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Julie Rovner
KFF Health News

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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.

This week, KFF Health News’ weekly policy news podcast — “What the Health?” — celebrates its 300th episode with a wide-ranging discussion of what’s happened in health policy since it launched in 2017 and what may happen in the next decade.

For this special conversation, host and chief Washington correspondent Julie Rovner is joined by three prominent “big thinkers” in health policy: Ezekiel Emanuel of the University of Pennsylvania; Jeff Goldsmith, president of Health Futures; and Farzad Mostashari, CEO of Aledade.

Among the takeaways from this week’s episode:

• Since 2017, dissatisfaction has permeated the U.S. health care system. The frustrations of providers, patients, and others in the field point to a variety of structural problems — many of which are challenging to address through policymaking due to the strength of interest-group politics. The emergence of the huge, profitable “SuperMed” firm UnitedHealth Group and the rise of urgent virtual care have also transformed health care in recent years.
• As high costs and big profits dominate the national conversation, lawmakers and policymakers have delivered surprises, including the beginnings of regulation of drug prices. Even the Trump administration, with its dedication to undermining the Affordable Care Act, demonstrated interest in encouraging competition. Meanwhile, on the clinical side, a number of pharmaceuticals are proving especially effective at reducing hospitalizations.
• Looking forward, the face of insurance is changing. Commercial insurance is seeing profits evaporate, private Medicare Advantage plans are draining taxpayer dollars, and employers are making expensive, short-sighted coverage decisions. Some stakeholders see a critical need to reconsider how to be more efficient and effective at delivering care in the United States.
• The deterioration of the patient’s experience signals a major disconnect between the organizational problems providing care and the everyday dedication of individual providers: The local hospital may provide excellent service to a patient experiencing a heart attack, yet Medicare will not pay for patients to have blood pressure cuffs at home, for instance. Low reimbursements for primary care providers exacerbate these problems.

Plus, our experts — drawing on extensive experience making government and private-sector policy and even practicing medicine — name their top candidates for attainable improvements that would make a big difference in the health care system.

Further reading by the panelists from this week’s episode:

• Health Affairs’ “Nine Health Care Megatrends, Part 1: System and Payment Reform,” by Ezekiel J. Emanuel.
• Health Affairs’ “We Have a National Strategy for Accountable Care, So What’s Next?” by Sean Cavanaugh, Mandy K. Cohen, and Farzad Mostashari.
• The Health Care Blog’s “What Can We Learn From the Envision Bankruptcy?” by Jeff Goldsmith.

Click to open the transcript

Transcript: Our 300th Episode!

KFF Health News’ ‘What the Health?’

Episode Title: Our 300th Episode!

Episode Number: 300

Published: June 1, 2023

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

Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent at KFF Health News. Usually I’m joined by some of the best and smartest health reporters in Washington. But today is our 300th episode, and we have something special planned. Instead of our usual news panel, I’ve invited some of my very favorite health policy thinkers, to cast the net a little wider, and talk about what’s happened to the health care system since we began the podcast in 2017 and what the future of health care might look like for the next, I don’t know, decade or so. So let me introduce our panel. We will put their full bios in the show notes. Otherwise, it would take our entire episode to talk about all that they have done. But it’s safe to say that these are not just some of the smartest people in health care, but also among the most accomplished, with experience making government health policy, private health policy, and, in two of the three cases, also practicing medicine. First up, we have Zeke Emanuel. He’s currently the vice provost for global initiatives and the co-director of the Healthcare Transformation Institute at the University of Pennsylvania. Hi, Zeke. Thanks for joining us.

Ezekiel Emanuel: Great. Wonderful to be here.

Rovner: Next, we have Jeff Goldsmith. He’s president of Health Futures, a health industry consulting firm and a longtime thinker, writer, and lecturer on all things health care — and, I must confess, one of the people who’s implanted many things in my head about what I think about health care. Thanks for joining us, Jeff.

Jeff Goldsmith: It’s a pleasure.

Rovner: Finally, we have Farzad Mostashari, who’s the founder and CEO of Aledade, a company that works with primary care physician practices that he modestly describes on his LinkedIn page as, quote, “helping independent practices save American health care. Thanks for coming, Farzad.

Mostashari: Pleasure to be here, Julie.

Rovner: So I want to divide this conversation into two main parts, roughly titled “Where We’ve Been” and “Where We’re Going,” and where we’ve been in this case means things that have happened since 2017, when the podcast began. For those of you who don’t remember, that was the first year of the Trump presidency, in the middle of the ultimately unsuccessful Republican effort to repeal and replace “Obamacare” and President Trump’s various executive decisions to try to undermine the Affordable Care Act in other ways. Anybody remember that fight over cost-sharing reductions? Let us please not recap that. So let us start not with cost sharing, but with the state of health care in 2017. I want to go around. What does each of you think is the biggest change in the health care system since 2017? Zeke, why don’t you start?

Emanuel: I think probably the biggest change is the growing dissatisfaction by every player in the system. I often say that if you remember back to 2010 — Farzad and I certainly remember, because of passage of the ACA — a lot of people were dissatisfied with the system. But frankly, the upper-middle-class hospitals were not dissatisfied with the system. And mostly the upper middle class could still call — get, you know, VIP care and make sure that they got their needs met. I don’t know anyone — anyone — in 2023 who is happy with the system; maybe there are a few people in the insurance industry who are for this very moment because their profits are higher. But everyone else, including every upper-middle-class and rich person I know, is pissed off and doesn’t think they’re getting good care and is just — doesn’t like the system. And I think that bespeaks very deep structural problems with our system. Different parts are actually doing fantastic, if you want to know the truth, in my opinion, like Farzad’s company giving great primary care, but the whole system sucks. And that I think is probably the biggest change. And again, it bespeaks burnout, it bespeaks payment problems, it bespeaks lots of other underlying problems.

Rovner: I feel like I know that that was growing leading up to the Affordable Care Act, how much the industry and everybody else just didn’t think the system was working, but I think it’s turning into anger. Jeff, what do you think is the biggest change since 2017?

Goldsmith: Well you know, for me, I guess the biggest surprise for me would be we finally got a “SuperMed.” You remember … [unintelligible] … thing about how we’re going to have 10 health systems that — you know, the entire country will be divided into 10 health systems. I think the biggest change has been the arrival of our first SuperMed, which is UnitedHealth Group. It’s doubled in size since 2016. It’s closing in on 3 billion a month in cash flow. So, I mean, I think we may not get another one, but we’ve certainly got one. And it’s on its way to being 10% of health care.

Rovner: And it’s very much — I mean, for people who don’t know — it’s very much more than an insurance company now.

Goldsmith: Yeah, it is. The insurance company is kind of a drag on earnings compared to several other pieces.

Rovner: Farzad, what do you think has changed most since 2017?

Mostashari: I remember in 2017, it really felt like UnitedHealth Group, what they were doing with Optum, was like a secret almost, and it certainly is not anymore. I think I would say covid happened, and one of the main things that has absolutely changed as a result of that is the availability of urgent virtual care. And pretty much all of us now — my mom, through her health system portal; my daughter, through her college portal; me, through my health plan portal — have access to basically hit a button and pretty quickly be able to see someone, usually a nurse practitioner, within a short amount of time. The consequences of that are going to be really interesting. I think, net, it is one of the few things that I think Zeke would agree is pleaser for people to be able to do that. But on the flip side of that, which is to be able to see a primary care doctor, for my parents, is three months out, and they’re 86 and they need to do it. So I think we’re seeing on the one hand, kind of a tale of two cities — like urgent, convenient care with someone who has no idea who you are is more available than ever, and longitudinal primary care with someone who has a long-term relationship with you is getting squeezed.

Rovner: I want to go around again. What’s the most unexpected change? And you don’t get to say the pandemic this time. Jeff, why don’t you start.

Goldsmith: Well, certainly the most unpleasant, unexpected change was the sudden flameout of Geisinger. That’s a really ominous development.

Rovner: Which we haven’t — we haven’t even talked about on the podcast yet. So you better give that a sentence or two.

Goldsmith: Well, Geisinger is — was — one of the elite multi-specialty clinics in the country. It was a follow-on to Mayo, 110-year-old, absolutely superb quality, and done everything in the integrated delivery system playbook. They had a large health plan. They had a widely distributed primary care network. They lost $840 million last year and were losing 20 million a month on operations — that’s arterial bleeding — and about six weeks ago announced a combination of some kind — don’t call it a merger — with Kaiser. It’s still not clear to me what they’ve done. But the big surprise to me was a $7 billion system that did everything you’re supposed to do ended up not being able to remain independent. That’s really scary to me.

Rovner: Yeah. Zeke, what surprised you the most?

Emanuel: I would say two things have surprised me the most. The first one was the fact that we got drug price regulation. Even that little bit we got, I think, very, very surprising. And I have to give credit to the administration. They’re using the small camel’s nose under the tent to really push it as big as they can, jawboning on insulin prices, etc. It’s far from ideal. You know, I’ve been as critical as anyone about the kind of compromises we had to make. But I think that we got something, and I think that’s really changed the psychology. So that would be one thing. The other thing, and here I may be attacked, is we’re still at 18% of GDP for health care spending. Predictions in 2010, even predictions in 2017, were to go over 20%. And we have actually — and it’s not because the economy has gone haywire on us; we’ve been growing at about 2% of GDP. Something is out there that is not as macro that has kept it — some of it’s high deductible, multifactorial. I do think that we also, you know, some of the things that Farzad mentioned, we’ve got virtual that is lower-cost. We do more home care. You know, hospital admissions continue to go down. Anyway, I do think that’s still a surprise. Now, people are feeling it because of high deductibles, because employers are transferring a lot more cost. Nonetheless, as a percent of GDP, it has remained flat for a decade.

Goldsmith: Right. It’ll be lower in ’22 than it was in ’21 when we finally get the numbers out.

Rovner: Farzad.

Mostashari: I want to continue on a little bit. It’s so easy to be pessimistic in health care and health policy. But again, some things that were a little bit — if you are so jaded and so scarred that you have very low expectations, even small victories, like Zeke said, end up being surprises to the upside. So I was surprised to the upside that the Trump administration, despite a lot of — you mentioned, a lot of efforts to undo the Affordable Care Act — were actually pretty good on value-based care and pretty good on turning attention to administrative simplification and to site-neutral payments and thinking about competition in health care markets. And those are obviously, all three of those, are things that the current administration’s support and is also continuing to push. So that was a pleasant surprise, I guess, to the to the upside.

Rovner: Also price transparency, right?

Mostashari: Yeah, I put that in the competition category. The other surprise is, for a long time — I spoke at a pharma group once, a bunch of CEOs, and I said, “Name me the drug that if I use more of it, there will be fewer hospitalizations.” And they kind of drew a blank, and they were like, “Well, vaccines?” And I was like, “OK, that’s pretty sad, right?” But now we actually have SGLT-2s, we have GLP-1s, like there’s actually a bunch of drugs that are going to be, I think, rightfully blockbusters that actually are making a big difference. And I think, in particular, the SGLT-2s I’m really excited about. They’re massively underutilized and I think —

Rovner: What are the SGLT-2s?

Mostashari: Zeke, you want to take this?

Emanuel: No, no, that’s you.

Mostashari: It’s a drug class that has proven to be pretty effective at reducing hospitalizations for people with congestive heart failure, with diabetes. And the more it’s studied, like — there’s a trend in pharma, right, or really anything, that, not what’s the first study with a second randomized trial, but what’s the fifth and sixth and seventh? Do they end up making the evidence stronger or reverting to the mean? And with these drug classes, they seem to be getting stronger and stronger and stronger and more and more generalized in terms of the potential benefit that they can bring. They’re expensive. But I remember a time when a lot of the drugs that are now generic were expensive. So if we take the long arc on this, I think this is going to be very good for health care.

Emanuel: Well, also, to the extent that they preempt hospitalizations, their cost-effectiveness — I don’t know what it is; I haven’t looked it up recently — but the cost-effectiveness is more reasonable, let us put it, than many other drugs that we get, particularly cancer drugs … [unintelligible].

Goldsmith: You know, there’s an even bigger one lurking out there if you’re talking about reducing hospitalizations, and that is the likelihood that we’ll have a dialysis-like solution for sepsis. There are a whole bunch of companies in this space. They’re attaching different molecules to the fibers. But we began seeing during covid, using some of these tools to take virus out of the blood, sepsis is a huge chunk of hospital utilization. It’s a huge chunk of expensive hospital utilization. And what, a third of the deaths, at least — if we could dialyze someone out of sepsis, I mean, it would be an enormous plus, both for health spending and for people’s lives.

Emanuel: I was just going to add one political element to what Farzad said first about the Trump administration, and this gets to how policy is made and the importance of personalities and people. There’s a whole school of history that people don’t matter, the blah, blah, blah. But the Trump administration’s interest in these various things, like price transparency, competition, site-neutral payments, and such, occurred only after they fired Secretary [of Health and Human Services Tom] Price. Secretary Price was sort of a health policy Neanderthal in that he wanted to go back to the 1950s. Many of your listeners will remember he greatly reduced their bundled payment experiments and randomized controlled trial by chopping it in, I think, half, or getting rid of a lot of places. He was totally for the old fee-for-service system, as an orthopedic surgeon, and I think once they got rid of him, actually the focus on, you know, how can we make this a better marketplace, which brings you, you know, not everything liberals can agree on that because many of the things go in, regulate prices and regulate access. And it’s an interesting thing. He had to be moved out for that change to actually happen.

Mostashari: But I’ll also say, though, putting political philosophy back in, not just personality, you look at what’s happening in Indiana, of all places, Zeke, where the legislature have been, I think, pretty forward on on some really great health policy stuff around, again, competition policy, noncompetes for doctors, certificate of need — like a whole bunch of stuff that have been anti-competitive, hospital price increasers they have taken square aim at. And I think that it aligns with like, if we’re going to have a market, like either we’re going to regulate really heavily, or we’re going to have a market-based approach that actually works, and you can’t have a market-based approach that works even a little if you have basically anti-competitive behaviors. So I think it actually does make sense.

Rovner: While we are on the subject of politics, the thing that I think most surprised me in the last seven years is that the pandemic did not convince everybody of the need for everybody to have some kind of health coverage. At the beginning, I thought, well, this is what’s going to get us to a national health plan, because everybody can get sick. And that didn’t happen. In fact, it feels like things got even more polarized. Did that surprise any of you guys or am I just being naive?

Goldsmith: We did get to a 91-million-person Medicaid program and a significant expansion of the exchanges. So it’s not like there wasn’t a realization that covering people had a salutary effect on the overall health of the population. It’s not clear that it lasted. I heard Sarah Huckabee Sanders on the radio the other day saying that throwing a bunch of people off of Medicaid was going to be liberating them from dependency. That was one of the most amazing Orwellian statements I’ve ever heard in my life. But it’s —

Emanuel: She thought if we got rid of her health insurance, it would liberate her from dependency?

Goldsmith: Oh, absolutely.

Mostashari: I do think that one of the things that took away that stink, though, Julie, was really pretty expansive and brave government action that made tests free, that made vaccines free, that made treatment, including monoclonals, free. If the concern was specifically the driver around covid, these programs that — 100% paid, regardless of your ability to pay, just like covered it at all, right? — I do think took away some of the drive that you were describing.

Rovner: And yet we’re peeling them all back one by one, you know, including —

Emanuel: Well, they were all emergency. I mean, all they have expansion was emergency. And, you know, that has to do with the way Washington budgets and all of that. I do think if we’re going to get to universal coverage, we’re going to have to get it in a way that keeps the costs under control. My own interpretation is we’ve reached the limit, and 18% is the limit. And if you want to get to 100% universal coverage, I can’t —

Mostashari: Oh, God, I can’t believe he just jinxed us like that.

Emanuel: I think that’s what the political economy says.

Rovner: You mean 18% of GDP?

Emanuel: Yeah. Yeah.

Goldsmith: But, Zeke, people are saying that when we got to 8, we were going to hit the wall. OK, you have a long enough memory, I mean —

Emanuel: I do, I do have that memory. But I do think you have seen more drastic action, as when things have gone up by employers to make it look less and less like insurance, frankly. And I do think that tells you where the limit is. And I think we’re going to have to think within that. And one of the things we have to do is be much more serious about areas where we have good evidence about cost savings. And we just haven’t done that. And for the last decade, every hospital — and I always talk about cost — but it’s a lot easier to negotiate higher rates from commercial than it is to actually be more efficient. And so what do they do? Focus on negotiating higher rates and have much more brains focusing on that than doing the time-motion studies to get efficient. Until they are forced, they’re not going to do that kind of efficiency. And that’s the thing. And you can’t do it on a dime. That’s the other thing, I think, partially that the Geisinger says: You can’t do the efficiency on a dime.

Goldsmith: Isn’t losing $20 million a month sort of a goad to action? I mean —

Emanuel: Well, Jeff, Jeff, here’s the question. I agree. But it couldn’t induce Geisinger to change fast enough. I mean, they didn’t have enough runway. If they were losing, that’s the first thing. And whether other hospitals and health systems are going to say, “Well, we have to get serious today,” I don’t know. I’m not privileged to their internal deliberations. I will say that, over the last decade, they’ve just continued the old playbook, as I’ve argued.

Mostashari: But I think that’s right, Zeke. But that’s what doesn’t give me hope in terms of your 18% political economy ceiling, because who’s going to make it, you know, like — and I don’t see the employers. I’d say if there’s one thing where there hasn’t been much change has been the employers continue to disappoint.

Rovner: Actually, Farzad, you’ve walked right into my next question, because I want to pivot to what’s going to happen, which is, who’s going to drive the health care train for the next decade?

Emanuel: I think employers are brain-dead on this. They are the worst part of the legion because they control all the profit and they have been terrible. They have chased very short-term profits or very short-term savings. What? Yeah, I know, I, well no, but —

Rovner: Farzad, Farzad’s making air quotes.

Emanuel: Farzad’s making the quotes, but absolutely it’s not been savings, but they’ve been listening to consultants who sold them a bill of goods and they haven’t been serious. And you know, to be honest, when you get something like Haven and you’ve got companies like J.P. Morgan and Amazon and Berkshire Hathaway making a hash of it, “What could I do?” is I think the response, and what they have to do is they have to get together and get out of health care in a responsible way, and that they are — they just, they can’t focus enough mind share on it.

Rovner: Even with, what was it, Amazon and J.P. Morgan? And I forget what the third one was.

Goldsmith: But Zeke, you know, right now the most profitable service line for those insurers isn’t commercial insurance; it’s Medicare Advantage

Emanuel: Yeah.

Goldsmith: And if I were to be a forecasting person, which I tend to do sometimes —

Emanuel: You are?

Goldsmith: I think, I think the profit is rapidly disappearing from commercial insurance, not only because more and more insurers are self-funded, or employers are self-funded and taking themselves out of the equation, but because the government can’t say no to its contractors — state governments, federal government. So I’m actually very concerned about the disappearance of the lever that commercial insurance represented in the emergence of a kind of a rent-seeking health insurance system.

Mostashari: That underscores the need, if more and more employers are self-insured, then they’re going to need to act. They can’t rely on the insurer; they need to demand something different than what they’ve been demanding from the TPAs [third-party administrators]. And I think that’s the opportunity, if I was going to be an optimist. I think that’s the opportunity. To Zeke’s point, from the beginning, everyone is unhappy. And if someone did come up with a TPA that promised cost corridors, as an example, more predictability, free stop loss, you know, like those kind of things and actually delivered slower trend, guaranteed lower trend on your rates. I think there’s room for that, but as Zeke said, not if they just keep listening to the same consultants.

Goldsmith: But Farzad, what seems to me has held them back is that their interest in health benefits cost is cyclical. When they’re awash in cash, they’re mainly interested in more cash; they’re not interested in tuning their health benefit and chasing away scarce workers. And right now, that scarcity of workers is one of the things that’s holding employers back from tightening down or fundamentally changing the logic of their health coverage — is that they are competing, particularly in the skilled part of our economy, for workers that they’re really having trouble getting. And to walk in the door and saying, “Well, we’re going to place all these conditions on, and we’re going to make you do X, Y, and Z,” they’re not going to do it.

Mostashari: I think the TPA 2.0, though — I agree with you that there’s typically been a zero-sum game around this between the employer and employee when it comes to less benefits, higher copays, higher deductibles, like, you’re taking something away from them. But you mentioned Medicare Advantage. What I think the promise has been there is you get more; the member gets more access to primary care or more benefits but for the same cost. And I agree with your facial expression there that our —

Goldsmith: I’m on Medicare Advantage. I mean, it’s just been a great big whoop. The main user experience has been robocalls, and I get about one every two months to send a nurse to my house to upcode me. That’s my Medicare Advantage experience. Big whoop.

Emanuel: So let me just say two things, one of which is I think the fact is that employers don’t have to go down the punitive route to have lower costs; they could focus on the provider and reorganize that system. And the problem of everyone in the system is just thinking about how do I screw the other provider, right? You know, how do I make doctors go through all this prior authorization so they won’t order that drug or they won’t order that MRI? That’s not a way to improve the system. That’s a way to make everyone pissed off.

Rovner: It’s doing a very good job at that.

Emanuel: Yeah, including the patient. Everyone hates it, and no one’s willing to get rid of it. I think Farzad is right; you need a total reconceptualization of how you’re going to deliver care so the answer is yes, not no. And what you get is better thinking so we’re more efficient and we get rid of the unnecessary stuff so that we can actually devote our time and attention and resources to people who need it. The second thing I would say, Jeff, is I think the wallowing and, and getting all the cream from Medicare Advantage is going to come to an end. I think the administration has sort of — you know, when you’re over 50% of the people and there’s all these articles coming out over and over again, you — I mean one of the things they haven’t realized — you end up in Washington putting a big target on your face. And Washington likes nothing more than, “These people are ripping off the government, and now we’re going to penalize them.” And I will say, you know, personally, we’ve started a very large project to try to fix the risk adjustment mechanism. We also need a large project, in my humble opinion, on fixing the fee structure, which is totally perverted.

Rovner: The fee structure for everybody or the fee structure for Medicare?

Emanuel: Well, if you fix it for Medicare, you’re going to fix it for everyone since they take Medicare prices and just inflate ’em. But I think those two things are going to happen, actually, if I had to say, over the next decade, and I do think the days of just getting tons of profit from Medicare Advantage are numbered.

Goldsmith: Well, but the way that’s going to work is, to sustain the 5% and to prevent their stock prices from falling, they’re going to come after providers hammer and tongs.

Rovner: They [being] the insurers, the Medicare Advantage companies.

Goldsmith: They’re just going to cut the rates. They’re not going to really, fundamentally — they’re not going to shift risks, Zeke. They’re not going to capitate them; they’re just going to cut the rates. So I think part of the dynamic there is you’re going to have the hospital folks kind of behind the scenes going, “Don’t cut Medicare Advantage, because we’re the people that are eventually going to bleed for it.” So I think the politics of doing this is actually a whole lot more complicated. You’re dead right; the mask is dropped. There’s a lot of games being played. But fixing it is going to be really hard politically.

Emanuel: Jeff, I agree with you. I think one of the major issues hospitals have to do — look, during covid, one of the tragedies is the government handed out $70 billion to hospitals and asked nothing in return. There was no, “Change this,” “focus on —”

Goldsmith: They asked them to stay open, Zeke They asked them to stay open 24/7 and to, you know, have their emergency room burn out and to suspend their elective care. What do you mean they didn’t ask them to do anything? They had to do those things to respond to the, the pandemic. Now, you’re saying you didn’t attach additional conditions about efficiency. Dead right, they didn’t.

Emanuel: Yeah.

Goldsmith: You’re right.

Emanuel: There was no structural change. $70 billion is a whole lot of money. And we ask no structural change for it. So we’re actually in a worse situation with hospitals today than we were before. And $70 went out the window.

Rovner: 70 billion.

Mostashari: Zeke and I first met when I was at the White House, the NEC [National Economic Council] or something, and we were arguing about $28 billion to take health care from paper and pen to electronic health records. And it seemed like a lot of money, 28 billion, to digitize American health care and, as Zeke is saying, 70 billion went out the door.

Goldsmith: Well, but, but remember what was going on. There was an authentic, bottomless national emergency. And we ended up throwing $6 trillion, $6 trillion, forget about 70 billion. We ended up throwing $6 trillion worth of money that we borrowed from our grandkids at that bottomless problem — not only covid, but the economic catastrophe that covid produced, the flash depression that the shutdowns produced. So there wasn’t a lot of time for fine-tuning the policy message here; it was shovel it out the door and pray.

Emanuel: Jeff, I agree. We had to rescue a very desperate situation. But it’s not as if the last decade hadn’t given us plenty of things that we could have asked the hospitals to do. Unlike —look, look, in 2009, when we were crafting the Affordable Care Act, I called around to everyone. I said, “All right, we got to change off fee-for-service to … [unintelligible]. What’s the best method to get doctors to do the right thing, to get standardized care, to reduce the inefficiencies,” blah, blah, blah. We hadn’t tried anything. 2021, 2020, we had actually better ideas about how we could implement change and actually make the system better. And we implemented … [unintelligible]. And that, I think, was a missed major opportunity.

Rovner: And actually that is sort of my next question. I want to bring this back to the patient. Zeke, you referred to this; the patient experience has gotten worse. We’ve heard it from everybody here. The more we can do to help people and cure them and treat their ailments, the more differentiated and diverse the system becomes and the much harder it is to navigate. I mean, is there any hope of doing something to improve the patient experience over maybe the next decade?

Goldsmith: Well, I’ll tell you. You asked Zeke; I got sick during 2015 to 2017. So after being a big expert on our health care system for 40 years, I actually used it: five major surgeries in 29 months. And my experience was very different than the picture you guys have been painting. Only three of the people that touched me were over the age of 40. That was a big difference. Getting rid of the boomers might help a lot, but I was astonished by the level of commitment and the team-based care that I got. They were all over it. It was really encouraging to me, scared to death though I was, that the level of service that I got — and I’m not an elite patient. I mean, in a couple of those instances, it was my local community hospital; it wasn’t the University of Chicago that was taking care of me. I was really pleasantly surprised by the level of teamwork and the commitment of the care teams that took care of me. It gave me hope that I didn’t have before.

Mostashari: And I think we always get into this when we start talking about organizations versus people, and the people — and there’s no one like the people in medicine, and they would do anything for their patients, they love their patients, and they’re trying to work against a system that structurally is against doing the right thing for the patient, that we know can help the patient. And there’s no doubt that once someone has a stroke, we spring into action. The question is, did that person have to have a stroke? How well are we doing at controlling blood pressure, Jeff? We suck at controlling blood pressure: 65% control rates. And we know that that’s going to prevent heart attacks and strokes. Once we — once someone has a heart attack, like, we will deliver excellent customer service to the person with a heart attack, and they will be grateful and they will say, “Doc, you saved my life,” but we won’t invest in allowing people to have Medicare to pay for blood pressure cuffs at home, right? Like, that’s what we are grappling with in health care and medicine, is that disjunct between the organizational incentives and delivery system that follows from it versus the dedication and the compassion of the people in it every day.

Emanuel: So, Julie, one of the things I would say over the next decade that we have to do, and here you have a specialist bowing to Farzad, which is we have to pay more for primary care. Right now, the system pays something like 7%. And in some markets like mine, in Philadelphia, it’s under 5%. It’s outrageously bad, that amount. We have to give primary care doctors more and expect more out of them. What do we have to expect? Chronic care coordination. The primary care doc ought to be your navigator, and we need to have them or someone in their practice, is the first line for mental health and behavioral health services, right? That kind of package, including, you know — and we could go on — extended office hours, etc., etc. That has to happen. And us specialists, my kind of folk, we need to be less. And I think that has got to be one of the shifts we make that will make the patient experience better; I think it’ll make the management of these chronic illnesses like hypertension — I’m completely on board with Farzad; that should be focus, focus, focus. I think that’s a critical change. And what gives me hope — again, I’m by nature a very optimistic person — what gives me hope is Farzad’s company and the 20 others in that space that are doing a bang-up job of primary care and showing that it can be done and it can be done well and cost-effectively and better for patients, and I think we have to embrace that. And one of the things that’s going to be critical is more value-based payments, changing the physician fee schedule, and things like that.

Goldsmith: Well, not to disagree at all that there’s an absurd pay gradient between primary care physicians and specialists, but think about why we have so many specialists in the first place and why they have so much political power and influence in our health policy environment. A lot of the young people that are coming out of medical training today are carrying 3 or 400 grand in debt. That is very different than Europe, where we’re not expecting people to bear this huge burden in going into medicine. Wouldn’t it be easier for people to go into primary care if they didn’t have to worry about the fact that if they go into primary care, they’re going to be 65 and on Medicare before those debts are paid off, and maybe not at all. So we’ve created some of this by how expensive medical education is, by how expensive general education is, for that matter. And we’re not going to do anything about that.

Emanuel: And the solution to that is trivial, right? It might be a $30 billion solution, which would be, you know, whatever — .07% tax on every dollar poured into a fund to fund education. It’s idiocy.

Goldsmith: But politically, Zeke, what you’re doing is giving $30 billion to the wealthiest professional group in the country. That’s the way it’s going to play politically. How are those folks in Alabama, you know, that are, they’re on Medicaid, going to view taking $30 billion and giving it to your kids or grandkids that want to be doctors?

Emanuel: I totally agree with you. It needs to be … [unintelligible].

Mostashari: I don’t disagree that there’s a big difference in cost of medical education here versus other countries. I do wonder, though, in that hypothetical where we make medical education free, if you still have the kind of disparities in pay between the anesthesiology and the surgeon and the primary care doc. I still think we’re — we would be in a place where primary care slots went unfilled this year.

Goldsmith: Not surprising.

Mostashari: Right.

Goldsmith: Not surprising at all.

Mostashari: And we have a big shortage. And, you know, we have urologists who employ 17 nurses and other people to increase the throughput of the practice, right? And a primary care capacity, a lot of that could be augmented. You don’t need necessarily to wait until we graduate a whole new crop of doctors. We could actually supplement our primary care capacity if there was more money in primary care. And as Zeke says, I don’t mean just increasing the fee schedule or just paying more, although that would be nice, but tying it to outcomes that actually make it so that we can pay more for primary care in a way that’s budget-neutral.

Emanuel: But it’s a crazy thing because all we would have to do is spend 3% more of total medical spending on primary care. And guess what? You’d increase their revenue 50%. And that would, Farzad’s — that would make — that would be transformative. And you could get that 3%, you know, 1½ from hospitals, from specialists, from other, and they would barely — well, … [unintelligible] … hospitals might notice. But in general, it wouldn’t be a tragedy to any other part of the system. And that’s the insanity of where we’re at. And as Jeff, I think correctly, points out, is, you know, the political optics of this and the political power of these various different groups going to marshal against it — I mean, you could take 1% of it from pharma, easy, maybe even 2% from pharma, easy. The thing which makes me pessimistic now — I was optimistic, now pessimistic — the thing which makes me pessimistic is the sclerosis which makes these kind of structural changes impossible, and that’s basically interest group politics. And it doesn’t cost much. That’s what’s crazy. You know, United can spend $1 billion a year running ads against various congresspeople to keep its position, and its profit margin wouldn’t be affected.

Rovner: All right. We can go on all day. I would love to go on all day, but I know you guys have places to get, so I want to ask one last question of each of you. If there’s one piece of low-hanging fruit that we could accomplish to, I won’t say fix the health care system, but to make it better over the next decade, what would it be? If you could wave a wand and just change one small part of the system?

Goldsmith: We need a Medicare formulary. I’m sorry, we need a Medicare formulary, and we need to basically put a bullet in the PBM [pharmacy benefit manager] business on the way to doing it. That would be mine. And that would free up tens of billions of dollars that we could use to finance some of the stuff that Zeke and Farzad have been talking about.

Rovner: I think that may be the one thing that Congress is actively looking at, so —

Goldsmith: We’ll see how far they get.

Rovner: Yeah. Farzad.

Mostashari: I think we talked about it: competition. I think there’s a — there needs to be a coordinated government regulatory, DOJ [Department of Justice], [Department of] Commerce, CMS [Centers for Medicare & Medicaid Services] response to competition policy — FTC [Federal Trade Commission], obviously — that looks at all the different issues: the payment policies that are digging the hole deeper, like site-neutral payments. I think you need to look at the nonprofit hospitals and which jurisdiction applies to them. I think you need to look at transparency. I think you need to look at transparency around ownership of physician practices. I think there needs to be noncompetes. I think there needs to be a whole set of things that tilt the field towards more competition in health care markets, because if you are big and have, you know, the will to use that market power to say all-or-none contracting, no tiering, no steering, no — none of that, right — then there’s just no purchase for any health care payment or delivery reforms, because you’re big and fat and happy and you don’t care.

Rovner: And you’re making your shareholders happy. Zeke.

Emanuel: Let me give one clinical and one that’s more policy. So the clinical is, Farzad already mentioned it, if we would focus on controlling blood pressure well in this country. We’ve got more than a hundred guidelines, you’ve got cheap, 200 drugs for this. It would both improve longevity, decrease morbidity, and reduce disparities, that single thing. And Farzad is the one who turned me on. I know exactly the place on our walks that he put the bug in my ear about it. We should be focused on that because, among other things, it’s a huge producer of disparities between Blacks and whites in terms of renal failure, blah, blah, blah. The one policy thing I think is we know we spend a trillion dollars on administration. It’s a ludicrous amount of money. We know what the solutions are, and a lot of them don’t require that much policy. What we need is someone in the federal government whose job it is to wake up every day and get that money going. Now, the federal government wouldn’t make that much of it, by the way. That’s one of the reasons the federal government hasn’t taken this on, because they do have standardized billing and blah, blah, blah. But everyone agrees that’s a ridiculous amount of money and it’s producing no health benefit. If anything, it’s producing stress, which is not a good thing. And I think the conservative estimates by David Cutler and Nikhil [Sahni] are, you know, we’re talking $250 billion. I mean, that’s real, real money. And it’s no health benefit, and no one likes that stuff. And a lot of it’s about gaming. And so I think that’s a place — and you’d, again, have to put some serious government backbone, including threats, behind it. But I think that’s free money.

Rovner: Well, we will see if any of this happens. I could go on all afternoon, but I promised I would let you all get back to your day jobs. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks, as always, to our ever-patient producer, Francis Ying, for helping gather all of this together. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can tweet me. I’m @jrovner. We will be back in your feed next week. Until then, be healthy.

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If the experience and the insurer’s explanation often seem arbitrary and absurd, that might be because companies appear increasingly likely to employ computer algorithms or people with little relevant experience to issue rapid-fire denials of claims — sometimes bundles at a time — without reviewing the patient’s medical chart. A job title at one company was “denial nurse.”

It’s a handy way for insurers to keep revenue high — and just the sort of thing that provisions of the Affordable Care Act were meant to prevent. Because the law prohibited insurers from deploying previously profit-protecting measures such as refusing to cover patients with preexisting conditions, the authors worried that insurers would compensate by increasing the number of denials.

And so, the law tasked the Department of Health and Human Services with monitoring denials both by health plans on the Obamacare marketplace and those offered through employers and insurers. It hasn’t fulfilled that assignment. Thus, denials have become another predictable, miserable part of the patient experience, with countless Americans unjustly being forced to pay out-of-pocket or, faced with that prospect, forgoing needed medical help.

A recent KFF study of ACA plans found that even when patients received care from in-network physicians — doctors and hospitals approved by these same insurers — the companies in 2021 nonetheless denied, on average, 17% of claims. One insurer denied 49% of claims in 2021; another’s turndowns hit an astonishing 80% in 2020. Despite the potentially dire impact that denials have on patients’ health or finances, data shows that people appeal only once in every 500 cases.

Sometimes, the insurers’ denials defy not just medical standards of care but also plain old human logic. Here is a sampling collected for the KFF Health News-NPR “Bill of the Month” joint project.

• Dean Peterson of Los Angeles said he was “shocked” when payment was denied for a heart procedure to treat an arrhythmia, which had caused him to faint with a heart rate of 300 beats per minute. After all, he had the insurer’s preapproval for the expensive ($143,206) intervention. More confusing still, the denial letter said the claim had been rejected because he had “asked for coverage for injections into nerves in your spine” (he hadn’t) that were “not medically needed.” Months later, after dozens of calls and a patient advocate’s assistance, the situation is still not resolved.
• An insurer’s letter was sent directly to a newborn child denying coverage for his fourth day in a neonatal intensive care unit. “You are drinking from a bottle,” the denial notification said, and “you are breathing on your own.” If only the baby could read.
• Deirdre O’Reilly’s college-age son, suffering a life-threatening anaphylactic allergic reaction, was saved by epinephrine shots and steroids administered intravenously in a hospital emergency room. His mother, utterly relieved by that news, was less pleased to be informed by the family’s insurer that the treatment was “not medically necessary.”

As it happens, O’Reilly is an intensive-care physician at the University of Vermont. “The worst part was not the money we owed,” she said of the $4,792 bill. “The worst part was that the denial letters made no sense — mostly pages of gobbledygook.” She has filed two appeals, so far without success.

Some denials are, of course, well considered, and some insurers deny only 2% of claims, the KFF study found. But the increase in denials, and the often strange rationales offered, might be explained, in part, by a ProPublica investigation of Cigna — an insurance giant, with 170 million customers worldwide.

ProPublica’s investigation, published in March, found that an automated system, called PXDX, allowed Cigna medical reviewers to sign off on 50 charts in 10 seconds, presumably without examining the patients’ records.

Decades ago, insurers’ reviews were reserved for a tiny fraction of expensive treatments to make sure providers were not ordering with an eye on profit instead of patient needs.

These reviews — and the denials — have now trickled down to the most mundane medical interventions and needs, including things such as asthma inhalers or the heart medicine that a patient has been on for months or years. What’s approved or denied can be based on an insurer’s shifting contracts with drug and device manufacturers rather than optimal patient treatment.

Automation makes reviews cheap and easy. A 2020 study estimated that the automated processing of claims saves U.S. insurers more than $11 billion annually.

But challenging a denial can take hours of patients’ and doctors’ time. Many people don’t have the knowledge or stamina to take on the task, unless the bill is especially large or the treatment obviously lifesaving. And the process for larger claims is often fabulously complicated.

The Affordable Care Act clearly stated that HHS “shall” collect the data on denials from private health insurers and group health plans and is supposed to make that information publicly available. (Who would choose a plan that denied half of patients’ claims?) The data is also supposed to be available to state insurance commissioners, who share with HHS the duties of oversight and trying to curb abuse.

To date, such information-gathering has been haphazard and limited to a small subset of plans, and the data isn’t audited to ensure it is complete, according to Karen Pollitz, a senior fellow at KFF and one of the authors of the KFF study. Federal oversight and enforcement based on the data are, therefore, more or less nonexistent.

HHS did not respond to requests for comment for this article.

The government has the power and duty to end the fire hose of reckless denials harming patients financially and medically. Thirteen years after the passage of the ACA, perhaps it is time for the mandated investigation and enforcement to begin.

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On May 16, the FTC sued to block the merger of drugmakers Amgen and Horizon Therapeutics, saying the tangled web of drug industry deal-making would enable Amgen to leverage the monopoly power of two top Horizon drugs that have no rivals.

In its lawsuit, the FTC said that if it allowed Amgen’s $27.8 billion purchase to go through, Amgen could pressure the companies that manage access to prescription drugs — pharmacy benefit managers, or PBMs — to boost the two extremely expensive Horizon products in a way that would inhibit any competition.

The suit, the first time since 2009 that the FTC has tried to block a drug company merger, reflects Chair Lina Khan’s strong interest in antitrust action. In announcing the suit, the agency said that by fighting monopoly powers it aimed to tame prices and improve patients’ access to cheaper products.

The FTC’s action is a “shot across the bow for the pharmaceutical industry,” said Robin Feldman, a professor and drug industry expert at the University of California College of the Law-San Francisco. David Balto, a former FTC official and attorney who fought the 2019 Bristol-Myers Squibb-Celgene and 2020 AbbVie-Allergan mergers, said FTC’s action was long overdue.

The Horizon-Amgen merger would “cost consumers in higher prices, less choice, and innovation,” he said. “The merger would have given Amgen even more tools to exploit consumers and harm competition.”

The FTC also announced an expansion of a yearlong investigation of the PBMs, saying it was looking at two giant drug-purchasing companies, Ascent Health Services and Zinc Health Services. Critics claim the PBMs set up these companies to conceal profits.

When Amgen announced its purchase of Horizon in December — the biggest biopharma transaction in 2022 — it showed particular interest in Horizon’s drugs for thyroid eye disease (Tepezza) and severe gout (Krystexxa), for which the company was charging up to $350,000 and $650,000, respectively, for a year of treatment. The complaint said the merger would disadvantage biotech rivals that have similar products in advanced clinical testing.

Amgen could promote the Horizon drugs through “cross-market bundling,” the FTC said. That means requiring PBMs to promote some of Amgen’s less popular drugs — the Horizon products, in this case — in exchange for Amgen offering the PBMs large rebates for its blockbusters. Amgen has nine drugs that each earned more than $1 billion last year, according to the complaint, the most popular being Enbrel, which treats rheumatoid arthritis and other diseases.

The three biggest PBMs negotiate prices and access to 80% of prescription drugs in the U.S., giving them enormous bargaining power. Their ability to influence which drugs Americans can get, and at what price, enables the PBMs to obtain billions in rebates from drug manufacturers.

“The prospect that Amgen could leverage its portfolio of blockbuster drugs to gain advantages over potential rivals is not hypothetical,” the FTC complaint states. “Amgen has deployed this very strategy to extract favorable terms from payers to protect sales of Amgen’s struggling drugs.”

The complaint noted that biotech Regeneron last year sued Amgen, alleging that the latter’s rebating strategy harmed Regeneron’s ability to sell its competing cholesterol drug, Praluent. Amgen’s Repatha generated $1.3 billion in global revenue in 2022.

It “may be effectively impossible” for smaller rivals to “match the value of bundled rebates that Amgen would be able to offer” as it leverages placement of the Horizon drugs on health plan formularies, the complaint states.

Business analysts were skeptical that the FTC action would succeed. Until now the commission and the Department of Justice have shied away from challenging pharmaceutical mergers, a precedent that will be hard to overcome.

Research on the impact of mergers has shown that they often benefit shareholders by increasing stock prices, but hurt innovation in drug development by trimming research projects and staffing.

Waves of consolidation shrank the field of leading pharma companies from 60 to 10 from 1995 to 2015. Most of the mergers in recent years have involved “big fish buying up lots of little fish,” such as biotech companies with promising drugs, Feldman said.

The giant Amgen-Horizon merger is an obvious exception, and therefore a good opportunity for the FTC to demonstrate a “theory of harm” around drug industry bundling maneuvers with PBMs, said Aaron Glick, a mergers analyst with Cowen & Co.

But that doesn’t mean the FTC will win.

Amgen may or may not engage in anti-competitive practices, but “a separate question is, how does this lawsuit fit under current antitrust laws and precedent?” Glick said. “The way the law is set up today, it seems unlikely it will hold up in court.”

The FTC’s argument about Amgen’s behavior with Horizon products is hypothetical. The pending Regeneron suit against Amgen, as well as other, successful lawsuits, suggests that rules are in place to suppress this kind of anti-competitive behavior when it occurs, Glick said.

The judge presiding over the case in U.S. District Court in Illinois is John Kness, who was appointed by then-President Donald Trump and is a former member of the Federalist Society, whose membership tends to be skeptical of antitrust efforts. The case is likely to be settled by Dec. 12, the deadline for the merger to go through under current terms.

Amgen sought to undercut the government’s case by agreeing not to bundle Horizon products in future negotiations with pharmacy benefit managers. That promise, while hard to enforce, might get a sympathetic hearing in court, Glick said.

Still, even a loss would enable the FTC to shed light on a problem in the industry and what it sees as a deficiency in antitrust laws that it wants Congress to correct, he said.

The day after suing to stop the merger, the FTC announced it was pushing further into an investigation of pharmacy benefit managers that it began last June. The agency demanded information from Ascent and Zinc, the two so-called rebate aggregators — drug purchasing organizations set up by PBMs Express Scripts and CVS Caremark.

At a May 10 hearing, Eli Lilly & Co. CEO Dave Ricks said that most of the $8 billion in rebate checks his company paid last year went to rebate aggregators, rather than to the PBMs directly. A “big chunk” of the $8 billion went overseas, he said. Ascent is based in Switzerland, while Emisar Pharma Services, an aggregator established by PBM OptumRx, is headquartered in Ireland. Zinc Health Services is registered in the U.S.

Critics say the aggregators enable PBMs to obscure the size and destination of rebates and other fees they charge as intermediaries in the drug business.

The PBMs say their efforts reduce prices at the pharmaceutical counter. Testimony in Congress and in FTC hearings over the past year indicate that, at least in some instances, they actually increase them.

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El 16 de mayo, la FTC interpuso una demanda para bloquear la fusión de las farmacéuticas Amgen y Horizon Therapeutics, alegando que la enmarañada red de acuerdos de la industria  permitiría a Amgen aprovechar el poder monopolístico de dos de los principales medicamentos de Horizon que no tienen rivales.

En su demanda, la FTC alegó que si se permitía la compra que pretende Amgen por $27,800 millones, Amgen podría presionar a las empresas que gestionan el acceso a los medicamentos con receta —los gestores de beneficios de farmacia, o PBM— para que impongan los dos productos extremadamente caros de Horizon de una manera que eliminaría cualquier competencia.

Es la primera vez desde 2009 que la FTC intenta bloquear una fusión de empresas farmacéuticas, y esta demanda refleja el gran interés de la presidenta Lina Khan por las medidas antimonopolio. Al anunciar la demanda, la agencia declaró que al luchar contra los poderes monopolísticos pretendía controlar los precios y mejorar el acceso de los pacientes a productos más baratos.

Para Robin Feldman, profesor y experto en la industria farmacéutica de la Facultad de Derecho de la Universidad de California en San Francisco, la actuación de la FTC es “un golpe frontal a la industria farmacéutica”. David Balto, ex funcionario de la FTC y abogado que luchó contra las fusiones Bristol-Myers Squibb-Celgene en 2019 y AbbVie-Allergan en 2020, dijo que la acción de la FTC era necesaria desde hace mucho tiempo.

La fusión Horizon-Amgen “costaría a los consumidores precios más altos, menos opciones e innovación”, señaló. “La fusión habría dado a Amgen aún más herramientas para explotar a los consumidores y dañar la competencia”.

La FTC también anunció la ampliación de una investigación de un año sobre los PBM, indicando que se investigaban dos gigantescas empresas de compra de medicamentos, Ascent Health Services y Zinc Health Services. Los críticos afirman que los PBM crearon estas empresas para ocultar beneficios.

Cuando Amgen anunció la compra de Horizon en diciembre —la mayor operación biofarmacéutica de 2022— mostró especial interés por los medicamentos de Horizon para la enfermedad tiroidea ocular (Tepezza) y la gota grave (Krystexxa), por los que la empresa cobraba hasta $350,000 y $650,000, respectivamente, por un año de tratamiento. Según la demanda, la fusión perjudicaría a rivales biotecnológicos que tienen productos similares en fase avanzada de pruebas clínicas.

Según la FTC, Amgen podría promocionar los fármacos de Horizon a través de la “venta cruzada”. Esto significa exigir a los PBM que promocionen algunos de los medicamentos menos populares de Amgen —los productos Horizon, en este caso— a cambio de que Amgen ofrezca a los PBM grandes descuentos por sus superventas. Según la denuncia, Amgen tiene nueve medicamentos que el año pasado generaron más de $1,000 millones cada uno. El más popular es Enbrel, que trata la artritis reumatoide y otras enfermedades.

Los tres mayores PBM negocian los precios y el acceso al 80% de los medicamentos recetados en Estados Unidos, lo que les confiere un enorme poder de negociación. Su capacidad para influir en los medicamentos a los que tienen acceso los estadounidenses, y a qué precio, les permite obtener miles de millones en descuentos de los fabricantes.

“La posibilidad de que Amgen pudiera aprovechar su cartera de medicamentos superventas para obtener ventajas sobre sus rivales potenciales no es hipotética”, afirma la denuncia de la FTC. “Amgen ha desplegado esta misma estrategia para conseguir condiciones favorables de los pagadores y proteger así las ventas de los medicamentos de Amgen en dificultades”.

La denuncia señaló que la biotecnológica Regeneron demandó el año pasado a Amgen, alegando que la estrategia de reembolso de esta última perjudicó la capacidad de Regeneron para vender su medicamento competidor contra el colesterol, Praluent. Repatha, de Amgen, generó unos ingresos mundiales de $1,300 millones en 2022.

Según la demanda, “puede resultar completamente imposible” para los rivales más pequeños “igualar el valor de los reembolsos agrupados que Amgen podría ofrecer”, ya que aprovecha la colocación de los medicamentos de Horizon en los formularios de los planes de salud.

Los analistas de la industria se mostraron escépticos sobre el éxito de la acción de la FTC. Hasta ahora, la Comisión y el Departamento de Justicia han evitado cuestionar las fusiones farmacéuticas, un precedente difícil de superar.

Las investigaciones sobre el impacto de las fusiones han demostrado que a menudo benefician a los accionistas al aumentar el precio de las acciones; pero perjudican la innovación en el desarrollo de fármacos al recortar los proyectos de investigación y el personal.

Las olas de consolidación redujeron el número de empresas farmacéuticas líderes de 60 a 10 entre 1995 y 2015. Según Feldman, la mayoría de las fusiones de los últimos años se han producido entre “peces gordos que adquieren muchos peces pequeños”, como empresas de biotecnología con fármacos prometedores.

La gigantesca fusión Amgen-Horizon es una excepción obvia y, por tanto, una buena oportunidad para que la FTC demuestre la “teoría del daño” en las maniobras de consolidación de la industria farmacéutica con los PBM, dijo Aaron Glick, analista de fusiones de Cowen & Co.

Pero eso no significa que la FTC vaya a ganar.

Amgen puede incurrir o no en prácticas anticompetitivas, pero “otra cuestión es cómo encaja esta demanda en las leyes antimonopolio y los precedentes actuales”, señaló Glick. “Tal y como está configurada la ley hoy, parece poco probable que se sostenga en los tribunales”.

El argumento de la FTC sobre el comportamiento de Amgen con los productos Horizon es hipotético. La demanda pendiente de Regeneron contra Amgen, así como otras demandas que han prosperado, sugiere que existen normas para suprimir este tipo de comportamiento anticompetitivo cuando se produce, añadió Glick.

El juez que preside el caso en el Tribunal de Distrito de Estados Unidos en Illinois es John Kness, quien fue nombrado por el entonces presidente Donald Trump y es un ex miembro de la Federalist Society, cuyos miembros tienden a ser escépticos sobre los esfuerzos antimonopolio.

Es probable que el caso se resuelva antes del 12 de diciembre, fecha límite para que la fusión se lleve a cabo en los términos actuales.

Amgen trató de socavar los argumentos del Gobierno comprometiéndose a no agrupar los productos de Horizon en futuras negociaciones con los gestores de beneficios farmacéuticos (PBM). Esta promesa, aunque difícil de hacer cumplir, podría obtener una audiencia favorable en corte, apuntó Glick.

Sin embargo, incluso una derrota permitiría a la FTC arrojar luz sobre un problema en la industria y lo que considera una deficiencia en las leyes antimonopolio que quiere que el Congreso corrija, explicó.

Al día siguiente de ir a corte para detener la fusión, la FTC anunció que profundizaba en una investigación sobre los gestores de beneficios farmacéuticos que inició el pasado mes de junio. La agencia solicitó información a Ascent y Zinc, los dos llamados agregadores de reembolsos, organizaciones de compra de medicamentos creadas por los PBM Express Scripts y CVS Caremark.

En una audiencia celebrada el 10 de mayo, el CEO de Eli Lilly & Co., Dave Ricks, afirmó que la mayor parte de los $8,000 millones en cheques de reembolso que su empresa pagó el año pasado fueron a parar a los agregadores de reembolsos, en lugar de directamente a los PBM. Una “gran parte” de los $8,000 millones fue a parar al extranjero, indicó Ricks. Ascent tiene su sede en Suiza, mientras que Emisar Pharma Services, un agregador establecido por PBM OptumRx, tiene su sede en Irlanda. Zinc Health Services está registrada en Estados Unidos.

Los críticos afirman que los agregadores permiten a los PBM ocultar la cuantía y el destino de los reembolsos y otras comisiones que cobran como intermediarios en el negocio de los medicamentos.

Por su parte, los PBM aseguran que sus esfuerzos reducen los precios en el mostrador de la farmacia. Los testimonios en el Congreso y en las audiencias de la FTC del año pasado indican que, al menos en algunos casos, en realidad los aumentan.

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.

The fate of the abortion pill mifepristone remains in jeopardy, as an appellate court panel during a hearing this week sounded sympathetic to a lower court’s ruling that the FDA should not have approved the drug more than two decades ago. No matter how the appeals court rules, the case seems headed for the Supreme Court.

Meanwhile, in the partisan standoff over raising the nation’s debt ceiling, a key sticking point has emerged: whether to add a work requirement to the state-federal Medicaid program. Republicans are adamant about adding one; Democrats point out that, in the few states that have tried them, red tape has resulted in eligible people wrongly losing their health coverage.

This week’s panelists are Julie Rovner of KFF Health News, Sandhya Raman of CQ Roll Call, Rachel Roubein of The Washington Post, and Victoria Knight of Axios.

Panelists

Sandhya Raman
CQ Roll Call

@SandhyaWrites

Read Sandhya's stories

Rachel Roubein
The Washington Post

@rachel_roubein

Read Rachel's stories

Victoria Knight
Axios

@victoriaregisk

Read Victoria's stories

Among the takeaways from this week’s episode:

• Hopes among abortion rights advocates for continued access to mifepristone dimmed as the three judges on the 5th Circuit Court of Appeals signaled they are skeptical of the FDA’s decades-old approval of the drug and of the Biden administration’s arguments defending it. Lawyers debated whether the Texas doctors challenging the drug had been harmed by it and thus had standing to sue. If the original ruling effectively revoking the drug’s approval is allowed to stand, the case could open the door to future legal challenges to the approval of controversial drugs.
• Two more states in the South are moving to restrict abortion, further cutting access to the procedure in the region. In North Carolina, a new Republican supermajority in the state legislature enabled the passage this week of a new, 12-week ban, as lawmakers in South Carolina consider a six-week ban.
• In Congress, the top Senate Republican said he will not back one senator’s months-long effort to hold up Pentagon nominations over a policy that supports troops and their dependents who must travel to other states to obtain an abortion.
• Envision Healthcare — which spent big in 2019 to fight legislation prohibiting some surprise medical bills — has filed for bankruptcy protection more than a year after the law took effect and cut into its bottom line. But a federal lawsuit from a group of emergency room physicians against Envision may move forward. The lawsuit claims the private equity-backed company is in violation of a California law banning corporate control of medical practices, and it could carry major consequences for the growing number of practices backed by private equity firms across the country.
• Monica Bertagnolli has been nominated to lead the National Institutes of Health. Currently the director of the National Cancer Institute, she will need to be confirmed by the Senate, which hasn’t confirmed an NIH chief since before the passage of the Affordable Care Act in 2010. Meanwhile, Sen. Bernie Sanders’ stewardship of a key health committee is causing delays on even bipartisan efforts.

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

Julie Rovner: The Washington Post’s “A 150-Year-Old Law Could Help Determine the Fate of U.S. Abortion Access,” by Dan Diamond and Ann E. Marimow.

Victoria Knight: The New York Times’ “World Health Organization Warns Against Using Artificial Sweeteners,” by April Rubin.

Rachel Roubein: CBS News’ “Thousands Face Medicaid Whiplash in South Dakota and North Carolina,” by Arielle Zionts of KFF Health News.

Sandhya Raman: CQ Roll Call’s “A Year After Dobbs Leak, Democrats Still See Abortion Driving 2024 Voters,” by Mary Ellen McIntire and Daniela Altimari.

Also mentioned in this week’s episode:

KFF Health News’ “ER Doctors Vow to Pursue Case Against Envision Despite Bankruptcy,” by Bernard J. Wolfson.

click to open the transcript

Transcript: The Abortion Pill Goes Back to Court

KFF Health News’ ‘What the Health?’

Episode Title: The Abortion Pill Goes Back to Court

Episode Number: 298

Published: May 18, 2023

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

Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent at KFF Health News. And I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, May 18, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So here we go. We are joined today via video conference by Rachel Roubein of The Washington Post.

Rachel Roubein: Hi. Thanks for having me.

Rovner: Victoria Knight of Axios.

Victoria Knight: Hi. Good morning.

Rovner: And Sandhya Raman of CQ Roll Call.

Sandhya Raman: Hi, and good morning, everyone.

Rovner: Lots and lots of health news this week, so we will dive right in. We’re going to start with abortion because there is so much breaking news on that front. On Wednesday, a three-judge panel of the 5th Circuit Court of Appeals in New Orleans held a hearing on the Biden administration’s appeal of a Texas ruling that the FDA was wrong when it approved the abortion pill mifepristone more than 22 years ago. The panel, which was randomly chosen from an already pretty conservative slate there in the 5th Circuit, appeared to be even more anti-abortion than most of the judges on that bench. So, Sandhya, you listened to this whole thing. What, if anything, did we glean from this hearing?

Raman: I think we gleaned a lot of things and a lot of things I think we have predicted from the start. I think going into this, looking at the various judges’ records, they have ruled on anti-abortion cases in the past in the favor of that. You take that in with a grain of salt. And from watching the arguments, it seemed like they were fairly skeptical of the challenge and FDA’s approval of mifepristone and the subsequent regulations. You could kind of see through the questioning the kinds of things that they were asking and just pretty skeptical of just a lot of the things that were being said by DOJ [the Department of Justice] and by Danco there yesterday. So —

Rovner: Yeah, we should say that the lawyer for the FDA had one sort of round of presentation and questions. And then the lawyer from Danco, the company that makes mifepristone, had another. And they were pretty tough on both of them.

Raman: Yeah, and I thought it was interesting because when we were listening to the arguments, the DOJ lawyer and the Danco lawyer were kind of arguing a lot of the time just that there shouldn’t be standing, that there isn’t necessarily proof in any of the filings that any of the doctors that that were suing have really had harm due to the FDA’s role. It was kind of down the road. I think one thing that Harrington, the judge for the DOJ, had said, that was the FDA approving a drug does not mean that anyone has to prescribe it, it does not mean anyone has to take it, that the fact that if you were treating someone after the fact, that’s a few steps down the line. And so that was kind of like a messaging thing that they were doing kind of over and over again. And then when we got to the Alliance Defending Freedom, which is representing the conservative doctors, Erin Hawley had said, you know, they are affected both physically and she said emotionally, which was interesting, kind of looking at that. And so it’ll depend on how the judges rule. I think that there were definitely some signs throughout the arguments about this not being as unprecedented and that the FDA is not untouchable in terms of the courts weighing in on regulation.

Rovner: If you were just listening to it, you didn’t sort of know all of this. And remember, these were two Trump-appointed judges and a George W. Bush-appointed judge who has a history of ruling in favor of anti-abortion efforts. But they were saying that, “Well, people sue the FDA all the time. You know, what’s the difference here?” Well, the difference here is nobody has ever sued the FDA saying that they were wrong to approve something 20 years ago. Nobody’s ever tried to get a drug taken off the market that way. There’s obviously lots of litigation against the FDA for the way it does some of its thing. I mean, it’s often little things and then people sue each other with the FDA caught in the middle — drugmakers and lots of patent suits. I was surprised that the appeals court judges took issue with what everybody I think acknowledges is a correct claim that this is unprecedented and this could open the door to other challenges to other drugs for any reason — you know, someone doesn’t like them. I mean, these doctors are not saying that they’ve prescribed this drug and women have taken it and had bad reactions. They’re saying that possibly, if someone takes it and has a bad reaction, that they would have to treat that person and that that would harm their conscience, even though, as the lawyers made it clear, no one has ever forced these doctors to take care of anyone against their conscience because there are already laws that protect against that. So it was very roundabout in a lot of ways.

Raman: I think one thing that they had mentioned was that, you know, some of the cases cited in the filings were, you know, someone had taken an imported version of a mifepristone, not the one that Danco made, and then someone else had been recommended not to take the drug but still took the drug and then had side effects related to that. But there is another thing that kind of stuck out to me, was when Judge [James] Ho had asked would the FDA adhere to whatever the final court decision was? And that was a little striking to me. And then the FDA had said, you know, we will. And they cited that they had signed an affidavit last year saying that they’re going to agree to whatever the final decision is. But there were a lot of parts of the case that were just very unusual compared to the other cases that I have watched on this or any other part of health care, I think.

Rovner: Although in fairness to the judges, I mean, there was — a lot of legal experts were saying that the FDA does have enforcement authority to determine what it’s going to enforce and what it isn’t. And Justice [Samuel] Alito, when he actually challenged the Supreme Court’s stay of the original ruling — Justice Alito questioned about whether FDA would even follow if this drug was deemed unapproved. So that’s at least been coming up as a discussion. Let’s move on because it could be weeks or even months before we hear back from this panel, and we will obviously keep watching it. There’s been plenty of action in the states, too, this week — not that surprising because it’s May and lots of state legislatures are wrapping up their sessions for the year. But we should point out that particularly North and South Carolina are acting on abortion because they’ve been two of the last states in the South where abortion had remained both legal and pretty much broadly available. That’s changing as of this week, though, isn’t it?

Roubein: That’s changing in North Carolina, for sure, after this week. The Republicans there have supermajorities as of April; a Democrat in the House switched to the Republican Party. And what they did there is they overrode a veto from Democratic Gov. Roy Cooper. And this new bill, which the main provisions go into effect July 1, will restrict abortions at 12 weeks in pregnancy. And now in South Carolina, it’s still a little bit to be determined. The House passed a bill last night which would restrict abortions after fetal cardiac activity’s detected — roughly six weeks. Now they’re sending that bill back to the Senate, which had already passed it. But they made some changes. And it’s not clear whether some of the Republican female senators who oppose a near-total ban will be in favor of these changes. So that one’s a bit up in the air.

Rovner: And obviously, the 12 weeks in North Carolina is going to be important because there are a lot of women coming from other states now to North Carolina and clinics are getting backed up. It is a time thing for women to sort of be able to get themselves together, often get child care, get time off from a job, have to find a hotel in most cases, and go to another state. So it’s going to turn out to be an issue.

Roubein: I think one of the provisions abortion rights groups are pointing to there is, because this is a 12-week ban, so roughly 90% of abortions are allowed to continue, but what Democrats really pointed out was that the bill requires an in-person visit 72 hours before obtaining an abortion. So that could kind of restrict people, as you mentioned, Julie, from being able to take that time and come in from out of state in North Carolina, which has become a destination for abortions.

Rovner: All right. Well, I want to circle back to something that’s been going on for a while in the U.S. Senate. We talked about it back in March. Alabama Republican Sen. Tommy Tuberville is single-handedly holding up many military promotions to protest a Biden administration policy that allows members of the military in states with abortion bans both time off and travel funds to obtain an abortion in another state. Defense Secretary Lloyd Austin says that this — the delayed promotions — is starting to impact the nation’s readiness. Is there any resolution to this in sight? It’s now been going on for, what, a month and a half.

Raman: I think that, you know, we’re getting somewhat closer to it, but it’s hard to tell. I mean, we’ve had Mitch McConnell say that he’s not supporting what Tuberville is doing with the blockade of military nominations, so that could be a little bit more pressure compared to anyone else in the caucus putting that pressure. But I think the other thing that had come up is that there had been a report this week that the administration was going to delay on deciding if Space Force Command was going to move from Colorado to Alabama because of Tuberville. And so I think that, if that is the case — two different pressure points — there might be movement. But it’s been happening for a long time. We’ve had hundreds of nominees delayed. And I think the pushback has not necessarily been fully partisan. Even before we had McConnell speak out, we’ve had other members of — Republican senators kind of say, you know, this is maybe not the best move to do this, so —

Rovner: I mean, given how important Republicans take the military, I get why he’s doing this. It’s a pressure point because it’s a DOD [Department of Defense] policy. But still, it looks funny for a Republican to be holding up something that’s really important to the military.

Raman: Earlier this year, I think it was last month, you know, the Senate had done their procedural vote on a Tuberville resolution on something that was kind of similar, when they had the VA [Department of Veterans Affairs] rule that allows them to provide abortions for, you know, the Hyde exceptions, so rape, incest, life of the mother. And, you know, that didn’t pass on a procedural vote. So maybe something like that could be, like, a bargaining point. But it would require Democrats to say, “Yes, we do want to vote on this.” And I think that the last comments that Tuberville had even said were that, you know, “Until this policy is gone, I don’t want to waiver.” So it might not be a solution, but it could be something.

Rovner: Well, speaking of things that are proving difficult to resolve, let’s talk about the debt ceiling talks. As of today, Thursday, there’s no agreement yet, although President Biden is going to cut his overseas trip short after Treasury Secretary Janet Yellen warned that the so-called x-date, when the Treasury can no longer pay its bills, could really happen as soon as June 1. One of the big sticking points appears to be work requirements for programs aimed at low-income Americans, which Republicans are demanding and Democrats are resisting. Welfare, now called Temporary Aid to Needy Families, already has work requirements, as does SNAP [Supplemental Nutrition Assistance Program], the current name for food stamps, which leaves Medicaid, which has been a particular sticking point over the last few years. I guess we were all right back in February when Biden and the Republicans seemed to take Medicare and Social Security off the table, and we all predicted the fight would come down to Medicaid. So here we are, yes?

Knight: Yep, we’re at Medicaid. But it does seem like we’re really going back and forth on it. I think the sentiment at first was kind of that this would be the first thing to fall out of a potential deal between Democrats and Republicans because Democrats are really opposed to this. But I don’t know. This week, President Biden made some comments that were a little confusing. It kind of made it sound like he was potentially open to the idea. And then the White House kind of walked that back this week and sent some press releases out that were like, We don’t want to touch Medicaid. And then I believe it was sometime yesterday, on Wednesday, the president said, “Maybe, but nothing of consequence,” when talking about work requirements. And Congress is leaving today. So I think it’s kind of still up in the air, but the door still seems to be open, I guess is kind of the takeaway.

Rovner: There seems to be some concern from Democrats on Capitol Hill that President Biden may give too much away in trying to avoid a debt default. I mean, he’s already sort of after, you know, “We will not negotiate on the debt ceiling, we will not negotiate on the debt ceiling” — I mean, the administration says they’re negotiating on the budget, but they’re negotiating on the debt ceiling, right?

Knight: Yeah. I mean, and it seems that President Biden, the administration, may be open to budget caps as well or cutting spending. And that was kind of something that it seemed like Democrats at first were not open to doing at all. I talked to some appropriators this week, and they’re pretty upset about — Democratic appropriators — they’re pretty upset because they want the debt ceiling and appropriations to be a separate process, and they’re being tied together right now. Yeah, I think they’re somewhat concerned with how the president is negotiating right now.

Rovner: Well, it’s May 18. There’s been no talk yet of a temporary — although I assume at some point we’re going to say, let’s just extend this out a few days, and let’s extend it out a few more days, and we’ll extend it out a few more days. So obviously, we will watch this space. So the mifepristone case is not the only judicial news this week. In that other case out of Texas, challenging the preventive health services part to the Affordable Care Act, the 5th Circuit Court of Appeals — lots of news out of New Orleans this week — temporarily stayed the ruling by Judge Reed O’Connor that the ACA unconstitutionally deputized the U.S. Preventive Health Services Task Force from deciding which preventive services should be provided without copays. Long sentence. I hope it makes sense. Reed O’Connor, of course, being the judge who tried unsuccessfully to declare the entire ACA unconstitutional in 2018. What happens now in this case? Nothing changes until it gets resolved, right?

Roubein: Right. Right now I think that just through that, this means that insurers will be required to continue covering services recommended by the U.S. Preventive Services Task Force without cost sharing in care.

Rovner: And that includes PrEP for HIV, which is what’s really at issue with these doctors who are suing the FDA — or actually I guess they’re suing HHS [the Department of Health and Human Services] in general — saying that they don’t want to be required to provide these drugs.

Roubein: Yeah, it does include PrEP.

Rovner: So that will continue. I imagine that will also find its way to the Supreme Court. Finally, in not really judicial but court-related news, Envision, the private equity-backed physician staffing firm, filed for Chapter 11 bankruptcy this week, presumably because the emergency room physician practices it owns can no longer send patients most surprise medical bills. ER bills were among the most common types of surprise bills, when patients would specifically take their emergency to an in-network hospital, only to find that the doctors in the emergency room were all out of network. Is this one small step towards taking some of the profit motive out of health care? I don’t see anybody, like, shedding a lot of tears for Envision declaring bankruptcy here.

Raman: I think the second part, that the lawsuit by the ER doctors against Envision, despite them filing for bankruptcy, is going forward is interesting, and it seems unusual to me, because they’re not asking for monetary damages, but they want, like, a legal finding that the way that the company’s business structure — ownership of the staffing groups — is illegal, and if, like, winning that would ban the practice in the state of California. And so I think if you’re looking at it in terms of, like, things that would happen over the course of time, policywise, that could be something interesting to kind of watch there.

Roubein: I just wanted to hearken back real quick to, like, 2019. In the middle of the surprise billing debate, Envision and another major doctor staffing firm spent significant sums of money to try and sway the surprise billing legislation that the House and the Senate were hashing out.

Rovner: Yeah, they made CNN and MSNBC very rich with their ads.

Roubein: Millions of them.

Rovner: In the ’90s, I covered, you know, this whole corporate practice of medicine thing because I think it’s every state has a law that says that corporations can’t practice medicine; only licensed health professionals can practice medicine. So I’ve always wondered about, you know, what this lawsuit is about anyway. How are these companies actually getting away with doing this? And the answer is maybe they’re not or maybe they won’t. It’s going to be interesting. There’s now so much profit motive and private equity in health care because there’s a lot of money to be made that it’s, I think somebody is actually starting to, you know, call on it. We will definitely see how this plays out. We may not have a “This Week in Private Equity” anymore. Well, let us go back to Capitol Hill, where we finally have a nominee to head the National Institutes of Health, current National Cancer Institute chief Monica Bertagnolli, who is also, ironically, a cancer patient at the moment, although her prognosis is very good, we are told. There hasn’t been a confirmed head of the NIH since Francis Collins stepped down at the end of 2021. Congress hasn’t had to confirm a new head of the NIH since before the passage of the Affordable Care Act. I imagine that Dr. Bertagnolli is going to have to navigate some pretty choppy confirmation waters, even in a Senate where Democrats are nominally in the majority, right?

Knight: Yeah, I spent some time talking to HELP [Health, Education, Labor and Pensions] Committee Republicans last week and this week, and they definitely have some things they want to see out of a new NIH director. They’re definitely concerned about gain-of-function research, potential funding of that type of research, which is supposed to, hypothetically, make viruses more virulent. So several of them said, you know, “We don’t want to see the agency funding that kind of research,” or, “We want restrictions around that kind of research.” They also are concerned with the agency giving a grant to an organization called EcoHealth, which was supposed to have done research in Wuhan that was around gain-of-function-type things. And I think they also, in general, are just concerned with how the NIH and the CDC [Centers for Disease Control and Prevention] responded to the covid pandemic, and they aren’t happy with some of the decisions they made, what they felt like were mandate — top-down mandates. And so I do think we will see, if we actually get a HELP confirmation hearing any time soon, we’ll see — I think it’s going to be pretty contentious possibly. And as you referenced, I kind of looked into this when I was writing my story, and there really has not been a contentious hearing in a long time. Francis Collins went through a unanimous voice vote when he was confirmed. And then the two previous NIH directors, they kind of sailed through their HELP confirmation hearings. And if you think about it, Francis Collins also has served under both Republican and Democratic presidents. And I wonder if we are coming to a point where that won’t happen anymore with NIH directors.

Rovner: Back when I first started covering the NIH, it was contentious because they were talking about fetal tissue research and stem cell research and stuff that was really controversial. But then Newt Gingrich, when he became speaker of the House, declared that, you know, he wanted the 21st century to be, you know, the century of biomedicine. And he vowed to double the funding for the NIH, which the Republicans did, you know, with the Democrats’ help. So NIH has been this sacred cow, if you will, bipartisanly for at least two decades. And now it’s sort of coming back to being a little bit controversial again. In talking about the debt ceiling and possible budget cuts, I mean, NIH has usually been spared from those. But I’m guessing that if there’s budget caps, NIH is going to be included in those places where we’re going to cut the budget, right?

Knight: Yeah, absolutely. I have been talking to a Republican House appropriator over the NIH. Robert Aderholt told me that, yes, they expect a cut in their budget because Defense and NIH, Labor, HHS are usually the biggest bills. And he told me Defense probably isn’t getting cut very much, so we’re expecting to get cut. So obviously, you know, it’s a messaging bill in the House, but I think the expectation is that they’re going to propose that. The Senate seemed pretty set on keeping NIH funding what it was. They had an NIH appropriations hearing recently. So, I mean, there’s going to be some difference between those two chambers. But I think it does seem likely, especially with all the debt ceiling stuff, that cuts are possible.

Rovner: So that’s NIH. In the meantime, now we have an opening at the CDC because Rochelle Walensky announced her resignation. Have we heard any inklings about who wants to step into that very hot seat?

Roubein: I can point to some reporting from my colleagues at the Post, Dan Diamond and Lena H. Sun. At the time, the day that Walensky announced that she’d be stepping down June 30, they had wrote that White House officials had, you know, been preparing for a little while for a potential departure and had begun gauging interest in the position. And some people that Dan and Lena named that the administration had approached is former New York City Health Commissioner Dave A. Chokshi, former North Carolina Health Secretary Mandy Cohen, and the California health state secretary. Now, we don’t know ultimately what the White House, President Biden, is going to do. I do think it’s worth pointing out that the new CDC director won’t have to be Senate-confirmed; that was passed in the big sweeping government funding bill, that a CDC director would need to be confirmed, but starting January 20, 2025. So, you know, sounds like something, you know, Democrats might have been interested in doing, kind of pushing that out. So, yeah.

Rovner: The CDC is, you know, sort of the one big Department of Health and Human Services job that does not come up for Senate confirmation. Obviously, that is being changed, but it’s not being changed yet. Well, both of these confirmations, mostly the NIH one at this point, comes up before the Senate HELP Committee, Victoria, as you pointed out. Chairman Bernie Sanders there is having — what shall we call them? — some growing pains as chairman of a committee with a heavy legislative workload. What’s the latest here? He’s still kind of working on getting some of these bipartisan bills through, isn’t he?

Knight: Yeah, there is a little bit of a snafu at a recent HELP Committee hearing where Ranking Member Bill Cassidy was not happy that Sen. Sanders was bringing up some amendments that he wasn’t aware of or that they had kind of agreed to table at some point and then he brought them back up during a hearing or during a markup, and so they ended up having to delay the markup itself and do it the next week. And these were bipartisan bills. So it was really just a process issue; it wasn’t so much the subject of the bills. And they kind of worked it out and were able to pass the bills out of the committee, or most of the bills out of the committee, the next week after that happened. So I think that Sen. Sanders is figuring out how to run the HELP Committee. What I’ve kind of heard is that he is somewhat more interested in labor issues than health, and so his focus is not maybe as much on health. And I think you can see that sometimes. Also, when you talk to Sen. Sanders, he’s very much a big-picture guy and isn’t so much in the process weeds often, whereas Sen. Cassidy loves the process.

Rovner: So we’re noticing.

Knight: Yeah, Sen. Cassidy loves the process. So they’re an interesting duo, I think.

Rovner: Yeah, I mean, I was interested that this week, you know, Sen. Sanders was among those there reintroducing the “Medicare for All” bill that obviously has no future in the immediate future. But at the same time, community health centers are up for reauthorization this year. And that has always been a pet issue, even when he was House member, you know, Rep. Sanders. This is one of the issues that I know he cares a lot about. And now he’s in charge of making sure that it gets reauthorized. So he’s got sort of these competing big-picture stuff and, not smaller, but smaller than the big-picture stuff that he really cares about. I’ll be curious to see what he’s able to do on that front. I assume there’s no word on that yet, even though the authorization ends Sept. 30, right?

Raman: The sense that I’ve gotten from talking to folks is that community health centers is higher up the totem pole than some of the other issues on the must-pass list. I mean, we still have to deal with the debt ceiling and everything related there. But I think that there has been a little bit more progress then. I mean, this week, at least in the House, Energy and Commerce had marked up their bill that had community health center funding in there. So I think there’s a little bit more push on that end because they’re, you know, fairly bipartisan, have seen interest across the board on that. So I think that they are making some progress there. It’s just that there’s so many other factors right now, and that makes it pretty tricky.

Rovner: The ironic thing about Congress — it’s summertime when everybody else sort of kicks back. — that’s when Congress kicks into gear. So a lot, I imagine, is going to happen in June and July. All right. That is this week’s news. Now it is time for our extra credit segment. That’s when we each recommend a story we read this week we think you should read too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Victoria, why don’t you go first this week?

Knight: Sure. My extra credit this week is called “World Health Organization Warns Against Using Artificial Sweeteners.” It was published in The New York Times. Basically, the WHO said this week that artificial sweeteners aren’t effective in reducing body fat and could actually increase the risk of Type 2 diabetes and cardiovascular diseases. They looked at the available evidence, and it’s just a set of guidelines that they’re issuing. It’s not binding to anything. You know, every country can kind of make their own decision based on this. But I think it was an interesting marker. If you look at the influx of all these artificial sweeteners over time that have kind of become a mainstream part of our diet, they’re available in a bunch of different things that you can get at the store, and people often turn to them when they’re trying to reduce sugar. And now this large body is saying they may actually worsen your health, not help you, and not even reduce fat. So I think that was just kind of interesting. The FDA did not respond to The New York Times’ request for the story, so I’m not sure their stance on this, but just something to note.

Rovner: I was interested that the WHO did that. It seemed sort of very not WHO-ish, but also interesting. Sandhya, why don’t you go next.

Raman: All right, so my extra credit this week is called “A Year After Dobbs Leak, Democrats Still See Abortion Driving 2024 Voters.” And it’s from my colleagues “What the Health?” alum Mary Ellen McIntire and Daniela Altimari. And they take a look at how Democrats are kind of seeing how abortion messaging isn’t fading a year after — almost — the Dobbs decision, are kind of doubling down on focusing on that. President Biden and Vice President Harris were both at the EMILYs List gala this week honoring Nancy Pelosi. And it also comes amid a lot of the state action we talked about earlier of a lot of abortion bans going into place. And so they have a good look at that that you can read.

Rovner: Rachel.

Roubein: My extra credit is called “Thousands Face Medicaid Whiplash in South Dakota and North Carolina,” by Arielle Zionts from KFF Health News. And she takes a look at the unwinding of keeping people on the Medicaid program, particularly in South Dakota and North Carolina, where the dynamic is really interesting, because both states have recently passed Medicaid expansion. So officials are kind of going through the Medicaid rolls beforehand. So some people who could be eligible soon may be getting kicked off, only to need to reapply, or officials need to tell them that they can reapply. So I thought it was a really interesting look on how this is playing out.

Rovner: Yeah, it is. I mean, talk about head-explodingly confusing for people; it’s like, “You’re not eligible now, but you will be in three weeks. So just kind of sit tight and don’t go to the doctor for the next couple of weeks,” basically where they are. Well, my story is from The Washington Post, and it’s called “A 150-Year-Old Law Could Help Determine the Fate of U.S. Abortion Access,” by Dan Diamond and Ann Marimow. And it’s about the Comstock Act, which we have talked about before. It’s a Reconstruction-era law pushed through Congress by an anti-vice crusader, Anthony Comstock, who I learned this week was not actually a member of Congress. He was just an interested party. The law purports to ban the mailing of all sorts of lewd and lascivious items, including those intended to be used for abortion. Abortion opponents are trying to resurrect the law, which has never been formally repealed. But it turns out that Comstock wasn’t actually all that anti-abortion. In a newly resurrected interview that Comstock did with Harper’s Weekly in 1915, he said he never intended for the law to interfere with the practice of medicine by licensed doctors, including for abortion. Quote, “A reputable doctor may tell his patient, in his office what is necessary, and a druggist may sell on a doctor’s written prescription drugs which he would not be allowed to sell otherwise.” That’s how Comstock is quoted as saying. Um, wow. It’s just another weird twist in an already very twisty story. But let’s keep track of the Comstock Law going forward. All right. That is our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us too. Special thanks, as always, to our ever-patient producer, Francis Ying. Also as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can tweet me. I’m still there. I’m at @jrovner. Sandhya?

Raman: @SandhyaWrites.

Rovner: Rachel.

Roubein: @rachel_roubein.

Rovner: Victoria.

Knight: @victoriaregisk.

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

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Davila was sick enough that staffers at the local hospital gave her 2 liters of IV fluids and prescribed a daily regimen of vitamins and medication. This will be Davila’s third child and she hopes the nausea means it’s another girl.

Davila had moved back to her hometown of Clayton, New Mexico, so her kids could grow up near family — her dad, aunts, uncles, and cousins all live in this remote community of about 2,800 people in the northeastern corner of the state. But Clayton’s hospital stopped delivering babies more than a decade ago.

Aside from being sick, Davila was worried about making the more than 3½-hour round trip to the closest labor and delivery doctors in the state.

“With gas and kids and just work — having to miss all the time,” Davila said. “It was going to be difficult financially, kind of.”

Then, Davila spotted a billboard advertising the use of telehealth at her local hospital.

In rural regions, having a baby can be particularly fraught. Small-town hospitals face declining local populations and poor reimbursement. Those that don’t shutter often halt obstetric services to save money — even as the number of U.S. mothers who die each year while pregnant or shortly after has hit historic highs, particularly for Black women.

More than half of rural counties lack obstetric care, according to a U.S. Government Accountability Office report released last year. Low Medicaid reimbursement rates and a lack of health workers are some of the biggest challenges, the agency reported. New Mexico Medicaid leaders say 17 of the state’s 33 counties have limited or no obstetric care.

Those realities prompted the Federal Office of Rural Health Policy, which is part of the Health Resources and Services Administration, to launch the Rural Maternity and Obstetrics Management Strategies Program, RMOMS. Ten regional efforts nationwide — including one that serves Davila in northeastern New Mexico — have been awarded federal grants to spend on telehealth and creating networks of hospitals and clinics.

“We’ve never done this sort of work before,” said Tom Morris, associate administrator for the office at HRSA. “We were really testing out a concept … could we improve access?”

After joining the telehealth program, Davila didn’t have to take the afternoon off work for a recent prenatal checkup. She drove less than a mile from her job at the county courthouse and parked near the hospital. As she stepped inside a ranch-style yellow-brick clinic building, staffers greeted Davila with hugs and laughter. She then sat on a white-papered exam table facing a large computer screen.

“Hello, everybody,” said Timothy Brininger, a family practice doctor who specializes in obstetrics. He peered out the other side of the screen from about 80 miles away at Miners Colfax Medical Center in Raton, New Mexico.

The visit was a relief — close enough for a lunchtime appointment — and with staff “I’ve known my whole life,” Davila said. She heard her baby’s heartbeat, had her blood drawn, and laughed about how she debated the due date with her husband in bed one night.

“They’re nice,” Davila said of the local staff. “They make me feel comfortable.”

Yet, Davila may be one of the last expectant mothers to benefit from the telehealth program. It is slated to run out of money at the end of August.

‘Oh My God, It Really Made a Difference’

The day after Davila’s prenatal checkup, Brininger sat at his desk in Raton and explained, “The closest OB doctor besides the one sitting in front of you who’s working today is over 100 miles in any direction.”

When the telehealth program runs out of money, Brininger said, he wants to keep devices the grant paid for that enable some patients to home-monitor with blood pressure cuffs, oxygen sensors, and fetal heart rate monitors “so they don’t have to drive to see us.”

The retired military doctor has thoughts about the pilot program ending: “I will hope that our tax dollars have been utilized effectively to learn something from this because otherwise it’s a shame.”

Because of the grant, 1,000 women and their families in northeastern New Mexico have been connected to social services like food assistance and lactation counselors since 2019. More than 760 mothers have used the program for medical care, including home, telehealth, and clinic appointments. In its first year, 57% of the women identified as Hispanic and 5% as Indigenous.

Jade Vandiver, 25, said she feels “like I wouldn’t have made it without them.”

In the early months of her pregnancy, Vandiver slept during the day and struggled with diabetic hypoglycemic episodes. Vandiver’s husband repeatedly rushed her to the Clayton hospital’s emergency room because “we were scared I was going to go into a coma or worse.”

There, hospital staffers suggested Vandiver join the program. She eventually began traveling to specialists in Albuquerque for often weekly visits.

The program covered travel and hotel costs for the family. After months of checkups, she had a planned delivery of Ezra, who’s now a healthy 6-month-old. The boy watched his mother’s smile as she talked.

Without the program, Vandiver likely would have delivered at home and been airlifted out — possibly to the smaller Raton hospital.

Raton’s Miners Colfax is a small critical access hospital that recently closed its intensive care unit. The hospital sits just off Interstate 25, less than 10 miles south of the Colorado border, and its patients can be transient, Chief Nursing Officer Rhonda Moniot said. Maintaining the hospital’s obstetric program “is not easy, financially it’s not easy,” she said.

Moms from the area “don’t always seek care when they need to,” she said. Substance use disorders are common, she said, and those babies are often delivered under emergency conditions and prematurely.

“If we can get them in that first trimester … we have healthier outcomes in the end,” Moniot said, pulling up a spreadsheet on her computer.

At Raton’s hospital, 41% of mothers who gave birth before the RMOMS program began failed to show up for their first-trimester prenatal exams. But over two years — even as the covid-19 pandemic scared many patients away from seeking care — the number dropped to only 25% of mothers missing prenatal checkups during their first three months of pregnancy.

“I was, like, oh my God, it really made a difference,” said Moniot, who helped launch the program at Miners Colfax in 2019.

‘Let’s Not Let It Die’

Just a few weeks before Davila’s checkup in Clayton, the New Mexico program’s executive director, Colleen Durocher, traveled nearly 1,600 miles east to Capitol Hill to lobby for money.

Durocher said she cornered HRSA’s Morris at an evening event while in Washington, D.C. She said she told him the program is working but that the one year of planning plus three years of implementation paid for by the federal government was not enough.

“Let’s not let it die,” Durocher said. “It would be a real waste to let those successes just end.”

By April, Sen. Martin Heinrich (D-N.M.) said he was impressed by the program’s “lifesaving” work and asked for $1 million in the federal budget for fiscal year 2024. But the money, if approved, would likely not arrive before Durocher runs out of funding in late summer.

As the August deadline looms, Durocher said one obvious option would be to simply extend the grant. HRSA spokesperson Elana Ross said the agency cannot extend funding for the program. Each site, though, can reapply by offering to target a new population, include new hospitals or clinics, or provide services in a new area.

Of the 10 regional programs across the country, the one in New Mexico and two others are slated to end their pilots this year. Seven other programs — from Minnesota to Arkansas — are scheduled to end in 2025 or 2026. During their first two years, the 2019 awardees reported more than 5,000 women received medical care, and all three recorded a decrease in preterm births during the second year of implementation, according to HRSA.

The three initial programs also expanded their patient navigation programs to connect “hundreds of women to emotional support, insurance coverage, and social services, such as transportation and home visiting,” agency spokesperson Ross wrote in an email.

New Mexico Medicaid’s interim Director Lorelei Kellogg said her agency would like to “emulate” the program’s care coordination among hospitals and health staff in other areas of the state but also alter it to work best for different Indigenous and tribal cultures as well as African American partners.

There is money in the state’s budget to pay for patient navigators or community health workers, but there are no funds dedicated to support the maternity program, she said.

In the meantime, the program’s funding is set to run out just days before Davila’s baby is due in early September. In the coming months, Davila, like many mothers with an uncomplicated pregnancy, will have monthly prenatal telehealth visits, then biweekly and, as her due date nears, weekly.

“It’s nicer to be able to just pop in,” she said, adding that “it would be harder for the community” if the program didn’t exist.

Still, Davila may be one of the last moms to benefit from it.

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 formal end May 11 of the national public health emergency for covid-19 will usher in lots of changes in the way Americans get vaccines, treatment, and testing for the coronavirus. It will also change the way some people get their health insurance, with millions likely to lose coverage altogether.

Meanwhile, two FDA advisory committees voted unanimously this week to allow the over-the-counter sale of a specific birth control pill. Advocates of making the pill easier to get say it could remove significant barriers to the use of effective contraception and prevent thousands of unplanned pregnancies every year. The FDA, however, must still formally approve the change, and some of its staff scientists have expressed concerns about whether teenagers and low-literacy adults will be able to follow the directions without the direct involvement of a medical professional.

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

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Margot Sanger-Katz
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Among the takeaways from this week’s episode:

• The formal public health emergency may be over, but covid definitely is not. More than 1,000 people in the United States died of the virus between April 19 and April 26, according to the Centers for Disease Control and Prevention. While most Americans have put covid in their rearview mirrors, it remains a risk around the country.
• The Senate Finance Committee held a hearing on “ghost networks,” lists of health professionals distributed by insurance companies who are not taking new patients or are not actually in the insurance company’s network. Ghost networks are a particular problem in mental health care, where few providers take health insurance at all.
• Another trend in the business of health care is primary care practices being bought by hospitals, insurance companies, and even Amazon. This strategy was popular in the 1990s, as health systems sought to “vertically integrate.” But now the larger entities may have other reasons for having their own networks of doctors, including using their patients to create revenue streams.
• Court battles continue over the fate of the abortion pill mifepristone, as a federal appeals court in New Orleans prepares to hear arguments about a lower-court judge’s ruling that would effectively cancel the drug’s approval by the FDA. In West Virginia, the maker of the generic version of the drug is challenging the right of the state to ban medication approved by federal officials. At the same time, a group of independent abortion clinics from various states is suing the FDA to drop restrictions on how mifepristone can be prescribed, joining mostly Democratic-led states seeking to ensure access to the drug.

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

Julie Rovner: Slate’s “Not Every Man Will Be as Dumb as Marcus Silva,” by Moira Donegan and Mark Joseph Stern.

Joanne Kenen: The Baltimore Banner’s “Baltimore Isn’t Accessible for People With Disabilities. Fixing It Would Cost Over $650 Million,” by Hallie Miller and Adam Willis.

Tami Luhby: CNN’s “Because of Florida Abortion Laws, She Carried Her Baby to Term Knowing He Would Die,” by Elizabeth Cohen, Carma Hassan, and Amanda Musa.

Margot Sanger-Katz: The New Yorker’s “The Problem With Planned Parenthood,” by Eyal Press.

Also mentioned in this week’s episode:

• CNN’s “Here’s How the End of the Covid-19 Public Health Emergency Affects You,” by Tami Luhby and Alex Leeds Matthews.
• The New York Times’ “Corporate Giants Buy Up Primary Care Practices at Rapid Pace,” by Reed Abelson.
• Vox’s “Independents Back Abortion Rights. They’re Less Sure Democrats Do,” by Rachel M. Cohen.

Click to open the transcript

Transcript: The Crisis Is Officially Ending, but Covid Confusion Lives On

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

Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent at KFF Health News. And I’m joined by some of the best and smartest health reporters in Washington. We are taping this week on Thursday, May 11, at 10:30 a.m. As always, news happens fast and things might have changed by the time you hear this. So here we go. We are joined today via video conference by Tami Luhby, of CNN.

Tami Luhby: Hello.

Rovner: Margot Sanger Katz, The New York Times.

Sanger-Katz: Good morning.

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

Joanne Kenen: Hi, everybody.

Rovner: So the news on the debt ceiling standoff, just so you know, is that there is no news. Congressional leaders and White House officials are meeting again on Friday, and we still expect to not see this settled until the last possible minute. But there was plenty of other health news. We will start with the official end of the U.S. public health emergency for covid. We have talked at some length about the Medicaid unwinding that’s now happening and a potential to end some telehealth service reimbursement. But there’s a lot more that’s going away after May 11. Tami, you’ve been working to compile everything that’s about to change. What are the high points here?

Luhby: Well, there are a lot of changes depending on what type of insurance you have and whether we’re talking about testing, treatment, or vaccines. So I can give you a quick rundown. We wrote a visual story on this today. If you go to CNN.com, you’ll find it on the homepage right now.

Rovner: I will link to it in the show notes for the podcast.

Luhby: Basically, many people will be paying more for treatments and for tests. However, vaccines will generally remain free for almost everyone. And basically, if you look at our story, you’ll see the color-coded guide as to how it may impact you. But basically, testing — at-home tests are no longer guaranteed to be free. So if you’ve been going to your CVS or somewhere else to pick up your eight tests a month, your insurer may opt to continue providing it for free, but I don’t think many will. And then for lab tests, again, it really depends. But if you have Medicaid, all tests will be free through 2024. However, if you have private insurance or Medicare, you will probably have to start paying out-of-pocket for tests that are ordered by your provider. Those deductibles, those pesky deductibles, and copays or coinsurance will start kicking in again. And for treatments, it’s a little bit different again. The cost will vary by treatment if you have Medicare or private insurance. However, Paxlovid and treatments that are purchased by the federal government, such as Paxlovid, will be free as long as supplies last. Now, also, if you’re uninsured, there is a whole different situation. It’ll be somewhat more difficult for them. But there are still options. And, you know, the White House has been working to provide free treatments and vaccines for them.

Rovner: So if you get covid, get it soon.

Luhby: Like today. Right, exactly. Yeah, but with vaccines, even though, again, they’re free as long as the federal supplies last — but because of the Affordable Care Act, the CARES Act, and the Inflation Reduction Act, people with private insurance, Medicare, and Medicaid will actually continue to be able to get free vaccines after the federal supplies run out.

Rovner: After May 11.

Luhby: It’s very confusing.

Rovner: It is very confusing. That’s why you did a whole graphic. Joanne, you wanted to add something.

Kenen: And the confusion is the problem. We have lots of problems, but, like, last week, we talked a little bit about this. You know, are we still in an emergency? We’re not in an emergency the way we were in 2020, 2021, but it’s not gone. We all know it’s much, much better, but it’s not gone. And it could get worse again, particularly if people are confused, if people don’t know how to test, if people don’t know that they can still get things. The four of us are professionals, and, like, Tami’s having to read this complicated color-coded chart — you know, you get this until September 2024, but this goes away in 2023. And, you know, if you have purple insurance, you get this. And if you have purple polka-dotted insurance, you get that. And the lack of clarity is dangerous, because if people don’t get what they’re eligible for because they hear “emergency over, everything — nothing’s free anymore” — we’re already having trouble with uptake. We don’t have enough people getting boosters. People don’t know that they can get Paxlovid and that it’s free and that it works. We are still in this very inadequate response. We’re not in the terrifying emergency of three years ago, but it’s not copacetic. You know, it’s not perfect. And this confusion is really part of what really worries me the most. And the people who are most likely to be hurt are the people who are always most likely to be hurt: the people who are poor, the people who are in underserved communities, the people who are less educated, and it’s disproportionately people in minority communities. We’ve seen this show before, and that’s part of what I worry about — that there’s a data issue that we’ll get to whenever Julie decides to get to it, right?

Rovner: Yeah, I mean, and that’s the thing. With so much of the emergency going away, we’re not really going to know as much as we have before.

Sanger-Katz: In some ways, how you feel about this transition really reflects how you feel about the way that our health care system works in general. You know, what happened for covid is —and I’m oversimplifying a little bit — is we sort of set up a single-payer system just for one disease. So everyone had access to all of the vaccines, everyone had access to all of the tests, everyone had access to all of the treatments basically for free. And we also created this huge expansion of Medicaid coverage by no longer allowing the states to kick people out if they no longer seem to be eligible. So we had the kind of system that I think a lot of people on the left would like to see, not just for one disease but for every disease, where you have kind of more universal coverage and where the cost of obtaining important treatments and prevention is zero to very low. And this is definitely going to be a bumpy transition, but it’s basically a transition to the way our health care system works for every other disease. So if you are someone who had some other kind of infectious disease or a chronic disease like cancer, rheumatoid arthritis, whatever, you’ve been sort of dealing with all of this stuff the whole time — that you have to pay for your drugs; that, you know, that testing is expensive; that it’s confusing where you get things; that, you know, there’s a lot of complexity and hoops you have to jump through; that a lot depends on what kind of insurance you have; that what kind of insurance you can get depends on your income and other demographic characteristics. And so I find this transition to be pretty interesting because it seems like it would be weird for the United States to just forever have one system for this disease and another system for every other disease. And of course, we do have this for people who are experiencing kidney disease: They get Medicare, they get the government system, regardless of whether they would otherwise be eligible for Medicare.

Rovner: We should point out that Congress did that in 1972. They haven’t really done it since.

Kenen: And when it was much more rare than it was today.

Rovner: And when people didn’t live very long with it mostly.

Kenen: We didn’t have as much diabetes either.

Sanger-Katz: But anyway, I just think this transition kind of just gives us a moment to reflect on, How does the system work in general? How do we feel about how the system works in general? Are these things good or bad? And I agree with everything that Joanne said, that the confusion around this is going to have public health impacts as relates to covid. But we have lots of other diseases where we just basically have the standard system, and now we’re going to have the standard system for covid, too.

Kenen: You could have gone to the hospital with the bad pneumonia and needed oxygen, needed a ventilator, and when they tested you, if you had covid, it was all free. And if you had, you know, regular old-fashioned pneumonia, you got a bill. I agree with everything Margot said, but it’s even that silly. You could have had the same symptoms in your same lungs and you had two different health care systems and financing systems. None of us have ever thought anything made sense.

Rovner: Yes, well, I actually —

Kenen: That’s why we have a podcast. Otherwise, you know —

Sanger-Katz: And also the way that the drugs and vaccines were developed was also totally different, right? With the government deeply involved in the technology and development, you know, funding the research, purchasing large quantities of these drugs in bulk in advance. I mean, this is just not the way that our system really works for other diseases. It’s been a very interesting sort of experiment, and I do wonder whether it will be replicated in the future.

Luhby: Right. But it was also clear that this is not the beginning of the pushback. I mean, Congress has not wanted to allocate more money, you know, and there’s been a lot of arguments and conflicts over the whole course of this so-called single-payer system, or this more flexible system. So the U.S.’ approach to health care has been pushing its way in for many months.

Rovner: I naively, at the beginning of the pandemic, when we first did this and when the Republicans all voted for it, it’s like, let’s have the federal government pay the hospitals for whatever care they’re providing and make everything free at point of service to the patient — and I thought, Wow, are we going to get used to this and maybe move on? And I think the answer is exactly the opposite. It’s like, let’s get rid of it as fast as we possibly can.

Kenen: There’s money that the government has put in. I believe it is $5 billion into the next generation of vaccines and treatments, because the vaccine we have has certainly saved many lives. But as we all know, it’s not perfect. You know, it’s preventing death, but not infection. It’s not ending circulation of the disease. So we need something better. This debt ceiling fight, if the people in the government could spend all $5 billion today — like we were joking, if you want to get covid, if you’re going to get covid, get it today — I mean, if they could, they would spend all $5 billion of it today, too, because that could be clawed back. I mean, that’s — it’s going to be part of the coming fight.

Luhby: But the question is, even if they develop it, will anyone take it, or will enough people take it? That’s another issue.

Rovner: Well, since we’re sort of on the subject, I’m going to skip ahead to what I was going to bring up towards the end, which I’m calling “This Week in Our Dysfunctional Health System.”

Kenen: We could call it that way every week.

Rovner: Yes, that’s true. But this is particularly about how our health system doesn’t work. First up is “ghost networks.” Those are where insurers provide lists of health care providers who are not, in fact, available to those patients. A quote “secret shopper survey” by the staff of the Senate Finance Committee found that more than 80% of mental health providers found in insurance directories in 12 plans from six states were unreachable, not accepting new patients, or not actually in network. This is not a new problem. We’ve been hearing about it for years and years. Why does it persist? One would think that you could clean up your provider directory. That would be possible, right?

Kenen: Didn’t they legislate that, though? Didn’t they say a few years ago you have to clean it up? I mean, there are going to be some mistakes because there’s, you know, many, many providers and people will make changes or leave practices or … [unintelligible] …  jobs or whatever. But I thought that they had supposedly, theoretically, taken care of this a couple years ago in one of the annual regulations for ACA or something.

Rovner: They supposedly, theoretically, took care of the hospitals reporting their prices in a way that consumers can understand, too. So we’ve discovered in our dysfunctional health care system that Congress passing legislation or HHS [the Department of Health and Human Services] putting out rules doesn’t necessarily make things so.

Kenen: Really?

Rovner: Yeah. I just — this was one that I had thought, Oh, boy, I have a whole file on that from like the 1990s.

Sanger-Katz: It’s a huge problem, though. I mean —

Rovner: Oh, it is.

Sanger-Katz: You know, we have a system where, for large groups of Americans, you are expected to shop for a health insurance plan. If you’re purchasing a marketplace plan for yourself, if you are purchasing a Medicare Advantage plan when you become eligible for Medicare, and in many cases, if you have a choice of employer plans, you know, you’re supposed to pick the plan that’s best for you. And we have a system that tells people that having those kinds of choices is good and maximizes the benefits to people, to be able to pick the best plan. But for a lot of people, being able to have the doctors and hospitals that they use or to have a choice of a wide range of doctors for various problems, including mental health services, is a huge selling point of one plan versus another. And again, you have these ghost networks, when you have this lack of transparency and accuracy of this information, it just causes people to be unable to make those good choices and it undermines the whole system of market competition that underpins all of this policy design. I think you can argue that there are not a million gazillion people who are actually shopping on the basis of this. But I do think that knowing whether your medical providers are covered when you’re choosing a new health care plan is actually something that a lot of people do look into when they are choosing a health insurance plan. And discovering that a doctor that you’ve been seeing for a long time and whose relationship you really value and whose care has been important to you is suddenly dishonestly represented as a part of an insurance plan that you’ve selected is just, you know, it’s a huge disappointment. It causes huge disruptions in people’s care. And I think the other thing that this study highlighted is that health insurance coverage for mental health services continues to be a very large problem. There has been quite a lot of legislation and regulation trying to expand coverage for mental health care. But there are these kind of lingering problems where a lot of mental health care providers simply don’t accept insurance or don’t accept very many patients who have insurance. And so I think that this report did a good job of highlighting that place where I think these problems are even worse than they are with the health care system at large. It’s just very hard to find mental health care providers who will take your insurance.

Rovner: And I would say, when you’re in mental health distress or you have a relative who’s in mental health distress, the last thing you need is to have to call 200 different providers to find one who can help you.

Kenen: A lot of the ones that are taking insurance are these online companies, and the good thing is that they’re taking insurance and that there may be convenience factors for people, although there’s also privacy and other factors on the downside. But there have been reports about, your data is not private, and I have no idea how you find out which company is a good actor in that department and which company is just selling identifiable data. I mean, I think it was The Washington Post that had a story about that a couple of weeks ago. You know, you click in on something — straight to the data broker. So, yeah, you get insurance coverage, but at a different price.

Rovner: Well, overlaid over all of this is consolidation, this time at the primary care level of health care. Margot, your colleague Reed Abelson had a big story this week on primary care practices being bought up by various larger players in the health care industry, including hospitals, insurance companies, pharmacy chains, and even Amazon. These larger entities say this can act as a move towards more coordinated, value-based care, which is what we say we all want. But there’s also the very real possibility that these giant, vertical, mega medical organizations can just start to name their own price. I mean, this is something that the FTC [Federal Trade Commission] in theory could go after but has been kind of loath to and that Congress could go after but has also been kind of loath to.

Sanger-Katz: Yeah, in some ways we’ve seen this movie before. There was a big wave of primary care acquisitions that happened, I think, in the 1990s by hospitals. And the hospitals learned pretty quickly that primary care doctors are kind of a money-losing proposition, and they divested a lot. But I think what Reed documented so nicely is that the entities that are buying primary care now are more diverse and they have different business strategies. So it’s not just hospitals who are sort of trying to get more patients referred to their higher-profit specialists, but it’s also Medicare Advantage insurers who benefit from being able to tell the primary care doctors to diagnose their patients with lots of diseases that generate profits for the plan, and it’s other kinds of groups that see primary care as kind of the front door to other services that can be revenue-generating. And it’s very — it will be very interesting to see what the effects of these will be and whether these will turn out to be good business decisions for these new entities and of course also whether it will turn out to be good for patient care.

Rovner: Yeah, I remember in the 1990s when hospitals were buying up doctor practices, the doctors ended up hating it because they were asked to work much harder, see patients for a shorter period of time, and some of them actually — because they were now on salary rather than being paid for each patient — were cutting back on, you know, in general, on the amount of care they were providing. And that was what I think ended up with a lot of these hospitals divesting. It didn’t work out the way the hospitals hoped it would. But as you point out, Margot, this is completely different, so we will — we will see how this moves on. All right. Let’s go back a little bit. We’re going to talk about abortion in a minute. But first, something that could prevent a lot of unintended pregnancies: On Wednesday, an advisory committee for the Food and Drug Administration — actually two advisory committees — unanimously recommended that the agency approve an over-the-counter birth control pill. This has been a long time coming here in the U.S., even though pills like these are available without prescription in much of Europe and have been for years. But while the FDA usually follows the recommendations of its advisory committees, we know that some FDA scientists have expressed concerns about over-the-counter availability. So what’s the problem with giving women easier access to something that so many depend on?

Kenen: There are trade-offs. And there are — some of the scientists at the FDA are more conservative than others about, What if the woman doesn’t understand how to take the pill properly? Things like that. I mean, obviously, if we go the over-the-counter route, as other countries are doing, there have to be very simple, easy-to-understand explanations in multiple languages. Pharmacists should be able to explain it like, you know, “You have to take it every day, and you have to take it at approximately the same time every day,” and things like that. So, you know, obviously not taking it right doesn’t protect you as much as taking it right. But there are a lot of people who will be able to get it. You know, getting a prescription is not always the easiest thing in the world. Or if you’re lucky, you just click on something and somebody calls your doctor and gets you a refill. But that doesn’t always work and not everybody has access to that, and you have to still see your doctor sometimes for renewals. So if you’re a working person who doesn’t have sick leave and you have to take time off from work every three months to get a refill or you have to hire child care or you have to take three buses — you know, it takes a whole day, and then you sit in a waiting room at a clinic. I mean, our health system is not patient-friendly.

Rovner: I was going to say, to go back to what Tami was talking about earlier — if pills are available over the counter, it’s going to depend on, you know, what your insurance is like, whether you would get it covered.

Kenen: The cost.

Rovner: That’s right. And it could end up being —

Kenen: But I don’t think the FDA is concerned about that.

Rovner: No, they’re not. That’s not their job.

Kenen: The pill is pretty safe, and these are lower-dose ones than the pills that were invented, you know, 50 years ago. These are lower-dose, safer drugs with fewer side effects. But I mean, there’s concern about the rare side effect, there’s concern about people not knowing how to take it, all that kind of stuff. But Julie just mentioned the cost of coverage is a separate issue because under the ACA it’s covered. And if it becomes over the counter, the mechanism for getting that covered is, at this point, unclear.

Sanger-Katz: But we do have a system now where, for a lot of women, obtaining birth control pills depends on being able to get a doctor’s appointment on a regular basis. I think, you know, this is not standard practice, but I do think that there are a lot of OB-GYNs who basically won’t write you for a birth control pill unless you come in on a regular basis to receive other kinds of health screenings. And I think many of them do that with good intentions because they want to make sure that people are getting Pap smears and other kinds of preventive health services. But on the other hand, it does mean that there are a lot of women who, if they don’t have time or they can’t afford to come in for regular doctor’s appointments, lose access to birth control. And I think over-the-counter pills is one way of counteracting that particular problem.

Rovner: And I think that’s exactly why so many of the medical groups are urging this. During the more than a decade-long fight over making the morning-after pill over the counter, the big hang-up was what to do about minors. Even President Obama, a major backer of women’s reproductive health rights, seemed unhappy at the idea of his then-barely teenage daughters being able to get birth control so easily and without notifying either parent. It seems unimaginable that we’re not going to have that same fight here. I mean, literally, we spent six years trying to figure out what age teens could be to safely buy morning-after pills, which are high doses of basically these birth control pills. I’m actually surprised that we haven’t really seen the minor fight yet.

Kenen: I think everyone’s waiting for somebody else to do it first. I mean, like Julie, I wasn’t expecting to hear more about age limitations, and that’ll probably come up when the FDA acts, because I think the advisory committee just wanted to — they were pretty strong saying, “Yeah, make this OTC.”

Sanger-Katz: I also think the politics around emergency contraception are a little bit different because I think that, while physicians understand that those pills are basically just high-dose birth control pills and that they work in just the same way as typical contraception, I think there’s a perception among many members of the public that because you can take them after unprotected sex, that they might be something closer to an abortion. Now, that is not true, but because I think that is a common misperception, it does lead to more discomfort around the availability of those pills, whereas birth control pills — while I think there are some people who object to their wide dissemination and certainly some who are concerned about them in the hands of children, I think they are more broadly accepted in our society.

Rovner: We obviously are going to see, and we’ll probably see fairly soon. We’re expecting, I guess, a decision from the FDA this summer, although with the morning-after pill we expected a decision from FDA that lingered on for many months, in some cases many years.

Kenen: And I think it’s at least hypothetically possible that states will not do what the FDA says. Say the FDA says they can be over the counter with no age limitations. I can see that becoming a fight in conservative states. I mean, I don’t know exactly the mechanism for how that would fall, but I could certainly think that somebody is going to dream up a mechanism so that a 12-year-old can’t get this over the counter.

Rovner: I want to move to abortion because first up is the continuing question over the fate of the abortion pill, which we get to say at this point: not the same as the emergency contraceptive pill, which, as Margot said, is just high-dosage regular birth control pills. Needless to say, that’s the one that we’re having the current court action over. And there was even more action this week, although not from that original case, which will be heard by the Court of Appeals later in this month. In West Virginia, a judge declined to throw out a case brought by GenBioPro. They are the maker of the generic version of mifepristone, the abortion pill. That generic, which accounts for more than half the market, would be rendered unapproved even under the compromise position of the Court of Appeals because it was approved after the 2016 cutoff period. Remember, the Court of Appeals said, We don’t want to cancel the approval, but we want to roll it back to the date when FDA started to loosen the restrictions on it. So, in theory, there would be no generic allowed, but that’s actually not even what the West Virginia lawsuit is about; it’s about challenging the state’s total abortion ban as violating the federal supremacy of the FDA over state laws. Joanne, that’s what sort of you were talking about now with contraceptives, too. And this is the big unanswered question: Can states basically overrule the FDA’s approval and the FDA’s approval for even an age limit?

Kenen: Well, I mean, I’m not saying they can, but I am saying that I don’t know where the question will come down. Go back to the regular birth control; I can certainly see conservative states trying to put age limits on it. And I don’t know how that’ll play out legally. But this is a different issue, and this is why the abortion pill lawsuits are not just about the abortion pill. They’re about drug safety and drug regulation in this country. The FDA is the agency we charge with deciding whether drugs are safe and good for human beings, and not the system of politicians and state legislators in 50 different states replacing their judgment. So obviously, it’s more complicated, because it’s abortion, but one of several bottom lines in this case is who gets to decide: the FDA or state legislature.

Rovner: And right: Do states get to overrule what the federal Food and Drug Administration says? Well, I —

Kenen: Remember, some states have had — you know, California’s had stricter regulations on several health things, you know, and that’s been allowed that you could have higher ceilings for various health — you know, carcinogenics and so forth. But they haven’t fundamentally challenged the authority of the FDA.

Rovner: Yet. Well, since confusion is our theme of the week, also this week a group of independent abortion clinics led by Whole Woman’s Health, which operates in several states, filed suit against the FDA, basically trying to add Virginia, Kansas, and Montana to the other 18 states that sued to force FDA to further reduce the agency’s current restrictions on mifepristone. A federal judge in Washington state ruled — the same day that Texas judge did that mifepristone should have its approval removed — judge in Washington said the drug should become even more easily available. In the real world, though, this is just sowing so much confusion that nobody knows what’s allowed and what isn’t, which I think is kind of the point for opponents, right? They just want to make everybody as confused as possible, if they can’t actually ban it.

Sanger-Katz: I think they actually want to ban it. I mean, I think that’s their primary goal. I’m sure there are some that will settle for confusion as a secondary outcome. I think just this whole mess of cases really highlights what a weird moment we are, where we’re having individual judges and individual jurisdictions making determinations about whether or not the FDA can or can’t approve the safety and efficacy of drugs. You know, as Joanne said, we’ve just had a system in this country since the foundation of the FDA where they are the scientific experts and they make determinations and those determinations affect drug availability and legal status around the country. And this is a very unusual situation where we’re seeing federal courts in different jurisdictions making their own judgments about what the FDA should do. And I think the Texas judge that struck down the approval of mifepristone, at least temporarily, has come in for a lot of criticism. But what the judge in Washington state did is sort of a flavor of the same thing. It’s telling the FDA, you know, how they should do their business. And it’s a weird thing.

Rovner: It is. Well, one last thing this week, since we’re talking about confusion, and the public is definitely confused, according to two different polls that are out this week — on the one hand, a Washington Post-ABC News poll found that a full two-thirds of respondents say mifepristone, the abortion pill, should stay on the market, and more than half say they disagree with the Supreme Court’s overturn of Roe v. Wade, including 70% of independents and more than a third of Republicans. Yet, in focus groups in April, more than a third of independents couldn’t differentiate Democrats’ position on abortion from Republicans’. As reported by Vox, one participant said, quote, “I really haven’t basically heard anything about which party is leaning toward it and which one isn’t.” When pressed, she said, “If I had to guess, I would say Democrat would probably be against it and Republican would probably be for it.” Another participant said she thought that Joe Biden helped get the Supreme Court judges who overturned Roe. We really do live in a bubble, don’t we? I think that was sort of the most mind-blowing thing I’ve read since — all the months since Roe got overturned, that there are people who care about this issue who have no idea where anybody stands.

Sanger-Katz: I think it’s just a truth about our political system that there are a lot of Americans who are what the political scientists call low-information voters. These are people who are just not following the news very closely and not following politics very closely. And they may have a certain set of opinions about issues of the day, but I think it is a big challenge to get those people aware of where candidates stand on issues of concern to them and to get them activated. And it doesn’t really surprise me that independent voters are the ones who seem to be confused about where the parties are, because they’re probably the least plugged into politics generally. And so, for Democrats, it does seem like this lack of information is potentially an opportunity for them, because it seems like when you ask voters what they want on abortion, they want things that are more aligned with Democratic politicians’ preferences than Republicans’. And so it strikes me that perhaps some of those people in the focus group who didn’t know who stood for what, maybe those are gettable voters for the Democratic Party. But I think — you know, we’re about to go into a very heated campaign season, you know, as we go into the presidential primaries and then the general election in which there are going to be a lot of ads, a lot of news coverage. And, you know, I think abortion is very likely to be a prominent issue during the campaigns. And I think it is almost certainly going to be a major goal of the Biden presidential reelection campaign to try to make sure that these people know where Biden stands relative to abortion, because it is an issue that so many voters agree with him on.

Rovner: And it makes you see, I mean, there’s a lot of Republicans who are trying to sort of finesse this issue now and say, you know, “Oh, well, we’re going to restrict it, but we’re not going to ban it,” or, “We have all these exceptions” that are, of course, in practice, you can’t use. Obviously, these are the kinds of voters who might be attracted to that. So we will obviously see this as it goes on.

Kenen: But Julie, do you remember whether they were actually voters? Because I had the same reaction to you: like, of all the things to not be sure of, that one was pretty surprising. But we also know that in places like Kansas where, you know, where there are not that many Democrats, these referenda won. Voters have supported abortion rights in the 2022 elections and in these state referenda. So independents must be voting with the —

Rovner: I was going to say, I think if you’re doing —

Kenen: Something isn’t totally — something is not totally adding up there.

Rovner: If you’re doing a focus group for politics, one presumes that you get voters. So, I mean, I think that was — that was the point of the focus group. But yeah, it’s —

Kenen: Or people who say they’re voters.

Rovner: Or people who say they’re voters. That is a different issue. All right. Well, something not that confusing: 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. Tami, why don’t you go first this week?

Luhby: OK. Well, I picked a story from CNN by my colleagues on the health team. It’s titled “Because of Florida Abortion Laws, She Carried Her Baby to Term Knowing He Would Die,” by Elizabeth Cohen, Carma Hassan, and Amanda Musa. And I have to say that when I first read this story, I couldn’t get through it, because it was so upsetting. And then when I selected it as an extra credit, I had to read it in full. But it’s about a family in Florida whose son was born without kidneys. They knew that he was going to die. And it’s about all of the effects from everything from, you know, the mother, Deborah Dorbert, on her physically and emotionally. But it also, you know, talked about the family and, you know, the effect on the marriage and the effect — which was just so upsetting — was on the 4-year-old son, who became very attached. I don’t think they even knew — well, it wasn’t a girl. It was actually a boy. But for some reason, this older son felt that it was a girl and just kept saying, like, “My sister is going to do X, Y, Z.” And, you know, how did the parents break it to him? Because he saw that his mother was, you know, pregnant and getting larger. And, you know, it was just figuring out how to break it to him that no baby was coming home. So the details are heart-wrenching. The quotes in the third paragraph: “‘He gasped for air a couple of times when I held him,’ said Dorbert. ‘I watched my child take his first breath, and I held him as he took his last one.’” So, you know, these are things that, you know — and we just talked about how the states are arguing over what exceptions there should be, if any, you know, and these are the stories that the legislators don’t think about when they pass these laws.

Rovner: I think I said this before because we’ve had a story like this almost every week. This one was particularly wrenching. But I think the one thing that all these stories are doing is helping people understand, particularly men, that there are complications in pregnancy, that they’re not that rare, that, you know, that they sort of throw off and say, “Oh, well, that’s, you know, one in a million,” — It’s not one in a million. It’s like one in a thousand. That’s a lot of people. So I mean, that’s why there are a lot of these stories, because there are a lot of pregnancies that don’t go as expected.

Luhby: Right. And it really shows the chilling effect on doctors because, you know, you would say, “Oh, it’s simple: life of the mother or, you know, life of the fetus” or something like that. That seems pretty straightforward, but it isn’t. And these doctors, in cases where, you know, other cases where it is the life of the mother, which seem, again, very straightforward, the doctors are not willing to do anything because they’re afraid.

Rovner: I know. Joanne.

Kenen: This is a story from The Baltimore Banner that has a very long title. It’s by Hallie Miller and Adam Willis, and it’s called “Baltimore Isn’t Accessible for People With Disabilities. Fixing It Would Cost Over $650 Million.” Baltimore is not that big a city. $650 million is a lot of curbs and barriers. And there’s also a lot of gun violence in Baltimore. If you drive around Baltimore, and I work there a few days a week, you see lots of people on walkers and scooters and wheelchairs because many of them are survivors of gun violence. And you see them struggling. And there were quotes from people saying they, you know, were afraid walking near the harbor that they would fall in because there wasn’t a path for them. It is not invisible, but we treat it like it’s invisible. And it’s been many years since the Americans with Disabilities Act was passed, and we still don’t have it right. It’s a — this one isn’t confusion like everything else we talked about today. I loved Margot’s phrase about confusion as a secondary outcome. I think you should write a novel with that title. But it’s — this isn’t confusion. This is just not doing the right thing for people who are — we’re just not protecting or valuing.

Rovner: And I’d say for whom there are laws that this should be happening. Margot.

Sanger-Katz: I had another story about abortion. This one was in The New Yorker, called “The Problem With Planned Parenthood,” by Eyal Press. The story sort of looked at Planned Parenthood, you know, which is kind of the largest abortion provider in the country. It’s — I mean, it’s really a network of providers. They have all these affiliates. They’re often seen as being more monolithic than perhaps they are. But this story argued that people who were operating independent abortion clinics, who do represent a lot of the abortion providers in the country as well, have felt that Planned Parenthood has been too cautious legally, too afraid of running afoul of state laws, and so that has led them to be very conservative and also too conservative from the perspective of business, and that there is a view that Planned Parenthood is not serving the role that it could be by expanding into areas where abortion is less available. I thought it was just interesting to hear these criticisms and hoped to understand that the community of abortion providers are, you know, they’re diverse and they have different perspectives on how abortion access should work and what kinds of services should be provided in different settings. And they also view each other as business competition in some cases. I mean, a lot of the complaints in this article had to do with Planned Parenthood opening clinics near to independent clinics and kind of taking away the business from them, making it harder for them to survive and operate. Anyway, I thought it was a very interesting window into these debates, and it did mesh with some of my reporting experience, particularly around the legal cautiousness. I did a story before the Dobbs decision came down from the Supreme Court where Planned Parenthood in several states had just stopped offering abortions even before the court had ruled, because they anticipated that the court would rule and they just didn’t want to make any mistake about running afoul of these laws such that, you know, women were denied care that was still legal in the days leading up to the Supreme Court decision.

Rovner: Yeah, it’s a really good story. Well, my story is kind of tangentially about abortion. It’s from Slate, and it’s called “Not Every Man Will Be as Dumb as Marcus Silva,” by Moira Donegan and Mark Joseph Stern. And it’s about a case from Texas, of course, that we talked about a couple of weeks ago, where an ex-husband is suing two friends of his ex-wife for wrongful death, for helping her get an abortion. Well, now the two friends have filed a countersuit claiming that the ex-husband knew his wife was going to have an abortion beforehand because he found the pill in her purse and he put it back so that he could use the threat of a lawsuit to force her to stay with him. It feels like a soap opera, except it is happening in real life. And my first thought when I read this is that it’s going to make some great episode of “Dateline” or “20/20.” That is our show, as always.

Kenen: Or, not “The Bachelor.”

Rovner: Yeah, but not “The Bachelor.” That is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us too. Special thanks, as always, to our ever-patient producer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can tweet me. I’m still there. I’m at @jrovner. Joanne?

Kenen: @JoanneKenen.

Rovner: Tami.

Luhby: @Luhby.

Rovner: Margot.

Sanger-Katz: @sangerkatz.

Rovner: We will be back in your feed next week, hopefully with a little less confusion. Until then, be healthy.

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When the first Humira biosimilar — essentially a generic version — finally hit the market in January, it came with an unpleasant surprise. The biosimilar’s maker, Amgen, launched two versions of the drug, which treats a host of conditions including rheumatoid arthritis. They were identical in every way but this: One was priced at about $1,600 for a two-week supply, 55% off Humira’s list price. But the other was priced at around $3,300, only about 5% off. And OptumRx, one of three powerhouse brokers that determine which drugs Americans get, recommended option No. 2: the more expensive version.

As Murdo Gordon, an Amgen executive vice president, explained in an earnings call, the higher price enabled his company to give bigger rebates, or post-sale discounts, to Optum and other intermediaries. Most of that money would be passed on to insurers, and patients, he said. Gordon did not mention that the higher-priced option would leave some patients paying much more out-of-pocket, undermining the whole rationale for generic drugs.

The Optum-Amgen announcements perfectly elucidated why, after years of thundering against drugmakers, Congress and the administration have now focused on regulating the deal-makers known as pharmacy benefit managers, or PBMs. Sen. Bernie Sanders’ health committee grilled a panel of PBM and pharmaceutical executives Wednesday in preparation for a vote on PBM legislation, expected Thursday.

The three biggest PBMs — OptumRx, CVS Caremark, and Express Scripts — control about 80% of prescription drug sales in America and are the most profitable parts of the health conglomerates in which they’re nestled. CVS Health, the fourth-largest U.S. corporation by revenue on Fortune’s list, owns CVS Caremark and the insurer Aetna; UnitedHealth Group, a close fifth, owns Optum; and Cigna, ranking 12th, owns Express Scripts. While serving as middlemen among drugmakers, insurers, and pharmacies, the three corporations also own the highest-grossing specialty drug and mail-order pharmacies.

“John D. Rockefeller would be happy to be alive today,” said David Balto, a former Federal Trade Commission attorney who represents clients suing PBMs. “He could own a PBM and monopolize economic power in ways he never imagined.”

Drug manufacturers claim that exorbitant PBM demands for rebates force them to set high list prices to earn a profit. Independent pharmacists say PBMs are driving them out of business. Physicians blame them for unpredictable, clinically invalid prescribing decisions. And patients complain that PBMs’ choices drain their pocketbooks.

With PBMs driving prices, competition has had the opposite effect from what economic theory predicted Medicare patients would spend out-of-pocket on drugs, one large study showed. Over a five-year period, patients were paying 50% more for branded drugs that had competitors than for those that didn’t.

All this makes the PBMs ripe targets for politicians of both parties. Yet the complexity and obscurity of their role in the drug marketplace have skeptics wondering whether legislation advancing in the House and Senate will actually help patients or lower prices at the pharmacy counter.

“We may try to make things better and actually make things worse,” Sen. Rand Paul (R-Ky.) said at Wednesday’s hearing.

The PBMs pass along most of their rebates to health plans, which will bear a larger share of patient drug costs in coming years under Medicare changes that are part of the 2022 Inflation Reduction Act. It’s likely that pressure on insurers will be passed along to PBMs and result in even more aggressive limits on physician prescription decisions, said Troyen Brennan, an adjunct Harvard University professor who was chief medical officer for CVS Health from 2008 to 2022.

Several congressional bills target drug company rebates to PBMs and what’s known as “spread pricing” — the extra money PBMs collect from insurers over what they pay pharmacies for drugs.

But those aren’t the big PBM revenue sources anymore, Brennan said. PBMs today mostly make money by owning mail-order and specialty pharmacies and from the government’s 340B program, created to help hospitals that treat a disproportionately elderly and poor population. Medicare requires drugmakers to provide big discounts to participating hospitals and the growing rosters of affiliated physician groups they own, and some of those discounts end up with PBMs.

Employers and the federal government decide where most of the rebate money goes, PBM leaders testified Wednesday — and health plans decide what out-of-pocket costs their covered members will pay.

In other words, drug companies blame PBMs for high drug counter prices, PBMs blame insurers, and insurers blame the drug companies, all part of a health care system that hinges on an unspoken bargain: Make life comfortable for some — mostly the upper and middle classes — at the expense of lower-income and poorly insured people who get what they get.

 PBMs’ extraction of money from patients in the name of “copayments” at the pharmacy counter “reintroduces medical underwriting” that was stripped away by the Affordable Care Act, Craig Garthwaite, a health care researcher at Northwestern’s Kellogg School of Management, told a Senate panel last year. Insurers can no longer pick and choose whom to insure, as they could before the landmark 2010 health law. But they are finding ways to make the sickest pay.

“People with expensive conditions are paying more for insurance so healthy people can pay less,” he said.

PBMs Evolve From Minnows to Whales

In 1967, a year before the first PBM was founded, spending on prescription drugs outside of a hospital in the U.S. totaled around $3.3 billion, compared with more than $600 billion in net payments last year. By 2005, when Medicare expanded to include coverage of outpatient drugs, government and private insurers depended on PBMs’ negotiating power to keep rising drug prices in check.

The Federal Trade Commission and Justice Department allowed the largest PBMs to gobble up competitors and merge with insurers during the Bush and Obama administrations on the grounds that bolstering their powers might rein in prices. The FTC fought state investigations of anti-competitive behavior, saying that pressure on PBMs would benefit consumers.

The FTC under President Joe Biden has switched course, at least partly because of the arrival of Chair Lina Khan, a vigorous proponent of antitrust policy who launched an investigation of the PBMs last June.

It came partly at the request of independent pharmacists, who rely on PBM reimbursements for the drugs they purchase and provide consumers. Thousands of pharmacists complained to the FTC that PBMs force them to accept unfairly low reimbursements — then slam them with opaque rules requiring them to pay back some of the money months later. Pharmacists returned $12.6 billion to PBMs in 2021, according to a recent Medicare Payment Advisory Commission report.

During a recent week, said Ashley Seyfarth, who owns Kare Drug in Aztec, New Mexico, a PBM reclaimed money from one prescription because the paperwork was faxed. It clawed back cash from another sale because Kare had kept the drug on the shelf an extra day, beyond the PBM’s time limit, to accommodate a patient delayed getting to the store.

And her reimbursements are “beyond low,” Seyfarth said. She laughed when asked whether contract terms with the PBMs were negotiable. “You aren’t negotiating anything,” she said. “It’s take it or leave it.”

PBMs “have the right to audit whether contract terms are agreed to,” Angela Banks, vice president of policy at the Pharmaceutical Care Management Association, the PBM trade group, said at a recent conference. “A lot of the complaints about PBMs come from two parties from whom we are extracting money: manufacturers and pharmacists.”

PBM pricing decisions are often murky. According to a recent study, in 2018 Medicare spent $2.6 billion more through PBMs for a year’s worth of 184 generic drugs than they would have cost at Costco. Doctors and hospitals find PBM formularies baffling, with dozens of variations depending on a patient’s health plan.

When Philadelphia-area internist Amy Davis writes a prescription, she has no idea what the pharmacy will bill her patients, she said, or whether a PBM has decided the drug needs prior authorization. Sometimes she doesn’t find out until a patient returns months later saying they skipped the drug because it was too expensive.

“We physicians are completely in the dark,” she said. “And it’s designed that way.”

The PBMs’ growing use of proprietary pharmacies, including mail-order operations, can interfere with the care of patients like Jasmine St. Clair, a 45-year-old restaurant manager and mother of six in Mount Juliet, Tennessee.

In October 2021, St. Clair’s treatment for a rare, non-smoking-related lung cancer was delayed three weeks after PBM giant Express Scripts insisted her prescription be filled by Accredo, the mail-order pharmacy it owns.

In the meantime, her fatigue and lower-back and neck pain became so bad “I couldn’t pick up my daughter, who was 2,” St. Clair said. “And I was really getting scared.”

After St. Clair started the four-pills-twice-a-day regimen, her tumor rapidly shrank. But in January, her husband’s insurance changed and the medications didn’t arrive on time. When she called Accredo to see what was wrong, “they said, ‘You owe $8,000. Would you like to pay by card?’”

The pharmacy attached to her oncology practice straightened out the payment issue and ensured her continued use of the drug, St. Clair said. Her oncologist, Johnetta Blakely, said these are daily occurrences in her practice.

“The problem with the PBMs and the specialty pharmacies they own is that they are so complicated and intertwined it’s hard to figure out what the heck they are doing,” Blakely said. “All this bureaucratic stuff is a distraction and takes away from things I could be doing, like asking Jasmine about her kids.”

What’s the Remedy?

Bipartisan House and Senate bills would require PBMs to reimburse pharmacies serving Medicaid patients based on an authorized price list, rather than using standards that allegedly allow PBMs to lowball pharmacies. The Congressional Budget Office has estimated the bills would save the federal government $1 billion over 10 years. Another Senate bill would require PBMs to report more of their earnings to the FTC, and would ban deceptive and unfair fees.

But PBMs have shown themselves adept at finding ways around regulation. A federal rule scheduled to take effect next year would curtail PBM “clawbacks” on independent pharmacies. But PBM contracts sent out to pharmacies in recent weeks get around that by lowering reimbursement fees and putting a percentage of their payments to pharmacies into a kind of escrow, said Douglas Hoey, CEO of the National Community Pharmacists Association.

When the Trump administration considered banning brand-name drug rebates in 2017, PBMs set up companies in Ireland and Switzerland to take over the negotiations and purchases. Doing so offered a tax advantage and allowed the PBMs to avoid scrutiny of the quantity and nature of those deals. Recently, Express Scripts set up another company to purchase generic drugs, in the Cayman Islands.

And PBMs appear adept at moving money from one pocket to another. “Yesterday’s rebates are today’s fees and potentially tomorrow’s something else,” said John O’Brien, CEO of the pharmaceutical industry-funded research group, the National Pharmaceutical Council.

Every arrangement that PBMs make with manufacturers, employers, and insurers is secret and proprietary, said Barak Richman, a Duke University Law School professor. This makes it nearly impossible to examine what kind of deals PBMs are making.

Antitrust law could be brought to bear on the PBMs, Richman said. And the Biden administration has shown an eagerness to possibly reverse mergers that have increased PBM clout. The Justice Department has taken similar steps.

But federal officials will have to move fast to slow the PBMs. Insurers that don’t have PBMs as part of their business have been shrinking in recent years because of the growing clout and buying power of the companies.

“I predict that any health insurer that doesn’t have a PBM is going to disappear in 10 years,” said Neeraj Sood, a professor at the University of Southern California Sol Price School of Public Policy. “Otherwise, there is no way to compete with the big three.”

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La marihuana y otros productos que contienen THC, el principal ingrediente psicoactivo de la planta, se han vuelto más potentes y peligrosos a medida que la legalización los ha vuelto más accesibles.

Décadas atrás, el contenido de THC de la hierba solía ser inferior al 1,5%. Hoy, algunos productos tienen más de un 90%.

La euforia de antaño ha dado paso a algo más alarmante. Cientos de miles de personas llegan a salas de emergencias por crisis relacionadas con la marihuana, y millones sufren trastornos psicológicos vinculados al consumo de cannabis, según investigaciones federales.

Pero los organismos reguladores no están a la altura.

En los estados que permiten la venta y el consumo de la marihuana y sus derivados, la protección al consumidor no es consistente.

“En muchos estados, los productos tienen una etiqueta de advertencia y poco más por parte de las entidades reguladoras”, dijo Cassin Coleman, vicepresidente del comité de asesoramiento científico de la Asociación Nacional de la Industria del Cannabis.

En general, el gobierno federal no ha intervenido. Sigue prohibiendo la marihuana como sustancia catalogada en la Lista 1 —como droga sin uso médico aceptado y con un alto riesgo de abuso— en virtud de la Ley de Sustancias Controladas (CSA). Pero en lo que respecta a la venta de cannabis, que muchos estados han legalizado, no regula características como la pureza o la potencia.

La Administración de Drogas y Alimentos (FDA) “básicamente se ha cruzado de brazos y no ha cumplido con su deber de proteger la salud pública”, afirmó Eric Lindblom, de la Facultad de Derecho de la Universidad de Georgetown que anteriormente trabajó en el Centro para Productos del Tabaco de la FDA.

La marihuana se ha transformado profundamente desde que generaciones de estadounidenses la usaron por primera vez.

El cannabis se cultiva para suministrar dosis mucho más altas de THC. En 1980, el contenido de THC de la marihuana confiscada era inferior al 1,5%. Hoy en día, muchas variedades de flores de cannabis —la materia vegetal que se puede fumar en un porro— tienen más de un 30% de THC.

Recientemente, en un dispensario de California el menú incluía una variedad con un 41% de THC.

La legalización también ha abierto la puerta a productos que se extraen de la marihuana pero que no siquiera parecidos: concentrados de THC aceitosos, cerosos o cristalinos que se calientan e inhalan mediante el vapeo o el dab, utilizando dispositivos parecidos a un soplete.

Los concentrados actuales pueden tener más de un 90% de THC. Algunos se anuncian como THC casi puro.

Pocos personifican la expansión de la marihuana de forma tan clara como John Boehner, ex presidente de la Cámara de Representantes de Estados Unidos. El republicano de Ohio se opuso durante mucho tiempo a la marihuana y, en 2011, se declaró “inalterablemente contrario” a su legalización.

Ahora forma parte del consejo directivo de Acreage Holdings, un productor de derivados de la marihuana.

Y Acreage Holdings ilustra la evolución del sector. Su marca Superflux comercializa un producto para vapear —”resina pura en un formato cómodo e instantáneo”— y concentrados como “budder”, “sugar”, “shatter” y “wax”. La empresa anuncia su concentrado de “THCa cristalino” como “lo último en potencia”.

Según el Instituto Nacional sobre el Abuso de Drogas, las concentraciones más elevadas entrañan mayores riesgos. “Los riesgos de dependencia física y adicción aumentan con la exposición a altas concentraciones de THC, y las dosis más altas de THC tienen más probabilidades de producir ansiedad, agitación, paranoia y psicosis”, se explica en su sitio web.

En 2021, 16,3 millones de personas en Estados Unidos —el 5,8% de las personas de 12 años en adelante— habían sufrido un trastorno por consumo de marihuana en el último año, según una encuesta publicada en enero por el Departamento de Salud y Servicios Humanos (HHS).

Esta cifra es muy superior a la suma de los trastornos por consumo de cocaína, heroína, metanfetamina, estimulantes de venta bajo receta, como Adderall, o analgésicos recetados, como fentanilo y OxyContin.

Otras drogas son más peligrosas que la marihuana, y la mayoría de las personas afectadas por su consumo padecieron un caso leve. Pero aproximadamente 1 de cada 7 —más de 2,6 millones de personas— padecieron un caso grave, según la encuesta federal.

La mayoría de los médicos equiparan el término “trastorno grave por consumo de sustancias” con la adicción, señaló Wilson Compton, subdirector del Instituto Nacional sobre el Abuso de Drogas.

El trastorno por consumo de cannabis “puede ser devastador”, afirmó Smita Das, psiquiatra de Stanford y presidenta de un consejo sobre adicciones de la Asociación Americana de Psiquiatría.

Das dijo que ha visto vidas destrozadas por el cannabis: personas de éxito que han perdido familias y trabajos. “Se encuentran en una situación en la que no saben cómo han llegado, porque sólo era un porro, sólo era cannabis, y no se suponía que el cannabis les creara adicción”, explicó Das.

Entre los diagnósticos médicos atribuidos a la marihuana figuran la “dependencia del cannabis con trastorno psicótico con delirios” y el síndrome de hiperémesis cannabinoide, una forma de vómito persistente.

Se estima que unas 800,000 personas realizaron visitas a emergencias relacionadas con la marihuana en 2021, según un estudio del gobierno publicado en diciembre de 2022.

Derecho a desintoxicación.

Un padre de Colorado pensó que era cuestión de tiempo para que el cannabis matara a su hijo.

En la primavera de 2021, el adolescente pasó un semáforo en rojo, chocó contra otro auto —resultando heridos él y el otro conductor— y huyó del lugar, según recordó el padre en una entrevista.

En los restos del accidente, el padre encontró porros, envases vacíos de un concentrado de THC de alta potencia conocido como “wax” y un vaporizador de THC.

En el teléfono móvil de su hijo descubrió mensajes de texto y decenas de referencias al “dabbing” y a la hierba. El adolescente dijo que había estado fumando antes del accidente y que intentó suicidarse.

Semanas después, la policía ordenó su ingreso involuntario en un hospital para una evaluación psiquiátrica. Según un informe policial, creía que lo perseguían francotiradores de un cártel de drogas.

El médico que evaluó al adolescente le diagnosticó “abuso de cannabis”.

“Deja de consumir dabs o wax, ya que pueden volverte extremadamente paranoico”, escribió el médico. “Vete directamente al programa de desintoxicación que elijas”.

Según el relato del padre, en los dos últimos años el adolescente sufrió varias retenciones involuntarias, docenas de encuentros con la policía, repetidos encarcelamientos y una serie de estadías en centros de tratamiento hospitalario.

A veces parecía fuera de la realidad, y enviaba mensajes de texto diciendo que Dios le hablaba y le daba superpoderes.

Los daños también fueron económicos. Los reclamos al seguro médico por su tratamiento ascendieron a casi $600,000 y los gastos de la familia llegaron a casi $40,000 hasta febrero.

En las entrevistas para este artículo, el padre habló bajo condición de anonimato para no perjudicar la recuperación de su hijo.

Está convencido de que la enfermedad mental de su hijo fue el resultado del consumo de drogas. Dijo que los síntomas remitían cuando su hijo dejaba de consumir THC y volvían cuando usaba de nuevo.

Su hijo tiene ahora 20 años, ha dejado la marihuana y le va bien, dijo el padre, y añadió: "No me cabe la menor duda de que el consumo de cannabis fue lo que le causó la psicosis, los delirios y la paranoia".

Regulación estatal desigual

Ahora, el uso médico de la marihuana es legal en 40 estados y el Distrito de Columbia, y el uso recreativo o para adultos es legal en 22 estados más el Distrito de Columbia, según MJBizDaily, una publicación especializada.

Al principio de la pandemia de covid-19, mientras gran parte de Estados Unidos cerró sus negocios, los dispensarios de marihuana siguieron abiertos. Muchos estados los declararon negocios esenciales.

Pero sólo dos estados que permiten el uso para adultos, Vermont y Connecticut, han puesto límites al contenido de THC —30% para la flor de cannabis y 60% para los concentrados de THC— y eximen de los límites a los cartuchos precargados, dijo Gillian Schauer de la Asociación de Reguladores de Cannabis, un grupo de reguladores estatales.

Algunos estados limitan el número de onzas o gramos que los consumidores pueden comprar. Sin embargo, incluso un poco de marihuana puede equivaler a mucho THC, apuntó Rosalie Liccardo Pacula, profesora de políticas de salud, economía y derecho en la Universidad del Sur de California.

Algunos estados sólo permiten el uso médico de productos con bajo contenido de THC; por ejemplo, en Texas, las sustancias que no contienen más de un 0,5% de THC en peso. Y algunos estados exigen etiquetas de advertencia. En Nueva Jersey, los productos de cannabis con más de un 40% de THC deben declarar: "Este es un producto de alta potencia y puede aumentar el riesgo de psicosis".

La normativa sobre marihuana de Colorado tiene más de 500 páginas. Sin embargo, se enfatizan los límites de las protecciones al consumidor: "Este producto se ha producido sin supervisión reglamentaria en materia de salud, seguridad o eficacia".

Determinar las normas adecuadas puede no ser sencillo. Por ejemplo, las etiquetas de advertencia podrían proteger a la industria de la marihuana de su responsabilidad, al igual que hicieron con las empresas tabacaleras durante años. Poner un tope a la potencia podría limitar las opciones de las personas que toman dosis elevadas para aliviar problemas médicos.

En general, en el ámbito estatal, la industria del cannabis ha frenado los esfuerzos reguladores argumentando que unas normas onerosas dificultarían la competencia entre las empresas legítimas y las ilícitas, explicó Pacula.

Pacula y otros investigadores han pedido al gobierno federal que intervenga.

Meses después de terminar su mandato como comisionado de la FDA, Scott Gottlieb hizo un llamamiento similar.

Al quejarse de que los estados habían llegado "muy lejos mientras el gobierno federal permanecía al margen", Gottlieb pidió "un esquema nacional uniforme para el THC que proteja a los consumidores."

Eso fue en 2019 y poco ha cambiado desde entonces.

¿Dónde está la FDA?

La FDA supervisa los alimentos, los medicamentos recetados, los de venta libre y los dispositivos médicos. Regula el tabaco, la nicotina y los vapes de nicotina. Supervisa las etiquetas de advertencia del tabaco. En interés de la salud y la seguridad públicas, también regula los productos botánicos, productos médicos que pueden incluir material vegetal.

Sin embargo, cuando se trata de la marihuana para fumar, los concentrados de THC derivados del cannabis que se vapean o dabean y los comestibles infundidos con THC, la FDA parece estar muy al margen.

La marihuana medicinal que se vende en los dispensarios no está aprobada por la FDA. La agencia no ha avalado su seguridad o eficacia ni ha determinado la dosis adecuada. No inspecciona las instalaciones donde se producen los productos ni evalúa el control de calidad.

La agencia sí invita a los fabricantes a someter los productos del cannabis a ensayos clínicos y a su proceso de aprobación de medicamentos.

El sitio web de la FDA señala que el THC es el ingrediente activo de dos medicamentos aprobados por la FDA para el tratamiento del cáncer. Aparentemente, sólo por eso la sustancia está bajo la jurisdicción de la FDA.

La FDA tiene "todo el poder que necesita para regular de forma mucho más eficaz los productos de cannabis legalizados por los estados", afirmó Lindblom, ex funcionario de la agencia.

Al menos públicamente, la FDA no le ha prestado atención a los concentrados de THC derivados del cannabis o la hierba fumada en porros, sino más bien en otras sustancias: una variante del THC derivada del cáñamo, que el gobierno federal ha legalizado, y un derivado diferente del cannabis llamado cannabidiol o CBD, que se ha comercializado como terapéutico.

"La FDA se ha comprometido a vigilar el mercado, identificar los productos de cannabis que plantean riesgos y actuar, dentro de nuestras competencias, para proteger al público", declaró Courtney Rhodes, vocera de la FDA.

"Muchos, la mayoría de los productos con THC se ajustan a la definición de marihuana, que es una sustancia controlada. La Drug Enforcement Administration (DEA) regula la marihuana en virtud de la Ley de Sustancias Controladas (CSA). Le remitimos a la DEA para preguntas sobre la regulación y aplicación de las disposiciones de la CSA", escribió Rhodes en un correo electrónico.

La DEA, dependiente del Departamento de Justicia, no respondió a las preguntas formuladas para este artículo.

En cuanto al Congreso, quizá su medida más importante haya sido limitar la aplicación de la prohibición federal.

"Hasta ahora, la respuesta federal a las acciones estatales para legalizar la marihuana ha consistido, sobre todo, en permitir que los estados apliquen sus propias leyes sobre la droga", señaló un informe de 2022 del Servicio de Investigación del Congreso.

En octubre, el presidente Joe Biden ordenó al secretario de Salud y Servicios Humanos y al fiscal general que revisaran la postura del gobierno federal respecto a la marihuana: si debería seguir clasificada entre las sustancias más peligrosas y estrictamente controladas.

En diciembre, Biden firmó un proyecto de ley que ampliaba la investigación sobre la marihuana y obligaba a las agencias federales a estudiar sus efectos. La ley dice que las agencias tienen un año para publicar sus conclusiones.

Algunos defensores de la marihuana dicen que el gobierno federal podría desempeñar un papel más constructivo.

"La NORML no opina que el cannabis sea inocuo, sino que la mejor forma de mitigar sus riesgos potenciales es mediante la legalización, la regulación y la educación pública", afirmó Paul Armentano, subdirector del grupo antes conocido como Organización Nacional para la Reforma de las Leyes sobre la Marihuana (NORML).

"Los productos tienen que someterse a pruebas de pureza y potencia", añadió, y "el gobierno federal podría ejercer cierta supervisión en la concesión de licencias a los laboratorios que prueban esos productos".

Mientras tanto, según Coleman, asesor de la Asociación Nacional de la Industria del Cannabis, los estados se quedan "teniendo que actuar como si fueran USDA + FDA + DEA, todo al mismo tiempo".

¿Y dónde deja eso a los consumidores? Algunos, como Wendy E., jubilada en sus 60 años, luchan contra los efectos de la marihuana.

Wendy, que habló con la condición de que no se revelara su nombre, empezó a fumar marihuana en la secundaria en los años 70 y la convirtió en su estilo de vida durante décadas.

Luego, cuando su estado la legalizó, la compró en dispensarios "y enseguida me di cuenta de que la potencia era mucho mayor que la que yo había consumido tradicionalmente", contó. "Parecía haber aumentado de manera exponencial".

En 2020, explicó, la marihuana legal —mucho más fuerte que la hierba ilícita de su juventud— la llevó a obsesionarse con el suicidio.

Antes, la mujer que se define como "hippie de la madre tierra" encontraba camaradería pasando un porro con sus amigos. Ahora asiste a reuniones de Marihuana Anónimos, con otras personas que se recuperan de esta adicción.

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

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

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

Panelists

Alice Miranda Ollstein
Politico

@AliceOllstein

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Rachel Cohrs
Stat News

@rachelcohrs

Read Rachel's stories

Joanne Kenen
Johns Hopkins Bloomberg School of Public Health and Politico

@JoanneKenen

Read Joanne's stories

Among the takeaways from this week’s episode:

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

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

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

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

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

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

Also mentioned in this week’s episode:

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

Click to open the transcript

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

KFF Health News’ ‘What the Health?’

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

Episode Number: 296

Published: May 4, 2023

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

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

Joanne Kenen: Hey, everybody.

Rovner: Rachel Cohrs of Stat News.

Rachel Cohrs: Good morning.

Rovner: And Alice Miranda Ollstein of Politico.

Ollstein: Hello.

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

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

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

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

Rovner: Yeah, I do too.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Kenen: I think he had a stroke, right?

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

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

Rovner: —he was not all there —

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

Rovner: Yeah, that’s for sure.

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

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

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

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

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

Rovner: Right. He knows how to negotiate.

Kenen: It just didn’t work.

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

Kenen: Maybe they’ll come out holding hands.

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

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

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

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

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

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

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

Ollstein: —right—

Rovner: —sort of balancing act going on.

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

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

Ollstein: Right.

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

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

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

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

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

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

Rovner: Yeah, mine too.

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

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

Kenen: That’s a whole other —

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

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

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

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

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

Ollstein: —exactly—

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

Ollstein: Exactly. You can’t boostrap loneliness.

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

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

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

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

Rovner: Yeah, they do. I mean, Republicans are big on doing things at the community level. That’s the idea, is let’s have government at the lowest level possible. Well, this will be an interesting issue to watch and see if it catches on more with the public health community. All right. That is this week’s news. Now it is time for our extra credit segment. That’s when we each recommend a story we read this week we think you should read too. As always, don’t worry if you miss it. We will post the links on the podcast page at KFF Health News and in our show notes on your phone or other mobile device. Rachel, why don’t you go first this week?

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

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

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

Rovner: Oh, I can’t wait. Alice.

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

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

Ollstein: Yeah.

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

Kenen: @JoanneKenen.

Rovner: Alice.

Ollstein: @AliceOllstein.

Rovner: Rachel.

Cohrs: @rachelcohrs.

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

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