KFF Health News' 'What the Health?': The Health of the Campaign
The Host
Julie Rovner
KFF Health News
Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
When it comes to health care, this year’s presidential campaign is increasingly a matter of which candidate voters choose to believe. Democrats, led by Vice President Kamala Harris, say Republicans want to further restrict reproductive rights and repeal the Affordable Care Act, pointing to their previous actions and claims. Meanwhile, Republicans, led by former President Donald Trump, insist they have no such plans.
Meanwhile, with open enrollment approaching for Medicare, the Biden administration dodges a political bullet, avoiding a sharp spike next year in Medicare prescription drug plan premiums.
This week’s panelists are Julie Rovner of KFF Health News, Alice Miranda Ollstein of Politico, Sandhya Raman of CQ Roll Call, and Anna Edney of Bloomberg News.
Panelists
Anna Edney
Bloomberg
Alice Miranda Ollstein
Politico
Sandhya Raman
CQ Roll Call
Among the takeaways from this week’s episode:
- This week, Sen. JD Vance of Ohio muddled his ticket’s stances on health policy during the vice presidential debate, including by downplaying the possibility of a national abortion ban. And Melania Trump, the former president’s wife, spoke out in support of abortion rights. Their comments seem designed to soothe voter concerns that former President Donald Trump could take actions to further block abortion access.
- Vance raised eyebrows with his debate-night claim that Trump “salvaged” the Affordable Care Act — when, in fact, the former president vowed to repeal the law and championed the GOP’s efforts to deliver on that promise. Meanwhile, Trump deflected questions from AARP about his plans for Medicare, replying, “What we have to do is make our country successful again.”
- On the Democratic side, Vice President Kamala Harris is campaigning on health, in particular by pushing out new ads highlighting the benefits of the ACA and Trump’s efforts to restrict abortion. Polls show health is a winning issue for Democrats and that the ACA is popular, especially its protections for those with preexisting conditions.
- Also in the news, the Centers for Medicare & Medicaid Services reported a slight dip in average Medicare drug plan premiums for next year. Coming in an annual report — out shortly before Election Day — it looks as though government subsidies cushioned changes to the system, sparing seniors from potentially paying in premiums what they may save under the new $2,000 annual out-of-pocket drug cost cap, for instance.
- And in abortion news, a judge struck down Georgia’s six-week abortion ban — but many providers have already left the state. And a new California law protects coverage for in vitro fertilization, including for LGBTQ+ couples.
Also this week, Rovner interviews KFF Health News’ Lauren Sausser, who reported and wrote the latest KFF Health News-Washington Post “Bill of the Month,” about a teen athlete whose needed surgery lacked a billing code. Do you have a confusing or outrageous medical bill you want to share? Tell us about it.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: KFF Health News’ “Doctors Urging Conference Boycotts Over Abortion Bans Face Uphill Battle,” by Ronnie Cohen.
Anna Edney: Bloomberg News’ “A Free Drug Experiment Bypasses the US Health System’s Secret Fees,” by John Tozzi.
Alice Miranda Ollstein: The Wall Street Journal’s “Hospitals Hit With IV Fluid Shortage After Hurricane Helene,” by Joseph Walker and Peter Loftus.
Sandhya Raman: The Asheville Citizen Times’ “Without Water After Helene, Residents at Asheville Public Housing Complex Fear for Their Health,” by Jacob Biba.
Also mentioned on this week’s podcast:
- SisterSong v. State of Georgia: Superior Court of Fulton County decision.
Click to open the transcript
Transcript: The Health of the Campaign
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Friday, October 4th, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go.
Rovner: Today we are joined via teleconference by Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Hello.
Rovner: Sandhya Raman of CQ Roll Call.
Raman: Hello, everyone.
Rovner: And Anna Edney of Bloomberg News.
Anna Edney: Hi there.
Rovner: Later in this episode, we’ll have my “Bill of the Month” interview with my KFF Health News colleague Lauren Sausser. This month’s patient is a high school athlete whose problem got fixed, but his bill did not. But first, the news.
We’re going to start this week with the campaign. It is October. I don’t know how that happened. On Tuesday, vice-presidential candidates Senator JD Vance of Ohio and Governor Tim Walz of Minnesota held their first and only debate. It felt very Midwestern nice, with Walz playing his usual Aw shucks self and Vance trying very hard to seem, for want of a better word, likable. Did we learn anything new from either candidate?
Edney: I don’t think I heard anything new, no — not that I can remember.
Rovner: I know, obviously, they exchanged some views on abortion. Vance tried very hard to distance himself from his own hard-line views on the subject, including denying that he’d ever supported a national abortion ban, which he did, by the way. Meanwhile, during the debate, former President [Donald] Trump announced on social media that he would veto a national abortion ban, something he’d not said in those exact words before. Alice, you’ve got a pretty provocative story out this week suggesting that this all might actually be working on a skeptical public. Is it?
Ollstein: Yes. This has been a theme I’ve been tracking for a little bit. It was part of the reporting I was doing in Michigan a couple weeks ago. One, what I thought was interesting about that night was Trump and Vance have been talking past each other on abortion and contradicting each other, and now …
Rovner: Oh, yeah.
Ollstein: … it finally seems that they are on the same page, in terms of trying to convince the public: Nothing to see here. We won’t do a national ban. Don’t worry about it. Democrats and abortion rights groups are running around screaming: They’re lying. Look at their record. Look at what their allies have proposed in things like Project 2025. But the Republican message on this front does seem to be working. Polls show that even people who care about abortion rights and support abortion rights in some of these key battleground states still plan to vote for Trump. It’s a continuation of a pattern we’ve seen over the past few years where a decent chunk of people vote for these state ballot initiatives to protect abortion but then also vote for anti-abortion politicians.
Voters contain multitudes. We don’t know exactly if it’s because they are not worried that Trump and Vance will pursue national restrictions. We don’t know if it’s because just other issues are more important to them. But I think it’s really worth keeping an eye on in terms of a pattern. And KFF has done some really interesting polling showing that people in states where the ballot initiatives have already passed sort of view it as, Oh, we took care of that, it’s settled, and they don’t see the urgency and the threat of a national ban in the way that Democrats and abortion rights groups want them to.
Rovner: Which we’ll talk about separately in a minute. In late breaking news, Melania Trump this week came out and said that she supports abortion rights. Is this part of the continuing muddle where everybody can see what it is that they want to see, or is this going to have any impact at all?
Ollstein: Can I say one more thing about the debate first?
Rovner: Sure.
Ollstein: OK. So what really struck me about what Vance said about abortion at the debate is he really portrayed two arguments that I’ve seen sort of trickle up from the grass roots of the anti-abortion movement. So one, there were some semantics quibbles around what is a ban. There’s really been an effort in the anti-abortion movement to say that only a total ban throughout pregnancy with no exceptions, only that they call a ban. Everything else, they don’t consider it a ban.
Rovner: It’s a national standard.
Ollstein: Yeah, minimum standard, federal standard. There’s a lot of different words they use — “limit,” “restriction.” But what they’re describing is what others call a ban. It’s not a different policy, and so we saw that on full display on the debate stage. We also saw this argument sort of that these government programs and funding and support are the answer to abortion, so, basically, promoting the idea that with enough child care supports and health care supports, fewer people would have abortions — which the data is mixed on that, I will say, from the U.S. and from other countries. But financial hardship is just one of many reasons people have abortions, so that would impact some people and not others. It also goes against a lot of the sort of traditional small-government, cut-government-spending Republican ethos, and so it is this really interesting sort of pro-natalist direction that some of the party wants to go in and some of the activist movement wants to go in. But there’s definitely some tension around that. And, of course, we’ve seen Republicans vote against those programs and funding at the state and federal level.
Rovner: Things like paid family leave have been a Democratic priority much, much longer than it’s been a Republican priority, if it ever was and if it is now.
Ollstein: But it’s interesting that he was promoting that to sort of show a kinder, gentler face to the anti-abortion movement, which has been a trend we’ve been seeing.
Rovner: Yes. Yes, not just from JD Vance but from lots of Republicans on the anti-abortion side. And Melania—
Ollstein: Sorry, back to Melania.
Rovner: Is there any impact from this?
Edney: Oh, it’s certainly worked for the Trump campaign to muddy the waters on any subject. If you think about immigration, certainly that worked before, and I think you can see where they’re realizing that. And they are coming together, like Alice mentioned, with JD Vance and Trump talking on the same page now a bit better but using sort of a, I don’t want to say “underling,” but like a second …
Rovner: A surrogate.
Edney: Yeah, a surrogate, a secondary character to say, I support abortion rights. And she has Trump’s ear, and that could really be a solid salve to a lot of people.
Rovner: I was fascinated because she’s been pretty much invisible all year. I think this is the first time we have actually heard her voice, the first time I have heard her voice in 2024.
Raman: I would add that it’s not unprecedented for a first lady on the Republican side to come out in favor of abortion rights. I think what makes it so interesting is, A, how close we are to the election and that we are actively in a campaign. When we look at the remarks that Laura Bush made several years ago, it was after [former President George W.] Bush had left office for a few years. And so this, I think, is just what really makes it, if the book is going to come out about a month or so before the election that …
Rovner: Melania’s book.
Raman: Yeah, Melania’s book, yes.
Rovner: So yes, we will see. All right. Well, abortion was not the only health issue that came up during the debate. So did the Affordable Care Act. JD Vance went as far to claim that Donald Trump is actually the one that saved the Affordable Care Act. That’s not exactly how I remember things happening. You’re shaking your head.
Raman: I think this was one of the most striking parts of the debate for me, just because he made several comments about how this was a bipartisan process and Trump was trying to salvage the ACA. And for those of us that were reporting in 2017, he was kind of ringleading the effort to repeal and replace the Affordable Care Act. And I guess there were just numerous claims within the few statements he made that were just all incorrect. He was talking about how Trump had divided risk pools, and that was not something that happened. I think that we assume that he was referring to the reinsurance waivers, but those were also created under the Obama administration, so it wasn’t like a Trump invention. We just had some approved under Trump. And he’d mentioned that enrollment was reaching record heights. Health enrollment grew more under the Biden administration than it did under Trump.
Rovner: Yeah, I went back and actually looked up those numbers because I was so, like, “What are you talking about?” Actually, it was the moderator question: Didn’t enrollment go up during the Trump administration? No, it went down every year.
Ollstein: The number of uninsured went up, in fact, during the Trump administration.
Rovner: That’s right.
Ollstein: But, I mean, this is, again, part of a long pattern. Trump has routinely taken credit for things that were the decisions of other administrations, both before and after him.
Rovner: And things that he tried to do and failed to do.
Ollstein: Right.
Rovner: Like lowering drug prices.
Ollstein: Right. Right, right, right. Exactly. Exactly. Like Anna said, there was very little new that was revealed in this exchange.
Rovner: Well, elsewhere on the campaign trail, the Harris campaign is working hard to elevate health care as an issue, including rolling out not just a 60-second ad warning of what repealing the Affordable Care Act could mean, but also issuing a 43-page white paper theorizing what Trump and Vance are likely to have in mind with their, quote, “concepts” of a health care plan based on what they’ve said and done in the past. They must be seeing something in the polls suggesting this could have some legs, don’t you think? I’m a little surprised, because everybody keeps saying: Not a health care election. This is not a health care election. But I don’t know. The Harris campaign sure keeps behaving like it might be.
Raman: Hammering in on the preexisting conditions and protecting those, just because that is such a popular part of the ACA across the board, is probably a good strategy for them, just because that is something that is not the most wonky with that and that people can understand in a campaign ad and kind of distill down.
Edney: Yeah, that was what I was thinking as well, is it’s a popular issue for, certainly, to be talking about, but also just the idea that he’s talking about it in a way that people think, Oh, we don’t have to worry. And Alice has made this point on abortion before. There’s a lot that he can do through executive order and things like that, and did do like taking away money for the navigators and things to help people enroll. So even if they don’t think it’s maybe going to be about health care fully, it makes sense to try to counter some of that. And you can’t do that on a debate stage most of the time, not in an effective way, but certainly putting out this paper, I mean, it did get some press and things like that, and if you really wanted to go read it, you could.
Rovner: Even I didn’t want to read all 43 pages.
Edney: Yeah.
Rovner: Well, as Anna previewed, the AARP released what’s normally a pretty routine interview with both candidates about issues important to Americans over age 50, things like Medicare, Social Security, and caregiving. But I think it’s fair to say that, at least, former President Trump’s answers were anything but routine. Asked how he would protect Medicare from cuts and improve the program, he said, and I quote: “What we have to do is make our country successful again. This has to do with Medicare and Social Security and other things. We have to let our country become successful, make our country successful again, and we’ll be able to do that.” How do you even respond to things like that? Or is this campaign now so completely divorced from the issues that literally nothing matters?
Edney: Well, I kind of noticed a trend in between that answer and one JD Vance gave when he was talking about abortion, and he said: We just need to make women trust us. They need to trust us again. We need to make them trust us. I was like, I don’t understand how that even connects. But also, how are you going to do that? And I think that this is the same thing. You’re just saying these words over and over again in relation. So in somebody’s mind, Medicare and success is Trump’s word, and trust and abortion as JD Vance’s thing, and you’re connecting these in their minds. And I was seeing this as a trend. It just felt familiar to me after listening to the vice-presidential debate. They’re not going to talk about any policy or anything, but repeating these words over and over again like you were listening to morning affirmations or something was going to really get that through in a voter’s mind is maybe what they’re going for.
Rovner: And I have to say, I mean, when candidates start to talk about actual policy ideas, it gets really wonky really fast. Sort of going back to the debate, JD Vance was talking about visas and immigration, and I think it’s an app that he was talking about. I know this stuff pretty well. I had no idea what he was talking about. I mean, maybe it does work better when Trump says, I’m not going to cut Medicare or Social Security, and leave it at that.
Ollstein: Well, right, because when you talk specific policies, that opens it up to critique. And when you just talk total platitudes, then it’s harder to pick apart and criticize, even though it’s clearly not an answer to the questions they’re asking. And it was even a little bit funny to me for the AARP interview, because I believe they sent in written responses, and so they had the ability—
Rovner: I think they also talked on the phone.
Ollstein: Oh, OK.
Rovner: So I think it was a little bit of both.
Ollstein: Right. Right, right, right. It wasn’t the sort of live televised interview. They could have looked up — it was an open-book test.
Rovner: It was.
Ollstein: And yet all of the responses from Trump were just like, We’re going to do something and it’s going to be great and awesome and it’ll fix everything, and it was completely devoid of policy specifics, which again may be smarter politically than actually saying what you plan to do, which as we’ve seen in Project 2025, generates a lot of backlash. But it is also a little bit dangerous to go into the election not knowing the specifics of what someone wants to do on health care.
Rovner: Yeah, I know. I find when I listen to some of these focus groups with undecided voters, we want to know what exactly they’re going to do, except they don’t really want to know what exactly they’re going to do. They think they do, but it appears that that is not necessarily the case. One thing that we know does matter, at least to people on Medicare, is the premiums they pay for their coverage. And unfortunately, for every administration, that announcement comes just weeks before Election Day every year. So this year, the Biden administration was worried about big jumps in premiums for Medicare Part D drug coverage, mostly thanks to the new caps on spending that will save consumers money but will cost insurers more. That didn’t happen, though. And in fact, average premiums will actually fall slightly next year.
Now, I’m not sure I understand exactly what the administration did to avoid this, but they used existing demonstration authority to boost payments to insurers. And, not surprisingly, Republicans are pretty furious. On the other hand, Republicans used pretty much this same authority to avoid Medicare premium spikes in the past. Anna, is this just political manipulation or good governing, or a little bit of both?
Edney: Yeah, it is certainly very timely and probably necessary also because the IRA, the Inflation Reduction Act, kept the seniors’ out-of-pocket pay at $2,000 a year. And so that was going to skyrocket premiums, and they did not want to face that, particularly in an election year. And as you mentioned, this all happens around that time. And so they did this demonstration, and I have read a few things trying to figure out exactly what it does, and I can’t.
Rovner: So it’s not just me. It’s complicated.
Edney: It’s not just you. It’s really complicated, and it has to do with payments that usually come at the end that insurers are now going to get upfront. And that’s the best I can tell you. But they’ll be getting some subsidies upfront, and it’s to try to spread these premium increases to help mitigate those so that seniors don’t have to then pay on that end instead of for their drugs out-of-pocket. So I think that they need to do something. I mean, already, the premiums were able to go up. I think it’s $35 a month, and some plans did elect to do that and others have them staying even. And you even have some with them going down a little bit. So I guess the moral of the story is for consumers to shop around this year, certainly.
Rovner: That’s right, and we will talk more about Medicare open enrollment, which opens in a couple of weeks, because it’s October, and all of these things happen at once. Moving back to abortion, a judge in Georgia struck down, at least for now, the state’s six-week abortion ban, quoting from “The Handmaid’s Tale” about how the law requires women to serve as human incubators. And I’ll put a link to the decision, because that’s quite the decision. But Alice, this is far from the last word on this, right?
Ollstein: Yes. It’s just so fascinating what a slow burn these lawsuits are. I mean, this, the one in North Dakota recently that restored access, these just sort of simmer under the radar for months or even years, and then a decision can have a major impact. And so access has been restored in some of these states. Some interesting things that came to mind were, one, it could be reversed again and pingpong back and forth, and all of that is very challenging for doctors and patients to manage.
But also — and I’m thinking more of North Dakota, because Georgia is sort of a medical powerhouse with a lot of providers and hospitals and facilities and stuff — but in North Dakota, the state’s only abortion clinic moved out of state, and they do not plan to move back as a result of this decision. This isn’t a switch you can flip back and forth. And so when access is restored on paper in the law, that doesn’t mean it’s going to be restored in practice. You need doctors willing to work in these states and provide the procedure. And even with the court rulings, they may not feel comfortable doing so, or the logistics are just too daunting to move back. So I would urge people to keep that in mind.
Rovner: Yeah, and the state’s already said that it’s going to appeal to the next-higher court. So we will see this continue, but I think it was definitely worth mentioning. We’ve talked a lot this year about women experiencing pregnancy complications not being able to get care in states with abortion bans and restrictions. Well, it’s happening in states where abortion is supposed to be widely available, too.
In California, the state’s attorney general filed suit this week against a Catholic hospital in the rural northern part of the state that refused to terminate the doomed pregnancy of a woman carrying twins after her water broke at 15 weeks, because they said one of the twins still had a heartbeat. She eventually was driven to the only other hospital within a hundred miles of the labor and delivery unit, where she did get the care that she needed, although she was hemorrhaging, but not until after a nurse at the Catholic hospital gave her a bucket of towels, quote, “in case something happens in the car.” Meanwhile, the labor and delivery unit at the hospital she was taken to is itself scheduled to close. Are women starting to get the idea that this is about more than just selective abortions and that no matter where they live, that being pregnant could be more dangerous than it has been in the past?
Raman: I was going to say this is something that abortion rights advocates have been saying for years now, that it’s not just abortion, that they point to things like the whole ordeal that we’ve been having with IVF [in vitro fertilization] and birth control and so many other things. Even in the last couple years, people trying to get other medications that have nothing to do with pregnancy and not being able to get those because they might have an effect or cause miscarriage or things like that. So I think in one way, yes. But at the same time, when you look at something like what we saw happen with the two deaths in Georgia, right? The messaging from the anti-abortion crowd has been that this was not because of the abortion ban but because of the regulations that allowed these people to get a medication abortion and that’s what’s driving the death.
So we think that, in some ways, there’s certain camps that are just going to be focused on a different side of how the emergency might not be related to abortion at all, or the branding is that this is not an abortion in certain cases versus an abortion, it’s just semantics. So I don’t know how many minds it’s changing at this point.
Ollstein: Like Sandhya said, the awareness that this is not just for so-called elective abortions. Obviously, that term is disputed and there’s gray area of what that means. I think the overwhelming focus in messaging — from Democrats, anyway — has been about these wanted pregnancies that suffer medical complications and people can’t get care, and so the spillover effect on miscarriage care. But I think the piece that’s new that this could emphasize is that it’s not a strict red-state-blue-state divide, that Catholic hospitals and other facilities in states with protections, like California — it could happen there, too. So I think that’s what this case may be contributing in a new way to people’s understanding.
Rovner: And, of course, this was happening long before Dobbs — I mean, with Catholic hospitals, particularly Catholic hospitals in areas where there are not a lot of hospitals, denying care according to Catholic teachings and women having basically no place, at least nearby, to go. So I think people are seeing it in a new light now that it seems to be happening in many, many places at the same time. Well, while we are visiting California, Governor Gavin Newsom this week signed legislation requiring large group health insurance plans to cover IVF and other fertility treatments starting next year. California is far from the first state to do this. I think it’s now up to over a dozen. But it’s by far the most populous state to do this. Do we expect to see more of this, particularly given, as you were saying, Sandhya, the attention that IVF is suddenly getting?
Raman: I think we could. We’ve had a lot of states do different variations of those so far, and they haven’t necessarily been blue versus red. I think one thing that was interesting about the California law in particular was that it included LGBTQ people within the infertility definition, which we’ve been having IVF laws for over 20 years at this point and I don’t know that that has been necessarily there in other ones. So I would be watching for more things like that and seeing how widespread that would be in some of the bills coming up in the next legislative cycle.
Rovner: Yes, and another issue that I suspect will continue to simmer beyond this election. Well, finally this week, two big business-of-health-related stories: Over the summer, we talked about how the CEO of Steward Health Care, which is a chain of hospitals bought out by private equity and basically run into bankruptcy, refused to show up to testify before the Senate Health, Education, Labor and Pensions Committee. Well, in the last two weeks, the committee, followed by the full Senate, voted to hold CEO Ralph de la Torre in criminal contempt. And as of last week, he is now ex-CEO Ralph de la Torre, and now he is suing the Senate over that contempt vote. If nothing else, I guess this raises the stakes in Congress to continue to look at the impact of private equity in health care?
Edney: Yeah, I think it’s interesting, because when you look at [Sen.] Bernie Sanders calling in pharmaceutical CEOs, they typically show up and they take their hits and they go home. And in this case, it probably kind of heightens that idea that private equity is the evil person. And I’m not saying everyone thinks pharma is not, but they do understand Washington. And there’s a chance that a lot of New York–focused, Wall Street–focused private equity folks may not get that quite in the same way or just may not view it as important. But now, that may be changing.
Rovner: I was surprised by how bipartisan this was.
Edney: Yeah.
Rovner: I mean, beating up on pharma tends to be a Democratic thing, but this was bipartisan in the committee and bipartisan in the Senate. I mean, it’s also important to remember that Steward Health Care is a chain of hospitals in a whole bunch of states, so there are a lot of senators who are seeing hospitals in, now, dire straits through this whole private equity thing, who I imagine are not very happy about it. And their constituents are not very happy about it. But I think the bipartisanship of it is what sort of stuck out to me.
Raman: I was just going to say hospitals are such a big employer for so many districts that I think that, but I would say this was the first time in 50 years they’ve sent a contemptor to the DOJ [Department of Justice]. And especially doing that in a unanimous fashion is just very striking to me, and I’m curious if DOJ kind of goes forth and does, takes penalty and action with it.
Rovner: Yeah, this is a real under-the-radar story that I think could explode in a big way at some point. Well, the other big, evolving business story this week involves Medicare Advantage, the private sector alternative that gives enrollees extra benefits and makes insurance shareholders rich, mostly at taxpayer expense. Well, the party is, if not ending, then at least slowly closing down. Humana’s stock price dropped dramatically this week after the company reported the new way Medicare officials are calculating quality scores from Medicare Advantage. They get stars. The more stars, the better. The new way that Humana appears to be getting its stars could effectively deprive it of its entire operating profit.
In separate news, UnitedHealthcare is suing Medicare over its Medicare Advantage payments in one of those single-judge conservative districts in Texas, of course. Democrats have been working to at least somewhat rein in these excess payments to Medicare Advantage for the past, I don’t know, two decades or so, but I assume this will all likely be reversed if Trump wins. And Medicare Advantage has been a troublesome issue because it’s really popular with beneficiaries, but it’s really expensive, because it’s really popular, because they get extra money, and some of that extra money goes to give extra benefits. Talk about things that are hard to explain to people. It’s great that you get all these extra benefits, but it’s costing the government more than it should.
Edney: Yeah.
Raman: I guess I do wonder if people, how much attention they’re paying. Are they going to switch plans if it’s dropping that many stars? If you’re on a Humana plan and a huge number of them got demoted to a lower rating, the next time you’re looking for a plan, are you going to switch to something else? And how often people are doing that and just if that would move the needle, because it’s just a longer process than overnight.
Rovner: Although, I think it isn’t just that people have to switch. If people stay in those plans with fewer stars, the company gets less money.
Raman: Yeah.
Rovner: Because they get bonuses when people are in the, quote-unquote, “higher quality” plan. So even if their four-star plan is now a three-star plan and they stay in it, the company’s going to lose money, which I think is why the stock price took such a quick and dramatic bath.
Edney: Yeah, I was surprised. It’s such a seemingly wonky issue, but it did really hit Humana very hard in the stock price. Technically, I think — correct me if I’m wrong — the stars aren’t even out yet. This is people doing searches to see if they can find some of them that have been changed at all, and so they’re coming out soon, but Humana particularly is very Medicare-focused out of all of the insurers. They rely on that for a large part of their revenue, so it is a big deal for them. I don’t know how much, but certainly Wall Street was. And as you mentioned with Trump, the Republicans typically really have supported Medicare Advantage because it is private insurers offering this instead of being just government-run Medicare. So that could have an effect.
It’s hard to tell why their stars went down currently. With UnitedHealth, you at least get a little insight. They’re suing because, last year, their star rating went down for some plans, they said, because of one bad customer service phone call. So someone from Medicare calls and does a test thing, and UnitedHealth says they didn’t ask the right question, so the person never got a chance to answer it correctly, and then their star ratings went down. So, it does feel like it could happen at any point for any reason, so I don’t know how conducive that is, how much that actually plays into people who might have a Humana plan that think, “Oh, I haven’t had any issues, so why would I change?”
Rovner: Yeah. All these under-the-hood things, as you point out, we have all looked at and don’t quite understand is worth billions and billions and billions of dollars. It’s one of the reasons why health care is so expensive and such a big part of the economy. All right. Well, we will continue to watch that space, too. That is the news for the week. Now we will play my “Bill of the Month” interview with Lauren Sausser, and then we will come back with our extra credits.
I am pleased to welcome to the podcast my KFF Health News colleague Lauren Sausser, who reported and wrote the latest KFF Health News “Bill of the Month.” Lauren, thanks for joining us.
Lauren Sausser: Thanks for having me.
Rovner: So tell us about this month’s patient, who he is, and what kind of medical care he needed.
Sausser: This month’s patient is a young man named Preston Nafz. He’s 17. He’s a senior in high school. He lives in Hoover, Alabama, which is right outside of Birmingham. And he played youth sports his whole life and recently is focused on lacrosse, but like many kids in this country, he has sort of cycled through a bunch of different sports, and ended up injured last year.
Rovner: And what happened?
Sausser: He had really debilitating pain in his hip, and the pain was progressive. And, obviously, they tried some treatments on one end of the spectrum, but it kept growing worse and worse. And at one point last year, he ended up limping off of the lacrosse field. He couldn’t do really simple things like turning over in bed or getting in and out of a car. These things were really painful for him. So he ended up as a patient at a sports medicine clinic, and providers at that clinic recommended surgery.
Rovner: And to cut to the chase, the story, at least medically, has a happy ending, right? The surgery worked? He’s better?
Sausser: Yes, the surgery worked. He ended up getting something late last year, a procedure called a sports hernia repair, which is a little bit of a misnomer because he didn’t actually have a hernia. But it’s kind of a catchall phrase that orthopedic surgeons use to talk about a procedure to relieve this type of pain that he was having in his pelvis, groin area. And the recovery was longer than he was anticipating, but yes, it medically does have a happy ending. He was able to play lacrosse again, although the last time I spoke to him, he had another sports-related injury. But the sports hernia repair did do what it was supposed to do, so that’s the good news.
Rovner: So it sounded like it should have been routine. Kid growing up, gets hurt playing sports, family has health insurance, goes to sports medicine, doctor fixes problem. Except for the bill, right?
Sausser: Yeah. So the interesting thing about this story, and this is really why we pursued it, is because there is no CPT [Current Procedural Terminology] code for a sports hernia repair. CPT codes, your listeners are probably familiar with, but they’re the medical codes that providers and insurers use to figure out how things get paid for. And it can become more complicated when there’s no code for a procedure, which was the case here. So Preston’s dad was told before the surgery that he was going to have to pay upfront because his insurance company, which was Blue Cross Blue Shield of Alabama, likely wasn’t going to pay for it.
Rovner: And how much was it upfront?
Sausser: It was just over $7,000. So the surgery itself was $6,000. There was, I think, almost $500 for anesthesia, a little over $600 for the facility fee. And Preston’s dad paid for it on a few different credit cards.
Rovner: So kid has the surgery, is in rehab, and Dad is now trying to recoup this money that he has paid for upfront. And what happened then?
Sausser: Yeah. Before the surgery even happened, Preston’s dad tried to call his insurance company and say: Can I get this covered? My son’s doctor says this is medically necessary. And initially, he got good news. His insurer said: It sounds like this is something that should be covered. If this is something that’s medically necessary, your insurance plan generally covers those things. As the date of the surgery grew closer and closer, he found that the people he was talking to at the insurance company weren’t being as definitive with their answers. And so before the surgery, he got a no. He said he got a no from his insurer saying that they were not going to cover this. Now, on the back end of the surgery, after he’d paid the bill with those credit cards, he tried to appeal that decision by filing a lot of paperwork. And he did end up getting a few hundred dollars reimbursed, but when the insurer sent him that check, it was unclear exactly what they were covering. And, obviously, that didn’t come close to the $7,000-plus that they had paid for it.
Rovner: So that’s what eventually happened with the bill, right? He ended up getting stuck with almost all of it?
Sausser: Yeah.
Rovner: Is there anything he could have done differently that might’ve helped this get reimbursed?
Sausser: That’s the tricky thing about this story, because they did do almost everything right. But it’s almost a cautionary tale for people who are faced with this prospect in the future. So if your provider is recommending something that doesn’t have a CPT code, it is going to be harder to get reimbursed from your insurer. You should assume that. That’s not to say it’s impossible, but it’s going to take more work on your end. It’s going to take more paperwork, it may take more work on your doctor’s end, and you should be prepared to get some pushback, if that makes sense.
Rovner: And has he just sort of written this off?
Sausser: I mean, he paid off the surgery using the credit cards. And the last I spoke to this family, they were still getting some confusing communication from their insurer. I don’t know that they’ve gotten the final, final no yet. I think that he still is invested in getting reimbursed if he can. But at this point, we’re approaching almost the one-year anniversary of the surgery, so it’s looking less likely.
Rovner: Well, we will keep following it. Lauren Sausser, thank you so much.
Sausser: Thanks for having me.
Rovner: OK, we’re back. Now it’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read too. Don’t worry if you miss the details. We’ll include links to all these stories in our show notes on your phone or other mobile device. We have two hurricane-related extra credits this week. Sandhya, why don’t you go first?
Raman: My extra credit this week is called “Without Water After Helene: Residents at Asheville Public Housing Complex Fear for Their Health,” and it is from the Asheville [North Carolina] Citizen Times, by Jacob Biba. And the story just looks at the residents of a specific complex in Asheville that have been hit really hard by the hurricane. And, when this was written, they’d been without water for two days and it might not come back for weeks, and just some of the public health impacts they were facing. One person couldn’t clean their nebulizer or their tracheostomy tube. Others were worrying about sanitation from not being able to flush toilets. I think it’s a good one to check out.
Rovner: Yeah. We think about so many things with hurricanes. We think about being without power. We don’t tend to think about being without water. Alice, you have a related story.
Ollstein: Yeah, and this is more of a supply chain story but really shows that these hurricanes and natural disasters can have really widespread impacts outside the region that they’re in. And so this is from The Wall Street Journal. It’s called “Hospitals Hit With IV Fluid Shortage After Hurricane Helene.” It’s by Joseph Walker and Peter Loftus, and it’s about a facility in North Carolina that produces, like I said, IV bag fluids that hospitals around the country depend on. And yeah, we’ve talked before about just how vulnerable our medical supply chains are and we don’t spread the risk around maybe as much as we need to in this age of climate instability. And so, yeah, hospitals, they’re not rationing the fluids, but they are taking steps to conserve. And so they’re thinking, OK, certain patients can take fluids orally instead of intravenously in order to conserve. And so that’s happening now. Hopefully, it doesn’t become rationing down the road. But, yeah, with the long recovery the region is expecting, it’s a bit scary.
Rovner: Anna.
Edney: I did one from a colleague of mine at Bloomberg, John Tozzi. It’s “A Free Drug Experiment Bypasses the US Health System’s Secret Fees.” So he looked at this Blue Shield of California plan that is deciding to just bypass the pharmacy benefit managers and go directly to a drugmaker to get a biosimilar of Humira, the rheumatoid arthritis and many other ailments drug. And they’re going to be getting it for $525 a month for this drug that a lot of the PBMs are offering for more than a thousand dollars. And so the PBMs mentioned to him, We give rebates, and it’s less than a thousand dollars. But they didn’t say if it was as low as $525. And Blue Shield of California seems to think that this is a really good deal and that they’re basically going to give it for free just to show that it can reach Americans affordably. And so I thought it was a good look at this plan and at maybe a trend, I don’t know, that plans might start going outside of the PBM network.
Rovner: We shall see. Well, I chose a story from KFF Health News this week from Ronnie Cohen, and it’s called “Doctors Urging Conference Boycotts Over Abortion Bans Face Uphill Battle,” and it’s a really thoughtful piece about how to best protest things you disagree with. In this case, some doctors want medical groups to move professional conferences out of states with abortion bans, in order to exert financial pressure and to make a point. But there are those who worry that that amounts to punishing the victims and that it won’t do much anyway, frankly, unless you’re the Super Bowl or the baseball All-Star Game. It’s not like your conference is going to make or break some city’s annual budget. But it’s a microcosm of a bigger debate that’s going on in medicine that I’ve been covering. How do doctors balance their duty to serve patients with their duty to themselves and their own families? There are obviously pregnant medical professionals who do not wish to travel to states with abortion bans lest something bad happens. It’s a struggle that is obviously going to continue. It’s a really interesting story.
OK. That is our show. Before we go this week, it is October and we want your scariest Halloween haikus. The winner will get their haiku illustrated by our award-winning in-house artists, and I will read it on the podcast that we tape on Halloween. We will have a link to the entry page in our show notes.
As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us too. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. Also, as always, you can email us your comments or questions. We’re at whatthehealth, all one word, @kff.org, or you can still find me at X. I’m @jrovner. Sandhya?
Raman: @SandhyaWrites.
Rovner: Anna?
Edney: @annaedney.
Rovner: Alice.
Ollstein: @AliceOllstein.
Rovner: We will be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': Congress Punts to a Looming Lame-Duck Session
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Julie Rovner
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
Congress has left Washington for the campaign trail, but after the Nov. 5 general election lawmakers will have to complete work on the annual spending bills for the fiscal year that starts Oct. 1. While the GOP had hoped to push spending decisions into 2025, Democrats forced a short-term spending patch that’s set to expire before Christmas.
Meanwhile, on the campaign trail, abortion continues to be among the hottest issues. Democrats are pressing their advantage with women voters while Republicans struggle — with apparently mixed effects — to neutralize it.
This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of Politico and the Johns Hopkins schools of nursing and public health, Alice Miranda Ollstein of Politico, and Lauren Weber of The Washington Post.
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Joanne Kenen
Johns Hopkins University and Politico
Alice Miranda Ollstein
Politico
Lauren Weber
The Washington Post
Among the takeaways from this week’s episode:
- When Congress returns after the election, there’s a chance lawmakers could then make progress on government spending and more consensus health priorities, like expanding telehealth access. After all, after the midterm elections in 2022, Congress passed federal patient protections against surprise medical billing.
- As Election Day approaches, Democrats are banging the drum on health care — which polls show is a winning issue for the party with voters. This week, Democrats made a last push to extend Affordable Care Act subsidies expanded during the pandemic — an issue that will likely drag into next year in the face of Republican opposition.
- The outcry over the first reported deaths tied to state abortion bans seems to be resonating on the campaign trail. With some states offering the chance to weigh in on abortion access via ballot measures, advocates are telling voters: These tragedies are examples of what happens when you leave abortion access to the states.
- And Sen. Bernie Sanders of Vermont summoned the chief executive of Novo Nordisk before the health committee he chairs this week to demand accountability for high drug prices. Despite centering on a campaign issue, the hearing — like other examples of pharmaceutical executives being thrust into the congressional hot seat — yielded no concessions.
Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: KFF Health News’ “How North Carolina Made Its Hospitals Do Something About Medical Debt,” by Noam N. Levey and Ames Alexander, The Charlotte Observer.
Lauren Weber: Stat’s “How the Next President Should Reform Medicare,” by Paul Ginsburg and Steve Lieberman.
Joanne Kenen: The Atlantic’s “The Woo-Woo Caucus Meets,” by Elaine Godfrey.
Alice Miranda Ollstein: Stat’s “How Special Olympics Kickstarted the Push for Better Disability Data,” by Timmy Broderick.
Also mentioned on this week’s podcast:
- KFF Health News’ “Florida’s New Covid Booster Guidance Is Straight-Up Misinformation,” by Arthur Allen, Daniel Chang, and Sam Whitehead.
- KFF Health News’ “Feds Killed Plan To Curb Medicare Advantage Overbilling After Industry Opposition,” by Fred Schulte.
- KFF Health News’ “Audits — Hidden Until Now — Reveal Millions in Medicare Advantage Overcharges,” by Fred Schulte and Holly K. Hacker.
- KFF Health News’ “ACA Plans Are Being Switched Without Enrollees’ OK,” by Julie Appleby.
- KFF Health News’ “Biden Administration Tightens Broker Access to Healthcare.gov To Thwart Rogue Sign-Ups,” by Julie Appleby.
click to open the transcript
Transcript: Congress Punts to a Looming Lame-Duck Session
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, September 26th, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So, here we go.
Today we are joined via teleconference by Lauren Weber of The Washington Post.
Lauren Weber: Hello hello.
Rovner: Alice Ollstein of Politico.
Alice Miranda Ollstein: Good morning.
Rovner: And Joanne Kenen of the Johns Hopkins Schools of Public Health and Nursing, and Politico.
Joanne Kenen: Hi, everybody.
Rovner: Big props to Emmarie for hosting last week while I was in Ann Arbor at the Michigan Daily reunion. I had a great time, but I brought back an unwelcome souvenir in the form of my first confirmed case of covid. So apologies in advance for the state of my voice. Now, let us get to the news.
To steal a headline from Politico earlier this week, Congress lined up in punt formation, passing a continuing resolution that will require them to come back after the election for what could be a busy lame-duck session. Somebody remind us who wanted this outcome — the Let’s only do the CR through December — and who wanted it to go into next year? Come on, easy question.
Ollstein: Well, the kicking it to right before Christmas, which sets up the stage for what we’ve seen so many times before where it just gets jammed through and people who have objections, generally conservatives who want to slash spending and add on a bunch of policy riders, which they tried and failed to do this time, will have a weaker base to operate from, given that everybody wants to go home for the holidays.
And so once again, we’re seeing people mad at Speaker Mike Johnson, who, again and again, even though he is fully from the hard right of the party, is not catering to their priorities as much as they would like. And so obviously his speakership depends on which party wins control of the House in November. But I think even if Republicans win control, I’m already starting to hear rumblings of throwing him overboard and replacing with someone who they think will cater to them more.
Rovner: It was so déjà vu all over again, which is, last year, as we approached October 1st and the Republican House could not pass any kind of a continuing resolution with just Republican votes, that eventually Kevin McCarthy had to turn to Democrats, and that’s how he lost his job.
And yet that’s exactly what happened here, which is the Republicans wanted to go until March, I guess on the theory that they were betting that they would be in full power in March and would have a chance to do a lot more of what they wanted in terms of spending bills than if they just wait and do it in the lame duck. And yet the speaker doesn’t seem to be paying the same price that Kevin McCarthy did. Is that just acknowledgment on the part of the right wing that they can’t do anything with their teeny tiny majority?
Kenen: I mean, yes, it’s pretty stalemate-y up there right now, and nobody is certain who’s going to control the House, and at this point it is likely to still be a narrow majority, whoever wins it. I mean, they’re six weeks out. Things can change. This has been an insane year. Nobody’s making predictions, but it looks like pretty divided.
Rovner: Whoever wins isn’t going to win by much.
Kenen: We have a pretty divided country, and the likelihood is we’re going to have a pretty divided House. So the dynamic will change depending on who’s in charge, but the Republicans are more fractious and divided right now than the Democrats, although that’s really easy to change, and even the Democrats have gone through their rambunctious divided phases, too.
Everybody just doesn’t know what’s next, because the top of the ticket is going to change things. So the more months you push out, the less money you’re spending. If you control the CR, if you make the CR, the continuing resolution, meaning current spending levels for six months, it’s a win for the Republicans in many ways because they’re keeping — they’re preventing increases. But in terms of policy, both sides get some of the things they want extended.
I don’t know if you can call it a productive stalemate. That’s sort of a contradiction in terms. But I mean, for the Republicans, longer, it would’ve been better.
Rovner: So now that we know that Congress has to come back after the election, there’s obviously things that they are able to do other than just the spending bills. And I’m thinking of a lot of unfinished health legislation like the telehealth extensions and the constant, Are we going to do something about pharmacy benefit managers? which has been this bipartisan issue that they never seem to solve.
I would remind the listeners that in 2022 after the election, that’s when they finally did the surprise-bills legislation. So doing big things in the lame duck is not unheard of. Is there anything any of you are particularly looking toward this time that might actually happen?
Kenen: It’s something like telehealth because it’s not that controversial. I mean, it’s easiest to get something through in — in lame duck, you want to get some things off the plate that are either overdue and need to be taken care of or that you don’t want hanging over you next year. So telehealth, which is, there are questions about does it save money, et cetera, and what form it should take and how some of it should be regulated, so forth, but the basic idea, telehealth is popular. Something like that, yes.
PBMs [pharmacy benefit managers] is a lot harder, where there is some agreement on the need to do something but there’s less agreement about what that something should look like. So although I’m not personally covering that day-to-day basis, in any sense, that’s harder. The more consensus there is and the fewer moving parts, the easier it is to do, as a rule. I mean, sometimes they do get something big done in lame duck, but a lot of it gets kicked.
And also there’s a huge, huge, huge tax fight next year, and it’s going to require a lot of wheeling and dealing no matter what shape it takes, because it’s expiring and things have to be either renewed or allowed to die. So that’s just going to be mega-enormous, and a lot of this stuff become bargaining chips in that larger debate, and that becomes the dominant domestic policy vehicle next year.
Rovner: Well, even before we get to the lame duck, we have to finish the campaign, which is only a month and a half away. And we are still talking about the Affordable Care Act in an election where it was not going to be a campaign issue, everybody said.
I know that you talked last week about all the specifics of the ways former President [Donald] Trump actually tried to sabotage rather than save the ACA and all the ways what [Sen.] JD Vance was talking about on “Meet the Press,” dividing up risk pools once again so sicker people would no longer be subsidized by the less sick, would turn the clock back to the individual insurance market as it existed before 2014.
Now the Democrats in the Senate are taking one last shot at the ACA with a bill — that will fail — to renew the expanded marketplace subsidies, so it will expire unless Congress acts by the end of next year. Might this last effort have some impact in the swing states, or is it just a lot more campaign noise?
Weber: I think this is a lot of campaign noise, to some extent. I mean, I think Democrats are clear in polling shows that the average American voter does trust Democrats more than Republicans on ACA and health issues and health insurance. So I do think this is a messaging push in part by the Dems to speak to voters. As we all know, this is a turnout election, so I think anything that they feel like voters care about, which often has to do with their pocketbook, I think they’re going to lead the drum on.
I do think it’s interesting again that JD Vance really is reiterating a talking point that Donald Trump used in the debate, which is that he said he had improved the ACA and many experts would say it was very much the opposite. Again, I think I did this on the last podcast, but let me reread this because I think it’s important as a fact check. Most of the Trump administration’s ACA-related actions included cutting the program.
So they reduced millions of dollars of funding for marketing and enrollment, and he repeatedly tried to overturn the law. So I think some of the messaging around this is getting convoluted, in part because it’s an election year, to your point.
Rovner: And because it’s popular. Because Nancy Pelosi was right. When people found out what was in it, it got popular.
Kenen: I think there are two things. I mean, I agree with what Lauren just said, but the Democrats came out in favor of extending the subsidies yesterday, which not only changed the eligibility criteria — more people, more higher up the middle-income chain could get subsidized — but also everybody in it had extra benefits for it, including people who were already covered. But it’s better for them.
The idea that Republicans are going to try to take that benefit away from people six weeks before an election — they were probably not. How they handle it next year? I was really surprised by the silence yesterday. The Democrats rolled out their plans for renewing this, and I didn’t see a lot of Republican pushback. So they were really quiet about it.
The other thing that struck me is that JD Vance went on on this risk pool thing last week on “Meet the Press” and in Raleigh, in North Carolina, and then there was pushback. And on that particular point, there’s been silence for the last week. I don’t think he stuck his neck out on that one again. Who knows what next week will bring, but it didn’t continue, and nor did I hear other Republicans saying, “Yeah, let’s go do that.”
So if that was a trial balloon, it was somewhat leaden. So I think that we really don’t know how the subsidy fight is going to play —how or when the subsidy fight will play out. It’s really, you know, we’ve all said many times before, once you give people the benefit, it’s really hard to take it away. And—
Rovner: Although we did that with the Child Tax Credit. We gave everybody the Child Tax Credit and then took it away.
Kenen: We did, and other things that were temporary during the pandemic, and we’ll just see how many of those temporary things do in fact go away. I mean, does it come back next year? I mean, now SALT [state and local taxes], right? I mean, Trump backed backing what’s called SALT. It’s a limit based on mortgage and state taxes. And now he’s talking about he’s going to rescue that like it wasn’t him who … So it all comes around again.
Ollstein: Yeah, and I think what you’re seeing is both sides drawing the battle lines for next year and signaling what the core arguments are going to be. And so you had Democrats come out with their bill this year, and you are hearing a lot of Republicans in hearings and speeches sprinkled around talking about claiming that there is a huge amount of fraud in the ACA marketplaces and linking that to the subsidies and saying, Why would we continue to subsidize something where there’s all this fraud?
I think that is going to be a big argument on that side next year for not extending the subsidies. So I would urge people to keep listening for that.
Kenen: And that came from a conservative think tank consulting firm in which they blame — I actually happened to read it this week, so it’s fresh in my mind. They’re blaming the fraud actually on brokers rather than individuals. They’re saying that people are—
Rovner: That was an investigation uncovered by my colleague Julie Appleby here at KFF Health News.
Kenen: Right. And they ran with that, and they were talking about the low end of the income bracket. And I’m waiting for the sequel in which the people at the upper end of the income bracket, which is the law that’s expiring that we’re talking about, it’s pretty — I’m waiting for the sequel Paragon paper saying, See, it’s even worse at the upper end, and that’s easy to get rid of because it’ll expire. That’s the argument of the day, but there’s so many flavors of anti-ACA arguments that we’ve just scratched the beginning of this round.
Rovner: Exactly. It’ll come back. All right, well, let us move on to abortion. Vice President [Kamala] Harris said in an interview this week that she would support ending the filibuster in the Senate in order to restore abortion rights with 51 rather than 60 votes, which has apparently cost her the endorsement of retiring West Virginia Democratic senator Joe Manchin. Was Manchin’s endorsement even that valuable to her? It’s not like West Virginia was going to vote Democratic anytime soon.
Ollstein: The Harris campaign has really leaned into emphasizing endorsements she’s been getting from across the ideological spectrum, from as far right as Dick Cheney to more centrist types and economists and national security people. And so she’s clearly trying to brandish her centrist credentials. So I guess in that sense. But like you said, Democrats are not going to win West Virginia, and so I think also he was getting upset about something, a position she’s been voicing for years now. This is not new, this question of the filibuster. So I doubt it’ll have much of an impact.
Kenen: It’s a real careful-what-you-wish for, because if the Senate goes Republican, which at the moment looks like it’s going to be a narrow Republican majority. We don’t know until November. There’s always a surprise. There’s always a surprise.
Rovner: You’re right. It’s more likely that it’ll be 51-49 Republican than it’ll be 51-49 Democrat.
Kenen: Right. So if the filibuster is going to be abolished, it would be to advance Republican conservative goals. So it’s sort of dangerous territory to walk into right now. The Democrats have played with abolishing the filibuster. They wanted to do it for voting rights issues, and they decided not to go there on legislation. They did modify it a number of years ago on judicial appointments and other Cabinet appointments and so forth.
But legislative, the filibuster still exists. It’s very, very, very heavily used, much more than historically, by both parties, whoever is in power. So changing it would be a really radical change in how things move or don’t move. So it could have a long tail, that remark.
Rovner: Meanwhile, Senate Democrats, who don’t have the votes now, as we know, to abolish the filibuster, because Manchin is among their one-vote margin, are continuing to press Republicans on reproductive rights issues that they think work in their favor. Earlier this week, the Senate Finance Committee had a hearing on EMTALA, the Emergency Medical Treatment and Labor Act.
It’s a federal law that’s supposed to guarantee women access to abortion in medical emergencies. But in practice, it has not. Last week we talked about the ProPublica stories on women whose pregnancy complications actually did lead to their death. Is this something that’s breaking through as a campaign issue? I do feel like we’ve seen so much more on pregnancy complications and the health impacts of those rather than just, straight, women who want to end pregnancies.
Ollstein: I just got back from Michigan, and I would say it is having a big impact. I was really interested in how Democrats were trying to campaign on abortion in Michigan, even now that the state does have protections. And I heard over and over from voters and candidates that Trump’s leave-it-to-the-states stance, they really are still energized by that.
They’re not mollified by that, because they are pointing to stories like the ones that just came out in Georgia and saying: See? That’s what happens when you leave it to the states. We may be fine, but we care about more than just ourselves. We’re going to vote based on our concern for women in other states as well. I found that really interesting to be hearing out in the field.
Rovner: Lauren, you want to add something?
Weber: Yeah, I just was going to add, I mean, Harris obviously highlighted this effectively in the debate, and I think that has helped bring it to more of a crescendo, but there’s obviously been a lot of reporting for months on this. I mean, the AP has talked about — I think they did a count. It’s over 100 women, at least, have been denied emergency care due to laws like this.
I’d be curious — and it sounds like Alice has this, for voters that are in swing states, that it’s breaking through to — I’d be curious how much this has siloed to people that are outraged by this, and so we’re hearing it and how much it’s skidding down to those that — the Republican talking points have been that these are rare, they don’t really happen, it’s a liberal push to get against this. I’d be curious how much it’s breaking through to folks of all stripes.
Rovner: I watched a big chunk of the Finance Committee hearing, and the anti-abortion witnesses were saying this is not how it worked, that ectopic pregnancies, pregnancy complications do not qualify as abortions, and basically just denying that it happened. They’re sitting here. They’re sitting at the witness table with the woman to whom this happened and saying that this does not happen. So it was a little bit difficult, shall we say. Go ahead.
Ollstein: Well, and the pushback I’ve been hearing from the anti-abortion side is less that it’s not happening and more that it’s not the fault of the laws, it’s the fault of the doctors. They are claiming that doctors are either intentionally withholding care or are wrong in their interpretation of the law and are withholding care for that reason. They’re pointing to the letter of the law and saying, Oh no, it doesn’t say let women bleed out and die, so clearly it’s fine. They’re not really grappling with the chilling effect it’s having.
Rovner: Although we do know that in Texas when, I think it was Amanda Zurawski, there was — no, it was Kate Cox who actually got a judge to say she should be allowed to have an abortion. Ken Paxton, the Texas attorney general, then threatened the hospital, said, If you do this, I will come after you. On the one hand, they say, Well, that’s not what the law says. On the other hand, there are people saying, Yeah, that’s what the law says.
Turning to the Republicans, Donald Trump had some more things to say about abortion this week, including that he is women’s protector and that women will, and I quote, “be happy, healthy, confident, and free. You will no longer be thinking about abortion.”
If that wasn’t enough, in Ohio, Bernie Moreno, who’s the Republican running against Senator Sherrod Brown in the otherwise very red state, said the other night that he doesn’t understand why women over 50 would even care about abortion, since, he suggested, they can no longer get pregnant, which isn’t correct, by the way. But who exactly are the voters that Trump and Moreno are going after here?
Kenen: Moreno is already lagging in the polls. Sherrod Brown is a pretty liberal Democrat in an increasingly conservative state, and he’s also very popular. And it looks like he’s on a glide path to win, and this probably made it easier for him to win. And there are men who support abortion rights, and there are women who oppose.
I mean, this country’s divided on abortion, but it’s not age-related. It’s not like if you’re under 50 and female, you care about abortion and nobody else does. I mean, that’s really not the way it works. Fifty-year-old and older women, some of whom had abortions when they were younger, would want that right for younger women, including their daughters. It’s not a quadrant. It’s not like, oh, only this segment cares.
Ollstein: It’s interesting that it comes amid Democrats really working to broaden who they consider an abortion voter, like I said, trying to encourage people in states where abortion is protected to vote for people in states where abortion is not protected and doing more outreach to men and saying this is a family issue, not just a women’s issue, and this affects everybody.
So as you see Democrats trying to broaden their outreach and get more people to care, you have Bernie Moreno saying the opposite, saying, I don’t understand why people care when it doesn’t affect their own particular life and situation.
Rovner: Although I will say, having listened to a bunch of interviews with undecided voters in the last couple of weeks, I do hear more and more voters saying: Well, such and such candidate, and this is on both sides, is not speaking to me. It’s almost like this election is about them individually and not about society writ large.
And I do hear that on both sides, and it’s kind of a surprise. And I don’t know, is that maybe where Moreno is coming from? Maybe that’s what he’s hearing, too, from his pollsters? It’s only that people are most interested in their own self-interest and not about others? Lauren, you wanted to add to that?
Weber: I mean, I would just say I think that’s a kind interpretation, Julie. I think that more likely than not, he was just speaking out of turn. And in some prior reporting I did this year on misinformation around birth control and contraception, I spoke to a bunch of women legislators, I believe it was in Idaho, who found that in speaking with their male legislator friends, that a lot of them were uncomfortable talking about abortion, birth control, et cetera, which led to a lot of these misconceptions. And I wonder if we’re seeing that here.
Ollstein: Just quickly, I think it’s also reflective of a particular conservative mind-set. I mean, it reminds me of when I was covering the Obamacare fight in Congress and you had Republican lawmakers making jokes about, Oh, well, wouldn’t want to lose coverage for my mammograms. And just what we were just talking about, about the separate risk pools and saying, Oh, I’m healthy. Why should I subsidize a sick person? when that’s literally how insurance works.
But I think just the very individualistic go-it-alone, rugged-individual mind-set is coming out here in different ways. And so it seems like he did not want this particular comment to be scrutinized as it is getting now, but I think we hear versions of this from conservative lawmakers all the time in terms of, Why should I have to care about, pay for, subsidize, et cetera, other people in society?
Rovner: Yeah, there’s a lot of that. Well, finally this week in reproductive health issues that never seem to go away, a federal judge in North Dakota this week slapped an injunction on the Equal Employment Opportunity Commission’s enforcement of some provisions of the 2022 Pregnant Workers Fairness Act, ruling that Catholic employers, including for-profit Catholic-owned entities, don’t have to provide workers with time off for abortions or fertility treatments that violate the church’s teachings.
Now, lest you think this only applies to North Dakota, it does not. There’s a long way to go before this ruling is made permanent, but it’s kind of awkward timing for Republicans when they’re trying to convince voters of their strong support of IVF [in vitro fertilization], and yet here we have a large Catholic entity saying, We don’t even want to give our workers time off for IVF.
Ollstein: Yeah, I think you’ve been hearing a lot of Republicans scoffing at the idea that anyone would oppose IVF, when there are many, many conservatives who do either oppose it in its entirety or oppose certain ways that it is currently commonly practiced. You had the Southern Baptist Convention vote earlier this year in opposition to IVF. You have these Catholic groups who are suing over it.
And so I think there needs to be a real reckoning with the level of opposition there is on the right, and I think that’s why you’re seeing an interesting response to Trump’s promise for free IVF for all and whether or not that is feasible. I think this shows that it would get a lot of pushback from groups on the right if they were ever to pursue that.
Rovner: Yeah, I will also note that this was a Trump-appointed judge, which is pretty … The EEOC, when they were doing these final regulations, acknowledged that there will be cases of religious employers and that they will look at those on a case-by-case basis. But this is a pretty sweeping ruling that basically says, we’re back to the Hobby Lobby Supreme Court case: If you don’t believe in something, you don’t have to do it.
I mean, that’s essentially where we are with this, and we will see as this moves forward. Well, moving on to another big election issue, drug prices, the CEO of Novo Nordisk, makers of the blockbuster obesity and diabetes drugs Ozempic and Wegovy, appeared at the Senate Health, Education, Labor and Pensions Committee on Tuesday in front of Senator Bernie Sanders, who has been one of their top critics.
And maybe it’s just my covid-addled brain, but I watched this hearing and I couldn’t make heads or tails of how Lars Jørgensen, the CEO, tried to explain why either the differences between prices in the U.S. and other countries for these drugs weren’t really that big, or how the prices here are actually the fault of PBMs, not his company. Was anybody able to follow this? It was super confusing, I will say, that he tried to …
First he says that, well, 80% of the people with insurance coverage can get these drugs for $25 a month or less, which I’m pretty sure only applies to people who are using it for diabetes, not for obesity, because I think most insurers aren’t covering it for obesity. And there was much backing and forthing about how much it costs and how much we pay and how much it would cost the country to actually allow people, everybody who’s eligible for these drugs, to use them. And no real response. I mean, this is a big-deal campaign issue, and yet I feel like this hearing was something of a bust.
Weber: I mean, do we really expect a CEO of a highly profitable drug to promise to reduce it immediately on the spot? I mean, I guess I’m not surprised that the hearing was a back-and-forth. From what I understand of what happened, I mean, most hearings with folks that have highly lucrative drugs, they’re not looking to give away pieces of the lucrative drugs. So I think to some extent we come back to that.
But I did think what was interesting about the hearing itself was that Sanders did confront him with promises from PBMs that they would be able to offer these drugs and not short the American consumer, which was actually a fascinating tactic on Sanders part. But again, what did we really walk away with? I’m not sure that we know.
Rovner: Yeah, I mean, even if you were interested in this issue — and I’m interested in this issue and I know this issue better than the average person, as I said —I literally could not follow it. I found it super frustrating. I mean, I know what Sanders was going for here. I just don’t feel like he got what he was hoping to. I don’t know. Maybe he was hoping to get the CEO to say, “We’ve been awful, and so many people need this drug, and we’re going to cut the price tomorrow.” And yes, you point out, Lauren, that did not happen. But we shall see.
Well, speaking of PBMs, the Federal Trade Commission late last week filed an administrative complaint against the nation’s three largest PBMs, accusing them of inflating insulin prices and steering patients toward higher-cost products so they, the PBMs, can make more money, which is, of course, the big problem with PBMs, which is that they get a piece of the action. So the more expensive the drug, the bigger the piece of the action that they get.
I was most interested in the fact that the FTC’s three Democratic appointees voted in favor of the legal action. Its two Republican appointees didn’t vote but actually recused themselves. This whole PBM issue is kind of awkward for Republicans who say they want to fight high drug prices, isn’t it? I feel like the whole PBM issue, which, as we said, is something that Congress in theory wants to get to during the lame-duck session, is tricky.
I mean, it’s less tricky for Democrats who can just demagogue it and a little bit more tricky for Republicans who tend to have more support from both the drug industry and the insurance industry and the PBM industry. How much can they say they want to fight high drug prices without irritating the people with whom they are allied?
Kenen: And the PBMs themselves are owned by insurers. The pharmaceutical drug pricing, it’s really, really, really confusing, right?
Rovner: Nobody understands it.
Kenen: The four of us, none of us cover pharma full time, but the four of us are all pretty sophisticated health care reporters. And if we had to take a final exam on the drug industry, none of us would probably get an A-plus. So I’d be surprised if they figure this out in lame duck. I mean, they could —there’s always the possibility that when they look at the outcome of things, they decide: We do need to cut a deal and get this off the plate. This is the best we’re going to get. We’re going to be in a worse position next month. And they do it.
But it just seems really sticky and complicated, and it doesn’t feel like it’s totally jelled yet to the point that they can move it. I would expect this to spill into next year. If a deal comes through, if a big budget deal comes through at the end of the year, it does have a lot of trade-offs and moving parts, and this could, in fact, get wrapped into it.
If I had to guess, I would say it’s more likely to spill into the following year, but maybe they’ve decided they’ve had enough and want to tie the bow on it and move on. And then it’ll go to court and we’ll spend the next year talking about the court fight against the PBM law. So it’s not going to be gone one way or another, and nor are high drug prices going to be gone one way or another.
Rovner: The issue that keeps on giving. Well, finally this week, a new entry in out This Week in Health Misinformation segment from, surprise, Florida. This is a story from my KFF Health News colleagues Arthur Allen, Daniel Chang, and Sam Whitehead. And the headline kind of says it all: “Florida’s New Covid Booster Guidance Is Straight-Up Misinformation.”
This is the continuing saga involving the state surgeon general, Joseph Ladapo, who’s been talking down the mRNA covid vaccine for several years now and is recommending that people at high risk from covid not get the latest booster. What surprised me about this story, though, was how reluctant other health leaders in Florida, including the Florida Medical Association, have been to call the surgeon general out on this.
I guess to avoid angering his boss, Republican governor Ron DeSantis, who’s known to respond to criticism with retribution. Anybody else surprised by the lack of pushback to this there in Florida? Lauren?
Weber: No, I’m not really surprised. I mean, we’ve seen the same thing over and over and over again. I mean, this is the man who really didn’t make a push to vaccinate against measles when there was an outbreak. He has previously stated that seniors over 65 should not get an mRNA vaccine, with misinformation about DNA fragments. We’ve seen this pattern over and over again.
He is a bit of a rogue state public health officer in a crew that usually everyone else is on pretty much the same page, whether or not they’re red- or blue-state public health officers. And I think what’s interesting about this story and what continues to be interesting is as we see RFK [Robert F. Kennedy Jr.] gaining influence, obviously, in Trump’s potential health picks, you do wonder if this is a bit of a tryout. Although Ladapo is tied to DeSantis, who Trump obviously has feelings about. So who knows there. But it very clearly is the politicization of public health writ large.
Kenen: And DeSantis, during the beginning of the pandemic, he disagreed with the CDC [Centers for Disease Control and Prevention] guidelines about who should get vaccinated, but he did push them for older people. And I think that was his cutoff. If you’re 15 up, you should have them. He was quite negative from the start on under. Florida’s vaccination rates for the older population back when they rolled out in late 2020, early 2021, were not — they were fairly high. And there’s been a change of tone. As the political base became more anti-vax, so did the Florida state government.
Rovner: And obviously, Florida, full of older people who vote. So, I mean, super-important constituency there. Well, we will watch that space. All right, that is this week’s news. Now it is time for our extra credits. That’s when we each recommend a story we read this week we think you should read, too. Don’t worry if you miss the details. We will include links to all these stories in our show notes on your phone or other device. Joanne, why don’t you go first this week?
Kenen: Elaine Godfrey in the Atlantic has a story called “The Woo-Woo Caucus Meets,” and it’s about a four-hour summit on the Hill with RFK Jr., moderated by Senator Ron Johnson of Wisconsin, who also has some unconventional ideas about vaccination and public health. The writer called it the “crunch-ificiation of conservatism.”
It was the merging of the anti-vax pharma-skeptic left and the Trump right and RFK Jr. talking about MAHA, Making America Healthy Again, and his priorities for what he expects to be a leading figure in some capacity in a Trump administration fixing our health. It was a really fun — just a little bit of sarcasm in that story, but it was a good read.
Rovner: Yeah, and I would point out that this goes, I mean, back more than two decades, which is that the anti-vax movement has always been this combination of the far left and the far right.
Kenen: But it’s changed now. I mean, the medical liberty movement, medical freedom movement and the libertarian streak has changed. It started changing before covid, but it’s not the same as it was a few years ago. It’s much more conservative-dominated, or conservative-slash-libertarian-dominated.
Rovner: Alice.
Ollstein: I have an interesting story from Stat. It’s called “How Special Olympics Kickstarted the Push for Better Disability Data.” It’s about how the Special Olympics, which just happened, over the years have helped shine a light on just how many people with developmental and intellectual disabilities just aren’t getting the health care that they need and aren’t even getting recognized as having those disabilities.
And the data we’re using today comes from the Clinton administration still. It’s way out of date. So there have been improvements because of these programs like Healthy Athletes that have been launched around this, but it’s still nowhere near good enough. And so this was a really fascinating story on that front and on a population that’s really falling through the cracks.
Rovner: It really was. Lauren.
Weber: I actually picked an opinion piece in Stat that’s called, quote, “How the Next President Should Reform Medicare,” by Paul Ginsburg and Steve Lieberman. And I want to give a shoutout to my former colleague Fred Schulte, who basically has single-handedly revealed — and now, obviously, there’s been a lot of fall-on coverage — but he was really beating this drum first, how much Medicare Advantage is overbilling the government.
And Fred, through a lot of FOIAs [Freedom of Information Act requests] — and KFF has sued to get access to these documents — has shown that, through government audits, the government’s being charged billions and billions of dollars more than it should be to pay for Medicare Advantage, which was billed as better than Medicare and a free-market solution and so on. But the reality is …
Rovner: It was billed as cheaper than Medicare.
Weber: And billed as cheaper.
Rovner: Which it’s not.
Weber: It’s not. And this opinion piece is really fascinating because it says, look, no presidential candidate wants to talk about changing Medicare, because all the folks that want to vote usually have Medicare. But something that you really could do to reduce Medicare costs is getting a handle around these Medicare Advantage astronomical sums. And I just want to shout out Fred, because I really think this kind of opinion piece is possible due to his tireless coverage to really dig into what’s some really wonky stuff that reveals a lot of money.
Rovner: Yes, I feel like we don’t talk about Medicare Advantage enough, and we will change that at some point in the not-too-distant future. All right, well, my story is from KFF Health News from my colleague Noam Levey, along with Ames Alexander of the Charlotte Observer. It’s called “How North Carolina Made Its Hospitals Do Something About Medical Debt.”
Those of you who are regular listeners may remember back in August when we talked about the federal government approving North Carolina’s unique new program to have hospitals forgive medical debt in exchange for higher Medicaid payments. It turns out that getting that deal with the state hospitals was a lot harder than it looked, and this piece tells the story in pretty vivid detail about how it all eventually got done. It is quite the tale and well worth your time.
OK, that is our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcast. We’d appreciate it if you left us a review. That helps other people find us, too. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X. I’m @jrovner. Lauren, where are you?
Weber: I’m still on X @LaurenWeberHP.
Rovner: Alice?
Ollstein: On X at @AliceOllstein.
Rovner: Joanne?
Kenen: X @JoanneKenen and Threads @JoanneKenen1.
Rovner: We will be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': American Health Under Trump — Past, Present, and Future
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Emmarie Huetteman
KFF Health News
Emmarie Huetteman, senior editor, oversees a team of Washington reporters, as well as “Bill of the Month” and KFF Health News’ “What the Health?” She previously spent more than a decade reporting on the federal government, most recently covering surprise medical bills, drug pricing reform, and other health policy debates in Washington and on the campaign trail.
Recent comments from former President Donald Trump and Republican lawmakers preview potential health policy pursuits under a second Trump administration. Trump is yet again eyeing changes to the Affordable Care Act, while key lawmakers want to repeal Medicare drug price negotiations.
Also, this week brought news of the first publicly reported death attributed to delayed care under a state abortion ban. Vice President Kamala Harris said the death shows the consequences of Trump’s actions to block abortion access.
This week’s panelists are Emmarie Huetteman of KFF Health News, Joanne Kenen of Politico and the Johns Hopkins University’s schools of nursing and public health, Tami Luhby of CNN, and Shefali Luthra of The 19th.
Panelists
Joanne Kenen
Johns Hopkins University and Politico
Tami Luhby
CNN
Shefali Luthra
The 19th
Among the takeaways from this week’s episode:
- Sen. JD Vance (R-Ohio), Trump’s running mate, says Trump is interested in loosening ACA rules to make cheaper policies available. While the campaign has said little about what Trump would do or how it would work, the changes could include eliminating protections against higher premiums for those with preexisting conditions. Republicans would also likely let enhanced subsidies for ACA premiums expire.
- Key Republican lawmakers said this week that they’re interested in repealing the Inflation Reduction Act’s provisions enabling Medicare drug pricing negotiations. Should Trump win, that stance could create intraparty tensions with the former president, who has vowed to “take on Big Pharma.”
- A state review board in Georgia ruled that the death in 2022 of a 28-year-old mother, after her doctors delayed performing a dilatation and curettage procedure, was preventable. Harris tied the death to Trump’s efforts to overturn Roe v. Wade, which included appointing three Supreme Court justices who voted to eliminate the constitutional right to an abortion.
- And in health tech news, the FDA has separately green-lighted two new Apple product functions: an Apple Watch feature that assesses the wearer’s risk of sleep apnea, and an AirPods feature that turns the earbuds into hearing aids.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Emmarie Huetteman: The Washington Post’s “What Warning Labels Could Look Like on Your Favorite Foods,” by Lauren Weber and Rachel Roubein.
Shefali Luthra: KFF Health News’ “At Catholic Hospitals, a Mission of Charity Runs Up Against High Care Costs for Patients,” by Rachana Pradhan.
Tami Luhby: Politico Magazine’s “Doctors Are Leaving Conservative States To Learn To Perform Abortions. We Followed One,” by Alice Miranda Ollstein.
Joanne Kenen: The New York Times’ “This Chatbot Pulls People Away From Conspiracy Theories,” by Teddy Rosenbluth, and The Atlantic’s “When Fact-Checks Backfire,” by Jerusalem Demsas.
Also mentioned on this week’s podcast:
ProPublica’s “Abortion Bans Have Delayed Emergency Medical Care. In Georgia, Experts Say This Mother’s Death Was Preventable,” by Kavitha Surana.
Click to Open the Transcript
Transcript: American Health Under Trump — Past, Present, and Future
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Emmarie Huetteman: Hello, and welcome back to “What The Health?” I’m Emmarie Huetteman, a senior editor for KFF Health News and the regular editor on this podcast. I’m filling in for Julie this week, joined by some of the best and smartest health reporters in Washington. We’re taping on Thursday, September 19th, at 10 a.m. As always, news happens fast and things might’ve changed by the time you hear this. So, here we go.
We’re joined today, by videoconference, by Tami Luhby of CNN.
Tami Luhby: Good morning.
Huetteman: Shefali Luthra of The 19th.
Shefali Luthra: Hello.
Huetteman: And Joanne Kenan of Politico and Johns Hopkins University Schools of Nursing and Public Health.
Joanne Kenan: Hi everybody.
Huetteman: No interview this week, so let’s get right to the news, shall we? It’s big, it’s popular, and if Donald Trump reclaims the presidency, it could be on the chopping block again. Yes, I’m talking, of course, about the Affordable Care Act. Over the weekend, Senator JD Vance claimed that Trump had “protected Americans” insured under the ACA from “losing their health coverage.” Trump himself made a similar claim during the recent debate, where he also said he has the “concepts of a plan” for health reform. Vance, who is Trump’s running mate, suggested the GOP could loosen regulations to make cheaper policies available. But otherwise, the Trump campaign has not said much about what his administration might change.
Meanwhile, Vice President Kamala Harris has backed off her own plan to change the ACA. You may remember that when she was running for president in 2019, Harris embraced a “Medicare for All” plan. Now, Harris says she plans to build on the existing health system rather than replace it. So let’s talk about what Trump might do as president. What sort of changes could Trump implement to make policies cheaper, as Vance has suggested?
Luhby: Well, one of the things that Vance has talked about, when he talks about deregulating the market, giving people more choice of plans, it’s actually separating people, the healthier people and the sicker enrollees, into separate, different risk pools, which is what existed before the ACA. And that may be, actually, better for the healthy people. That might lower their premiums. But it would cause a lot of problems for sicker enrollees, those with chronic health conditions or serious illnesses, because they would see their premium skyrocket. And this is one of the reasons why health care was so unaffordable for many people prior to the ACA. So Vance says that he wants to protect people with preexisting conditions. That’s what everyone says. It’s a very popular and well-known provision of the ACA. But by separating people into different risk pools, it would actually hurt people with preexisting conditions, because it may make their health insurance unaffordable.
Kenan: The difference between pre-ACA and post-ACA is it might actually even be as bad or possibly worse for people with preexisting conditions. Right now, everybody’s in one unified risk pool, right? Whether you’re sick or healthy, your costs, more or less, get averaged out, and that’s how premiums are calculated. Before ACA, people with preexisting conditions just couldn’t get covered necessarily, or if they got covered, it was sky-high, the premiums. By doing what Tami just described, the people, presumably, in the riskiest pool, the sickest people, the insurers would have to offer them coverage. They couldn’t say, “No, you’re sick, you can’t have it,” because there’s guaranteed coverage. But it would be sky-high. So it would be de facto no insurance for most of those people unless the government were to subsidize them to a really high extent, which I didn’t hear JD Vance mention the other day.
Luthra: Right.
Luhby: And one of the other things that they talked about, more choice. I mean, one of the issues that a lot of people complained about in the ACA, early on, was that they didn’t want substance abuse coverage. There’s 10 health-essential benefits which every insurer has to cover — pregnancy, maternal care, et cetera. And 60-year-old men or even 60-year-old women said: Why am I paying for this? This is making my plan more expensive. But again, as Joanne said, it’s evening out the costs among everyone so that it’s making health care more affordable for everyone. And if you allow people to start picking and choosing what benefits they want covered, it’s going to make the plans more expensive for those who need the higher-cost care.
Luthra: Tami alluded to something that is really important, which is that these conditions we’re talking about are very common. A lot of people get pregnant, for example. A lot of people have chronic health conditions. We are not the healthiest country in the world. And so when you think about who would be affected by this, it’s quite a large number of Americans who would no longer be able to get affordable health coverage and a small group of people who probably would. Because, I mean, one thing that’s worth noting —right? — is even if you are healthy for a time, that’s a transient state. And you can be healthy when you are young and get older and suddenly have knee problems, and then things look very different.
Huetteman: It seems like if they use the exact words, “preexisting-condition protections,” and said they were trying to roll them back in order to make policies cheaper, that might be just a bad political move all around. Preexisting-condition protections are pretty popular, right?
Luhby: Yes, they certainly are. But that’s why they’re saying they’re going to continue it. But what’s also popular is choice. And that’s been one of the knocks against the Affordable Care Act, is that, while there are a lot of plans out there, they do have to conform to certain requirements, and therefore that gives people less choice. I mean, and remember, one of the things that we started by talking about, what a second Trump administration might look like for health care. One of the things the first Trump administration did is loosen the rules on short-term plans, which don’t have to conform to the ACA. And prior, they were available for a short time as a bridge between policies, but the Trump administration lengthened them to up to three years. And the goal of the Trump administration was that people would have more choice. They could pick skinnier plans that they felt would cover them. But they didn’t always realize that if they got into a car accident, if they were diagnosed with cancer, if something bad happened, they did not have all of the protections that ACA plans have.
Huetteman: Joanne, you have something to add.
Kenan: So the first thing is that they spent years and a lot of political capital trying and failing to repeal the ACA or to make major changes in the ACA. The reason it failed is because even then, when the ACA was sort of quasi-popular and there was a lot of controversy still, the preexisting-condition part was extremely popular. Since then, the ACA has become even more popular. What [former President Barack] Obama said when he was speaking to the Democratic National Committee convention the other night — remember that aside where he said, Hey, they don’t call it Obamacare anymore now that it’s popular. It is popular. You’ve even had Republican senators going on record saying it’s here to stay.
So major overhaul of it is, politically, not going to be popular. Plus, the Republicans, even if they capture the Senate, which is what most of the prognosticators are saying right now, it would be a small majority. If the Republicans have 51, 52, none of us know exactly what’s going to happen, because we’re in a rather rapidly changing political environment. But say the Republicans capture the Senate and say Trump is in the White House. They’re not going to have 60 votes. They’re not going to have anywhere near 60 votes. I’m not even sure if there was a way to do this under reconciliation, which would require 51. I’m not sure they have 51 votes. So and then if they do it through some kind of regulatory approach — which I think is harder to do, something this massive, but people find a way — then it ends up in court.
So I think it’s politically unfeasible, and I think it’s practically unfeasible. I think there are smaller things they could do to weaken it. I mean, they did last time, and coverage dropped under Trump, last time. I mean, they could not promote it. They could not market it. They could not have navigators helping people. There’s lots of things they could do to shrink it and damage it, but there’s a difference between denting something and having a frontal collision. And we’ve all seen Vance have to roll back other things that he’s predicted Trump would do, so this is very TBD.
Huetteman: One of the bigger issues with the ACA going into next year is these enhanced subsidies that Joe Biden implemented under the pandemic, that helped a lot of people pay for their premiums, will expire at the end of 2025. And depending on which party has control after this election, that could decide the fate of the subsidies. Joanne, you had something to add on this.
Kenan: That’s the big vulnerability. And it’s not so much, are they going to repeal it or define their concept of a plan? I mean, the subsidies are vulnerable because they expire without action, and they’re part of a larger debate that’s going to happen no matter who wins the presidency and no matter who wins Congress. It’s that a lot of the tax cuts expire in 2025. The subsidies are part of that tax, but many aspects of the tax bill are going to be a huge issue no matter who’s in charge.
The subsidies are vulnerable, right? Republicans think that they went too high. Basically those subsidies let more middle-class people with a higher income get ACA subsidies, so insurance is more affordable. And quite a few million people — Tami might remember how many, because I don’t — are getting subsidized this way. It’s not free. They don’t get the biggest subsidies as somebody who’s lower-income, but they are getting enough subsidies that we saw ACA enrollment go up. That is where the big political battle over the ACA is inevitable. I mean, that is going to happen no matter what else happens around aspects of repealing or redesigning or anything else. This is inevitable. They expire unless there’s action. There will be a fight.
Luhby: Yeah, these—
Kenan: And I don’t know how it’ll turn out, right?
Luhby: These subsidies were created as part of the American Rescue Plan in 2021 and were extended for two years as part of the Inflation Reduction Act, which the Republicans don’t like. And they have, as Joanne said, they’ve allowed more middle-class people to come in, and also, they’re more generous subsidies than in the past. Plus they’ve made policies free for a lot of lower-income people. Folks can get these policies without premiums. So enrollment has skyrocketed, in large part because of these subsidies. Now there are more than 20 million people enrolled. It’s a record. So the Biden administration would like to keep that intact, especially if Harris wins the presidency. But it will be a big fight in Congress next year, as part of the overall Tax Cuts and Jobs Act negotiations, and we’ll see what the Democrats might have to give up in order to retain the subsidies. The—
Kenan: It’s going to be, yeah.
Luhby: Enhanced subsidies.
Kenan: There are deals to be had with tax cuts versus subsidies, because these are large, sprawling bills with many moving parts. But it’s way too early to know if Republicans are willing to deal on this and what a deal would look like. We’re nowhere near there. But yeah, if you talk about ACA battles in 2025, that’s number one.
Huetteman: Well, speaking of health policies that are on the GOP agenda, some high-ranking Republican lawmakers are saying they want to repeal the Inflation Reduction Act if the party wins big in November, particularly the part that enables Medicare drug negotiations. You may recall their objections from when Congress passed the law two years ago. Republicans argue the negotiations harm innovation and amount to government price controls. But on the other hand, drug prices are an issue where Trump kind of sort of agrees with Democrats. He has promised to “take on Big Pharma.” Does this mean we could see a Republican Congress fighting with Trump over drug price negotiations?
Luhby: Well, he did have a lot of executive orders and a lot of efforts that were very un-Republican-like. One was called Most Favored Nation. He didn’t say that we should do negotiations. We were just going to piggyback on the negotiations done in other countries and get their lower prices. He didn’t really get very far in a lot of those measures, so it didn’t come to a fight with the Republican Congress. But he may leave the negotiation process alone, the next set of drugs, that’ll be 15 drugs, that, we’ll find out next year, that will be negotiated. So he could leave that alone. If he tries to expand it, yeah, he may have some problems with the Republican Congress. But as we’ve also seen, a Republican Congress has acquiesced to his demands in the past.
Huetteman: And Congress certainly has no shortage of battles teed up for 2025, of course. Speaking of, here we are again. Yesterday, in the House of Representatives, Democrats and Republicans joined together to defeat a stopgap spending bill that would’ve kept the government open. To be sure they didn’t have the same objections, Democrats opposed a Republican amendment that would impose new voter registration requirements about proving citizenship. And hard-right Republicans objected to the size of the temporary spending bill, $1.6 trillion. Trump weighed in on social media, calling on Republicans to oppose any government spending bill at all, unless it comes with a citizenship measure.
Now, Senate Republican leaders, in particular, are not thrilled about this. Here are the words of [Senate minority Leader] Mitch McConnell, who said it better than I can: “It would be politically beyond stupid for us to do that right before the election, because certainly, we’d get the blame” for that government shutdown. What happens now?
Kenan: Last-minute agreement, like, I feel. I used to cover the Hill full time. I no longer do, but it was, like, late nights standing in the hallway for a last-minute reprieve. At some point, they’re going to probably keep the government open, but with Trump’s demands and the citizenship proof of a life for voters and all that, it’s going to be really messy. Mike Johnson became speaker after a whole bunch of other speakers failed to keep the government open.
Huetteman: That’s right.
Kenan: Probation spell, we went through chaos, he has a small majority. He survived because the Democrats intervened on his behalf once, because of Ukraine. We have no idea the dynamics of — do the Democrats want to see complete chaos so the Republicans get blamed? Who knows? I don’t think it’s going to be a handshake tomorrow and Let’s do a deal. What they usually do is continue current spending levels and what they call a continuing resolution. So you keep status quo for one month, two months, three months, sometimes 10 months. The odds are, the government will stay open at some kind of a last-minute patchwork deal that nobody particularly likes, but that’s likely. I wouldn’t say that certain. Republicans have backed off shutting the government down for a while now, a couple of years.
Huetteman: It’s worth noting, though, that even this bill that they just voted down would’ve only kicked the can down to March. So we are still talking about something that the new Congress would have to deal with pretty quickly, even if we can get something done short-term. But we’ve got a lot of news today. So moving on to reproductive health news.
This week, Senate Republicans, again, blocked a bill that would’ve guaranteed access to in vitro fertilization nationwide. That federal bill would, of course, have overridden state laws that restrict access to the procedure. You may recall that Republicans also blocked that bill earlier this summer, describing it as a political show vote. And indeed, Democrats are trying to get Republicans on the record, opposing IVF, in order to draw contrast with the GOP before voters go to the polls. What do we think? Did Democrats succeed here in showing voters their lawmakers really think about IVF?
Luthra: I mean, realistically, yes, I think this is a very effective strategy for Democrats. If they could talk about abortion and IVF every day, all day, they would. We can look at Taylor Swift’s endorsement of Kamala Harris and [Minnesota Gov.] Tim Walz. She specifically mentions reproductive rights, and she mentions IVF in particular, noting that she thinks that these are the candidates who will support access to that fertility regimen. IVF is very popular, and it is obviously going to be a major battle, because it is the next frontier for the anti-abortion movement, and the Republican Party is allied very closely to this movement. Even if there have been more fractures emerging lately, I just don’t see how Republicans can find a way to make this a political winner for them, unless they figure out a way to change their tune, at least temporarily, without alienating that ally they have.
Huetteman: Absolutely. And meanwhile, speaking of the consequences of these actions on abortion lately, this week we learned of the first publicly reported death from delayed care under a state abortion ban. ProPublica reported the heart-wrenching story of a 28-year-old mother in Georgia who died in 2022 after her doctors held off on performing a D&C [dilation and curettage procedure]. Performing a D&C in Georgia is a felony, with a few exceptions. Sorry, this is difficult to talk about, especially if you or someone you know has needed a D&C, and that may be a lot of us, whether we know it or not.
Her name was Amber Thurman. Amber needed the D&C because she was suffering from a rare complication after taking the abortion pill. She developed a serious infection, and she died on the operating table. Georgia’s Maternal Mortality Review Committee determined that Amber Thurman’s death was preventable. ProPublica says at least one other woman has died from being unable to access illegal abortions and timely medical care. And as the story said, “There are almost certainly others.” On Tuesday, Vice President Harris said Amber’s death shows the consequences of Trump’s actions to block abortion access. How does this affect the national conversation about abortion? Does it change anything?
Luthra: I mean, it should, and I don’t think it’s that simple. And it’s tough, because, I mean, these stories are incredible pieces of journalism, and what they show us are that two women are dead because of abortion bans — and that there are almost certainly many more, because these deaths were in 2022, very soon after the Dobbs decision. And what has been really striking, at the same time, is that the anti-abortion movement has very clear talking points on these deaths. And they’re doing what we have seen them do, in so many cases, where women have almost lost their lives, and now, in these cases where they have, which is they blame the doctors. And they have been going out of their way to argue that, actually, the exceptions that exist in these laws are very clear, even though doctor after doctor will tell you they are not, and that it is the doctor’s fault for not providing care when there is very obviously an exception.
They are also arguing that this is further proof that medication abortion, which is responsible for the vast majority of abortions in this country, is unsafe, even though, as you noted and as these stories noted, the complications these women experienced are very rare and could be addressed and treated for and do not have to be fatal if you have access to health care and doctors who are not handcuffed by your state’s abortion laws. And so what I think happens then is this is something that should matter and that should change our conversation. And there are people talking about this and making clear that this is because of the reproductive health world that we live in, but I don’t think it will necessarily change the course of where we are headed, despite the fact that what abortion opponents are saying is not true and despite the fact that these abortion bans remain very unpopular.
Kenan: I think you can, and she said it really well, but I think in terms of, does it change minds? Think about the two bumper stickers, right? One is “Abortion bans kill,” and the other one is “The abortion pill kills.” And both of these women had medication abortions. Those side effects are very, very, very unusual, that dangerous side effects, are extremely unusual. There’s years of data, there’s like no drug on Earth that is a hundred percent, a thousand percent, a hundred thousand percent safe. So these were tragedies in which the women did develop severe life-threatening side effects, didn’t get the proper treatment. But think about your bumper stickers. I don’t think this changes a lot of minds.
Huetteman: All right. Well, unfortunately we will keep watching for this and more news on this subject. But in state news, Nevada will become the 18th state to use its Medicaid funds to cover abortions after a recent court ruling. While federal funds are generally barred from paying for abortions, states do have more flexibility to use their own Medicaid funds to cover the procedure. And, North Dakota’s abortion ban has been overturned, after a judge ruled that the state’s constitution protects a woman’s right to an abortion until the fetus is viable. But there’s a bigger challenge: The state has no abortion clinics left. We’ve talked a lot on this podcast about how overturning Roe has effectively created new, largely geographical classes of haves and have-nots, people who can access abortion care and people who can’t. It seems like the lesson out of North Dakota right now is that evening that playing field isn’t as simple as changing the law, yes?
Luthra: Absolutely. And this is something that we have seen even before Roe was overturned. I mean, an example that I think about a lot is Texas, which had had this very big abortion law passed in 2013, and it was litigated in the courts, was in and out of effect before it went to the Supreme Court and was largely struck down. But clinics closed in the meantime. And what that tells us is that when clinics close, they largely don’t reopen. It is very, very hard to open an abortion clinic. It is expensive. It can be dangerous because of harassment. You need to find providers. You need to build up a medical infrastructure that doesn’t exist. And we are seeing several states with ballot measures to try to undo abortion bans in their states — Florida, Missouri, Nebraska with their 12-week ban. We are seeing efforts across the country to try and restore access to these states.
But the question is exactly what you pointed out, which is there is a right in name and there is a right in practice. And for all the difficulties of creating a right in name, creating a right in practice is even harder. And there is just so much more that we will need to be following as journalists, and also as people who consume health care, to fully see what it takes for people to be able to get reproductive health care, including abortion, after they have lost it.
Huetteman: All right. And with fewer than 50 days left until Election Day and way fewer before early voting begins, a court in Nebraska has ruled that competing abortion rights measures can appear on the ballot there this fall. Two measures, one that would expand access and one that would restrict it, qualified for the ballot. Nebraska will be the first state to ask residents to vote on two opposing abortion ballot measures. Currently, the state bans abortion in most cases, starting at 12 weeks. There are at least nine other states with ballot measures to protect abortion rights this fall, but this one’s pretty unusual. What do we think? Will this be confusing to Nebraska voters?
Luthra: I mean, I imagine if I were a voter, I would be confused. Most people don’t follow the ins and outs of what’s on their ballot until you get close to Election Day and you are bombarded with advertisements. And I think this is really striking, because it is just part of, I guess, maybe not long, because this only happened two years ago, but part of a repeated pattern of abortion opponents trying to find different ways to get around the fact that ballot measures restoring abortion rights or protecting abortion rights largely win. And so how do you find a way around that? You can try and create confusion. You can try and raise the threshold for approval like they tried and failed to do in Ohio. You can, maybe in Nebraska this is more effective, put multiple measures on the ballot. You can try, as they tried and failed to do in Missouri, try and stop something from appearing on the ballot.
And I think this is just something that we need to watch and see. Is this the thing that finally sticks? Does this finally undercut efforts to use direct voting to restore abortion rights? Which we should also note is a strategy with an expiration date of sorts, because not every state allows for this direct democracy approach. And we’re actually hitting the end of the list of states very soon where this is a viable strategy.
Huetteman: And as we know, every state where a ballot measure has addressed this issue since Roe was overturned has fallen on the side of abortion rights, ultimately. It’ll be curious to see what happens here, where voters have both choices right before them.
Well, let’s wrap up with tech news this week. Are you wearing an Apple Watch right now? Or maybe you’re listening to us on AirPods? Well, that watch could soon tell you if you might have sleep apnea. Or, if you have trouble hearing, those earbuds could soon help you hear better. The FDA has given separate green lights to two new Apple product functions. One is an Apple Watch change that assesses the wearer’s risk of sleep apnea. And the FDA also authorized Apple AirPods as the first over-the-counter hearing-aid software, to assist those with mild to moderate hearing loss. Hearing aids can be pretty expensive, and some resist wearing them due to stigma or stubbornness. What does this mean for people with these conditions, and also about the possibilities for health tech?
Kenan: I mean, none of us are covering the FDA’s tech division full time or even much at all. So basically there’s been a trend toward sort of overlap with consumer and health products. Many of us have something on our wrists or something in our phone that is monitoring something or other, and there’s been some controversy about how accurate some of them are. My understanding with the sleep apnea thing, that it doesn’t actually diagnose it. It tracks your sleep patterns, and if it sees some red flags, it says: You might have sleep apnea. You should go see a doctor. That’s what I think that does.
Huetteman: That’s right.
Kenan: You’re asleep when you’re having sleep apnea. You don’t necessarily know what’s happening. So it’s arguably a useful thing that you have kind of an alert system. The hearing aids, it’s not just these. The FDA, a few months ago, authorized more over-the-counter hearing aids of various types, which have made them much cheaper and much more accessible. This is an advance, another category, another type to have people wearing earbuds anyway. I know people who have the over-the-counter hearing aids, and they are small and cheap, so that industry has really been disrupted by tech. So we are seeing not necessarily some of the sky-in-the-pie promises of health and tech from a few years ago but some useful things for consumers to either make things more accessible or affordable, like the earbuds — although I would lose them — or just a useful tool or a potentially useful tool, I don’t know how great the data is, saying ask your doctor about this. Sleep apnea is dangerous.
So my mom is about to turn 90, and we have a fall monitor on her watch that we actually pay for, an extra service, that they alert emergency. I was with her once when she fell. They called her and said, Are you okay? And she said, Yes, my daughter’s here and et cetera. Except, at 90, she still plays pingpong, doubles pingpong, not a lot of movement for 90 year olds, and it does get the fall monitor very confused. I think it’s been trained. So yeah, I mean, it’s not that expensive, and it’s great peace of mind. People would much rather have it on their watch, because young cool people wear smartwatches, than those buttons around their neck. I would’ve never gotten my mother to wear a button around her neck. So it’s part of a larger trend of tech becoming a health tool, and it’s not a panacea, but the affordability for over-the-counter hearing aids is a big deal.
Huetteman: Right, right. This is expanded access. If you’ve got this consumer product already in your pocket, on your wrist, in your ears, why not have it help with your health? We’ve already kind of adjusted, in many ways, to health tech. We had Fitbits. We’ve had things that have tracked our heart rates and that sort of thing, or even our phones can do that at this point. But hearing aids, in many cases for people who have mild or moderate hearing loss, they don’t even go for a hearing aid, because they don’t want to be stigmatized as being maybe a little older and being unable to hear, even if they might just muddle through. But if you’ve already got those AirPods in, because you’re going to take a call later, I mean, that’s pretty below the radar. You don’t have to feel too self-conscious about that one, so …
Kenan: Yeah, my mom would look cool, but she actually doesn’t need them, so that’s OK.
Huetteman: If she’s playing pingpong at her age, she already looks cool.
Kenan: She plays pingpong very slowly. I hope I’m doing the equivalent when I’m 90. I hope I’m 90, you know?
Huetteman: Hear, hear.
Kenan: You know.
Huetteman: OK, that’s this week’s news. Now it’s time for our extra credit segment. That’s when we each recommend a story we read this week that we think you should read, too. As always, don’t worry if you miss it. We’ll post the links in the podcast page at kffhealthnews.org and in our show notes, on your phone or other mobile device. Shefali, why don’t you go first this week?
Luthra: All right. My story is from KFF Health News by the great Rachana Pradhan. The headline is, “At Catholic Hospitals, a Mission of Charity Runs Up Against High Care Costs for Patients.” The story is one of my favorite genres of stories, which is stories about how everyone loves their hospital and their hospital is a business. And Rachana does a great job looking at the history of Catholic hospitals and the extent to which they were founded as these beacons of charitable care meant to improve the community. But actually, when you look at where Catholic hospitals are now — and Catholic hospitals have really proliferated in the past several years — they look a lot like businesses and a lot less like charities. There’s some fascinating patient stories and also analyses in here, showing that Catholic hospitals are less likely than other nonprofit hospitals to treat Medicaid patients. They are great at going after patients for unpaid medical bills, including suing them, garnishing wages, reporting them to credit bureaus. It’s really great. It’s the exact kind of journalism that I think we need more of, and I love this story, and I hope others do, too.
Huetteman: Excellent. It is a great piece of journalism. We hope everyone will take some time to read it. Tami, why don’t you go?
Luhby: OK. My extra credit is an in-depth piece by one of our very own, Alice Miranda Ollstein of Politico, and it’s titled, “Doctors Are Leaving Conservative States to Perform Abortions. We Followed One.” So Alice followed a doctor who spent a month in Delaware learning how to perform abortions, because she couldn’t obtain that training in her home state, across the country. Alice notes that Politico granted the doctor anonymity due to her fear of professional repercussions and the threat of physical violence for seeking abortion training, which is concerning to hear. While many stories have written about states’ abortion bans, Alice’s piece provides a different perspective. She writes about the lengths the doctors must go to obtain training in the procedure and the negative effects that the overturning of Roe has had on medical education.
The doctor she profiled spent nearly two years searching for a position where she could obtain this training, before landing at Delaware’s Planned Parenthood. It cost nearly $8,000. The doctor had to pull together grants and scholarships in order to cover the costs. Alice walked readers through the doctor’s training in both surgical and medical abortions and through her ethical and medical thoughts after seeing — and this is one thing that stuck with me in the story — what’s called the “products of conception” on a little tray. So the story is very moving, and it’s well worth your time.
Huetteman: Absolutely. And the more detail we can get about what these sorts of procedures and this training looks like for doctors, the better we understand what we’re actually talking about when we’re talking about these abortion bans and other restrictions on reproductive health. Joanne, why don’t you talk to us about your extra credit this week?
Luthra: OK. There’s a piece in the New York Times by Teddy Rosenbluth called “This Chatbot Pulls People Away from Conspiracy Theories.” And there’s also a related podcast at the Atlantic called, by Jerusalem Demsas, “When Fact-Checks Backfire.” They’re both about the same piece of research that appeared in Science. Basically, debunking, or fact-checking, has not really worked very well in pulling people away from misinformation and conspiracy theories. There had been some research suggesting that if you try to debunk something, it was the backfire effect, that you actually made it stick more. That doesn’t always happen. There’s sort of some people that it does and some people it doesn’t — that’s beginning to be understood more.
And what this study, the Times reported on and the Atlantic podcast discussed, is using AI, because we all think that AI is going to be generating more disinformation, but AI is also going to be fighting disinformation. And this is an example of it, where the people in this study had a dialogue, a written, typed-in dialogue, where the chatbot that gave a bespoke response to conspiracy beliefs, including vaccines and other public health things. And that these individually tailored, back-and-forth dialogue, with an AI bot, actually made about 20% of the people, which is, in this field, a lot, drop their or modify their beliefs or drop their conspiracy beliefs. And that it stuck. It wasn’t just because some of these fact-checks work for like a week or two. These, they checked in with people two months later and the changes in their thinking had stuck. So it’s not a solution to disinformation and conspiracy belief, but it is a fairly significant arrow to new techniques and more research to how to debunk it better without a backfire effect.
Huetteman: That’s great. Thanks for sharing those. All right. My extra credit this week comes from two of our podcast pals at The Washington Post, Lauren Weber and Rachel Roubein. The headline is, “What Warning Labels Could Look Like on Your Favorite Foods.” They report that the FDA is considering labeling food to identify when they have a high saturated fat content, sodium, sugar, those sorts of things that we should all be paying attention to on nutrition labels. But their proposal falls short, critics say. It’s not quite as good, they say, at identifying the health risk factors of certain amounts of sodium and sugar in our food, especially compared to other countries.
They do an extensive study on Chile’s food labeling, in fact. And if you’re like me and you buy a lot of your groceries for your household and you try to look at the nutrition labels, you might be surprised by some of the items the article identifies as being particularly high in sodium, like Cheerios. Bad news for my family this morning.
All right, that’s our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left a review. That helps other people find us, too. Special thanks, as always, to our amazing engineer, Francis Ying. And as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you could try tweeting me. I’m lurking on X, @emmarieDC. Shefali.
Luthra: I’m @shefalil.
Huetteman: Joanne.
Kenan: @JoanneKenen on Twitter, @joanneKenen1 on Threads.
Huetteman: And Tami.
Luhby: Best place to find me is cnn.com.
Huetteman: We’ll be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': At GOP Convention, Health Policy Is Mostly MIA
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Julie Rovner
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
The Republican National Convention highlighted a number of policy issues this week, but health care was not among them. That was not much of a surprise, as it is not a top priority for former President Donald Trump or most GOP voters. The nomination of Sen. J.D. Vance of Ohio adds an outspoken abortion opponent to the Republican ticket, though he brings no particular background or expertise in health care.
Meanwhile, abortion opponents are busy trying to block state ballot questions from reaching voters in November. Legal battles over potential proposals continue in several states, including Florida, Arkansas, and Arizona.
This week’s panelists are Julie Rovner of KFF Health News, Alice Miranda Ollstein of Politico, Sarah Karlin-Smith of the Pink Sheet, and Joanne Kenen of the Johns Hopkins schools of public health and nursing and Politico Magazine.
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Alice Miranda Ollstein
Politico
Joanne Kenen
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Sarah Karlin-Smith
Pink Sheet
Among the takeaways from this week’s episode:
- Sen. J.D. Vance of Ohio has cast few votes on health policy since joining Congress last year. He has taken a doctrinaire approach to abortion restrictions, though, including expressing support for prohibiting abortion-related interstate travel and invoking the Comstock Act to block use of the mail for abortion medications. He also speaks openly about his mother’s struggles with addiction, framing it as a health rather than criminal issue in a way that resonates with many Americans.
- Although Republicans have largely abandoned calls to repeal and replace the Affordable Care Act, it would be easy for former President Donald Trump to undermine the program in a second term; expanded subsidies for coverage are due to expire next year, and there’s always the option to cut spending on marketing the program, as Trump did during his first term.
- Trump’s recent comments to Robert F. Kennedy Jr. about childhood vaccinations echoed tropes linked to the anti-vaccination movement — particularly the false claim that while one vaccine may be safe, it is perhaps dangerous to receive several at once. The federal vaccination schedule has been rigorously evaluated and found to be safe and effective.
- Covid is surging once again, with President Joe Biden among those testing positive this week. The virus is proving a year-round concern and has peaked regularly in summertime; covid spreads best indoors, and lately millions of Americans have taken refuge inside from extremely high temperatures. Meanwhile, the virology community is concerned that the nation isn’t testing enough animals or humans to understand the risk posed by bird flu.
Also this week, Rovner interviews KFF Health News’ Renuka Rayasam, who wrote the June installment of KFF Health News-NPR’s “Bill of the Month,” about a patient who walked into what he thought was an urgent care center and walked out with an emergency room bill. If you have an exorbitant or baffling medical bill, you can send it to us here.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: Time magazine’s “‘We’re Living in a Nightmare:’ Inside the Health Crisis of a Texas Bitcoin Town,” by Andrew R Chow.
Joanne Kenen: The Washington Post’s “A Mom Struggles To Feed Her Kids After GOP States Reject Federal Funds,” by Annie Gowen.
Alice Miranda Ollstein: ProPublica’s “Texas Sends Millions to Crisis Pregnancy Centers. It’s Meant To Help Needy Families, but No One Knows if It Works,” by Cassandra Jaramillo, Jeremy Kohler, and Sophie Chou, ProPublica, and Jessica Kegu, CBS News.
Sarah Karlin-Smith: The New York Times’ “Promised Cures, Tainted Cells: How Cord Blood Banks Mislead Patients,” by Sarah Kliff and Azeen Ghorayshi.
Also mentioned on this week’s podcast:
The Wall Street Journal’s “Mail-Order Drugs Were Supposed To Keep Costs Down. It’s Doing the Opposite,” by Jared S. Hopkins.
Click to open the transcript
Transcript: At GOP Convention, Health Policy Is Mostly MIA
KFF Health News’ ‘What the Health?’Episode Title: ‘At GOP Convention, Health Policy Is Mostly MIA’Episode Number: 356Published: July 18, 2024
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, July 18, at 10 a.m. As always, news happens fast and things might’ve changed by the time you hear this. So, here we go.
We are joined today via video conference by Alice Miranda Ollstein, of Politico.
Alice Miranda Ollstein: Good morning.
Rovner: Sarah Karlin-Smith at the Pink Sheet.
Sarah Karlin-Smith: Hi, everybody.
Rovner: And Joanne Kenen of the Johns Hopkins Schools of public health and nursing, and Politico Magazine.
Joanne Kenen: Hi, everybody.
Rovner: Later in this episode, we’ll have my interview with KFF Health News’ Renuka Rayasam, about the latest “Bill of the Month.” This month’s patient went to a facility with urgent care in its name but then got charged emergency room prices. But first, this week’s news.
So as of this morning, we are most of the way through the Republican National Convention, which obviously has a somewhat different tone than was expected, following last weekend’s assassination attempt on former President Donald Trump. The big news of the week is Trump’s selection of Ohio Republican Sen. JD Vance as his running mate. Vance has only been in the Senate since 2023, had not served previously in public office, and he doesn’t have much of a record on much of anything in health care. So, what do we know about what he thinks?
Ollstein: Well, I have been most focused on his abortion record, which is somewhat more extensive than his record on other health policy. Obviously, Congress has not done very much on abortion, but he’s been loud and proud about his anti-abortion views, including calling for national restrictions. He calls it a national minimum standard, but the idea is that he does not want people in conservative states where abortion is banned to be able to travel to progressive states where it is allowed. He has given interviews to that effect. He has signed letters to that effect. He has called for enforcement of the Comstock Act, which, as we’ve talked about before, is this long dormant statute that prohibits the mailing of abortion drugs or medical instruments that could be used to terminate a pregnancy. And so this is a very interesting moment to pick Vance.
The Republican Party is attempting to reach out to more moderate voters and convince them that they are hoping to leave this issue to the states. Vance’s record somewhat says otherwise. He also opposed efforts in his own state of Ohio to hold a referendum that ended up striking down that state’s abortion ban. So, definitely a lot for Democrats to go after in his record and they are not wasting any time; they are already doing it.
Rovner: Yeah, I’m kind of surprised because Vance, very much like Trump, has been kind of everywhere, or at least he has said that he’s kind of everywhere on abortion. But as you mentioned, Alice, you don’t have to look very hard to see that he’s pretty doctrinaire on the issue. Do you think people are going to buy this newer, softer Republicanism on abortion?
Ollstein: Well, abortion rights groups that I’ve spoken to are worried that people are buying it. They’re worried as they campaign around the country that the Republican Party’s attempt to walk away from their past calls for national restrictions on abortion are breaking through to people. And so they are trying really hard to counter that message and to stress that Republicans can and would pursue national restrictions, if elected.
I think both Democratic candidates and abortion rights groups are working to say even the leave-it-to-states position is too extreme and is harming people. And so they’re lifting up the stories of people in Texas and other states with bans who have experienced severe medical harm as a result of being denied an abortion. And so they’re lifting up those stories to say, “Hey, even saying let’s leave it to the states, let’s not do a national ban — even that is unacceptable in the eyes of the left.”
Kenen: The other issue obviously with his life story is opioids. His mother was addicted. Originally it began with being prescribed a legal painkiller. It’s a familiar story: became addicted, he was raised by his grandmother. His mother, who he showed on TV last night and she was either in tears or really close to tears, she’s 10 years sober now. He had a tough life and opioids was part of the reason he had a tough life. And whatever you think of his politics, that particular element of his life story resonates with people because it may explain some of his political views. But that experience is not a partisan experience and he was a kid. So I think he clearly does see opioids as a medical problem, not just, oh, let’s throw them in jail. I mean, the country and the Republican Party, that has been a change. It’s not a change that’s completed, but that shift is across party lines as well. That’s part of him that — it’s something you listen to when he tells that story.
I mean also, he told a story about his grandmother late in life, the grandmother who raised him, having, when she died, they found 19 handguns in the house all over the place. And he told sort of a funny story that she was old and frail and she always wanted to have one within reach. And all I could think of is, all these unlocked handguns with kids in the house! I mean, which is not a regulatory issue, but there’s a gun safety issue there. I’m just thinking, oh my God, 19 guns in drawers all over the house. But he’s obviously a very, the Republican Party is … I mean, after the assassination attempt, you have not heard Donald Trump say, “Maybe I need to rethink my position on gun control.” I mean, that’s not part of the dialogue right now.
I think having someone with that experience, talking about it the way he does, is a positive thing, really. Saying, “Here’s what we went through. Here’s why. Here’s how awful it was. Here’s how difficult it was to get out of it. And this is what these families need.” I mean, that is …
Rovner: Although it’s a little bit ironic because he’s very anti-social programs, in general.
Karlin-Smith: And he’s had a bad track record of trying to address the opioid crisis. He had a charity he started that he ended I guess about when he was running for Senate that really was deemed nonsuccessful. It also had questionable ties to Purdue Pharma, that’s sort of responsible for the opioid crisis. And the other thing that you sometimes hear in both him and Trump’s rhetoric is the blaming of immigrants and the drug cartels and all of that stuff for the opioid crisis. So, there’s a little bit of use of the topic, I think, to drop anti-immigrant sentiment and not really think about how to address the actual health struggles.
Kenen: When he talks about his family, he’s not saying China sent my mother fentanyl. I think it is good for people to hear stories from the perspective of a family who had this, as it is a health problem, reminding people that this is not thugs on the street shooting heroin. It’s a substance abuse disorder, it’s a disease. And so I think the country has come a long way, but it isn’t where it needs to be in terms of understanding that it’s a behavioral health problem. So I think in that sense he will probably be a reminder of that. But he doesn’t have a health record. I mean, he wasn’t there during the Obamacare wars. We don’t really know what he thinks about. I’m not aware of anything he’s really said about entitlements and Medicare. He does come from the state … I mean, Trump is saying he won’t touch it. But I mean if he said Medicare stuff, I missed it. I mean, if one of you knows, correct …
Karlin-Smith: Well, he has actually said that he supports Medicare drug price negotiation at times, which is interesting and unique for a Republican. And I mean Trump, as well, has been a bit different from the traditional Republican, I think, when it comes to the pharma industry and stuff, but I think that maybe is even a bridge too far in some ways.
Rovner: Yeah, he’s generally pretty anti-social program, so it’ll be interesting to see how he walks that line.
Well, this is all good segue into my next question, which is, health in general has been mostly MIA during this convention, including any update on Trump’s ear injury from the attempted assassination. Are we finally post-repeal-and-replace in the Republican Party? Or is this just one of those things that they don’t want to talk about but might yet take up if they get into office?
Kenen: We don’t know what the balance of power is in the Senate and the House, right? I mean, that’s probably going to be part of it. I mean, if they have huge … if they capture both chambers with huge majorities, it’s a new ballgame. Whether they actually try to repeal it, versus there’s all sorts of ways they can undermine it. Trump did not succeed in repealing it. Trump and the House Republicans did not, the Republicans in general did not succeed in repealing it, despite a lot of effort. But they did undermine it in all sorts of ways and coverage actually fell during the Trump administration. ACA [Affordable Care Act] coverage did drop; it didn’t vanish completely, but it dropped. And under Biden it continued to grow. Now, the Republicans get their health care through the ACA, so it’s become much more normalized, but we don’t know what they will do. Trump is not a predictable politician, right? I mean, he often made a big deal about trying to lower drug prices early in his term, and then nothing. And then he even released huge, long list of things …
I remember one of our reporters — Sarah and I were both … Sarah, Alice, and I were all at Politico — and I think it was David who counted the number of question marks in that report. And at the end of the day, nothing much happened. I don’t think the ACA is untouchable; it may or may not be unrepealable in its entirety, but it’s certainly not untouchable.
Rovner: Well, he also changes positions on a whim, as we’ve seen. Most politicians you can at least count on to, when they take a position, to keep it at least for a matter of days or weeks, and Trump sometimes in the same interview can sort of contradict himself, as we know. But I mean, obviously a quick way to undermine the ACA, as you say, would just be to let the extended subsidies expire because they would need to be re-upped if that’s going to continue and there are many millions of people that are now …
Kenen: And they expire next year.
Rovner: … Yes, that are …
Kenen: And there are also two other things. You cut the navigating budget. You cut advertising. You don’t try to sell it. I don’t mean literally sell it, but you don’t try to go out and urge … I mean, that was their playbook last time, and that’s why — it’s one reason enrollment dropped. And that was, the subsidies were under Biden, the extended subsidies. So that’s one year away.
Ollstein: But it’s no surprise that this hasn’t been a big topic of discussion at the RNC [Republican National Convention]. I mean, polling shows that voters trust Democrats more on health care; it’s one of their best issues. It’s not a good issue for Republicans. And so it was fully expected that they would stick to things that are more favorable to them: crime, inflation, whatnot. So, I do expect to hear a lot about health care at the DNC [Democratic National Convention] in a few weeks. But beyond that, we do not know what’s going to happen at the DNC.
Rovner: Yeah.
Karlin-Smith: I was going to say, the one health issue we haven’t really touched on, which the Republicans have been hammering on, is transgender health care and pushing limits on it, especially for people transitioning, children, and adolescents. And I think that’s clearly been a strategic move, particularly as they’ve gotten into more political trouble with abortion and women in the party. They clearly seem to think that the transgender issue, in general, appeals more to their base and it’s less risky for them.
Rovner: Their culture warrior base, as you will. Yeah, and we have in fact seen a fair bit of that. Well, before we leave the convention, one more item: It seems that Trump and RFK Jr. [independent presidential candidate Robert F. Kennedy Jr.] had a phone conversation, which of course leaked to the public, during which they talked about vaccine resistance. Now we know that RFK Jr. is a longtime anti-vaxxer. What, if anything, does the recounting of this conversation suggest about former President Trump’s vaccine views? And we’ve talked about this a little bit before, he’s been very antimandate for the covid vaccine, but it’s been a little bit of a blank on basic childhood vaccines.
Karlin-Smith: And I mean, his remarks are, they’re almost a little bit difficult to parse, they don’t quite make sense, but they seem to be essentially repeating anti-vax tropes around, well, maybe one vaccine on their own isn’t dangerous, but we give kids too many vaccines at a time or too close together. And all of that stuff has been debunked over the years as incorrect. The vaccine schedule has been rigorously evaluated for safety and efficacy and so forth.
That said, Trump obviously was in office when we spearheaded the development of covid vaccines, which ended up being wildly successful, and he didn’t really undermine that process, I guess, for the most part when he was in office. So it’s hard to know. Again, there’s a lot of difficulty in predicting what Trump will actually do and it may depend a lot who he surrounds himself with and who he appoints to key positions in his health department and what their views are. Because he seems like he can be easily persuaded and right now he may just be in, again, campaign mode, very much trying to appeal to a certain population. And you could easily see him — because he doesn’t seem to care about switching positions — just pivoting and being slightly less anti-vax. But it’s certainly concerning to people who have been even more about the U.S. anti-vax sentiments since covid and decreases in vaccination rates.
Rovner: It did feel like he was trying to say what he thought RFK Jr. wanted to hear, so as to win his endorsement, which we know that Trump is very good at doing. He channels what he says depending on who he’s talking to, which is what a lot of politicians do. He just tends to do it more obviously than many others.
Kenen: Julie, we heard this at the tail end of the 2016 campaign. He made a few comments, exactly, very, very similar to this, the size of a horse vaccine and you see the changes — there’s too many, too many vaccines, too large doses. We heard this briefly in the late 2016, and we heard it at the very — I no longer remember whether it was during transition in 2016 or whether it was early in 2017 when he was in the White House — but we heard a little bit of this then, too. And he had a meeting with RFK then. And RFK said that Trump was talking about maybe setting up a commission and RFK at one point said that Trump had asked him to head the commission. We don’t think that was necessarily the case.
First of all, there was no commission. The White House never confirmed that they had asked RFK to lead it. Who knows who said what in a closed room, or who heard what or what they wanted to hear; we don’t know. But we heard this whole episode, including Trump and RFK, at approximately the beginning of 2017, and it did go away. Covid didn’t happen right away; covid was later. There was no anti-vax commission. There was no vax commission. There was no change in vaccination policy in those early years prepandemic. And as Sarah just pointed out, Trump was incredibly pro-vaccine during the pandemic. I mean, the Operation Warp Speed was hailed by even people who didn’t like anything else about Trump. When public health liked Operation Warp Speed, he got vaccines into arms fast, faster than many of us thought, right?
The difference — there were anti-vaxxers then; there have been since smallpox — but it is much more politicized and much more prominent, and in some ways it has almost replaced the ACA as your identifying health issue. If you talk to somebody about the ACA, you know what party they are, you even know where within the party they are, what wing. And that’s not 100% true of anti-vaxxers. There are anti-vaxxers on both sides, but the politicization has been on the Republican-medical-libertarian side, that you-can’t-tell-me-what-to-do-it’s-my-body side. It is much more part of his base and a more intense, visible, and vocal part of his base. So, it’s the same comments, or very similar comments, to the same person in a different political context.
Rovner: Well, I think it’s safe to say that abortion does remain the most potent political health issue of the year, and there was lots of state-based abortion election news this week. As we’ve been discussing all year, as many as a dozen states will have abortion questions on the ballot for voters this November, but not without a fight. Florida has just added an addendum to its ballot measures, suggesting that if passed, it could cost the state money. And in Arkansas and Montana, there are now legal fights over which signatures should or shouldn’t be counted in getting some of those questions to the ballot.
Alice, in every state that’s voted on abortion since Dobbs [v. Jackson Women’s Health Organization], the abortion-right side has prevailed. Is the strategy here to try to prevent people from voting in the first place?
Ollstein: Oh, yes. I wrote a story about this in January. It’s been true for a while, and it’s been true in the states that already had their votes, too. There were efforts in Ohio to make a vote harder or to block it entirely. There were efforts in Michigan to do so. And even the same tactics are being repeated. And so the fight over the cost estimate in Florida, which is usually just a very boring, bureaucratic, routine thing, has become this political fight. And that also happened in Missouri. So, we’re seeing these trends and patterns and basically any aspect of this process that can be mobilized to become a fight between conservative state officials and these groups that are attempting to get these measures on the ballot, it has been. And so Arizona is also having a fight over the language that is going to go in the voter guide that goes out to everybody. So there’s a fight going on there that’s going to go to court next week about whether it says fetus or unborn child. So, all of these little aspects of it, there’s going to be more lawsuits over signature, validation, and so it’s going to be a knockdown, drag-out fight to the end.
It’s been really interesting to see that conservative efforts to mount these so-called decline-to-sign campaigns, where they go out and try to just convince people not to sign the petition — those have completely failed, even in states that haven’t gotten the kind of national support and funding that Florida and Nevada and some of these states have. Even those places have met their signature goals and so they’re now moving to this next phase of the fight, which is these legal and bureaucratic challenges.
Rovner: This is going to play out, I suspect, right, almost until the last minute, in terms of getting some of these on the ballot.
Meanwhile, here on Capitol Hill, there’s an effort underway by some abortion rights backers to repeal the 1873 Comstock Act, which some anti-abortion activists say could be used to establish a national abortion ban. On the one hand, repealing the law would take away that possibility. On the other hand, suggesting that it needs to be repealed undercuts the Biden administration’s contention that the law is currently unenforceable. This seemed to be a pretty risky proposition for abortion rights forces no matter which way they go, right?
Ollstein: Well, for a while, the theory on the abortion rights side was, oh, we shouldn’t draw attention to Comstock because we don’t want to give the right the idea of using it to make a backdoor abortion ban. But that doesn’t really hold water anymore because they clearly know about it and they clearly have the idea already and are open about their desire to use it in documents like Project 2025, in letters from lawmakers urging enforcement of the Comstock Act. And so the whole …
Rovner: In concurring opinions in Supreme Court cases.
Ollstein: … Exactly, exactly. In legal filings in Supreme Court cases from the plaintiffs. So clearly, the whole “don’t give the right the idea thing” is not really the strategy anymore; the right already has the idea. And so now I think it’s more like you said, about undercutting the legal argument that it is not enforceable anyway. But those who do advocate for its repeal say, “Why wouldn’t we take this tool out of contention?” But this is sort of a philosophical fight because they don’t have the votes to repeal it anyway.
Rovner: Yeah, though I think the idea is if you bring it up you put Republicans on the record, as …
Ollstein: Sure, but they’ve been doing that on so many things. I mean, they’ve been doing that on IVF [in vitro fertilization], they’ve been doing that on contraception, they’ve been doing that on abortion, they’ve been doing it on the right to travel for an abortion. They’ve been doing it over and over and over and I don’t see a lot of evidence that it’s making a big impact in the election. I could be wrong, but I think that’s the current state of things.
Rovner: Yeah, I’m with you on that one.
All right, well, while we are all busy living our lives and talking about politics, covid is making its now annual summer comeback. President Biden is currently quarantining at his beach house in Rehoboth after testing positive. HHS [Department of Health and Human Services] Secretary Xavier Becerra was diagnosed earlier this week. And wastewater testing shows covid levels are “very high” in seven states, including big ones like Florida, Texas, and California. Sarah, do we just not care anymore? Is this just not news?
Karlin-Smith: Probably, it depends on who you ask, right? But I think obviously with Biden getting covid, it’s going to get more attention again. I think that a lot of health officials, including in the Biden administration, spent a lot of time trying to maybe optimistically hope that covid was going to become a seasonal struggle, much like flu, where we really sort of know a more defined risk period in the winter and that helps us manage it a bit. And always sort of seemed a little bit more optimistic than reality. And I think recently I’ve listened to some CDC [Centers for Disease Control and Prevention] meetings and stuff where — it’s not really, it’s a little bit subtle — but I think they’re finally kind of coming around to, oh wait, actually this is something where we probably are going to have these two peaks every year. They’re sort of year-round risk. But there hasn’t been a ton done to actually think through, OK, what does that mean for how we handle it?
In this country, every year they have been approving a second vaccine for the people most at risk, although uptake of that is incredibly low. So it does seem like it’s become a little bit of a neglected public health crisis. And certainly in the news sometimes when something kind of stays at this sort of constant level of problem, but nothing changes, it can sometimes, I think, be harder for news outlets to figure out how to draw attention to it.
Rovner: It does seem like, I mean, most of the prominent people who have been getting it have been getting mild cases. I imagine that that sort of has something to do … We’re not seeing … even Biden, who’s as we all know, 81, is quarantining at his beach house, so.
Karlin-Smith: Right, I mean, if you kind of stay up to date, as the terminology is, on your vaccinations, you don’t have a lot of high-risk conditions, if you are in certain at-risk groups you get Paxlovid. For the most part a lot of people are doing well. But that said, I think, I’m afraid to say the numbers, but if you look up the amount of deaths per week and so forth, it’s still quite high. We’re still losing — again, more people are still dying from covid every year, quite a few more than from the flu. I mean, one thing I think people have also pointed out is when new babies are born, you can’t get vaccinated until you’re 6 months. The under-6-month population has been impacted quite a bit again. So, it is that tension. And we saw it with the flu before covid, which is every year flu is actually a very big issue in the U.S. and the public health world for hospitals and stuff but the U.S. never quite put enough maybe attention or pressure to figure out how to actually change that dynamic and get better flu vaccine uptake and so forth.
Kenen: And the intense heat makes it, I mean — covid is much, much, much, much more transmissible inside than outside. And the intense heat — we’re not sitting around enjoying warm weather, we’re inside hiding from sweltering weather. We’re all in Washington or the Washington area, and it’s been hot with a capital H for weeks here, weeks. So people are inside. They can’t even be outside in the evening, it’s still hot. So we think of winter as being the indoors time in most of the country, and summer sort of the indoors time in only certain states. But right now we are in more transmissible environments for covid and …
Rovner: Meanwhile, while we’re all trying to ignore covid, we have bird flu that seems to be getting more and more serious, although people seem to just not want to think about it. We’re looking at obviously in many states bird flu spreading to dairy cows and therefore spreading to dairy workers. Sarah, we don’t really even know how big this problem is, right? Because we’re not really looking for it?
Karlin-Smith: That seems to be one of the biggest concerns of people in the public health-virology community who are criticizing the current response right now, is just we’re not testing enough, both in terms of animal populations that could be impacted and then the people that work or live closely by these animal populations, to figure out how this virus is spreading, how many people are actually impacted. Is the genetics of the virus changing? And the problem of course then is, if you don’t do this tracking, there’s a sense that we can get ourselves in a situation where it’s too late. By the time we realize something is wrong, it’s going to already be a very dangerous situation.
Rovner: Yeah, I mean, before covid, the big concern about a pandemic was bird flu. And was bird flu jumping from birds to other animals to humans, which is exactly what we’re seeing even though we’re not seeing a ton of it yet.
Kenen: We’re not seeing a ton of it, and in its current form, to the best of our knowledge, it’s not that dangerous. The fear is the more species it’s in and the more people it’s in, the more opportunities it has to become more dangerous. So, just because people have not become seriously ill, which is great, but it doesn’t mean it stays great, we just don’t — Sarah knows more about this than I do, but the flu virus mutates very easily. It combines with other flu viruses. That’s why you hear about Type A and Type B and all that. I mean, it’s not a stable virus and that is not, I’m not sure if stable is the right …
Rovner: It’s why we need a different flu shot every year.
Kenen: Right, and the flu shots we have, bird flu is different.
Rovner: Well, we will continue to watch that.
Kenen: Sarah can correct anything I just got wrong. But I think the gist was right, right?
Rovner: Sarah is nodding.
All right, well finally, one follow up from last week in the wake of the report from the Federal Trade Commission on self-dealing by pharmacy benefits managers: We get a piece from The Wall Street Journal this week [“Mail-Order Drugs Were Supposed To Keep Costs Down. It’s Doing the Opposite.”] documenting how much more mail-order pharmacies, particularly mail-order pharmacies owned by said PBMs [pharmacy benefit managers] are charging. Quoting from the story, “Branded drugs filled by mail were marked up on average three to six times higher than the cost of medicines dispensed by chain and grocery-store pharmacies, and roughly 35 times higher than those filled by independent pharmacies.” That’s according to the study commissioned by the Washington State Pharmacy Association. It’s not been a great month for the PBM industry. Sarah, I’m going to ask you what I asked the panel last week: Is Congress finally ready to do something?
Karlin-Smith: It seemed like Congress has finally been ready to do something for a while. Certainly, both sides have passed legislation and committees and so forth, and it’s been pretty bipartisan. So we’ll see. I think some of it costs — I forget if some of it costs a little money — but some of it does save. And that’s always an issue. And we know that Congress is just not very good at passing stand-alone bills on particular topics, so I think the key times will be to look at when we get to any big end-of-year funding deals and that sort of thing, depending on all the dynamics with the election and the lame duck, but …
Rovner: I mean, this has been so bipartisan. I mean, there’s bipartisan irritation in both houses, in both parties.
Karlin-Smith: Right, and I think the antitrust sort of element of this with PBMs kind of appeals to the Republican side of the aisle quite a bit. And that’s why there’s always been a bit of bipartisan interest. And the question becomes: PBMs sort of fill the role that in other countries government price negotiators fill. And that’s not particularly popular in the U.S., particularly on the Republican side of the aisle. And so most of the legislation that is pending, I think, will maybe hopefully get us to some transparency solutions, tweak some things around the edges, but it’s not really going to solve the crisis. It’s going to be, I mean, a very [Washington,] D.C. health policy move, which is kind of, take some incremental steps that might eventually move us down to later reforms, but it’s going to be slow-moving, whatever happens. So, PBMs are going to be in the spotlight for probably a while longer.
Rovner: Yes, which popular issue moves slower: drug prices or gun control?
All right, well finally this week the health policy community has lost another giant. Gail Wilensky, who ran Medicare and Medicaid under the first President Bush, and the advisory group MedPAC for many years after that, died of cancer last week at age 81. Gail managed to be both polite and outspoken at the same time. A Republican economist who worked with and disagreed with both Democrats and Republicans, and who, I think it’s fair to say, was respected by just about everyone who ever dealt with her. She taught me, and lots of others, a large chunk of what I know about health policy. She will be very much missed. Joanne, I guess you worked with her probably as long as I did.
Kenen: Yeah, I’m the one who told you she had died, right?
Rovner: That’s true.
Kenen: I think that when I heard her speak in a professional setting in the last few years, she talked to her about herself not as a Republican health economist, but as a free market health economist. She was very well respected and very well liked, but she also ended up being a person without a party. But she was a fixture and she was a nice person.
Rovner: And she wasn’t afraid to say when she was the head of MedPAC she made a lot of people angry. She made a lot of Republicans angry in some of those sort of positions that she took. She basically called it as she saw it and let the chips fall.
Kenen: And Julie, she went to Michigan, right?
Rovner: Yes, and she went to Michigan. That’s true. A fellow Michigan Wolverine. All right, well, that is the news for this week. Now we will play my interview with Renuka Rayasam, and then we will come back and do our extra credits.
I am pleased to welcome to the podcast my KFF Health News colleague Renuka Rayasam, who reported and wrote the latest KFF Health News-NPR “Bill of the Month.” It’s about what should have been a simple visit to an urgent care center but of course turned out to be anything but. Renu, thanks for joining us.
Renuka Rayasam: Thanks for having me.
Rovner: So, tell us about this month’s patient, who he is, and what kind of medical problem he had.
Rayasam: Sure, let me tell you about the patient in this month’s “Bill of the Month.” His name is Tim Chong. He’s a Dallas man, and last December he felt severe stomach pain and he didn’t know what it was from. And he thought at first maybe he’d had some food poisoning. But the pain didn’t subside and he thought, OK, I don’t want to have to pay an ER bill, so let me go to an urgent care. And he opted to visit Parkland Health’s Urgent Care Emergency Center, where he learned he had a kidney stone and was told to go home and that it would pass on its own.
Rovner: Now, we’re told all the time exactly what he was told, that if we have a health problem that needs immediate attention but probably not a hospital-level emergency, we should go to an urgent care center rather than a hospital emergency room. And most insurers encourage you to do this; they give you a big incentive by charging a far smaller copay for urgent care. So, that’s what he tried to do, right?
Rayasam: That’s what he tried to do, at least that’s what he thought he was doing. Like I said, this is a facility, it’s called Urgent Care Emergency Center. He told me that he walked in, he thought he was at an urgent care, he got checked out, was told it was a kidney stone. He actually went back five days later because his stomach pain worsened and didn’t get better. And it wasn’t until he got the bills the following month that he realized he was actually at an emergency center and not an urgent care center. His bill was $500 for each visit, not $50 for each visit as he had anticipated.
Rovner: And no one told him when he went there?
Rayasam: He said no one told him. And we reached out to Parkland Health and they said, “Well, we have notices all over the place. We label it very clearly: This is an emergency care center, you may be charged emergency care fees,” but they also sent me a picture of some of those notices and those are notices that are buried among a lot of different notices on walls. Plus, this is a person who is suffering from severe stomach pain. He was really not in a position to read those disclosures. He went by what the front desk staff did or didn’t tell him and what the name of the facility was.
Rovner: I was going to say, there was a sign that said “Urgent Care,” right?
Rayasam: Right, absolutely. Urgent Care Emergency Center, right? And so when we reached out to Parkland, they said, “Hey, we are clearly labeled as an emergency center. We’re an extension of the main emergency room.” And that’s the other thing you have to remember about this case, which is that this is the person who knew Parkland’s facility. He knew they had a separate emergency room center and he said, “I didn’t go into that building. I didn’t go into the building that’s labeled emergency room. I run into this building labeled Urgent Care Emergency Center.” Parkland says, hey, this is an extension of their main emergency room. This is where they send lower-level emergency cases, but obviously it’s a really confusing name and a really confusing setup.
Rovner: Yeah, absolutely. So, how did this all turn out? Medically, he was OK eventually, right?
Rayasam: Medically he was OK eventually. Eventually the stone did pass. And it wasn’t until he got these bills that he kind of knew what happened. When he first got the bills, he thought, well, obviously there’s some mistake. He talked to his insurer. His insurer, BlueCross and BlueShield of Texas, told him that Parkland had billed these visits using emergency room codes and he thought, wait a second, why are they using emergency room codes? I didn’t go into the emergency room. And that’s when Parkland told him, “Hey, you actually did go into an emergency room. Sorry for your confusion. You still owe us $1,000 total.” He paid part of the bills. He was trying to challenge the bills and he reached out to us at “Bill of the Month,” but eventually his bill got sent to collection and Parkland’s sort of standing by their decision to charge him $500 for each visit.
Rovner: So he basically still owes $1,000?
Rayasam: Yes, that’s right.
Rovner: So what’s the takeaway here? This feels like the ultimate bait and switch. How do you possibly make sure that a facility that says urgent care on the door isn’t actually a hospital emergency room?
Rayasam: That’s a great question. When it comes to the American medical system, unfortunately patients still have to do a lot of self-triage. One expert I’ve talked to said it’s still up to the patients to walk through the right door. Regulators have done a little bit, in Texas in particular, of making sure these facilities, these freestanding emergency room centers, as they’re called — and this one is hospital-owned, so the name is confusin, but it’s technically a freestanding emergency center, so it did have the name emergency in the name of the facility, and I think that that’s required in Texas — but I’ve talked to others who’ve said, you should ban the term urgent care from a facility that’s not urgent care. Because this is a concept that’s very familiar to most Americans. Urgent care has been around for decades; you have an idea of what an urgent care is.
And when you look at this place on its website, it’s called Urgent Care Emergency Center, it’s sort of advertised as a separate clinic within Parkland structure. It’s closed on nights, it’s closed on Sundays. The list of things they say they treat very much resembles an urgent care. So, this patient’s confusion I think is very, very understandable and he’s certainly not the only one that’s had that confusion at this facility. Regulators could ban the term urgent care for facilities that bill like emergency rooms. But until that happens it’s up to the patients to call, to check, and to ask about billing when they show up, which isn’t always easy to do when you’re suffering from severe stomach pain.
Rovner: Another thing for patients to watch out for.
Rayasam: Yes, absolutely, and worry about.
Rovner: Yes, Renuka Rayasam, thank you so much for joining.
Rayasam: Thank you, Julie.
Rovner: OK, we are back. It’s time for our extra credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device.
Sarah, why don’t you go first this week?
Karlin-Smith: Sure, I looked at a New York Times piece called “Promised Cures, Tainted Cells: How Cord Blood Banks Mislead Patients.” And it’s about the often very aggressive sort of tactics of these banks to convince women to save some of the cord blood after they give birth with the promise that it may be able to help treat your child’s illness down the road. And the investigation into this found that there’s a number of problems. One is that, for the most part, the science has progressed in a way that some of what people used to maybe use some of these cells for, they now use adult stem cells. The other is these banks are just not actually storing the products properly and much of it gets contaminated so it couldn’t even be used. Or sometimes you just don’t even collect enough, I guess, of the tissue to even be able to use it.
In one instance, they documented a family that — the bank knew that the cells were contaminated and were still charging them for quite a long time. And the other thing that I actually personally found fascinated by this — because my OB-GYN actually did kind of, I feel like, push one of these companies — was that they can pay the OB-GYNs quite a hefty fee for what seems like a very small amount of work. And it’s not subject to the same sort of kickback type of regulation that there may be for other pharmaceutical/medical device interactions between doctors and parts of the biotech industry. So I found that quite fascinating as well, what the economic incentives are to push this on people.
Rovner: Yeah. One more example of capitalism and health care being uncomfortable bedfellows, Chapter 1 Million. Joanne?
Kenen: There was a fantastic piece in The Washington Post by Annie Gowan: “A Mom Struggles To Feed Her Kids After GOP States Reject Federal Funds,” which was a long headline, but it was also a long story. But it was one of those wonderful narrative stories that really put a human face on a policy decision.
The federal government has created some extra funds for childhood nutrition, childhood food, and some of the Republican governors, including in this particular family’s case, the Republican Gov. Kevin Stitt in Oklahoma, have turned down these funds. And families … So this is a single, full-time working mom. She is employed. She’s got three teenagers. They’re all athletic and active and hungry and she doesn’t have enough food for them. And particularly in the summer when they don’t get meals in school, the struggle to get enough food, she goes without meals. Her kids — one of the kids actually works in the food pantry where they get their food from. The amount of time and energy this mom spends just making sure her children get fed when there is a source of revenue that her state chose not to us: It’s a really, really good story. It’s long, but I read it all even before Julie sent it to me. I said, “I already read that one.” It’s really very good and it’s very human. And, why?
Rovner: Policy affects real people.
Kenen: This is hungry teenagers.
Rovner: It’s one of things that journalism is for.
Kenen: Right, right, and they’re also not eating real healthy food because they’re not living on grapefruits and vegetables. They’re living on starchy stuff.
Rovner: Alice?
Ollstein: I chose a good piece from ProPublica called “Texas Sends Millions to Crisis Pregnancy Centers. It’s Meant To Help Needy Families, but No One Knows if It Works.” And it is about just how little oversight there is of the budgets of taxpayer dollars that are going to these anti-abortion centers that in many cases use the majority of funding not for providing services. A lot of it goes to overhead. And so there’s a lot of fascinating details in there. These centers can bill the state a lot of money just for handing out pamphlets, for handing out supplies that were donated that they got for free. They get to charge the state for handing those out. And there’s just not a lot of evaluation of, is this serving people? Is this improving health outcomes? And I think it’s a good critical look at this as other states are moving towards adopting similar programs to what’s going on in Texas.
Rovner: Yeah, we’re seeing a lot of states put a lot of money towards some of these centers.
Well, my extra credit this week is from Time magazine. It’s called, “‘We’re Living in a Nightmare:’ Inside the Health Crisis of a Texas Bitcoin Town,” by Andrew Chow. And in case we didn’t already have enough to worry about, it seems that the noise that comes from the giant server farms used to mine bitcoin can cause all manner of health problems for those in the surrounding areasm from headaches to nausea and vomiting to hypertension. At a local meeting, one resident reported that “her 8-year-old daughter was losing her hearing and fluids were leaking from her ears.”
The company that operates the bitcoin plant says it’s in the process of moving to a quieter cooling system. That’s what makes all the noise. But as cryptocurrency mining continues to grow and spread, it’s likely that other communities will be affected in the way the people of Granbury, Texas, have been.
All right. That is our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcast. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, I’m @jrovner. Sarah, where are you these days?
Karlin-Smith: I’m mostly on X @SarahKarlin or on some other platforms like Bluesky, at @sarahkarlin-smith.
Rovner: Alice?
Ollstein: I’m on X @AliceOllstein and on Bluesky @alicemiranda.
Rovner: Joanne?
Kenen: A little bit on X @JoanneKenen and a little bit on Threads @joannekenen1.
Rovner: We will be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': Florida Limits Abortion — For Now
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Julie Rovner
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
Florida this week became a major focus for advocates on both main sides of the abortion debate. The Florida Supreme Court simultaneously ruled that the state’s 15-week ban, passed in 2022, can take effect immediately before a more sweeping, six-week ban replaces it in May and that voters can decide in November whether to create a state right to abortion.
Meanwhile, President Joe Biden, gearing up for the general election campaign, is highlighting his administration’s health accomplishments, including drug price negotiations for Medicare.
This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of the Johns Hopkins University schools of nursing and public health, Tami Luhby of CNN, and Lauren Weber of The Washington Post.
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Joanne Kenen
Johns Hopkins Bloomberg School of Public Health and Politico
Tami Luhby
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Lauren Weber
The Washington Post
Among the takeaways from this week’s episode:
- The Florida Supreme Court’s decisions this week will affect abortion access not only in the state, but also throughout the region. Florida’s six-week ban, which takes effect on May 1, would leave North Carolina and Virginia as the only remaining Southern states offering the procedure beyond that point in pregnancy — and, in North Carolina, abortion is banned at 12 weeks after a woman’s last menstrual period.
- Since the U.S. Supreme Court overturned the constitutional right to an abortion in 2022, six states have voted on their own constitutional amendments related to abortion access. In every case, the side favoring abortion rights has won. But Florida’s measure this fall will appear on the ballot with the presidential race. Could the two contests, waged side by side, boost turnout and influence the results?
- Former President Donald Trump made many attempts during his term to undermine the Affordable Care Act, and this week the Biden administration reversed another one of those lingering attempts. Under a new regulation, the use of short-term insurance plans will be limited to four months — down from 36 months under Trump. The plans, which Biden officials call “junk plans” due to their limited benefits, will also be required to provide clearer explanations of coverage to consumers.
- In other Biden administration news, March has come and gone without the release of an anticipated ban on menthol flavoring in tobacco, and anti-tobacco groups are suing to force administration officials to finish the job. Menthol cigarettes are particularly popular in the Black community, and — like Trump’s decision as president to punt a ban on vaping to avoid alienating voters in 2020 — the Biden administration may be loath to raise the issue this year. Activists say, however, that it may be at the expense of Black lives.
- “This Week in Medical Misinformation” looks at an article from PolitiFact about the health misinformation that persists even with the pandemic mostly in the rearview mirror.
Also this week, Rovner interviews health care analyst Jeff Goldsmith about the growing size and influence of UnitedHealth Group in the wake of the Change Healthcare hack.
Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: Politico’s “Republicans Are Rushing to Defend IVF. The Anti-Abortion Movement Hopes to Change Their Minds,” by Megan Messerly and Alice Miranda Ollstein.
Tami Luhby: The Washington Post’s “Biden Summons Bernie Sanders to Help Boost Drug-Price Campaign,” by Dan Diamond.
Lauren Weber: The Washington Post’s “Bird Flu Detected in Dairy Worker Who Had Contact With Infected Cattle in Texas,” by Lena H. Sun and Rachel Roubein.
Joanne Kenen: The 19th’s “Survivors Sidelined: How Illinois’ Sexual Assault Survivor Law Allows Hospitals to Deny Care,” by Kate Martin, APM Reports.
Also mentioned on this week’s podcast:
- KFF Health News’ “ACA Plans Are Being Switched Without Enrollees’ OK,” by Julie Appleby.
- KFF Health News’ “Your Doctor or Your Insurer? Little-Known Rules May Ease the Choice in Medicare Advantage,” by Susan Jaffe.
- Health Affairs’ “Will the Change Healthcare Incident Change Health Care?” by Jeff C. Goldsmith.
- The Health Care Blog’s “Optum: Testing Time for an Invisible Empire,” by Jeff Goldsmith.
click to open the transcript
Transcript: Florida Limits Abortion — For Now
KFF Health News’ ‘What the Health?’Episode Title: Florida Limits Abortion — For NowEpisode Number: 341Published: April 4, 2024
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, April 4, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this, so here we go.
We are joined today via video conference by Tami Luhby of CNN.
Tami Luhby: Good morning.
Rovner: Joanne Kenen of the Johns Hopkins University Schools of Nursing and Public Health and Politico magazine.
Joanne Kenen: Hi, everybody.
Rovner: And Lauren Weber, the Washington Post.
Lauren Weber: Hello.
Rovner: Later in this episode, we’ll have an interview with Health Policy Analyst and Consultant Jeff Goldsmith about the continuing fallout from the Change Healthcare hack. But first, this week’s news. One of these weeks, we won’t have to lead with abortion news, but this is not that week. On Monday, the Florida Supreme Court ruled separately, but at the same time, that state voters could decide this November whether to make a right to abortion part of the state’s constitution and that the state’s constitution currently does not guarantee that right.
So the state’s 15-week abortion ban signed by Gov. Ron DeSantis in April of 2022 can take immediate effect. But wait, there’s more. First, the decision on the 15-week ban overruled years of precedent that Florida’s Constitution did, in fact, protect the right to abortion. And second, allowing the 15-week ban to take effect automatically triggers an even more sweeping six-week ban that Gov. DeSantis signed in 2023. That will take effect May 1. That’s the one he signed in the middle of the night without an audience people may remember. And this is going to affect far more people than just the population of Florida, right?
Kenen: The whole South. This is it. If you count the South as North Carolina and what we think of as the South, North Carolina is the only state that still has legal abortion, and that is only up to 12 weeks. And there are some conditions and hurdles, but you can still get an abortion in North Carolina.
But to get from a place, people were going to Florida, it’s easier to get from Alabama to Florida than it is from Alabama to even Charlotte. I think I read it’s a 17-hour drive from Florida or something like that. I don’t remember. It’s long. So it’s not just people who live within Florida, but people who live in 11 or 12 states in the American South have far fewer options.
Rovner: And even though the Florida ban feels less than a complete ban because it allows abortions up to six weeks, the fine print actually makes this one of the most restrictive bans in the country. It looks, in effect, like most people won’t be able to get abortions in Florida at all.
Weber: I would say that’s right, Julie. And just to reiterate what Joanne said, 80,000 women get abortions in Florida every year. That’s about one in 12 women in America that get abortions per year, and they will no longer have that kind of access because, at six weeks, a lot of women don’t know they’re pregnant. So, I mean, that’s a very restrictive abortion ban.
Rovner: Remember that six weeks isn’t really six weeks of having been pregnant. Six weeks is six weeks since your last menstrual period, which can be as little as two weeks in some cases.
Kenen: And I also think that even if you do know within six weeks, getting an appointment, given how few places there are in the entire South, even if you know and you get on the phone right away, can you get an appointment before your six weeks is an additional challenge because access is really limited …
Rovner: Right.
Kenen: … intentionally.
Rovner: Yes, and we’ve seen this with other six-week bans. We should point out that some people consider Virginia the South still, and you can go to Virginia, but that’s basically the last place that a good chunk of the country, geographically, if not population-wise, would need to turn to in order to get an abortion.
Well, if that’s not all confusing enough, even if voters do approve the ballot measure in November, the Florida Supreme Court suggested it could still strike down a right to abortion based on a majority of justices findings that the state’s constitution could include personhood rights for fetuses.
I’m having trouble wrapping my head around why the justices would allow a vote whose results they might then overturn. But I guess this is part of the continuing evolution, if you will, to use that word, of this concept of personhood for fetuses and embryos, and what has us talking about IVF, right?
Weber: Yeah, absolutely. I think, as many conservative Christian groups will say, this is the natural line that pro-life is. I mean, they argue, and while they’re pushing this view is not necessarily held by the majority of constituents, but this is their argument that a fetus, an embryo, such as one that could be used in IVF, is a person.
And so, I mean, I think that’s kind of the natural conclusion of pro-life ideology as we’re seeing it right now. And I think it will have a lot of political effects going forward because that IVF is obviously much more popular than abortion. I think we’ll see a lot of voting firepower potentially used on that.
Rovner: Well, I’m so glad you said that because I want to turn to politics. Some Democrats are suggesting that this could boost turnout for Democrats and help, if not put Florida in play for president, maybe the Democrat running to unseat Senator Rick Scott, the Republican.
On the other hand, while abortion ballot questions have done very well around the country, as we know, even in states redder than Florida, there is evidence that some Republicans vote for abortion rights measures and then turn around and vote at the same time for Republicans who would then vote to overturn them.
There are in fact Florida abortion rights advocates who don’t want Democrats to make this issue partisan because they want Republicans to come and vote for the ballot measure, which needs a 60% majority to pass, even if those Republicans then go on to vote for other Republicans. So, who really is helped by this entire mess, or is it impossible to tell at this point?
Weber: I think it’s impossible to tell, but I do think what is complicating is we haven’t seen the presidential race thrown into these abortion ballots. I mean, what we’re looking at is two candidates who potentially are facing a lot of low turnout due to lack of enthusiasm in their bases for both of them. And I am curious if the abortion ballot measures could have much more of an impact on the presidential race than maybe some of these other lower-office races that we’ve seen. I think that’s the main question that I guess we’ll see in November.
Rovner: As we have spoken about many times, President Biden is not super comfortable talking about this issue. He’s an 81-year-old Catholic. It does not come naturally to him to be in favor of abortion rights, which he now is. But Vice President Harris has been sent out. She’s sort of become the standard-bearer for this administration on reproductive health issues, and she’s been very active. And Joanne, you wanted to say something?
Kenen: There are a couple of points. In addition to the abortion ballot initiative. There’s also a marijuana legalization. I think we will see higher turnout and particularly among younger people who have been pretty disaffected this election. So that’s one, whether it affects the presidential race, whether it affects the Senate race. I mean, just as Democrats feel really strong about abortion, Republicans feel really strong about immigration. We don’t know what’s going to happen in November, but I do think this boosts turnout. The second thing to remember, though, is in terms of abortion ballot initiatives have passed every time they’ve come up since the fall of Roe [v. Wade].
This is a 60% threshold, and I do not believe that any state has reached that. I think the highest was about 57%. So even though it may get well over 50, it could get 59.9, the Florida ballot initiative needs 60%. That is a tall order. So you might end up seeing a big turnout, a big pro-abortion rights vote, maybe a big legal weed vote, and the abortion measure could still fail. But I do think it definitely changes the dynamics of Florida from the presidential race on down the ballot. I do think it is a different race than we would’ve seen beforehand.
Rovner: And I will point out, since she didn’t, that Joanne has spent time covering Florida and covering the politics in Florida. So you know where of you speak on this.
Kenen: Well, I lived there for a while, though it was a while ago. The state has, in fact, changed like everything else, including me, right? But I’m somewhat familiar with Florida. I was just there a few weeks ago in fact.
Rovner: And I want to underscore something that Lauren said, which is that we’ve seen all of these ballot measures since Roe was overturned, but we have not seen these ballot measures stacked on top of the presidential race. So I think that will be interesting to watch as we go forward this year.
Well, back here in D.C., the Biden administration issued a long-awaited rule reigning in the use of those short-term health plans that Democrats like to call junk insurance and that President Trump had expanded when he was in office. Tami, what is the new rule, and what will it do?
Luhby: Well, it’s actually curtailing the short-term plans and pretty much reversing the Trump administration rule. So it’s the latest move by the president to contrast his approach to health care with that of former President Donald Trump. Trump extended the duration of the short-term health insurance plans to just under a year and allowed them to be renewed for a total of 36 months. And it was seen as an effort to weaken the Affordable Care Act, draw out younger people, make it more difficult for the marketplace, probably send the older, sicker people there, which would raise premiums, basically cause more chaos in the marketplace.
Rovner: Yeah. And remind us why these plans can be problematic.
Luhby: I will tell you that the short-term plans do not have to adhere to Obamacare’s consumer protections, which is the big difference. For instance, they’re not required to provide comprehensive coverage, and they can discriminate against people with pre-existing conditions, charge them more, deny them, et cetera. As I’d said, the Trump administration heralded them as a cheaper alternative because since they can underwrite, they have typically cheaper premiums. But they also have very limited benefits, or they can have limited benefits depending on the patient or the consumer.
So the Biden rule, which was proposed last month as a series of actions aimed at lowering health care costs, limits the duration of new sales of these controversial plans to three months, with the option of renewal for a maximum of four months. So it’s going on these new plans from 36 months potentially to four months, which was the original idea of these plans because originally they were thought to be for people who might be switching jobs or have a temporary lapse in coverage. They were not intended to be a substitute for full insurance. And it also requires, notably, that the plans provide consumers with a clear explanation of their benefits and inform them of how to find more comprehensive coverage.
Rovner: And obviously this will continue to be controversial, but I think the Democrats, in general, who support the Affordable Care Act feel pretty strongly that this is something that’s going to help them. And as we talked about, we’re not sure yet how the administration is going to play the abortion issue in the campaign, but it is pretty clear that they are doubling down on health care.
One problem for the administration, as we have talked about, is that particularly on really popular things like Medicare drug price negotiations, lots of the public has no idea that that’s happened or if it’s happened that it’s because the Democrats did it. So, in part of an effort to overcome that, Biden invited Bernie Sanders to the White House this week. What was that about?
Luhby: Well, that’s my extra credit. Would you like me to discuss that now?
Rovner: Sure, let’s do that now.
Luhby: OK. So my extra credit is a Washington Post story titled “Biden Summons Bernie Sanders to Help Boost Drug-Price Campaign,” by Dan Diamond. And I have to admit, I hope I can do that here, that I am a fangirl of Dan Diamond’s stories, and even more so now because apparently, the Biden administration gave Dan a heads-up in advance, that since he published a pretty in-depth story an hour before the embargo lifted for the rest of us who were only given a few tidbits of information about what this meeting or what this speech was going to be about at the uncharacteristically late hour of 8:30 at night.
So Dan’s story looked at how the two former rivals, Joe Biden and [Sen.] Bernie Sanders, who were rivals in the 2020 Democratic presidential nomination, how they had very different views on how the nation’s health care system should operate and Dan’s story looked at how they were uniting to improve awareness of Biden’s efforts to lower drug prices and improve his chances in November. Biden invited Sanders to the White House to discuss the administration’s actions on drug prices, including the latest effort to reduce the out-of-pocket cost of inhalers, which really hasn’t gotten a lot of press.
Sanders brings his progressive credentials and his two-decade-plus track record of fighting for lower drug prices and, “naming and shaming individual pharmaceutical companies and executives.” He’s known to be pretty outspoken and fiery. So the story’s a good example of policy meets politics in an election year. It relays that most Americans still don’t know about the administration’s efforts despite the numerous speeches, news releases, and officials’ trips around the country, hence the need to tap Sanders, and it also provides a nice walk down memory lane, revisiting the duo’s battles in the 2020 primary as well as some of former President Trump’s drug price efforts.
Rovner: Yeah. And a little peek behind the journalistic curtain. I think we all got this sort of mysterious note from Sanders’ press people the night before saying, “If you’ll agree to our embargo, we’ll tell you about this secret thing that’s going to happen,” followed by an advisory from the White House saying that Bernie Sanders was coming to the White House to talk about drugs. [inaudible 00:13:30] …
Luhby: Right. And also, uncharacteristically, when I asked for a comment from Sanders directly, they said tomorrow, which is not like Sanders at all.
Kenen: Sanders and Biden were obviously opponents in the primary, but Sanders has really been very supportive of Biden. I think he’s really sort of highlighted the progressive things that Biden has done and stayed quiet about the more centrist things that Biden has done. He’s been a real ally, and he still has a lot of credibility, and I think they sort of like each other in a funny way. You can sort of see it, but that’s their issue.
Luhby: Biden has also been able to do things that other people have not been able to do with the congressional Democrats. Biden has been able to do things that congressional Democrats have tried to for years and have not been able to, and they may not be the extent to which the Democrats would like. If you remember the 2019 Medicare Drug Negotiation bill, I think, was 250 drugs a year. What ended up passing in the IRA [Inflation Reduction Act] was 10 drugs and ramping up, but at least it’s something.
Kenen: And it’s more than 20 years in the making. I mean, this goes way, way back.
Luhby: Mm-hmm.
Rovner: And I was going to underscore something that Joanne said earlier about Florida, which is that both sides are trying to gin up their base, and young people are really fond of Bernie Sanders in a lot of the things that he says, and this may be a way that Biden can ironically use the Medicare drug price negotiation issue to stir up his young person base to get them out to vote. So I was interested in the combination.
Kenen: So it’s Bernie Sanders and legal weed.
Rovner: That’s right. It’s Bernie Sanders and legal weed, at least in Florida.
Kenen: I’m not implying anything about Bernie Sanders’ use of it. It’s just the dynamic for the young voters.
Rovner: Yes. Things to draw young people out to the polls in November. Well, while the Biden administration is doing lots of things using its regulatory power, one thing it is not doing, at least not yet, is banning menthol flavoring in tobacco.
This is a regulation that’s now been sitting around for nearly two years and that officials had promised to finalize by the end of March, which of course was last week and which didn’t happen. So now three anti-tobacco groups have sued to try to force the regulation over the finish line. Somebody remind us why banning menthol is so very controversial.
Weber: It’s controversial in part because a lot of industry will say that banning menthol will lead to over-policing in Black communities. The jury is very much out on if that is an accurate representation or part of the cigarette playbook to keep cigarettes on the market. Look, a presidential election year and things to do with smoking is not new.
When I was at KFF Health News with Rachel Bluth back in the day, we wrote a story about how Trump postponed a vape ban to some extent because he was worried about vaping voters. So I mean, I think what you’re seeing is a pretty clear political calculus by the Biden folks to push this off into the new year, but as activists and public health advocates will say, it’s at the expense of, potentially, Black lives.
Rovner: That’s right.
Weber: So banning menthol cigarettes would really… what it would do is statistically save Black Americans who die from, predominantly from smoking these types of cigarettes. So it’s a pretty weighty decision to put off with a political calculus.
Rovner: He’s taking incoming from both sides. I mean, obviously, there are members of the Black community who say, as you point out, this could lead to an unnecessary crackdown on African American smokers who use menthol more statistically than anybody else does. Although, there’s some young people who use it too. On the other hand, you have people representing public health for the Black community saying, “We want you to ban this” because, as you point out, people are dying from smoking-related illnesses by using this product. So it’s a win-win, lose-lose here that is continuing on. We’ll be interested to see what, if the lawsuit can produce anything.
Well, speaking of things that are controversial, we also have Medicare Advantage. The private plan alternative to traditional Medicare now enrolls more than half of those in the program, many who like the extra benefits that often come with the plans and others who feel that they can’t afford traditional Medicare’s premiums and other cost-sharing. Except one reason those extra benefits exist is because the government is overpaying those Medicare Advantage plans. That’s a vestige of Republican plans to discourage enrollment in original Medicare that date back to the early part of this century.
So now taxpayers are footing more of the Medicare bill than they should. This week’s news is that the federal government is effectively trimming back some of those overpayments. And investors in the insurance companies, who make money from the overpayments, are going crazy. This is the subhead on a story from the Wall Street Journal, “Managed care stocks are set to fall due to disappointment with the government’s decision not to revise the 2025 Medicare payment proposal.” How is this ever going to get sorted out? Somebody always is going to be a loser in this game, either the patients or the insurance companies or the taxpayers. Everybody cannot win here.
Luhby: Right. And Humana got hit really hard when the rule came out because it is really focused on Medicare Advantage. So yeah, the insurers were hit, but as everything with the market, it’s not forever.
Rovner: I’m continually puzzled by … if the payments were equivalent, which was what they were originally supposed to be. Originally, originally back in the 1980s, insurance companies came to Congress and said, “We can provide managed care and Medicare cheaper, so you can pay us 95% of the average that you pay for a fee for service patient. We can make a profit on that.”
Well, that is long since gone. The question is how much more they will make. And as I point out, when they get overpaid, they do have to rebate those back effectively to the patients in terms of higher benefits. And that’s why many of them offer dental coverage and eyeglasses coverage and other types of, quote-unquote, extra benefits that Medicare doesn’t offer.
But also you get this lack of choice, and so we see when people try to leave these plans and go back to traditional Medicare, they can’t, which is only one of the sort of things that I think a lot of people don’t know about how Medicare Advantage works. Another place with an awful lot of small print.
Weber: It’s a lot of small print under a very good marketing name. The name itself implies that you’re making a better choice, but that isn’t necessarily what the small print would say.
Kenen: And there are people who are very satisfied with it and who get great care. I mean, it’s not monolithic. I mean, it is popular. It is growing and growing and growing. It’s partly economic, and there’s some plans that patients like, and there’s word of mouth or that were negotiated as part of union agreements and are actually pretty strong benefits. But they’re also people who are really encountering a lot of trouble with prior authorization, and limited networks, and your doctor’s no longer in it, et cetera, et cetera.
I think that those things, I actually checked with somebody about the provider networks, what we know about who’s dropping out, and I don’t think there’s really up-to-date data, but there is a perception, and you’re hearing it and seeing it online. But they do an incredible amount of marketing, an incredible amount of marketing. And if you’re in it and you like it and you save money and you’re getting great health care, terrific. You’re going to stay in it.
If you’re in it and you don’t like it and you’re not getting great health care and a lot of hassles or you can’t see the right doctors, it’s hard to get out and get back into it depending on what state you’re living … It’s not monolithic. But I think we might be between the financial pressures from the government and some of the debates about some of these things they’re doing there may be some reconsideration. But they have strong backers in Congress and not just Republicans.
Rovner: Oh, yeah. I mean, and as you point out, more than half of the people in Medicare are now on Medicare Advantage. I did want to sort of highlight my colleague Susan Jaffe, who has a story this week about the fact that patients can’t change plans in the middle of the year, but plans can drop providers in the middle of the year, so people may sign up for a health plan because their doctor or their hospital is in it and then suddenly find out mid-year that their doctor and their hospital is no longer in it.
There are occasionally, if you’re in the middle of treatment, there are opportunities sometimes to change, but often there aren’t. People do end up in these plans, and they can be happy for, basically, until they’re not, that there are trade-offs when you do it. And I think, as we point out, there’s so much marketing, and the marketing somehow doesn’t ever talk about the trade-offs that you make when you go into Medicare Advantage.
Luhby: Well, one also thing is that this is the peak 65 year, where the most baby boomers, and where are they coming from? They’re coming from private commercial insurance, so they’re familiar with it, and they were like, “Oh, OK, that’s seemingly very much like my employer plan. Sure, that sounds great. I know how to deal with that.” So that’s one of the things. And one cudgel that the insurers have is they say, “Oh, government, you’re going reduce our payments. We’re going to reduce the benefits and increase the premiums because we’re not going to have all of that extra government funding.” And that can scare the government because they don’t want the insurers to tell their patients, who are older patients who vote, “Oh, because of the government, we can no longer offer you all of these benefits, or we’ve had to raise your premium because of that.” So we’ll see if they actually do that.
Kenen: Joe Biden took away your gym, right?
Luhby: Exactly.
Rovner: [inaudible 00:22:11].
Luhby: And your dental benefits. So that’s always the threat that the insurers roll out. That’s the first thing that they say often, but we’ll see what happens. We don’t know yet until the fall, when enrollment starts, what will actually happen?
Rovner: We saw exactly that in the late ’90s after Congress balanced the budget. They took a big whack out of the payments for what was then, I think, called Medicare Plus Choice. It was the previous version of Medicare Advantage, and a lot of the companies just completely dropped out of the program. And a lot of the people, who as Joanne said, had been in those plants had been very happy, threw a fit and came to Congress to complain, and lo and behold, a lot of those payments got increased again. In fact, that was what led to the big increase in payments in 2003 was the huge cut that they made to payments, which drove a lot of the insurers out of the program. So we do know that the insurers will pack up and leave if they’re not paid what they consider to be enough to stay in the program.
Moving on. One of the things that Jeff Goldsmith talks about in this week’s interview is that our health system has become one of deep distrust between patients, providers, and insurers. Speaking of Medicare Advantage. That is sad and dysfunctional, except that sometimes there are good reasons for that distrust. One example comes this week from my KFF Health News colleague Julie Appleby. It seems that unscrupulous insurance brokers are disenrolling people in Obamacare plans from their health plans and putting them in different plans, which is unbeknownst to them until they find their doctor is no longer in their network or their drug isn’t covered.
The brokers who are doing this can earn bigger commissions. But patients can end up not just having to pay for their own medical care but owing the government money because suddenly they’re in plans getting subsidies that don’t match their incomes. It is a big mess. And it seems that the obvious solution, which would be making it harder for agents to access people’s enrollment information so they can switch them, would delay legitimate enrollment. It has to be easy for agents to basically manipulate people’s applications. So how do you guard against bad actors without inconveniencing everyone? This seems to be the question here and the question for Medicare Advantage, Lauren.
Weber: I was going to say, I mean, I think that’s the question Medicare itself has been dealing with for years. I mean, there’s a reason that many federal prosecutors call this a pay-and-chase situation in which there is rampant Medicare fraud. They prioritize the ease of patients accessing care to the disadvantage of some folks, or in this case, the American taxpayer, in this case, actual patients, being swindled.
But I don’t have an answer. I don’t think anyone really has an answer, considering we’re seeing things like the $2 billion catheter fraud that we’ve talked about here. So I think again, this is one of these things where the government’s been left a little flat-footed in trying to protect against bad actors.
Rovner: Yeah, well, the health sector is what a fifth of the economy now, so I guess it shouldn’t come as much of a surprise that you have not just bad actors, people who are making a lot of money from doing illegal things and find it to be worth their while and that some of them get caught, but presumably most of them don’t. I guess that’s what happens when you have that much money in one place, you need sort of better watchdogs. All right. Well, finally, this week in medical misinformation comes from PolitiFact in a story called “Four Years After Shelter-in-Place, Covid-19 Misinformation Persists.” That’s an understatement.
That last part was mine. At the top of the list says, “We have discussed before is growing resistance to vaccines in general, not just the covid vaccine,” which is not all that surprising considering how many people now believe fictitious stories about celebrities dropping dead immediately after receiving vaccines. There’s even a movie called “Died Suddenly.” Or that government leaders and the superrich orchestrated the pandemic. That’s another popular story that goes around. Or that Dr. Tony Fauci brought the virus to the United States a year before the pandemic. Lauren, health misinformation is your beat. Is it getting any better now that the pandemic is largely behind us, or is it just continuing unabated?
Weber: No, I would argue it’s possibly getting worse because the trust in institutions is at an all-time low. Social media has allowed for fire hose. I mean, it’s made everything … it’s made the public square that used to be more limited, all corners of the country.
I would say that misinformation has led to mistrust about basic medical things, including childhood vaccinations, but also other medical treatment and care. And I think you’re really seeing this kind of post-truth world post-covid, this distrust, this misinfo is going to continue for some time. And there’s too much to cover on my beat. There’s constantly stories around the bend, and I don’t expect that improving anytime soon.
Kenen: Every single time a celebrity, not just dies, because it’s always no matter what happens, it’s blamed on the covid vaccine, but also gets sick. I mean, Princess Kate. We don’t know everything about her health, but I mean, all of us know it wasn’t. Whatever it is, it’s not because the covid vaccine. But if you go online, you hear that that’s whatever she has it’s because she’s vaccinated.
And the other thing is it’s fed into this general vaccine mistrust. So when I wrote about the RSV vaccine, which we talked about a few weeks ago, it wasn’t so much that there’s a campaign against the RSV vaccine. There is somewhat of that. But it’s just this massive, “vaccines are bad.” So it’s spilling over into anything with a needle attached is part of this horrible plot to kill us all. So it’s just sort of this miasma of anti-vaccination that’s hovering over a lot of health care.
Rovner: Well, at the risk of getting a little too bleak, that will be the news for this week. Now, we will play my interview with Jeff Goldsmith, and then we’ll come back and do our extra credits. I am pleased to welcome back to the podcast Jeff Goldsmith, one of my favorite big-picture health system analysts. Jeff has been writing of late about the Change Healthcare hack and the growing size and influence of its owner, UnitedHealth Group, and what that means for the country’s entire health enterprise. Jeff, thanks for joining us again.
Jeff Goldsmith: You bet.
Rovner: So the lead of your latest piece gives a pretty vivid description of just how big United has become, and I just want to read it. “Years ago, the largest living thing in the world was thought to be the blue whale. Then someone discovered that the largest living thing in the world was actually the 106-acre, 47,000-tree Pando aspen grove in central Utah, which genetic testing revealed to be a single organism.
With its enormous network of underground roots and symbiotic relationship with a vast ecosystem of fungi, that aspen grove is a great metaphor for UnitedHealth Group. United, whose revenues amount to more than 8% of the U.S. health system, is the largest health care enterprise in the world.” Let’s pick up from there for people like me who haven’t been paying as much attention as maybe they should have, and still think that United is mainly a health insurance company. That is not true and hasn’t been for some time, has it?
Goldsmith: The difference between United and a health insurance company is that it also has $226 billion worth of care system revenues in it, some of which are services rendered to United and other, believe it or not, services rendered to United competitors. So, there isn’t anything remotely that size in the health insurance world. That $226 billion is more than double the size of Kaiser. Just to give you an idea of the scale.
Rovner: Which, of course, is the other companies that are both insurers and providers. That’s pretty much the only other really big one, right?
Goldsmith: Yes. I have a graphic in the piece that shows the Optum Health part, which is the care delivery part of Optum, is just about the same size as Kaiser, but it generates six and a half billion dollars in profit versus Kaiser’s $323 million. So it dwarfs Kaiser in terms of profitability even though it’s about the same size top line.
Rovner: So split it up for people who don’t know. What are sort of the main components that make up UnitedHealth Group?
Goldsmith: Well, there’s a very large health insurance business, $280 billion health insurance business. Then, there is a care system called Optum Health, which is about $95 billion. It has 90,000 affiliated or employed docs, a huge chain of MedExpress urgent care centers, surgery centers, a couple of very large home health care agencies. So that’s the care delivery part of United.
There’s Optum Insight, which is about $19 billion. That’s the part that Change Healthcare was inside of. It’s a business intelligence and corporate services business, and consulting business, that also manages care systems financials. And then, finally, there’s Optum Rx, which is about $116 billion, so a little bit more than half of Optum’s total, and that is a pharmacy benefit management company. Believe it or not, the third-largest one. So there are bigger pharmacy benefits management companies than Optum, but those are the three big pieces.
Rovner: I feel like this is almost as big as a lot of the government health programs, isn’t it?
Goldsmith: Yeah. I mean, I can’t remember top line how big the VA [Department of Veterans Affairs] is these days, but it’s VA scale, but it’s in a bunch of little pieces scattered all over the United States. I mean, that’s the big part of all of this. The care system is in at least 30 states. I have a map showing where some of the locations are. That map took me months to find. There isn’t a real registry of what the company owns, but it is a vast enterprise. And they’re great assets, if you’ll pardon a financial term for them.
Some of the finest risk-bearing multispecialty group practices in the United States are a part of Optum: Healthcare Partners based in Los Angeles; The Everett Clinic; the former Fallon Clinic, and Atrius in New England, which are the two finest risk-bearing, multispecialty physician groups in the Northeast. They weren’t dredging the bottom here at all. They got a tremendous number of high-quality groups that they’ve pulled together in the organization. The issue is it really an organization or is it a collection of assets that have been acquired at a very rapid pace over a period of the last 15 years.
Rovner: One of the things that I think the Change Healthcare hack proved for a lot of people is that nobody realized what a significant percentage of claims processing could go through one company. You have to wonder, have regulators, either at the state or federal level, kind of fallen down on this and sort of let this happen so that when somebody hacks into it, half the system seems to go down?
Goldsmith: The federal government challenged the Change acquisition and basically lost in court. They were unable to make the case. They were arguing that Change controlling all of these transactions of not only United but a lot of other insurers gave them access to information that enabled United to have some type of unfair competitive advantage. It was a difficult argument to make that didn’t make it. But the result of the Change acquisition was that about a third of the U.S. health system’s money flowed through one company’s leaky pipes.
And what we’re sort of learning as we learn more about Change is that there were something like a hundred separate programs inside Change, all of which somehow were vulnerable to this hack. And I think that’s one of the things that I think when [Sen.] Ron Wyden and [Sen.] Mark Warner get around to getting some facts about this, they’re going to wonder how did that happen. How could you have that many applications, that loosely tied together, that they were vulnerable to something like this?
And what my spies tell me is that a hacker, and it could have been a single hacker, not a country, but one guy was able to drop down into all of those data silos, vacuum out the data, and then delete the backups, so that United was basically left with no claims trail, no provider directories, nothing, and has had to reconstruct them; panicky reconstruction here in the last six weeks.
Rovner: Which I imagine is what’s taking so long for some of these providers to get back online.
Goldsmith: Julie, the part I don’t understand, is if it is true that that Change was processing a trillion and a half dollars worth of claims a year, a month interruption is $125 billion. That’s $125 billion that didn’t get paid to providers of care after the fact of them rendering the care. So the extent of the damage done by this is difficult to comprehend.
I mean, I have a lot of provider contacts and friends. Some of them, believe it or not, had no Change exposure at all because their main payers didn’t use Change. Some of them, it was all their payers used, and cash flow just ceased, and they had to go to the bank and borrow money to make their payrolls. None of this, for some reason, has made it in its full glory out into the press, and it isn’t that there aren’t incredibly high-quality business reporters in this field. There are.
Rovner: I know. I live in Maryland. I’ve driven over the Francis Scott Key Bridge in Baltimore. I know what it means. I mean, basically took apart the Baltimore Beltway. I mean, no longer goes in a circle. And I know how big the Port of Baltimore is, and I feel like everybody can understand that because it’s visceral. You can see it. There’s video of the bridge falling down. There isn’t video of somebody hacking into Change Healthcare and stopping a lot of the health system in its tracks.
Goldsmith: The metaphor that occurred to me, as you know, I’m a metaphor junkie, was actually Deepwater Horizon, and of course, we had a camera on that gushing well the whole time. This is like a gusher of red ink, a Deepwater Horizon-sized gusher of red ink that went on for a month. From what I’m able to understand, people are able to file the claims now. How many people have actually been paid for the month or six weeks’ worth of work they’ve done is elusive. And I still don’t have access to really good facts on how much of what they owed people they’ve actually paid.
I do know a lot of my investor analyst friends are waiting for United’s first-quarter financials to drop, which will probably show a four- or five-day drop in their medical loss ratio because of all the claims they were not able to pay, and therefore money was sitting in their coffers earning, what, 5% interest. That’s going to be kind of a festival when the first-quarter financials drop. And, of course, it isn’t just United, Humana, the Elevance, Cigna, all the rest of them. A lot of these folks use Change to process their claims. So there’s going to be a swollen offer here on the health insurance side from a month of not paying their bills.
Rovner: Well, is it the next Standard Oil? Is it going to have to be taken apart at some point?
Goldsmith: Yeah, but I mean, the question is, on what basis? Our health care system is so vast and fragmented, even a generous interpretation of antitrust laws, you’d have trouble finding a case. The Justice Department or FTC [Federal Trade Commission] is going to try again. But I’ll tell you, I think they’ve got their work cut out for them. I think the real issue isn’t anti-competitiveness, it’s a national security issue. If you have a third of the health systems dollars flowing through one company’s leaky pipes, that’s not an antitrust problem. It’s a national security problem, and I think there are some folks in the U.S. Senate that are righteously pissed about this.
There’s a lot of fact-finding that needs to happen here and a lot of work that needs to be done to make this system more secure. And I’ve also argued to make it simpler. Change was processing 15 billion transactions a year. That’s 44 transactions for every man, woman, and child in the country, and that was only a third of them. What are we doing with 100 billion transactions? What’s up with that? It beggars the imagination to believe that we to minutely manage every single one of those transactions. That is just an astonishing waste of money. It’s also an incredible insult to our care system. The assumption that there at any moment, every one of those folks could potentially be ripping us off, and we can’t have that.
Rovner: So we’re spending all of this money to try and not be ripped off for presumably less money.
Goldsmith: Hundreds of billions of dollars, but who’s counting?
Rovner: It’s kind of a depressing picture of what our health system is becoming, but I feel like it is kind of an apt picture for what our health system has become.
Goldsmith: It’s the level of mistrust. The idea that every one of his patients is trying to get a free lunch, and every doctor is trying to pad his income. We’ve built a system based on those twin assumptions. And when you think about them for a minute, they really are appalling assumptions. Most of what motivated me when I had cancer was fear.
I wasn’t trying to get stuff I wasn’t entitled to or didn’t need. I wanted to figure out a way to not be killed by the thing in my throat. And my doctors were motivated by a fear that if they let me go, maybe my heirs would sue them. I guess this idea that we are just helpless pawns of a behaviorist model of incentives, I think the economists ran wild with this thesis. And I think it’s given us a system that doesn’t work for anybody.
Rovner: Is there a way to fix it?
Goldsmith: I think we ought to cut the number of transactions in half. We ought to go and look at how many prior authorizations are really needed. Is this a model we really want to continue with, effectively universal surveillance of every clinical decision? We ought to be paying in bundles. We ought to pay our primary care physicians monthly for every patient that they see that’s a continuing patient and not chisel them over every single thing they do. We ought to pay for complex care in bundles where a cancer treatment is basically one transaction instead of hundreds.
I think we could get a long way to simplifying and reducing the absurd administrative overburden by doing those things. I also think that the idea that we have 1,100 health insurers. United’s the biggest, but it’s not by any means the only health insurer. There’s 1,100 rule sets that determine what data you need in order to pay a claim and whether a claim is justified or not. I think that’s a crazy level of variation. So I think we need to attack the variation. We’ve had health policy conversations about this for years and not done anything, and I think it’s really time to do it.
Rovner: Maybe this will give some incentive to some people to actually do something. Jeff Goldsmith, thank you so much.
Goldsmith: Julie. It’s good talking to you.
Rovner: OK. We are back, and time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Tami, you’ve already done yours this week. Lauren, why don’t you go next?
Weber: Yeah. I think we’re all keeping an eye on this in this podcast, but the title of this story is “Bird Flu Detected in Dairy Worker Who Had Contact With Infected Cattle in Texas,” which was written by my colleagues, Lena Sun and Rachel Roubein. Also, great pieces by Helen Branswell in the Texas Tribune on this as well.
But, essentially, just so listeners know, there has been a case of human bird flu detected, which is very concerning. As all of us on this podcast know, avian human flu is one of the worst-case scenarios in terms of a pathogen and infectiousness. As of right now, this is only one person. It seems to be isolated. We don’t know. We’ll see how this continues to mutate, but definitely something to keep an eye on for potential threat risk. TBD.
Rovner: Yeah. It is something I think that every health reporter is watching with some concern. Although, as you point out, we really don’t know very much yet. And so far, we have not seen. I think what the experts are watching for is human-to-human transmission, and we haven’t seen that yet.
Kenen: And this person seems to have a mild case, from the limited information we have, which is also a good sign for both that individual and everybody else in terms of spreadability.
Rovner: But we will continue to watch that space. Joanne.
Kenen: Well, you said enough bleak, but I’m afraid this is somewhat bleak. This is a piece by Kate Martin from APM Reports, which is part of American Public Media, and it was published in cooperation with The 19th, and the headline is “Survivors Sidelined: How Illinois’ Sexual Assault Survivor Law Allows Hospitals to Deny Care.” So there’s a very, very strong sort of everybody points to it as great law in Illinois saying that what kind of care hospitals have to provide to sexual assault victims and what kind of testing and counseling and everything. This whole series of services that legally they must do, and they’re not doing it. Even in cases of children being assaulted, they’re sending people 40 miles away, 80 miles away, 40 miles away. They’re not doing rape kits. They’re not connecting them to the counselors, et cetera. It is a pretty horrifying story. It begins with a story of a 4-year-old because they didn’t do what they were supposed to do. The father was the suspected perpetrator, and because the hospital didn’t do what they should have done he still has joint custody of this little girl.
Rovner: My story this week is from our podcast colleague, Alice [Miranda] Ollstein, and her Politico colleague, Megan Messerly, and it’s called “Republicans Are Rushing to Defend IVF. The Anti-Abortion Movement Hopes to Change Their Minds.” And it’s about the fact that while maybe not trying to outlaw IVF entirely, the anti-abortion movement does want to dramatically change how it’s practiced in the U.S.
For example, they would like to decrease the number of embryos that can be created and transplanted, both of which would likely make the already expensive treatment even more expensive still. Anti-abortion activists also would like to ban pre-implantation genetic testing so that, “Defective embryos can’t be discarded.” Except that couples with genes for deadly diseases often turn to IVF exactly because they don’t want to pass those diseases on to their children, and they would like to test them before they are implanted.
In other words, the anti-abortion movement may or may not be coming for contraception, but it definitely is coming for IVF. OK, that is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks, as always, to our technical guru, Francis Ying, and our editor Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, @jrovner, or @julierovner at Bluesky and @julie.rovner at Threads. Tami, where can we find you?
Luhby: I’m at cnn.com.
Rovner: There you go. Joanne.
Kenen: @JoanneKenen on X, and @joannekenen1 on Threads.
Rovner: Lauren.
Weber: @LaurenWeberHP on X
Rovner: We will be back in your feed next week. Until then, be healthy.
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Courts, Elections, Medicare, Multimedia, States, The Health Law, Abortion, Biden Administration, Drug Costs, Florida, KFF Health News' 'What The Health?', Misinformation, Podcasts, Tobacco
KFF Health News' 'What the Health?': The ACA Turns 14
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Julie Rovner
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
The Affordable Care Act was signed into law 14 years ago this week, and Health and Human Services Secretary Xavier Becerra joined KFF Health News’ Julie Rovner on this week’s “What the Health?” podcast to discuss its accomplishments so far — and the challenges that remain for the health law.
Meanwhile, Congress appears on its way to, finally, finishing the fiscal 2024 spending bills, including funding for HHS — without many of the reproductive or gender-affirming health care restrictions Republicans had sought.
This week’s panelists are Julie Rovner of KFF Health News, Mary Agnes Carey of KFF Health News, Tami Luhby of CNN, and Alice Miranda Ollstein of Politico.
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Among the takeaways from this week’s episode:
- The Supreme Court will hear oral arguments next week in a case that could decide whether the abortion pill mifepristone will remain easily accessible. The case itself deals with national restrictions rather than an outright ban. But, depending on how the court rules, it could have far-reaching results — for instance, preventing people from getting the pills in the mail and limiting how far into pregnancy the treatment can be used.
- The case is about more than abortion. Drug companies and medical groups are concerned about the precedent it would set for courts to substitute their judgment for that of the FDA regarding drug approvals.
- Abortion-related ballot questions are in play in several states. The total number ultimately depends on the success of citizen-led efforts to collect signatures to gain a spot. Such efforts face opposition from anti-abortion groups and elected officials who don’t want the questions to reach the ballot box. Their fear, based on precedents, is that abortion protections tend to pass.
- The Biden administration issued an executive order this week to improve research on women’s health across the federal government. It has multiple components, including provisions intended to increase research on illnesses and diseases associated with postmenopausal women. It also aims to increase the number of women participating in clinical trials.
- This Week in Medical Misinformation: The Supreme Court heard oral arguments in the case Murthy v. Missouri. At issue is whether Biden administration officials overstepped their authority when asking companies like Meta, Google, and X to remove or downgrade content flagged as covid-19 misinformation.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: The Washington Post’s “Arizona Lawmaker Tells Her Abortion Story to Show ‘Reality’ of Restrictions,” by Praveena Somasundaram. (Full speech here.)
Alice Miranda Ollstein: CNN’s “Why Your Doctor’s Office Is Spamming You With Appointment Reminders,” by Nathaniel Meyersohn.
Tami Luhby: KFF Health News’ “Georgia’s Medicaid Work Requirement Costing Taxpayers Millions Despite Low Enrollment,” by Andy Miller and Renuka Rayasam.
Mary Agnes Carey: The New York Times’ “When Medicaid Comes After the Family Home,” by Paula Span, and The AP’s “State Medicaid Offices Target Dead People’s Homes to Recoup Their Health Care Costs,” by Amanda Seitz.
Also mentioned on this week’s podcast:
- NPR’s “Standard Pregnancy Care Is Now Dangerously Disrupted in Louisiana, Report Reveals,” by Rosemary Westwood.
- The Washington Post’s “As the Cost of Storing Frozen Eggs Rises, Some Families Opt to Destroy Them,” by Amber Ferguson.
Click to open the transcript
Transcript: The ACA Turns 14
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, March 21, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So here we go.
We are joined today via video conference by Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Hello.
Rovner: Tami Luhby of CNN.
Tami Luhby: Hello.
Rovner: And my KFF Health News colleague Mary Agnes Carey.
Mary Agnes Carey: It’s great to be here.
Rovner: Later in this episode to mark the 14th anniversary of the Affordable Care Act, we’ll have my interview with Health and Human Services Secretary Xavier Becerra, but first, this week’s news. So it appears our long national nightmare following the progress of the fiscal 2024 spending bill for the Department of Health and Human Services is nearly over, nearly halfway through the fiscal year. The White House, House, and Senate have, as far as we can tell, reached a compromise on the last tranche of spending bills, which is a good thing because the latest temporary spending bill runs out at midnight Friday. Funding for the Department of Health and Human Services, from what I’ve seen so far, is basically flat, which is a win for the Democrats because the Republicans had fought for a cut of something in the neighborhood of 22%.
Now, assuming this all happens, the House is scheduled to vote, as we speak now, on Friday at 11 a.m., leaving the Senate not very much time to avert a possible partial shutdown. Democrats seem also to have avoided adding all manner of new restrictions on reproductive and gender-affirming health care to the HHS part of the bill. It’s the last big train leaving the station likely until after the election. So Alice, we’ll get to the add-ons in a minute, but have you seen anything in the HHS funding worthy of note or did they manage to fend off everything that would’ve been significantly newsworthy?
Ollstein: Like you said, it is basically flat. It’s a small increase, less than 1% overall for HHS, and then a lot of individual programs are just completely flat, which advocacy groups argue is really a cut when you factor in inflation. The cost of providing services and buying medications and running programs and whatnot goes up. So flat funding is a cut in practice. I’m hearing that particularly from the Title X family planning folks that have had flat funding for a decade now even as demand for services and costs have gone up.
So I think that in the current environment, Democrats are ready to vote for this. They don’t want to see a shutdown. And in the House, the bill passage will depend on those Democratic votes because they are likely to lose a lot of Republicans. Republicans are mad that there weren’t deeper cuts to spending and, as you alluded to, they’re mad that they didn’t get these policy rider wins they were banking on.
Rovner: As I’ve mentioned, since this is a must-pass bill, there are always the efforts to add non-spending things to it. And on health care, apparently, the effort to add the PBM, pharmacy benefit regulation bill we’ve talked about so much failed, but lawmakers did finally get a one-year deal to extend PEPFAR, the international AIDS/HIV program. Alice, you’ve been dutifully following this since it expired last year. Remind us why it got held up and what they finally get.
Ollstein: What happened in the end is it is a one-year reauthorization that’s a so-called clean reauthorization, meaning they are not adding new anti-abortion restrictions and provisions that the Republicans wanted. So what we reported this week is, like any compromise, no one’s happy. So Republicans are upset that they didn’t get the anti-abortion restrictions they wanted, and I’ll explain more on that in a second, and Democrats are upset that this is just a one-year reauthorization. It’s the first reauthorization that’s this sort of short-term stopgap length. In the program’s decades of history, it’s always been a full five-year reauthorization up until now. But the fight over abortion and accusations that program funds were flowing to abortion providers really split Congress on this.
Even though you had mainstream leadership Republicans who were saying, “Look, we just want to reauthorize this as-is,” you had a small but very vocal contingent of hard-line anti-abortion lawmakers backed by some really influential groups like the Heritage Foundation and SBA [Susan B. Anthony Pro-Life America] who were saying, “No, we have to insist on a shorter-term reauthorization,” so that they hope Trump will be in office next year and can impose these exact same anti-abortion restrictions through executive action. So they’re basically trying to punt control of the program into what they hope is a more favorable environment, where either they’ll have the votes in Congress to make these changes and restrictions to the program or they can do it through the White House.
Rovner: So basically, the fight over PEPFAR, not over. So as I already mentioned, Saturday is the 14th anniversary of the Affordable Care Act, which you’ll hear more about in my interview with HHS Secretary Becerra, but I wanted to pose to you guys one of the questions that I posed to him. As Nancy Pelosi famously predicted, at least according to public opinion polls, the more people learned about the health law, indeed, the more they are liking it. But it still lacks the popularity and branding of big government health programs, like Medicare and Medicaid, and I think lots of people still don’t know that lots of the provisions that they like, things like letting your adult children stay on your health plan until they’re 26 or banning preexisting condition exclusions, those were things that came from the Affordable Care Act. Any theories as to why it is still so polarizing? Republicans didn’t love Medicare and Medicaid at the beginning either, so I don’t think it’s just that Republicans still talk about it.
Luhby: Part of it I think is because there are so many provisions and they’re not labeled the Affordable Care Act like Medicare is. Actually to some extent, Medicaid may not be as well known in some states because states have different Medicaid programs and different names and so do the ACA exchanges. So that’s part of it, but also, things like why do you get a free mammogram and why you get to go for a routine checkup every year; that’s not labeled as an Affordable Care Act provision, that’s just the preventive services. So I think that it would be difficult now after 14 years to bring all of that into the everyday branding by doctors and health providers. But that’s certainly what the administration and advocates are trying to do by sending out a lot of messages that list all of the benefits of the ACA.
Rovner: I will say this is the biggest full-court press I’ve seen an administration do on the ACA in quite a while. Obviously, it’s a presidential election year and it’s something that the Biden administration is proud of, but at least I would think that maybe just all the publicity might be part of their strategy. Mac, you wanted to say something.
Carey: No, absolutely. It’s going to be part of the Biden reelection campaign. They’re going to be pushing it, talking a lot about it. We have to remember we’ve had this ringside seat to all the Republican opposition to the Affordable Care Act. All the conversation about we’re going to repeal it and put something better in, former President Trump is still sending that message out to the electorate. I don’t know how much confusion, if any confusion, it creates, but to Tami’s point, you’ve got millions of people that have gotten coverage under the Affordable Care Act but millions more have benefited by all these provisions we’re talking about: the preventive care provisions, leaving adult kids up to 26 on your health insurance plan, that kind of thing.
Also, give it time. Fourteen years is a long time, but it’s not the time of Medicare, which was created in 1965, and Medicaid. So I think over time, the Affordable Care Act is part of the fabric and it will continue to be. But absolutely, for sure, President Biden is going to run on this, like you said, Julie, full-court press, talk extensively about it in the reelection campaign.
Ollstein: It makes sense that they’re leaning really hard on Obamacare as a message because, even if everyone isn’t familiar with it, a lot more people are familiar with it and like it than, polling shows, on the Biden administration’s other big health care accomplishment, which is drug price negotiation, which polling shows that most people, and even most seniors, who are the ones who are set to benefit the most, aren’t aware that it exists. And that makes sense because they’re not feeling the impact of the lower prices yet because this whole thing just started and it won’t be until 2026 that they’ll really actually experience cheaper medications. But people are already feeling the direct impact of Obamacare on their lives, and so it does make sense that they’re going to lean really hard on this.
Rovner: Of course, we went through the same thing with Obamacare, which also didn’t take full effect until, really, this is really the 10th anniversary of the full effect of the Affordable Care Act because it didn’t take effect until 2014. Tami, you wanted to add something.
Luhby: No, I was going to say it’s also the seventh anniversary of the Trump administration and congressional Republicans trying to tear apart the Affordable Care Act and repeal and replace it, which is the messaging that you’re seeing now is very similar to what you saw in 2017. It’s just surprising to me that with very intensive messaging on both sides at that time about what the Republicans saying what the problems are and the Democrats saying what all of the benefits are, — including the protections for people with preexisting conditions and the other things we’ve mentioned — that more people don’t associate those provisions with the ACA now. But the Biden administration is trying to revive all of that and remind people, as they did in 2018 in the successful midterm elections for the Democrats, that the ACA does provide a lot of the benefits that they are taking advantage of and appreciate.
Rovner: I think, in some ways, the 2017 fight was one of the best things that ever happened to the ACA in terms of helping people understand what actually was in it, because the Democrats managed to frighten people about things that they liked being taken away. Here we go again. All right, let us turn to abortion. There’s a new report out from the Guttmacher Institute that finds a dramatic jump in the use of medication abortion in 2023, the first full year since the Supreme Court reversed the nationwide right to abortion in the Dobbs [v. Jackson Women’s Health Organization] case, more than 60% of abortions use medication rather than a procedure last year. This news comes as the Supreme Court next week prepares to hear oral arguments in a case that could dramatically restrict availability of the abortion pill mifepristone. Alice, remind us what’s at stake in this case. It’s no longer whether they’re going to just outright cancel the approval.
Ollstein: That’s right. So the Supreme Court is taking up the narrowed version of this from the 5th Circuit. So what’s at stake are national restrictions on abortion pills, but not a national outright ban like you mentioned. But those restrictions could be really sweeping and really impactful. It would prevent people from getting the pills through the mail like they currently do. It would prevent people from potentially getting them in any other way other than directly from a doctor. So this would apply to red states and blue states alike. It would override abortion rights provisions in blue states that have done a lot to increase access to the pills. And it would also restrict their use back to the first seven weeks of pregnancy instead of 10, which is a big deal because people don’t often find out they’re pregnant until getting close to that line or beyond.
So this is a really big deal, and I think you can really see, especially from the flurry of amicus briefs have been filed, that anxiety about this case in the medical community and the pharmaceutical community, the scientific community, it goes way beyond the impact just on abortion. People are really worried about setting a precedent where the FDA’s scientific judgment is second-guessed by courts, and they worry that a win for the anti-abortion groups in this case would open the door to people challenging all kinds of other medications that they have an issue with: contraception, covid vaccines, HIV drugs, the list goes on and on, gender-affirming care medications, all sorts of things. So there are the bucket of potential impacts on abortion specifically, which are certainly significant, and then there’s the bigger slippery slope fears as well.
Rovner: Also, this is obviously still way political. More than just the abortion pill. It’s been a while since we’ve talked about state ballot measures. We, I think, feel like we spent all of last year talking about abortion state ballot measures. Alice, catch us up real quick on where we are. How many states have them? And what is this campaign against, by the anti-abortion people, to try to prevent them from getting on the ballot?
Ollstein: Check me if I’m wrong, but I don’t believe we know for sure about, especially the states that have citizen-led ballot initiatives where people are gathering signatures. So Florida had one of the earliest deadlines and they did meet their signature threshold. But they are now waiting on the state Supreme Court to say whether or not they have a green light to go forward this fall. A lot of other states are still collecting signatures. I think the only states we know for sure are the ones where the state legislature is the one that is ordering it to be put on the ballot, not regular citizens gathering signatures.
We still don’t know, but things are moving forward. I was just in Arizona reporting on their efforts. Things are moving forward there. Things are moving forward in Montana. They just got a court ruling in their favor to put something on the ballot. And things are moving forward in Missouri, a lot of places. So this could be really huge. Of course, like you mentioned, anti-abortion groups and anti-abortion elected officials are doing a lot of different things to try to prevent this from going on the ballot.
It’s interesting, you heard arguments over the last couple years against this being more along the lines of, “Oh, this is allowing these out-of-state big-money groups to swoop in and mislead and tell us what to do,” and those were the anti-abortion arguments against allowing people to vote on this directly. Now, you’re hearing, I’m hearing, more arguments along the lines of, “This shouldn’t be something subject to a popular vote at all. We shouldn’t put this up for a vote at all.” They consider this a human rights issue, and so I think that’s a really interesting evolution as well, particularly when the fall of Roe [v. Wade] was celebrated for returning the question of abortion access to the people, but maybe not these people specifically.
Rovner: I’ve been interested in seeing some of these anti-abortion groups trying to launch campaigns to get people not to put signatures on petitions. That’s moving it back a step I don’t think I’d ever seen. I don’t think I’ve ever seen a campaign to say, “Don’t sign the petition that would put this on the ballot to let people vote on it.” But that’s what we’re seeing, right?
Ollstein: Well, that’s what I went to Arizona to see firsthand is how that’s working, and it’s fascinating. They really worry that if it gets on the ballot, it’ll pass. It has in every state so far, so it’s reasonable for them to assume that. So they’re trying to prevent it from getting on the ballot. The way they’re doing that is they’re tracking the locations of signature gatherers and trying to go where they are and trying to intervene and hold up signs. I saw this firsthand. I saw it at a street fair. People were gathering signatures and several anti-abortion demonstrators were standing right in front of them with big signs and trying to argue with people and deter them from signing. It was not working, from what I observed. And from the overall signature count statewide, it was not working in Arizona. But it’s fascinating that they’re trying this.
Carey: I was going to say just our reporting from our KFF Health News colleagues found that 13 states are weighing abortion-related ballot measures, most of which would protect abortion rights. To your point, the scope is pretty extensive. And for all the reasons Alice just discussed, it’s quite the issue.
Rovner: Yeah, and we will obviously talk more about this as the election gets closer. I know we talk about Texas a lot on this podcast, but this week, I want to highlight a study from next door in Louisiana, also a very strong anti-abortion state. A new report from three groups, all of which support abortion rights, charges that, as in Texas, women with pregnancy complications are being forced to wait for care until their conditions become critical. And in some cases, women with nonviable pregnancies are being forced to have C-section surgery because their doctors don’t dare use medication or other less-risky procedures in case they could be accused of performing an abortion.
At some point, you have to think that somebody is going to have a malpractice case. Having a C-section because your doctor is afraid to terminate a nonviable pregnancy seems like pretty dangerous and rather aggressive way to go. This is the first I’ve ever heard of this. Alice, have you heard anything about this?
Ollstein: Not the C-section statistics specifically, but definitely the delays in care and some of the other impacts described in that report have absolutely been reported in other states and in legal challenges that have come up in Texas, in Oklahoma, in Tennessee, in Idaho by people who were denied abortions and experienced medical harms because of it. So I think that fits into the broader pattern. And it’s just more evidence about how this is having a chilling effect on doctors. And the exact letter of the law may be one thing, and you have elected officials pointing to exemptions and provisions in the law, but the chilling effect, the fear and the confusion in the medical community, is something in addition to that.
Rovner: As we put it out before, doctors have legitimate fears even if they don’t want to get dragged into court and have to hire lawyers and take time off — even if they’re innocent, even if they have what they consider to be pretty strong evidence that whatever it was that they did was legitimate under the law in terms of taking care of pregnant women. A lot of them, they don’t want to come under scrutiny, let’s put it that way, and it is hard to blame them about that.
Meanwhile, the backlash over the Alabama Supreme Court decision that fertilized embryos for IVF have legal rights is continuing as blue states that made themselves safe spaces for those seeking abortion are now trying to welcome those seeking IVF. Anybody think this is going to be as big a voting issue as abortion this fall? It’s certainly looking like those who support IVF, including some Republicans, are trying to push it.
Carey: I would think yes, it absolutely will be because it has been brought into the abortion debate. The actual Alabama issue is about an Alabama law and whether or not this particular, the litigants who sued were … it was germane and covered by the law, but it’s been brought into the abortion issue. The whole IVF thing is so compelling, about storage of the embryos and what people have to pay and all the restrictions around it and some of the choices they’re making. I guess that you could say more people have been touched by IVF perhaps than the actual abortion issue. So now, it’s very personal to them and it’s been elevated, and Republicans have tried to get around it by saying they support it, but then there’s arguments that whether or not that’s a toothless protection of IVF. It came out of nowhere I think for a lot of politicians and they’ve been scrambling and trying to figure it out. But to your point, Julie, I do wonder if it will be elevated in the election. And it was something they didn’t think they’d have to contend with, rather, and now they do.
Rovner: Obviously, it’s an issue that splits the anti-abortion community because now we’ve had all these very strong pro-lifers like Mike Pence saying, “I created my family using IVF.” Nikki Haley. There are a lot of very strong anti-abortion Republicans who have used IVF. So you’ve got some on the far … saying, “No, no, no, you can’t create embryos and then destroy them,” and then you’ve got those who are saying, “But we need to make sure that IVF is still available to people. If we’re going to call ourselves pro-life, we should be in favor of people getting pregnant and having babies, which is what IVF is for.” Alice, I see you nodding your head.
Ollstein: Yeah. So we’re having sort of a frustrating discourse around this right now because Democrats are saying, “Republicans want to ban IVF.” And Republicans are saying, “No, we don’t. We support IVF. We love IVF. IVF is awesome.” And neither is totally accurate. It’s just missing a lot of nuance. Republicans who say they support IVF also support a lot of different kinds of restrictions on the way it’s currently practiced. So they might correctly argue that they don’t want to ban it entirely, but they do want it practiced in a different way than it is now, such as the production of many embryos, some of which are discarded. So I think people are just not being asked the right questions right now. I think you got to get beyond, “Do you support IVF?” That gives people a way to dodge. I think you really have to drill into, “OK. How specifically do you want this regulated and what would that mean for people?”
Carey: Right, and the whole debate with some of the abortion rights opponents, some of them want the federal government to regulate it. Mike Johnson, speaker of the House, has come out and said, “No, no, that can be done at the state level.” So they’ve got this whole split internally in the party that is, again, a fight they didn’t anticipate.
Rovner: Well, Mac, something that you alluded to that I was struck by was a piece in The Washington Post this week about couples facing increasing costs to store their IVF embryos, often hundreds of dollars a year, which is forcing them to choose between letting the embryos go or losing a chance to possibly have another child. It’s obviously a big issue. I’m wondering what the anti-IVF forces think about that. As we’ve seen in Alabama, it’s not like you can just pick your embryos up in a cooler and move them someplace else. Moving them is actually a very big deal.
I don’t wish to minimize this, but I remember you have storage units for things, not obviously for embryos. One of the ways that they make money is that they just keep raising the cost because they think you won’t bother to move your things, so that you’ll just keep paying the increased cost. It feels like that’s a little bit of what’s happening here with these stored embryos, and at some point, it just gets prohibitively expensive for people to keep them in storage. I didn’t realize how expensive it was.
Carey: They’re all over the place. In preparing for this discussion, I’ve read things about people are paying $600 a year, other people are paying $1,200 a year. There’s big jumps from year to year. It can be an extremely expensive proposition. Oh, my goodness.
Rovner: IVF itself, I think as we’ve mentioned, is also extremely expensive and time-consuming, and emotionally expensive. It is not something that people enter into lightly. So I think we will definitely see more as we go. There’s also women’s health news this week that doesn’t have to do with reproduction. That’s new. Earlier this week, President Biden issued an executive order attempting to ensure that women are better represented in medical research. Tami, what does this order do and why was it needed?
Luhby: Well, it’s another attempt by the Biden administration, as we’ve discussed, to focus on reproductive health and reproductive rights. During the State of the Union address earlier this month, Biden asked Congress to invest $12 billion in new funding for women’s health research. And there are actually multiple components to the executive order, but the big ones are that it calls for supporting research into health and diseases that are more likely to occur midlife for women after menopause, such as rheumatoid arthritis, heart attacks, osteoporosis, and as well as ways to improve the management of menopause-related issues.
We are definitely seeing that menopause care is of increasing focus in a multitude of areas including employer health insurance, but the executive order also aims to increase the number of women participating in clinical trials since they’re poorly represented now. We know that certain medications and certain treatments have different effects on women than men, but we don’t really know that that well because they’re not as represented in these clinical trials. Then it also directs agencies to develop and strengthen research and data standards on women’s health across all of the relevant research and funding opportunities in the government.
Rovner: I’ll say that this is an issue I have very strong feelings about because I covered the debate in 1992 about including women in medical research. At the time, doctors didn’t want to have women in clinical trials because they were worried about hormones, and they might get pregnant, and we wouldn’t really know what that meant for whatever it was that we were testing. Someone suggested that “If you’re going to use these treatments and drugs on women, maybe you should test them on women too.” Then I won an award in 2015 for a story about how they still weren’t doing it, even though it was required by laws.
Carey: And here we are, 2024.
Rovner: Yeah, here we are. It just continues, but at least they’re trying. All right, finally, this week in medical misinformation, we travel to the Supreme Court, where the justices heard oral arguments in a case brought by two Republican state attorneys general charging that the Biden administration, quote, “coerced” social media platforms, Google, Meta, and X, into downgrading or taking down what public health officials deemed covid disinformation. I didn’t listen to the arguments, but all the coverage I saw suggested that the justices were not buying what the attorneys general were selling.
Yet another public-health-adjacent case to watch for a decision later this spring, but I think this is really going to be an important one in terms of what public officials can and cannot do using their authority as public health officials. We’re obviously in a bit of a public health trust crisis, so we will see how that goes.
All right, that is the news for this week. Now, we will play my interview with HHS Secretary Xavier Becerra, then we will be back with our extra credits.
I am so pleased to welcome back to the podcast Health and Human Services Secretary Xavier Becerra. I’ve asked him to join us to talk about the Affordable Care Act, which was signed into law 14 years ago this weekend. Mr. Secretary, thanks so much for coming back.
Xavier Becerra: Julie, great to be with you on a great week.
Rovner: So the Affordable Care Act has come a long way, not just in the 14 years since President Obama signed it into law, but in the 10 years since the healthcare.gov website so spectacularly failed to launch, but this year’s enrollment setting a record, right?
Becerra: That’s right, and you should have said, “You’ve come a long way, baby.”
Rovner: So what do we know about this year’s enrollment numbers?
Becerra: Another record breaker. Julie, every year that President Biden has been in office, we have broken records. Today, more Americans have health insurance than ever in the history of the country. More than 300 million people can now go to a doctor, leave their child in a hospital and know they won’t go bankrupt because they have their own health insurance. That’s the kind of peace of mind you can’t buy. Some 21.5 million Americans today look to the marketplace on the Affordable Care Act to get their coverage. By the way, the Affordable Care Act overall, some 45 million Americans today count on the ACA for their health care insurance, whether it’s through the marketplace, through Medicaid, or some of these basic plans that were also permitted under the ACA.
Rovner: Obviously, one of the reasons for such a big uptake is the expanded subsidies that were extended by the Inflation Reduction Act in 2022, but those expire at the end of next year, the end of 2025. What do you think would happen to enrollment if they’re not renewed?
Becerra: Well, and that’s the big question. The fact that the president made health care affordable was the big news. Because having the Affordable Care Act was great, but if people still felt it was unaffordable, they wouldn’t sign on. They now know that this is the best deal in town and people are signing up. When you can get health insurance coverage for $10 or less a month in your premiums, that’s a great deal. You can’t even go see a movie at a theater today for under $10. Now, you can get health care coverage for a full month, Julie. Again, as I always tell people, that doesn’t even include the popcorn and the refreshment at the movie theater, and so it’s a big deal. But without the subsidies, some people would still say, “Ah, it’s still too expensive.” So that’s why the president in his budget calls for extending those subsidies permanently.
Rovner: So there are still 10 states that haven’t taken up the federal government’s offer to pay 90% of the costs to expand Medicaid to all low-income adults in their states. I know Mississippi is considering a bill right now. Are there other states that you expect could join them sometime in the near future? Or are any of those 10 states likely to join the other 40?
Becerra: We’re hoping that the other 10 states join the 40 that have come on board where millions of Americans today have coverage. They are forsaking quite a bit of money. I was in North Carolina recently where Gov. [Roy] Cooper successfully navigated the passage of expansion for Medicaid. Not only was he able to help some 600,000-plus North Carolinians get health coverage, but he also got a check for $1.6 billion as a bonus. Not bad.
Rovner: No, not bad at all. So many years into this law, I feel like people now understand a lot of what it did: let adult children stay on their parents’ health plans until the age of 26; banning most preexisting condition exclusions in health coverage. Yet most people still don’t know that those provisions that they support were actually created by Obamacare or even that Obamacare and the Affordable Care Act are the same thing. Medicare has had such great branding success over the years. Why hasn’t the ACA?
Becerra: Actually, Julie, I think that’s changing. Today, about two-thirds of Americans tell you that they support the marketplaces in the Affordable Care Act. I think we’re actually now beginning an era where it’s no longer the big three, where you had Social Security, Medicare, and Medicaid and everyone protects those. Today, I think it’s the big four, the cleanup hitter being marketplace. Today, you would find tens of millions of Americans who would say, “Keep your dirty, stinking hands off of my marketplace.”
Rovner: Well, we will see as that goes forward. Obviously, President Biden was heavily involved in the development of the Affordable Care Act as vice president, as were you as a member of the House Ways and Means Committee at the time. What do you hope is this administration’s biggest legacy to leave to the health law?
Becerra: Julie, I think it’s making it affordable. The president made a commitment when he was first running to be president. He said on health care he was going to make it more affordable for more Americans with better benefits, and that’s what he’s done. The ACA is perfect proof. And Americans are signing up and signaling they agree by the millions. To go from 12 million people on the Affordable Care Act marketplace to 21.5 million in three years, that’s big news.
Rovner: So if I may, one question on another topic. Next week, the Supreme Court’s oral arguments occur in the case it could substantially restrict the availability of the abortion pill mifepristone. Obviously, this is something that’s being handled by the Justice Department, but what is it about this case that worries you most as HHS secretary, about the potential impact if the court rolls back FDA approval to the 2016 regulations?
Becerra: Well, Julie, as you well know from your years of covering health care, today there are Americans who have less protection, fewer rights, than many of us growing up. My daughters, my three daughters today, have fewer protections and access to health care than my wife had when she was their age. That’s not the America most of us know. To see another case where, now, medication abortion, which is used by millions of Americans — in fact, it’s the most common form of care that is received by a woman who needs to have abortion services — that is now at stake. But we believe that if the Supreme Court believes in science and it believes in the facts, because mifepristone has been used safely and effectively publicly for more than 20 years, that we’re going to be fine.
The thing that worries me as much, not just in the reduction of access to care for women in America, is the fact that mifepristone went through a process at the FDA similar to scores and scores of other medications that Americans rely on, that have nothing to do with abortion. And if the process is shut down by the Supreme Court for mifepristone, then it’s probably now at risk for all those other drugs, and therefore those other drugs that Americans rely on for diabetes, for cancer, who knows what, might also be challenged as not having gone through the right process.
Rovner: I know the drug industry is very, very worried about this case and watching it closely, and so will we. Mr. Secretary, thank you so much for joining us.
Becerra: Always good to be with you, Julie.
Rovner: OK, we are back. It’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Tami, why don’t you go first this week?
Luhby: OK, my extra credit this week is an article about Georgia’s unique Medicaid program from KFF Health News’ Andy Miller and Renuka Rayasam. It’s titled “Georgia’s Medicaid Work Requirement Costing Taxpayers Millions Despite Low Enrollment.” And I’m really glad they did this story. I and many others wrote about Georgia launching this program initially but haven’t done follow-up. So I was very happy to see this story.
As many of our listeners probably know, the Trump administration allowed multiple states to impose work requirements in Medicaid for the first time in the program’s history in 2018. But the efforts were eventually stopped by the courts in all states except Georgia. Georgia was allowed to proceed with adding its work requirement to Medicaid because it was actually going to expand coverage to allowing adults with incomes up to 100% of the poverty line to qualify. So the Georgia Pathways to Coverage initiative began last June.
Andy and Renuka took a look at how it’s faring, and the answer is actually not so well. Only about 3,500 people have signed up, far short of the 25,000 that the state projected for the first year. What’s more, the program has cost taxpayers at least $26 million so far, with more than 90% of that going towards administrative and consulting costs rather than actual medical care for low-income people.
By contrast, expanding Medicaid under the Affordable Care Act to people with 138% of the poverty line would make at least 359,000 uninsured Georgia residents newly eligible for coverage and reduce state spending by $710 million over two years. That’s what the advocates are pushing. So we’ll see what happens in coming months. One thing that’s also noted in the story is that about 45% of Pathways applications were still waiting to be processed.
Rovner: I will point out that we did talk a couple of weeks ago about the low enrollment in the Georgia program. What we had not seen was how much it’s actually costing the states per enrollee. So it is really good story. Alice, why don’t you go next?
Ollstein: Yeah, so I have some very relatable news from CNN. It’s called “Why Your Doctor’s Office Is Spamming You With Appointment Reminders.” It’s about why we all get so many obnoxious repeat reminders for every medical appointment. It both explains why medical practices that operate on such a tiny profit margin are so anxious about no-shows and last-minute cancellations, and so that’s part of it. But also part of it is that there are all these different systems that don’t communicate with one another. So the prescription drug system and the electronic medical records system and the doctor’s office’s own system are all operating in parallel and not coordinating with one another, and that’s why you get all these annoying multiple reminders. The medical community is becoming aware that it’s backfiring because the more you get, the more you start tuning them out and you don’t pay attention to which ones might be important. So they are working on it. So a somewhat hopeful piece of news.
Rovner: Raise your hand if you have multiple patient portals that you have to deal with for your multiple …
Ollstein: Oh, my God, yes.
Rovner: I will note that everybody’s hands go up. Mac?
Carey: I have not one but two stories on a very important issue: Medicaid estate recovery. The first is from Paula Span at The New York Times. The headline says it all, “When Medicaid Comes After the Family Home.” And the second story is an AP piece by Amanda Seitz, and that’s titled “State Medicaid Offices Target Dead People’s Homes to Recoup Their Health Care Costs.” Now, these stories are both about a program that’s been around since 1993. That’s when Congress mandated Medicaid beneficiaries over the age of 55 that have used long-term care services, and I’m talking about nursing homes or home care, that states must try to recover those expenses from the beneficiaries’ estates after their deaths.
As you can imagine, this might be a problem for the beneficiaries. They might have to sell a family home, try to find other ways to pay a big bill from Medicaid. Rep. Jan Schakowsky, she’s a Democrat of Illinois, has reintroduced her bill. It’s called the Stop Unfair Medicaid Recoveries Act. She’s trying to end the practice. She thinks it’s cruel and harmful, and her argument is, in fact, the federal and state governments spend way more than what they collect, and these collections often go after low-income families that can’t afford the bill anyway.
So even though it’s been around, it’s important to read up on this. A critical point in the stories was do states properly warn people that assets were going to be recovered if they enroll a loved one in Medicaid for long-term care and so on. So great reading, people should bone up on that.
Rovner: This is one of those issues that just keeps resurfacing and doesn’t ever seem to get dealt with. Well, my story this week is from The Washington Post, although I will say it was covered widely in dozens of outlets. It’s called “Arizona Lawmaker Tells Her Abortion Story to Show ‘Reality’ of Restrictions.” On Monday, Arizona State Sen. Eva Birch stood up on the Senate floor and gave a speech unlike anything I have ever seen. She’s a former nurse at a women’s health clinic. She’s also had fertility issues of her own for at least a decade, having both had a miscarriage and an abortion for a nonviable pregnancy in between successfully delivering her two sons.
Now, she’s pregnant again, but with another nonviable pregnancy, which she plans to terminate. Her point in telling her story in public on the Senate floor, she said, was to underscore how cruel — her words — Arizona’s abortion restrictions are. She’s been subject to a waiting period, required to undergo an invasive transvaginal ultrasound to obtain information she and her doctor already knew about her pregnancy, and to listen to a lecture on abortion, quote, “alternatives,” like adoption, which clearly don’t apply in her case.
While she gave the speech on the floor, several of her Democratic colleagues stood in the camera shot behind her, while many of the Republicans reportedly walked out of the chamber. I will link to the story, but I will also link to the entire speech for those who want to hear it.
OK, that is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks as always to our technical guru, Francis Ying, and our fill-in editor for today, Stephanie Stapleton. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, @jrovner, or @julierovner at Bluesky and @julie.rovner at Threads. Mary Agnes, where are you hanging out these days?
Carey: I’m hanging out on X, @MaryAgnesCarey.
Rovner: Alice?
Ollstein: @AliceOllstein on X, and @alicemiranda on Bluesky.
Rovner: Tami?
Luhby: The best place to find me is at cnn.com.
Rovner: There you go. We will be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': Maybe It’s a Health Care Election After All
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Julie Rovner
KFF Health News
Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
The general election campaign for president is (unofficially) on, as President Joe Biden and former President Donald Trump have each apparently secured enough delegates to become his respective party’s nominee. And health care is turning out to be an unexpectedly front-and-center campaign issue, as Trump in recent weeks has suggested he may be interested in cutting Medicare and taking another swing at repealing and replacing the Affordable Care Act.
Meanwhile, the February cyberattack of Change Healthcare, a subsidiary of insurance giant UnitedHealth Group, continues to roil the health industry, as thousands of hospitals, doctors, nursing homes, and other providers are unable to process claims and get paid.
This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Joanne Kenen of Johns Hopkins University and Politico Magazine, and Margot Sanger-Katz of The New York Times.
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Anna Edney
Bloomberg
Joanne Kenen
Johns Hopkins Bloomberg School of Public Health and Politico
Margot Sanger-Katz
The New York Times
Among the takeaways from this week’s episode:
- It is unclear exactly what Trump meant in his recent remarks about possible cuts to Medicare and Social Security, though his comments provided an opening for Biden to pounce. By running as the candidate who would protect entitlements, Biden could position himself well, particularly with older voters, as the general election begins.
- Health care is shaping up to be the sleeper issue in this election, with high stakes for coverage. The Biden administration’s expanded subsidies for ACA plans are scheduled to expire at the end of next year, and the president’s latest budget request highlights his interest in expanding coverage, especially for postpartum women and for children. Plus, Republicans are eyeing what changes they could make should Trump reclaim the presidency.
- Meanwhile, Republicans are grappling with an internal party divide over access to in vitro fertilization, and Trump’s mixed messaging on abortion may not be helping him with his base. Could a running mate with more moderate perspectives help soften his image with voters who oppose abortion bans?
- A federal appeals court ruled that a Texas law requiring teenagers to obtain parental consent for birth control outweighs federal rules allowing teens to access prescription contraceptives confidentially. But concerns that if the U.S. Supreme Court heard the case a conservative-majority ruling would broaden the law’s impact to other states may dampen the chances of further appeals, leaving the law in effect. Also, the federal courts are making it harder to file cases in jurisdictions with friendly judges, a tactic known as judge-shopping, which conservative groups have used recently in reproductive health challenges.
- And weeks later, the Change Healthcare hack continues to cause widespread issues with medical billing. Some small providers fear continued payment delays could force them to close, and it is possible that the hack’s repercussions could soon block some patients from accessing care at all.
Also this week, Rovner interviews Kelly Henning of Bloomberg Philanthropies about a new, four-part documentary series on the history of public health, “The Invisible Shield.”
Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: The Washington Post’s “Navy Demoted Ronny Jackson After Probe Into White House Behavior,” by Dan Diamond and Alex Horton.
Joanne Kenen: The Atlantic’s “Frigid Offices Might Be Killing Women’s Productivity,” by Olga Khazan.
Margot Sanger-Katz: Stat’s “Rigid Rules at Methadone Clinics Are Jeopardizing Patients’ Path to Recover From Opioid Addiction,” by Lev Facher.
Anna Edney: Scientific American’s “How Hospitals Are Going Green Under Biden’s Climate Legislation,” by Ariel Wittenberg and E&E News.
Also mentioned on this week’s podcast:
- KFF Health News’ “Energy-Hog Hospitals: When They Start Thinking Green, They See Green,” by Julie Appleby.
- Stat’s “The War on Recovery: How the U.S. Is Sabotaging Its Best Tools to Prevent Deaths in the Opioid Epidemic,” by Lev Facher.
Click to open the transcript
Transcript: Maybe It’s a Health Care Election After All
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, March 14, at 10 a.m. Happy Pi Day, everyone. As always, news happens fast and things might have changed by the time you hear this, so here we go. We are joined today via video conference by Margot Sanger-Katz of The New York Times.
Margot Sanger-Katz: Good morning, everybody.
Rovner: Anna Edney of Bloomberg News.
Anna Edney: Hi there.
Rovner: And Joanne Kenen of the Johns Hopkins University and Politico Magazine.
Joanne Kenen: Hey, everyone.
Rovner: Later in this episode we’ll have my interview with Dr. Kelly Henning, head of the public health program at Bloomberg Philanthropies. She’ll give us a preview of the new four-part documentary series on the history of public health called “The Invisible Shield;” It premieres on PBS March 26. But first this week’s news. We’re going to start here in Washington with the annual State of the Union / budget dance, which this year coincides with the formal launch of the general election campaign, with both President Biden and former President Donald Trump having clinched their respective nominations this week.
Despite earlier claims that this year’s campaign would mostly ignore health issues, that’s turning out not so much to be the case. Biden in his speech highlighted reproductive health, which we’ll talk about in a minute, as well as prescription drug prices and the Affordable Care Act expansions. His proposed budget released on Monday includes suggestions of how to operationalize some of those proposals, including expanding Medicare’s drug negotiating powers. Did anything in particular in the speech or the budget jump out at any of you? Anything we weren’t expecting.
Edney: I wouldn’t say there was anything that I wasn’t expecting. There were things that I was told I should not expect and that I feel like I’ve been proven right, and so I’m happy about that, and that was the Medicare drug price negotiation. I thought that that was a win that he was going to take a lap on during the State of the Union, and certainly he did. And he’s also talking about trying to expand it, although that seems to face an extremely uphill battle, but it’s a good talking point.
Rovner: Well, and of course the expanded subsidies from the ACA expire at the end of next year. I imagine there’s going to be enough of a fight just to keep those going, right?
Edney: Yeah, certainly. I think people really appreciate the subsidies. If those were to go away, then the uninsured rate could go up. It’s probably an odd place in a way for Republicans, too, who are talking about, again, still in some circles, in some ways, getting rid of Obamacare. We’re back at that place even though I don’t think anyone thinks that’s entirely realistic.
Rovner: Oh, you are anticipating my next question, which is that former President Trump, who is known for being all over the place on a lot of issues, has been pretty steadfast all along about protecting Medicare and Social Security, but he’s now backing away from even that. In an interview on CNBC this week, Trump said, and I’m quoting, “There is a lot you can do in terms of entitlements in terms of cutting” — which his staff said was referring to waste and fraud, but which appears to open that up as a general election campaign issue. Yes, the Biden people seem to be already jumping on it.
Sanger-Katz: Yes. They could not be more excited about this. I think this has been an issue that Biden has really wanted to run on as the protector of these programs for the elderly. He had this confrontation with Congress in the State of the Union last year, as you may remember, in which he tried to get them to promise not to touch these programs. And I think his goal of weaponizing this issue has been very much hindered by Trump’s reluctance to take it on. I think there are Republicans, certainly in Congress, and I think that we saw during the presidential primary some other candidates for president who were more interested in rethinking these programs and concerned about the long-term trajectory of the federal deficit. Trump has historically not been one of them. What Trump meant exactly, I think, is sort of TBD, but I think it does provide this opening. I’m sure that we’ll see Biden talking about this a lot more as the campaign wears on and it wouldn’t surprise me at all to see this clip in television ads and featured again and again.
Kenen: So it’s both, I mean, it’s basically, he’s talked about reopening the repeal fight as Julie just mentioned, which did not go too well for the Republicans last time, and there’s plenty to cut in Medicare. If you read the whole quote, he does then talk about fraud and abuse and mismanagement, but the soundbite is the soundbite. Those are the words that came out of his mouth, whether he meant it that way or not, and we will see that campaign ad a lot, some version of it.
Rovner: My theory is that he was, and this is something that Trump does, he was on CNBC, he knew he was talking to a business audience, and he liked to say what he thinks the audience wants to hear without — you would think by now he would know that speaking to one audience doesn’t mean that you’re only speaking to that one audience. I think that’s why he’s all over the place on a lot of issues because he tends to tailor his remarks to what he thinks the people he is speaking directly to want to hear. But meanwhile, Anna, as you mentioned, he’s also raised the specter of the Affordable Care Act repeal again.
Sanger-Katz: I do think the juxtaposition of the Biden budget and State of the Union and these remarks from Trump, who now is officially the presumptive nominee for president, I think it really does highlight that there are pretty high stakes in health care for this election. I think it’s not been a focus of our discussion of this election so far. But Julie, you’ve mentioned the expiration of these subsidies that have made Affordable Care Act plans substantially more affordable for Americans and substantially more appealing, nearly doubling the number of people who are enrolled in these plans.
That is a policy that is going to expire at the end of next year. And so you could imagine a scenario, even if Trump did not want to repeal the Affordable Care Act, which he does occasionally continue to make noises about, where that could just go away through pure inertia if you didn’t have an administration that was actively trying to extend that policy and you could see a real retrenchment: increases in prices, people leaving the market, potentially some instability in the marketplace itself, where you might see insurers exiting or other kinds of problems and a situation much more akin to what we saw in the Trump administration where those markets were “OK, but were a little bit rocky and not that popular.”
I think similarly for Medicare and Medicaid, these big federal health programs, Biden has really been committed to, as he says, not cutting them. The Medicare price negotiation for drugs has provided a little bit more savings for the program. So it’s on a little bit of a better fiscal trajectory, and he has these additional proposals, again, I think long shots politically to try to shore up Medicare’s finances more. So you see this commitment to these programs and certainly this commitment to — there were multiple things in the budget to try to liberalize and expand Medicaid coverage to make postpartum coverage for women after they give birth, permanently one year after birth, people would have coverage.
Right now, that’s an option for states, but it’s not required for every state. And additionally to try to, in an optional basis, make it a little easier to keep kids enrolled in Medicaid for longer, to just allow states to keep kids in for the first six years of life and then three years at a time after that. So again, that’s an option, but I think you see the Biden administration making a commitment to expand and shore up these programs, and I do think a Trump administration and a Republican Congress might be coming at these programs with a bit more of a scalpel.
Rovner: And also, I mean, one of the things we haven’t talked about very much since we’re on the subject of the campaign is that this year Trump is ready in a way that he was not, certainly not in 2016 and not even in 2020. He’s got the Heritage Foundation behind him with this whole 2025 blueprint, people with actual expertise in knowing what to turn, what to do, actually, how to manipulate the bureaucracy in a way that the first Trump administration didn’t have to. So I think we could see, in fact, a lot more on health care that Republicans writ large would like to do if Trump is reelected. Joanne, you wanted to add something.
Kenen: Yeah, I mean, we all didn’t see this year as a health care election, and I still think that larger existential issues about democracy, it’s a reprise. It’s 2020 all over again in many ways, but abortion yes, abortion is a health care issue, and that was still going …
Rovner: We’re getting to that next.
Kenen: I know, but I mean we all knew that was still going to be a ballot driver, a voter driver. But Trump, with two remarks, however, well, there’s a difference between the people at the Heritage Foundation writing detailed policy plans about how they’re going to dismantle the CDC [Centers for Disease Control and Prevention] as we currently know it versus what Trump says off the cuff. I mean, if you say to a normal person on the street, we want to divide the CDC in two, that’s not going to trigger anything for a voter. But when you start talking about we want to take away your health care subsidies and cut Medicare, so these are sort of, some observers have called them unforced errors, but basically right now, yeah, we’re in another health care election. Not the top issue — and also depending on what else goes on in the world, because it’s a pretty shaky place at the moment. By September, will it be a top three issue? None of us know, but right now it’s more of a health care election than it was shaping up to be even just a few weeks ago.
Rovner: Yeah. Well, one thing, as you said, that we all know will be a big campaign issue this fall is abortion. We saw that in the State of the Union with the gallery full of women who’d been denied abortion, IVF services, and other forms of reproductive health care and the dozens of Democratic women on the floor of the House wearing white from head to toe as a statement of support for reproductive health care. While Democrats do have some divides over how strongly to embrace abortion rights, a big one is whether restoring Roe [v. Wade] is enough or they need to go even further in assuring access to basically all manner of reproductive health care.
It’s actually the Republicans who are most on the defensive, particularly over IVF and other state efforts that would restrict birth control by declaring personhood from the moment of fertilization. Along those lines, one of the more interesting stories I saw this week suggested that Donald Trump, who has fretted aloud about how unpopular the anti-abortion position is among the public, seems less likely to choose a strong pro-lifer as his running mate this time. Remember Mike Pence came along with that big anti-abortion background. What would this mean? It’s not like he’s going to choose Susan Collins or Lisa Murkowski or some Republican that we know actually supports abortion rights. I’m not sure I see what this could do for him and who might fit this category.
Kenen: Well, I think there’s a good chance he’ll choose a woman, and we all have names at the tip of our tongues, but we don’t know yet. But yeah, I mean they need to soften some of this stuff. But Trump’s own attempt right now bragging about appointing the justices that killed Roe, at the same time, he’s apparently talking about a 15-week ban or a 16-week ban, which is very different than zero. So he’s giving a mixed message. That’s not what his base wants to hear from him, obviously. I mean, Julie, you’ll probably get to this, but the IVF thing is also pitting anti-abortion Republican against anti-abortion Republican, with Mike Pence, again, being a very good example where Mike Pence’s anti-abortion bona fides are pretty clear, but he has been public about his kids are IVF babies? I’m not sure if all of them are, but at least some of them are. So he does not think that two cells in a freezer or eight cells or 16 cells is the same to child. In his view, it’s a potential child. So yeah.
Edney: I think you can do a lot with a vice president. We see Biden has his own issues with the abortion issue and, as people have pointed out, he demurred from saying that word in the State of the Union and we see just it was recently announced that Vice President Kamala Harris is going to visit an abortion clinic. So you can appease maybe the other side, and that might be what Trump is looking to do. I think, as Joanne mentioned, his base wants him to be anti-abortion, but now you’re getting all of these fractures in the Republican Party and you need someone that maybe can massage that and help with the crowd that’s been voting on the state level, voting on more of a personal level, to keep reproductive rights, even though his base doesn’t seem to be that that’s what they want. So I feel like he may be looking to choose someone who’s very different or has some differences that he can, not acknowledge, but that they can go out and please the other side.
Rovner: Of course, the only person who really fits that bill is Nikki Haley, who is very, very strongly anti-abortion, but at least tried, not very well, but tried to say that there are other people around and they believe other things and we should embrace them, too. I can’t think of another Republican except for Nikki Haley who’s really tried to do that. Margot, you wanted to say something?
Sanger-Katz: Oh, I was just going to say that if this reporting is correct, I think it does really reflect the political moment that Trump finds himself in. I think when he was running the last time, I think he really had to convince the anti-abortion voter, the evangelical voter, to come along with him. I think they had reservations about his character, about his commitment to their cause. He was seen as someone who maybe wasn’t really a true believer in these issues. And so I think he had to do these things, like choosing Mike Pence, choosing someone who was one of them. Pre-publishing a list of judges that he would consider for the Supreme Court who were seen as rock solid on abortion. He had to convince these voters that he was the real deal and that he was going to be on their side, and I just don’t think he really has that problem to the same degree right now.
I think he’s consolidated support among that segment of the electorate and his bigger concern going into the general election, and also the primaries are over, and so his bigger concern going into the general election is how to deal with more moderate swing voters, suburban women, and other groups who I think are a little bit concerned about the extreme anti-abortion policies that have been pursued in some of these states. And I think they might be reluctant to vote for Trump if they see him as being associated with those policies. So you see him maybe thinking about how to soften his image on this issue.
Rovner: I should point out the primaries aren’t actually over, most of states still haven’t had their primaries, but the primaries are effectively over for president because both candidates have now amassed enough delegates to have the nomination.
Sanger-Katz: Yes, that’s right. And it’s not over until the convention, although I think the way that the Republicans have arranged their convention, it’s very hard to imagine anyone other than Trump being president no matter what happens.
Rovner: Yes.
Sanger-Katz: Or not being president. Sorry, being the nominee.
Rovner: Being the nominee, yes, indeed. Well, we are only two weeks away from the Supreme Court oral arguments in the abortion pill case and a little over a month from another set of Supreme Court oral arguments surrounding whether doctors have to provide abortions in medical emergencies. And the cases just keep on coming in court this week. A three-judge panel from the 5th Circuit Court of Appeals upheld in part a lower court ruling that held that Texas’ law requiring parents to provide consent before their teenage daughters may obtain prescription birth control, Trump’s federal rules requiring patient confidentiality even for minors at federally funded Title X clinics.
Two things about this case. First, it’s a fight that goes all the way back to the Reagan administration and something called the “Squeal Rule,” which I did not cover, I only read about, but it’s something that the courts have repeatedly ruled against, that Title X is in fact allowed to maintain patient privacy even for teenagers. And the second thing is that the lower court ruling came from Texas federal Judge Matthew Kacsmaryk, who also wrote the decision attempting to overturn the FDA’s approval of the abortion drug mifepristone. This one, though, we might not expect to get to the Supreme Court.
Kenen: But we’re often wrong on these kinds of things.
Rovner: Yeah, that’s true.
Kenen: I mean, things that seem based on the historical pathway that shouldn’t have gotten to the court are getting to the court and the whole debate has shifted so far to the right. An interesting aside, there is a move, and I read this yesterday, but now I’m forgetting the details, so one of you can clarify for me. I can’t remember whether they’re considering doing this or the way they’ve actually put into place steps to prevent judge-shopping.
Rovner: That’s next.
Kenen: OK, I’m sorry, I’m doing such a good job of reading your mind.
Rovner: You are such a good job, Joanne.
Kenen: But I mean so many in these cases go back to one. If there was a bingo card for reproductive lawsuits, there might be one face in it.
Rovner: Two, Judge [Reed] O’Connor, remember the guy with the Affordable Care Act.
Kenen: Right. But so much of this is going back to judge-shopping or district-shopping for the judge. So a lot of these things that we thought wouldn’t get to the court have gotten to the court.
Rovner: Yeah, well, no, I was going to say in this case, though, there seems to be some suggestion that those who support the confidentiality and the Title X rules might not want to appeal this to the Supreme Court because they’re afraid they’ll lose. That this is the Supreme Court that overturned Roe, it would almost certainly be a Supreme Court that would rule against Title X confidentiality for birth control, that perhaps they want to just let this lie. I think as it stands now it only applies to the 5th Circuit. So Texas, Louisiana, and I forget what else is in the 5th Circuit, but it wouldn’t apply around the country and in this case, I guess it’s just Texas because it’s Texas’ law that conflicts with the rules.
Kenen: Except when one state does something, it doesn’t mean that it’s only Texas’ law six months from now.
Rovner: Right. What starts in Texas doesn’t necessarily stay in Texas.
Kenen: Right, it could go to Nevada. They may decide that they have a losing case and they want to wait 20 years, but other people end up taking things — I mean, it is very unpredictable and a huge amount of the docket is reproductive health right now.
Rovner: I would say the one thing we know is that Justice Alito, when he said that the Supreme Court was going to stop having to deal with this issue was either disingenuous or just very wrong because that is certainly not what’s happened. Well, as Joanne already jumped ahead a little bit, I mentioned Judge Kacsmaryk for a specific reason. Also this week, the Judicial Conference of the United States, which makes rules for how the federal courts work, voted to make it harder to judge-shop by filing cases in specific places like Amarillo, Texas, where there’s only one sitting federal judge. This is why Judge Kacsmaryk has gotten so many of those hot-button cases. Not because kookie stuff happens all the time in Amarillo, but because plaintiffs have specifically filed suit there to get their cases in front of him. The change by the judicial conference basically sets things back to the way they used to be, right, where it was at least partly random, which judge you got when you filed a case.
Kenen: But there are also some organizations that have intentionally based themselves in Amarillo so that they’re there. I mean, we may also see, if the rules go back to the old days, we may also still say you have a better case for filing in where you actually operate. So everybody just keeps hopping around and playing the field to their advantage.
Rovner: Yeah. And I imagine in some places there’s only a couple of judges, I think it was mostly Texas that had these one-judge districts where you knew if you filed there, you were going to get that judge, so — the people who watch these things and who worry about judge-shopping seem to be heartened by this decision by the judicial conference. So I’m not someone who is an expert in that sort of thing, but they seem to think that this will deter it, if not stop it entirely.
Moving on, remember a couple of weeks ago when I said that the hack of UnitedHealth [Group] subsidiary Change Healthcare was the most undercovered story in health? Clearly, I had no idea how true that was going to become. That processes 15 billion — with a B — claims every year handles one of every three patient records is still down, meaning hospitals, doctor’s offices, nursing homes, and all other manner of health providers still mostly aren’t getting paid. Some are worrying they soon won’t be able to pay their employees. How big could this whole mess ultimately become? I don’t think anybody anticipated it would be as big as it already is.
Sanger-Katz: I think it’s affecting a number of federal programs, too, that rely on this data, like quality measurement. And it really is a reflection, first of all, obviously of the consolidation of all of this, which I know that you guys have talked about on the podcast before, but also just the digitization and interconnectedness of everything. All of these programs are relying on this billing information, and we use that not just to pay people, but also to evaluate what kind of health care is being delivered, and what quality it is, and how much we should pay people in Medicare Advantage, and on all kinds of other things. So it’s this really complex, interconnected web of information that has been disrupted by this hack, and I think there’s going to be quite a lot of fallout.
Edney: And the coverage that I’ve read we’re potentially, and not in an alarmist way, but weeks away from maybe some patients not getting care because of this, particularly at the small providers. Some of my colleagues did a story yesterday on the small cancer providers who are really struggling and aren’t sure how long they’re going to be able to keep the lights on because they just aren’t getting paid. And there are programs now that have been set up but maybe aren’t offering enough money in these no-interest loans and things like that. So it seems like a really precarious situation for a lot of them. And now we see that HHS [Department of Health and Human Services] is looking into this other side of it. They’re going to investigate whether there were some HIPAA violations. So not looking exactly at the money exchange, but what happened in this hack, which is interesting because I haven’t seen a lot about that, and I did wonder, “Oh, what happened with these patients’ information that was stolen?” And UnitedHealth has taken a huge hit. I mean, it’s a huge company and it’s just taken a huge hit to its reputation and I think …
Rovner: And to its stock price.
Edney: And it’s stock price. That is very true. And they don’t know when they’re actually going to be able to resolve all of this. I mean, it’s just a huge mess.
Rovner: And not to forget they paid $22 million in ransom two weeks ago. When I saw that, I assumed that this was going to be almost over because usually I know when a hospital gets hacked, everybody says, don’t pay ransom, but they pay the ransom, they get their material back, they unlock what was locked away. And often that ends it, although it then encourages other people to do it because hey, if you do it, you can get paid ransom. Frankly, for UnitedHealthcare, I thought $22 million was a fairly low sum, but it does not appear — I think this has become such a mess that they’re going to have to rebuild the entire operation in order to make it work. At least, not a computer expert here. But that’s the way I understand this is going on.
Kenen: But I also think this, I mean none of us are cyber experts, but I’m also wondering if this is going to lead to some kind of rethinking about alternative ways of paying people. If this created such chaos, and not just chaos, damage, real damage, the incentive to do something similar to another, intermediate, even if it’s not quite this big. It’s like, “Wait, no one wants to be the next one.” So what kind of push is there going to be, not just for greater cybersecurity, but for Plan B when there is a crisis? And I don’t know if that’s something that the cyberexperts can put together in what kind of timeline — if HHS was to require that or whether the industry just decides they need it without requirements that this is not OK. It’s going to keep happening if it’s profitable for whoever’s doing it.
Rovner: I remember, ruefully, Joanne and I were there together covering HIPAA when they were passing it, which of course had nothing whatsoever to do with medical privacy at the time, but what it did do was give that first big push to start digitizing medical information. And there was all this talk about how wonderful it was going to be when we had all this digitally and researchers could do so much with it, and patients would be able to have all of their records in one place and …
Kenen: You get to have 19 passwords for 19 different forums now.
Rovner: Yes. But in 1995 it all seemed like a great, wonderful new world of everything being way more efficient. And I don’t remember ever hearing somebody talking about hacking this information, although as I point out the part of HIPAA that we all know, the patient medical records privacy, was added on literally at the last minute because someone said, “Uh-oh, if we’re going to digitize all this information, maybe we better be sure that it doesn’t fall into the wrong hands.” So at least somebody had some idea that we could be here. What are we 20, 30 … are we 30 years later? It’s been a long time. Anyway, that’s my two cents. All right, next up, Mississippi is flirting with actually expanding Medicaid under the Affordable Care Act. It’s one of only 10 remaining states that has not extended the program to people who have very low incomes but don’t meet the so-called categorical eligibility requirements like being a pregnant woman or child or person with a disability.
The Mississippi House passed an expansion bill including a fairly stringent work requirement by a veto-proof majority last week, week before.
Kenen: I think two weeks ago.
Rovner: But even if it passed the Senate and gets signed by the governor, which is still a pretty big if, the governor is reportedly lobbying hard against it. The plan would require a waiver from the Biden administration, which is not a big fan of work requirements. On the other hand, even if it doesn’t happen, and I would probably put my money at this point that it’s not going to happen this year, does it signal that some of the most strident, holdout states might be seeing the attraction of a 90% federal match and some of the pleas of their hospital associations? Anna, I see you nodding.
Edney: Yeah, I mean it was a little surprising, but this is also why I love statehouses. They just do these unexpected things that maybe make sense for their constituents sometimes, and it’s not all the time. I thought that it seemed like they had come around to the fact that this is a lot of money for Mississippi and it can help a lot of people. I think I’ve seen numbers like maybe adding 200,000 or so to the rolls, and so that’s a huge boost for people living there. And with the work requirement, is it true that even if the Biden administration rejects it, this plan can still go into place, right?
Kenen: The House version.
Edney: The House version.
Kenen: Yes.
Edney: Yeah.
Rovner: My guess is that’s why the governor is lobbying so hard against it. But yeah.
Kenen: I mean, I think that we had been watching a couple of states, we keep hearing Alabama was one of the states that has been talking about it but not doing anything about it. Wyoming, which surprised me when they had a little spurt of activity, which I think has subsided. I mean, what we’ve been saying ever since the Supreme Court made this optional for states more than 10 years ago now. Was it 2012? We’ve been saying eventually they’ll all do it. Keeping in mind that original Medicaid in [19]65, it took until 1982, which neither Julie nor I covered, until the last state, which was Arizona, took regular Medicare, Medicaid, the big — forget the ACA stuff. I mean, Medicaid was not in all states for almost 20 years. So I think we’ve all said eventually they’re going to do it. I don’t think that we are about to see a domino effect that North Carolina, which is a purple state, they did it a few months ago, maybe a year by now.
There was talk then that, “Oh, all the rest will do it.” No, all the rest will probably do it eventually, but not tomorrow. Mississippi is one of the poorest states in the country. It has one of the lowest health statuses of their population, obesity, diabetes, other chronic diseases. It has a very small Medicaid program. The eligibility levels are even for very, very, very poor childless adults, you can’t get on their plan. But have we heard rural hospitals pushing for this for a decade? Yes. Have we heard chambers of commerce in some of these states wanting it because communities without hospitals or communities without robust health systems are not economically attractive? We’ve been hearing the business community push for this for a long time. But the holdouts are still holdouts and I do think they will all take it. I don’t think it’s imminent.
Rovner: Yeah, I think that’s probably a fair assessment.
Kenen: It makes good economic sense, I mean, you’re getting all this money from the federal government to cover poor people and keep your hospitals open. But it’s a political fight. It’s not just a …
Rovner: It’s ideology.
Kenen: Yes, it’s not a [inaudible]. And it’s called Obamacare.
Edney: And sometimes things just have to fall into place. Mississippi got a new speaker of the House in their state government, so that’s his decision to push this as something that the House was going to take up. So whether that happens in other places, whether all those cards fall into places can take more time.
Kenen: Well, the last thing is we also know it’s popular with voters because we’ve seen it on the ballot in what, seven states, eight states, I forgot. And it won, and it won pretty big in really conservative states like Idaho and Utah. So as Julie said, this is ideology, it’s state lawmakers, it’s governors, it’s not voters, it’s not hospitals, it’s not chambers of commerce. It’s not particularly rural hospitals. A lot of people think this makes sense, but their own governments don’t think it makes sense.
Rovner: Yes. Well, another of those stories that moves very, very slowly. Finally, “This Week in Medical Misinformation”: I want to call out those who are fighting back against those who are accusing them of spreading false or misleading claims. I know this sounds confusing. Specifically, 16 conservative state attorneys general have called on YouTube to correct a, quote, “context disclaimer” that it put on videos posted by the anti-abortion Alliance Defending Freedom claiming serious and scientifically unproven harms that can be caused by the abortion pill mifepristone.
Unfortunately, for YouTube, their context disclaimer was a little clunky and conflated medication and surgical abortion, which still doesn’t make the original ADF videos more accurate, just means that the disclaimer wasn’t quite right. Meanwhile, more anti-abortion states are having legal rather than medical experts try to “explain” — and I put explain in air quotes — when an abortion to save the life of a woman is or isn’t legal, which isn’t really helping clarify the situation much if you are a doctor worried about having your license pulled or, at best, ending up having to defend yourself in court. It feels like misinformation is now being used as a weapon as well as a way to mislead people. Or am I reading this wrong?
Edney: I mean, I had to read that disclaimer a few times. Just the whole back-and-forth was confusing enough. And so it does feel like we’re getting into this new era of, if you say one wrong thing against the disinformation, that’s going to be used against you. So everybody has to be really careful. And the disclaimer, it was odd because I thought it said the procedure is [inaudible]. So that made me think, oh, they’re just talking about the actual surgical abortion. But it was clunky. I think clunky is a good word that you used for it. So yeah.
Rovner: Yeah, it worries me. I think I see all of this — people who want to put out misinformation. I’m not accusing ADF of saying, “We’re going to put out misinformation.” I think this is what they’ve been saying all along, but people who do want to put out misinformation for misinformation’s sake are then going to hit back at the people who point out that it’s misinformation, which of course there’s no way for the public to then know who the heck is right. And it undercuts the idea of trying to point out some of this misinformation. People ask me wherever I go, “What are we going to do about this misinformation?” My answer is, “I don’t know, but I hope somebody thinks of something.”
Kenen: I mean, if you word something poorly, you got to fix it. I mean, that’s just the bottom line. Just like we as journalists have to come clean when we make a mistake. And it feels bad to have to write a correction, but we do it. So Google has been working on — there’s a group convened by the Institute of Medicine [National Academy of Medicine] and the World Health Organization and some others that have come out with guidelines and credible communicators, like who can you trust? I mean, we talked about the RSV [respiratory syncytial virus] story I did a few weeks ago, and if you Google RSV vaccine on and you look on YouTube or Google, it’s not that there’s zero misinformation, but there’s a lot less than there used to be. And what comes up first is the reliable stuff: CDC, Mayo Clinic, things like that. So YouTube has been really working on weeding out the disinformation, but again, for their own credibility, if they want to be seen as clean arbiters of going with credibility, if they get something mushy, they’ve got to de-mush it at the end.
Rovner: And I will say that Twitter of all places — or X, whatever you want to call it, the place that everybody now is like, “Don’t go there. It’s just a mess” — has these community notes that get attached to some of the posts that I actually find fairly helpful and it lets you rate it.
Kenen: Some of them, I mean overall, there’s actually research on that. We’ll talk about my book when it comes out next year, but we have stuff. I’m in the final stages of co-authoring a book that … it goes into misinformation, which is why I’ve learned a lot about this. Community Notes has been really uneven and …
Rovner: I guess when it pops up in my feed, I have found it surprisingly helpful and I thought, “This is not what I expect to see on this site.”
Kenen: And it hasn’t stopped [Elon] Musk himself from tweeting misinformation about drugs …
Rovner: That’s certainly true.
Kenen: … drugs he doesn’t like, including the birth control pill he tells people not to use because it promotes suicide. So basically, yeah, Julie, you’re right that we need tools to fight it, and none of the tools we currently have are particularly effective yet. And absolutely everything gets politicized.
Sanger-Katz: And it’s a real challenge I think for these social media platforms. You know what I mean? They don’t really want to be in the editorial business. I think they don’t really want to be in the moderation business in large part. And so you can see them grappling with the problem of the most egregious forms of misinformation on their platforms, but doing it clumsily and anxiously and maybe making mistakes along the way. I think it’s not a natural function for these companies, and I think it’s not a comfortable function for the people that run these companies, who I think are much more committed to free discourse and algorithmic sharing of information and trying to boost engagement as opposed to trying to operate the way a newspaper editor might be in selecting the most useful and true information and foregrounding that.
Kenen: Yeah, I mean that’s what the Supreme Court has been grappling with too, is another [inaudible] … what are the rules of the game? What should be legally enforced? What is their responsibility, that the social media company’s responsibilities, to moderate versus what is just people get to post? I mean, Google’s trying to use algorithms to promote credible communicators. It’s not that nothing wrong is there, but it’s not what you see first.
Rovner: I think it’s definitely the issue of the 2020s. It is not going away anytime soon.
Kenen: And it’s not just about health.
Rovner: Oh, absolutely. I know. Well, that is the news for this week. Now, we will play my interview with Dr. Kelly Henning of Bloomberg Philanthropies, and then we’ll come back with our extra credits.
I am so pleased to welcome to the podcast Dr. Kelly Henning, who heads the Bloomberg Philanthropies Public Health program. She’s here to tell us about a new documentary series about the past, present, and future of public health called “The Invisible Shield.” It premieres on PBS on March 26. Dr. Henning, thank you so much for joining us.
Kelly Henning: Thank you for having me.
Rovner: So the tagline for this series is, “Public health saved your life today, and you don’t even know it.” You’ve worked in public health in a lot of capacities for a lot of years, so have I. Why has public health been so invisible for most of the time?
Henning: It’s a really interesting phenomenon, and I think, Julie, we all take public health for granted on some level. It is what really protects people across the country and across the world, but it is quite invisible. So usually if things are working really well in public health, you don’t think about it at all. Things like excellent vaccination programs, clean water, clean air, these are all public health programs. But I think most people don’t really give them a lot of thought every day.
Rovner: Until we need them, and then they get completely controversial.
Henning: So to that point, covid-19 and the recent pandemic really was a moment when public health was in the spotlight very much no longer behind an invisible shield, but quite out in front. And so this seemed like a moment when we really wanted to unpack a little bit more around public health and talk about how it works, why it’s so important, and what some of the opportunities are to continue to support it.
Rovner: I feel like even before the pandemic, though, the perceptions of public health were changing. I guess it had something to do with a general anti-science, anti-authority rising trend. Were there warning signs that public health was about to explode in people’s consciousness in not necessarily a good way?
Henning: Well, I think those are all good points, but I also think that there are young generations of students who have become very interested in public health. It’s one of the leading undergraduate majors nowadays. Johns Hopkins Bloomberg School of Public Health has more applications than ever before, and that was occurring before the pandemic and even more so throughout. So I think it’s a bit of a mixed situation. I do think public health in the United States has had some really difficult times in terms of life expectancy. So we started to see declines in life expectancy way back in 2017. So we have had challenges on the program side, but I think this film is an opportunity for us to talk more deeply about public health.
Rovner: Remind people what are some of the things that public health has brought us besides, we talk about vaccines and clean water and clean air, but there’s a lot more to public health than the big headlines.
Henning: Yeah, I mean, for example, seat belts. Every day we get into our vehicle, we put a seat belt on, but I think most people don’t realize that was initially extremely controversial and actually not so easy to get that policy in place. And yet it saved literally tens of hundreds of thousands of lives across the U.S. and now across the world. So seat belts are something that often come to mind. Similar to that are things like child restraints, what we would call car seats in the U.S. That’s another similar strategy that’s been very much promoted and the evidence has been created through public health initiatives. There are other things like window guards. In cities, there are window guards that help children not fall out of windows from high buildings. Again, those are public health initiatives that many people are quite unaware of.
Rovner: How can this documentary help change the perception of public health? Right now I think when people think of public health, they think of people fighting over mask mandates and people fighting over covid vaccines.
Henning: Yeah, I really hope that this documentary will give people some perspective around all the ways in which public health has been working behind the scenes over decades. Also, I hope that this documentary will allow the public to see some of those workers and what they face, those public health front-line workers. And those are not just physicians, but scientists, activists, reformers, engineers, government officials, all kinds of people from all disciplines working in public health. It’s a moment to shine a light on that. And then lastly, I hope it’s hopeful. I hope it shows us that there are opportunities still to come in the space of public health and many, many more things we can do together.
Rovner: Longtime listeners to the podcast will know that I’ve been exploring the question of why it has been so difficult to communicate the benefits of public health to the public, as I’ve talked to lots of people, including experts in messaging and communication. What is your solution for how we can better communicate to the public all of the things that public health has done for them?
Henning: Well, Julie, I don’t have one solution, but I do think that public health has to take this issue of communication more seriously. So we have to really develop strategies and meet people where they are, make sure that we are bringing those messages to communities, and the messengers are people that the community feels are trustworthy and that are really appropriate spokespeople for them. I also think that this issue of communications is evolving. People are getting their information in different ways, so public health has to move with the times and be prepared for that. And lastly, I think this “Invisible Shield” documentary is an opportunity for people to hear and learn and understand more about the history of public health and where it’s going.
Rovner: Dr. Kelly Henning, thank you so much for joining us. I really look forward to watching the entire series. OK, we are back. It’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Joanne, you have everybody’s favorite story this week. Why don’t you go first?
Kenen: I demanded the right to do this one, and it’s Olga, I think her last name is pronounced Khazan. I actually know her and I don’t know how to pronounce her name, but Olga Khazan, apologies if I’ve got it wrong, from The Atlantic, has a story that says “Frigid Offices Might Be Killing Women’s Productivity.” Well, from all of us who are cold, I’m not sure I would want to use the word “frigid,” but of all of us who are cold in the office and sitting there with blankets. I used to have a contraband, very small space heater hidden behind a trash basket under my desk. We freeze because men like colder temperatures and they’re wearing suits. So we’ve been complaining about being cold, but there’s actually a study now that shows that it actually hurts our actual cognitive performance. And this is one study, there’s more to come, but it may also be one explanation for why high school girls do worse than high school boys on math SATs.
Rovner: Did not read that part.
Kenen: It’s not just comfort in the battle over the thermostat, it’s actually how do our brains function and can we do our best if we’re really cold?
Rovner: True. Anna.
Edney: This is a departure from my normal doom and gloom. So I’m happy to say this is in Scientific American, “How Hospitals Are Going Green Under Biden’s Climate Legislation.” I thought it was interesting. Apparently if you’re a not-for-profit, there were tax credits that you were not able to use, but the Inflation Reduction Act changed that so that there are some hospitals, and they talked to this Valley Children’s in California, that there had been rolling blackouts after some fires and things like that, and they wanted to put in a micro-grid and a solar farm. And so they’ve been able to do that.
And health care contributes a decent amount. I think it’s like 8.5% of U.S. greenhouse gas emissions. And Biden had established this Office of Climate Change [and Health Equity] a few years ago and within the health department. So this is something that they’re trying to do to battle those things. And I thought that it was just interesting that we’re talking about this on the day that the top story, Margot, in The New York Times is, not by you, but is about how there’s this huge surge in energy demand. And so this is a way people are trying to do it on their own and not be so reliant on that overpowered grid.
Rovner: KFF Health News has done a bunch of stories about contribution to climate change from the health sector, which I had no idea, but it’s big. Margot.
Sanger-Katz: I wanted to highlight the second story in this Lev Facher series on treatment for opioid addiction in Stat called “Rigid Rules at Methadone Clinics Are Jeopardizing Patients’ Path to Recovery From Opioid Addiction,” which is a nice long title that tells you a lot about what is in the story. But I think methadone treatment is a really evidence-based treatment that can be really helpful for a lot of people who have opioid addiction. And I think what this story highlights is that the mechanics of how a lot of these programs work are really hard. They’re punitive, they’re difficult to navigate, they make it really hard for people to have normal lives while they’re undergoing methadone treatment and then, in some cases, arbitrarily so. And so I think it just points out that there are opportunities to potentially do this better in a way that better supports recovery and it supports the lives of people who are in recovery.
Rovner: Yeah, it used the phrase “liquid handcuffs,” which I had not seen before, which was pretty vivid. For those of you who weren’t listening, the Part One of this series was an extra credit last week, so I’ll post links to both of them. My story’s from our friend Dan Diamond at The Washington Post. It’s called “Navy Demoted Ronnie Jackson After Probe Into White House Behavior.” Ronnie Jackson, in case you don’t remember, was the White House physician under Presidents [Barack] Obama and Trump and a 2021 inspector general’s report found, and I’m reading from the story here, quote, “that Jackson berated subordinates in the White House medical unit, made sexual and denigrating statements about a female subordinate, consumed alcohol inappropriately with subordinates, and consumed the sleep drug Ambien while on duty as the president’s physician.” In response to the report, the Navy demoted Jackson retroactively — he’s retired —from a rear admiral down to a captain.
Now, why is any of this important? Well, mainly because Jackson is now a member of Congress and because he still incorrectly refers to himself as a retired admiral. It’s a pretty vivid story, you should really read it.
OK. That is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, @jrovner. Margot, where are you these days?
Sanger-Katz: I’m at all the places @Sanger-Katz, although not particularly active on any of them.
Rovner: Anna.
Edney: On X, it’s @annaedney and on Threads it’s @anna_edneyreports.
Rovner: Joanne.
Kenen: I’m Threads @joannekenen1, and I’ve been using LinkedIn more. I think some of the other panelists have said that people are beginning to treat that as a place to post, and I think many of us are seeing a little bit more traction there.
Rovner: Great. Well, we will be back in your feed next week. Until then, be healthy.
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The State of the Union Is … Busy
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Julie Rovner
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
President Joe Biden is working to lay out his health agenda for a second term, even as Congress races to finish its overdue spending bills for the fiscal year that began last October.
Meanwhile, Alabama lawmakers try to reopen the state’s fertility clinics over the protests of abortion opponents, and pharmacy giants CVS and Walgreens announce they are ready to begin federally regulated sales of the abortion pill mifepristone.
This week’s panelists are Julie Rovner of KFF Health News, Sarah Karlin-Smith of the Pink Sheet, Alice Miranda Ollstein of Politico, and Sandhya Raman of CQ Roll Call.
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Sarah Karlin-Smith
Pink Sheet
Alice Miranda Ollstein
Politico
Sandhya Raman
CQ Roll Call
Among the takeaways from this week’s episode:
- Lawmakers in Washington are completing work on the first batch of spending bills to avert a government shutdown. The package includes a bare-bones health bill, leaving out certain bipartisan proposals that have been in the works on drug prices and pandemic preparedness. Doctors do get some relief in the bill from Medicare cuts that took effect in January, but the pay cuts are not canceled.
- The White House is floating proposals on drug prices that include expanding Medicare negotiations to more drugs; applying negotiated prices earlier in the market life of drugs; and capping out-of-pocket maximum drug payments at $2,000 for all patients, not just seniors. At least some of the ideas have been proposed before and couldn’t clear even a Democratic-controlled Congress. But they also keep up pressure on the pharmaceutical industry as it challenges the government in court — and as Election Day nears.
- Many in public health are expressing frustration after the Centers for Disease Control and Prevention softened its covid-19 isolation guidance. The change points to the need for a national dialogue about societal support for best practices in public health — especially by expanding access to paid leave and child care.
- Meanwhile, CVS and Walgreens announced their pharmacies will distribute the abortion pill mifepristone, and enthusiasm is waning for the first over-the-counter birth control pill amid questions about how patients will pay its higher-than-anticipated list price of $20 per month.
- Alabama’s governor signed a law protecting access to in vitro fertilization, granting providers immunity from the state Supreme Court’s recent “embryonic personhood” decision. But with opposition from conservative groups, is the new law also bound for the Alabama Supreme Court?
Also this week, Rovner interviews White House domestic policy adviser Neera Tanden about Biden’s health agenda.
Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: NPR’s “How States Giving Rights to Fetuses Could Set Up a National Case on Abortion,” by Regan McCarthy.
Sarah Karlin-Smith: Stat’s “The War on Recovery,” by Lev Facher.
Alice Miranda Ollstein: KFF Health News’ “Why Even Public Health Experts Have Limited Insight Into Stopping Gun Violence in America,” by Christine Spolar.
Sandhya Raman: The Journal’s “‘My Son Is Not There Anymore’: How Young People With Psychosis Are Falling Through the Cracks,” by Órla Ryan.
Also mentioned on this week’s podcast:
- NBC News’ “CDC Updates Covid Isolation Guidelines for People Who Test Positive,” by Erika Edwards.
- New York Magazine’s “Did Trump Really Vow to Defund Schools With Vaccine Mandates?” by Margaret Hartmann.
click to open the transcript
Transcript: The State of the Union Is … Busy
KFF Health News’ ‘What the Health?’Episode Title: The State of the Union Is … BusyEpisode Number: 337Published: March 7, 2024
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, March 7, at 9 a.m. As always, news happens fast and things might have changed by the time you hear this, so here we go. We are joined today via video conference by Alice Miranda Ollstein, of Politico.
Alice Miranda Ollstein: Hello.
Rovner: Sarah Karlin-Smith, of the Pink Sheet.
Sarah Karlin-Smith: Hi, everybody.
Rovner: And Sandhya Raman, of CQ Roll Call.
Raman: Good morning.
Rovner: Later in this episode we’ll have my interview with White House domestic policy adviser Neera Tanden about the Biden administration’s health accomplishment so far and their priorities for 2024. But first, this week’s news. It is a big week here in the nation’s capital. In addition to sitting through President Biden’s State of the Union address, lawmakers appear on the way to finishing at least some of the spending bills for the fiscal year that began last Oct. 1. Good thing, too, because the president will deliver to Congress a proposed budget for the next fiscal year that starts Oct. 1, 2024, next Monday. Sandhya, which spending bills are getting done this week, and which ones are left?
Sandhya Raman: We’re about half-and-half as of last night. The House is done with their six-bill deal that they released. Congress came to a bipartisan agreement on Sunday and released then, so the FDA is in that part, in the agriculture bill. We also have a number of health extenders that we can …
Rovner: Which we’ll get to in a second.
Raman: Now it’s on to the Senate and then to Biden’s desk, and then we still have the Labor HHS [Department of Labor and Department of Health and Human Services] bill with all of the health funding that we’re still waiting on sometime this month.
Rovner: Yeah, it’s fair to say that the half that they’re getting done now are the easy ones, right? It’s the big ones that are left.
Ollstein: Although, if they were so easy, why didn’t they get them done a long time ago? There have been a lot of fights over policy riders that have been holding things up, in addition to disagreements about spending levels, which are perennial of course. But I was very interested to see that in this first tranche of bills, Republicans dropped their insistence on a provision banning mail delivery of abortion pills through the FDA, which they had been fighting for for months and months and months, and that led to votes on that particular bill being canceled multiple times. It’s interesting that they did give up on that.
Rovner: Yes. I shouldn’t say these were the easy ones, I should say these were the easier ones. Not that there’s a reason that it’s March and they’re only just now getting them done, but they have until the 22nd to get the rest of them done. How is that looking?
Raman: We still have not seen text on those yet. If they’re able to get there, we would see that in the next week or so, before then. And it remains to be seen, that traditionally the health in Labor HHS is one of the trickiest ones to get across the finish line in a normal year, and this year has been especially difficult given, like Alice said, all of the different policy riders and different back-and-forth there. It remains to be seen how that’ll play out.
Rovner: They have a couple of weeks and we will see. All right, well as you mentioned, as part of this first spending minibus, as they like to call it, is a small package of health bills. We talked about some of these last week, but tell us what made the final cut into this current six-bill package.
Raman: It’s whittled down a lot from what I think a lot of lawmakers were hoping. It’s pretty bare-bones in terms of what we have now. It’s a lot of programs that have traditionally been added to funding bills in the past, extending the special diabetes program, community health center funding, the National Health Service Corps, some sexual risk-avoidance programs. All of these would be pegged to the end of 2024. It kind of left out a lot of the things that Congress has been working on, on health care.
Rovner: Even bipartisan things that Congress has been working for on health care.
Raman: Yeah. They didn’t come to agreement on some of the pandemic and emergency preparedness stuff. There were some provisions for the SUPPORT Act — the 2018 really big opioid law — but a lot of them were not there. The PBM [pharmacy benefit managers] reform, all of that, was not, not this round.
Rovner: But at least judging from the press releases I got, there is some relief for doctor fees in Medicare. They didn’t restore the entire 3.3% cut, I believe it is, but I think they restored all but three-quarters of a percent of the cut. It’s made doctors, I won’t say happy, but at least they got acknowledged in this package and we’ll see what happens with the rest of them. Well, by the time you hear this, the president’s State of the Union speech will have come and gone, but the White House is pitching hard some of the changes that the president will be proposing on drug prices. Sarah, how significant are these proposals? They seem to be bigger iterations of what we’re already doing.
Karlin-Smith: Right. Biden is proposing expanding the Medicare Drug [Price] Negotiation program that Congress passed through the Inflation Reduction Act. He wants to go from Medicare being able to negotiate eventually up to 20 drugs a year to up to 50. He seems to be suggesting letting drugs have a negotiated price earlier in their life, letting them have less time on the market before negotiation. Also, thinking about applying some of the provisions of the IRA right now that only apply to Medicare to people in commercial plans, so this $2,000 maximum out-of-pocket spending for patients. Then also there are penalties that drugmakers get if they raise prices above inflation that would also apply to commercial plans. He’s actually proposed a lot of this before in previous budgets and actually Democrats, if you go back in time, tried to actually get some of these things in the initial IRA and even with a Democratic-controlled capital, could not actually get Democratic agreement to go broader on some of the provisions.
Rovner: Thank you, Sen. [Joe] Manchin.
Karlin-Smith: That said, I think it is significant that Biden is still pressing on this, even if they would really need big Democratic majorities and more progressive Democratic majorities to get this passed, because it’s keeping the pressure on the pharmaceutical industry. There were times before the IRA was passed where people were saying, “Pharma just needs to take this hit, it’s not going to be as bad as they think it is. Then they’ll get a breather for a while.” They’re clearly not getting that. The public is still very concerned about drug pricing, and they’re both fighting the current IRA in court. Actually, today there’s a number of big oral arguments happening. At the same time, they’re trying to get this version of the IRA improved somehow through legislation. All at the same time Democrats are saying, “Actually, this is just the start, we’re going to keep going.” It’s a big challenge and maybe not the respite they thought they might’ve gotten after this initial IRA was passed.
Rovner: But as you point out, still a very big voting issue. All right, well I want to talk about covid, which we haven’t said in a while. Last Friday, the Centers for Disease Control and Prevention officially changed its guidance about what people should do if they get covid. There’s been a lot of chatter about this. Sarah, what exactly got changed and why are people so upset?
Karlin-Smith: The CDC’s old guidance, if you will, basically said if you had covid, you should isolate for five days. If you go back in time, you’ll remember we probably talked about how that was controversial on its own when that first happened, because we know a lot of people are infectious and still test positive for covid much longer than five days. Now they’re basically saying, if you have covid, you can return to the public once you’re fever-free for 24 hours and your symptoms are improving. I think the implication here is, that for a lot of people, this would be before five days. They do emphasize to some degree that you should take precautions, masking, think about ventilation, maybe avoid vulnerable people if you can.
But I think there’s some in the public health world that are really frustrated by this. They feel like it’s not science- and evidence-based. We know people are going to be infectious and contagious in many cases for longer than periods of time where the CDC is saying, “Sure, go out in public, go back to work.” On the flip side, CDC is arguing, people weren’t really following their old guidance. In part because we don’t have a society set up to structurally allow them to easily do this. Most people don’t have paid sick time. They maybe don’t have people to watch their children if they’re trying to isolate from them. I think the tension is that, we’ve learned a lot from covid and it’s highlighted a lot of the flaws already in our public health system, the things we don’t do well with other respiratory diseases like flu, like RSV. And CDC is saying, “Well, we’re going to bring covid in line with those,” instead of thinking about, “OK, how can we actually improve as a society managing respiratory viruses moving forward, come up with solutions that work.”
I think there probably are ways for CDC to acknowledge some of the realities. CDC does not have the power to give every American paid sick time. But if CDC doesn’t push to say the public needs this for public health, how are we ever going to get there? I think that’s really a lot of the frustration in a lot of the public health community in particular, that they’re just capitulating to a society that doesn’t care about public health instead of really trying to push the agenda forward.
Rovner: Or a society that’s actively opposed to public health, as it sometimes seems. I know speaking for my NF1, I was sick for most of January, and I used up all my covid tests proving that I didn’t have covid. I stayed home for a few days because I felt really crappy, and when I started to feel better, I wore a mask for two weeks because, hello, that seemed to be a practical thing to do, even though I think what I had was a cold. But if I get sick again, I don’t have any more covid tests and I’m not going to take one every day because now they cost $20 a pop. Which I suspect was behind a lot of this. It’s like, “OK, if you’re sick with a respiratory ailment, stay home until you start to feel better and then be careful.” That’s essentially what the advice is, right?
Ollstein: Yeah. Although one other criticism I heard was specifically basing the new guidance on being fever-free, a lot of people don’t get a fever, they have other symptoms or they don’t have symptoms at all, and that’s even more insidious for allowing spread. I heard that criticism as well, but I completely agree with Sarah, that this seems like allowing public behavior to shape the guidance rather than trying to shape the public behavior with the guidance.
Rovner: Although some of that is how public health works, they don’t want to recommend things that they know people aren’t going to do or that they know the vast majority of people aren’t going to do. This is the difficulty of public health, which we will talk about more. While meanwhile, speaking in Virginia earlier this week, former President Donald Trump vowed to pull all federal funding for schools with vaccine mandates. Now, from the context of what he was saying, it seemed pretty clear that he was talking only about covid vaccine mandates, but that’s not what he actually said. What would it mean to lift all school vaccine mandates? That sounds a little bit scary.
Raman: That would basically affect almost every public school district nationwide. But even if it’s just covid shots, I think that’s still a little bit of a shift. You see Trump not taking as much public credit anymore for the fact that the covid vaccines were developed under his administration, Operation Warp Speed, that started under the Trump administration. It’s a little bit of a shift compared to then.
Rovner: I’m old enough to remember two cycles ago, when there were Republicans who were anti-vaccine or at least anti-vaccine curious, and the rest of the Republican Party was like, “No, no, no, no, no.” That doesn’t seem to be the case anymore. Now it seems to be much more mainstream to be anti-vax in general. Cough, cough. We see the measles outbreak in Florida, so we will clearly watch that space, too.
All right, moving on to abortion. Later this month, the Supreme Court will hear oral argument in the case that could severely restrict distribution of the abortion pill mifepristone. But in the meantime, pharmacy giants, CVS and Walgreens have announced they will begin distributing the abortion pill at their pharmacies. Alice, why now and what does this mean?
Ollstein: It’s interesting that this came more than a year after the big pharmacies were given permission to do this. They say it took this long because they had to get all of these systems up in place to make sure that only certified pharmacists were filling prescriptions from certified prescribing doctors. All of this is required because when the Biden administration, when the FDA, moved to allow this form of distribution of the abortion pill, they still left some restrictions known as REMS [risk evaluation and mitigation strategies] in place. That made it take a little more time, more bureaucracy, more box checking, to get to this point. It is interesting that given the uncertainty with the Supreme Court, they are moving forward with this. It’s this interesting state-versus-federal issue, because we reported a year ago that Walgreens and CVS would not distribute the pills in states where Republican state attorneys general have threatened them with lawsuits.
So, they’ve noted the uncertainty at the state level, but even with this uncertainty at the federal level with the Supreme Court, which could come in and say this form of distribution is not allowed, they’re still moving forward. It is limited. It’s not going to be, even in blue states where abortion is protected by law, they’re not going to be at every single CVS. They’re going to do a slower, phased rollout, see how it goes. I’m interested in seeing if any problems arise. I’m also interested in seeing, anti-abortion groups have vowed to protest these big pharmacy chains for making this medication available. They’ve disrupted corporate meetings, they’ve protested outside brick-and-mortar pharmacies, and so we’ll see if any of that continues and has an effect as well.
Rovner: It’s hard to see how the anti-abortion groups though could have enough people to protest every CVS and Walgreens selling the abortion pill. That will be an interesting numbers situation. Well, in a case of not-so-great timing, if only for the confusion potential, also this week we learned that the first approved over-the-counter birth control pill, called Opill, is finally being shipped. Now, this is not the abortion pill. It won’t require a prescription, that’s the whole point of it being over-the-counter. But I’ve seen a lot of advocacy groups that worked on this for years now complaining that the $20 per month that the pill is going to cost, it’s still going to be too much for many who need it. Since it’s over-the-counter, it’s not going to be covered by most insurance. This is a separate issue of its own that’s a little bit controversial.
Karlin-Smith: You can with over-the-counter drugs, if you have a flexible spending account or an HSA or something else, you may be able to use money that’s somehow connected to your health insurance benefit or you’re getting some tax breaks on it. However, I think this over-the-counter pill is probably envisioned most for people that somehow don’t have insurance, because we know the Affordable Care Act provides birth control methods with no out-of-pocket costs for people. So if you have insurance, most likely you would be getting a better deal getting a prescription and going that route for the same product or something similar.
The question becomes then, does this help the people who fall in those gaps who are probably likely to have less financial means to begin with? There’s been some polling and things that suggest this may be too high a price point for them. I know there are some discounts on the price. Essentially if you can buy three months upfront or even some larger quantities, although again that means you then have to have that larger sum of money upfront, so that’s a big tug of war. I think the companies argue this is pretty similar pricing to other over-the-counter drug products in terms of volume and stuff, so we’ll see what happens.
Rovner: I think they were hoping it was going to be more like $5 a month and not $20 a month. I think that came as a little bit of a disappointment to a lot of these groups that have been working on this for a very long time.
Ollstein: Just quickly, the jury is also still out on insurance coverage, including advocacy groups are also pressuring public insurance, Medicaid, to come out and say they’ll cover it as well. So we’ll keep an eye on that.
Rovner: Yeah, although Medicaid does cover prescription birth control. All right, well let us catch up on the IVF [in vitro fertilization] controversy in Alabama, where there was some breaking news over last night. When we left off last week, the Alabama Legislature was trying to come up with legislation that would grant immunity to fertility clinics or their staff for “damaging or killing fertilized embryos,” without overtly overruling the state Supreme Court decision from February that those embryos are, “extrauterine children.” Alice, how’s that all going?
Ollstein: Well, it was very interesting to see a bunch of anti-abortion groups come out against the bill that Alabama, mostly Republicans, put together and passed and the Republican governor signed it into law. The groups were asking her to veto it; they didn’t want that kind of immunity for discarding or destroying embryos. Now what we will see is if there’s going to be a lawsuit that lands this new law right back in front of the same state Supreme Court that just opened this whole Pandora’s box in the first place, that’s very possible. That’s one thing I’m watching. I guess we should also watch for other states to take up this issue. A lot of states have fetal personhood language, either in their constitutions or in statute or something, so really any of those states could become the next Alabama. All it would take is someone to bring a court challenge and try to get a similar ruling.
Rovner: I was amused though that the [Alabama] Statehouse passed the immunity law yesterday, Wednesday during the day. But the Senate passed it later in the evening and the governor signed it. I guess she didn’t want to let it hang there while these big national anti-abortion groups were asking her to veto it. So by the time I woke up this morning, it was already law.
Ollstein: It’s just been really interesting, because the anti-abortion groups say they support IVF, but they came out against the Democrats’ federal bill that would provide federal protections. They came out against nonbinding House resolutions that Republicans put forward saying they support IVF, and they came out against this Alabama fix. So it’s unclear what form of IVF, if any, they do support.
Rovner: Meanwhile, in Kentucky, the state Senate has overwhelmingly passed a bill that would permit a parent to seek child support retroactively to cover pregnancy expenses up until the child reaches age 1. So you have until the child turns 1 to sue for child support. Now, this isn’t technically a “personhood” bill, and it’s legit that there are expenses associated with becoming a parent even before a baby is born, but it’s skating right up to the edge of that whole personhood thing.
It brings me to my extra credit for this week, which I’m going to do early. It’s a story from NPR called, “How States Giving Rights to Fetuses Could Set Up a National Case on Abortion,” by Regan McCarthy of member station WFSU in Tallahassee. In light of Florida’s tabling of a vote on its personhood bill in the wake of the Alabama ruling last week, the story poses a question I hadn’t really thought about in the context of the personhood debate, whether some of these partway recognition laws, not just the one in Kentucky, but there was one in Georgia last year, giving tax deductions for children who are not yet born as long as you could determine a heartbeat in the second half of the year, because obviously in the first half of the year the child would’ve been born.
Whether those are part of a very long game that will give courts the ability to put them all together at some point and declare not just embryos but zygotes children. Is this in some ways the same playbook that anti-abortion forces use to get Roe [v. Wade] overturned? That was a very, very long game and at least this story speculates that that might be what they’re doing now with personhood.
Ollstein: Some anti-abortion groups are very open that it is what they want to do. They have been seeding the idea in amicus briefs and state policies. They’ve been trying to tuck personhood language into all of these things to eventually prompt such a ruling, ideally from the Supreme Court and, in their view. So whether that moves forward remains to be seen, but it’s certainly the next goal. One of many next goals on the horizon.
Rovner: Yes, one of many. All right, well moving on. Last week I called the cyberattack on Change Healthcare, a subsidiary of UnitedHealth Group, the biggest under-covered story in health care. Well, it is not under-covered anymore. Two weeks later, thousands of hospitals, pharmacies, and doctor practices still can’t get their claims paid. It seems that someone, though it’s not entirely clear who, paid the hackers $22 million in ransom. But last time I checked the systems were still not fully up. I saw a letter this morning from the Medicaid directors worrying about Medicaid programs getting claims fulfilled. How big a wake-up call has this been for the health industry, Sarah? This is a bigger deal than anybody expected.
Karlin-Smith: There’s certainly been cyberattacks on parts of the health system before in hospitals. I think the breadth of this, because it’s UnitedHealth [Group], is really significant. Particularly, because it seems like some health systems were concerned that the broader United network of companies and systems would get impacted, so they sort of disconnected from things that weren’t directly changed health care, and that ended up having broader ramifications. It’s one consequence of United being such a big monolith.
Then the potential that United paid a ransom here, which is not 100% clear what happened, is very worrisome. Again, because there’s this sense that, that will then increase the — first, you’re paying the people that then might go back and do this, so you’re giving them more money to hack. But also again, it sets up a precedent, that you can hack health systems and they will pay you. Because it is so dangerous, particularly when you start to get involved in attacking the actual systems that provide people care. So much, if you’ve been in a hospital lately or so forth, is run on computer systems and devices, so it is incredibly disruptive, but you don’t want to incentivize hackers to be attacking that.
Rovner: I certainly learned through this how big Change Healthcare, which I had never heard of before this hack and I suspect most people even who do health policy had never heard of before this attack, how embedded they are in so much of the health care system. These hackers knew enough to go after this particular system that affected so much in basically one hack. I’m imagining as this goes forward, for those who didn’t listen to last week’s podcast, we also talked about the Justice Department’s new investigation into the size of UnitedHealth [Group], an antitrust investigation for… It was obviously not prompted by this, it was prompted by something else, but I think a lot of people are thinking about, how big should we let one piece of the health care system get in light of all these cyberattacks?
All right, well we’ll obviously come back to this issue, too, as it resolves, one would hope. That is the news for this week. Now we will play my interview with White House domestic policy adviser Neera Tanden, and then we will come back with our extra credits.
I am so pleased to welcome to the podcast Neera Tanden, domestic policy adviser to President Biden, and director of the White House Domestic Policy Council. For those of you who don’t already know her, Neera has spent most of the last two decades making health policy here in Washington, having worked on health issues for Hillary Clinton, President Barack Obama, and now President Joe Biden. Neera, thank you so much for joining us.
Neera Tanden: It’s really great to be with you, Julie.
Rovner: As we tape this, the State of the Union is still a few hours away and I know there’s stuff you can’t talk about yet. But in general, health care has been a top-of-mind issue for the Biden administration, and I assume it will continue to be. First, remind us of some of the highlights of the president’s term so far on health care.
Tanden: It’s a top concern for the president. It’s a top issue for us, but that’s also because it’s really a top issue for voters. We know voters have had significant concerns about access, but also about costs. That is why this administration has really done more on costs than any administration. This is my third, as you noted, so I’m really proud of all the work we’ve done on prescription drugs, on lowering costs of health care in the exchanges, on really trying to think through the cost burden for families when it comes to health care.
When we talk about prescription drugs, it’s a wide-ranging agenda, there are things or policies that people have talked about for decades, like Medicare negotiating drug prices, that this president is the first president to truly deliver on, which he will talk about in the State of the Union. But we’ve also innovated in different policies through the Inflation Reduction Act, the inflation rebates, which ensure that drug companies don’t raise the price of drugs faster than inflation. When they do, they pay a rebate both to Medicare but also ultimately to consumers. Those our high-impact policies that will really take a comprehensive approach on lowering prices.
Rovner: Yet for all the president has accomplished, and people who listen to the podcast regularly will know that it has been way more than was expected given the general polarization around Washington right now. Why does the president seem to get so little credit for getting done more things than a lot of his predecessors were able to do in two terms?
Tanden: Well, I think people do recognize the importance of prescription drug coverage. And health care as an issue that the president — it’s not my place to talk about politics, but he does have significant advantages on issues like health care. That I think, is because we’ve demonstrated tangible results. People understand what $35 insulin means. What I really want to point to in the Medicare negotiation process is, Sept. 1, Medicare will likely have a list of drugs which are significantly lower costs, that process is underway. But my expectation, you know I’m not part of it, that’s being negotiated by CMS [Centers for Medicare & Medicaid Services] and HHS, but we expect to have a list of 10 drugs that are high-cost items for seniors in which they’ll see a price that is lower than what they pay now. That’s another way in which, like $35 insulin, we’ll have tangible proof points of what this administration will be delivering for families.
Rovner: There’s now a record number of people who have health insurance under the Affordable Care Act, which I remember you also worked on. But in surveys, as you noted, voters now say they’re less worried about coverage and more worried about not being able to pay their medical bills even if they have insurance. I know a lot of what you’re doing on the drug side is limited to Medicare. Now, do you expect you’re going to be able to expand that to everybody else?
Tanden: First and foremost, our drug prices will be public, as you know. And as you know, prices in Medicare have been able to influence other elements of the health care system. That is really an important part of this. Which is that again, those prices will be public and our hope is that the private sector adopts those prices, because they’re ones that are negotiated. We expect this to affect, not just seniors, but families throughout the country.
There are additional actions we’ll be taking on Medicare drug negotiation. That will be a significant portion of the president’s remarks on health care, not just what we’ve been able to do in Medicare drug negotiation, but how we can really build on that and really ensure that we are dramatically reducing drug costs throughout the system. I look forward to hearing the president on that topic.
Rovner: I know we’re also going to get the budget next week. Are there any other big health issues that will be a priority this year?
Tanden: The president will have a range of policies on issues like access to sickle cell therapies, ensuring affordable generic drugs are accessible to everybody, ensuring that we are building on the Affordable Care Act gains. You mentioned this, but I just really do want to step back and talk about access under the Affordable Care Act. Because I think if people started off at the beginning of this administration and said the ACA marketplaces close to double, people would’ve been shocked. You know this well, a lot of people thought the exchanges were maximizing their potential. There are a lot of people who may not be interested in that, but the president had, in working with Congress, made the exchanges more affordable.
We’ve seen record adoption: 21 million people covered through the ACA exchanges today, when it was 12 million when we started. That’s 9 million more people who have the security of affordable health care coverage. I think it’s a really important point, which is, why are people signing up? Because it is a lot more affordable? Most people can get a very affordable plan. People are saving on average $800, and that affordability is crucial. Of course we have to do more work to reduce costs throughout the health care system. But it’s an important reminder that when you lower drug costs, you also have the ability to lower premiums and it’s another way in which we can drive health care costs down. I would be genuinely honest with you, which is, I did not think we would be able to do all of these things at the beginning of the administration. The president has been laser-focused on delivering, and as you know from your work on the ACA, he did think it was a big deal.
Rovner: I have that on a T-shirt.
Tanden: A lot of people have talked about different things, but he has been really focused on strengthening the ACA. He’ll talk about how we need to strengthen it in the future, and how that is another choice that we face this year, whether we’re going to entertain repealing the ACA or build on it and ensure that the millions of people who are using the ACA have the security to know that it’s there for them into the future. Not just on access, but that also means protections for preexisting conditions, ensuring women can no longer be discriminated against, the lifetime annual limits. There’s just a variety of ways that ACA has transformed the health care system to be much more focused on consumers.
Rovner: Last question. Obviously reproductive health, big, big issue this year. IVF in particular has been in the news these past couple of weeks, thanks to the Alabama Supreme Court. Is there anything that President Biden can do using his own executive power to protect access to reproductive health technology? And will we hear him at some point address this whole personhood movement that we’re starting to see bubble back up?
Tanden: I think the president will be very forceful on reproductive rights and will discuss the whole set of freedoms that are at stake and reproductive rights and our core freedom at stake this year. You and I both know that attacks on IVF are actually just the effectuation of the attacks on Roe. What animates the attacks on Roe, would ultimately affect IVF. I felt like I was a voice in the wilderness for the last couple of decades, where people were saying … They’re just really focused on Roe v. Wade. It won’t have any impact on IVF or [indecipherable] they’re just scare tactics when you talk about IVF.
Obviously the ideological underpinnings of attacks on Roe ultimately mean that you would have to take on IVF, which is exactly what women are saying. I think the president will speak forcefully to the attacks on women’s dignity that women are seeing throughout this country, and how this ideological battle has translated to misery and pain for millions of women. Misery and pain for their families. And has really reached the point where women who are desperate to have a family are having their reproductive rights restricted because of the ideological views of a minority of the country. That is a huge issue for women, a huge issue for the country, and exactly why he’ll talk about moving forward on freedoms and not moving us back, sometimes decades, on freedom.
Rovner: Well, Neera Tanden, you have a lot to keep you busy. I hope we can call on you again.
Tanden: There’s few people who know the health care system as well as Julie Rovner, so it’s just a pleasure to be with you.
Rovner: OK, we are back. It’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. I already did mine. Sandhya, why don’t you go next?
Raman: My extra credit this week is called “My Son Is Not There Anymore: How Young People With Psychosis Are Falling Through the Cracks,” and it’s by Órla Ryan for The Journal. This was a really interesting story about schizophrenia in Ireland and just how the earlier someone’s symptoms are treated the better the outcome. But a lot of children and minors with psychosis and schizophrenia struggle to get access to the care they need and just fall through the cracks of being transferred from one system to another, especially if they’re also dealing with disabilities. If some of these symptoms are treated before puberty, the severity is likely to go down a lot and they’re much less likely to experience psychosis. She takes a really interesting look at a specific case and some of the consequences there.
Rovner: I feel like we don’t look enough at what other countries health systems are doing because we could all learn from each other. Alice, why don’t you go next?
Ollstein: I have a piece by KFF Health News called “Why Even Public Health Experts Have Limited Insight Into Stopping Gun Violence in America.” It’s looking at the toll taken by the long-standing restrictions on federal funding for research into gun violence, investigating it as a public health issue. Only recently this has started to erode at the federal level and some funding has been approved for this research, but it is so small compared to the death toll of gun violence. This article sort of argues that lacking that data for so many years is why a lot of the quote-unquote “solutions” that places have tried to implement to prevent gun violence, just don’t work. They haven’t worked, they haven’t stopped these mass shootings, which continue to happen. So, arguing that, if we had better data on why things happen and how to make it less lethal, and safe, in various spaces, that we could implement some things that actually work.
Rovner: Yeah, we didn’t have the research just as this problem was exploding and now we are paying the price. Sarah.
Karlin-Smith: I looked at the first in a Stat News series by Lev Facher, “The War on Recovery: How the U.S. Is Sabotaging Its Best Tools to Prevent Deaths in the Opioid Epidemic.” It looks at why the U.S. has had access to cheap effective medicines that help reduce the risk of overdose and death for people that are struggling with opioid-use disorder haven’t actually been able, in most cases, to get access to these drugs, methadone and buprenorphine.
The reasons range from even people not being allowed to take the drugs when they’re in prison, to not being able to hold certain jobs if you’re taking these prescription medications, to Narcotics Anonymous essentially banning people from coming to those meetings if they use these drugs, to doctors not being willing or open to prescribing them. Then of course, there’s what always seems to come up these days, the private equity angle. Which is that methadone clinics are becoming increasingly owned by private equity and they’ve actually pushed back on and lobbied against policies that would make it easier for people to get methadone treatment. Because one big barrier to methadone treatment is, right now you largely have to go every day to a clinic to get your medicine, which it can be difficult to incorporate into your life if you need to hold a job and take care of kids and so forth.
It’s just a really fascinating dive into why we have the tools to make what is really a terrible crisis that kills so many people much, much better in the U.S. but we’re just not using them. Speaking of how other countries handle it, the piece goes a little bit into how other countries have had more success in actually being open to and using these tools and the differences between them and the U.S.
Rovner: Yeah, it’s a really good story. All right, that is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, @jrovner, or @julierovner at Bluesky or @julie.rovner at Threads. . Sarah, where are you these days?
Karlin-Smith: Trying mostly to be on Blue Sky, but on X, Twitter a little bit at either @SarahKarlin or @sarahkarlin-smith.
Rovner: Alice.
Ollstein: @alicemiranda on Blue Sky, and @AliceOllstein on X.
Rovner: Sandhya.
Raman: @SandhyaWrites on X and on Blue Sky.
Rovner: We will be back in your feed next week. Until then, be healthy.
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An Arm and a Leg: Wait, Is Insulin Cheaper Now?
Pharmaceutical companies that manufacture insulin made headlines last year when they voluntarily agreed to provide discount cards that lower the monthly cost of insulin for many people to $35.
But getting your hands on this card — and persuading a pharmacist to accept it — can be a hassle.
Pharmaceutical companies that manufacture insulin made headlines last year when they voluntarily agreed to provide discount cards that lower the monthly cost of insulin for many people to $35.
But getting your hands on this card — and persuading a pharmacist to accept it — can be a hassle.
In this episode of “An Arm and a Leg,” producer Emily Pisacreta speaks with “insulin activists” and pharmaceutical experts to find out what this change in prices means for people with diabetes and why the fight for affordable insulin isn’t over yet.
Dan Weissmann
Host and producer of "An Arm and a Leg." Previously, Dan was a staff reporter for Marketplace and Chicago's WBEZ. His work also appears on All Things Considered, Marketplace, the BBC, 99 Percent Invisible, and Reveal, from the Center for Investigative Reporting.
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Emily Pisacreta
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Transcript: Wait, Is Insulin Cheaper Now?
Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.
Dan: Hey there. Right after the holidays, I got an email from a listener named Brianna.It started, “Happy new year Dan! I was just reading the news about the price of insulin going down to $35! Is that for everyone?”
And I was like, Huh. I had a sense that there was some news about the price of insulin, but 35 dollars a month for everyone? That sounded like a BIG reduction. And big news.I googled the latest stories, and I was… not totally sure what I was seeing.
I was definitely seeing some new stories about people paying 35 bucks from here on out. And there seemed to be some federal law involved, and politicians were patting themselves on the back. But it just wasn’t totally clear: Was insulin now 35 dollars for everyone? Did the outrageous price of insulin get solved while I wasn’t looking?
And I mean, I’ve kinda been looking. We’ve done a couple of episodes about the price of insulin already — because insulin is iconic. It represents the wild cost of prescription drugs in this country. More than 8 million Americans take insulin to treat their diabetes – and for some, going without it could actually kill you.
And its price got jacked up so much — huge multiples over like ten years — — that one in four of those people who couldn’t go without… took to rationing: Seeing how much they could go without, short of actually dying.
So I asked our senior producer Emily Pisacreta to take the case.
Emily: I feel more like the senior insulin correspondent, which is fine with me as the resident type 1 diabetic! And a lot has happened since the last time we talked about insulin on this show. We really do need an update.
Dan: This is an “Arm and a Leg”, a show about why healthcare costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann, I’m a reporter and I like a challenge. So our job here is to take one of the most enraging, terrifying, depressing parts of American life, and bring you something entertaining, empowering and useful.
Today we have a question: what’s going on with insulin? Is it $35 now?
Emily: Well, there have been some BIG improvements — bigger than I thought when I started reporting. A lot of people can get their monthly supply of insulin for just $35. But it is oversimplified to say it just costs $35 now. And the people who have been fighting to lower the price of insulin over the past decade? They’re still very pissed. So let me walk you through what changed, what led to those changes, and what’s still unresolved.
Dan: OK!
Emily: For years now, there’s been a giant push from people with diabetes to get the federal government to do something about the high cost of insulin. In 2022, finally something came through. I’m talking about a provision in Inflation Reduction Act.
Dan: Yes– I remember this– the Inflation Reduction Act was a big infrastructure bill that included, like renewable energy subsidies, and– honestly, this is the reason that I remember the bill, because we did an episode about this part– letting medicare negotiate some drug prices?
Emily: Exactly. It said people on Medicare would be able to get a month’s supply of insulin for no more than $35 out of pocket. But of course that left a big gaping hole. BECAUSE that’s cool for people on Medicare, but what about the rest of us? And the pharma companies were feeling the heat. Here’s President Biden in his State of the Union last year:
President Biden: Big pharma has been unfairly charging people hundreds of dollars, four to $500 a month making record profits. Not anymore. Not anymore.
Emily: By the way, those pharma companies? There’s three of them who make insulin.
That’s the American company Eli Lilly, the Danish company Novo Nordisk, and the French company Sanofi. OK so: not long after Joe Biden talked about their record profits, the insulin makers were back in the news. …
Eli Lilly was the first to announce they were going to slash prices on several of their most popular insulins, and limit out of pocket spending to $35 a month.
Fox News: This is a big story.
Next, Novo Nordisk and Sanofi made similar announcements.
CNN: Millions of Americans are affected by this major news this morning for millions of people suffering from diabetes and high prescription drug costs.
Basically, the insulin manufacturers all said hey, you’re not covered by this Medicare thing? We’re going to bring your copay down to $35 ourselves. So if you have commercial insurance Print out this card, take it to the pharmacy, and your copay will be no more than $35 for a month’s supply of insulin.
Dan: And what if you’re uninsured?
Emily: Well, they have a card for that, too.
Dan: OK so what I’m hearing is you need a card.
DAN: Yes. How do you get one?
Emily: The insulin makers set special phone numbers you can call. Or you can visit their websites, fill out a little form, and download the card.
Dan: Sounds simple, unless I’m missing something?
Emily: In all honesty, I had no problem with those steps. But I wouldn’t assume that’s the case for everyone. And I’m also not rationing insulin right now.
Zoe Witt: When you are rationing insulin, maybe you aren’t even fully rationing insulin yet, but you don’t know how you’re going to get Your next prescription, your next fill of insulin…You are in crisis. Like, you, you do not have the capability to sift through these websites. It’s very confusing. It’s very overwhelming.
Emily: This is someone who frequently speaks to people struggling to afford insulin.
Zoe Witt: my name is Zoe Witt. I work with Mutual Aid Diabetes.
Emily: Mutual Aid Diabetes. That’s an all volunteer group that has banded together to help diabetics get what they need, when they need it. They help people with cash and with free diabetes supplies, including insulin, no questions asked. That means Zoe knows the ins and outs of every obstacle to getting insulin.
Zoe Witt: Our healthcare system is like a whack a mole from hell.
Emily: And Zoe reminds me: if you’re not taking enough insulin, you probably feel awful. Maybe not even thinking straight. And it can affect your eyes, making it hard to read.
Zoe Witt: It just is unmanageable
Emily: Zoe says they talk with people all the time who are too stressed out or too debilitated to download these cards and use them. Diabetes folks walk people through the process. And once someone has the card… Mutual Aid Diabetes gives people the 35 bucks, too, if they say they need it. Because $35 can be a barrier for a lot of people. And it’s actually $70 sometimes if you use 2 types of insulin at once, which lots of people do… myself included.
Dan: Wow. OK. But then once people have the cards they typically have no problem?
Emily: Well, your pharmacist has to know what they’re doing, too. So sometimes it means a patient having to educate their pharmacist– or even bring the doctor in to help troubleshoot — which is no picnic. And people with diabetes are always having to deal with insurance roadblocks at the pharmacy, so I don’t want to make anything sound simpler than it is.
Dan: It’s like a whack a mole from hell!
Emily: Exactly! And the cards don’t solve everything. Especially this: if you have insurance, these cards only apply to the insulin your insurance plan already covers. If you normally need a prior authorization to get the right insulin for you… that is still the case.
Dan: Right. Okay. like prior authorization is this roadblock to getting all kinds of treatment, that you and your doctor agree that you should have, and your insurance company can say, we disagree. We’re s not authorizing this. And then you’re stuck.
Emily: Right.
Dan:But in terms of what the pharma companies. can do to kind of offer you a deal. They’re basically doing it. Is that right?
Emily: I think that’s fair to say.
Dan: That’s super interesting. All right. So it’s not solved, but this is a big step forward. And what’s not solved is: some people are still on the hook for the list price for insulin — the price without any discounts or insurance or whatever. But you found big improvements there too, right?
Emily: Yes! When the companies announced all these discount cards, they announced a whole other big change, too. Slashing the list prices of a bunch of different insulins by up 75%. So a vial that once was north of $300 is now being listed at around $70.
Dan: OK, that sounds like a big improvement.
Emily: It’s a big, big deal. Actual price reductions are what diabetes advocates have been demanding all along. And… while these are still the highest prices in the world for these same insulins, to see them drop from triple to double digits, it’s wild.
Dan: I sense that there’s a “but” here.
Emily: Well, the Big Three didn’t lower the price of every type of insulin, only ones that have been around since the 1990s or early 2000s. Newer insulins that work faster or last longer are not included here.
Dan: And I’m guessing not all insulins work the same way.
Emily: Right. Some people can switch between types or brands of insulin easily. For other people, there can be allergies or one works better with their body with another kind. It’s complicated. It’s medicine! AND… there have been some issues with pharmacies actually stocking lower list price insulin. That is a whole ‘nother saga… an episode for another day. But the important thing is… a bunch of insulin is a lot cheaper now.
Dan: Wow. Emily, you said right at the top: The changes here are bigger and better than you realized before you started reporting.
Emily: Yes but there’s still a lot more to say.
Right. After the break, we’ll’ hear from you about why these changes happened NOW. And what it means for people with diabetes and really all of us…
[midroll]
So. We have seen some big changes in the last year — including DRUG COMPANIES expanding their discount programs and lowering the sticker prices on insulin, dramatically. Why now? I’m guessing this wasn’t because they had a big change of heart.
Emily: I can’t speak to what’s in pharma’s hearts. But I did talk to someone who knows a lot about pharma’s brain.
Ed Silverman: my name is Ed Silverman, and I work at Stat News, a health and life sciences website,
Emily: I’m a big fan of Stat News
Dan: Me too, man! Their reporting is great.
Emily: And Ed Silverman. He’s been covering the pharmaceutical industry for almost 30 years. He thinks activism from people with diabetes over the years created political pressure that played a big role in the decision to slash prices. But there was also something kind of hidden at work.
Ed Silverman: It’s not altruism, here was a real mechanism, government mechanism in place that helped change the equation and therefore the thinking back at the companies.
Dan: OK… what is he talking about?
Emily: So, Dan: do you remember the stimulus bill, the American Rescue Plan?
Dan: I’m starting to feel like this episode is a quiz on recent-ish legislation. And I think I’m gonna do pretty well here:.The American Rescue Plan was a trillion dollar stimulus that Joe Biden got passed right after he got into office– am I right?
Emily: OK, hotshot. Do you remember how in part 8 section 9816 they sunsetted the limit on the maximum rebate for single source drugs and innovator multiple source drugs?
Dan: Um, busted. No.
Emily: Ok so here’s the deal: it’s obviously kinda wonky so I’ll simplify– in that little section Congress made a tweak to Medicaid, basically raising penalties on drug-makers for jacking up prices too far, too fast. So if you’re a pharma company who has raised the price of a drug by a lot very quickly, which is true of insulin, and a lot of people on Medicaid use your drug, which is also true of insulin, then you have to pay a big penalty. In the case of insulin, that penalty would be more than you’d make selling the insulin to Medicaid. A LOT more: So, unless you bring the price back down, you’re going to owe Medicaid a lot of moolah. And those penalties were set to kick in January 1st 2024.
Dan: So you’re telling me: Part of what the pharma companies did here came right out of a small part of a giant federal law from 2021.
Emily: Yep. And there’s another big wheel turning in the background here. Novo Nordisk and Eli Lilly, two companies who really got their start by selling insulin, now make other diabetes drugs — drugs that are now increasingly used for weight loss. And it’s a bonanza.
GMA: It is literally the hottest drug in the country right now.
Fox News: all people are talking about these days is Ozempic, wegovy. Oh my gosh, this person lost 20 pounds. This person lost 50 pounds.
Ozempic Ad: [Jingle:] “Oh, Oh, Oh, Ozempic![Announcer:] Once weekly Ozempic is helping many people with type 2 diabetes like James lower their blood sugar.
Emily: Drugs like Ozempic, Wegovy, Mounjaro. They’ve been in super high demand. And there’s been a ton of hype about their various potential health benefits. For weight loss, for heart health. Scientists are even interested in whether it can help people with substance use disorders. Meanwhile, for Eli Lilly and Novo Nordisk, the returns on these drugs dwarf anything else they’re selling. Novo Nordisk even became the biggest company in Europe – for like a minute… but still.
Dan: OK, this is interesting, but what does it have to do with the price of insulin?
Emily: I’d wondered… maybe these companies can just better afford to buy some political peace by lowering insulin prices, because they are making so much bank on these new drugs, ? Ed Silverman had a take on that.
Ed Silverman: It makes perfect sense that these cash cows, these medicines that are used for diabetes and, weight loss are going to become increasingly important to their bottom line more than other medicines
Emily: More than insulin. And they’re selling so much so fast, they can hardly keep up with demand. Which could end up affecting people who need insulin.
Dan: Wait, how?
Emily: Look, for example, in November, Novo Nordisk said they were investing 3 and half billion dollars into ramping up production of injection pens for Wegovy, one of their top drugs in this category. Less than a week later, Novo announced they would be phasing out one of their insulin products from the US market – an insulin called Levemir. It’s one of the insulins whose prices they just dropped. And… coincidence… Levemir also comes in a pen.
Dan: So Novo Nordisk is phasing out an insulin pen so they can make more Wegovy pens?
Emily: Well, we don’t know that for sure. But Novo Nordisk did tell me that “manufacturing constraints” were part of why they’re dumping Levimir. They said it was one of several reasons and also wrote: “We made this decision after careful consideration and are confident that given the advanced notice, U.S. patients will have access to alternative treatments and can transition to other options.
Dan: Huh. OK.
Emily: But even if pulling this insulin Levemir off the market had nothing to do with their trouble meeting the demand for their big blockbuster drug… it brings to mind an important question about all the changes we talked about today — whether it’s the copay savings or the lowered list prices. Here’s Ed Silverman.
Ed Silverman there’s no guarantee that the companies will keep these in place. Maybe after time, some of the attention on insulin is diverted and maybe eighteen months from now, one company might quietly roll back some of the Benefits, if you want to use that word, there’s nothing requiring them to maintain the steps they’ve taken.
Emily: I asked all three insulin makers about this. None of them promised there would never be any backsies. Lilly wrote back “Lilly is committed to ensuring all patients can access any Lilly medicine they need” — and touted their efforts to date. Similarly, Sanofi wrote “We continually review our affordability offerings to support our aim that no one should struggle to pay for their insulin. Novo Nordisk’s response was “Novo Nordisk increases the price of some of our medicines each year, in response to changes in the healthcare system, market conditions, and the impact of inflation.”
Dan: Yeah, that especially does not sound like a pinky-swear, no-backsies kind of response.
Emily: AND that’s not much comfort for insulin activists. Folks like Shaina Kasper, who works for T1International. They’re a group that’s been at the forefront of this fight for years. I Asked her…
Emily-on-tape: So is this issue of high insulin prices just resolved now?
Shaina Kasper: No, it hasn’t been. It’s been really frustrating…
Emily Shaina and others are worried that the announcements from the manufacturers about savings cards and voluntary list price reductions will take the pressure off the government to do something more sweeping. Because for now…
Shaina: The manufacturers really hold all of the power here And if patients are counting on these programs to literally be able to survive, that has life and death consequences
Dan: This question about who holds the power, it reminds me of a story we did a few months ago… the one about how the writer John Green led a kind of online crusade targeting the drug-maker Johnson & Johnson. And how, even though the pressure campaign worked — J & J ended up allowing lower-priced versions of an important tuberculosis drug — activists who worked on the issue were like: It’s a problem that Johnson & Johnson has the power to say yes or no here..
Emily: Exactly. That which pharma giveth, pharma can taketh. At least the way things are set up now. Now I should say, all three companies told me they plan to continue their affordability offerings. But if insulin continues to be the poster child for high drug prices, prices virtually everyone in America agrees are too high…it does raise the question: are voluntary programs from pharmaceutical companies the solution we want? To Zoe from Mutual Aid Diabetes, the answer is no. They find these manufacturer savings cards kind of a bitter pill… no pun intended.
Zoe Witt: there’s certainly no justice in these programs,
Emily: And zoe for one would say that justice is overdue.
Zoe Witt: These companies have price gouged us. for years, making obscene amounts of money. Then, presumably, as, we’re often told is the justification for these ridiculous prices, they did research and development for more diabetes drugs, which are Ozempic, Monjoro, etc. And now, these companies, for, the next 15 years, are set to make, billions and billions of dollars, on these drugs,
Emily: I asked the big three insulin manufacturers about what Zoe said – about how angry folks like them are over the cost of insulin. Novo Nordisk said “we continually review and revise our offerings as well as work with diverse stakeholders to create solutions for differing patient needs. ” And Sanofi and Lily both said something very similar.
Emily: So… in the end– or at least for now– here’s the answer to our listener’s question…. There are more avenues than ever to get a month’s supply of insulin for $35. Great. It may be a lot easier to avoid rationing your insulin now than it was a couple years ago. That’s also really great. But people with diabetes do not think this fight is over.
Dan: So what DO they want?
Emily: Some people still want the federal government to just put a cap on what people pay for insulin, like by law.. Others are working to build alternatives to the existing pharmaceutical industry, like California’s CalRx program.
Dan: Cal Rx… now you’re calling back our story from the last time we talked about insulin.
Emily: Yep, Cal Rx is the state of California’s attempt to enter the insulin market, to introduce some low priced generics and sell them essentially at cost. Other states are joining in. Even if some of these specific plans fall apart — even if California somehow can’t get its government-sponsored insulin to market, even if Pharma rolls back some of the discounts…the past few years have been enormous for people with diabetes. Mostly because they’ve found each other.
Zoe Witt: I was rationing insulin in 2018, I didn’t even know that there was a term for it. I didn’t know other people were doing it. I know a lot of people died that year. And there were multiple occasions where I, in retrospect, definitely almost died. And the one good thing that has, that has happened between now and then is that people have been talking about it and People are now more comfortable telling others that they’re struggling, that they can’t get their insulin.
Emily: Connecting with Mutual Aid Diabetes or other networks to get or give help.
Zoe Witt: We’re all keeping each other alive, like to me, that’s the number one thing that has changed.
Emily: I think that’s a huge lesson here, and a takeaway that’s not new on this show. Keeping each other alive — or even just keeping each other from getting bankrupted by the medical system — is up to us. And while a mutual aid group modeled exactly like Mutual Aid Diabetes may not work for every disease or every drug, Zoe says they’re more than willing to talk to anyone who might be interested in trying.
Zoe Witt: I mean, we’ve even had people ask, like, is there like a mutual aid asthma or something like for inhalers?
Emily: Their advice?
Zoe Witt: I think that, you know, to start, you would want, like, probably at least, like, five to ten ”ride-or dies,” like, people that are really willing to, like, go the extra mile,
Dan: Five to ten– that just does not sound like that many! (I mean, I think.) One thing I’m taking away is: This is a lot of activism over a long time, that eventually had a big effect. Another thing I’m taking away here? Sneaky policy changes — like lifting the Medicaid rebate cap — can make a huge difference. God bless whatever nerds are writing the next little bit of law to sneak into a giant bill, like a hacker with a virus.
Emily: Totally. OK. I gotta take a shot, and eat my lunch.
Dan: Go for it. We’ll be back with a new episode in a few weeks. Till then, take care of yourself.
This episode of an arm and a leg was produced by Emily Pisacreta and me, Dan Weissman and edited by Ellen Weiss.
Adam Raymonda is our audio wizard. Our music is by Dave Weiner and blue dot sessions.
Gabrielle Healy is our managing editor for audience. She edits the first aid kit newsletter.
Bea Bosco is our consulting director of operations. Sarah Ballama is our operations manager.
And Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in depth journalism about healthcare in America and a core program at KFF, an independent source of health policy research, polling and journalism.
Zach Dyer is senior audio producer at KFF Health News. He’s editorial liaison to this show.
And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor, allowing us to accept tax exempt donations. You can learn more about INN at INN. org.
Finally, thanks to everybody who supports this show financially– you can join in any time at arm and a leg show dot com, slash, support — and thanks for listening.
“An Arm and a Leg” is a co-production of KFF Health News and Public Road Productions.
To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and X, formerly known as Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.
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Patients See First Savings From Biden’s Drug Price Push, as Pharma Lines Up Its Lawyers
Last year alone, David Mitchell paid $16,525 for 12 little bottles of Pomalyst, one of the pricey medications that treat his multiple myeloma, a blood cancer he was diagnosed with in 2010.
The drugs have kept his cancer at bay. But their rapidly increasing costs so infuriated Mitchell that he was inspired to create an advocacy movement.
Last year alone, David Mitchell paid $16,525 for 12 little bottles of Pomalyst, one of the pricey medications that treat his multiple myeloma, a blood cancer he was diagnosed with in 2010.
The drugs have kept his cancer at bay. But their rapidly increasing costs so infuriated Mitchell that he was inspired to create an advocacy movement.
Patients for Affordable Drugs, which he founded in 2016, was instrumental in getting drug price reforms into the 2022 Inflation Reduction Act. Those changes are kicking in now, and Mitchell, 73, is an early beneficiary.
In January, he plunked down $3,308 for a Pomalyst refill “and that’s it,” he said. Under the law, he has no further responsibility for his drug costs this year — a savings of more than $13,000.
The law caps out-of-pocket spending on brand-name drugs for Medicare beneficiaries at about $3,500 in 2024. The patient cap for all drugs drops to $2,000 next year.
“From a selfish perspective, I feel great about it,” he said. But the payment cap will be “truly life-changing” for hundreds of thousands of other Medicare patients, Mitchell said.
President Joe Biden’s battle against high drug prices is mostly embodied in the IRA, as the law is known — a grab bag of measures intended to give Medicare patients immediate relief and, in the long term, to impose government controls on what pharmaceutical companies charge for their products. The law represents the most significant overhaul for the U.S. drug marketplace in decades.
With Election Day on the horizon, the president is trying to make sure voters know who was responsible. This month, the White House began a campaign to get the word out to seniors.
“The days where Americans pay two to three times what they pay for prescription drugs in other countries are ending,” Biden said in a Feb. 1 statement.
KFF polling indicates Biden has work to do. Just a quarter of adults were aware that the IRA includes provisions on drug prices in July, nearly a year after the president signed it. He isn’t helped by the name of the law, the “Inflation Reduction Act,” which says nothing about health care or drug costs.
Biden’s own estimate of drug price inflation is quite conservative: U.S. patients sometimes pay more than 10 times as much for their drugs compared with people in other countries. The popular weight loss drug Wegovy lists for $936 a month in the U.S., for example — and $83 in France.
Additional sections of the law provide free vaccines and $35-a-month insulin and federal subsidies to patients earning up to 150% of the federal poverty level, and require drugmakers to pay the government rebates for medicines whose prices rise faster than inflation. But the most controversial provision enables Medicare to negotiate prices for certain expensive drugs that have been on the market for at least nine years. It’s key to Biden’s attempt to weaken the drug industry’s grip.
Responding to Pressure
The impact of Medicare’s bargaining over drug prices for privately insured Americans remains unclear. States have taken additional steps, such as cutting copays for insulin for the privately insured.
However, insurers are increasing premiums in response to their higher costs under the IRA. Monthly premiums on traditional Medicare drug plans jumped to $48 from $40 this year, on average.
On Feb. 1, the Centers for Medicare & Medicaid Services sent pharmaceutical makers opening bids for the first 10 expensive drugs it selected for negotiation. The companies are responding to the bids — while filing nine lawsuits that aim to kill the negotiations altogether, arguing that limiting their profits will strangle the pipeline of lifesaving drugs. A federal court in Texas dismissed one of the suits on Feb. 12, without taking up the substantive legal issue over constitutionality.
The nonpartisan Congressional Budget Office predicted the IRA’s drug pricing elements would save the federal government $237 billion over 10 years while reducing the number of drugs coming to market in that period by about two.
If the government prevails in the courts, new prices for those 10 drugs will be announced by September and take effect in 2026. The government will negotiate an additional 15 drugs for 2027, another 15 for 2028, and 20 more each year thereafter. CMS has been mum about the size of its offers, but AstraZeneca CEO Pascal Soriot on Feb. 8 called the opening bid for his company’s drug Farxiga (which earned $2.8 billion in U.S. sales in fiscal year 2023) “relatively encouraging.”
Related Biden administration efforts, as well as legislation with bipartisan support, could complement the Inflation Reduction Act’s swing at drug prices.
The House and Senate have passed bills that require greater transparency and less self-serving behavior by pharmacy benefit managers, the secretive intermediaries that decide which drugs go on patients’ formularies, the lists detailing which prescriptions are available to health plan enrollees. The Federal Trade Commission is investigating anti-competitive action by leading PBMs, as well as drug company patenting tricks that slow the entry of cheaper drugs to the market.
‘Sending a Message’
Months after drug companies began suing to stop price negotiations, the Biden administration released a framework describing when it could “march in” and essentially seize drugs created through research funded by the National Institutes of Health if they are unreasonably priced.
The timing of the march-in announcement “suggests that it’s about sending a message” to the drug industry, said Robin Feldman, who leads the Center for Innovation at the University of California Law-San Francisco. And so, in a way, does the Inflation Reduction Act itself, she said.
“I have always thought that the IRA would reverberate well beyond the unlucky 10 and others that get pulled into the net later,” Feldman said. “Companies are likely to try to moderate their behavior to stay out of negotiations. I think of all the things going on as attempts to corral the market into more reasonable pathways.”
The IRA issues did not appear to be top of mind to most executives and investors as they gathered to make deals at the annual J.P. Morgan Healthcare Conference in San Francisco last month.
“I think the industry is navigating its way beyond this,” said Matthew Price, chief operating officer of Promontory Therapeutics, a cancer drug startup, in an interview there. The drugs up for negotiation “look to be assets that were already nearing the end of their patent life. So maybe the impact on revenues is less than feared. There’s alarm around this, but it was probably inevitable that a negotiation mechanism of some kind would have to come in.”
Investors generally appear sanguine about the impact of the law. A recent S&P Global report suggests “healthy revenue growth through 2027” for the pharmaceutical industry.
Back in Washington, many of the changes await action by the courts and Congress and could be shelved depending on the results of the fall election.
The restructuring of Medicare Part D, which covers most retail prescription drugs, is already lowering costs for many Medicare patients who spent more than $3,500 a year on their Part D drugs. In 2020 that was about 1.3 million patients, 200,000 of whom spent $5,000 or more out-of-pocket, according to KFF research.
“That’s real savings,” said Tricia Neuman, executive director of KFF’s Medicare policy program, “and it’s targeted to people who are really sick.”
Although the drug industry is spending millions to fight the IRA, the Part D portion of the bill could end up boosting their sales. While it forces the industry to further discount the highest-grossing drugs, the bill makes it easier for Medicare patients to pick up their medicines because they’ll be able to afford them, said Stacie Dusetzina, a Vanderbilt University School of Medicine researcher. She was the lead author of a 2022 study showing that cancer patients who didn’t get income subsidies were about half as likely to fill prescriptions.
States and foundations that help patients pay for their drugs will save money, enabling them to procure more drugs for more patients, said Gina Upchurch, the executive director of Senior PharmAssist, a Durham, North Carolina-based drug assistance program, and a member of the Medicare Payment Advisory Commission. “This is good news for the drug companies,” she said.
Relief for Patients
Lynn Scarfuto, 73, a retired nurse who lives on a fixed income in upstate New York, spent $1,157 for drugs last year, while most of her share of the $205,000 annual cost for the leukemia drug Imbruvica was paid by a charity, the Patient Access Network Foundation. This year, through the IRA, she’ll pay nothing because the foundation’s first monthly Imbruvica payment covered her entire responsibility. Imbruvica, marketed jointly by AbbVie and Janssen, a subsidiary of Johnson & Johnson, is one of the 10 drugs subject to Medicare negotiations.
“For Medicare patients, the Inflation Reduction Act is a great, wonderful thing,” Scarfuto said. “I hope the negotiation continues as they have promised, adding more drugs every year.”
Mitchell, a PR specialist who had worked with such clients as the Campaign for Tobacco-Free Kids and pharmaceutical giant J&J, went to an emergency room with severe back pain in November 2010 and discovered he had a cancer that had broken a vertebra and five ribs and left holes in his pelvis, skull, and forearm bones. He responded well to surgery and treatment but was shocked at the price of his drugs.
His Patients for Affordable Drugs group has become a powerful voice in Washington, engaging tens of thousands of patients, including Scarfuto, to tell their stories and lobby legislatures. The work is supported in part by millions in grants from Arnold Ventures, a philanthropy that has supported health care policies like lower drug prices, access to contraception, and solutions to the opioid epidemic.
“What got the IRA over the finish line in part was angry people who said we want something done with this,” Mitchell said. “Our patients gave voice to that.”
Arnold Ventures has provided funding for KFF Health News.
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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Courts, Health Care Costs, Health Industry, Insurance, Medicare, Pharmaceuticals, Biden Administration, Cancer, Drug Costs, New York, Treating Cancer