we evaluate and treat obesity in children. And what she gets into is that there are a lot of children’s health experts, especially mental health experts, who are deeply concerned about what the impacts of these new guidelines could be, how they might exacerbate weight stigma, and how the long-term ramifications of some of the treatment guidelines could actually have worse outcomes for young people as a result, by building on weight stigma, which could lead to different kinds of unhealthy behaviors, could lead to mental health harms that could have much longer term repercussions, possibly more, in fact, dangerous than the actual problems that these guidelines are trying to treat. And one thing that Jen notes I think is really important is that the implications of weight stigma, in particular, are especially harmful for young girls who, as we know, are already facing so many mental health crises in general right now. I thought this was a really important look at a potentially really troubling unintended consequence, and I’m really glad Jen wrote about it.

Rovner: Yeah, I had no idea. It was a very counterintuitive but really interesting piece. Margot, what do you have this week?

Sanger-Katz: I wanted to suggest an article in ProPublica called “How Obamacare Enabled a Multibillion-Dollar Christian Health Care Cash Grab,” by J. David McSwane and Ryan Gabrielson which is just this wonderful historic dive into how the Affordable Care Act ended up allowing something called Christian health ministries to provide an alternative to health insurance. As we all know, the Affordable Care Act basically said, if you’re going to offer health insurance, it has to meet certain minimum guidelines in terms of what it covers and how it works. And these Christian health sharing ministries are just this huge, huge exception where basically it’s just, you know, groups of religiously affiliated people can get together and just pay for each other’s health care or not, depending on what they want to do. There has been a lot of reporting over the years about the degree to which these plans are kind of scammy or poorly run or are not paying for needed health care for their members who think that they are an alternative to insurance. And so this piece is just fun because it looked at the lobbying that generated this strange policy.

Rovner: Yeah. You know, I remember when they got the Christian sharing ministries exception into the ACA and not really knowing where it came from. Well, this story explains exactly where it came from. So it is quite an eye-popping read. Mine is from my KHN colleague Sarah Varney, and it’s called “Girls in Texas Could Get Birth Control at Federal Clinics, Until a Christian Father Objected. Now, for decades, underage girls have been able to get contraception from federally funded Title X family planning clinics without parental permission. An effort by the Reagan administration in the early 1980s, dubbed the “Squeal Rule,” which would have required that parents be notified after the fact, was struck down in federal court and the Reagan administration did not appeal it. And no, I was not there to cover that at that time. I did look it up. A couple of months ago, Judge Matthew Kacsmaryk — yes, that Judge Kacsmaryk, who will any day now rule on whether the FDA approval of the abortion pill should be revoked — ruled in favor of a father in Texas, not a father whose daughters did or said they wanted to obtain contraception from a Title X clinic. But the father complained that the very possibility that his daughters could get birth control without his consent rendered that portion of the law — which has been in effect since Title X, was signed by Richard Nixon in 1970 — unconstitutional. And of course, the judge agreed with him. So for now, the ruling only applies in Texas. But lest you think they’re not coming for your birth control, think again.

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 ever-patient producer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth — all one word — @kff.org. Or you can tweet me. I’m @jrovner. Shefali?

Luthra: I’m @shefalil

Rovner: Victoria.

Knight: @victoriaregisk

Rovner: Margot.

Sanger-Katz: @sangerkatz

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

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