Me formé como médica y he hecho esta misma pregunta a los pacientes miles de veces, así que pienso mucho en cómo cuantificar la suma de caderas doloridas, muslos punzantes y el dolor adormecedor cerca de mi omóplato izquierdo. Hago una pausa y luego, generalmente de manera arbitraria, elijo un número. “¿Tres o cuatro?”, aventuro, sabiendo que la respuesta real es larga, complicada e imposible de medir de esta manera unidimensional.

El dolor es algo escurridizo. A veces es ardiente, a veces perforante, a veces oprime profundo en los músculos. El mío puede depender de mi estado de ánimo o de cuánto le preste atención, y puede “desaparecer” casi por completo si estoy concentrada en una película o tarea.

El dolor también puede ser lo suficientemente incapacitante como para cancelar vacaciones, o tan abrumador que vuelve a las personas adictas a los opioides. Incluso el dolor de 10+ puede ser soportable cuando se tolera por una buena razón, como dar a luz.

Pero, ¿cuál es el propósito de los dolores que tengo ahora, efectos persistentes de una lesión en la cabeza?

El concepto de reducir estos matices del dolor a un solo número data de la década de 1970. Pero hoy en día la escala del cero a 10 parece vetusta debido a lo que se llamó una “revolución del dolor” en los años 90, cuando la nueva forma de abordar el dolor —principalmente con opioides— se presentó como un progreso.

Los médicos de hoy tienen una comprensión más completa del tratamiento del dolor, así como de las terribles consecuencias de recetar opioides con liviandad. Lo que están aprendiendo ahora es cómo medir mejor el dolor y tratar sus muchas formas.

Hace unos 30 años, los médicos que defendían el uso de opioides dieron nueva vida a lo que había sido hasta el momento una especialidad marginal: la gestión del dolor. Comenzaron a promover la idea de que el dolor debería medirse en cada cita como un “quinto signo vital”. La Sociedad Americana del Dolor llegó a registrar la frase. Pero a diferencia de los otros signos vitales —presión arterial, temperatura, frecuencia cardíaca y frecuencia respiratoria— el dolor no tenía una escala objetiva.

¿Cómo medir lo inmensurable?

La sociedad alentó a los médicos y enfermeras a usar el sistema de calificación de cero a 10. Alrededor de esa época, la Administración de Drogas y Alimentos (FDA) aprobó OxyContin, un analgésico opioide de liberación lenta fabricado por Purdue Pharma.

El propio fabricante de medicamentos instó a los médicos a registrar y tratar el dolor de manera rutinaria, y promovió agresivamente los opioides como una solución obvia. Para ser justos, en una época en la que el dolor a menudo se ignoraba o se trataba de manera insuficiente, el sistema de calificación de cero a 10 podría considerarse un avance.

Las bombas de morfina no estaban disponibles para aquellos pacientes con cáncer que vi en los años 80, incluso aquellos con un dolor agonizante por cáncer en los huesos; los médicos consideraban el dolor como una parte inevitable de la enfermedad. En la sala de emergencias donde trabajé a principios de los 90, recetar incluso unas pocas píldoras de opioides era un inconveniente: requería pedirle a la enfermera jefe que desbloqueara un recetario especial y hacer una copia para la agencia estatal que rastreaba los patrones de prescripción.

Los reguladores (con razón) se preocupaban de que repartir narcóticos llevara a la adicción. Como resultado, algunos pacientes necesitados de alivio probablemente se quedaron sin él.

Después que los médicos del dolor y los fabricantes de opioides hicieran campaña para un uso más amplio de estas drogas — alegando que las formas más nuevas no eran adictivas, o mucho menos que las formulaciones anteriores — recetar los medicamentos se volvió mucho más fácil y se promovieron para todo tipo de dolor, ya sea una artritis de rodilla o problemas de espalda.

Como joven médica que se unía a la “revolución del dolor”, probablemente les pregunté a los pacientes miles de veces que calificaran su dolor en una escala de cero a 10 y escribí muchas recetas cada semana para medicamentos para el dolor, ya que monitorear “el quinto signo vital” se volvió rápidamente rutinario en el sistema médico.

Con el tiempo, la medición del dolor de cero a 10 se convirtió en caja necesaria para llenar en los registros médicos electrónicos. La Commission on the Accreditation of Healthcare Organizations hizo que evaluar el dolor regularmente fuera un requisito previo para que los centros médicos recibieran dólares federales de atención médica.

Los grupos médicos agregaron el tratamiento del dolor a su lista de derechos de los pacientes, y la satisfacción con el tratamiento del dolor se convirtió en un componente de las encuestas de pacientes posteriores a la cita médica. (Una mala calificación podría significar un menor reembolso por parte de algunos aseguradoras).

Pero este enfoque para la gestión del dolor tenía claros inconvenientes. Estudios revelaban que medir el dolor de los pacientes no resultaba en un mejor control del dolor. Los médicos mostraban poco interés en, o no sabían cómo responder a la respuesta registrada. Y que los pacientes estuvieran satisfechos con discutir su dolor con el médico no significaba necesariamente que recibieran un tratamiento adecuado.

Al mismo tiempo, los medicamentos estaban alimentando la creciente epidemia de opioides. La investigación mostró que se estimaba que entre el 3% y el 19% de las personas que recibían una receta de medicamentos para el dolor desarrollaban una adicción.

Sin embargo, los médicos que querían tratar el dolor tenían pocas otras opciones. “Teníamos un buen sentido de que estos medicamentos no eran la única forma de manejar el dolor”, me dijo Linda Porter, directora de la Oficina de Políticas y Planificación del Dolor de los Institutos Nacionales de Salud. “Pero no teníamos una buena comprensión de la complejidad o las alternativas”.

El entusiasmo por los narcóticos dejó muchas variedades de dolor sin explorar y sin tratar durante años.

Solo en 2018, un año en que casi 50,000 estadounidenses murieron por una sobredosis, el Congreso comenzó a financiar un programa —la Red de Investigación Clínica de la Fase Temprana del Dolor, o EPPIC-Net— diseñado para explorar tipos de dolor y encontrar mejores soluciones. La red conecta especialistas en 12 centros clínicos académicos especializados y está destinada a iniciar nuevas investigaciones en este campo y encontrar soluciones a medida para diferentes tipos de dolor.

Una escala de cero a 10 puede tener sentido en ciertas situaciones, como cuando una enfermera la usa para ajustar la dosis de medicación para un paciente hospitalizado después de una cirugía o un accidente. Y los investigadores y especialistas en dolor han intentado crear mejores herramientas de calificación — docenas, de hecho, ninguna de las cuales fue adecuada para capturar la complejidad del dolor, concluyó un panel de expertos europeos.

Por ejemplo, la Administración de Salud de Veteranos creó una que tenía preguntas adicionales e indicaciones visuales: una calificación de 5 se correlacionaba con un ceño fruncido y un nivel de dolor que “interrumpe algunas actividades”. La encuesta tardaba mucho más y producía resultados que no eran mejores que el sistema de cero a 10.

Para la década de 2010, muchas organizaciones médicas, incluida la Asociación Médica Estadounidense y la Academia Estadounidense de Médicos de Familia, estaban rechazando no solo la escala de cero a 10, sino toda la noción de que un paciente podía informar su dolor de manera numérica y significativa.

En los años en que los opioides habían dominado los remedios para el dolor, algunos medicamentos — como la gabapentina y la pregabalina para la neuropatía, y los parches y cremas de lidocaína para los dolores musculoesqueléticos — estaban disponibles.

“Había una creciente conciencia de la increíble complejidad del dolor, y de que tendrías que encontrar los medicamentos adecuados para los pacientes adecuados”, me dijo Rebecca Hommer, directora interina de EPPIC-Net.

Los investigadores ahora están buscando biomarcadores asociados con diferentes tipos de dolor para que los estudios de medicamentos puedan usar medidas más objetivas para evaluar sus efectos. Una mejor comprensión de las vías neurales y los neurotransmisores que crean diferentes tipos de dolor también podría ayudar a los investigadores a diseñar medicamentos para interrumpirlos y domesticarlos.

Es poco probable que cualquier tratamiento que surja de esta investigación sea un éxito de taquilla como los opioides; por diseño, serán útiles para menos personas. Eso también los hace prospectos menos atractivos para las compañías farmacéuticas.

Así que EPPIC-Net está ayudando a pequeños laboratorios, académicos e incluso a médicos individuales a diseñar y realizar ensayos en etapa temprana para probar la seguridad y eficacia de moléculas prometedoras para aliviar el dolor.

Esa información se entregará a las farmacéuticas para ensayos en etapa tardía, todo con el objetivo de obtener nuevos medicamentos aprobados por la FDA más rápidamente. Los primeros ensayos de EPPIC-Net están comenzando. Encontrar mejores tratamientos no será una tarea fácil, porque el sistema nervioso es un universo en gran parte inexplorado de moléculas, células y conexiones eléctricas.

El Premio Nobel de Fisiología o Medicina 2021 fue para los científicos que descubrieron los mecanismos que nos permiten sentir las sensaciones más básicas: el frío y el calor. En comparación, el dolor es una hidra, un monstruo de muchas cabezas. Un simple número puede parecer definitivo. Pero no ayuda a nadie a que el dolor desaparezca.

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

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

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

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

Panelists

Margot Sanger-Katz
The New York Times

@sangerkatz

Read Margot's stories.

Sandhya Raman
CQ Roll Call

@SandhyaWrites

Read Sandhya's stories.

Among the takeaways from this week’s episode:

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

click to open the transcript

Transcript: Live From Aspen: Health and the 2024 Elections

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

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

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

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

Sanger-Katz: Hey, everybody.

Rovner: And Sandhya Raman of CQ Roll Call.

Raman: Good evening everyone.

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

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

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

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

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

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

Rovner: They’ve been ducking this issue.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: But it’s like 20%, isn’t it?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Sanger-Katz: Maybe last time.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: Nine-hundred …

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Sanger-Katz: Yes.

Rovner: More questions.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Raman: Yep.

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

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

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

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

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

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

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

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

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

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

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

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

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Es el último capítulo de una larga saga que involucra a Magellan Diagnostics, con sede en Massachusetts, que pagará $42 millones en multas, según el Departamento de Justicia (DOJ).

Aunque muchos de los dispositivos propensos a fallas se utilizaron desde 2013 hasta 2017, algunos fueron retirados del mercado recién en 2021. El DOJ dijo que este mal funcionamiento produjo resultados inexactos para “potencialmente decenas de miles” de niños y otros pacientes.

Los médicos no consideran seguro ningún nivel de plomo en sangre, especialmente en niños.

Varias ciudades de Estados Unidos, incluyendo Washington, DC, y Flint, en Michigan, han luchado con una contaminación generalizada de plomo en sus suministros de agua en las últimas dos décadas, lo que hace que las pruebas precisas sean críticas para la salud pública.

Es posible que se hayan utilizado kits defectuosos de Magellan para analizar la exposición al plomo en niños hasta principios de la década de 2020, basándose en el retiro del mercado en 2021.

Esto es lo que los padres deben saber.

¿Cuáles pruebas eran defectuosas?

Los resultados inexactos provinieron de tres dispositivos de Magellan: LeadCare Ultra, LeadCare II y LeadCare Plus. Uno de ellos, el LeadCare II, utiliza principalmente muestras de punción en el dedo y representó más de la mitad de todas las pruebas de plomo en sangre realizadas en el país desde 2013 hasta 2017, según el DOJ.

A menudo se usaba en consultorios médicos para verificar los niveles de plomo en los niños.

Los otros dos también podían usarse extrayendo sangre de una vena y pueden haber sido más comunes en laboratorios que en consultorios médicos. La empresa “se enteró por primera vez de que un mal funcionamiento en su dispositivo LeadCare Ultra podría causar resultados inexactos de pruebas de plomo, específicamente, resultados de pruebas de plomo que eran falsamente bajos” en junio de 2013 mientras buscaba la aprobación regulatoria para vender el producto, dijo el DOJ.

Pero, según el acuerdo, no divulgó esa información y siguió comercializando las pruebas.

La agencia dijo que las pruebas de 2013 indicaron que el mismo defecto afectaba al dispositivo LeadCare II. Un retiro del mercado en 2021 incluyó la mayoría de los tres tipos de kits para pruebas distribuidos desde el 27 de octubre de 2020.

En un comunicado de prensa para anunciar la resolución, la empresa dijo que “los problemas subyacentes que afectaron los resultados de algunos de los productos de Magellan de 2013 a 2018 han sido completa y eficazmente solucionados” y que las pruebas que actualmente venden son seguras.

¿Qué significa un resultado “falsamente bajo”?

A menudo se realiza la prueba a los niños durante las visitas al pediatra al año y nuevamente a los 2 años. Los niveles elevados de plomo pueden poner a los niños en riesgo de retraso en el desarrollo, menor coeficiente intelectual y otros problemas. Y los síntomas, como dolor de estómago, falta de apetito o irritabilidad, pueden no aparecer hasta que se alcancen niveles altos.

Los resultados de pruebas falsamente bajos podrían significar que los padres y los médicos no eran conscientes del problema.

Eso es preocupante porque el tratamiento para la intoxicación por plomo es, al principio, principalmente preventivo. Los resultados que muestran niveles elevados deberían llevar a los padres y a los funcionarios de salud a determinar las fuentes de plomo y tomar medidas para prevenir una ingesta continua de este metal, dijo Janine Kerr, educadora de salud del Programa de Prevención de la Intoxicación por Plomo en la Infancia del Departamento de Salud de Virginia.

Los niños pueden estar expuestos al plomo de diversas maneras, incluyendo el consumo de agua contaminada con plomo de tuberías viejas, como en Flint y Washington; la ingestión de escamas de pintura a base de plomo que a menudo se encuentran en casas antiguas; o, como se informó recientemente, comiendo algunas marcas de puré de manzana con sabor a canela.

¿Qué deben hacer los padres ahora?

“Los padres pueden contactar al pediatra para determinar si su hijo tuvo una prueba de plomo en sangre con un dispositivo LeadCare” y discutir si es necesario repetirla, dijo Maida Galvez, pediatra y profesora en la Escuela de Medicina Icahn en Mount Sinai en Nueva York.

Durante un retiro anterior de algunos dispositivos de Magellan, en 2017, los Centros para el Control y Prevención de Enfermedades (CDC) recomendaron que se les hiciera otra prueba a los pacientes si estaban embarazadas, amamantando o eran niños menores de 6 años y tenían un nivel de plomo en sangre de menos de 10 microgramos por decilitro según lo determinado por un dispositivo Magellan de una extracción de sangre venosa.

El retiro de dispositivos Magellan en 2021 recomendó repetir la prueba a los niños cuyos resultados fueran inferiores al nivel de referencia actual de los CDC de 3.5 microgramos por decilitro. Muchas de esas pruebas eran del tipo de punción en el dedo.

Kerr, del Departamento de Salud de Virginia, dijo que su agencia no ha recibido muchas llamadas sobre ese retiro.

Las pruebas de punción en el dedo “no se utilizan tan ampliamente en Virginia”, explicó Kerr, agregando que “recibimos muchas preguntas sobre el retiro del puré de manzana”.

En cualquier caso, dijo, el “mejor curso de acción para los padres es hablar con un proveedor de atención médica”.

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

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

It’s not surprising that the nursing home industry is filing lawsuits to block new Biden administration rules requiring minimum staffing at facilities that accept federal dollars. What is slightly surprising is the pushback against the rules from members of Congress. Lawmakers don’t appear to have the votes to disapprove the rule, but they might be able to force a floor vote, which could be embarrassing for the administration.

Meanwhile, Senate Democrats aim to force Republicans who proclaim support for contraceptive access to vote for a bill guaranteeing it, which all but a handful have refused to do.

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

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Sandhya Raman
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Among the takeaways from this week’s episode:

• In suing to block the Biden administration’s staffing rules, the nursing home industry is arguing that the Centers for Medicare & Medicaid Services lacks the authority to implement the requirements and that the rules, if enforced, could force many facilities to downsize or close.
• Anthony Fauci, the retired director of the National Institute of Allergy and Infectious Diseases and the man who advised both Presidents Donald Trump and Joe Biden on the covid-19 pandemic, testified this week before the congressional committee charged with reviewing the government’s pandemic response. Fauci, the subject of many conspiracy theories, pushed back hard, particularly on the charge that he covered up evidence that the pandemic began because dangerous microbes escaped from a lab in China partly funded by the National Institutes of Health.
• A giant inflatable intrauterine device was positioned near Union Station in Washington, D.C., marking what seemed to be “Contraceptive Week” on Capitol Hill. Republican senators blocked an effort by Senate Majority Leader Chuck Schumer to force a vote on consideration of legislation to codify the federal right to contraception. Immediately after, Schumer announced a vote for next week on codifying access to in vitro fertilization services.
• Hospitals in London appear to be the latest, high-profile cyberattack victims, raising the question of whether it might be time for some sort of international cybercrime-fighting agency. In the United States, health systems and government officials are still in the very early stages of tackling the problem, and it is not clear whether Congress or the administration will take the lead.
• An FDA advisory panel this week recommended against the formal approval of MDMA, a psychedelic also known as ecstasy, to treat post-traumatic stress disorder. Members of the panel said there was not enough evidence to recommend its use. But the discussion did provide more guidance about what companies need to present in terms of trials and evidence to make their argument for approval more feasible.

Also this week, Rovner interviews KFF Health News’ Bram Sable-Smith, who reported and wrote the latest KFF Health News-NPR “Bill of the Month” feature about a free cruise that turned out to be anything but. If you have an outrageous or baffling bill you’d like to send us, you can do that here.

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

• Julie Rovner: Abortion, Every Day’s “EXCLUSIVE: Health Data Breach at America’s Largest Crisis Pregnancy Org,” by Jessica Valenti.
• Alice Miranda Ollstein: The Washington Post’s “Conservative Attacks on Birth Control Could Threaten Access,” by Lauren Weber.
• Rachel Cohrs Zhang: ProPublica’s “This Mississippi Hospital Transfers Some Patients to Jail to Await Mental Health Treatment,” by Isabelle Taft, Mississippi Today.
• Sandhya Raman: Air Mail’s “Roanoke’s Requiem,” by Clara Molot.

Click to open the transcript

Transcript: Nursing Home Staffing Rules Prompt Pushback

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

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, June 6, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So here we go. We are joined today via video conference by Alice Miranda Ollstein of Politico.

Alice Miranda Ollstein: Hello.

Rovner: Sandhya Raman of CQ Roll Call.

Sandhya Raman: Good morning.

Rovner: And Rachel Cohrs Zhang of Stat News.

Rachel Cohrs Zhang: Hi, everybody.

Rovner: Later in this episode, we’ll have my interview with KFF Health News’ Bram Sable-Smith, who reported and wrote this month’s KFF Health News/NPR “Bill of the Month.” It’s about a free cruise that turned out to be anything but. But first, this week’s news. We’re going to start this week with those controversial nursing home staffing rules.

In case you’ve forgotten, back in May, the Biden administration finalized rules that would require nursing homes that receive federal funding, which is basically all of them, to have nurses on duty 24/7/365, as well as impose other minimum staffing requirements.

The nursing home industry, which has been fighting this effort literally for decades, is doing what most big powerful health industry players do when an administration does something it doesn’t like: filing lawsuits. So what is their problem with the requirement to have sufficient staff to care for patients who, by definition, can’t care for themselves or they wouldn’t be in nursing homes?

Cohrs Zhang: Well, I think the groups are arguing that CMS [Centers for Medicare & Medicaid Service] doesn’t have authority to implement these rules, and that if Congress had wanted these minimum staffing requirements, Congress should have done that and they didn’t. So they’re arguing that they’re overstepping their boundaries, and we are seeing this lawsuit again in Texas, which is a popular venue for the health care industry to try to challenge rules or legislation that they don’t like.

So, I think it isn’t a surprise that we would see these groups sue, given the financial issues at stake, given the fearmongering about facilities having to close, and just the hiring that could have to happen for a lot of these facilities. So it’s not necessarily a surprise, but it will certainly be interesting and impactful for facilities and for seniors across the nation as this plays out.

Rovner: I mean, basically one of their arguments is that there just aren’t enough people to hire, that they can’t get the number of people that they would need, and that seems to be actually pretty persuasive argument at some point, right?

Cohrs Zhang: I mean, there is controversy about why staffing shortages happen. Certainly there could be issues with the pipeline or with nursing schools, education. But I think there are also arguments that unions or workers’ rights groups would make that maybe if facilities paid better, then they would get more people to work for them. Or that people might exit the industry because of working conditions, because of understaffing, and just that makes it harder on the workers who are actually there if their workloads are too much. Or they’re expected to do more work — longer hours or overtime — or their vacation is limited, that kind of thing.

So I think it is a surprisingly controversial issue that doesn’t have an easy answer, but that’s the perspectives that we’re seeing here.

Rovner: I mean, layering onto this, it’s not just the industry versus the administration. Now Congress is getting into the act, which you rarely see. They’re talking about using the Congressional Review Act, which is something that Congress can do. But of course, when you’re in the middle of an administration that’s done it, it would get vetoed by the president. So they can’t probably do anything. Sandhya, I see you nodding your head. These members of Congress just want to make a statement here?

Raman: Yeah. So Sen. James Lankford insured the resolution earlier this week to block the rule’s implementation, and it’s mostly Republicans that have signed on, but we also have [Sen.] Joe Manchin and [Sen.] Jon Tester. But the way it stands, it doesn’t have enough folks on board yet, and it would also need to be taken up. It faces an uphill climb like many of these things.

Rovner: Somebody actually asked me yesterday though, can they do this? And the answer is yes, there is the Congressional Review Act. Yes, Congress with just a majority vote and no filibuster in the Senate can overturn an administration rule. But like I said, it usually happens when an administration changes its hands because it does have to be signed by the president and the president can veto it.

If the president vetoes it, then they would need a veto override majority, which they clearly don’t seem to have in this case. But obviously there is enough concern about this issue. I think there’s been a Congressional Review Act resolution introduced in the House too, right?

Ollstein: It’s really tough because, like Rachel said, these jobs are low-paid. They’re emotionally and physically grueling. It’s really hard to find people willing to do this work. And at the same time, the current situation seems really untenable for patients. There’s been so many reports of really horrible patient safety and hygiene issues and all kinds of stuff in part, not entirely the fault of understaffing, but not helped by understaffing certainly.

I think, like, we see on so many fronts in health care, there are attempts to do something about this situation that has become untenable, but any attempt also will piss off someone and be challenged.

Rovner: Yeah, absolutely. And we should point out that nursing homes are staffed primarily not by nurses, but by nurses aides of various training levels. So this is not entirely about a nursing shortage, it is about a shortage of workers who want to do this, as you say, very grueling and usually underpaid work.

Well, speaking of controversial things, Dr. Tony Fauci, the now-retired head of the NIH’s National Institute of Allergy and Infectious Diseases, and currently the man most conspiracy theorists hold responsible for the entire covid-19 pandemic, testified before the House Select Committee on the pandemic Monday. And not surprisingly, sparks flew. What, if anything, did we learn from this hearing?

Cohrs Zhang: The interesting part of this hearing was watching how Dr. Fauci positioned himself in response to a lot of these criticisms that have been circulating. The committee has been going through different witnesses, and specifically it criticized one of his deputies, essentially, who had some unflattering emails released showing that he appeared to be trying to delete emails or use personal accounts to avoid public records requests from journalists or other organizations …

Rovner: I’m shocked, shocked that officials would want to keep their information away from prying reporters’ eyes.

Cohrs Zhang: It’s not surprising, but it is surprising to see it in writing. But this is, again, everyone is working from home and channels of communication were changing. But I think we did see Dr. Fauci pretty aggressively distancing himself, downplaying the relationship he had with this individual and saying that they worked on research together, but he wasn’t necessarily advising agency policy.

So that’s at least how he was framing the relationship. So he definitely downplayed that. And I think an interesting comment he made — I’m curious to see what you think about this, Julie — was that he didn’t say that the lab leak theory itself was a conspiracy, but his involvement and a cover-up was a conspiracy. And so it did seem that some of the rhetoric has at least changed. He seemed more open-minded, I guess, to a lab leak theory than I expected.

Rovner: I thought he was pretty careful about that. I think it was the last thing he said, which is that we’re never really going to know. I mean, it could have been a lab leak. It could have happened. It could have been an animal from the wet market. The Chinese have not been very forthcoming with information. I personally keep wondering why we keep pounding at this.

I mean, it seems unlikely that it was a lab leak and then a conspiracy to cover it up. It clearly was one or the other, and there’s a lot of differences of opinions. And that was the last thing he said is that it could have been either. We don’t know. That’s always struck me as the, “OK, let’s talk about something else.” Anyway, let’s talk about something else.

Raman: I was just going to add, we did see a personal side to him, which I think we didn’t see as much when he was in his official role when he was talking. It was about the death threats that he and his family have been receiving when responding to a lot of the misinformation going around about that. And I thought that was striking compared to, just juxtaposed, with a lot of the other [indecipherable] with [Rep.] Marjorie Taylor Greene saying, “Oh, you’re not a real doctor.” There’s a lot of colorful protesters. And I just thought that stood out, too.

Rovner: Yeah, he did obviously, I think, relish the chance to defend himself from a lot of the charges that have been leveled at him. And I think … his wife is a prominent scientist in her own right — obviously can take care of herself — but I think he was particularly angry that there had been death threats leveled toward his grown daughters, which probably a bit out of line. Alice, you wanted to add something.

Ollstein: Yeah, I think it’s also been interesting to see the shift among Democrats on the committee over time. I think they’ve gone from an attitude of Republicans are on a total witch hunt, this is completely political, this is muddying the waters and fueling conspiracy theories and will lead to worse public health outcomes. And I think based on some of the revelations, like Rachel said about emails and such, they have come to a position of, oh, there might be some things that need investigating and need accountability in here.

But I think their frustration seems to be what it’s always been in that how will this lead to making the country better prepared in the future for the next pandemic — which may or may not already be circulating, but certainly is inevitable at some point. Either way, it’s all well and good to hold officials accountable for things they may have done, but how does that lead to making the country more prepared, improving pandemic response in the future? That’s what they feel is the missing piece here.

Rovner: Yeah. I think there was not a lot of that at this hearing, although I feel like they had to go through this maybe to get over to the other side and start thinking about what we can do in the future to avoid similar kinds of problems. And obviously you get a disease that you have no idea what to do about, and people try to muddle through the best they can. All right, now we are going to move on and we’ll talk about abortion where there is always lots of news.

Here in Washington, there is a giant inflatable IUD flying over Union Station Wednesday to highlight what seems to be Contraception Week on Capitol Hill. Not coincidentally, it’s also the anniversary this week of the Supreme Court’s 1965 ruling Griswold v. Connecticut that created the right to birth control. Alice, what are Democrats, particularly in the Senate where they’re in charge, doing to try to highlight these potential threats to contraceptive access?

Ollstein: So this vote that happened that was blocked because only two Republicans crossed the aisle to support this Right to Contraception bill — it’s the two you expect, it’s [Sen.] Lisa Murkowski and [Sen.] Susan Collins — and you’re already seeing Democrats really make hay of this. Both Democrats and their campaign arms and outside allied groups are planning to just absolutely blitz this in ads. They’re holding events in swing states related to it, and they’re going hard against individual Republicans for their votes.

I think the Republicans I talked to who voted no, they had a funny mixed message about why they were voting no on it. They were both saying that the bill was this sinister Trojan horse for forcing religious groups to promote contraception and even abortion and also gender-affirming care somehow. But also, the bill was a pointless stunt that wouldn’t really do anything because there is no threat to contraception. But also Republicans have their own rival bill to promote access to contraception.

So access to contraception isn’t a problem, but please support my bill to improve access to contraception. It’s a tough message. Whereas Democrats’ message is a lot simpler. You can argue with it on the merits, but it’s a lot simpler. They point to the fact that Supreme Court Justice Clarence Thomas has expressed interest and actually called on the court to revisit precedents that protect the right to contraception.

Lots of states have thwarted attempts to enact protections for contraception. And a lot of anti-abortion groups have really made a big push to muddy the waters on medical understanding of what is contraception versus what is abortion, which we can get into later.

Rovner: Yes, which we will. Sandhya, did you want to add something?

Raman: Yeah, and I think that something that I would add to what Alice was saying is just how this is kind of at the same time a little bit different for the Democrats. Something that I wrote about this week was just that after the Dobbs [v. Jackson Women’s Health Organization] decision, we had the then-Democratic House vote on several different bills, but the Democrats have not really been holding this chamber-wide vote on bills related to abortion, contraception for the most part. And so this was the first time that they are stepping into that.

They’ve done the unanimous consent requests on a lot of these bills. And even just a couple months ago when talks are really heating up on IVF, there’s other things that we have to get to, appropriations and things like that, and this would just get bogged down. And they were shying away from taking floor time to do this. So I think that was an interesting move that they’re doing this now and that they’re going to vote on an IVF next week and whatever else next down the line.

Rovner: Yeah, I noticed that as soon as this bill went down, Sen. [Chuck] Schumer teed up the Right to IVF bill for a vote next week. But Alice, as you were alluding to, I mean, where this gets really uncomfortable for Republicans is that fine line between contraception and abortion. Our colleague Lauren Weber has a story about this this week [“Conservative Attacks on Birth Control Could Threaten Access,”], which is your extra credit, so why don’t you tell us about it?

Ollstein: Yeah. So she did a really great job highlighting how, especially at the state level where a lot of these battles are playing out, anti-abortion groups that are very influential are making arguments that certain forms of birth control are abortifacients. This is completely disputed by medical experts and the FDA [Food and Drug Administration] that regulates these products. They say, just to be clear about what we’re talking about, we’re talking about some forms of emergency contraception, which is taken after sex to prevent pregnancy. It is not an abortifacient. It won’t work if you’re already pregnant. It prevents pregnancy. It does not terminate a pregnancy. They are also saying this about some IUDs, intrauterine devices, and even about some hormonal birth control pills.

So there’s been pushback that Lauren detailed in her story, including from some Republicans who are trying to correct the record. But this misinformation is getting really entrenched, and I think it’s something we should all be paying attention to when it crops up, especially in the mouths of people in power.

Rovner: I mean, when I first started writing about it it was not entirely clear. There was thought that one of the ways the morning-after pill worked was by preventing implantation of a fertilized egg, which some people consider, if you consider that fertilization and not implantation, is the beginning of life. According to doctors, implantation is the beginning of pregnancy, among other things, because that’s when you can test for it.

But those who believe that fertilization is the beginning of life — and therefore something that prevents implantation is an abortion — were concerned that IUDs, and mostly progesterone-based birth control that prevented implantation, were abortifacients. Except that in the years since, it’s been shown that that’s not the case.

Ollstein: Right.

Rovner: That in fact, both IUDs and the morning-after pill work by preventing ovulation. There is no fertilized egg because there’s no egg. So they are not abortifacients. On the other hand, the FDA changed the labeling on the morning-after pill because of this. And yet the Hobby Lobby case [Burwell v. Hobby Lobby Stores Inc.] that the decision was written by Justice [Samuel] Alito, basically took that premise, that they were allowed to not offer these forms of contraception because they believed that they were acted as abortifacients, even though science suggests that they didn’t. It’s not something new, and it’s not something I don’t think is going to go away anytime in the near future.

Raman: I would add that it also came up in this week’s Senate Health [Committee] hearing, that line of questioning about whether or not different parts of birth control were abortifacients. Sen. [Patty] Murray did that line of questioning with Dr. Christina Francis, who’s the head of the anti-abortion obstetrician-gynecology group and went through on Plan B, IUDs and different things. And there was a back and forth of evading questions, but she did call IUDs as abortifacients, which goes back to the same thing that we’re saying.

Rovner: Right, which they have done all along.

Ollstein: Yeah. I mean, I think this really spotlights a challenge here, which is that Republicans’ response to votes like this week and things that are playing out in the state level, they’re scoffing and saying, “It’s absolutely ridiculous to suggest that Republicans are trying to ban birth control. This is completely a political concoction by Democrats to scare people into voting for them in November.”

What we’re talking about here are not bans on birth control, but there are policies that have been introduced at both the state and federal level that would make birth control, especially certain forms like we were just talking about, way harder to access. So there are proposals to carve them out of Obamacare’s contraception mandate, so they’re not covered by insurance.

That’s not a ban. You can still go pay out-of-pocket, but I remember all the people who were paying out-of-pocket for IUDs before Obamacare: hundreds and hundreds of dollars for something that is now completely free. And so what we’re seeing right now are not bans, but I think it’s important to think about the ways it would still restrict access for a lot of people.

Rovner: Before we leave the nation’s capital it seems that the Supreme Court’s upcoming decision on the abortion pill may not be the last word on the case. While it seemed likely from the oral arguments that the justices will agree that the Texas doctors who brought the case don’t have standing, there were three state attorneys general who sought to become part of the case when it was first considered back in Texas. So it would go back to Judge [Matthew] Kacsmaryk, our original judge who said that the entire abortion pill approval should be overturned. It feels like this is not the end of fighting about the abortion pill’s approval at the federal level. I mean, I assume that that’s something that the drug industry, among others, won’t be happy about.

Ollstein: Courts could find that the states don’t have standing either, that this policy does not harm them in any real way. In fact, Democratic attorneys general have argued the exact opposite, that the availability of mifepristone helps states: saves a lot of money; it prevents pregnancy; it treats people’s medical needs. So obviously, Kacsmaryk has a very long anti-abortion record and has sided with these challenges in a lot of cases. But that doesn’t mean that this would necessarily go anywhere.

But your bigger point that the Supreme Court’s upcoming ruling on mifepristone is not the end, it certainly is not. There’s going to be a lot more court challenges, some already in motion. There’s going to be state-level policy fights. There’s going to be federal-level policy fights. If Trump is elected, groups want him to do a lot of things through executive order to restrict mifepristone or remove it from the market entirely through the FDA. So yes, this is not going to be over for the foreseeable future.

Rovner: Well, meanwhile, in a case that might be over for the foreseeable future, the Texas Supreme Court last week officially rejected the case brought by 20 women who nearly died when they were unable to get timely care for pregnancy complications. The justices said in their ruling that while the women definitely did suffer, the fault lay with the doctors who declined to treat them rather than the vagueness of the state’s abortion ban. So where does that leave the debate about medical exceptions?

Ollstein: So anti-abortion groups’ response to a lot of the challenges to these abortion bans and stories about women in medical emergencies who are getting denied care and suffering real harm as a result, their response has been that there’s nothing wrong with the law. The law is perfectly clear, and that doctors are either accidentally or intentionally misinterpreting the law for political reasons. Meanwhile, doctors say it’s not clear at all. It’s not clear how honestly close to dead someone has to be in order to receive an abortion.

Rovner: And it’s not just in Texas. This is true in a bunch of states, right? The doctors don’t know …

Ollstein: In many states.

Rovner: … right? …

Ollstein: Exactly.

Rovner: … when they can intervene.

Ollstein: Right. And so I think the upcoming Supreme Court ruling on EMTALA [Emergency Medical Treatment and Active Labor Law], which we’ve talked about, could give some indication either way of what doctors are and are not able to do, but that won’t really resolve it either. There is still so much gray area. And so patients and doctors are going to state courts to plead for clarity. They’re going to their legislatures to plead for clarity. And they’re going to state medical boards, including in Texas, to plead for clarity. And so far, they have not gotten any.

Most legislatures have been unwilling to revisit their bans and clarify or expand the exceptions even as these stories play out on the ground of doctors who say, “I know that providing an abortion for this patient is the right thing medically and ethically to do, but I’m so afraid of being hit with criminal charges that I put the patient on a plane out of state instead.” Yeah, it’s just really tough.

And so what we wrote about it is we keep talking about doctors being torn between conflicting state and federal law, and that’s absolutely true, but what we dug into is that the state law just looms so much larger than the federal laws. So when you’re weighing, should I maybe violate EMTALA or should I maybe violate my state’s ban, they’re not going to want to violate their state’s ban because that means jail time, that means losing their license, that means having their freedom and their livelihood taken away.

Whereas an EMTALA violation may or may not mean a fine somewhere down the road. The enforcement has not been as aggressive at the federal level from the Biden administration as a lot of doctors would like it to be. And so, in that environment, they’re really deferring to the state law, and that means some people are not getting care that they maybe need.

Rovner: I say in the meantime, we had yet another jury just last week about a woman who had a miscarriage and could not get a D&C [dilation and curettage procedure] basically. When she went in there was no fetal heartbeat, but she ended up miscarrying at home and almost dying. She was sent away, I believe, from three different facilities. This continues to happen because doctors are concerned about when it is appropriate for them to intervene. And they seem, you’re right, to be leaning towards the “let’s not get in trouble with the state” law, so let’s wait to provide care as long as we think we can.

Well, moving on, we have two stories this week about efforts to treat post-traumatic stress disorder, particularly in military veterans. On Tuesday, an FDA advisory committee recommended against approval of the psychedelic MDMA, better known as ecstasy, for the treatment of PTSD. My understanding is that the panel didn’t reject the idea outright that this could be helpful, only that there isn’t enough evidence yet to approve it. Was I reading that right? Rachel, you guys covered this pretty closely.

Cohrs Zhang: Yes. Yeah, my colleagues did cover this. Certainly I think what’s a discouraging sign, I don’t think there’s any way around it, for some of these companies that are looking at psychedelics and trying to figure out some sort of approval pathway for conditions like PTSD.

One of my colleagues, Meghana Keshavan, she chatted with a dozen companies yesterday and they were trying to put a positive spin on it, that having some opinion or some discussion of a treatment like this by the advisory committee could lay out more clear standards for what companies would have to present in order to get something approved. So I think obviously they have a vested interest in spinning this positively.

But it is a very innovative space and certainly was a short-term setback. But it certainly isn’t a long-term issue if some of these companies are able to present stronger evidence or better trial design. I think there were some questions about whether trial participants actually could figure out whether they were placebo or not, which if you’re taking psychedelic drugs, yeah, that’s kind of a challenge in terms of trial design.

So I think there are some interesting questions, and I am confident that this’ll be something the FDA and industry is going to have to figure out in a space that’s new like this.

Rovner: Yeah, it’s been interesting to follow. Well, in something that does seem to help, one of the first controlled studies of service dogs to treat PTSD has found that man’s best friend can be a therapist as well. Those veterans who got specially trained dogs showed much more improvement in their symptoms than those who were on the doggy wait list as determined by professionals who didn’t know who had the dogs and who didn’t. So pet therapy for the win here?

Raman: I mean, this is the biggest study of this kind that we’ve had so far, and it seems promising. I think one thing will be interesting is if there’s more research, if this would change policy down the line for the VA [Department of Veterans Affairs] or other agencies to be able to get these kinds of service dogs in the hands of more vets.

Rovner: Yeah, I know there’s a huge demand for these kinds of service dogs. I know a lot of people who basically have started training service dogs for veterans. Obviously they were able to do this study because there was a long wait list. They were able to look at people who were waiting but hadn’t gotten a dog yet. So at least in the short term, possibly some help for some people.

Finally this week, in a segment I’m calling “Misery Loves Company,” it’s not just the U.S. where big health systems are getting cyberhacked. Across the pond, quoting here from the BBC, major hospitals in London have declared a critical incident after a cyberattack led to operations being canceled and emergency patients being diverted elsewhere. This sounds painfully familiar.

Maybe we need an international cybercrime fighting agency. Is there one? Is there at least, do we know, is there a task force working on this? Obviously the bigger, more centralized your health care system, the bigger problem this becomes, as we saw with Change Healthcare belonging to United[Healthcare], and this is now … I guess it’s a contractor that works for the NHS [National Health Service]. You can see the potential for really bad stuff here.

Cohrs Zhang: That’s a good question about some international standards, Julie, but I think what we have seen is Sen. Ron Wyden, who leads the Senate Finance Committee, did write to HHS [Department of Health and Human Services] this week and asked HHS to add to multiple-factor authentication as a condition of participation for some of these facilities to try to institute standards that way.

And again, I think there are questions about how much HHS can actually do, but I think it’s a signal that Congress might not want to do anything or think they can do anything if they’re asking the administration to do something here. But we’re still in the very early stages of systems viewing this as worthy of investment and just education about some of the best practices here.

Yeah, certainly it’s going to be a business opportunity for some consulting firms to help these hospitals increase their cybersecurity measures and certainly will be a global market if we see these attacks continue in other places, too.

Rovner: Maybe our health records will be as protected as our Spotify accounts. It would apparently be a step forward. All right, well, that is the news for this week. Now we will play my “Bill of the Month” interview with Bram Sable-Smith, and then we will come back and do our extra credits.

I am pleased to welcome back to the podcast my KFF Health News colleague Bram Sable-Smith, who reported and wrote the latest KFF Health News-NPR “Bill of the Month” about a free cruise that turned out to be anything but. Welcome back to the podcast, Bram.

Bram Sable-Smith: Thanks for having me.

Rovner: So tell us about this month’s patient, who he is, and what happened to him. This is one of the wilder Bills of the Month, I think.

Sable-Smith: Right. So his name is Vincent Wasney. He lives in Saginaw, Michigan. Never been on an airplane before, neither had his [fiancée], Sarah. But when they bought their first house in 2019, their Realtor, as a gift, gifted them tickets for a cruise. My Realtor gave me a tote bag. So, what a Realtor, first of all! What an incredible gift.

Rovner: My Realtor gave me a wine opener, which I do still use.

Sable-Smith: If it sailed to the Caribbean, it’d be equivalent. So their cruise got delayed because of the pandemic, but they set sail in December 2022. And they were having a great time. One of the highlights of their trip was they went to this private island called CocoCay for Royal Caribbean guests, and it included an excursion to go swimming with pigs.

Rovner: Wild pigs, right?

Sable-Smith: Wild pigs, a big fancy water park, all kinds of food. They were having a great time. But it’s also on that island that Vincent started feeling off. And so in the past, Vincent has had seizures. About 10 years earlier, he had had a few seizures. They decided he was probably epileptic, and he was on medicine for a while. He went off the medicine because they were worried about liver damage, and he’d been relatively seizure-free for a long time. It’d been a long time since he’d had a seizure.

But when he was on that island having a great time, it’s when he started to feel off. And when they got back on the cruise ship for the last full day of the cruise, he had a seizure in his room. And he was taken down to the medical center on the cruise ship and he was observed. He was given fluids for a while, and then sent back to his room, where he had a second seizure. Once again, went down to the medical center on the ship, where he had a third seizure. It was time to get him off the boat. He needed to get onto land and go to a hospital. And so they were close enough to land that they were able to do the evacuation by boat instead of having to do something like a helicopter to do a medevac that way. And so a rescue boat came to the ship. He was lowered off the ship. He was in a stretcher and it was lowered down to the rescue boat by a rope.

His fiancée, Sarah, climbed down a rope ladder to get into the boat as well to go with them to land. And then he was taken to land in an ambulance ride to the hospital, et cetera. But, before they were allowed to disembark, they were given their bill and told “It’s time to pay this. You have to pay this bill.”

Rovner: And how much was it?

Sable-Smith: So the bill for the medical services was $2,500. This was a free cruise. They had budgeted to pay for internet, $150 for internet. They had budgeted to pay for their alcoholic drinks. They had budgeted to pay for their tips. So they had saved up a few hundred dollars, which is what they thought would be their bill at the end of this cruise. Now, that completely exploded into this $2,500 bill just for medical expenses alone.

And as they’re waiting to evacuate the ship, they’re like, “We can’t pay this. We don’t have this money.” So that led to some negotiations. They ended up basically taking all the money out of their bank accounts, including their mortgage payment. They maxed out Vincent’s credit card, but they were still $1,000 short. And they later learned once they were on land that Vincent’s credit card had been overdrafted by $1,000 to cover that additional expense.

Rovner: So it turns out that he was uninsured at the time, and we’ll talk about that in a minute. But even if he had had insurance, the cruise ship wasn’t going to let him off the boat until he paid in full, even though it was an emergency? Did I read that right?

Sable-Smith: That’s certainly the feeling that they had at the time. When Vincent was short the $1,000, eventually they were let off the ship, but they did end up, as we said, getting that credit card overdrafted. But I think what’s important to note here is that even though he was uninsured at the time, even if he had had insurance, and even if he had had travel insurance, which he also did not have at the time, which we can talk about, he still would’ve been required to pay upfront and then submit the receipts later to try to get reimbursed for the payments.

And that’s because on the cruise’s website, they explain that they do not accept “land-based health insurance plans” when they’re on the vessel.

Rovner: In fact, as you mentioned, a lot of health insurance doesn’t cover care on a cruise ship or, in fact, anywhere outside the United States. So lots of people buy travel insurance in case they have a medical emergency. Why didn’t they?

Sable-Smith: So travel insurance is often purchased when you purchase the tickets. You’ll buy a ticket to the cruise and then it will prompt you, say, “Hey, do you want some travel insurance to protect you while you’re on this ship?” And that’s the way that most people are buying travel insurance. Well, remember, this cruise was a gift from their realtors, so they never bought the ticket. So they never got that prompting to say, “Hey, time to buy some travel insurance to protect yourself on the trip.”

And again, these were inexperienced travelers. They’d never been on an airplane before. The furthest either one of them had been from Michigan was Vincent went to Washington, D.C., one time on a school trip. And so they didn’t really know what travel insurance was. They knew it existed. But as Vincent explained, he said, “I thought this was for lost luggage and trip cancellations. I didn’t realize that this was something for medical expenses you might incur when you’re out at sea.”

Rovner: And it’s really both. I mean, it is for lost luggage and cancellation, right?

Sable-Smith: And it is for lost luggage and cancellation. Yeah, that’s right.

Rovner: So what eventually happened to Vincent and what eventually happened to the bill?

Sable-Smith: Well, once he got taken to the hospital, he got an additional bill, or actually several additional bills, one from the hospital, two from a couple doctors who saw him at the hospital who billed separately, and also one from the ambulance services. As we know, he had already drained his bank account and maxed out his credit card and had it overdrafted to cover the expenses on the ship. So he was working on paying those off. And then for the additional bills he incurred on land, he had set up payment plans, really small ones, $25, $50 a month, but going to four separate entities.

He actually missed a couple payments on his bill to the hospital, and that ended up getting sent to collections. Again, none of these are charging interest, but these are still quite some burdens. And so he was paying them off bit by bit by bit. He set up a GoFundMe campaign, which is something that a lot of people end up doing who never expect to have to cover these kinds of emergency expenses, or reach out publicly for help like that. And they got quite a bit of help from family and friends. Including, Vincent picked up Frisbee golf during the pandemic, and he’s made quite a lot of good friends that way. And that community really came through for them as well. So with those GoFundMe payments, they were able to make their house payment. It was helpful with some of these bills that they had lingering leftover from the cruise.

Rovner: So what’s the takeaway here, other than that nothing that seems free is ever really free?

Sable-Smith: Yeah, right. Well, the takeaway is to be informed before you leave about a plan for how are you going to cover medical expenses when you’re going traveling. I think this is something that a lot of people are going to be doing this summer, going on vacations. I’ve got vacations planned. What’s your plan for covering medical expenses? And if you’re leaving the country, if you’re going on a cruise, someplace where your land-based American health insurance might not cover you, you should consider travel insurance.

And when you’re considering travel insurance, they come in all sorts of varieties. So you want to make sure that they’re going to cover your particular cases. So some plans, for example, won’t cover pre-existing conditions. Some plans won’t cover care for risky activities like rock climbing. So you want to know what you’re going to be doing during your trip, and you want to make sure when you’re purchasing travel insurance to find a plan that’s going to cover your particular needs.

Rovner: Very well explained. Bram Sable-Smith, thank you very much.

Sable-Smith: Always a pleasure.

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

Raman: So my extra credit is “Roanoke’s Requiem,” and it’s an Air Mail from Clara Molot. And this is a really interesting piece. So at least 16 alumni from the classes of 2011 to 2019 of Roanoke have been diagnosed with cancer since 2010, which is a much higher rate when compared to the rate for 20-somethings in the U.S. and 15-times-higher mortality rate. And so the piece does some looking at some of the work that’s being done to uncover why this is happening.

Rovner: It’s quite a scary story. Rachel?

Cohrs Zhang: Yes. So the story I chose, it was co-published by ProPublica in Mississippi Today. The headline is “This Mississippi Hospital Transfers Some Patients to Jail to Await Mental Health Treatment,” by Isabelle Taft. And I mean, truly such a harrowing story of … obviously we know that there’s capacity issues with mental health treatment, but the idea that patients would be involuntarily committed, go to a hospital, and then be transferred to a jail having committed no crime, having no recourse.

I mean, some of these detentions happened. It was like two months long where these patients who are already suffering are then thrown out of their comfortable environments into jail as they awaited county facilities to open up spots for them. And I think the story also did a good job of pointing out that other jurisdictions had found other solutions to this other than placing suffering people in jail. So yeah, it just felt like it was a really great classic example of investigative journalism that’ll have an impact.

Rovner: Local investigative journalism — not just investigative journalism — which is really rare, yet it was a really good piece. Well, my extra credit this week is from Jessica Valenti, who writes a super-helpful newsletter called Abortion, Every Day. Usually it’s an aggregation of stories from around the country, but this week she also has her own exclusive [“EXCLUSIVE: Health Data Breach at America’s Largest Crisis Pregnancy Org,”] about how Heartbeat International, which runs the nation’s largest network of crisis pregnancy centers, is collecting and sharing private health data, including due dates, dates of last menstrual periods, addresses, and even family living arrangements.

Isn’t this a violation of HIPAA, you may ask? Well, probably not, because HIPAA only applies to health care providers and insurers and the vast majority of crisis pregnancy centers don’t deliver medical care. You don’t need a medical license to give a pregnancy test or even do an ultrasound. Among other things, personal health data has been used for training sales staff, and until recently was readily available to anyone on the web without password protection. It’s a pretty eye-opening story.

All right, that is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks as always to our technical guru, Francis Ying, and our fill-in editor this week, Stephanie Stapleton. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, I’m at @jrovner. Sandhya?

Raman: @SandhyaWrites.

Rovner: Alice?

Ollstein: @AliceOllstein.

Rovner: Rachel?

Cohrs Zhang: @rachelcohrs.

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

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Ballad Health, a 20-hospital system in northeast Tennessee and southwest Virginia, has received A grades and an annual stamp of approval from the Tennessee Department of Health. This has occurred as Ballad hospitals consistently fall short of performance targets established by the state, according to health department documents.

Because the state’s scoring rubric largely ignores the hospitals’ performance, only 5% of Ballad’s final score is based on actual quality of care, and Ballad has suffered no penalty for failing to meet the state’s goals in about 50 areas — including surgery complications, emergency room speed, and patient satisfaction.

“It doesn’t make any sense,” said Ron Allgood, 75, of Kingsport, Tennessee, who said he had a heart attack in a Ballad ER in 2022 after waiting for three hours with chest pains. “It seems that nobody listens to the patients.”

Ballad Health was created six years ago after Tennessee and Virginia lawmakers waived federal anti-monopoly laws so two competing hospital companies could merge. The monopoly agreement established two quality measures to compare Ballad’s care against the state’s baseline expectations: about 17 “target” measures, on which hospitals are expected to improve and their performance factors into their grade; and more than 50 “monitoring” measures, which Ballad must report, but how the hospitals perform on them is not factored into Ballad’s grade.

Ballad has failed to meet the baseline values on 75% or more of all quality measures in recent years — and some are not even close — according to reports the company has submitted to the health department.

Since the merger, Ballad has become the only option for hospital care for most of about 1.1 million residents in a 29-county region at the nexus of Tennessee, Virginia, Kentucky, and North Carolina. Critics are vocal. Protesters rallied outside a Ballad hospital for months. For years, longtime residents like Allgood have alleged Ballad’s leadership has diminished the hospitals they’ve relied on their entire lives.

“It’s a shadow of the hospital we used to have,” Allgood said.

And yet, every year since the merger, the Tennessee health department has reported that the benefits of the hospital merger outweigh the risks of a monopoly, and that Ballad “continues to provide a Public Advantage.” Tennessee has also given Ballad an A grade in every year but two, when the scoring system was suspended due to the covid-19 pandemic and no grade issued.

The department’s latest report, released this month, awarded Ballad 93.6 of 100 possible points, including 15 points just for reporting the monitoring measures. If Tennessee rescored Ballad based on its performance, its score would drop from 93.6 to about 79.7, based on the scoring rubric described in health department documents. Tennessee considers scores of 85 or higher to be “satisfactory,” the documents state.

Larry Fitzgerald, who monitored Ballad for the Tennessee government before retiring this year, said it was obvious the state’s scoring rubric should be changed.

Fitzgerald likened Ballad to a student getting 15 free points on a test for writing any answer.

“Do I think Ballad should be required to show improvement on those measures? Yes, absolutely,” Fitzgerald said. “I think any human being you spoke with would give the same answer.”

Ballad Health declined to comment. Tennessee Department of Health spokesperson Dean Flener declined an interview request and directed all questions about Ballad to the Tennessee Attorney General’s Office, which also has a role in regulating the monopoly. Amy Wilhite, a spokesperson for the AG’s office, directed those questions back to the health department and provided documents showing it is the agency responsible for how Ballad is scored.

The Virginia Department of Health, which is also supposed to perform “active supervision” of Ballad as part of the monopoly agreement, has fallen several years behind schedule. Its most recent assessment of the company was for fiscal year 2020, when it found that the benefits of the monopoly “outweigh the disadvantages.” Erik Bodin, a Virginia official who oversees the agreement, said more recent reports are not yet ready to be released.

Ballad Health was formed in 2018 after state officials approved the nation’s biggest so-called Certificate of Public Advantage, or COPA, agreement, allowing a merger of the Tri-Cities region’s only two hospital systems — Mountain States Health Alliance and Wellmont Health System. Nationwide, COPAs have been used in about 10 hospital mergers over the past three decades, but none has involved as many hospitals as Ballad’s.

The Federal Trade Commission has warned that hospital monopolies lead to increased prices and decreased quality of care. To offset the perils of Ballad’s monopoly, officials required the new company to agree to more robust regulation by state health officials and a long list of special conditions, including the state’s quality-of-care measurements.

Ballad failed to meet the baseline on about 80% of those quality measures from July 2021 to June 2022, according to a report the company submitted to the health department. The following year, Ballad fell short on about 75% of the quality measures, and some got dramatically worse, another company report shows.

For example, the median time Ballad patients spend in the ER before being admitted to the hospital has risen each year and is now nearly 11 hours, according to the latest Ballad report. That’s more than three times what it was when the monopoly began, and more than 2.5 times the state baseline.

And yet Ballad’s grade is not lowered by the lack of speed in its ERs.

Fitzgerald, Tennessee’s former Ballad monitor, who previously served as an executive in the University of Virginia Health System, said a hospital company with competitors would have more reason than Ballad to improve its ER speeds.

“When I was at UVA, we monitored this stuff passionately because — and I think this is the key point here — we had competition,” Fitzgerald said. “And if we didn’t score well, the competition took advantage.”

Midwest correspondent Samantha Liss contributed to this report.

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

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Los casos de sarampión están aumentando en Estados Unidos. En el primer trimestre de este año, se registró un número de casos 17 veces mayor con respecto al promedio registrado durante el mismo período en los cuatro años anteriores, según los Centros para el Control y Prevención de Enfermedades (CDC). La mitad de las personas infectadas, principalmente niños, han sido hospitalizadas.

Y se espera que las cifras sigan empeorando, en gran medida porque cada vez más padres deciden no vacunar a sus hijos contra el sarampión y otras enfermedades como la polio y la tos ferina.

Este año, el 80% de los casos ha sido en personas no vacunadas o con un estatus de vacunación desconocido. Muchos padres han sido influenciados por una avalancha de desinformación difundida por políticos y personalidades en redes sociales, podcasts, y en la TV, que repiten falsas creencias, erosionando la confianza en la ciencia que respalda las vacunas infantiles de rutina.

A continuación, examinamos algunos mitos frecuentes de la retórica antivacunas y explicamos por qué está equivocada:

“No es para tanto”

Una idea errónea común es que las vacunas no son necesarias porque las enfermedades que previenen no son peligrosas u ocurren con muy poca frecuencia como para ser motivo de preocupación. Aunque se hayan reportado casos de sarampión en 19 estados, los escépticos acusan a funcionarios de salud pública y a los medios de comunicación de sembrar temor sobre la enfermedad sin fundamento.

Por ejemplo, una nota publicada en el sitio web del National Vaccine Information Center, una fuente habitual de desinformación sobre las vacunas, sostuvo que la preocupación creciente por el sarampión “es una exageración al estilo de ‘el cielo se cae'”. El artículo decía que contraer el sarampión, las paperas, la varicela y la gripe (también llamada influenza) era “políticamente incorrecto”.

Según los CDC, el sarampión resulta fatal en aproximadamente 2 de cada 1,000 niños infectados. Si este nivel de riesgo suena aceptable, vale la pena señalar que un número mucho mayor de niños con sarampión requieren hospitalización por neumonía y otras complicaciones serias.

Por cada 10 casos de sarampión, un niño con la enfermedad desarrolla una infección de oído que puede causar la pérdida auditiva permanente. Otro efecto extraño del virus es que puede destruir la inmunidad de una persona, y así afectar su capacidad para recuperarse de la gripe y otras afecciones comunes.

Las vacunas contra el sarampión han evitado la muerte de alrededor de 94 millones de personas, principalmente niños, en los últimos 50 años, según un análisis de abril de la Organización Mundial de la Salud (OMS). Junto con las vacunas contra la polio y otras enfermedades, se estima que las vacunas han salvado 154 millones de vidas en todo el mundo.

Algunos escépticos de las vacunas sostienen que las enfermedades que previenen ya no son una amenaza porque se han vuelto relativamente poco frecuentes en el país. (Lo cual es cierto, gracias a la vacunación). Es el razonamiento que invocó el cirujano general de Florida, Joseph Ladapo, durante un brote de sarampión en febrero, cuando dijo a los padres que sus hijos no vacunados podían seguir yendo a la escuela. “Hay mucha inmunidad”, dijo Ladapo.

A medida que esta actitud relajada hacia las vacunas convence a los padres de no dárselas a sus hijos, la inmunidad colectiva disminuye y los brotes serán cada vez más grandes y se propagarán más rápido.

En 2019, un brote de rápido crecimiento afectó a una comunidad con tasas de vacunación insuficientes en Samoa y mató a 83 personas en cuatro meses. Las tasas persistentemente bajas de vacunación contra el sarampión en la República Democrática del Congo mataron a más de 5,600 personas a causa de la enfermedad en brotes masivos el año pasado.

“Nunca se sabe”

Desde los orígenes de las vacunas, siempre ha existido un grupo que ha desconfiado porque no son naturales, en comparación con las infecciones y plagas que abundan en la naturaleza. Los miedos y dudas sobre las vacunas han ido cambiando a lo largo de las décadas. En el 1800, por ejemplo, los escépticos pensaban que las vacunas contra la viruela hacían que a las personas les salieran cuernos y que se comportaran como bestias.

En tiempos más recientes, los escépticos han vinculado las vacunas con una variedad de afecciones, desde el trastorno por déficit de atención e hiperactividad hasta el autismo y las enfermedades del sistema inmunológico. Los estudios científicos no respaldan estas afirmaciones.

La realidad es que las vacunas están entre las intervenciones médicas más estudiadas. En el siglo pasado, las vacunas han pasado por estudios científicos y ensayos clínicos masivos tanto en las fases de desarrollo como después, durante su uso generalizado.

Más de 12,000 personas participaron en los ensayos clínicos de la última vacuna aprobada para prevenir el sarampión, las paperas y la rubéola. Al probar la vacuna en un gran número de personas, los investigadores pueden detectar riesgos poco comunes, lo cual es importante porque se administran a millones de personas sanas.

Para evaluar los riesgos a largo plazo, los científicos analizan grandes cantidades de datos para identificar señales de daño. Por ejemplo, un grupo danés analizó una base de datos de más de 657,000 niños y encontró que aquellos que fueron vacunados contra el sarampión cuando eran bebés no tenían más probabilidades de ser diagnosticados con autismo que aquellos que no fueron vacunados.

En otro estudio, los investigadores analizaron registros de 805,000 niños nacidos entre 1990 y 2001 y no encontraron ninguna prueba de que las vacunaciones múltiples pudieran afectar el sistema inmune de los niños.

Pero las personas que promueven la desinformación sobre las vacunas, como el candidato a la presidencia Robert F. Kennedy Jr., descartan los estudios masivos respaldados por la ciencia.

Por ejemplo, Kennedy sostiene que los ensayos clínicos para las nuevas vacunas no son confiables porque no se compara a los niños vacunados con un grupo que recibe un placebo, como solución salina u otra sustancia sin efecto. En vez de utilizar un placebo, muchos ensayos modernos comparan las vacunas actualizadas con otras más antiguas. Esto se debe a que se considera no ético poner en peligro a los niños al darles una vacuna falsa cuando se conoce el efecto protector de la inmunización.

En un ensayo clínico de vacunas contra la polio realizado en la década de 1950, 16 niños que recibieron un placebo murieron de polio y 34 quedaron paralizados, dijo Paul Offit, director del Centro de Educación Sobre Vacunas del Hospital de Niños de Philadelphia y autor de un libro sobre la primera vacuna contra la polio.

“Demasiadas y demasiado pronto”

Varios de los libros sobre vacunas más vendidos en Amazon promueven la peligrosa idea de que los padres deberían omitir o retrasar la vacunación de sus hijos. “Puede ser que no todas las vacunas en el calendario de los CDC sean adecuadas para todos los niños en todo momento”, escribe Paul Thomas en su libro más vendido “The Vaccine-Friendly Plan”. Para respaldar su argumento, dice que los niños que han seguido “mi protocolo están entre los más sanos del mundo”.

Desde la publicación del libro, la licencia médica de Thomas fue suspendida temporalmente en Oregon y Washington.

La Junta Médica de Oregon documentó cómo Thomas convenció a los padres a omitir vacunas recomendadas por los CDC e “hizo llorar” a una madre que no estaba de acuerdo. Varios niños bajo su cuidado contrajeron tos ferina y rotavirus, ambas enfermedades que se previenen fácilmente con vacunas, escribió la junta.

Thomas le recetó suplementos de aceite de pescado y homeopatía a un niño que tenía una laceración profunda en el cuero cabelludo en lugar de darle una vacuna de emergencia contra el tétanos. El niño desarrolló un cuadro de tétanos grave y estuvo en el hospital por casi dos meses, donde tuvo que someterse a una intubación, una traqueotomía y una sonda de alimentación para sobrevivir.

El calendario de vacunación recomendado por los CDC se diseñó para proteger a los niños en los momentos más vulnerables de su vida y minimizar los efectos secundarios. Por ejemplo, la vacuna combinada contra el sarampión, las paperas y la rubéola no se administra durante el primer año de vida del bebé porque los anticuerpos que transmite temporalmente la madre pueden interferir con la respuesta inmunitaria. Y como algunos bebés no generan una respuesta inmunitaria fuerte con esa primera dosis, los CDC recomiendan una segunda dosis alrededor del momento en que los niños comiencen el jardín de infantes, ya que el sarampión y otros virus se propagan rápidamente en contextos grupales.

No se recomienda retrasar mucho más las dosis de esta vacuna ya que los datos sugieren que los niños vacunados a los 10 años o más tienen más probabilidades de desarrollar reacciones adversas, como convulsiones o fatiga.

Alrededor de una docena de otras vacunas siguen su propio esquema cronológico, con superposiciones para obtener la mejor respuesta. Los estudios han demostrado que la vacuna contra el sarampión, las paperas y la rubéola se puede administrar de forma segura y eficaz combinada con otras vacunas.

“Ellos no quieren que lo sepas”

En la introducción del nuevo libro de Ladapo sobre cómo superar el miedo en la salud pública, Kennedy compara al cirujano general de Florida con Galileo. Así como la Inquisición católica condenó al famoso astrónomo por promover teorías sobre el universo, sugiere Kennedy, las instituciones científicas reprimen a los disidentes de las vacunas por razones nefastas.

“La persecución de científicos y médicos que se atreven a cuestionar las doctrinas contemporáneas no es nada nuevo”, escribe Kennedy. Su compañera de fórmula, la abogada Nicole Shanahan, ha hecho campaña con la idea de que las conversaciones sobre los peligros de las vacunas se están censurando y que las corporaciones influyen sobre los CDC y otras agencias federales para ocultar datos.

En el podcast más escuchado en Estados Unidos, “The Joe Rogan Experience”, a menudo figuran invitados que desconfían del consenso científico. El año pasado, en el programa, Kennedy repitió el mito muchas veces desmentido de que las vacunas causan autismo.

Lejos de ignorar ese miedo, los epidemiólogos lo han tomado en serio. Han realizado más de una docena de estudios en busca de un vínculo entre las vacunas y el autismo, y no han encontrado ninguno. “Hemos refutado de manera concluyente la teoría de que las vacunas están relacionadas con el autismo”, afirmó Gideon Meyerowitz-Katz, epidemiólogo de la Universidad de Wollongong en Australia. “Es por esto que el sistema de salud pública tiende a cerrar esas conversaciones rápidamente”.

Las agencias federales son transparentes con respecto a las reacciones que pueden causar las vacunas, incluyendo convulsiones y dolor en el brazo. Y el gobierno tiene un programa para compensar a las personas si se determina científicamente que sus lesiones son el resultado de las vacunas. Alrededor de 1 a 3.5 de cada millón de dosis de la vacuna contra el sarampión, las paperas y la rubéola pueden provocar una reacción alérgica potencialmente mortal. Se estima que el riesgo de muerte a causa de un rayo durante toda la vida de una persona es hasta cuatro veces mayor.

“Lo más convincente que puedo decir es que mi hija tiene todas sus vacunas y que todos los pediatras y profesionales de salud pública que conozco han vacunado a sus hijos”, dijo Meyerowitz-Katz. “Nadie haría eso si pensara que existen riesgos graves”.

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

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The Host

Julie Rovner
KFF Health News

@jrovner

Read Julie's stories.

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

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

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

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

Panelists

Rachel Cohrs Zhang
Stat News

@rachelcohrs

Read Rachel's stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories.

Sandhya Raman
CQ Roll Call

@SandhyaWrites

Read Sandhya's stories.

Among the takeaways from this week’s episode:

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

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

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

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

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

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

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

Also mentioned on this week’s podcast:

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

Click to open the transcript

Transcript: Bird Flu Lands as the Next Public Health Challenge

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

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

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

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

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

Alice Miranda Ollstein: Hello.

Rovner: Rachel Cohrs Zhang of Stat News.

Rachel Cohrs Zhang: Hi, everybody.

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

Sandhya Raman: Hi, everyone.

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

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

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

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

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

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

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

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

Rovner: Alice, you want to add something.

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

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

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

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

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

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

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

Rovner: Although some did. And nice pun there.

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

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

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

Rovner: Yes, they shared jurisdiction over Medicare.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Grover: Better late than never.

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

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

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

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

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

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

Rovner: And that was an explicit goal.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Grover: I would think so, yes.

Rovner: And asking more students about it.

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

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

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

Rovner: Atul Grover, thank you so much.

Grover: Thanks for having me.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

OK, that is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. And happy birthday today to half of my weekly live audience: Aspen the corgi turns 4 today.

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

Raman: @SandhyaWrites.

Rovner: Alice.

Ollstein: @AliceOllstein.

Rovner: Rachel.

Cohrs Zhang: @rachelcohrs.

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

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According to FDA documents obtained through the Freedom of Information Act, the agency “became aware” of the AGGA from a joint investigation by KFF Health News and CBS News in March 2023, then responded with its first-ever inspection of Johns Dental months later.

That inspection found that the Indiana dental device manufacturer didn’t require all customer complaints to be investigated and the company did not investigate some complaints about people being hurt by products, including the AGGA, the FDA documents state. The FDA requires device companies to investigate complaints and forward them to the agency. Johns Dental had “never” alerted the FDA to any such complaints, according to the documents.

The AGGA, which its inventor testified has been used on more than 10,000 patients, was promoted by dentists nationwide, some of whom said it could “grow” or “expand” an adult’s jaw without surgery and treat common ailments like sleep apnea. But these claims were not backed by peer-reviewed research, and Johns Dental has settled lawsuits from 20 patients who alleged the AGGA caused them grievous harm. The company has not admitted liability.

Two former FDA officials said the AGGA was likely able to stay on the market — and off the FDA’s radar — for so long because of the lack of inspections and investigations at Johns Dental. Madris Kinard, a former FDA manager who founded Device Events, which analyzes FDA data, said it defies belief that Johns Dental never received a complaint worthy of relaying to the FDA.

“That’s a red flag for me. If I don’t see a single report to the FDA, I typically think there is something going on,” Kinard said. “When they don’t report, what you have is devices that stay on the market much longer than they should. And patients get harmed.”

Johns Dental Laboratories declined to comment when reached by phone and its lawyers did not respond to requests for an interview. The family-owned company, which has operated since 1939 in the western Indiana city of Terre Haute, sells dozens of products to dentists and makes hundreds of retainers and sleep apnea appliances each month, according to its website.

Twelve of Johns Dental’s products are registered with the FDA as Class II medical devices, meaning they carry at least a moderate risk, and some have been featured on the company website for at least two decades, according to screen captures preserved by the Internet Archive.

The AGGA, which was invented by Tennessee dentist Steve Galella in the 1990s, was not registered with the FDA like Johns Dental’s other devices. Company owner Jerry Neuenschwander has said in sworn court depositions that Johns Dental started making the AGGA in 2012 and became Galella’s exclusive manufacturer in 2015 and that at one point the AGGA was responsible for about one-sixth of Johns Dental’s total sales revenue.

In another deposition, Johns Dental CEO Lisa Bendixen said the company made about 3,000 to 4,000 AGGAs a year and paid Galella’s company a “royalty” of $50 to $65 for every sale.

“We are not dentists. We do not know how these appliances work. All we do is manufacture to Dr. Galella’s specifications,” she said, according to a deposition transcript.

The FDA’s lack of knowledge about the AGGA likely contributed to its loose oversight of Johns Dental. When asked to explain the lack of inspection, the FDA said that, based on what it knew at the time, it was not required to inspect Johns Dental until 2018 when the company registered as a “contract manufacturer” of other medical devices. Prior to 2018, the FDA was only aware of Johns Dental operating as a “dental laboratory,” which normally do not manufacture their own products and only modify devices made by other companies to fit dentists’ specifications. The FDA does not regularly inspect dental labs, although it can if it has concerns or gets complaints, the agency said.

Kinard said that based on her experience at the FDA she believes the agency prioritizes medical devices over dental devices, which may have contributed to the lack of inspections at Johns Dental.

“There hasn’t been much attention to dental devices in the past,” Kinard said. “Hopefully that’s going to change because of dental implant failures, as well as this device, which has quite obviously had serious issues.”

The AGGA resembles a retainer and uses springs to apply pressure to the front teeth and upper palate, according to a patent application. Last year, the KFF Health News-CBS News investigation revealed the AGGA was not backed by any peer-reviewed research and had never been submitted to the FDA for review. At the time, at least 20 patients had alleged in lawsuits that the AGGA had caused grievous harm to their teeth, gums, and bone — and some said they’d lost teeth. Multiple dental specialists said in interviews that they had examined AGGA patients whose teeth had been shoved out of position by the device, sometimes causing tens of thousands of dollars in damage.

“The entire concept of this device, of this treatment, makes zero sense,” said Kasey Li, a maxillofacial surgeon who published research on AGGA patients that appeared on a National Institutes of Health website. “It doesn’t grow the jaw. It doesn’t widen the jaw. It just pushes the teeth out of their original position.

Johns Dental and Galella have negotiated out-of-court settlements with the original 20 AGGA plaintiffs without publicly admitting fault. At least 13 more AGGA patients have filed similar lawsuits since the KFF Health News-CBS News investigation. Johns Dental and Galella denied wrongdoing or have not yet responded to the allegations in the newer lawsuits.

Galella declined to be interviewed in 2023 and neither he nor his attorneys responded to recent requests for comment. One of his attorneys, Alan Fumuso, said in a 2023 statement that the AGGA “is safe and can achieve beneficial results” when used properly.

In the wake of the KFF Health News-CBS News report, Johns Dental abruptly stopped making the AGGA, according to the newly released FDA documents. The Department of Justice soon after opened a criminal investigation into the AGGA that was ongoing as of December, according to court filings. No charges have been filed. A DOJ spokesperson declined comment.

Spurred by the March 2023 news report, the FDA inspected Johns Dental in July. The FDA’s website shows that Johns Dental was issued seven citations, but the substance of the agency’s findings was not known until the inspection report was obtained this year.

FDA investigator David Gasparovich wrote in that report that he arrived unannounced at Johns Dental last July and was met by five attorneys who instructed employees not to answer any questions about the AGGA or the company’s complaint policies. Neuenschwander was told by his attorney not to talk to the inspector, the report states.

“He asked if he could photograph my credentials,” Gasparovich wrote in his report. “This was the last conversation I would have with Mr. Neuenschwander at the request of his attorney.”

The FDA requires device companies to investigate product complaints and submit a “medical device report” to the agency within 30 days if the products may have contributed to serious injury or death. Gasparovich’s inspection report states that Johns Dental had “not adequately investigated customer complaints,” and its complaint policies were “not adequately established,” allowing employees to not investigate if the product was not first returned to the company.

Johns Dental received four complaints about the AGGA after the KFF Health News-CBS News report, including one that came after the FDA announced “safety concerns” about the device, according to the inspection report.

“Zero (0) out of the four (4) complaints were investigated,” Gasparovich wrote in the report. “Each complaint was closed on the same day it was received.”

In the months after Gasparovich’s inspection, Johns Dental sent letters to the FDA saying it revised its complaint policies to require more investigations and hired a consultant and an auditor to address other FDA concerns, according to the documents obtained through FOIA.

Former FDA analyst M. Jason Brooke, now an attorney who advises medical device companies, said the FDA uses an internal risk-based algorithm to determine when to inspect manufacturers and he advises his clients to expect inspections every three to five years.

Brooke said the AGGA is an example of how the FDA’s oversight can be hamstrung by its reliance on device manufacturers to be transparent. If device companies don’t report to the agency, it can be left unaware of patient complaints, malfunctions, or even entire products, he said.

When a company “doesn’t follow the law,” Brooke said, “the FDA is in the dark.”

“If there aren’t complaints coming from patients, doctors, competitors, or the company itself, then in a lot of ways, there’s just a dearth of information for the FDA to consume to trigger an inspection,” Brooke said.

CBS News producer Nicole Keller contributed to this article.

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

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

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

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

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

Panelists

Anna Edney
Bloomberg

@annaedney

Read Anna's stories.

Joanne Kenen
Johns Hopkins University and Politico

@JoanneKenen

Read Joanne's articles.

Lauren Weber
The Washington Post

@LaurenWeberHP

Read Lauren's stories.

Among the takeaways from this week’s episode:

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

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

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

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

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

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

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

Also mentioned on this week’s podcast:

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

Click to open the transcript

Transcript: Newly Minted Doctors Are Avoiding Abortion Ban States

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

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

Lauren Weber: Hello. Hello.

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

Joanne Kenen: Hi, everybody.

Rovner: And Anna Edney of Bloomberg News.

Anna Edney: Hi there.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Kenen: Unsign.

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

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

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

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

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

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

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

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

Edney: Right.

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: And exacerbating health inequities that we already have.

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

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

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

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

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

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

Kenen: You speak English.

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

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

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

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

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

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

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

Rovner: Although they should —

Kenen: They should.

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

Kenen: They should.

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

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

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

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

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

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

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

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

Rovner: They’re tangentially involved.

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

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

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

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

Houghton: Hi.

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

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

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

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

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

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

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

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

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

Houghton: Exactly.

Rovner: And that’s not what happened.

Houghton: Not at all.

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

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

Rovner: So that’s a big difference.

Houghton: A very big difference.

Rovner: Was Cass expected to pay the rest?

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

Rovner: So what eventually happened?

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

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

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

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

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

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

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

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

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

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

Houghton: Thank you so much.

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

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

Rovner: It is. Joanne?

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

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

Rovner: Yeah. It really was. Lauren?

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

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

As we mentioned, this is all still under — in court, in various places at various levels — but I do think it’s one of the next big battles that are shaping up in reproductive health. It’s a really good piece. OK, that is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at Twitter, @jrovner, or @julierovner at Bluesky and @julie.rovner at Threads. Joanne, are you hanging anywhere on social media?

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

Rovner: Anna?

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

Rovner: Lauren?

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

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

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Las pruebas han detectado el virus en el ganado en nueve estados, principalmente en Texas y Nuevo México, y más recientemente en Colorado, dijo Nirav Shah, director principal adjunto de los Centros para el Control y Prevención de Enfermedades (CDC), en un evento del 1 de mayo.

Otros animales, y al menos una persona en Texas, también se infectaron con el H5N1. Pero lo que más temen los científicos es si el virus se propagara de manera eficiente de persona a persona. Eso no ha sucedido y podría no suceder. Shah dijo que los CDC consideran que el brote de H5N1 “es un riesgo bajo para el público en general en este momento”.

Los virus evolucionan y los brotes pueden cambiar rápidamente. “Como con cualquier brote importante, esto se mueve a la velocidad de un tren bala”, dijo Shah. “De lo que hablamos ahora es de un instantánea de ese tren que se mueve rápidamente”. Lo que quiere decir es que lo que hoy se sabe sobre la gripe aviar H5N1 seguramente cambiará.

Con eso en mente, KFF Health News explica lo que se necesita saber ahora.

¿Quién contrae el virus que causa la gripe aviar?

Principalmente las aves. Sin embargo, en los últimos años, el virus de la gripe aviar H5N1 ha estado saltando cada vez más de las aves a los mamíferos en todo el mundo. La creciente lista, de más de 50 especies, incluye focas, cabras, zorrinos, gatos y perros salvajes en un zoológico en el Reino Unido. Al menos 24,000 leones marinos murieron en brotes de gripe aviar H5N1 en Sudamérica el año pasado.

Lo que hace que el brote actual en el ganado sea inusual es que se está propagando rápidamente de vaca a vaca, mientras que los otros casos, excepto las infecciones de leones marinos, parecen limitados. Los investigadores saben esto porque las secuencias genéticas de los virus H5N1 extraídos de las vacas este año eran casi idénticas entre sí.

El brote de ganado también preocupa porque agarró al país desprevenido. Los investigadores que examinan los genomas del virus sugieren que originalmente se transmitió de las aves a las vacas a finales del año pasado en Texas, y desde entonces se ha propagado entre muchas más vacas de las que se han examinado.

“Nuestros análisis muestran que esto ha estado circulando en vacas durante unos cuatro meses, bajo nuestras narices”, dijo Michael Worobey, biólogo especializado en evolución de la Universidad de Arizona en Tucson.

¿Es este el comienzo de la próxima pandemia?

Aún no. Pero es algo que vale la pena considerar porque una pandemia de gripe aviar sería una pesadilla. Más de la mitad de las personas infectadas por cepas anteriores del virus de la gripe aviar H5N1 de 2003 a 2016 murieron.

Incluso si las tasas de mortalidad resultan ser menos severas para la cepa H5N1 que circula actualmente en el ganado, las repercusiones podrían implicar muchas personas enfermas y hospitales demasiado abrumados para manejar otras emergencias médicas.

Aunque al menos una persona se infectó con el H5N1 este año, el virus no puede provocar una pandemia en su estado actual.

Para alcanzar este horrible estatus, un patógeno necesita enfermar a muchas personas en varios continentes. Y para lograrlo, el virus H5N1 necesitaría infectar a toneladas de personas. Eso no sucederá a través de saltos ocasionales del virus de los animales de granja a las personas. Más bien, el virus debe adquirir mutaciones para propagarse de persona a persona, como la gripe estacional, como una infección respiratoria transmitida principalmente por el aire cuando las personas tosen, estornudan y respiran.

Como aprendimos de covid-19, los virus transmitidos por el aire son difíciles de frenar.

Eso aún no ha sucedido. Sin embargo, los virus H5N1 ahora tienen muchas oportunidades para evolucionar a medida que se replican dentro de los organismos de miles de vacas. Como todos los virus, mutan a medida que se replican, y las mutaciones que mejoran la supervivencia del virus se transmiten a la próxima generación. Y debido a que las vacas son mamíferos, los virus podrían estar mejorando en reproducirse dentro de células más cercanas a las nuestras que las de las aves.

La evolución de un virus de gripe aviar listo para una pandemia podría facilitarse por una especie de superpoder que poseen muchos virus. Es decir, a veces intercambian sus genes con otras cepas en un proceso llamado recombinación.

En un estudio publicado en 2009, Worobey y otros investigadores rastrearon el origen de la pandemia del virus de la gripe porcina H1N1 en eventos en los que diferentes virus que causaban esta gripe, la gripe aviar y la gripe humana mezclaban y combinaban sus genes dentro de cerdos que se estaban infectando simultáneamente. Los cerdos no necesitan estar involucrados esta vez, advirtió Worobey.

¿Comenzará una pandemia si una persona bebe leche contaminada con el virus?

Aún no. La leche de vaca, así como la leche en polvo y la fórmula infantil, que se venden en tiendas se consideran seguras porque la ley requiere que toda la leche vendida comercialmente sea pasteurizada. Este proceso de calentar la leche a altas temperaturas mata bacterias, virus y otros microorganismos.

Las pruebas han identificado fragmentos de virus H5N1 en la leche comercial, pero confirman que los fragmentos del virus están muertos y, por lo tanto, son inofensivos.

Sin embargo, la leche “cruda” no pasteurizada ha demostrado contener virus H5N1 vivos, por eso la Administración de Drogas y Alimentos (FDA) y otras autoridades sanitarias recomiendan firmemente a las personas que no la tomen, porque podrían enfermarse de gravedad o algo peor.

Pero, aún así, es poco probable que se desate una pandemia porque el virus, en su forma actual, no se propaga eficientemente de persona a persona, como lo hace, por ejemplo, la gripe estacional.

¿Qué se debe hacer?

¡Mucho! Debido a la falta de vigilancia, el Departamento de Agricultura (USDA) y otras agencias han permitido que la gripe aviar H5N1 se propague en el ganado, sin ser detectada. Para hacerse cargo de la situación, el USDA recientemente ordenó que se sometan a pruebas a todas las vacas lecheras en lactancia antes que los ganaderos las trasladen a otros estados, y que se informen los resultados de las pruebas.

Pero al igual que restringir las pruebas de covid a los viajeros internacionales a principios de 2020 permitió que el coronavirus se propagara sin ser detectado, testear solo a las vacas que se mueven entre estados dejaría pasar muchos casos.

Estas pruebas limitadas no revelarán cómo se está propagando el virus entre el ganado, información que los ganaderos necesitan desesperadamente para frenarlo. Una hipótesis principal es que los virus se están transfiriendo de una vaca a la siguiente a través de las máquinas utilizadas para ordeñarlas.

Para aumentar las pruebas, Fred Gingrich, director ejecutivo de la American Association of Bovine Practitioners, dijo que el gobierno debería ofrecer fondos a los ganaderos para que informen casos y así tengan un incentivo para hacer pruebas. De lo contrario, dijo, informar solo daña la reputación por encima de las pérdidas financieras.

“Estos brotes tienen un impacto económico significativo”, dijo Gingrich. “Los ganaderos pierden aproximadamente el 20% de su producción de leche en un brote porque los animales dejan de comer, producen menos leche, y parte de esa leche es anormal y no se puede vender”.

Gingrich agregó que el gobierno ha hecho gratuitas las pruebas de H5N1 para los ganaderos, pero no han presupuestado dinero para los veterinarios que deben tomar muestras de las vacas, transportar las muestras y presentar los documentos. “Las pruebas son la parte menos costosa”, explicó.

Si las pruebas en las granjas siguen siendo esquivas, los virólogos aún pueden aprender mucho analizando secuencias genómicas del virus H5N1 de muestras de ganado. Las diferencias entre las secuencias cuentan una historia sobre dónde y cuándo comenzó el brote actual, el camino que recorre y si los virus están adquiriendo mutaciones que representan una amenaza para las personas.

Sin embargo, esta investigación vital se ha visto obstaculizada porque el USDA publica los datos incompletos y con cuentagotas, dijo Worobey.

El gobierno también debería ayudar a los criadores de aves de corral a prevenir brotes de H5N1, ya que estos matan a muchas aves y representan una amenaza constante de potenciales saltos de especies, dijo Maurice Pitesky, especialista en enfermedades de aves de la Universidad de California-Davis.

Las aves acuáticas como los patos y los gansos son las fuentes habituales de brotes en granjas avícolas, y los investigadores pueden detectar su proximidad mediante el uso de sensores remotos y otras tecnologías. Eso puede significar una vigilancia rutinaria para detectar signos tempranos de infecciones en aves de corral, usar cañones de agua para ahuyentar a las bandadas migratorias, reubicar animales de granja o llevarlos temporalmente a cobertizos. “Deberíamos estar invirtiendo en prevención”, dijo Pitesky.

Bien, no es una pandemia, pero ¿qué podría pasarle a las personas que contraigan la gripe aviar H5N1 de este año?

Realmente nadie lo sabe. Solo una persona en Texas fue diagnosticada con la enfermedad este año, en abril. Esta persona trabajaba con vacas lecheras, y tuvo un caso leve con una infección en el ojo. Los CDC se enteraron de esto debido a su proceso de vigilancia. Las clínicas deben alertar a los departamentos de salud estatales cuando diagnostican a trabajadores agrícolas con gripe, utilizando pruebas que detectan virus de la influenza en general.

Los departamentos de salud estatales luego confirman la prueba y, si es positiva, envían una muestra de la persona a un laboratorio de los CDC, donde se verifica específicamente la presencia del virus H5N1. “Hasta ahora hemos recibido 23”, dijo Shah. “Todos menos uno resultaron negativos”.

Agregó que funcionarios del departamento de salud estatal también están monitoreando a alrededor de 150 personas que han pasado tiempo alrededor de ganado. Están en contacto con estos trabajadores agrícolas con llamadas telefónicas, mensajes de texto o visitas en persona para ver si desarrollan síntomas. Y si eso sucede, les harán pruebas.

Otra forma de evaluar a los trabajadores agrícolas sería testear su sangre en busca de anticuerpos contra el virus de la gripe aviar H5N1; un resultado positivo indicaría que podrían haberse infectado sin saberlo. Pero Shah dijo que los funcionarios de salud aún no están haciendo este trabajo.

“El hecho de que hayan pasado cuatro meses y aún no hayamos hecho esto no es una buena señal”, dijo Worobey. “No estoy muy preocupado por una pandemia en este momento, pero deberíamos comenzar a actuar como si no quisiéramos que sucediera”.

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

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