March Medicaid Madness
The Host
Julie Rovner
KHN
Julie Rovner is chief Washington correspondent and host of KHN’s weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
With Medicare and Social Security apparently off the table for federal budget cuts, the focus has turned to Medicaid, the federal-state health program for those with low incomes. President Joe Biden has made it clear he wants to protect the program, along with the Affordable Care Act, but Republicans will likely propose cuts to both when they present a proposed budget in the next several weeks.
Meanwhile, confusion over abortion restrictions continues, particularly at the FDA. One lawsuit in Texas calls for a federal judge to temporarily halt distribution of the abortion pill mifepristone. A separate suit, though, asks a different federal judge to temporarily make the drug easier to get, by removing some of the FDA’s safety restrictions.
This week’s panelists are Julie Rovner of Kaiser Health News, Alice Miranda Ollstein of Politico, Rachel Cohrs of STAT News, and Lauren Weber of The Washington Post.
Panelists
Rachel Cohrs
Stat News
Alice Miranda Ollstein
Politico
Lauren Weber
The Washington Post
Among the takeaways from this week’s episode:
- States are working to review Medicaid eligibility for millions of people as pandemic-era coverage rules lapse at the end of March, amid fears that many Americans kicked off Medicaid who are eligible for free or near-free coverage under the ACA won’t know their options and will go uninsured.
- Biden promised this week to stop Republicans from “gutting” Medicaid and the ACA. But not all Republicans are on board with cuts to Medicaid. Between the party’s narrow majority in the House and the fact that Medicaid pays for nursing homes for many seniors, cutting the program is a politically dicey move.
- A national group that pushed the use of ivermectin to treat covid-19 is now hyping the drug as a treatment for flu and RSV — despite a lack of clinical evidence to support their claims that it is effective against any of those illnesses. Nonetheless, there is a movement of people, many of them doctors, who believe ivermectin works.
- In reproductive health news, a federal judge recently ruled that a Texas law cannot be used to prosecute groups that help women travel out of state to obtain abortions. And the abortion issue has highlighted the role of attorneys general around the country — politicizing a formerly nonpartisan state post. –And Eli Lilly announced plans to cut the price of some insulin products and cap out-of-pocket costs, though their reasons may not be completely altruistic: An expert pointed out that a change to Medicaid rebates next year means drugmakers soon will have to pay the government every time a patient fills a prescription for insulin, meaning Eli Lilly’s plan could save the company money.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: The New York Times’ “A Drug Company Exploited a Safety Requirement to Make Money,” by Rebecca Robbins.
Alice Miranda Ollstein: The New York Times’ “Alone and Exploited, Migrant Children Work Brutal Jobs Across the U.S.,” by Hannah Dreier.
Rachel Cohrs: STAT News’ “Nonprofit Hospitals Are Failing Americans. Their Boards May Be a Reason Why,” by Sanjay Kishore and Suhas Gondi.
Lauren Weber: KHN and CBS News’ “This Dental Device Was Sold to Fix Patients’ Jaws. Lawsuits Claim It Wrecked Their Teeth,” by Brett Kelman and Anna Werner.
Also mentioned in this week’s podcast:
- Politico’s “Why One State’s Plan to Unwind a Covid-Era Medicaid Rule Is Raising Red Flags,” by Megan Messerly.
- The Washington Post’s “Doctors Who Touted Ivermectin as Covid Fix Now Pushing It for Flu, RSV,” by Lauren Weber.
- NPR’s “To Safeguard Healthy Twins in Utero, She Had to ‘Escape’ Texas for Abortion Procedure,” by Selena Simmons-Duffin.
- The Daily Beast’s “Tennessee Abortion Ban a ‘Nightmare’ for Woman With Doomed Pregnancy,” by Michael Daly.
click to open the transcript
Transcript: March Medicaid Madness
KHN’s ‘What the Health?’Episode Title: Medicaid March MadnessEpisode Number: 287Published: March 2, 2023
Julie Rovner: Hello and welcome back to KHN’s “What the Health?” I’m Julie Rovner, chief Washington correspondent at Kaiser Health News. And I’m joined by some of the best and smartest health reporters in Washington. We are taping this week on Thursday, March 2, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So, here we go. We are joined today via video conference by Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Good morning.
Rovner: Rachel Cohrs of Stat News.
Rachel Cohrs: Hi, everybody.
Rovner: And we officially welcome to the podcast panel this week Lauren Weber, ex of KHN and now at The Washington Post covering a cool new beat on health and science disinformation. Lauren, welcome back to the podcast.
Lauren Weber: Thanks for having me.
Rovner: So we’re going to get right to this week’s news. We’ve talked a lot about the political fight swirling around Medicare the past couple of weeks. So this week, I want to talk more about Medicaid. Our regular listeners will know, or should know, that states are beginning to re-determine eligibility for people who got on Medicaid during the covid pandemic and were allowed to stay on until now. In fact, Arkansas is vowing to re-determine eligibility for half a million people over the next six months. Alice, the last time Arkansas tried to do something bureaucratically complicated with Medicaid, it didn’t turn out so well, did it?
Ollstein: No. It was so much of a cautionary tale that no other state until now has gone down that path, although now at least a couple are attempting to. So Arkansas was the only state to actually move forward under the Trump administration with implementing Medicaid work requirements. And we covered it at the time, and just thousands and thousands of people lost coverage who should have qualified. They were working. They just couldn’t navigate the reporting system. Part of the problem was that you had to report your working hours online and a lot of people who are poor don’t have access to the internet. And, you know, the system was buggy and clunky and it was just a huge mess. But that is not stopping the state from trying again on several fronts. One, they want to do Medicaid work requirements again. The governor, Sarah Huckabee Sanders, has said that they plan to do that and also they plan to do their redeterminations for the end of the public health emergency in half the time the federal government would like states to take to do it. The federal government has incentives for states to go slow and take a full year to make sure people know how to prove whether or not they qualify for Medicaid and to learn what other insurance coverage options might be available to them. For instance, you know, Obamacare plans that are free or almost free.
Rovner: Yeah. Presumably most of the people who are no longer eligible for Medicaid but are still low-income will be eligible for Obamacare with hefty subsidies.
Ollstein: That’s right. So the fear is that history will repeat itself. A lot of people who should be covered will be dropped from coverage and won’t even know it because the state didn’t take the time to contact people and seek them out.
Rovner: This is something that we will certainly follow as it plays out over the next year. More broadly, though, there have been whispers — well, more than whispers, whines — over the past couple of weeks that President [Joe] Biden’s challenge to Republicans not to cut Social Security and Medicare, and Republicans’ apparent acceptance of that challenge, specifically leaves out Medicaid. Now, I never thought that was true, at least for the Democrats. But earlier this week, President Biden extended his promises to Medicaid and the Affordable Care Act. How much of a threat is there really to Medicaid in the coming budget battles? Rachel, you wrote about that today.
Cohrs: There is a lot of anxiety swirling around this on the Hill. I know there’s a former Trump White House official who’s circulated some documents that are making people a little bit nervous about Republicans’ position. But it is useful to look at existing documents out there. It is not reflective necessarily of the consensus Republican position. And it’s a very diverse party right now in the House. They have an incredibly narrow majority and Kevin McCarthy is really going to have to walk a tightrope here. And I think it is important to remember that when Medicaid has come up on steep ballot initiatives in red states, so many times it has passed overwhelmingly. So I think there is an argument to be made that Medicaid enjoys more political support among the GOP voting populace than maybe it does among members of Congress. So I think I am viewing it with caution. You know, obviously, it’s something that we’re going to have to be tracking and watching as these negotiations develop. But Democrats still hold the Senate and they still hold the presidency. So Republicans have more leverage than they did last Congress, but they’re still … Democrats still have a lot of sway here.
Rovner: Although I’ll just point out, as I think I pointed out before, that in 2017, when the Republicans tried to repeal the Affordable Care Act, one of the things they discovered is that Medicaid is actually kind of popular. I think … much to their surprise, they discovered that Medicaid is also kind of popular, maybe not as much as Medicare, but more than I think they thought. So I guess the budget wars really get started next week: We get President Biden’s budget, right?
Ollstein: And House Republicans are allegedly working on something. We don’t know when it will come or how much detail it will have, but it will be some sort of counter to Biden’s budget. But, you know, the real work will come later, in hashing it out in negotiations. And, really, a small number of people will be involved in that. And so just like Rachel said, you know, you’re going to see a lot of proposals thrown out over the next several months. Not all of them should necessarily be taken seriously or taken as determinative. Just one last interesting thing: This has been a really interesting education time, both for lawmakers and the public on just who is covered under these programs. I mean, the idea is that Medicare is so untouchable, is this third rail, because it is primarily seniors, and seniors vote. And seniors are more politically important to conservatives and Republicans. But people forget a lot of seniors are also on Medicaid. They get their nursing home coverage through there. And so I’ve heard a lot of Democratic lawmakers really hammering that argument lately and saying, look, you know, the stereotype for Medicaid is that it’s just poor adults, but …
Rovner: Yeah, moms and kids. That was how it started out.
Ollstein: Exactly.
Rovner: It was poor moms and kids.
Ollstein: Exactly. But it’s a lot more than that now. And it is more politically dicey to go after it than maybe people think.
Rovner: Yeah, I think Nancy Pelosi … in 2017 when, you know, if the threat with Medicare is throwing Granny off the cliff in her wheelchair, the threat of Medicaid is throwing Granny out of her nursing home, both of which have their political perils. All right. Well, we’ll definitely see this one play out for a while. I want to move to the public health beat. Lauren, you had a really cool story on the front page of The Washington Post this week about how the promise of ivermectin to treat infectious diseases in humans. And for those who forget, ivermectin is an anti-wormer drug that I give to my horse and both of my dogs. But the idea of using it for various infectious diseases just won’t die. What is the latest ivermectin craze?
Weber: Yes, and to be clear, there is an ivermectin that is a pill that can be given to humans, which is what these folks are talking about. But there’s this group called the Front Line COVID-19 Critical Care Alliance that really pushed ivermectin in the height of covid. As we all know on this podcast, scientific study after scientific study after clinical trial has disproved that there is any efficacy for that. But this group has continued to push it. And I discovered, looking at their website back this winter, that they’re now pushing it for the flu and RSV. And as I asked the CDC [Centers for Disease Control and Prevention] and medical experts, there’s no clinical data to support pushing that for the flu or RSV. And, you know, as one scientist said to me, they had data that … had antiviral properties in a test tube. But as one scientist said to me, well, if you put Coca-Cola in a test tube, it would show it had antiviral properties as well. So there’s a lot of pushback to these folks. But, that said, they told me that they have had their protocols downloaded over a million times. You know, they’re … absolutely have some prominence and have, you know, converted a share of the American population to the belief that this is a useful medical treatment for them. And one of the doctors that has left their group over their support of ivermectin said to me, “Look, I’m not surprised that they’re continuing to push this for something else. This is what they do now. They push this for other things.” And so it’s quite interesting to see this continue to play out as we continue into covid, to see them kind of expand, as these folks said to me, into other diseases.
Rovner: I know I mean, usually when we see these kinds of things, it’s because the people who are pushing them are also selling them and making money off of them. And I know that’s the case in some of this, but a lot of these are just doctors who are writing prescriptions for ivermectin. Right? I mean, this is an actual belief that they have.
Weber: Yeah, some of them do make money off of telehealth appointments. They can charge up to a couple hundred dollars for telehealth appointments. And one of the couple of co-founders had a lucrative Substack and book deal that talks about ivermectin and do get paid by this alliance. One of them made almost a quarter of a million dollars in salary from the alliance. But yeah, I mean, the average doctor that’s prescribing ivermectin, I mean — there were over 400,000 ivermectin prescriptions in, I think, it was August of 2021. So that’s a lot of prescriptions.
Rovner: They’re not all making money off of it.
Weber: They’re not all making money. And I mean, what’s wild to me is Merck has come out and said, which, in a very rare statement for a pharmaceutical company, you know, don’t prescribe our drug for this. And when I asked them about RSV and the flu, they said, yeah, our statement would still stand on that. So it’s a movement, to some extent. And the folks I talked to about it, they really believe …
Rovner: And I will say, for a while in 2021, you couldn’t get horse wormer, which is a very nasty-tasting paste, even the horses don’t really like it. Because it was hard to get ivermectin at all. So we’ll see where this goes next. Here’s one of those “in case you missed It” stories. The Tulsa World this week has an interview with former Republican Sen. James Inhofe, who said, in his blunt Inhofe way, that he retired last year not only because he’s 88, but because he’s still suffering the effects of long covid. And he’s not the only one — quote, “five or six others have [long covid], but I’m the only one who admits it,” he told the paper, referring to other members of the Senate, presumably other Republican members of the Senate. Now, mind you, the very conservative Inhofe voted against just about every covid funding bill. And my impression from not going to the Hill regularly in 2021 and 2022 is that while covid seemed to be floating around in the air, lots of people were getting it, very few people seemed to be getting very sick. But now we’re thinking that’s not really the case, right?
Ollstein: When I saw this, I immediately went back to a story I wrote about a year ago on Tim Kaine’s long covid diagnosis and his attempts to convince his colleagues to put more research funding or treatment funding, more basic covid prevention funding … you know, fewer people will get long covid if fewer people get covid in the first place. And there was just zero appetite on the Republican side for that. And that’s why a lot of it didn’t end up passing. Inhofe was one of the Republicans I talked to, and I said, you know, do you think you should do more about long covid? What do you think about this? And this is what he told me: “I have other priorities. We’re handling all we can right now.” And then he added that long covid is not that well defined. And he argued there’s no way to determine how many people are affected. Well.
Rovner: OK.
Ollstein: So that … in “Quotes That Aged Poorly Hall of Fame.”
Rovner: You know, obviously Tim Kaine came forward and talked about it. But now I’m wondering if there are people who are slowing down or looking like they’re not well, maybe they have long covid and don’t want to say.
Ollstein: Well, I mean, something that Tim Kaine’s case shows is that there’s no one thing it can look like and somebody can look completely healthy and normal on the outside and be suffering symptoms. And Tim Kaine has also said that members of Congress have quietly disclosed to him and thanked him for speaking up, but said they weren’t willing to do it themselves. And he, Tim Kaine, told me that he felt more comfortable speaking up because the kind of symptoms he had were less stigmatized. They weren’t anything in terms of impeding his mental capacity and function. And there’s just a lot of stigma and fear of people coming forward and admitting they’re having a problem.
Rovner: I find it kind of ironic that last week we talked about how, you know, members of Congress and politicians with mental health, you know, normally stigmatizing problems are more willing to talk about it. And yet here are people with long covid not willing to talk about it. So maybe we’ll see a little bit more after this or maybe not. I want to talk a little bit about artificial intelligence and health care. I’ve been wanting to talk about this for a while, but this week seems to be everyone is talking about AI. There have been a spate of stories about how different types of artificial intelligence are aiding in medical care, but also some cautionary tales, particularly about chat engines. They get all their information from the internet, good or bad. Now, we already have robots that do intricate surgeries and lots and lots of treatment algorithms. On the other hand, the little bit of AI that I already have that’s medical-oriented, my Fitbit, that sometimes accurately tracks my exercise and sometimes doesn’t, and the chat bot from my favorite chain drugstore that honestly cannot keep my medication straight. None of that makes me terribly optimistic about launching into health AI. Is this, like most tech, going to roll out a little before it’s ready and then we’ll work the bugs out? Or maybe are we going to be a little bit more careful with some of this stuff?
Cohrs: I think we’ve already seen some examples of things rolling out before they’re exactly ready. And I just thought of my colleague Casey Ross’ reporting on Epic’s algorithm that was supposed to help …
Rovner: Epic, the electronic medical records company.
Cohrs: Yes, yes. They had this algorithm that was supposed to help doctors treat sepsis patients, and it didn’t work. The problem with using AI in health care is that there are life-and-death consequences for some of these things. If you’re misdiagnosing someone, if you’re giving them medicine they don’t need, there are, like, those big consequences. But there are also the smaller ones too. And my colleague Brittany Trang wrote about how with doctor’s notes or transcripts of conversations between a physician and a patient sometimes AI has difficulty differentiating between an “mm-hm” or an “uh-huh” and telling whether that’s a yes or a no. And so I think that there’s just all of these really fascinating issues that we’re going to have to work through. And I think there is enormous potential, certainly, and I think there’s getting more experimentation. But like you said, I think in health care it’s just a very different beast when you’re rolling things out and making sure that they work.
Weber: Yeah, I wanted to add, I mean, one of the things that I found really interesting is that doctors’ offices are using some of it to reduce some of the administrative burden. As we all know, prior authorizations suck up a lot of time for doctors’ offices. And it seems like this has actually been really helpful for them. That said, I mean, that comes with the caveat of — my colleagues and I and much reporting has shown that — sometimes these things just make up references for studies. They just make it up. That level of “Is this just a made-up study that supports what I’m saying?” I think is really jarring. This isn’t quite like using Google. It cannot be trusted to the level … and I think people do have caution with it and they will have to continue to have caution with it. But I think we’re really only at the forefront of figuring out how this all plays out.
Rovner: I was talking before we started taping about how I got a text from my favorite chain drugstore saying that I was out of refills and that they would call my doctor, which is fine. And then they said, “Text ‘Yes’ if you would like us to call” … some other doctor. I’m like, “Who the heck is this other doctor?” And then I realize he’s the doctor I saw at urgent care last September when I burned myself. I’m like, “Why on earth would you even have him in your system?” So, you know, that’s the sort of thing … it’s like, we’re going to be really helpful and do something really stupid. I worry that Congress, in trying to regulate tech, and failing so far — I mean, we’ve seen how much they do and don’t know about, you know, Facebook and Instagram and the hand-wringing over TikTok because it’s owned by the Chinese — I can’t imagine any kind of serious, thoughtful regulation on this. We’re going to have to basically rely on the medical industry to decide how to roll this out, right? Or might somebody step in?
Ollstein: I mean, there could be agency, you know, rulemaking, potentially. But, yes, it’s the classic conundrum of technology evolving way faster than government can act to regulate it. I mean, we see that on so many fronts. I mean, look how long has gone without any kind of update. And, you know, the kinds of ways health information is shared are completely different from when that law was written, so …
Rovner: Indeed.
Weber: And as Rachel said, I mean, this is life-or-death consequences in some places. So the slowness with which the government regulates things could really have a problem here, because this is not something that is just little …
Rovner: Of the things that keep me awake at night, this is one of the things that keeps me awake at night. All right. Well, one of these weeks, we will not have a ton of reproductive health news. But this week isn’t it. As of this taping, we still have not gotten a decision in that Texas case challenging the FDA approval of the abortion pill, mifepristone, back in the year 2000. But there’s plenty of other abortion news happening in the Lone Star State. First, a federal judge in Texas who was not handpicked by the anti-abortion groups ruled that Texas officials cannot enforce the state’s abortion ban against groups who help women get abortion out of state, including abortion funds that help women get the money to go out of state to get an abortion. The judge also questioned whether the state’s pre-Roe ban is even in effect or has actually been repealed, although there are overlapping bans in the state that … so that wouldn’t make abortion legal. But still, this is a win for the abortion rights side, right, Alice?
Ollstein: Yeah, I think the right knows that there are two main ways that people are still getting abortions who live in ban states. They’re traveling out of state or they are ordering pills in the mail. And so they are moving to try to cut off both of those avenues. And, you know, running into some difficulty in doing so, both in the courts and just practically in terms of enforcing. This is part of that bigger battle to try to cut off, you know, people’s remaining avenues to access the procedure.
Rovner: Well, speaking exactly of that, Texas being Texas, this week, we saw a bill introduced in the state legislature that would ban the websites that include information about how to get abortion pills and would punish internet providers that fail to block those sites. It would also overturn the court ruling we just talked about by allowing criminal prosecution of anyone who helps someone get an abortion. Even a year ago, I would have said this is an obvious legislative overreach, but this is Texas. So now maybe not so much.
Ollstein: I mean, I think lots of states are just throwing things at the wall to see what sticks and to see what gets through the courts. You had states test the waters on banning certain kinds of out-of-state travel, and that hasn’t gone anywhere yet. But even things that don’t end up passing and being implemented can have a chilling effect. You have a lot of confusion right now. You have a lot of people not sure what’s legal, what’s not. And if you create this atmosphere of fear where people might be afraid to go out of state, might be afraid to ask for funding to go out of state, afraid to Google around and see what their options are that serves the intended impacts of these proposals, in terms of preventing people from exploring their options and seeing what they can do to terminate a pregnancy.
Rovner: Yeah. Well, meanwhile, a dozen states that are not named Texas are suing the FDA, trying to get it to roll back some of the prescribing requirements around the abortion pill. The states are arguing that not only are the risk-mitigation rules unnecessary, given the proven safety of mifepristone, but that some of the certification requirements could invade the privacy of patients and prescribers and subject them to harassment or worse. They’re asking the judge to halt enforcement of the restrictions while the case is being litigated. That could run right into [U.S. District] Judge [Matthew] Kacsmaryk’s possible injunction in Texas banning mifepristone nationwide. Then what happens? If you’ve got one judge saying, “OK, you can’t sell this nationwide,” and another judge saying … “Of course you can sell it, and you can’t use these safety restrictions that the FDA has put around it.” Then the FDA has two conflicting decisions in front of it.
Weber: Yeah, and I find the battles of the AGs and the abortion wars are really fascinating because, I mean, this is a lawsuit brought by states, which is attorneys general, Democratic attorneys general. And you’re seeing that play out. I mean, you see that in Texas, too, with [Ken] Paxton. You see it in Michigan with [Dana] Nessel. I mean, I would argue one of the things that attorney generals have been the most prominent on in the last several decades of American history and have actually had immediate effects on due to the fall of Roe v. Wade. So we’ll see what happens. But it is fascinating to see in real time this proxy battle, so to speak, between the two sides play out across the states and across the country.
Rovner: No, it’s funny. State AGs did do the tobacco settlement.
Weber: Yes.
Rovner: I mean, that would not have happened. But what was interesting about that is that it was very bipartisan.
Weber: Well, they were on the same side.
Rovner: And this is not.
Weber: Yeah, I mean, yeah, they were on the same side. This is a different deal. And I think to some extent, and I did some reporting on this last year, it speaks to the politicization of that office and what that office has become and how it’s become, frankly, a huge launching pad for people’s political careers. And the rhetoric there often is really notched up to the highest levels on both sides. So, you know, as we continue to see that play out, I think a lot of these folks will end up being folks you see on the national stage for quite some time.
Ollstein: I’ve been really interested in the states where the attorney general has clashed with other parts of their own state government. And so in North Carolina, for example, right now you have the current Democratic attorney general who is planning to run for governor. And he said, I’m not going to defend our state restrictions on abortion pills in court because I agree with the people challenging them. And then you have the Republican state legislatures saying, well, if he’s not going to defend these laws, we will. So that kind of clash has happened in Kentucky and other states where the attorney general is not always on the same side with other state officials.
Rovner: If that’s not confusing enough, we have a story out of Mississippi this week, one of the few states where voters technically have the ability to put a question on the ballot, except that process has been blocked for the moment by a technicality. Now, Republican legislators are proposing to restart the ballot initiative process. They would fix the technicality, but not for abortion questions. Reading from the AP story here, quote, “If the proposed new initiative process is adopted, state legislators would be the only people in Mississippi with the power to change abortion laws.” Really? I mean, it’s hard to conceive that they could say you can have a ballot question, but not on this.
Ollstein: This is, again, part of a national trend. There are several Republican-controlled states that are moving right now to attempt to limit the ability of people to put a measure on the ballot. And this, you know, comes as a direct result of last year. Six states had abortion-related referendums on their ballot. And in all six, the pro-abortion rights side won. Each one was a little different. We don’t need to get into it, but that’s the important thing. And so people voted pretty overwhelmingly, even in really red states like Kentucky and Montana. And so other states that fear that could happen there are now moving to make that process harder in different ways. You have Mississippi trying to do, like, a carve-out where nothing on abortion can make it through. Other states are just trying to raise, like, the signature threshold or the vote threshold people need to get these passed. There are a lot of different ways they’re going about it.
Rovner: I covered the Mississippi “personhood” amendment back in 2011. It was the first statewide vote on, you know, granting personhood to fetuses. And everybody assumed it was going to win, and it didn’t, even in Mississippi. So I think there’s reason for the legislators who are trying to re-stand up this ballot initiative process to worry about what might come up and how the voters might vote on it. Well, because I continue to hear people say that women trying to have babies are not being affected by state abortion bans and restrictions, this week we have not one but two stories of pregnant women who were very much impacted by abortion bans. One from NPR is the story of a Texas woman pregnant with twins — except one twin had genetic defects not only incompatible with life, but that threatened the life of both the other twin and the pregnant woman. She not only had to leave the state for a procedure to preserve her own life and that of the surviving twin, but doctors in Texas couldn’t even tell her explicitly what was going on for fear of being brought up on charges of violating the state’s ban. I think, Alice, you were the one talking about how, you know, women are afraid to Google. Doctors are afraid to say anything.
Ollstein: Yeah, absolutely. I mean, it’s a really chilling and litigious environment right now. And I think, as more and more of these stories start to come forward, I think that is spurring the debates you’re seeing in a lot of states right now about adding or clarifying or expanding the kind of exceptions that exist on these bans. So you have very heated debates going on right now in Utah and Tennessee and in several states around, you know, should we add more exceptions because there are some Republican lawmakers who are looking at these really tragic stories that are trickling out and saying, “This isn’t what we intended when we voted for this ban. Let’s go back and revisit.” Whether exceptions even work when they are on the books is another question that we can discuss. I mean, we have seen them not be effective in other states and people not able to navigate them.
Rovner: We’ve seen a lot of these stories about women whose water broke early and at what point is it threatening her life? How close to death does she have to be before doctors can step in? I mean, we’ve seen four or five of these. It’s not like they’re one-offs. The other story this week is from the Daily Beast. It’s about a 28-year-old Tennessee woman whose fetus had anomalies with its heart, brain, and kidneys. That woman also had to leave the state at her own expense to protect her own health. Is there a point where anti-abortion forces might realize they are actually deterring women who want babies from getting pregnant for fear of complications that they won’t be able to get treated?
Ollstein: Most of the pushback I’ve seen from anti-abortion groups, they claim that the state laws are fine and that doctors are misinterpreting them. And there is a semantic tug of war going on right now where anti-abortion groups are trying to argue that intervening in a medical emergency shouldn’t even count as an abortion. Doctors argue, no, it is an abortion. It’s the same procedure medically, and thus we are afraid to do it under the current law. And the anti-abortion groups are saying, “Oh, no, you’re saying that in bad faith; that doesn’t count as an abortion. An abortion is when it’s intended to kill the fetus.” So you’re having this challenging tug of war, and it’s not really clear what states are going to do. There’s a lot of state bills on this making their way through legislatures right now.
Rovner: And doctors and patients are caught in the middle. Well, finally this week, Eli Lilly announced it would lower, in some cases dramatically, the list prices for some of its insulin products. You may remember that, last year, Democrats in Congress passed a $35-per-month cap for Medicare beneficiaries but couldn’t get those last few votes to apply the cap to the rest of the population. Lilly is getting very good press. Its stock price went up, even though it’s not really capping all the out-of-pocket costs for insulin for everybody. But I’m guessing they’re not doing this out of the goodness of their drugmaking heart, right, Rachel?
Cohrs: Probably not. Even though there’s a quote from their CEO that implied that that was the case. I think there was one drug pricing expert at West Health Policy Center, Sean Dickson, who is very sharp on these issues, knows the programs well. And he pointed out that there’s a new policy going into effect in Medicaid next year, and it’s really, really wonky and complicated. But I’ll do my best to try to explain that, generally, in the Medicare program, rebates are capped, or they have been historically, at the price of the drug. So you can’t charge a drugmaker a rebate that’s higher than the cost. But …
Rovner: That would make sense.
Cohrs: Right. But that math can get kind of wonky when there are really high drug price increases and then that math gets really messed up. But Congress, I want to say it was in 2021, tweaked this policy to discourage those big price increases. And they said, you know what? We’re going to raise the rebate cap in Medicaid, which means that, drugmakers, if you are taking really big price increases, you may have to pay us every time someone on Medicaid fills those prescriptions. And I think people thought about insulin right away as a drug that has these really high rebates already and could be a candidate disproportionately impacted by this policy. So I thought that was an interesting point that Sean made about the timing of this. That change is supposed to go into effect early next year. So this could, in theory, save Lilly a lot of money in the Medicaid program because we don’t know exactly what their net prices were before.
Rovner: But this is very convenient.
Cohrs: It’s convenient. And there’s a chance that they’re not really losing any money right now, depending on how their contracts work with insurers. So I think, yeah, there is definitely a possibility for some ulterior motives here.
Rovner: And plus, the thing that I learned this week that I hadn’t known before is that there are starting to be some generic competition. The three big insulin makers, which are Lilly, Sanofi, and Novo Nordisk, may actually not become the, almost, the only insulin maker. So it’s probably in Lilly’s interest to step forward now. And, you know, they’re reducing the prices on their most popular insulins, but not necessarily their most expensive insulin. So I think there’s still money to be made in this segment. But they sure did get, you know, I watched all the stories come across. It’s, like, it’s all, oh, look at this great thing that Lilly has done and that everything’s going to be cheap. And it’s, like, not quite. But …
Cohrs: But it is different. It’s a big step. And I think …
Rovner: It is. It is.
Cohrs: Somebody has to go first in breaking this cycle. And I think it will be interesting to see how that plays out for them and whether the other two companies do follow suit. Sen. Bernie Sanders asked them to and said, you know, why don’t you just all do the same thing and lower prices on more products? So, yeah, we’ll see how it plays out.
Weber: Day to day, I mean, that’s a huge difference for people. I mean, that is a lot of money. That is a big deal. So, I mean, you know, no matter what the motivation, at the end of the day, I think the American public will be much happier with having to pay a lot less for insulin.
Rovner: Yeah, I’m just saying that not everybody who takes insulin is going to pay a lot less for insulin.
Weber: Right. Which is very fair, very fair.
Rovner: But many more people than before, which is, I think, why it got lauded by everybody. Although I will … I wrote in my notes, please, someone mention Josh Hawley taking credit and calling for legislation. Sen. Hawley from Missouri, who voted against extending the $35 cap, as all Republicans did, to the rest of the population, put out a tweet yesterday that was, like, this is a great thing and now we should have, you know, legislation to follow up. And I’m like: OK.
Cohrs: You’ll have to check on that. I actually think Hawley may have voted for it.
Rovner: Oh, a-ha. All right.
Cohrs: There were a few Republicans.
Rovner: Thank you.
Cohrs: It’s not enough, though.
Rovner: Yeah, I remember that they couldn’t get those last few votes. Yes, I think [Sen. Joe] Manchin voted against. He was the one, the last Democrat they couldn’t get right. That’s why they ended up dropping …
Cohrs: Uh, it had to be a 60-vote threshold, so …
Rovner: Oh, that’s right.
Cohrs: Yeah.
Rovner: All right. Good. Thank you. Good point, Rachel. All right. Well, that is the news for this week. Now it is time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at khn.org and in our show notes on your phone or other mobile device. Alice, why don’t you go first this week?
Ollstein: Yeah. So I did the incredible New York Times investigation by Hannah Dreier on child labor. This is about undocumented, unaccompanied migrant children who are coming to the U.S. And the reason I’m bringing it up on our podcast is there is a health angle. So HHS [the Department of Health and Human Services], their Office of Refugee Resettlement has jurisdiction over these kids’ welfare and making sure they are safe. And that is not happening right now. The system is so overwhelmed that they have been cutting corners in how they vet the sponsors that they release the kids to. Of course, we remember that there were tons of problems with these kids being detained and kept for way too long and that being a huge threat to their physical and mental health. But this is sort of the pendulum has swung too far in the opposite direction, and they’re being released to people who in some cases straight up trafficking them and in other cases just forcing them to work and drop out of school, even if it’s not a trafficking situation. And so this reporting has already had an impact. The HHS has announced all these new initiatives to try to stop this. So we’ll see if they are effective. But really moving, incredible reporting.
Rovner: Yeah, it was an incredible story. Lauren.
Weber: I’m going to shout out my former KHN colleague Brett Kelman. I loved his piece on, I guess you can’t call it a medical device because it wasn’t approved by the FDA, which is the point of the story. But this device that was supposed to fix your jaw so you didn’t have to have expensive jaw surgery. Well, what it ended up doing is it messed up all these people’s teeth and totally destroyed their mouths and left them with a bunch more medical and dental bills. And, you know, what I find interesting about the story, what I find interesting about the trend in general is the problem is, they never applied for anything with the FDA. So people were using this device, but they didn’t check, they didn’t know. And I think that speaks to the American public’s perception that devices and medical devices and things like this are safe to use. But a lot of times the FDA regulations are outdated or are not on top of this or the agency is so understaffed and not investigating that things like this slipped through the cracks. And then you have people — and it’s 10,000 patients, I believe, that have used this tool — that did not do what it is supposed to do and, in fact, injured them along the way. And I think that the FDA piece of that is really interesting. It’s something I’ve run into before looking at air cleaners and how they fit the gaps of that. And I think it’s something we’re going to continue to see as we examine how these agencies are really stacking up to the evolution of technology today.
Rovner: Yeah, capitalism is going to push everything. Rachel.
Cohrs: So my extra credit this week is actually an opinion piece, in Stat, and the headline is “Nonprofit Hospitals Are Failing Americans. Their Boards May Be a Reason Why.” It was written by Sanjay Kishore and Suhas Gondi. I think the part that really stood out to me is they analyzed the backgrounds and makeups of hospital boards, especially nonprofit hospitals. I think they analyzed like 20 large facilities. And the statistic that really surprised me was that, I think, 44% of those board members came from the financial sector representing investment funds, real estate, and other entities. Less than 15% were health care workers, 13% were physicians, and less than 1% were nurses. And, you know, I’ve spent a lot of time and we’ve spent a lot of time thinking about just how nonprofit hospitals are operating as businesses. And I think a lot of other publications have done great work as well making that point. But I think this is just a stark statistic that shows these boards that are supposed to be holding these organizations accountable are thinking about the bottom line, because that’s what the financial services sector is all about, and that there’s so much disproportionately less clinical representation. So obviously hospitals need admin sides to run, and they are businesses, and a lot of them don’t have very large margins. But the statistics just really surprised me as to the balance there.
Rovner: Yeah, I felt like this is one, you know, we’ve all been sort of enmeshed in this, you know, what are we going to do about the nonprofit hospitals that are not actually acting as charitable institutions? But I think the boards had been something that I had not seen anybody else look at until now. So it’s a really interesting piece. All right. Well, my story this week is the other big investigation from The New York Times. It’s called “A Drug Company Exploited a Safety Requirement to Make Money,” by Rebecca Robbins. And it’s about those same risk-mitigation rules from the FDA that are at the heart of those abortion drug lawsuits we talked about a few minutes ago. Except in this case, the drug company in question, Jazz Pharmaceuticals, somehow patented its risk-mitigation strategy as the distribution center — it’s actually called the REMS [Risk Evaluation and Mitigation Strategies] — which is managed to fend off generic competition for the company’s narcolepsy drug. It had also had a response already. It has produced a bipartisan bill in the Senate to close the loophole — but [I’ll] never underestimate the creativity of drugmakers when it comes to protecting their profit. It’s quite a story. OK. That’s our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks, as always, to our ever-patient producer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth — all one word — at kff.org. Or you can tweet me. I’m @jrovner. Alice?
Ollstein: @AliceOllstein
Rovner: Rachel.
Cohrs: @rachelcohrs
Rovner: Lauren.
Weber: @LaurenWeberHP
Rovner: We will be back in your feed next week. In the meantime, be healthy.
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The Kids Are Not OK
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Julie Rovner
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Julie Rovner is chief Washington correspondent and host of KHN’s weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
Teen girls “are experiencing record high levels of violence, sadness, and suicide risk,” according to a new survey from the Centers for Disease Control and Prevention. In 2021, according to the survey, nearly 3 in 5 U.S. teen girls reported feeling “persistently sad or hopeless.”
Meanwhile, a conservative judge in Texas has delayed his ruling in a case that could ban a key drug used in medication abortion. A group of anti-abortion doctors is suing to challenge the FDA’s approval decades ago of the abortion pill mifepristone.
This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico, and Sandhya Raman of CQ Roll Call.
Panelists
Alice Miranda Ollstein
Politico
Joanne Kenen
Johns Hopkins Bloomberg School of Public Health and Politico
Sandhya Raman
CQ Roll Call
Among the takeaways from this week’s episode:
- American teenagers reported record rates of sadness in 2021, with especially high levels of depression in girls and teens identifying as LGBTQ+, according to a startling CDC report. Sexual violence, mass shootings, cyberbullying, and climate change are among the intensifying problems plaguing young people.
- New polling shows more Americans are dissatisfied with abortion policy than ever before, as a U.S. district court judge in Texas makes a last call for arguments on the fate of mifepristone. The case is undermining confidence in continued access to the drug, and many providers are discussing using only misoprostol for medication abortions. Misoprostol is used with mifepristone in the current two-drug regimen but is safe and effective, though slightly less so, when used on its own.
- There are big holes in federal health privacy protections, and some companies that provide health care, like mental health services, exploit those loopholes to sell personal, identifying information about their customers. And this week, Republican Gov. Glenn Youngkin of Virginia blocked a state law that would have banned search warrants for data collected by menstrual tracking apps.
- California plans to manufacture insulin, directly taking on high prices for the diabetes drug. While other states have expressed interest in following suit, it will likely be up to wealthy, populous California to prove the concept.
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 “Is the Deadly Fungi Pandemic in ‘The Last of Us’ Actually Possible?” by Michaeleen Doucleff
Alice Ollstein: The New York Times’ “Childbirth Is Deadlier for Black Families Even When They’re Rich, Expansive Study Finds,” by Claire Cain Miller, Sarah Kliff, and Larry Buchanan; interactive produced by Larry Buchanan and Shannon Lin
Joanne Kenen: NPR’s “In Tennessee, a Medicaid Mix-Up Could Land You on a ‘Most Wanted’ List,” by Blake Farmer
Sandhya Raman: Bloomberg Businessweek’s “Zantac’s Maker Kept Quiet About Cancer Risks for 40 Years,” by Anna Edney, Susan Berfield, and Jef Feeley
Also mentioned in this week’s podcast:
- The CDC’s “U.S. Teen Girls Experiencing Increased Sadness and Violence”
- The Fun Violence Archive’s “Mass Shootings in 2023”
- The Washington Post’s “Now for Sale: Data on Your Mental Health,” by Drew Harwell
Click to open the transcript
Transcript: The Kids Are Not OK
KHN’s ‘What the Health?’Episode Title: The Kids Are Not OKEpisode Number: 285Published: Feb. 16, 2023
Julie Rovner: Hello and welcome back to KHN’s “What the Health?” I’m Julie Rovner, chief Washington correspondent at Kaiser Health News. And I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Feb. 16, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. Today we are joined via video conference by Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Good morning.
Rovner: Sandhya Raman of CQ Roll Call.
Sandhya Raman: Good morning.
Rovner: And Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico.
Joanne Kenen: Hi, everybody.
Rovner: Later in this episode we’ll have the winner of KHN’s health policy valentines contest. I hope everyone had a pleasant Valentine’s Day with someone that you love. But first, this week’s health news. I’m calling our lede segment this week “The Kids Are Not OK,” and we’ll get to the gun violence stuff in a minute. First is news from the Centers for Disease Control and Prevention’s Youth Risk Behavior Survey. And let me just read from the press release, quote, “Nearly 3 in 5 — 57% — of U.S. teen girls felt persistently sad or hopeless in 2021, double that of boys representing a nearly 60% increase, and the highest level reported over the past decade.” According to the survey, teens who identify as LGBTQ+ have, quote, “ongoing and extreme distress. More than 1 in 5 of that group said they had attempted suicide in the year before the survey.” Now, clearly, 2021 was a bad year for most of us. The pandemic was still raging, but the political fights over things like vaccines and masking were raging, too. But these rates of mental health problems found by the biannual survey of high school students has gone up in every report since 2001. Why is this happening? What is wrong with our young people and what can we do to help?
Kenen: Well, whatever’s wrong with our young people is going to also be wrong with our old people. I mean, we create the world in which … I mean, I’m a mother and I’m an aunt and I’m an extended-family motherly person. There’s something about the world that we have created for our young people. Julie, we grew up in the Cold War. We grew up … we don’t remember the missile crisis and things like that. But we did grow up in an era of anxiety, existential threats. And yet, for our generation, it wasn’t as bad as it is for this generation. And in this generation, you look at kids who seem to be on top of the world, and they feel like the world is on top of them.
Rovner: Well, at least in my case, you couldn’t be bullied unless you were in person … which is not true anymore.
Kenen: But even 2000, 2001, it wasn’t. That’s not the only thing going on here. And it’s not only the pandemic. I mean, it’s lots of things.
Ollstein: What really jumped out to me in this data was the really high rates of rape and sexual violence. You know, the CDC has said that 1 in 5 teen girls have experienced sexual violence just in the past year, and more than 1 in 10 say they’ve been forced to have sex. This was grouped together with the mental health, depression, suicidal ideation data, indicating that these things are related. And so I think in order to pinpoint some factors, it really seems like … people don’t know how to relate to each other in a sexual way that’s healthy. I think a lot about the efforts to restrict education about sex and sexuality in schools and how that could potentially make this even worse.
Rovner: And remember, this is a survey of high school students. So these are younger young people, or at least early in their, you know, sexual awareness.
Kenen: Yeah, but there was assault and unwanted … there was ugly stuff in prior generations, tons of it. And it wasn’t … and in some ways it was more secretive and more shameful. I mean, I’m not saying it’s not a problem. It’s obviously a huge problem. Alice is right. But it’s not unique to this generation. It’s hard to measure because we weren’t looking for it. But it certainly wasn’t something that didn’t happen. But I think it was even more secretive in the past. So I agree with Alice, but I don’t think that’s all of it.
Rovner: Sandhya.
Ollstein: And you’re right that it’s hard to know for past generations.
Kenen: But they didn’t ask that question.
Ollstein: Since they’ve been asking, it’s gotten worse. They say it’s … sexual violence is up 20% since 2017. Rape is up 27% since 2019. So since they’ve been investigating this, it’s getting worse.
Raman: I would also add the cyberbullying element is a huge piece. You know, if we were looking at this maybe 20 years ago, that was not the same case. The amount of time that teens and young people spend online is much greater now, even within the data they looked at it — that cyberbullying was a lot higher for teens, for LGBTQ youth. And that has been a broad issue that, even this week in Congress, the Senate Judiciary Committee was looking at protecting kids online. And a huge element of that was cyberbullying. You heard from different parents who had lost a child due to excessive cyberbullying on a lot of these social media apps and due to suicide or other mental health issues. And I think that’s a huge piece of now versus, you know, several years ago.
Rovner: Yeah, I agree. Well, clearly, one factor in the declining mental well-being of high school students is the threat of being swept up in a mass shooting event. As if this week’s shooting at Michigan State University wasn’t awful enough, some of the students who had to shelter in place for hours in East Lansing were also survivors of the Oxford, Michigan, high school shooting in 2021. And there was even one student that we know of who was at Sandy Hook Elementary in 2012. Now, in college, there have been 71 mass shootings, defined as an incident in which four or more people are shot or killed, so far in 2023, according to the Gun Violence Archive, and it’s only the middle of February. And just in time, Gallup reports that 63% of Americans are dissatisfied with the nation’s gun laws. Up 7 percentage points from last year and the highest level in 23 years. Is there any way to get this any closer to the top of the issues for lawmakers to address? I mean, they got something tiny done last year, but it feels like the problem is just exploding.
Raman: No, I was going to say, even last year with the incremental stuff was really difficult to get across the board. And, even going back to the CDC data, there were survey results about how many kids are afraid to go to school right now. And that was one of the factors that was rising. And gun violence is obviously a factor in safety, especially for kids now. But I think on a federal level, getting something additional across the line, especially with this split Congress, is going to be really difficult. It might be more of a state-level thing. I think Michigan is already talking about doing something, but it might have to be more on that end than federal.
Ollstein: Yeah, absolutely. And not only with the divided Congress, but I think a lot of the champions of gun reform on the Republican side have since retired. I’m thinking of Sen. [Pat] Toomey, in particular. And so not only do you have a House-Senate divide, but you don’t have some of the voices on the right calling for this that you’re used to.
Rovner: Yeah, the sides seem to be retreating to the poles, as usual, and the public is not happy about it.
Kenen: Well, one last thing, Julie, really quickly. I mean, I think young people today are very aware of climate as an existential threat, which was not true of prior generations.
Rovner: Yes.
Kenen: And I think kids have this real profound fear. And I think that feeds into the anxiety part of it. At least, you know, they just …
Rovner: Yeah, I think that’s absolutely true. And that’s something that’s been ratcheting up over the past several years as we’ve seen this mental well-being …
Kenen: The pace of damage to the Earth is faster than the scientists had projected.
Rovner: All right. Well, now we’re going to turn to abortion, which is another place where the public is not happy with how it’s being regulated. Yet a different Gallup poll finds Americans more dissatisfied with U.S. abortion policy than any time in 23 years, with a record 69% of adults reporting dissatisfaction. That includes 46% who want less strict laws and only 14% who say they want more restrictions. Yet the political energy seems like it’s with the anti-abortion side, or am I misreading that?
Ollstein: I think there’s a lot of activity on both sides. I mean, Sandhya mentioned Michigan, and I think that’s a spot — along with Minnesota, where Democrats really won big in this past election and want to use their new state-level power to advance some abortion rights measures. But I think you’re seeing a lot more on the “anti-” side, and you’re seeing a lot more splits within the anti-abortion side over how to restrict abortion, how far to go, what kind of exemptions to include, if any. And so you’re seeing a lot more debate, whereas the left, who wants to protect abortion rights, seems a little bit more unified on what they want to do right now. And then, like guns, the federal level is pretty stalemate, roadblock. Nothing much is going to happen there.
Rovner: But also, I think it’s that, you know — and I’m as guilty of this as anybody — that the journalists would rather cover squabbles than people who are actually together. So maybe it’s getting a little more ink. Well, it continues to look like a single federal judge in Texas might well try to ban the abortion pill. mifepristone nationwide. Trump appointee Matthew Kaczmarek did not rule as expected last week in a case charging FDA with wrongly approving the drug 22 years ago. Rather, the judge gave the parties two more weeks to submit briefs, which seems to have prompted every party with the least bit of interest in this case to file amicus briefs. I have never seen anything like this at the federal district court level. It looks like a major Supreme Court case, but it’s not. Has anybody else seen anything like this? I mean, this case seems to be taking on as much importance as your average big Supreme Court case.
Ollstein: It very well could be a Supreme Court case in the future. And I think that’s reflected there, too. And I also want to note that part of the reason for the couple of weeks of delay the judge ordered was to allow the drugmaker to have time to submit arguments because the drugmaker, Danco [Laboratories], says that the different parties in the suit, even the FDA, aren’t really representing their interests and they want to argue for the right to market their product. So that’s pretty interesting. But then, yeah, you have the attorneys general, Democrats, and Republicans lining up on either side of the case. The Republican attorneys general saying, “We support banning this medication nationwide” and the Democratic attorneys general saying, “No, let’s trust the FDA and their scientific process to approve this drug.”
Kenen: I mean, I think there’s sort of a significance in how it’s described because you can say, well, Congress gave the FDA the power to approve drugs. But the anti-abortion movement does not call this a medication abortion. They call it chemical abortion. And therefore, they’re treating this not as a drug but as a lethal chemical. You know, whether the judge goes along with that thinking … we know he’s a strongly anti-abortion judge. There’s no question. And there’s a widespread anticipation that he is going to rule with the anti-abortion side. But we never know what a judge is going to do until a judge does it. And Alice has covered this much more closely than I have, so she’ll probably want to weigh in more. But the issue is, is he going to think that the court should overrule the FDA or is he going to think this is a, quote, “chemical,” not a, quote “medication,” and therefore that the FDA is irrelevant? And I mean, Alice, you can give a better restatement of what I just said since you’ve written about it.
Rovner: I want to respond to Alice’s earlier point about the drug company wanting to get involved, because the big question here, not to get into too much legal minutiae, is why did the people who are suing have standing to sue? They have not been injured by the ability to sell this drug for 22 years. No one’s making them buy it. Arguably, the only party that has standing is the drug company, because if it was cut off, they would lose money. They have an obvious injury here. So the legal niceties of this may not go together either. Alice, do you want to do a follow-up?
Ollstein: Yeah, I mean, to go to the standing issue, the people challenging the FDA approval here are conservative doctors who say that they’ve had to do follow-up treatment for patients who’ve taken the abortion pill and then need follow-up treatment, and that takes their time and attention away from treating other patients. I mean, doctors treating a patient, that’s kind of their job. So I think there’s definitely a question on harm and standing there. Just a couple of thoughts on the case. Abortion rights groups both say that this could be an absolute crisis, disaster across the country. But then they also point out that people will still be able to have medication abortions because the two-pill regimen that’s been used for 20 years, it can still work with just the second pill. So this case is about banning the first pill. The different providers who have spoken out say we’re preparing to just provide abortions via the second pill, if needed.
Rovner: And that second pill, misoprostol, is not going to be pulled off the market. It’s used for many, many things. It just happens it also can end a pregnancy.
Ollstein: Exactly. Way harder to ban. And that’s one thing. Medication abortions will still continue if the judge rules how people expect him to. You know, another thing with all the amicus briefs and the drug company intervening as people are bringing up, if we allow someone to come in 20 years after the fact and challenge FDA approval of something, doesn’t that open Pandora’s box to people challenging all kinds of things, I mean, vaccines and whatnot? And won’t that cause chaos and not make drug companies feel like they can trust the process and have confidence in bringing drugs to market in the U.S.? So that’s another piece of the puzzle as well.
Raman: I would add that there’s already a little bit of chaos because, you know, whatever ruling we have, likely later this month, is almost definitely going to be appealed and then probably appeals again. So it’s going … we could have a back-and-forth process where providers might go one way and then the other. And then, in the contingency stuff they’ve been doing, piggybacking on what Alice was saying, is that if they do this misoprostol regimen, it’s not as straightforward as the two-dose that you’re used to in that there are different amounts of dosage, you might have to do repeated dosages. It’s not as simple, even if that’s done in a lot of other parts of the world. And then some providers have said that they would also just switch to doing all surgical abortions. But that also is more timely. You’d have to do the whole thing in clinic rather than send someone home with the pill. And then that is going to take longer. You’re going to schedule fewer patients. There’s already that many different contingency plans that these clinics are going to have to do regardless of what we hear down the line and through the appeals process.
Rovner: We already know that clinics are backed up from women coming from other states. So patients are having to wait longer to get abortions. And, you know, as … it gets further along, you have to do different procedures that are more expensive. It’s already piling up in different places. Well, speaking of some other different places, we’re seeing a lot of national pro- and anti-abortion groups getting involved in a Wisconsin Supreme Court election, of all things. What is up with that?
Ollstein: Well, that could decide the fate of abortion access in that state. You know, you have the split of a Democratic governor and a Republican legislature. So things really could come down. You know, the state had a pre-Roe ban that went into effect. So things are expected to come down to the makeup of the Supreme Court. And so you’re having just tons of outside money being poured into this race for that reason and really putting a spotlight on how much power are these state supreme courts have. And it’s true in other states as well. And there are many cases pending in different states. You know, I’ve been following the Kentucky one, in particular, but there are a bunch of different cases pending before a state supreme court that could really re-legalize or maintain the ban on abortion.
Kenen: There are also election issues and, on abortion, in the state of Wisconsin, election rules, election certification issues that it’s one of the three or four states where that’s really a hot potato. And that’s another reason this race is getting so much attention. I mean, it’s the state Supreme Court race that’s getting a huge amount of national attention and national money. So there are several issues I would agree with Alice on. The No. 1 is probably abortion. But it’s not only abortion.
Raman: And it’s interesting because this is the first time that EMILY’s List has endorsed ever a state Supreme Court race. And I think another thing to consider is that, you know, this is still considered a nonpartisan race since it’s a court seat. I mean …
Rovner: In theory.
Raman: In theory, yes. Even though all of these groups are looking at the histories of how people have ruled in the past. But I think that’s another thing that makes it a little bit more interesting given it’s not strictly a Democrat or Republican endorsement, like a lot of the other things that we’ve been following.
Rovner: Yes. And I saw on the other side the Susan B Anthony List, the anti-abortion group, said … put out a press release this week saying they’re going to have six-figure spending in Wisconsin on this race. So …
Kenen: It’ll be very good for the Wisconsin economy.
Rovner: It will be very good for the Wisconsin economy. Well, anti-abortion lawmakers are busy in a bunch of states pursuing another new trend, giving tax breaks to so-called crisis pregnancy centers that, at least when abortion was legal, lured pregnant women in by pretending to be an abortion clinic and then trying to convince them not to terminate their pregnancies. Missouri has already allowed donors to these crisis pregnancy centers to write off contributions on their state taxes. Now, Kansas, Arkansas, and Oklahoma are considering similar programs, but Kansas is the only one of those states where abortion is still legal. What are CPCs going to do now that they can’t pose as abortion facilities?
Raman: I think there’s still a lot of confusion for folks. I mean, given how a lot of these laws have been changing back and forth. I mean, even as folks that follow this very closely, there’s so many different things where someone … I think we’ve looked at polling before where people don’t always know: Is abortion illegal or not legal in our state? Or at what point? It’s difficult to keep track of, with so many changes going back and forth. So I think that there could feasibly still be people who might be looking for an abortion that don’t understand or — we’ve seen that a lot of these clinics have also bought a lot of ads so that you might be searching for an abortion and you get redirected to one of these clinics. So I think there’s still overlap in folks that might be searching for one and end up at another.
Kenen: I don’t know how much online presence they have, because that could be across state lines. You know, if someone’s on or near a border, there’s all sorts of … people might think that surgical abortions are legal, but medication is not, or that they can or someone could help them order pills. You can never underestimate how confused Americans are about any number of things. So … but they also might …
Rovner: This is confusing, to be fair.
Kenen: Yes. But they also might concentrate their efforts less on the no-abortion states and move more to the abortion states. Or they may advertise in ways that captures or attempts to capture people who are looking to go out of state or to get a cross-state-line prescription, whatever. They can promote themselves in different ways. Or they may also just decide to not do as much in Texas and do a lot more in upstate New York. I mean, I don’t know how they’re going to totally respond to the legal landscape either.
Ollstein: Yeah. And they’ve also become sort of a legal force of their own. I know they’re involved in challenging some of California’s pro-abortion rights policies. The CDC is specifically. So they also have … are trying to play a role on that front, in addition to direct patients’ interface or however we want to phrase it.
Rovner: All right. Well, while we’re talking about patients’ privacy, I want to talk about data. First, a kind of terrifying story from The Washington Post this week details how data brokers have been selling the names and addresses of people with depression, anxiety, and other mental health disorders so they can be advertised to. A lot of this has come from people using mental health apps or websites that are not covered by the HIPAA privacy rules because they are not technically covered health entities. A separate story this week notes how Virginia Gov. Glenn Youngkin helped defeat a bill in the Virginia legislature to provide legal protections to women’s menstrual data contained in period tracking apps. A Virginia official who was opposing the bill said it would put limits on search warrants, which could lead to other problems down the road. One researcher described the privacy practices of the vast majority of mental health apps as, quote, “exceptionally creepy.” How concerned should we be about all of this?
Kenen: I found that really horrifying. And a family friend who had been looking for a therapist and I said, well, maybe — and they were having trouble finding somebody in network and it’s very expensive — and I said, “Well, maybe you should look into some of the online ones that do take insurance.” And after reading that, I told that person, “I’m not so sure that it’s a good idea.” And we do have a shortage of mental health providers in this country. We have an even greater shortage of mental health providers that take insurance. There’s been a lot of talk about how telemedicine for mental health is at least part of the answer. But this should really raise … because they’re not just selling de-identified data. Some of them in that article were selling people’s names, address, diagnosis, and medical history. If it was truly, truly, truly de-identified, it’s different then. And that can be used for research. But a lot of what’s so-called de-identified isn’t de-identified. And this doesn’t even pretend to be. This is, like, search, and you can find out who the person is, an awful lot of intimate detail about their lives. So unless there’s some real safeguards, would you want any of your medical data with your name on it being sold? No. It is. It is being. But …
Rovner: When the HIPAA rules first went into effect, which was around the year 2000, actually it took a few years — researchers came to Capitol Hill screaming because they were afraid they weren’t going to be able to get any of this de-identified data and they weren’t going to be able to continue to do research. Now, we seem to have gone far in the other direction. And I know that there are efforts on Capitol Hill to do things to update the women’s reproductive information, keeping that private. Anybody think that they might get into an expansion of HIPAA? I mean, that’s really all it would take would be to create more covered entities.
Raman: Yeah, it isn’t as much about the expansion of HIPAA, but there have definitely been pretty concerted efforts to get … the U.S. doesn’t have a comprehensive data privacy law. You know, in contrast to, like, the EU or something. And that has been a big effort for the lawmakers that are focused on tech policy for a while. Even the hearing earlier this week with Senate Judiciary, they brought up several bills. And the issue has been that all of these issues are bipartisan, folks are on board. It’s just not enough people are on board, and little things that have been getting in the way there. And so that has been an issue. And I think even during that hearing, we had one researcher bring up different sites — like NEDA, which is mentioned in some of these lawsuits by some of the hospitals — have been collecting all of this data. But then they, as researchers, are not able to get access to that data, and that would be extremely beneficial for them to be able to say this is what the impact of some of these things are on kids. So it’s a Catch-22 where it’s, like, OK a) we’re not having the research be able to get the data, b) we’re having it sold in a malicious way and c) we haven’t been able to find a solution to mitigate all of this.
Kenen: Yeah, I don’t know about the prospects for a gigantic tech bill because it has many components and they’re controversial and hard to get 60 votes for. But I think there’s a difference between selling stuff about who bought shoes versus someone who is on an anti-psychotic or an antidepressant or whatever, or getting marital counseling, whatever. I mean, these are not the same issue as the whole constellation of tech issues. I can see this being something bipartisan. HIPAA has been updated a little bit, but the fundamental HIPAA law dates back to what, ’96, Julie? … I think that’s when it was.
Rovner: Yeah, although …
Kenen: It has been updated, but it hasn’t been overhauled to really fit the cyber universe we live in.
Rovner: But also Congress never really did HIPAA. People don’t remember this: The 1996 law basically had a provision that said Congress needs to fundamentally address privacy if we’re going to move more towards digital health records, which at the time was starting to happen. And if they don’t, then the secretary of Health and Human Services is authorized to put out regs. And guess what? Congress didn’t do it. So the HIPAA regs that we have now were put out at the end of the Clinton administration. Congress was never able to come together on this. So now things have obviously gotten worse.
Kenen: Yes. And since the Supreme Court now doesn’t like agencies regulating that, that seems to create an entire new existential question. But do I think that medical privacy is something that you could find some kind of bipartisan lanes on? I don’t think a lot of bipartisan things are going to happen in the next two years. This does seem to be one of the few areas that is not a red-blue ideological issue. And I can see Republicans and Democrats being horrified by some of this and maybe not totally sealing it up, but putting … better guardrails on what can be brokered.
Raman: One of the issues has been, I think even in the past, was that California is the one state that has implemented a few layers of very intense data privacy laws. And so, you know, when you have people in leadership that are in from California and it’s hard to get some of those compromises across when it might be more watered down than something California has and take precedent being federal. So it’s one of the many layers of why it’s been difficult over the past year to get any of this stuff done.
Rovner: Well, we should note that the Biden administration is actually working on some enforcement. Earlier this month, the Federal Trade Commission fined the prescription drug discounter GoodRx $1.5 million for illegally sharing customer’s personal health information. It was the very first enforcement action under a 2009 law that applies to health record vendors and others not covered by HIPAA. So at least there’s one avenue where this could be pursued. I imagine we’ll be seeing more of that if not, you know, whether or not they can reach all of these things seems unlikely.
Kenen: Yeah, doing it piecemeal does not seem to be the approach, and I’m not even sure how much $1.5 million is for GoodRx. I don’t think that’s a lot of money for any major pharmaceutical entity.
Rovner: No. And there are a lot of people who use it. All right. Well, finally this week, while we’re talking about drugs, I’ve been trying to get to this for a while. California has — speaking of California, things that other states haven’t done — California has decided to try to limit the cost of insulin for people with diabetes by manufacturing it itself. Could this set a precedent to really disrupt the insulin market, or is California just so big and wealthy that it’s basically the only state that could do something like this — or only state they would do something like this?
Ollstein: So I will note that Gov. [Gretchen] Whitmer in Michigan has also proposed state manufacturing of insulin. So California might not be the only one. I think the idea is that insulin is pretty cheap to manufacture. It’s become the poster child for out-of-control drug prices for that reason — the disparity between what it costs for patients and what it costs to make is so vast. And so I think you are likely to have a few states. But I think it will take a state doing it successfully to get a significant number of others to follow.
Rovner: I think there might be a thought that because California is so big, it could disrupt the market elsewhere — I mean, in the country. That strikes me as a reach. But it’s, you know, Congress, again — talking about things that Congress can’t do — they managed to limit insulin prices for people on Medicare, but not even for everybody else.
Kenen: There was also a good piece in The Atlantic, maybe two or three months ago, that some of these new diabetic drugs, which are injectables and very expensive, mean you don’t need insulin. So … but by addressing making insulin really cheap, which is a good … I mean so people who are on insulin and need insulin … but there are some people who actually could take one of these other drugs and then they wouldn’t be able to afford these other drugs, which might be better for them. And then they’ll end up on cheap insulin. So it’s always more complicated than it sounds. And I also think there’s different kinds of insulin. Someone else on the panel might, you know, that I’m not sure that …
Rovner: There are lots of different formulations.
Kenen: There are two major kinds of diabetes, obviously, Type 1 and Type 2. And then there’s different patients with different degrees of … you know, how far their other health conditions is advanced, etc., etc. So cheap insulin is not even a solution for diabetes. It’s one part of a solution for one of many chronic diseases in America.
Rovner: Well, we will never not have enough things to talk about. That is the news for this week. Now it is time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at khn.org and in our show notes on your phone or other mobile device. Joanne, why don’t you kick us off this week?
Kenen: Yes. This was a collaboration between NPR, Nashville Public Radio, and Kaiser Health News, aired on NPR by Blake Farmer. “In Tennessee, a Medicaid Mix-Up Could Land You on a ‘Most Wanted’ List.” And basically, Tennessee is cracking down on Medicaid fraud. Most Medicaid fraud is actually from doctors and other health care providers — there have been a bunch of home health scandals and so forth. The amount of fraud and the amount of money involved in patient fraud is small, and yet they’re spending a huge amount of money to try to capture a small amount of fraud. And there are huge mistakes. Like the person in this article was just … she was entitled to Medicaid. She did nothing wrong. But they publicly … like, they don’t even wait for you to be convicted. They’re publishing … they’re making public the charge. This woman turned out to be … it had to do with an old address on … an expired driver’s license that got the system confused. She was doing nothing wrong, and yet she was completely blacklisted, employment and everything else because she was accused of being a felon in publicly available databases. So, a) are they looking in the right place for fraud? And b) are they protecting people’s rights? Clearly the latter they are not because they were publishing … people were accused but not convicted, and then they weren’t removing it in a timely, effective way. So this woman is, like, unemployable. She can’t rent an apartment, and she did nothing wrong. So there’s a whole series of abuses in this story. Not that Medicaid fraud is a good thing. Medicaid fraud is a bad thing, but this is not the way to go after it.
Rovner: This was one in a series of horrifying stories this week. Alice, you have another horrifying story.
Ollstein: Yes. Although this is under the banner of more evidence to bolster the upsetting things that we sort of already knew. This is a really good piece from The New York Times, laying out a lot of data to show that there is these differences in maternal mortality between Black and white women that can’t be attributed to income, showing that even wealthier Black women still face much worse outcomes. And so they say, you know, even when you account for income, even when you account for education and a lot of other factors, there are still these impacts of structural racism in the health system that continue to put Black mothers more in danger. And so this is coming at a time when there’s a lot of focus on this. But there has been sort of a lot of focus on the income, socioeconomic side and people recommending that states expand postpartum coverage of Medicaid. And that certainly is recommended, and experts think that would help. But this shows that it won’t completely solve the problem and there are other factors to address.
Kenen: And it’s not just in maternal mortality. I mean, the racial disparities in health care are not just income-related.
Rovner: And finally, Sandhya, you have a story from one of our fellow podcast panelists.
Raman: Yeah, the story I picked is “Zantac’s Maker Kept Quiet About Cancer Risks for 40 Years,” and that’s at Bloomberg News from Anna Edney, Susan Berfield, and Jef Feeley. And this was a really great story about Zantac, the heartburn and reflux drug that was once one of the world’s best-selling prescription medications. And then in 2020, it was pulled off the U.S. market over cancer risks. And the article goes through how since its beginnings, Glaxo’s own scientists, the drugmaker, had warned that it could be dangerous, but proving some of this has been a little difficult. … But the story goes through some of the documents that show that Glaxo chose not to look into this, even though the leading health agencies — EPA, FDA, WHO — all say NDMA is a carcinogen.
Rovner: Yeah, it’s quite the investigation. Well worth reading. Well, my story is a little less horrifying than everybody else’s. It’s from my former NPR Science Desk colleague Michaeleen Doucleff and it’s called “Is the Deadly Fungi Pandemic in ‘The Last of Us’ Actually Possible?” And I will cut to the chase. The answer is most almost certainly no. But that’s not to say we shouldn’t be worried about fungi and fungal diseases, particularly as the Earth continues to warm, which is what touches off the pandemic in the video game/HBO miniseries that’s airing now. There are new fungal diseases that can be pretty nasty, too, but zombies, almost certainly not. Well, maybe, certainly not. Anyway, listen to or read Michaeleen’s story. Before we go, this week was Valentine’s Day and, as promised, we have the winner of KHN’s best health policy valentine, as chosen by our editors and social media staff. This year’s winner is Jennifer Goldberg, and it goes as follows: “Roses are red, candy is sweet. Adding #Dental to #Medicare makes it more complete!” Congrats to Jennifer and thanks everyone for your creative health policy valentines.
OK, that’s our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review — that helps other people find us, too. Special thanks, as always, to our ever-patient producer, Francis Ying. As always, you can email us your comments or questions. We’re at whatthehealth — all one word — @kff.org. Or you can tweet me. I’m @jrovner. Joanne?
Kenen: @JoanneKenen
Rovner: Sandhya?
Raman: @SandhyaWrites
Rovner: Alice.
Ollstein: @AliceOllstein
Rovner: We will be back in your feed next week. Until then, be healthy.
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A Health-Heavy State of the Union
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Julie Rovner is chief Washington correspondent and host of KHN’s weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
Health care was a recurring theme throughout President Joe Biden’s 2023 State of the Union address on Capitol Hill this week. He took a victory lap on recent accomplishments like capping prescription drug costs for seniors on Medicare. He urged Congress to do more, including making permanent the boosted insurance premium subsidies added to the Affordable Care Act during the pandemic. And he sparred with Republicans in the audience — who jeered and called him a liar — over GOP proposals that would cut Medicare and Social Security.
Meanwhile, abortion rights advocates and opponents are anxiously awaiting a federal court decision out of Texas that could result in a nationwide ban on mifepristone, one of two drugs used in medication abortion.
This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Rachel Cohrs of Stat, and Sarah Karlin-Smith of the Pink Sheet.
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Among the takeaways from this week’s episode:
- President Joe Biden’s State of the Union address emphasized recent victories against high health care costs, like Medicare coverage caps on insulin and out-of-pocket caps on prescription drug spending. Biden’s lively, informal exchange with lawmakers over potential cuts to Medicare and Social Security seemed to steal the show, though the political fight over cutting costs in those entitlement programs is rooted in a key question: What constitutes a “cut”?
- Biden’s calls for bipartisanship to extend health programs like pandemic-era subsidies for Affordable Care Act health plans are expected to clash with conservative demands to slash federal government spending. And last year’s Senate fights demonstrate that sometimes the opposition comes from within the Democratic Party.
- While some abortion advocates praised Biden for vowing to veto a federal abortion ban, others felt he did not talk enough about the looming challenges to abortion access in the courts. A decision is expected soon in a Texas court case challenging the future use of mifepristone. The Trump-appointed judge’s decision could ban the drug nationwide, meaning it would be barred even in states where abortion continues to be legal.
- The FDA is at the center of the abortion pill case, which challenges its approval of the drug decades ago and could set a precedent for legal challenges to the approval of other drugs. In other FDA news, the agency recently changed policy to allow gay men to donate blood; announced new food safety leadership in response to the baby formula crisis; and kicked back to Congress a question of how to regulate CBD, or cannabidiol, products.
- In drug pricing, the top-selling pharmaceutical, Humira, will soon reach the end of its patent, which will offer a telling look at how competition influences the price of biosimilars — and the problems that remain for lawmakers to resolve.
Also this week, Rovner interviews Kate Baicker of the University of Chicago about a new paper providing a possible middle ground in the effort to establish universal health insurance coverage in the U.S.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week they think you should read, too:
Julie Rovner: The New York Times’ “Don’t Let Republican ‘Judge Shoppers’ Thwart the Will of Voters,” by Stephen I. Vladeck
Alice Miranda Ollstein: Politico’s “Mpox Is Simmering South of the Border, Threatening a Resurgence,” by Carmen Paun
Sarah Karlin-Smith: KHN’s “Decisions by CVS and Optum Panicked Thousands of Their Sickest Patients,” by Arthur Allen
Rachel Cohrs: ProPublica’s “UnitedHealthcare Tried to Deny Coverage to a Chronically Ill Patient. He Fought Back, Exposing the Insurer’s Inner Workings,” by David Armstrong, Patrick Rucker, and Maya Miller
Also mentioned in this week’s podcast:
- The Associated Press’ “20 Attorneys General Warn Walgreens, CVS Over Abortion Pills,” by Jim Salter
- NPR’s “A Trump-Appointed Texas Judge Could Force a Major Abortion Pill off the Market,” by Sarah McCammon
- Politico’s “Federal Judge Says Constitutional Right to Abortion May Still Exist, Despite Dobbs,” by Kyle Cheney and Josh Gerstein
- The Becker Friedman Institute’s “Achieving Universal Health Insurance Coverage in the United States: Addressing Market Failures or Providing a Social Floor?” by Katherine Baicker, Amitabh Chandra, and Mark Shepard
click to open the transcript
Transcript: A Health-Heavy State of the Union
KHN’s ‘What the Health?’Episode Title: A Health-Heavy State of the UnionEpisode Number: 284Published: Feb. 9, 2023
Julie Rovner: Hello and welcome back to KHN’s “What the Health?” I’m Julie Rovner, chief Washington correspondent at Kaiser Health News. And I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Feb. 9, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. We are joined today via video conference by Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Good morning.
Rovner: Rachel Cohrs of Stat News.
Rachel Cohrs: Hi, everybody.
Rovner: And Sarah Karlin-Smith of the Pink Sheet.
Sarah Karlin-Smith: Hi, Julie.
Rovner: Later in this episode, we’ll play my interview with Kate Baicker of the University of Chicago. She’s one of the authors of a new paper outlining a new proposal for the U.S. to achieve universal health insurance coverage, something every other developing nation already has, but we have not yet been able to achieve. But first, this week’s health news. We’re going to start, of course, with the State of the Union, which was livelier than usual, with way more back and forth than I’ve ever seen at one of these, and also more health-heavy than usual. I’m going to start with entitlements, notably the president threatening Republican proposals to hold the debt ceiling hostage for cuts in Social Security and Medicare. I’m still trying to decide whether this was intended or not, but Biden nevertheless ended up getting Republicans to vow not to demand cuts in Social Security and Medicare in exchange for raising the debt ceiling later this year. Here is the tape.
President Joe Biden: So, folks, as we all apparently agree, Social Security and Medicare is off the books now, right? And they’re not going to strike … [prolonged applause] All right. We got unanimity!
Rovner: So was this very clever or very lucky or both?
Ollstein: Well, it’s a little not quite what it seems. Republicans have been swearing up and down more recently that they never intended to cut Medicare and Social Security. But when they say “We want to reform it, we want to shore it up,” they’re talking about things that could limit benefits for beneficiaries. So it’s a semantics game, in part. I also want to point out that neither Republicans nor Biden have yet said that they consider Medicaid in that same untouchable category. So that really jumped out at me in the speech as well.
Rovner: Yeah, I mean, if you don’t touch Social Security or Medicare — and the Republicans are trying to say that because this has been used as a weapon for so many years — then basically that leaves Medicaid. And as we discovered in 2017, when they were trying to repeal the Affordable Care Act, Medicaid is actually pretty popular, too, because it takes care of a lot of people’s grandparents in nursing homes. I’m wondering when somebody is going to bring that up. Obviously, over the years, many, quote-unquote, “cuts” have been made to both Social Security and Medicare, mainly to slow the growth of the programs so that we can continue to afford them. Many more, quote-unquote, “cuts” will have to be made going forward. Every time you reduce payment to a drugmaker or a hospital or any other health care provider, that’s a cut, but it helps beneficiaries. So, you know, you say “cuts,” [and] beneficiaries say “they’re going to cut our benefits.” Not necessarily. They may just be making the program more affordable, including for the beneficiaries. I mean, this is just the continuous back and forth of each side, weaponizing Medicare in particular, right?
Ollstein: Well, and until we see actual proposals on paper, like you’re indicating, it is a semantics game — what some people consider a cut might not be what other people consider a cut. And there’s going to be all sorts of rhetorical games over the next several months along these lines. So, I’m waiting till we see an actual black-and-white proposal that we can all pick at and analyze together.
Rovner: Well, as we have seen, there’s danger in putting things on paper, as Rick Scott discovered this week. For those who don’t remember, it was his rather infamous proposal — was it last summer, I think? It was before the election — suggesting that all federal programs be sunsetted every five years and then have to be reauthorized, which would include Social Security and Medicare and Medicaid. And that’s not playing well at this point, as I think was predicted at the time, including by us. So moving on, I was also impressed at how the speechwriters managed to combine the, quote, “victory lap” stuff, record Affordable Care [Act] enrollment, Medicare drug price changes, limits on insulin, and surprise bills with the agenda ahead: expanding insulin price caps to the non-Medicare population, Medicaid expansion in the states that haven’t done it, making the Affordable Care Act subsidies expansions permanent. But none of these things — popular, though they may be — are likely to happen in this Congress, are they? … These are the things that fell out of the bill that passed last year.
Cohrs: Right. A lot of those cost money, which is going to cause even more problems this Congress than it did in the last one. And I thought it was pretty informative that the chair of the Energy and Commerce Committee in the House threw cold water on the insulin price-cap idea because it did gain some Republican support in the Senate when it came up for a vote. That was complicated. We won’t go into it. But yeah, it wasn’t a straight up-and-down vote on that policy, really. So I think there was some hope that maybe Republicans could get on board with it. But I think, because it applies to private market insurers, [it was called] a socialist policy, like, they just don’t want government in private plans, even though it’s a wildly popular policy. So, yeah, I think that doesn’t seem like a good signal for that policy in particular and for Medicaid expansion and a lot of these things. Democrats couldn’t even do it when they all agreed or had power in both the House and the Senate. So it’s definitely not a good indication for a lot of these things.
Ollstein: Let’s not forget that [Sen. Joe] Manchin [D-W.Va.] was the one who put the kibosh on the federal Medicaid expansion. He thought it wasn’t fair to states like his that expanded a long time ago and have been paying in a little bit. He thought it wasn’t right that states that were holdouts get a free ride. And the other Democrats argued back that it’s not fair for the residents in those states to be left out in the cold uninsured either. So this will continue. But like Rachel said, not going anywhere soon.
Rovner: So the things that in theory could happen, and these didn’t mostly come up in the speech or didn’t come up very much. But earlier in the day, Biden officials were floating a quote-unquote, “unity agenda” that included a long list of potentially bipartisan health issues, starting with the “cancer moonshot,” mental health and opioid treatment, strengthening the mental health parity rules. Some of these things actually could happen, right?
Cohrs: Yeah, I think especially on the mental health package, I think there was some unfinished business from last Congress, from the Senate Finance Committee. I think that all of these are issues that have been talked about this Congress already. And the leaders have signaled that they might be interested in. But I think there is some daylight here, and we’re still in very much the agenda-setting, throwing ideas out there that are a very vague part of this Congress. And I think actually getting things down on paper and going through hearings and that kind of thing will signal which areas there might actually be some agreement on. But again, spending is going to be a big challenge and there’s just not going to be time to get to everything.
Rovner: I think one of my frustrations is that normally the State of the Union comes right before the president’s budget comes out, usually within a week or two. And this year, the president’s budget isn’t coming out until March 9. So we have this, you know, talk about agenda-setting. We’re going to have a lot of time for people to just yap at each other without any specifics. But speaking of things that didn’t and aren’t likely to happen, the president didn’t talk very much about abortion. And what he did say — like threatening to veto any abortion ban Congress might pass, which won’t happen either with Democrats in charge of the Senate — that disappointed abortion rights supporters. They’re not happy, right, Alice?
Ollstein: Some were not. To be fair, some praised the speech, praised the president for saying the word “abortion.” This was a big thing over much of his career, including the beginning of his presidency. He would talk around it and not actually say the word “abortion,” which the groups felt contributed to stigma around it. And so the big mainstream groups, Planned Parenthood, NARAL, put out statements praising the speech, praising him for saying he would veto a ban, although, again, like you said, that’s a hypothetical. It’s not going to happen. But some other groups were critical that, one, he didn’t talk about some of the very looming direct threats to abortion access in the courts that we’re probably going to get to later.
Rovner: In a minute.
Ollstein: Just in a minute! But they were frustrated that he didn’t lay out more specifics that his administration will actually do to respond to the current loss of access in a lot of the country. They felt that we’re in a crisis moment and he spent less of the speech on abortion than he did on resort fees. That was a sore point for some advocates who I talked to.
Rovner: There was a lot of emphasis on junk fees. And I get why: These are the things that drive people crazy, and, particularly, in times of high inflation. But yes, abortion came very late in the speech — almost after a lot of people had tuned out and stopped paying attention, which I think also made some people unhappy. Well, speaking of abortion, here we are waiting for another make-or-break court decision out of Texas. Alice, this time it’s the future of the “abortion pill,” not just in Texas, but around the nation that’s at stake. How did we get here? And could we really see the abortion pill banned nationwide?
Ollstein: We really could. People have really been sleeping on this case, including some elected officials who were slow to realize the impact it could have. And mainly what people don’t understand is a bunch of states already ban all methods of abortion, including the pill, and then some additional states besides that have restrictions just on the pill. So this will mainly hit blue states and states where abortion access still exists. And so it could really have a huge impact because those states are now serving more than just their own populations. And in a lot of places, losing access to medication abortion means losing access to all abortion because there aren’t clinical services available. And so my colleague and I did some reporting on how the Biden administration is preparing or not for this ruling. They rebuffed calls from activists to declare a public health emergency for abortion. They said they don’t think that would help. While they do plan to appeal the ruling should the FDA lose, the upheaval that could happen in the meantime can’t really be overstated. And not to mention that an appeal would go to the 5th Circuit, which is very conservative, and then to the Supreme Court, which just overturned Roe v. Wade. And so while most experts we’ve talked to don’t think the legal arguments are that sound, you just can’t really …
Rovner: And remind us, this is the lawsuit that’s challenging the 22-year-old approval of the drug in the first place.
Ollstein: Exactly. And so health care legal experts also say that besides the absolute upheaval in the abortion space that this could cause, this would just completely destroy any certainty around drug approvals for the FDA. If anybody could come back decades later and challenge the approval of a drug, how can drugmakers feel comfortable developing and submitting things for approval and making their plans around that? It’s very chaotic.
Rovner: Sarah, is the FDA worried about this case? Has it not been on their radar either?
Karlin-Smith: I mean, they’re involved in the defense.
Rovner: They’re being sued.
Karlin-Smith: Right. I think it is a concern if this is used, right? If the folks who want this drug pulled would win, does it become precedent-setting in a way that you can get other products pulled? Perhaps. Again, the sentiments would not be there for a lot of other products in the way to use it. But it is a bit concerning when you think about judges having this power to overrule the scientific decisions we’ve left to civil servants, not politicians or judges, because they have expertise in science and medicine and clinical trial design and all these things we just would not expect judges to be able to rule on.
Rovner: Well, speaking of more politics, this week — actually, last week — a group of 20 state attorneys general from states with abortion restrictions wrote to CVS and Walgreens, which had already announced that they would apply to become providers of the abortion pill, warning them not to rely on the Justice Department’s interpretation of a 19th-century law that banned the use of the U.S. mail to send abortifacients. The letter doesn’t outright threaten the companies. It merely says that, quote, “We offer you these thoughts on the current legal landscape.” Has anybody sued over this yet? And what do we expect to happen here? I mean, are CVS and Walgreens going to back off their plans to become providers?
Ollstein: Well, the anti-abortion elected officials and advocacy groups are hoping that’s the case. But I think this could play out in so many ways. I mean, one, we have this national ruling that could come down, but we also have a few state rulings that could flip things the other way and force states that have put restrictions on the abortion pill to lift those restrictions and allow it. So now we have cases pending in North Carolina and West Virginia. One of them is by the manufacturer of the abortion pill, saying that states don’t have the right to put the FDA’s hat on their own heads and make those decisions. And the other is by an abortion provider, a doctor who says that these state restrictions hurt her ability to practice and hurt her patients. And so it’s just wild that we can swing anywhere from a national ban to forcing states with bans to lift those bans. I mean, it’s just all up in the air right now. I wanted to quickly point out two other things. A lot of activist groups say they are not counting on the Biden administration to adequately respond to this crisis. And so they’re doing a couple things. One, they’re encouraging people to do something known as “advance provision,” which is order abortion pills before they’re pregnant, before you need them, and just have them on hand just in case. And so they’re advising people do that in advance of the ruling. Interestingly, the FDA does not support that practice, but activist groups are encouraging it anyways. And then the other thing is the abortion pill regimen is actually two pills. And the big FDA lawsuit only goes after the first one. And so people are saying, you know, you can terminate a pregnancy just by taking a few of the second pill, even though that has a higher rate of not working and needing a follow-up procedure. And so …
Rovner: Although it’s still like, 95%, right?
Ollstein: It’s still very effective, but not quite as effective as using the two pills together.
Rovner: And I think it used to be when people would go to Mexico, that’s what they would get. They would get misoprostol, not mifepristone, which is what we think of as “the abortion pill” — and also methotrexate, which we talked about in the context of people with diseases for which methotrexate is indicated not being able to get it because it can cause abortions. But that’s another option there, right? And … it would be hard for FDA to pull those drugs because those drugs do have a lot of uses for other diseases.
Karlin-Smith: Or FDA could, I guess, be forced to take off the formal indication for use for abortion, but the drug would be out there and then could be subject to off-label prescribing, which then could potentially, I guess, impact insurance coverage if you’re using it for abortion. Pivot to if you had to go back to this one-drug regimen while, yes, it would still exist and be possible, I think a lot of providers are worried about the added burden that would create on folks that help people obtain abortion. And this system is just not set up to have enough workers to deal with that more complicated regimen. And it seems like it could end up leading to more need for surgical abortions, depending on how well it works and so forth. So I think logistically it creates a lot more challenges.
Rovner: Yeah, it’s a mess. Well, meanwhile, last issue here, we have a curious story out of a lawsuit in federal district court here in Washington, D.C., in which a judge proffered the notion that while the Supreme Court may have found no right to abortion in the 14th Amendment, that doesn’t mean there isn’t a federal right under the 13th Amendment. That’s the one barring slavery, specifically the restriction on the pregnant person’s personal liberty. As the judge correctly pointed out, the majority in last year’s Dobbs [v. Jackson Women’s Health Organization] ruling may well believe there’s no right to abortion anywhere in the Constitution. But that’s not the question that they litigated. Is this potentially an avenue that abortion rights advocates are going to explore?
Ollstein: I am not hearing a lot of hope being placed on this. If it goes anywhere, it would go back to the same Supreme Court that just ruled last year. And so abortion rights advocates are not optimistic about this strategy, but I think it’s a good indication of really both sides right now just trying to get as creative as possible and explore every legal avenue in the U.S. Constitution, in state constitutions, things where it never says the word abortion, but you could interpret it a certain way. I think that’s what we’re seeing right now. And so it’s really interesting to see where it goes.
Rovner: We are literally at the point where everybody is throwing whatever they can against the wall and seeing what sticks. All right. Well, let us turn to the federal research establishment. Late last month, a panel of advisers recommended a set of policies to strengthen oversight of so-called gain-of-function research that could inadvertently cause new pandemics. This was also one of the subjects of the first House hearing that called leading federal public health officials up on the carpet. What do we learn from the hearing? And has the federal government actually been funding gain-of-function research, or do we even know for sure?
Cohrs: So there has been a moratorium on this sort of research. And the interim director of the NIH [National Institutes of Health] quibbled over the term “gain-of-function research.” And he said we’re talking about a very select part of all of the research that could technically fall under that umbrella term. But he did say that there is a moratorium on funding that right now; there’s not current funding because they are reviewing their practices. And an advisory board did pass proposals and he laid out the process forward for that. So once those are finalized, he’ll write a memo to [Department of Health and Human Services] HHS Secretary Xavier Becerra, then it will get to the White House. So there is this bureaucratic progression that these new guidelines are going to go under, and it’s been pretty transparent and public so far. But we’ll see how things ultimately turn out. But I think they are very sensitive to this politically and they are trying to create guidelines that offer some lessons learned from some of the criticism they’ve gotten recently.
Rovner: And I think, I mean, this has become one of the major lines of argument about Republicans trying to figure out where covid came from. Perhaps it came from U.S.-funded gain-of-function research in China, which we don’t know, I don’t think. But there’s been a lot of “Yes, you did”-“No, you didn’t” going on. I mean, Sarah, does this go back to the, you know, politicians playing scientists?
Karlin-Smith: A little bit. And I think at the hearing, a lot of the Republicans who are pressuring NIH in particular on this are not super interested in listening to the subtleties and nuance of the argument. They just really want to make the point and bring up in people’s minds the possibility of, you know, covid being a lab leak, which I think … which hasn’t 100% been ruled out, but it’s kind of on the 98%, probably 99% ruled out by a lot of scientists. And so it was very hard for NIH and those lawmakers to have a reasonable discussion about the nuances and where this research might possibly benefit us in future pandemic prep. What type of precautions do need to be put in place? And I think NIH was trying to strive to communicate that actually a lot of what was recommended in this oversight report is things they’ve been working on and have put in place. But the hearing was designed by Republicans more to land those political punches and sound bites and not really delve into “Are there policy improvements that could be made here?”
Rovner: Well, speaking of civil servants trying to do their science policy jobs, the FDA’s been busy the last couple of weeks, including lifting a ban on men who have sex with other men donating blood. That’s a ban that’s been in effect in one way or another since the 1980s, when AIDS was first discovered. And in the wake of baby formula shortages, there’s now going to be a new deputy commissioner for food. And finally, the agency is asking Congress for new authority to regulate CBD [cannabidiol] products, particularly as more states legalize marijuana in all forms for recreational use. Sarah, this is an awful lot of stuff at once. Big policy changes where they try to hide some of them, or did they just all show up at once because that’s when they got finished?
Karlin-Smith: The food changes were sort of driven by events not quite within their control, and the blood policy, the CBD stuff were things in the works for some number of years now. So FDA is busy, and these are different divisions operating under it. I think the CBD stuff is drawing a lot of frustration because FDA had been working on considering how to regulate this aspect of hemp for a while now. And instead of coming up with a policy and taking action, they’ve rewound the circle; we’re back to square one and putting it on Congress’ issues. So that’s like one area where there’s a lot of frustration versus, I think, people are generally happier that the blood donation process was finally gone through and changed.
Rovner: Yes, the wheels of the federal regulatory process move slowly, as we know. All right. Finally this week, drug prices. Humira — which is a biological that treats rheumatoid arthritis and many other serious ailments, and for which you have undoubtedly seen TV commercials if you have ever turned on your television, because it’s the top-selling pharmaceutical in the world — is reaching the end of its patent life. That will soon provide the first real test of where the Affordable Care Act’s pathway to allow biosimilar competitors — effectively biologics version of generic drugs — whether that will actually bring down prices. Because there’s a chance here that there’s going to be a bunch of competitors to Humira and the price isn’t going to come down, right?
Karlin-Smith: Yeah, I mean, that’s a major concern for a number of reasons that get us back to the broader U.S. drug pricing debate and — including the role of pharmacy benefit managers in figuring out how people get coverage of their drugs. So Humira is one of the first biologics to lose patent protection, where patients actually fill the prescriptions themselves and give themselves the medicine, which is a very different payment system than if you’re getting a biologic medicine at a doctor’s office or a hospital. And so the way that most of the insurers are covering the drug for this year, they’re actually going to charge patients the same out-of-pocket cost in most instances, as if you’ve got the brand drug or the biosimilar. And because, unlike traditional generic medicines, a lot of these, at least initially, they’re not what is called auto-substitutable. So if your doctor writes you Humira, the pharmacist doesn’t automatically give you that generic. So you’d actually have to request a new prescription from your doctor, and they’d have to write it. And if you’re not going to pay less, why are you motivated to do that?
Rovner: When you’re not even positive how much whether the drug works the same way, whether the biosimilar works the same way.
Karlin-Smith: Right. And they think people are a little bit more hesitant. They don’t understand how biosimilars work compared to generic drugs, where it took — again, when the generic drug industry first started, it took people a while to get comfortable. So there are those issues. So, basically, what has happened is AbbVie has given insurance plans and payers’ discounts on their brand drug to keep it in a good place on their formularies. So there will be savings to the broader health system, for sure. The problem is if that doesn’t get passed on to the patients, and AbbVie can continue their market monopoly, my worry is, down the line, what happens to this biosimilar industry overall? Humira is not the only top-selling, big-selling biologic medicine where we want to bring down the cost. So if these biosimilar competitors don’t eventually gain market share and make money off of doing this, why are they going to go back and develop a biosimilar and try and lower the cost of the next big drug? And that’s what people are watching. I think there’s cautious optimism that, as more biosimilars for Humira launch, there will be some pressure for insurance companies to cut deals and lower prices and not just rely on making money off high rebates. But we don’t really know how it’s going to play out. And AbbVie was pretty creative over the years. In some ways that helped patients and others questionable — how much of … like, you know, there’s high concentration of the drug, low concentration. There is citrate-free, non-citrate-free. And that means that not all the competitors are going to be exactly the same in a way that creates as much competition as it seems at first. So yeah, it’s going to be messy.
Rovner: This is the famous evergreening that we saw with drugs. I mean, where they would change something small and get a whole new patent life.
Karlin-Smith: Right. So usually with generic research, you need three direct competitors to help bring the price down a lot. But in the case of Humira, while there’s going to be, probably at least six competitors this summer, maybe more, they’re not all direct competitors for the same version of Humira. So it sort of bifurcates the space a bit more and makes it harder to, you know, figure out the economics of all of that.
Rovner: Well, if you thought that drug pricing was confusing, now we’re adding a whole new level to it. So, I’m sure we will be talking about this more as we go forward. OK. That’s the news for this week. Now, we will play my interview with Kate Baicker of the University of Chicago. Then we will come back and do our extra credits.
I am excited to welcome to the podcast Katherine Baicker, currently the dean of the University of Chicago Harris School of Public Policy and soon to be provost of the university. Congratulations.
Katherine Baicker: Thank you so much.
Rovner: So, Kate is a health economist who is well known to health policy students for a lot of things, but most notably as the co-lead author of the Oregon Medicaid health experiment, which was able to follow a randomized population of people who got Medicaid coverage and a population that didn’t to help determine the actual impact of having Medicaid health insurance. Today, she’s here as lead author of a paper with a new way to possibly provide health coverage to all Americans. Kate, thank you so much for joining us.
Baicker: It’s a pleasure.
Rovner: So your new paper is called “Achieving Universal Health Insurance Coverage in the United States: Addressing Market Failures or Providing a Social Safety Net.” And in that single sentence, you’ve pretty much summed up the entire health insurance debate for, like, the last half-century. For those who don’t know, why is it that the U.S. doesn’t have universal insurance when literally all of our economic competitors do?
Baicker: Well, like so many things about our health care system, it goes back to the history of how it evolved, as well as some things that are different about the U.S. from other countries. If you look at how big the U.S. is geographically, how diverse our country is, how heterogeneous the health needs are. A lot of the solutions you see in other countries might not work so well in the U.S.
Rovner: So … and we’ve basically just not ever gotten over the hump here.
Baicker: Well, I also think we haven’t been asking the right questions necessarily. There is a real debate about whether health care is a “right” or not. And, of course, your listeners can’t see my “air quotes,” but I put that in air quotes because I think that’s the wrong question. Health care is not just one thing. Health care is a continuum of things. And if we just boil it down to should people have access to care or not, that doesn’t let us engage with the hard question of how much care we want to provide to everyone and how we’re going to pay for it.
Rovner: So I know a lot of people assume that the Affordable Care Act would — I’ll use my air quotes — “fix” the U.S. health insurance problem. And it has gone a long way to cover a lot of previously uninsured people. But who are the rest of the uninsured and why don’t they have coverage? It’s not necessarily who you think, right?
Baicker: That’s right. And, you know, the ACA, or Obamacare, actually made a lot of headway in covering big swaths of the uninsured population. There was a lot of discussion about health insurance exchanges, but actually more people were covered by Medicaid expansions than by health insurance exchanges. But both of those, as well as letting young people up to age 26 get on their parents’ policies. All of this chipped away at the ranks of the uninsured, but it left, for example, undocumented immigrants uninsured and also the vast majority of the uninsured people in the U.S. are already eligible for either a public program or heavily subsidized private insurance. And we have a problem of takeup and availability, not just affordability.
Rovner: So let’s get to your proposal. It’s not really that different from things that either we’ve tried in some parts of our health insurance ecosystem or what other countries do. What would it actually look like if we were to do it?
Baicker: Well, if you go back to what I think is the right question of how much health care do we want to make sure that everyone has access to and how are we going to get them enrolled in those programs? I think one key feature is having that coverage be as low-hassle as possible, automatic if possible, because we know that nonfinancial barriers to insurance are responsible for a lot of the uninsured population we still see today.
Rovner: We’ve seen that with pension plans, right? That automatically enrolling people get more people to actually put money away?
Baicker: That’s right. That’s one of the takeaways from behavioral economics is that defaults matter. Meaning what the baseline is and letting you opt in and out makes a big difference because people tend to stick with where they are. There’s a lot of inertia in saving for retirement, in enrolling in health insurance, in lots of different things. And being sophisticated in how we design the mechanics of those programs is important, as well as making sure that they’re financially affordable to people. So one step is making sure that whatever is available to people is as easy as possible for them to take advantage of. But the other is having a much harder discussion about what we want that basic package to be. And when you say “I want everybody to have all of the care that might possibly be available, no matter what price and no matter how much it impacts their health,” that’s more than 100% of GDP. We just can’t do that and still have any money for anything like food and housing and education and roads and all of the things that we also care about. So if we had that tough discussion as a nation, as a body politic, to say, here is the care that we think is really high-value that we think is a right for everyone and that we want to make sure is available to everyone, then people could be automatically enrolled in that default package and have the option to get more care that is more expensive and maybe a little less effective, but still worth it to them that they purchase on their own. And that opens up a whole host of other questions and ethical dilemmas that I’m sure you’re going to want to ask about.
Rovner: But it also — as a lot of people are concerned, that something like “Medicare for All” would eliminate the incentive to innovate new kinds of care. I mean, obviously, there’s this race to figure out, you know, a drug to treat Alzheimer’s and that if the federal government were to basically set prices for everything, that there would be no more innovation incentive. You actually address that here, right?
Baicker: Yes. And I’m so glad you raised that concern, because there are many challenges to having a monolithic one-size-fits-all Medicare for All type plan. One of them is, you know, affordability for the system and accessibility. But another is the dulled incentive for innovation and the dulled drive towards having new medicines and new treatments available. Medicare is very slow to innovate. It took 40-plus years for Medicare to include prescription drugs at all. And that was because when Medicare was formed in the Sixties, prescription medicine wasn’t a very important part of health care. It wasn’t a very expensive part of health care, there just weren’t that many drugs to treat people. Well, now those medicines are crucial to health and well-being. And Medicare finally added a prescription drug benefit in 2005. But that was a long lag, and that’s just one example. So I think having some fundamental access to care that we know is of high value for everyone could be coupled with having the option to purchase more generous insurance that covers more things. And that private insurance layered on top would really provide the financial incentives for continued innovation. It acknowledges the reality that in a world of scarce resources, higher-income people are going to have more health care than lower-income people. And that is an ugly reality and one that we ought to grapple with ethically, and as a matter of public policy priorities. I would argue we’re already rationing care. It is not possible for public programs to pay for all care for all people, no matter what the price, no matter what the health benefit, and being intentional about defining what it is we’re going to cover with public dollars and then letting people buy more care with private dollars is a way perhaps to make a financially sustainable system that also promotes innovation.
Rovner: And this isn’t really new. I mean, lots of other countries do this. I was in Switzerland a decade ago, and I remember that they … their extra-benefit package includes things like single rooms in hospitals and homeopathic medicine and things that I’m not sure we would end up putting into our top-up plans, but it’s something that’s important to them.
Baicker: Yes. And when people point to our European counterparts and say, look, they all have single-payer. In fact, a lot of them have a hybrid system like the one that we’re describing. And it’s important to differentiate: We’re talking about a basic plan that’s available for everyone. That doesn’t mean that it only covers cheap things. It should only cover high-value things. But some cheap things are incredibly ineffective and low-value, and some expensive things are really important for health and very high-value. So it’s about the value of the dollar spent in terms of producing health, not whether it’s expensive or cheap. And so when you think about having a top-up plan, it shouldn’t be about billing cost sharing that, you know, lower-income people are exposed to in the basic plan. It should be about adding services that are of less health importance but still valuable to the people purchasing them.
Rovner: Obviously, the biggest issue here is going to be who’s going to make that determination? I’m old enough to remember fights over the ACA, death panels, and the independent Medicare advisory board that never happened. In fact, there were a lot of these, you know, we’re going to appoint experts. And it never happened because none of the experts ever wanted to be on these panels. How do you overcome that hurdle of actually grappling with the decision of what should be covered?
Baicker: Yes, the devil is always in the details for these things, and you put your finger on a really important one where we haven’t provided a robust answer, and our analysis is meant to highlight the importance of making these hard decisions and the value of this framework. But we don’t have a magic bullet for this. I would argue that having Congress make this decision every year is a recipe for lobbying and decision-making that doesn’t actually line up with value. There’s an opportunity perhaps to have a panel of experts who, as you note, is just a hop, skip and a jump from being called a “death panel.” But I think we can rely on some clinical guidelines as guardrails on this. And we do have some examples of experimentation in this direction in the U.S. In fact, more than experimentation — if you look at Medicare Advantage, this used to be a small part of the Medicare program. These are private plans for Medicare beneficiaries that are now, I think, pretty soon going to be the majority of plans that people have. And it’s a mechanism for people to choose among plans that have some things that have to be covered, but can then add additional benefits for enrollees, and it can be a little more tailored to what people value in their plans. So I don’t think that’s the answer either. But it’s a proof of concept that we can do something like this in the U.S.
Rovner: So in some ways this would bridge the gap between Republican marketplace ideas and Democratic Medicare for All ideas. But it feels like, since the fight over the Affordable Care Act, Republicans have moved more to the right on health care and Democrats have moved more to the left on health care. You are no stranger to partisan politics nor the ways of Washington, D.C. How could everybody be brought back to what I daresay looks like a political compromise?
Baicker: Well, I’m an economist, as you noted, and that’s notoriously bad at understanding actual human beings. I don’t have any idea for the path forward through the political thicket that we’re in. In some ways, it is a little disheartening to see how difficult it is to do some basic commonsense things. In any complicated system like the U.S. health care system, there are always small technical fixes that need to be made that are just commonsense, that ought not to be political. And it’s hard to do those.
Rovner: We’re lacking in common sense right now in Washington.
Baicker: Yeah. So I can’t say that I’m hugely optimistic about a big change happening right away. On the other hand, I think covid really highlighted to people across the political spectrum how important it is to have continuity of coverage, how disparate our current system is in terms of access to care, how problematic it is to have your main avenue of health insurance be through your employer when a pandemic is coupled with a recession. So I think the challenges and the vast inequities of our health care system were laid bare during covid. So it is perhaps salient enough that people might be willing to consider alternative structures. But I can’t say I’m holding my breath.
Rovner: Well, Kate Baicker, thank you very much for, if anything, a great thought experiment. It’s really wonderful to look your way through … it’s like, oh, we could get there, maybe in another half a century.
Baicker: I hope sooner than that.
Rovner: I do, too. Thank you so much.
Baicker: My pleasure.
Rovner: OK, we’re back. And it’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it; we will post the links on the podcast page at khn.org and in our show notes on your phone or other mobile device. Rachel, why don’t you go first this week?
Cohrs: My extra credit is headlined “UnitedHealthcare Tried to Deny Coverage to a Chronically Ill Patient. He Fought Back, Exposing the Insurer’s Inner Workings,” in ProPublica by David Armstrong, Patrick Rucker, and Maya Miller. And I thought this story was just such a good illustration of the jargon that we use in D.C., of, like, utilization management and prior authorization. And sometimes these terms just feel so impersonal. But I feel like this story did such a good job walking through one patient’s struggle to find something that worked and then just the arbitrary choices that insurers were making, looking at their bottom line to try to prevent him from getting a very expensive treatment that actually did increase his quality of life significantly. So I would definitely recommend, as we’re thinking about insurers’ role in this whole health care cost debate as well.
Rovner: Yeah, it does bring home how the patient is always in the middle of this. Alice.
Ollstein: I chose a piece by my colleague Carmen Paun called “Mpox Is Simmering South of the Border, Threatening a Resurgence,” and it’s about how the U.S. was extremely successful in vaccinating high-risk people against mpox, which for folks who still remember the artist formerly known as monkeypox, the name was changed to reduce stigma and be more accurate. The U.S. vaccination campaign and messaging campaign to the most high-risk populations was really successful and did the trick. But as we learned from covid and every other infectious disease, if you don’t take care of other parts of the world, it could eventually come back. We’re not an island, and even islands aren’t safe. But, you know, this is about a bunch of countries, including Mexico, that really have made no mass vaccination effort at all. You know, some civil society groups are trying on their own, but they just don’t have official government backing. And that’s really dangerous. And it meant that cases are surging in parts of Latin America and parts of Africa. And as we saw from covid, that leads to the development of new variants and things traveling back to the U.S. and other places around the world. So, certainly, something to pay attention to.
Rovner: Public health is important. World public health is important. Sarah.
Karlin-Smith: I looked at a piece called “Decisions by CVS and Optum Panicked Thousands of Their Sickest Patients,” by Arthur Allen for Kaiser Health News. It’s a deep dive into CVS and Optum moving out of, to some degree, business places where they provide home infusion services of perinatal nutrition to people that essentially cannot eat or drink in most cases. And they basically decided that it’s not a great business opportunity for them in many cases. But these are people that really depend on these services to live and survive, and they’re very complex medicines and essential nutrition to get and deliver. And at the same time, I think what really fascinated me about this story is it talks about this dynamic of while companies are getting out of the space where you’re providing this service to people that need these IV treatments to survive and live, there also has been development of these medical spas, as they’re called, where people that actually do not need IV hydration or IV nutrition are essentially being given it for nonmedical purposes. And there’s a lot of money being made there. And it just shows you how some of the profit incentives in our system don’t necessarily align with treating the people that actually need the health care first.
Rovner: Yeah, it’s like the people with diabetes not being able to get their drugs because people in Hollywood want to lose 10 pounds fast. But this obviously is, you know, another life-or-death issue. Well, I chose an op-ed this week in The New York Times by the University of Texas law professor Steven I. Vladeck called “Don’t Let Republican ‘Judge Shoppers’ Thwart the Will of Voters.” And it answered a lot of questions for me. First, how is it that so many suits end up in front of the same judges who the plaintiffs know are likely to rule in their favor, and all in Texas? So it turns out that Texas has distributed its federal judges in a way that in nine districts there is only one judge. And in 10 more, there are only two judges. Obviously, there’s no random draw in those districts where there’s only one judge. That’s what you’re going to get. So we keep seeing some of the same Texas judges, first Judge Reed O’Connor in Fort Worth, and now Matthew Kacsmaryk, a former advocate for a conservative think tank and the only federal judge in Amarillo. Judge O’Connor had the big ACA case, now has a big preventive care case. Judge Kacsmaryk has the abortion pill case that we’ve been talking about. It’s a really interesting piece about how that could really twist justice. But it also includes several ways to fix it. We’ll have to see if any of them actually get taken up.
OK. That is our show for this week. As always, if you enjoyed the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review — that helps other people find us, too. Special thanks, as always, to our ever-patient producer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth — all one word — @kff.org. Or you can tweet me as long as Twitter is still up. I’m @jrovner. Alice?
Ollstein: @AliceOllstein
Rovner: Rachel
Cohrs: @rachelcohrs
Rovner: Sarah.
Karlin-Smith: @SarahKarlin
Rovner: We will be back in your feed next week. Until then, be healthy.
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