“Estamos trabajando de buena fe con Oxford para alcanzar un nuevo acuerdo justo”, decía la carta, continuando con la frase tranquilizadora: “Sus médicos seguirán siendo parte de la red y debería mantener sus citas con sus proveedores”.

En los meses siguientes, llegaron una avalancha de comunicaciones sobre la disputa tanto del hospital como de la aseguradora. Pasaban de “tienes que preocuparte” a “no tienes que preocuparte'”, contó Feldman.

A fines de febrero, finalmente cayó la bomba: desde el 1 de marzo, el Mount Sinai ya no estaría en la red de la aseguradora de Feldman.

“De repente tuve que cambiar todos mis médicos, gran estrés”, dijo Feldman. Eso incluía no solo a un querido médico de atención primaria, sino también a un ginecólogo, un ortopedista y un fisioterapeuta.

Uno de los aspectos más injustos del seguro médico, en un sistema que a menudo parece diseñado para la frustración, es este: los pacientes solo pueden cambiar de seguro durante los períodos de inscripción abierta al final del año o cuando experimentan “eventos de vida” que califican para una inscripción especial, como un divorcio o un cambio de trabajo.

Pero los contratos de las aseguradoras con médicos, hospitales y farmacéuticas (o sus intermediarios, los llamados administradores de beneficios farmacéuticos) pueden cambiar abruptamente de la noche a la mañana.

Esto es particularmente irritante para los pacientes porque, ya sea que tengan cobertura a través de un empleador o compren un seguro en el mercado, generalmente eligen un plan en función de si cubre a sus médicos y hospitales preferidos, o a un medicamento costoso que necesitan.

Resulta que esa cobertura particular podría desaparecer en cualquier momento durante el término de la póliza.

Los consumidores están en riesgo, según un informe reciente de la Robert Wood Johnson Foundation, en la creciente guerra de precios entre grandes sistemas hospitalarios y mega aseguradoras en un mercado despiadado.

Estas disputas de contratos están aumentando rápidamente, el sitio web Becker’s Hospital Review cita 21 enfrentamientos entre aseguradoras y proveedores en el tercer trimestre de 2023, un aumento del 91% comparado con el mismo período el año anterior.

Por ejemplo, en septiembre pasado, los médicos de Baptist Health en Kentucky cortaron abruptamente la relación con los pacientes inscritos en los planes de Medicare Advantage de Humana, y los médicos de Vanderbilt Health en Tennessee rompieron los contratos lo hicieron con varios planes de Humana, en abril.

En ambos casos los pacientes desesperados tuvieron que buscar frenéticamente nuevos médicos dentro de la red en otros sistemas hospitalarios.

Y expertos predicen más cancelaciones de contratos en un mercado cruel. (las cancelaciones que ocurren dentro del período de inscripción, generalmente entre noviembre y enero por lo menos permite que los pacientes abandonados busquen un nuevo plan que cubra sus médicos y medicamentos).

“La respuesta humana correcta es que esto es horrible”, dijo Allison Hoffman, profesora de derecho de la Universidad de Pennsylvania, incluso si la práctica, por ahora, es “probablemente legal”.

Hoffman dijo que encontró una cláusula “enterrada” en la página 32 de su propio plan médico, de 60 páginas, que sugería que los contratos entre proveedores y aseguradoras pueden cambiar en cualquier momento.

Los reguladores estatales y federales tienen la autoridad para regular las redes de aseguradoras y podrían poner fin a la práctica, dijo Hoffman. Pero hasta ahora “no ha habido regulación federal sobre la continuidad de la cobertura”, especialmente sobre cómo definirla. Sospecha que el aparente aumento en disputas de contratos entre aseguradoras y proveedores se deriva de las regulaciones sobre la transparencia de los precios hospitalarios, que entraron en vigencia en 2022 y han permitido a los hospitales comparar tasas de reembolso entre sí.

De hecho, el Mount Sinai dijo que exigía un mejor reembolso de UnitedHealthcare porque descubrió que estaba recibiendo pagos considerablemente más bajos que otras “instituciones similares”.

Muchas aseguradoras dicen que continuarán pagando por un período después de que termine un contrato —en general de entre 60 a 90 días— o para completar un “episodio de atención” particular, como un embarazo.

Pero, por ejemplo, con el cáncer, ¿eso significaría una ronda de quimioterapia o el curso completo de un tratamiento, que podría durar muchos años? ¿Es continuidad de cobertura si un paciente debe cambiar de oncólogo en medio de una terapia, o si tiene que dejar a un terapeuta eficaz?

Erin Moses, que trabaja para una pequeña organización sin fines de lucro, encontró a un nuevo terapeuta que le gustó después que ella y su esposo se mudaron a la Costa Central de California en febrero del año pasado. En septiembre, recibió una factura de la práctica que decía que había terminado su contrato con Anthem porque la aseguradora era lenta con sus reembolsos. Esto la dejó con una factura de $814.

“No es que no pudiéramos pagarlo, pero mi esposo y yo estamos tratando de ahorrar para una casa, y eso es mucho dinero”, dijo.

A menudo, a los pacientes los toma desprevenidos, sin saber qué hacer. Cuando Laura Alley se cayó de una escalera en septiembre de 2020 y necesitó cirugía para reparar su pelvis quebrada, el hospital y el cirujano estaban en la red.

Alley escribió al proyecto “Bill of the Month” de KFF Health News y NPR y dijo: “Lo que no podía saber de ninguna manera era que el grupo que proporcionaba la anestesia estaba en disputa con el proveedor de seguros de nuestra firma, y que desde el 30 de julio de 2020, ya no estaban en la red”.

Se sintió “como un títere”, dijo. “Mientras trabajo para recuperarme de una lesión traumática, estoy atrapada en medio de una disputa entre una enorme compañía de seguros y un gran grupo de médicos”.

Alley es dueña de una pequeña firma de arquitectura con su esposo, y terminaron pagando “casi $10,000” por servicios de anestesia fuera de la red. (Este tipo de factura fuera de la red para el paciente ahora estaría prohibido por el No Surprises Act, vigente desde 2022).

Nada de esto será noticia para Feldman, la paciente del Mount Sinai que fue una inocente espectadora en la disputa del sistema hospitalario con Oxford Health Plans. Los padres de Feldman la llamaron recientemente, diciendo que recibieron una carta de su aseguradora, Anthem, diciendo que el 1 de mayo podría terminar su contrato con el Hospital NewYork-Presbyterian, en donde la madrastra de Feldman recibe tratamiento por un cáncer de mama.

Es malo para la salud —y para la cordura— de los pacientes que las promesas percibidas de atención en sus planes de seguro puedan desaparecer repentinamente a mitad de año. Y los reguladores pueden hacer algo al respecto: obligar a los proveedores y aseguradoras a mantener sus contratos entre sí durante todo el término de las pólizas de los pacientes, para que ninguno quedé atrapado en una guerra con la que no tienen nada que ver.

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 general election campaign for president is (unofficially) on, as President Joe Biden and former President Donald Trump have each apparently secured enough delegates to become his respective party’s nominee. And health care is turning out to be an unexpectedly front-and-center campaign issue, as Trump in recent weeks has suggested he may be interested in cutting Medicare and taking another swing at repealing and replacing the Affordable Care Act.

Meanwhile, the February cyberattack of Change Healthcare, a subsidiary of insurance giant UnitedHealth Group, continues to roil the health industry, as thousands of hospitals, doctors, nursing homes, and other providers are unable to process claims and get paid.

This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Joanne Kenen of Johns Hopkins University and Politico Magazine, and Margot Sanger-Katz of The New York Times.

Panelists

Anna Edney
Bloomberg

@annaedney

Read Anna's stories.

Joanne Kenen
Johns Hopkins Bloomberg School of Public Health and Politico

@JoanneKenen

Read Joanne's articles.

Margot Sanger-Katz
The New York Times

@sangerkatz

Read Margot's stories.

Among the takeaways from this week’s episode:

• It is unclear exactly what Trump meant in his recent remarks about possible cuts to Medicare and Social Security, though his comments provided an opening for Biden to pounce. By running as the candidate who would protect entitlements, Biden could position himself well, particularly with older voters, as the general election begins.
• Health care is shaping up to be the sleeper issue in this election, with high stakes for coverage. The Biden administration’s expanded subsidies for ACA plans are scheduled to expire at the end of next year, and the president’s latest budget request highlights his interest in expanding coverage, especially for postpartum women and for children. Plus, Republicans are eyeing what changes they could make should Trump reclaim the presidency.
• Meanwhile, Republicans are grappling with an internal party divide over access to in vitro fertilization, and Trump’s mixed messaging on abortion may not be helping him with his base. Could a running mate with more moderate perspectives help soften his image with voters who oppose abortion bans?
• A federal appeals court ruled that a Texas law requiring teenagers to obtain parental consent for birth control outweighs federal rules allowing teens to access prescription contraceptives confidentially. But concerns that if the U.S. Supreme Court heard the case a conservative-majority ruling would broaden the law’s impact to other states may dampen the chances of further appeals, leaving the law in effect. Also, the federal courts are making it harder to file cases in jurisdictions with friendly judges, a tactic known as judge-shopping, which conservative groups have used recently in reproductive health challenges.
• And weeks later, the Change Healthcare hack continues to cause widespread issues with medical billing. Some small providers fear continued payment delays could force them to close, and it is possible that the hack’s repercussions could soon block some patients from accessing care at all.

Also this week, Rovner interviews Kelly Henning of Bloomberg Philanthropies about a new, four-part documentary series on the history of public health, “The Invisible Shield.”

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

Julie Rovner: The Washington Post’s “Navy Demoted Ronny Jackson After Probe Into White House Behavior,” by Dan Diamond and Alex Horton.

Joanne Kenen: The Atlantic’s “Frigid Offices Might Be Killing Women’s Productivity,” by Olga Khazan.

Margot Sanger-Katz: Stat’s “Rigid Rules at Methadone Clinics Are Jeopardizing Patients’ Path to Recover From Opioid Addiction,” by Lev Facher.

Anna Edney: Scientific American’s “How Hospitals Are Going Green Under Biden’s Climate Legislation,” by Ariel Wittenberg and E&E News.

Also mentioned on this week’s podcast:

• KFF Health News’ “Energy-Hog Hospitals: When They Start Thinking Green, They See Green,” by Julie Appleby.
• Stat’s “The War on Recovery: How the U.S. Is Sabotaging Its Best Tools to Prevent Deaths in the Opioid Epidemic,” by Lev Facher.

Click to open the transcript

Transcript: Maybe It’s a Health Care Election After All

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, March 14, at 10 a.m. Happy Pi Day, everyone. As always, news happens fast and things might have changed by the time you hear this, so here we go. We are joined today via video conference by Margot Sanger-Katz of The New York Times.

Margot Sanger-Katz: Good morning, everybody.

Rovner: Anna Edney of Bloomberg News.

Anna Edney: Hi there.

Rovner: And Joanne Kenen of the Johns Hopkins University and Politico Magazine.

Joanne Kenen: Hey, everyone.

Rovner: Later in this episode we’ll have my interview with Dr. Kelly Henning, head of the public health program at Bloomberg Philanthropies. She’ll give us a preview of the new four-part documentary series on the history of public health called “The Invisible Shield;” It premieres on PBS March 26. But first this week’s news. We’re going to start here in Washington with the annual State of the Union / budget dance, which this year coincides with the formal launch of the general election campaign, with both President Biden and former President Donald Trump having clinched their respective nominations this week.

Despite earlier claims that this year’s campaign would mostly ignore health issues, that’s turning out not so much to be the case. Biden in his speech highlighted reproductive health, which we’ll talk about in a minute, as well as prescription drug prices and the Affordable Care Act expansions. His proposed budget released on Monday includes suggestions of how to operationalize some of those proposals, including expanding Medicare’s drug negotiating powers. Did anything in particular in the speech or the budget jump out at any of you? Anything we weren’t expecting.

Edney: I wouldn’t say there was anything that I wasn’t expecting. There were things that I was told I should not expect and that I feel like I’ve been proven right, and so I’m happy about that, and that was the Medicare drug price negotiation. I thought that that was a win that he was going to take a lap on during the State of the Union, and certainly he did. And he’s also talking about trying to expand it, although that seems to face an extremely uphill battle, but it’s a good talking point.

Rovner: Well, and of course the expanded subsidies from the ACA expire at the end of next year. I imagine there’s going to be enough of a fight just to keep those going, right?

Edney: Yeah, certainly. I think people really appreciate the subsidies. If those were to go away, then the uninsured rate could go up. It’s probably an odd place in a way for Republicans, too, who are talking about, again, still in some circles, in some ways, getting rid of Obamacare. We’re back at that place even though I don’t think anyone thinks that’s entirely realistic.

Rovner: Oh, you are anticipating my next question, which is that former President Trump, who is known for being all over the place on a lot of issues, has been pretty steadfast all along about protecting Medicare and Social Security, but he’s now backing away from even that. In an interview on CNBC this week, Trump said, and I’m quoting, “There is a lot you can do in terms of entitlements in terms of cutting” — which his staff said was referring to waste and fraud, but which appears to open that up as a general election campaign issue. Yes, the Biden people seem to be already jumping on it.

Sanger-Katz: Yes. They could not be more excited about this. I think this has been an issue that Biden has really wanted to run on as the protector of these programs for the elderly. He had this confrontation with Congress in the State of the Union last year, as you may remember, in which he tried to get them to promise not to touch these programs. And I think his goal of weaponizing this issue has been very much hindered by Trump’s reluctance to take it on. I think there are Republicans, certainly in Congress, and I think that we saw during the presidential primary some other candidates for president who were more interested in rethinking these programs and concerned about the long-term trajectory of the federal deficit. Trump has historically not been one of them. What Trump meant exactly, I think, is sort of TBD, but I think it does provide this opening. I’m sure that we’ll see Biden talking about this a lot more as the campaign wears on and it wouldn’t surprise me at all to see this clip in television ads and featured again and again.

Kenen: So it’s both, I mean, it’s basically, he’s talked about reopening the repeal fight as Julie just mentioned, which did not go too well for the Republicans last time, and there’s plenty to cut in Medicare. If you read the whole quote, he does then talk about fraud and abuse and mismanagement, but the soundbite is the soundbite. Those are the words that came out of his mouth, whether he meant it that way or not, and we will see that campaign ad a lot, some version of it.

Rovner: My theory is that he was, and this is something that Trump does, he was on CNBC, he knew he was talking to a business audience, and he liked to say what he thinks the audience wants to hear without — you would think by now he would know that speaking to one audience doesn’t mean that you’re only speaking to that one audience. I think that’s why he’s all over the place on a lot of issues because he tends to tailor his remarks to what he thinks the people he is speaking directly to want to hear. But meanwhile, Anna, as you mentioned, he’s also raised the specter of the Affordable Care Act repeal again.

Sanger-Katz: I do think the juxtaposition of the Biden budget and State of the Union and these remarks from Trump, who now is officially the presumptive nominee for president, I think it really does highlight that there are pretty high stakes in health care for this election. I think it’s not been a focus of our discussion of this election so far. But Julie, you’ve mentioned the expiration of these subsidies that have made Affordable Care Act plans substantially more affordable for Americans and substantially more appealing, nearly doubling the number of people who are enrolled in these plans.

That is a policy that is going to expire at the end of next year. And so you could imagine a scenario, even if Trump did not want to repeal the Affordable Care Act, which he does occasionally continue to make noises about, where that could just go away through pure inertia if you didn’t have an administration that was actively trying to extend that policy and you could see a real retrenchment: increases in prices, people leaving the market, potentially some instability in the marketplace itself, where you might see insurers exiting or other kinds of problems and a situation much more akin to what we saw in the Trump administration where those markets were “OK, but were a little bit rocky and not that popular.”

I think similarly for Medicare and Medicaid, these big federal health programs, Biden has really been committed to, as he says, not cutting them. The Medicare price negotiation for drugs has provided a little bit more savings for the program. So it’s on a little bit of a better fiscal trajectory, and he has these additional proposals, again, I think long shots politically to try to shore up Medicare’s finances more. So you see this commitment to these programs and certainly this commitment to — there were multiple things in the budget to try to liberalize and expand Medicaid coverage to make postpartum coverage for women after they give birth, permanently one year after birth, people would have coverage.

Right now, that’s an option for states, but it’s not required for every state. And additionally to try to, in an optional basis, make it a little easier to keep kids enrolled in Medicaid for longer, to just allow states to keep kids in for the first six years of life and then three years at a time after that. So again, that’s an option, but I think you see the Biden administration making a commitment to expand and shore up these programs, and I do think a Trump administration and a Republican Congress might be coming at these programs with a bit more of a scalpel.

Rovner: And also, I mean, one of the things we haven’t talked about very much since we’re on the subject of the campaign is that this year Trump is ready in a way that he was not, certainly not in 2016 and not even in 2020. He’s got the Heritage Foundation behind him with this whole 2025 blueprint, people with actual expertise in knowing what to turn, what to do, actually, how to manipulate the bureaucracy in a way that the first Trump administration didn’t have to. So I think we could see, in fact, a lot more on health care that Republicans writ large would like to do if Trump is reelected. Joanne, you wanted to add something.

Kenen: Yeah, I mean, we all didn’t see this year as a health care election, and I still think that larger existential issues about democracy, it’s a reprise. It’s 2020 all over again in many ways, but abortion yes, abortion is a health care issue, and that was still going …

Rovner: We’re getting to that next.

Kenen: I know, but I mean we all knew that was still going to be a ballot driver, a voter driver. But Trump, with two remarks, however, well, there’s a difference between the people at the Heritage Foundation writing detailed policy plans about how they’re going to dismantle the CDC [Centers for Disease Control and Prevention] as we currently know it versus what Trump says off the cuff. I mean, if you say to a normal person on the street, we want to divide the CDC in two, that’s not going to trigger anything for a voter. But when you start talking about we want to take away your health care subsidies and cut Medicare, so these are sort of, some observers have called them unforced errors, but basically right now, yeah, we’re in another health care election. Not the top issue — and also depending on what else goes on in the world, because it’s a pretty shaky place at the moment. By September, will it be a top three issue? None of us know, but right now it’s more of a health care election than it was shaping up to be even just a few weeks ago.

Rovner: Yeah. Well, one thing, as you said, that we all know will be a big campaign issue this fall is abortion. We saw that in the State of the Union with the gallery full of women who’d been denied abortion, IVF services, and other forms of reproductive health care and the dozens of Democratic women on the floor of the House wearing white from head to toe as a statement of support for reproductive health care. While Democrats do have some divides over how strongly to embrace abortion rights, a big one is whether restoring Roe [v. Wade] is enough or they need to go even further in assuring access to basically all manner of reproductive health care.

It’s actually the Republicans who are most on the defensive, particularly over IVF and other state efforts that would restrict birth control by declaring personhood from the moment of fertilization. Along those lines, one of the more interesting stories I saw this week suggested that Donald Trump, who has fretted aloud about how unpopular the anti-abortion position is among the public, seems less likely to choose a strong pro-lifer as his running mate this time. Remember Mike Pence came along with that big anti-abortion background. What would this mean? It’s not like he’s going to choose Susan Collins or Lisa Murkowski or some Republican that we know actually supports abortion rights. I’m not sure I see what this could do for him and who might fit this category.

Kenen: Well, I think there’s a good chance he’ll choose a woman, and we all have names at the tip of our tongues, but we don’t know yet. But yeah, I mean they need to soften some of this stuff. But Trump’s own attempt right now bragging about appointing the justices that killed Roe, at the same time, he’s apparently talking about a 15-week ban or a 16-week ban, which is very different than zero. So he’s giving a mixed message. That’s not what his base wants to hear from him, obviously. I mean, Julie, you’ll probably get to this, but the IVF thing is also pitting anti-abortion Republican against anti-abortion Republican, with Mike Pence, again, being a very good example where Mike Pence’s anti-abortion bona fides are pretty clear, but he has been public about his kids are IVF babies? I’m not sure if all of them are, but at least some of them are. So he does not think that two cells in a freezer or eight cells or 16 cells is the same to child. In his view, it’s a potential child. So yeah.

Edney: I think you can do a lot with a vice president. We see Biden has his own issues with the abortion issue and, as people have pointed out, he demurred from saying that word in the State of the Union and we see just it was recently announced that Vice President Kamala Harris is going to visit an abortion clinic. So you can appease maybe the other side, and that might be what Trump is looking to do. I think, as Joanne mentioned, his base wants him to be anti-abortion, but now you’re getting all of these fractures in the Republican Party and you need someone that maybe can massage that and help with the crowd that’s been voting on the state level, voting on more of a personal level, to keep reproductive rights, even though his base doesn’t seem to be that that’s what they want. So I feel like he may be looking to choose someone who’s very different or has some differences that he can, not acknowledge, but that they can go out and please the other side.

Rovner: Of course, the only person who really fits that bill is Nikki Haley, who is very, very strongly anti-abortion, but at least tried, not very well, but tried to say that there are other people around and they believe other things and we should embrace them, too. I can’t think of another Republican except for Nikki Haley who’s really tried to do that. Margot, you wanted to say something?

Sanger-Katz: Oh, I was just going to say that if this reporting is correct, I think it does really reflect the political moment that Trump finds himself in. I think when he was running the last time, I think he really had to convince the anti-abortion voter, the evangelical voter, to come along with him. I think they had reservations about his character, about his commitment to their cause. He was seen as someone who maybe wasn’t really a true believer in these issues. And so I think he had to do these things, like choosing Mike Pence, choosing someone who was one of them. Pre-publishing a list of judges that he would consider for the Supreme Court who were seen as rock solid on abortion. He had to convince these voters that he was the real deal and that he was going to be on their side, and I just don’t think he really has that problem to the same degree right now.

I think he’s consolidated support among that segment of the electorate and his bigger concern going into the general election, and also the primaries are over, and so his bigger concern going into the general election is how to deal with more moderate swing voters, suburban women, and other groups who I think are a little bit concerned about the extreme anti-abortion policies that have been pursued in some of these states. And I think they might be reluctant to vote for Trump if they see him as being associated with those policies. So you see him maybe thinking about how to soften his image on this issue.

Rovner: I should point out the primaries aren’t actually over, most of states still haven’t had their primaries, but the primaries are effectively over for president because both candidates have now amassed enough delegates to have the nomination.

Sanger-Katz: Yes, that’s right. And it’s not over until the convention, although I think the way that the Republicans have arranged their convention, it’s very hard to imagine anyone other than Trump being president no matter what happens.

Rovner: Yes.

Sanger-Katz: Or not being president. Sorry, being the nominee.

Rovner: Being the nominee, yes, indeed. Well, we are only two weeks away from the Supreme Court oral arguments in the abortion pill case and a little over a month from another set of Supreme Court oral arguments surrounding whether doctors have to provide abortions in medical emergencies. And the cases just keep on coming in court this week. A three-judge panel from the 5th Circuit Court of Appeals upheld in part a lower court ruling that held that Texas’ law requiring parents to provide consent before their teenage daughters may obtain prescription birth control, Trump’s federal rules requiring patient confidentiality even for minors at federally funded Title X clinics.

Two things about this case. First, it’s a fight that goes all the way back to the Reagan administration and something called the “Squeal Rule,” which I did not cover, I only read about, but it’s something that the courts have repeatedly ruled against, that Title X is in fact allowed to maintain patient privacy even for teenagers. And the second thing is that the lower court ruling came from Texas federal Judge Matthew Kacsmaryk, who also wrote the decision attempting to overturn the FDA’s approval of the abortion drug mifepristone. This one, though, we might not expect to get to the Supreme Court.

Kenen: But we’re often wrong on these kinds of things.

Rovner: Yeah, that’s true.

Kenen: I mean, things that seem based on the historical pathway that shouldn’t have gotten to the court are getting to the court and the whole debate has shifted so far to the right. An interesting aside, there is a move, and I read this yesterday, but now I’m forgetting the details, so one of you can clarify for me. I can’t remember whether they’re considering doing this or the way they’ve actually put into place steps to prevent judge-shopping.

Rovner: That’s next.

Kenen: OK, I’m sorry, I’m doing such a good job of reading your mind.

Rovner: You are such a good job, Joanne.

Kenen: But I mean so many in these cases go back to one. If there was a bingo card for reproductive lawsuits, there might be one face in it.

Rovner: Two, Judge [Reed] O’Connor, remember the guy with the Affordable Care Act.

Kenen: Right. But so much of this is going back to judge-shopping or district-shopping for the judge. So a lot of these things that we thought wouldn’t get to the court have gotten to the court.

Rovner: Yeah, well, no, I was going to say in this case, though, there seems to be some suggestion that those who support the confidentiality and the Title X rules might not want to appeal this to the Supreme Court because they’re afraid they’ll lose. That this is the Supreme Court that overturned Roe, it would almost certainly be a Supreme Court that would rule against Title X confidentiality for birth control, that perhaps they want to just let this lie. I think as it stands now it only applies to the 5th Circuit. So Texas, Louisiana, and I forget what else is in the 5th Circuit, but it wouldn’t apply around the country and in this case, I guess it’s just Texas because it’s Texas’ law that conflicts with the rules.

Kenen: Except when one state does something, it doesn’t mean that it’s only Texas’ law six months from now.

Rovner: Right. What starts in Texas doesn’t necessarily stay in Texas.

Kenen: Right, it could go to Nevada. They may decide that they have a losing case and they want to wait 20 years, but other people end up taking things — I mean, it is very unpredictable and a huge amount of the docket is reproductive health right now.

Rovner: I would say the one thing we know is that Justice Alito, when he said that the Supreme Court was going to stop having to deal with this issue was either disingenuous or just very wrong because that is certainly not what’s happened. Well, as Joanne already jumped ahead a little bit, I mentioned Judge Kacsmaryk for a specific reason. Also this week, the Judicial Conference of the United States, which makes rules for how the federal courts work, voted to make it harder to judge-shop by filing cases in specific places like Amarillo, Texas, where there’s only one sitting federal judge. This is why Judge Kacsmaryk has gotten so many of those hot-button cases. Not because kookie stuff happens all the time in Amarillo, but because plaintiffs have specifically filed suit there to get their cases in front of him. The change by the judicial conference basically sets things back to the way they used to be, right, where it was at least partly random, which judge you got when you filed a case.

Kenen: But there are also some organizations that have intentionally based themselves in Amarillo so that they’re there. I mean, we may also see, if the rules go back to the old days, we may also still say you have a better case for filing in where you actually operate. So everybody just keeps hopping around and playing the field to their advantage.

Rovner: Yeah. And I imagine in some places there’s only a couple of judges, I think it was mostly Texas that had these one-judge districts where you knew if you filed there, you were going to get that judge, so — the people who watch these things and who worry about judge-shopping seem to be heartened by this decision by the judicial conference. So I’m not someone who is an expert in that sort of thing, but they seem to think that this will deter it, if not stop it entirely.

Moving on, remember a couple of weeks ago when I said that the hack of UnitedHealth [Group] subsidiary Change Healthcare was the most undercovered story in health? Clearly, I had no idea how true that was going to become. That processes 15 billion — with a B — claims every year handles one of every three patient records is still down, meaning hospitals, doctor’s offices, nursing homes, and all other manner of health providers still mostly aren’t getting paid. Some are worrying they soon won’t be able to pay their employees. How big could this whole mess ultimately become? I don’t think anybody anticipated it would be as big as it already is.

Sanger-Katz: I think it’s affecting a number of federal programs, too, that rely on this data, like quality measurement. And it really is a reflection, first of all, obviously of the consolidation of all of this, which I know that you guys have talked about on the podcast before, but also just the digitization and interconnectedness of everything. All of these programs are relying on this billing information, and we use that not just to pay people, but also to evaluate what kind of health care is being delivered, and what quality it is, and how much we should pay people in Medicare Advantage, and on all kinds of other things. So it’s this really complex, interconnected web of information that has been disrupted by this hack, and I think there’s going to be quite a lot of fallout.

Edney: And the coverage that I’ve read we’re potentially, and not in an alarmist way, but weeks away from maybe some patients not getting care because of this, particularly at the small providers. Some of my colleagues did a story yesterday on the small cancer providers who are really struggling and aren’t sure how long they’re going to be able to keep the lights on because they just aren’t getting paid. And there are programs now that have been set up but maybe aren’t offering enough money in these no-interest loans and things like that. So it seems like a really precarious situation for a lot of them. And now we see that HHS [Department of Health and Human Services] is looking into this other side of it. They’re going to investigate whether there were some HIPAA violations. So not looking exactly at the money exchange, but what happened in this hack, which is interesting because I haven’t seen a lot about that, and I did wonder, “Oh, what happened with these patients’ information that was stolen?” And UnitedHealth has taken a huge hit. I mean, it’s a huge company and it’s just taken a huge hit to its reputation and I think …

Rovner: And to its stock price.

Edney: And it’s stock price. That is very true. And they don’t know when they’re actually going to be able to resolve all of this. I mean, it’s just a huge mess.

Rovner: And not to forget they paid $22 million in ransom two weeks ago. When I saw that, I assumed that this was going to be almost over because usually I know when a hospital gets hacked, everybody says, don’t pay ransom, but they pay the ransom, they get their material back, they unlock what was locked away. And often that ends it, although it then encourages other people to do it because hey, if you do it, you can get paid ransom. Frankly, for UnitedHealthcare, I thought $22 million was a fairly low sum, but it does not appear — I think this has become such a mess that they’re going to have to rebuild the entire operation in order to make it work. At least, not a computer expert here. But that’s the way I understand this is going on.

Kenen: But I also think this, I mean none of us are cyber experts, but I’m also wondering if this is going to lead to some kind of rethinking about alternative ways of paying people. If this created such chaos, and not just chaos, damage, real damage, the incentive to do something similar to another, intermediate, even if it’s not quite this big. It’s like, “Wait, no one wants to be the next one.” So what kind of push is there going to be, not just for greater cybersecurity, but for Plan B when there is a crisis? And I don’t know if that’s something that the cyberexperts can put together in what kind of timeline — if HHS was to require that or whether the industry just decides they need it without requirements that this is not OK. It’s going to keep happening if it’s profitable for whoever’s doing it.

Rovner: I remember, ruefully, Joanne and I were there together covering HIPAA when they were passing it, which of course had nothing whatsoever to do with medical privacy at the time, but what it did do was give that first big push to start digitizing medical information. And there was all this talk about how wonderful it was going to be when we had all this digitally and researchers could do so much with it, and patients would be able to have all of their records in one place and …

Kenen: You get to have 19 passwords for 19 different forums now.

Rovner: Yes. But in 1995 it all seemed like a great, wonderful new world of everything being way more efficient. And I don’t remember ever hearing somebody talking about hacking this information, although as I point out the part of HIPAA that we all know, the patient medical records privacy, was added on literally at the last minute because someone said, “Uh-oh, if we’re going to digitize all this information, maybe we better be sure that it doesn’t fall into the wrong hands.” So at least somebody had some idea that we could be here. What are we 20, 30 … are we 30 years later? It’s been a long time. Anyway, that’s my two cents. All right, next up, Mississippi is flirting with actually expanding Medicaid under the Affordable Care Act. It’s one of only 10 remaining states that has not extended the program to people who have very low incomes but don’t meet the so-called categorical eligibility requirements like being a pregnant woman or child or person with a disability.

The Mississippi House passed an expansion bill including a fairly stringent work requirement by a veto-proof majority last week, week before.

Kenen: I think two weeks ago.

Rovner: But even if it passed the Senate and gets signed by the governor, which is still a pretty big if, the governor is reportedly lobbying hard against it. The plan would require a waiver from the Biden administration, which is not a big fan of work requirements. On the other hand, even if it doesn’t happen, and I would probably put my money at this point that it’s not going to happen this year, does it signal that some of the most strident, holdout states might be seeing the attraction of a 90% federal match and some of the pleas of their hospital associations? Anna, I see you nodding.

Edney: Yeah, I mean it was a little surprising, but this is also why I love statehouses. They just do these unexpected things that maybe make sense for their constituents sometimes, and it’s not all the time. I thought that it seemed like they had come around to the fact that this is a lot of money for Mississippi and it can help a lot of people. I think I’ve seen numbers like maybe adding 200,000 or so to the rolls, and so that’s a huge boost for people living there. And with the work requirement, is it true that even if the Biden administration rejects it, this plan can still go into place, right?

Kenen: The House version.

Edney: The House version.

Kenen: Yes.

Edney: Yeah.

Rovner: My guess is that’s why the governor is lobbying so hard against it. But yeah.

Kenen: I mean, I think that we had been watching a couple of states, we keep hearing Alabama was one of the states that has been talking about it but not doing anything about it. Wyoming, which surprised me when they had a little spurt of activity, which I think has subsided. I mean, what we’ve been saying ever since the Supreme Court made this optional for states more than 10 years ago now. Was it 2012? We’ve been saying eventually they’ll all do it. Keeping in mind that original Medicaid in [19]65, it took until 1982, which neither Julie nor I covered, until the last state, which was Arizona, took regular Medicare, Medicaid, the big — forget the ACA stuff. I mean, Medicaid was not in all states for almost 20 years. So I think we’ve all said eventually they’re going to do it. I don’t think that we are about to see a domino effect that North Carolina, which is a purple state, they did it a few months ago, maybe a year by now.

There was talk then that, “Oh, all the rest will do it.” No, all the rest will probably do it eventually, but not tomorrow. Mississippi is one of the poorest states in the country. It has one of the lowest health statuses of their population, obesity, diabetes, other chronic diseases. It has a very small Medicaid program. The eligibility levels are even for very, very, very poor childless adults, you can’t get on their plan. But have we heard rural hospitals pushing for this for a decade? Yes. Have we heard chambers of commerce in some of these states wanting it because communities without hospitals or communities without robust health systems are not economically attractive? We’ve been hearing the business community push for this for a long time. But the holdouts are still holdouts and I do think they will all take it. I don’t think it’s imminent.

Rovner: Yeah, I think that’s probably a fair assessment.

Kenen: It makes good economic sense, I mean, you’re getting all this money from the federal government to cover poor people and keep your hospitals open. But it’s a political fight. It’s not just a …

Rovner: It’s ideology.

Kenen: Yes, it’s not a [inaudible]. And it’s called Obamacare.

Edney: And sometimes things just have to fall into place. Mississippi got a new speaker of the House in their state government, so that’s his decision to push this as something that the House was going to take up. So whether that happens in other places, whether all those cards fall into places can take more time.

Kenen: Well, the last thing is we also know it’s popular with voters because we’ve seen it on the ballot in what, seven states, eight states, I forgot. And it won, and it won pretty big in really conservative states like Idaho and Utah. So as Julie said, this is ideology, it’s state lawmakers, it’s governors, it’s not voters, it’s not hospitals, it’s not chambers of commerce. It’s not particularly rural hospitals. A lot of people think this makes sense, but their own governments don’t think it makes sense.

Rovner: Yes. Well, another of those stories that moves very, very slowly. Finally, “This Week in Medical Misinformation”: I want to call out those who are fighting back against those who are accusing them of spreading false or misleading claims. I know this sounds confusing. Specifically, 16 conservative state attorneys general have called on YouTube to correct a, quote, “context disclaimer” that it put on videos posted by the anti-abortion Alliance Defending Freedom claiming serious and scientifically unproven harms that can be caused by the abortion pill mifepristone.

Unfortunately, for YouTube, their context disclaimer was a little clunky and conflated medication and surgical abortion, which still doesn’t make the original ADF videos more accurate, just means that the disclaimer wasn’t quite right. Meanwhile, more anti-abortion states are having legal rather than medical experts try to “explain” — and I put explain in air quotes — when an abortion to save the life of a woman is or isn’t legal, which isn’t really helping clarify the situation much if you are a doctor worried about having your license pulled or, at best, ending up having to defend yourself in court. It feels like misinformation is now being used as a weapon as well as a way to mislead people. Or am I reading this wrong?

Edney: I mean, I had to read that disclaimer a few times. Just the whole back-and-forth was confusing enough. And so it does feel like we’re getting into this new era of, if you say one wrong thing against the disinformation, that’s going to be used against you. So everybody has to be really careful. And the disclaimer, it was odd because I thought it said the procedure is [inaudible]. So that made me think, oh, they’re just talking about the actual surgical abortion. But it was clunky. I think clunky is a good word that you used for it. So yeah.

Rovner: Yeah, it worries me. I think I see all of this — people who want to put out misinformation. I’m not accusing ADF of saying, “We’re going to put out misinformation.” I think this is what they’ve been saying all along, but people who do want to put out misinformation for misinformation’s sake are then going to hit back at the people who point out that it’s misinformation, which of course there’s no way for the public to then know who the heck is right. And it undercuts the idea of trying to point out some of this misinformation. People ask me wherever I go, “What are we going to do about this misinformation?” My answer is, “I don’t know, but I hope somebody thinks of something.”

Kenen: I mean, if you word something poorly, you got to fix it. I mean, that’s just the bottom line. Just like we as journalists have to come clean when we make a mistake. And it feels bad to have to write a correction, but we do it. So Google has been working on — there’s a group convened by the Institute of Medicine [National Academy of Medicine] and the World Health Organization and some others that have come out with guidelines and credible communicators, like who can you trust? I mean, we talked about the RSV [respiratory syncytial virus] story I did a few weeks ago, and if you Google RSV vaccine on and you look on YouTube or Google, it’s not that there’s zero misinformation, but there’s a lot less than there used to be. And what comes up first is the reliable stuff: CDC, Mayo Clinic, things like that. So YouTube has been really working on weeding out the disinformation, but again, for their own credibility, if they want to be seen as clean arbiters of going with credibility, if they get something mushy, they’ve got to de-mush it at the end.

Rovner: And I will say that Twitter of all places — or X, whatever you want to call it, the place that everybody now is like, “Don’t go there. It’s just a mess” — has these community notes that get attached to some of the posts that I actually find fairly helpful and it lets you rate it.

Kenen: Some of them, I mean overall, there’s actually research on that. We’ll talk about my book when it comes out next year, but we have stuff. I’m in the final stages of co-authoring a book that … it goes into misinformation, which is why I’ve learned a lot about this. Community Notes has been really uneven and …

Rovner: I guess when it pops up in my feed, I have found it surprisingly helpful and I thought, “This is not what I expect to see on this site.”

Kenen: And it hasn’t stopped [Elon] Musk himself from tweeting misinformation about drugs …

Rovner: That’s certainly true.

Kenen: … drugs he doesn’t like, including the birth control pill he tells people not to use because it promotes suicide. So basically, yeah, Julie, you’re right that we need tools to fight it, and none of the tools we currently have are particularly effective yet. And absolutely everything gets politicized.

Sanger-Katz: And it’s a real challenge I think for these social media platforms. You know what I mean? They don’t really want to be in the editorial business. I think they don’t really want to be in the moderation business in large part. And so you can see them grappling with the problem of the most egregious forms of misinformation on their platforms, but doing it clumsily and anxiously and maybe making mistakes along the way. I think it’s not a natural function for these companies, and I think it’s not a comfortable function for the people that run these companies, who I think are much more committed to free discourse and algorithmic sharing of information and trying to boost engagement as opposed to trying to operate the way a newspaper editor might be in selecting the most useful and true information and foregrounding that.

Kenen: Yeah, I mean that’s what the Supreme Court has been grappling with too, is another [inaudible] … what are the rules of the game? What should be legally enforced? What is their responsibility, that the social media company’s responsibilities, to moderate versus what is just people get to post? I mean, Google’s trying to use algorithms to promote credible communicators. It’s not that nothing wrong is there, but it’s not what you see first.

Rovner: I think it’s definitely the issue of the 2020s. It is not going away anytime soon.

Kenen: And it’s not just about health.

Rovner: Oh, absolutely. I know. Well, that is the news for this week. Now, we will play my interview with Dr. Kelly Henning of Bloomberg Philanthropies, and then we’ll come back with our extra credits.

I am so pleased to welcome to the podcast Dr. Kelly Henning, who heads the Bloomberg Philanthropies Public Health program. She’s here to tell us about a new documentary series about the past, present, and future of public health called “The Invisible Shield.” It premieres on PBS on March 26. Dr. Henning, thank you so much for joining us.

Kelly Henning: Thank you for having me.

Rovner: So the tagline for this series is, “Public health saved your life today, and you don’t even know it.” You’ve worked in public health in a lot of capacities for a lot of years, so have I. Why has public health been so invisible for most of the time?

Henning: It’s a really interesting phenomenon, and I think, Julie, we all take public health for granted on some level. It is what really protects people across the country and across the world, but it is quite invisible. So usually if things are working really well in public health, you don’t think about it at all. Things like excellent vaccination programs, clean water, clean air, these are all public health programs. But I think most people don’t really give them a lot of thought every day.

Rovner: Until we need them, and then they get completely controversial.

Henning: So to that point, covid-19 and the recent pandemic really was a moment when public health was in the spotlight very much no longer behind an invisible shield, but quite out in front. And so this seemed like a moment when we really wanted to unpack a little bit more around public health and talk about how it works, why it’s so important, and what some of the opportunities are to continue to support it.

Rovner: I feel like even before the pandemic, though, the perceptions of public health were changing. I guess it had something to do with a general anti-science, anti-authority rising trend. Were there warning signs that public health was about to explode in people’s consciousness in not necessarily a good way?

Henning: Well, I think those are all good points, but I also think that there are young generations of students who have become very interested in public health. It’s one of the leading undergraduate majors nowadays. Johns Hopkins Bloomberg School of Public Health has more applications than ever before, and that was occurring before the pandemic and even more so throughout. So I think it’s a bit of a mixed situation. I do think public health in the United States has had some really difficult times in terms of life expectancy. So we started to see declines in life expectancy way back in 2017. So we have had challenges on the program side, but I think this film is an opportunity for us to talk more deeply about public health.

Rovner: Remind people what are some of the things that public health has brought us besides, we talk about vaccines and clean water and clean air, but there’s a lot more to public health than the big headlines.

Henning: Yeah, I mean, for example, seat belts. Every day we get into our vehicle, we put a seat belt on, but I think most people don’t realize that was initially extremely controversial and actually not so easy to get that policy in place. And yet it saved literally tens of hundreds of thousands of lives across the U.S. and now across the world. So seat belts are something that often come to mind. Similar to that are things like child restraints, what we would call car seats in the U.S. That’s another similar strategy that’s been very much promoted and the evidence has been created through public health initiatives. There are other things like window guards. In cities, there are window guards that help children not fall out of windows from high buildings. Again, those are public health initiatives that many people are quite unaware of.

Rovner: How can this documentary help change the perception of public health? Right now I think when people think of public health, they think of people fighting over mask mandates and people fighting over covid vaccines.

Henning: Yeah, I really hope that this documentary will give people some perspective around all the ways in which public health has been working behind the scenes over decades. Also, I hope that this documentary will allow the public to see some of those workers and what they face, those public health front-line workers. And those are not just physicians, but scientists, activists, reformers, engineers, government officials, all kinds of people from all disciplines working in public health. It’s a moment to shine a light on that. And then lastly, I hope it’s hopeful. I hope it shows us that there are opportunities still to come in the space of public health and many, many more things we can do together.

Rovner: Longtime listeners to the podcast will know that I’ve been exploring the question of why it has been so difficult to communicate the benefits of public health to the public, as I’ve talked to lots of people, including experts in messaging and communication. What is your solution for how we can better communicate to the public all of the things that public health has done for them?

Henning: Well, Julie, I don’t have one solution, but I do think that public health has to take this issue of communication more seriously. So we have to really develop strategies and meet people where they are, make sure that we are bringing those messages to communities, and the messengers are people that the community feels are trustworthy and that are really appropriate spokespeople for them. I also think that this issue of communications is evolving. People are getting their information in different ways, so public health has to move with the times and be prepared for that. And lastly, I think this “Invisible Shield” documentary is an opportunity for people to hear and learn and understand more about the history of public health and where it’s going.

Rovner: Dr. Kelly Henning, thank you so much for joining us. I really look forward to watching the entire series. OK, we are back. It’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Joanne, you have everybody’s favorite story this week. Why don’t you go first?

Kenen: I demanded the right to do this one, and it’s Olga, I think her last name is pronounced Khazan. I actually know her and I don’t know how to pronounce her name, but Olga Khazan, apologies if I’ve got it wrong, from The Atlantic, has a story that says “Frigid Offices Might Be Killing Women’s Productivity.” Well, from all of us who are cold, I’m not sure I would want to use the word “frigid,” but of all of us who are cold in the office and sitting there with blankets. I used to have a contraband, very small space heater hidden behind a trash basket under my desk. We freeze because men like colder temperatures and they’re wearing suits. So we’ve been complaining about being cold, but there’s actually a study now that shows that it actually hurts our actual cognitive performance. And this is one study, there’s more to come, but it may also be one explanation for why high school girls do worse than high school boys on math SATs.

Rovner: Did not read that part.

Kenen: It’s not just comfort in the battle over the thermostat, it’s actually how do our brains function and can we do our best if we’re really cold?

Rovner: True. Anna.

Edney: This is a departure from my normal doom and gloom. So I’m happy to say this is in Scientific American, “How Hospitals Are Going Green Under Biden’s Climate Legislation.” I thought it was interesting. Apparently if you’re a not-for-profit, there were tax credits that you were not able to use, but the Inflation Reduction Act changed that so that there are some hospitals, and they talked to this Valley Children’s in California, that there had been rolling blackouts after some fires and things like that, and they wanted to put in a micro-grid and a solar farm. And so they’ve been able to do that.

And health care contributes a decent amount. I think it’s like 8.5% of U.S. greenhouse gas emissions. And Biden had established this Office of Climate Change [and Health Equity] a few years ago and within the health department. So this is something that they’re trying to do to battle those things. And I thought that it was just interesting that we’re talking about this on the day that the top story, Margot, in The New York Times is, not by you, but is about how there’s this huge surge in energy demand. And so this is a way people are trying to do it on their own and not be so reliant on that overpowered grid.

Rovner: KFF Health News has done a bunch of stories about contribution to climate change from the health sector, which I had no idea, but it’s big. Margot.

Sanger-Katz: I wanted to highlight the second story in this Lev Facher series on treatment for opioid addiction in Stat called “Rigid Rules at Methadone Clinics Are Jeopardizing Patients’ Path to Recovery From Opioid Addiction,” which is a nice long title that tells you a lot about what is in the story. But I think methadone treatment is a really evidence-based treatment that can be really helpful for a lot of people who have opioid addiction. And I think what this story highlights is that the mechanics of how a lot of these programs work are really hard. They’re punitive, they’re difficult to navigate, they make it really hard for people to have normal lives while they’re undergoing methadone treatment and then, in some cases, arbitrarily so. And so I think it just points out that there are opportunities to potentially do this better in a way that better supports recovery and it supports the lives of people who are in recovery.

Rovner: Yeah, it used the phrase “liquid handcuffs,” which I had not seen before, which was pretty vivid. For those of you who weren’t listening, the Part One of this series was an extra credit last week, so I’ll post links to both of them. My story’s from our friend Dan Diamond at The Washington Post. It’s called “Navy Demoted Ronnie Jackson After Probe Into White House Behavior.” Ronnie Jackson, in case you don’t remember, was the White House physician under Presidents [Barack] Obama and Trump and a 2021 inspector general’s report found, and I’m reading from the story here, quote, “that Jackson berated subordinates in the White House medical unit, made sexual and denigrating statements about a female subordinate, consumed alcohol inappropriately with subordinates, and consumed the sleep drug Ambien while on duty as the president’s physician.” In response to the report, the Navy demoted Jackson retroactively — he’s retired —from a rear admiral down to a captain.

Now, why is any of this important? Well, mainly because Jackson is now a member of Congress and because he still incorrectly refers to himself as a retired admiral. It’s a pretty vivid story, you should really read it.

OK. That is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, @jrovner. Margot, where are you these days?

Sanger-Katz: I’m at all the places @Sanger-Katz, although not particularly active on any of them.

Rovner: Anna.

Edney: On X, it’s @annaedney and on Threads it’s @anna_edneyreports.

Rovner: Joanne.

Kenen: I’m Threads @joannekenen1, and I’ve been using LinkedIn more. I think some of the other panelists have said that people are beginning to treat that as a place to post, and I think many of us are seeing a little bit more traction there.

Rovner: Great. Well, we will be back in your feed next week. Until then, be healthy.

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The 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.

President Joe Biden is working to lay out his health agenda for a second term, even as Congress races to finish its overdue spending bills for the fiscal year that began last October.

Meanwhile, Alabama lawmakers try to reopen the state’s fertility clinics over the protests of abortion opponents, and pharmacy giants CVS and Walgreens announce they are ready to begin federally regulated sales of the abortion pill mifepristone.

This week’s panelists are Julie Rovner of KFF Health News, Sarah Karlin-Smith of the Pink Sheet, Alice Miranda Ollstein of Politico, and Sandhya Raman of CQ Roll Call.

Panelists

Sarah Karlin-Smith
Pink Sheet

@SarahKarlin

Read Sarah's stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories.

Sandhya Raman
CQ Roll Call

@SandhyaWrites

Read Sandhya's stories.

Among the takeaways from this week’s episode:

• Lawmakers in Washington are completing work on the first batch of spending bills to avert a government shutdown. The package includes a bare-bones health bill, leaving out certain bipartisan proposals that have been in the works on drug prices and pandemic preparedness. Doctors do get some relief in the bill from Medicare cuts that took effect in January, but the pay cuts are not canceled.
• The White House is floating proposals on drug prices that include expanding Medicare negotiations to more drugs; applying negotiated prices earlier in the market life of drugs; and capping out-of-pocket maximum drug payments at $2,000 for all patients, not just seniors. At least some of the ideas have been proposed before and couldn’t clear even a Democratic-controlled Congress. But they also keep up pressure on the pharmaceutical industry as it challenges the government in court — and as Election Day nears.
• Many in public health are expressing frustration after the Centers for Disease Control and Prevention softened its covid-19 isolation guidance. The change points to the need for a national dialogue about societal support for best practices in public health — especially by expanding access to paid leave and child care.
• Meanwhile, CVS and Walgreens announced their pharmacies will distribute the abortion pill mifepristone, and enthusiasm is waning for the first over-the-counter birth control pill amid questions about how patients will pay its higher-than-anticipated list price of $20 per month.
• Alabama’s governor signed a law protecting access to in vitro fertilization, granting providers immunity from the state Supreme Court’s recent “embryonic personhood” decision. But with opposition from conservative groups, is the new law also bound for the Alabama Supreme Court?

Also this week, Rovner interviews White House domestic policy adviser Neera Tanden about Biden’s health agenda.

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

Julie Rovner: NPR’s “How States Giving Rights to Fetuses Could Set Up a National Case on Abortion,” by Regan McCarthy.

Sarah Karlin-Smith: Stat’s  “The War on Recovery,” by Lev Facher.

Alice Miranda Ollstein: KFF Health News’ “Why Even Public Health Experts Have Limited Insight Into Stopping Gun Violence in America,” by Christine Spolar.

Sandhya Raman: The Journal’s “‘My Son Is Not There Anymore’: How Young People With Psychosis Are Falling Through the Cracks,” by Órla Ryan.

Also mentioned on this week’s podcast:

• NBC News’ “CDC Updates Covid Isolation Guidelines for People Who Test Positive,” by Erika Edwards.
• New York Magazine’s “Did Trump Really Vow to Defund Schools With Vaccine Mandates?” by Margaret Hartmann.

click to open the transcript

Transcript: The State of the Union Is … Busy

KFF Health News’ ‘What the Health?’Episode Title: The State of the Union Is … BusyEpisode Number: 337Published: March 7, 2024

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, March 7, at 9 a.m. As always, news happens fast and things might have changed by the time you hear this, so here we go. We are joined today via video conference by Alice Miranda Ollstein, of Politico.

Alice Miranda Ollstein: Hello.

Rovner: Sarah Karlin-Smith, of the Pink Sheet.

Sarah Karlin-Smith: Hi, everybody.

Rovner: And Sandhya Raman, of CQ Roll Call.

Raman: Good morning.

Rovner: Later in this episode we’ll have my interview with White House domestic policy adviser Neera Tanden about the Biden administration’s health accomplishment so far and their priorities for 2024. But first, this week’s news. It is a big week here in the nation’s capital. In addition to sitting through President Biden’s State of the Union address, lawmakers appear on the way to finishing at least some of the spending bills for the fiscal year that began last Oct. 1. Good thing, too, because the president will deliver to Congress a proposed budget for the next fiscal year that starts Oct. 1, 2024, next Monday. Sandhya, which spending bills are getting done this week, and which ones are left?

Sandhya Raman: We’re about half-and-half as of last night. The House is done with their six-bill deal that they released. Congress came to a bipartisan agreement on Sunday and released then, so the FDA is in that part, in the agriculture bill. We also have a number of health extenders that we can …

Rovner: Which we’ll get to in a second.

Raman: Now it’s on to the Senate and then to Biden’s desk, and then we still have the Labor HHS [Department of Labor and Department of Health and Human Services] bill with all of the health funding that we’re still waiting on sometime this month.

Rovner: Yeah, it’s fair to say that the half that they’re getting done now are the easy ones, right? It’s the big ones that are left.

Ollstein: Although, if they were so easy, why didn’t they get them done a long time ago? There have been a lot of fights over policy riders that have been holding things up, in addition to disagreements about spending levels, which are perennial of course. But I was very interested to see that in this first tranche of bills, Republicans dropped their insistence on a provision banning mail delivery of abortion pills through the FDA, which they had been fighting for for months and months and months, and that led to votes on that particular bill being canceled multiple times. It’s interesting that they did give up on that.

Rovner: Yes. I shouldn’t say these were the easy ones, I should say these were the easier ones. Not that there’s a reason that it’s March and they’re only just now getting them done, but they have until the 22nd to get the rest of them done. How is that looking?

Raman: We still have not seen text on those yet. If they’re able to get there, we would see that in the next week or so, before then. And it remains to be seen, that traditionally the health in Labor HHS is one of the trickiest ones to get across the finish line in a normal year, and this year has been especially difficult given, like Alice said, all of the different policy riders and different back-and-forth there. It remains to be seen how that’ll play out.

Rovner: They have a couple of weeks and we will see. All right, well as you mentioned, as part of this first spending minibus, as they like to call it, is a small package of health bills. We talked about some of these last week, but tell us what made the final cut into this current six-bill package.

Raman: It’s whittled down a lot from what I think a lot of lawmakers were hoping. It’s pretty bare-bones in terms of what we have now. It’s a lot of programs that have traditionally been added to funding bills in the past, extending the special diabetes program, community health center funding, the National Health Service Corps, some sexual risk-avoidance programs. All of these would be pegged to the end of 2024. It kind of left out a lot of the things that Congress has been working on, on health care.

Rovner: Even bipartisan things that Congress has been working for on health care.

Raman: Yeah. They didn’t come to agreement on some of the pandemic and emergency preparedness stuff. There were some provisions for the SUPPORT Act — the 2018 really big opioid law — but a lot of them were not there. The PBM [pharmacy benefit managers] reform, all of that, was not, not this round.

Rovner: But at least judging from the press releases I got, there is some relief for doctor fees in Medicare. They didn’t restore the entire 3.3% cut, I believe it is, but I think they restored all but three-quarters of a percent of the cut. It’s made doctors, I won’t say happy, but at least they got acknowledged in this package and we’ll see what happens with the rest of them. Well, by the time you hear this, the president’s State of the Union speech will have come and gone, but the White House is pitching hard some of the changes that the president will be proposing on drug prices. Sarah, how significant are these proposals? They seem to be bigger iterations of what we’re already doing.

Karlin-Smith: Right. Biden is proposing expanding the Medicare Drug [Price] Negotiation program that Congress passed through the Inflation Reduction Act. He wants to go from Medicare being able to negotiate eventually up to 20 drugs a year to up to 50. He seems to be suggesting letting drugs have a negotiated price earlier in their life, letting them have less time on the market before negotiation. Also, thinking about applying some of the provisions of the IRA right now that only apply to Medicare to people in commercial plans, so this $2,000 maximum out-of-pocket spending for patients. Then also there are penalties that drugmakers get if they raise prices above inflation that would also apply to commercial plans. He’s actually proposed a lot of this before in previous budgets and actually Democrats, if you go back in time, tried to actually get some of these things in the initial IRA and even with a Democratic-controlled capital, could not actually get Democratic agreement to go broader on some of the provisions.

Rovner: Thank you, Sen. [Joe] Manchin.

Karlin-Smith: That said, I think it is significant that Biden is still pressing on this, even if they would really need big Democratic majorities and more progressive Democratic majorities to get this passed, because it’s keeping the pressure on the pharmaceutical industry. There were times before the IRA was passed where people were saying, “Pharma just needs to take this hit, it’s not going to be as bad as they think it is. Then they’ll get a breather for a while.” They’re clearly not getting that. The public is still very concerned about drug pricing, and they’re both fighting the current IRA in court. Actually, today there’s a number of big oral arguments happening. At the same time, they’re trying to get this version of the IRA improved somehow through legislation. All at the same time Democrats are saying, “Actually, this is just the start, we’re going to keep going.” It’s a big challenge and maybe not the respite they thought they might’ve gotten after this initial IRA was passed.

Rovner: But as you point out, still a very big voting issue. All right, well I want to talk about covid, which we haven’t said in a while. Last Friday, the Centers for Disease Control and Prevention officially changed its guidance about what people should do if they get covid. There’s been a lot of chatter about this. Sarah, what exactly got changed and why are people so upset?

Karlin-Smith: The CDC’s old guidance, if you will, basically said if you had covid, you should isolate for five days. If you go back in time, you’ll remember we probably talked about how that was controversial on its own when that first happened, because we know a lot of people are infectious and still test positive for covid much longer than five days. Now they’re basically saying, if you have covid, you can return to the public once you’re fever-free for 24 hours and your symptoms are improving. I think the implication here is, that for a lot of people, this would be before five days. They do emphasize to some degree that you should take precautions, masking, think about ventilation, maybe avoid vulnerable people if you can.

But I think there’s some in the public health world that are really frustrated by this. They feel like it’s not science- and evidence-based. We know people are going to be infectious and contagious in many cases for longer than periods of time where the CDC is saying, “Sure, go out in public, go back to work.” On the flip side, CDC is arguing, people weren’t really following their old guidance. In part because we don’t have a society set up to structurally allow them to easily do this. Most people don’t have paid sick time. They maybe don’t have people to watch their children if they’re trying to isolate from them. I think the tension is that, we’ve learned a lot from covid and it’s highlighted a lot of the flaws already in our public health system, the things we don’t do well with other respiratory diseases like flu, like RSV. And CDC is saying, “Well, we’re going to bring covid in line with those,” instead of thinking about, “OK, how can we actually improve as a society managing respiratory viruses moving forward, come up with solutions that work.”

I think there probably are ways for CDC to acknowledge some of the realities. CDC does not have the power to give every American paid sick time. But if CDC doesn’t push to say the public needs this for public health, how are we ever going to get there? I think that’s really a lot of the frustration in a lot of the public health community in particular, that they’re just capitulating to a society that doesn’t care about public health instead of really trying to push the agenda forward.

Rovner: Or a society that’s actively opposed to public health, as it sometimes seems. I know speaking for my NF1, I was sick for most of January, and I used up all my covid tests proving that I didn’t have covid. I stayed home for a few days because I felt really crappy, and when I started to feel better, I wore a mask for two weeks because, hello, that seemed to be a practical thing to do, even though I think what I had was a cold. But if I get sick again, I don’t have any more covid tests and I’m not going to take one every day because now they cost $20 a pop. Which I suspect was behind a lot of this. It’s like, “OK, if you’re sick with a respiratory ailment, stay home until you start to feel better and then be careful.” That’s essentially what the advice is, right?

Ollstein: Yeah. Although one other criticism I heard was specifically basing the new guidance on being fever-free, a lot of people don’t get a fever, they have other symptoms or they don’t have symptoms at all, and that’s even more insidious for allowing spread. I heard that criticism as well, but I completely agree with Sarah, that this seems like allowing public behavior to shape the guidance rather than trying to shape the public behavior with the guidance.

Rovner: Although some of that is how public health works, they don’t want to recommend things that they know people aren’t going to do or that they know the vast majority of people aren’t going to do. This is the difficulty of public health, which we will talk about more. While meanwhile, speaking in Virginia earlier this week, former President Donald Trump vowed to pull all federal funding for schools with vaccine mandates. Now, from the context of what he was saying, it seemed pretty clear that he was talking only about covid vaccine mandates, but that’s not what he actually said. What would it mean to lift all school vaccine mandates? That sounds a little bit scary.

Raman: That would basically affect almost every public school district nationwide. But even if it’s just covid shots, I think that’s still a little bit of a shift. You see Trump not taking as much public credit anymore for the fact that the covid vaccines were developed under his administration, Operation Warp Speed, that started under the Trump administration. It’s a little bit of a shift compared to then.

Rovner: I’m old enough to remember two cycles ago, when there were Republicans who were anti-vaccine or at least anti-vaccine curious, and the rest of the Republican Party was like, “No, no, no, no, no.” That doesn’t seem to be the case anymore. Now it seems to be much more mainstream to be anti-vax in general. Cough, cough. We see the measles outbreak in Florida, so we will clearly watch that space, too.

All right, moving on to abortion. Later this month, the Supreme Court will hear oral argument in the case that could severely restrict distribution of the abortion pill mifepristone. But in the meantime, pharmacy giants, CVS and Walgreens have announced they will begin distributing the abortion pill at their pharmacies. Alice, why now and what does this mean?

Ollstein: It’s interesting that this came more than a year after the big pharmacies were given permission to do this. They say it took this long because they had to get all of these systems up in place to make sure that only certified pharmacists were filling prescriptions from certified prescribing doctors. All of this is required because when the Biden administration, when the FDA, moved to allow this form of distribution of the abortion pill, they still left some restrictions known as REMS [risk evaluation and mitigation strategies] in place. That made it take a little more time, more bureaucracy, more box checking, to get to this point. It is interesting that given the uncertainty with the Supreme Court, they are moving forward with this. It’s this interesting state-versus-federal issue, because we reported a year ago that Walgreens and CVS would not distribute the pills in states where Republican state attorneys general have threatened them with lawsuits.

So, they’ve noted the uncertainty at the state level, but even with this uncertainty at the federal level with the Supreme Court, which could come in and say this form of distribution is not allowed, they’re still moving forward. It is limited. It’s not going to be, even in blue states where abortion is protected by law, they’re not going to be at every single CVS. They’re going to do a slower, phased rollout, see how it goes. I’m interested in seeing if any problems arise. I’m also interested in seeing, anti-abortion groups have vowed to protest these big pharmacy chains for making this medication available. They’ve disrupted corporate meetings, they’ve protested outside brick-and-mortar pharmacies, and so we’ll see if any of that continues and has an effect as well.

Rovner: It’s hard to see how the anti-abortion groups though could have enough people to protest every CVS and Walgreens selling the abortion pill. That will be an interesting numbers situation. Well, in a case of not-so-great timing, if only for the confusion potential, also this week we learned that the first approved over-the-counter birth control pill, called Opill, is finally being shipped. Now, this is not the abortion pill. It won’t require a prescription, that’s the whole point of it being over-the-counter. But I’ve seen a lot of advocacy groups that worked on this for years now complaining that the $20 per month that the pill is going to cost, it’s still going to be too much for many who need it. Since it’s over-the-counter, it’s not going to be covered by most insurance. This is a separate issue of its own that’s a little bit controversial.

Karlin-Smith: You can with over-the-counter drugs, if you have a flexible spending account or an HSA or something else, you may be able to use money that’s somehow connected to your health insurance benefit or you’re getting some tax breaks on it. However, I think this over-the-counter pill is probably envisioned most for people that somehow don’t have insurance, because we know the Affordable Care Act provides birth control methods with no out-of-pocket costs for people. So if you have insurance, most likely you would be getting a better deal getting a prescription and going that route for the same product or something similar.

The question becomes then, does this help the people who fall in those gaps who are probably likely to have less financial means to begin with? There’s been some polling and things that suggest this may be too high a price point for them. I know there are some discounts on the price. Essentially if you can buy three months upfront or even some larger quantities, although again that means you then have to have that larger sum of money upfront, so that’s a big tug of war. I think the companies argue this is pretty similar pricing to other over-the-counter drug products in terms of volume and stuff, so we’ll see what happens.

Rovner: I think they were hoping it was going to be more like $5 a month and not $20 a month. I think that came as a little bit of a disappointment to a lot of these groups that have been working on this for a very long time.

Ollstein: Just quickly, the jury is also still out on insurance coverage, including advocacy groups are also pressuring public insurance, Medicaid, to come out and say they’ll cover it as well. So we’ll keep an eye on that.

Rovner: Yeah, although Medicaid does cover prescription birth control. All right, well let us catch up on the IVF [in vitro fertilization] controversy in Alabama, where there was some breaking news over last night. When we left off last week, the Alabama Legislature was trying to come up with legislation that would grant immunity to fertility clinics or their staff for “damaging or killing fertilized embryos,” without overtly overruling the state Supreme Court decision from February that those embryos are, “extrauterine children.” Alice, how’s that all going?

Ollstein: Well, it was very interesting to see a bunch of anti-abortion groups come out against the bill that Alabama, mostly Republicans, put together and passed and the Republican governor signed it into law. The groups were asking her to veto it; they didn’t want that kind of immunity for discarding or destroying embryos. Now what we will see is if there’s going to be a lawsuit that lands this new law right back in front of the same state Supreme Court that just opened this whole Pandora’s box in the first place, that’s very possible. That’s one thing I’m watching. I guess we should also watch for other states to take up this issue. A lot of states have fetal personhood language, either in their constitutions or in statute or something, so really any of those states could become the next Alabama. All it would take is someone to bring a court challenge and try to get a similar ruling.

Rovner: I was amused though that the [Alabama] Statehouse passed the immunity law yesterday, Wednesday during the day. But the Senate passed it later in the evening and the governor signed it. I guess she didn’t want to let it hang there while these big national anti-abortion groups were asking her to veto it. So by the time I woke up this morning, it was already law.

Ollstein: It’s just been really interesting, because the anti-abortion groups say they support IVF, but they came out against the Democrats’ federal bill that would provide federal protections. They came out against nonbinding House resolutions that Republicans put forward saying they support IVF, and they came out against this Alabama fix. So it’s unclear what form of IVF, if any, they do support.

Rovner: Meanwhile, in Kentucky, the state Senate has overwhelmingly passed a bill that would permit a parent to seek child support retroactively to cover pregnancy expenses up until the child reaches age 1. So you have until the child turns 1 to sue for child support. Now, this isn’t technically a “personhood” bill, and it’s legit that there are expenses associated with becoming a parent even before a baby is born, but it’s skating right up to the edge of that whole personhood thing.

It brings me to my extra credit for this week, which I’m going to do early. It’s a story from NPR called, “How States Giving Rights to Fetuses Could Set Up a National Case on Abortion,” by Regan McCarthy of member station WFSU in Tallahassee. In light of Florida’s tabling of a vote on its personhood bill in the wake of the Alabama ruling last week, the story poses a question I hadn’t really thought about in the context of the personhood debate, whether some of these partway recognition laws, not just the one in Kentucky, but there was one in Georgia last year, giving tax deductions for children who are not yet born as long as you could determine a heartbeat in the second half of the year, because obviously in the first half of the year the child would’ve been born.

Whether those are part of a very long game that will give courts the ability to put them all together at some point and declare not just embryos but zygotes children. Is this in some ways the same playbook that anti-abortion forces use to get Roe [v. Wade] overturned? That was a very, very long game and at least this story speculates that that might be what they’re doing now with personhood.

Ollstein: Some anti-abortion groups are very open that it is what they want to do. They have been seeding the idea in amicus briefs and state policies. They’ve been trying to tuck personhood language into all of these things to eventually prompt such a ruling, ideally from the Supreme Court and, in their view. So whether that moves forward remains to be seen, but it’s certainly the next goal. One of many next goals on the horizon.

Rovner: Yes, one of many. All right, well moving on. Last week I called the cyberattack on Change Healthcare, a subsidiary of UnitedHealth Group, the biggest under-covered story in health care. Well, it is not under-covered anymore. Two weeks later, thousands of hospitals, pharmacies, and doctor practices still can’t get their claims paid. It seems that someone, though it’s not entirely clear who, paid the hackers $22 million in ransom. But last time I checked the systems were still not fully up. I saw a letter this morning from the Medicaid directors worrying about Medicaid programs getting claims fulfilled. How big a wake-up call has this been for the health industry, Sarah? This is a bigger deal than anybody expected.

Karlin-Smith: There’s certainly been cyberattacks on parts of the health system before in hospitals. I think the breadth of this, because it’s UnitedHealth [Group], is really significant. Particularly, because it seems like some health systems were concerned that the broader United network of companies and systems would get impacted, so they sort of disconnected from things that weren’t directly changed health care, and that ended up having broader ramifications. It’s one consequence of United being such a big monolith.

Then the potential that United paid a ransom here, which is not 100% clear what happened, is very worrisome. Again, because there’s this sense that, that will then increase the — first, you’re paying the people that then might go back and do this, so you’re giving them more money to hack. But also again, it sets up a precedent, that you can hack health systems and they will pay you. Because it is so dangerous, particularly when you start to get involved in attacking the actual systems that provide people care. So much, if you’ve been in a hospital lately or so forth, is run on computer systems and devices, so it is incredibly disruptive, but you don’t want to incentivize hackers to be attacking that.

Rovner: I certainly learned through this how big Change Healthcare, which I had never heard of before this hack and I suspect most people even who do health policy had never heard of before this attack, how embedded they are in so much of the health care system. These hackers knew enough to go after this particular system that affected so much in basically one hack. I’m imagining as this goes forward, for those who didn’t listen to last week’s podcast, we also talked about the Justice Department’s new investigation into the size of UnitedHealth [Group], an antitrust investigation for… It was obviously not prompted by this, it was prompted by something else, but I think a lot of people are thinking about, how big should we let one piece of the health care system get in light of all these cyberattacks?

All right, well we’ll obviously come back to this issue, too, as it resolves, one would hope. That is the news for this week. Now we will play my interview with White House domestic policy adviser Neera Tanden, and then we will come back with our extra credits.

I am so pleased to welcome to the podcast Neera Tanden, domestic policy adviser to President Biden, and director of the White House Domestic Policy Council. For those of you who don’t already know her, Neera has spent most of the last two decades making health policy here in Washington, having worked on health issues for Hillary Clinton, President Barack Obama, and now President Joe Biden. Neera, thank you so much for joining us.

Neera Tanden: It’s really great to be with you, Julie.

Rovner: As we tape this, the State of the Union is still a few hours away and I know there’s stuff you can’t talk about yet. But in general, health care has been a top-of-mind issue for the Biden administration, and I assume it will continue to be. First, remind us of some of the highlights of the president’s term so far on health care.

Tanden: It’s a top concern for the president. It’s a top issue for us, but that’s also because it’s really a top issue for voters. We know voters have had significant concerns about access, but also about costs. That is why this administration has really done more on costs than any administration. This is my third, as you noted, so I’m really proud of all the work we’ve done on prescription drugs, on lowering costs of health care in the exchanges, on really trying to think through the cost burden for families when it comes to health care.

When we talk about prescription drugs, it’s a wide-ranging agenda, there are things or policies that people have talked about for decades, like Medicare negotiating drug prices, that this president is the first president to truly deliver on, which he will talk about in the State of the Union. But we’ve also innovated in different policies through the Inflation Reduction Act, the inflation rebates, which ensure that drug companies don’t raise the price of drugs faster than inflation. When they do, they pay a rebate both to Medicare but also ultimately to consumers. Those our high-impact policies that will really take a comprehensive approach on lowering prices.

Rovner: Yet for all the president has accomplished, and people who listen to the podcast regularly will know that it has been way more than was expected given the general polarization around Washington right now. Why does the president seem to get so little credit for getting done more things than a lot of his predecessors were able to do in two terms?

Tanden: Well, I think people do recognize the importance of prescription drug coverage. And health care as an issue that the president — it’s not my place to talk about politics, but he does have significant advantages on issues like health care. That I think, is because we’ve demonstrated tangible results. People understand what $35 insulin means. What I really want to point to in the Medicare negotiation process is, Sept. 1, Medicare will likely have a list of drugs which are significantly lower costs, that process is underway. But my expectation, you know I’m not part of it, that’s being negotiated by CMS [Centers for Medicare & Medicaid Services] and HHS, but we expect to have a list of 10 drugs that are high-cost items for seniors in which they’ll see a price that is lower than what they pay now. That’s another way in which, like $35 insulin, we’ll have tangible proof points of what this administration will be delivering for families.

Rovner: There’s now a record number of people who have health insurance under the Affordable Care Act, which I remember you also worked on. But in surveys, as you noted, voters now say they’re less worried about coverage and more worried about not being able to pay their medical bills even if they have insurance. I know a lot of what you’re doing on the drug side is limited to Medicare. Now, do you expect you’re going to be able to expand that to everybody else?

Tanden: First and foremost, our drug prices will be public, as you know. And as you know, prices in Medicare have been able to influence other elements of the health care system. That is really an important part of this. Which is that again, those prices will be public and our hope is that the private sector adopts those prices, because they’re ones that are negotiated. We expect this to affect, not just seniors, but families throughout the country.

There are additional actions we’ll be taking on Medicare drug negotiation. That will be a significant portion of the president’s remarks on health care, not just what we’ve been able to do in Medicare drug negotiation, but how we can really build on that and really ensure that we are dramatically reducing drug costs throughout the system. I look forward to hearing the president on that topic.

Rovner: I know we’re also going to get the budget next week. Are there any other big health issues that will be a priority this year?

Tanden: The president will have a range of policies on issues like access to sickle cell therapies, ensuring affordable generic drugs are accessible to everybody, ensuring that we are building on the Affordable Care Act gains. You mentioned this, but I just really do want to step back and talk about access under the Affordable Care Act. Because I think if people started off at the beginning of this administration and said the ACA marketplaces close to double, people would’ve been shocked. You know this well, a lot of people thought the exchanges were maximizing their potential. There are a lot of people who may not be interested in that, but the president had, in working with Congress, made the exchanges more affordable.

We’ve seen record adoption: 21 million people covered through the ACA exchanges today, when it was 12 million when we started. That’s 9 million more people who have the security of affordable health care coverage. I think it’s a really important point, which is, why are people signing up? Because it is a lot more affordable? Most people can get a very affordable plan. People are saving on average $800, and that affordability is crucial. Of course we have to do more work to reduce costs throughout the health care system. But it’s an important reminder that when you lower drug costs, you also have the ability to lower premiums and it’s another way in which we can drive health care costs down. I would be genuinely honest with you, which is, I did not think we would be able to do all of these things at the beginning of the administration. The president has been laser-focused on delivering, and as you know from your work on the ACA, he did think it was a big deal.

Rovner: I have that on a T-shirt.

Tanden: A lot of people have talked about different things, but he has been really focused on strengthening the ACA. He’ll talk about how we need to strengthen it in the future, and how that is another choice that we face this year, whether we’re going to entertain repealing the ACA or build on it and ensure that the millions of people who are using the ACA have the security to know that it’s there for them into the future. Not just on access, but that also means protections for preexisting conditions, ensuring women can no longer be discriminated against, the lifetime annual limits. There’s just a variety of ways that ACA has transformed the health care system to be much more focused on consumers.

Rovner: Last question. Obviously reproductive health, big, big issue this year. IVF in particular has been in the news these past couple of weeks, thanks to the Alabama Supreme Court. Is there anything that President Biden can do using his own executive power to protect access to reproductive health technology? And will we hear him at some point address this whole personhood movement that we’re starting to see bubble back up?

Tanden: I think the president will be very forceful on reproductive rights and will discuss the whole set of freedoms that are at stake and reproductive rights and our core freedom at stake this year. You and I both know that attacks on IVF are actually just the effectuation of the attacks on Roe. What animates the attacks on Roe, would ultimately affect IVF. I felt like I was a voice in the wilderness for the last couple of decades, where people were saying … They’re just really focused on Roe v. Wade. It won’t have any impact on IVF or [indecipherable] they’re just scare tactics when you talk about IVF.

Obviously the ideological underpinnings of attacks on Roe ultimately mean that you would have to take on IVF, which is exactly what women are saying. I think the president will speak forcefully to the attacks on women’s dignity that women are seeing throughout this country, and how this ideological battle has translated to misery and pain for millions of women. Misery and pain for their families. And has really reached the point where women who are desperate to have a family are having their reproductive rights restricted because of the ideological views of a minority of the country. That is a huge issue for women, a huge issue for the country, and exactly why he’ll talk about moving forward on freedoms and not moving us back, sometimes decades, on freedom.

Rovner: Well, Neera Tanden, you have a lot to keep you busy. I hope we can call on you again.

Tanden: There’s few people who know the health care system as well as Julie Rovner, so it’s just a pleasure to be with you.

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

Raman: My extra credit this week is called “My Son Is Not There Anymore: How Young People With Psychosis Are Falling Through the Cracks,” and it’s by Órla Ryan for The Journal. This was a really interesting story about schizophrenia in Ireland and just how the earlier someone’s symptoms are treated the better the outcome. But a lot of children and minors with psychosis and schizophrenia struggle to get access to the care they need and just fall through the cracks of being transferred from one system to another, especially if they’re also dealing with disabilities. If some of these symptoms are treated before puberty, the severity is likely to go down a lot and they’re much less likely to experience psychosis. She takes a really interesting look at a specific case and some of the consequences there.

Rovner: I feel like we don’t look enough at what other countries health systems are doing because we could all learn from each other. Alice, why don’t you go next?

Ollstein: I have a piece by KFF Health News called “Why Even Public Health Experts Have Limited Insight Into Stopping Gun Violence in America.” It’s looking at the toll taken by the long-standing restrictions on federal funding for research into gun violence, investigating it as a public health issue. Only recently this has started to erode at the federal level and some funding has been approved for this research, but it is so small compared to the death toll of gun violence. This article sort of argues that lacking that data for so many years is why a lot of the quote-unquote “solutions” that places have tried to implement to prevent gun violence, just don’t work. They haven’t worked, they haven’t stopped these mass shootings, which continue to happen. So, arguing that, if we had better data on why things happen and how to make it less lethal, and safe, in various spaces, that we could implement some things that actually work.

Rovner: Yeah, we didn’t have the research just as this problem was exploding and now we are paying the price. Sarah.

Karlin-Smith: I looked at the first in a Stat News series by Lev Facher, “The War on Recovery: How the U.S. Is Sabotaging Its Best Tools to Prevent Deaths in the Opioid Epidemic.” It looks at why the U.S. has had access to cheap effective medicines that help reduce the risk of overdose and death for people that are struggling with opioid-use disorder haven’t actually been able, in most cases, to get access to these drugs, methadone and buprenorphine.

The reasons range from even people not being allowed to take the drugs when they’re in prison, to not being able to hold certain jobs if you’re taking these prescription medications, to Narcotics Anonymous essentially banning people from coming to those meetings if they use these drugs, to doctors not being willing or open to prescribing them. Then of course, there’s what always seems to come up these days, the private equity angle. Which is that methadone clinics are becoming increasingly owned by private equity and they’ve actually pushed back on and lobbied against policies that would make it easier for people to get methadone treatment. Because one big barrier to methadone treatment is, right now you largely have to go every day to a clinic to get your medicine, which it can be difficult to incorporate into your life if you need to hold a job and take care of kids and so forth.

It’s just a really fascinating dive into why we have the tools to make what is really a terrible crisis that kills so many people much, much better in the U.S. but we’re just not using them. Speaking of how other countries handle it, the piece goes a little bit into how other countries have had more success in actually being open to and using these tools and the differences between them and the U.S.

Rovner: Yeah, it’s a really good story. All right, that is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, @jrovner, or @julierovner at Bluesky or @julie.rovner at Threads. . Sarah, where are you these days?

Karlin-Smith: Trying mostly to be on Blue Sky, but on X, Twitter a little bit at either @SarahKarlin or @sarahkarlin-smith.

Rovner: Alice.

Ollstein: @alicemiranda on Blue Sky, and @AliceOllstein on X.

Rovner: Sandhya.

Raman: @SandhyaWrites on X and on Blue Sky.

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

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Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

Occupational Therapists Change Lives. CMS Must Better Support Them.

Occupational therapists are critical in helping patients adjust to new circumstances, empowering them with the tools they need to overcome barriers and regain control over their lives. Whether you’re transitioning from homelessness into a home (“In Los Angeles, Occupational Therapists Tapped to Help Homeless Stay Housed,” Jan. 24) or relearning how to do everyday tasks following a stroke, OTs are key to patients’ care plan.

But the critical care provided by OTs is being threatened by another year of payment cuts imposed by Medicare, our nation’s health care program for people age 65 and up. Many older patients treated by OTs access insurance coverage through Medicare, which typically reimburses providers at a lower rate than private insurers. And now, with payment cuts that went into effect on Jan. 1 — despite warnings and backlash from lawmakers, patients, and providers — OTs are struggling to deliver care with lower Medicare payment.

Investing in occupational therapy improves health outcomes for patients, has the potential to reduce the burden on hospitals and other health care clinicians, and keeps individuals healthy and independent. Medicare’s payment cuts only compromise the ability of providers to deliver comprehensive, compassionate care. Medicare must recognize the long-term patient benefits occupational therapy has to offer.

Luckily, Congress is considering a bill that would reverse these harmful payment cuts. The Preserving Seniors’ Access to Physicians Act of 2023 (HR 6683), would reverse the cuts that went into effect on Jan. 1, alleviating financial stress for occupational therapists and preserving patient access. I strongly urge lawmakers to prioritize and protect occupational therapy services and immediately pass HR 6683 for America’s Medicare patients.

— Doug Fosco, an occupational therapist practicing at Two Trees Physical Therapy in Ventura, California

An assistant professor at Ontario’s Western University weighed in on X.

Great to see the role of #occupationaltherapy with persons who experience #homelessness profiled in @latimes. Thanks #deborahpitts for your work in LA with @USC and #skidrowhousingtrust . Check it out @CAOT_ACE @OSOTvoice ! @CAEHomelessness https://t.co/S5s9jhgoxI

— Carrie Anne Marshall, PhD (@cannemarshall) January 24, 2024

— Carrie Anne Marshall, Sydenham, Ontario

Congress Must Finish the Job on Site-Neutral Payments

There’s an obvious solution to rein in government spending and patient out-of-pocket costs: Pay identical prices for identical care (“In Fight Over Medicare Payments, the Hospital Lobby Shows Its Strength,” Feb. 13).

As a community oncologist, it is clear to me how Medicare favors hospitals by paying more for services provided in hospital outpatient departments (HOPDs) than the same care delivered in community-based facilities. For example, last year, Medicare paid over 2.5 times as much in an HOPD as in a free-standing office for drug administration services. It’s not just Medicare paying too much; patients also face higher out-of-pocket costs for care provided in HOPDs. If the Lower Costs, More Transparency Act is signed into law, cancer patients would immediately pay less for treatments like chemotherapy.

One unintended consequence of current payment disparities is consolidation. To leverage higher reimbursements, health systems scoop up independent practices — a growing problem that is particularly pronounced in oncology. From 2008 to 2020, 435 community cancer clinics closed, while 722 contracted with or were acquired by hospitals. This consolidation is reducing patient access, particularly in rural areas, where many independent clinics operate small satellite sites that tend to be the first to close when hospitals acquire a community-based practice.

It’s time for Congress to finish the job through bills like the Lower Costs, More Transparency Act and the SITE Act, which would help level the playing field once and for all.

— Scott Rushing, Vancouver, Washington

The chief marketing officer of SKYGEN cut to the chase on X.

In the battle to control healthcare costs, hospitals are deploying their political power to protect their bottom lines. https://t.co/97r502KrpM

— Donald H. Polite (@DonaldPolite) February 15, 2024

— Donald H. Polite, Milwaukee

The ‘Gold Card’ Shuffle

Prior authorization, by definition, creates delays in care and bureaucratic barriers for physicians — which is why it is so troubling that many insurers now require prior authorization for large categories of procedures with no evidence of overuse or inappropriate use. With health insurers increasingly implementing questionable prior authorization policies, state and federal lawmakers are racing to erect safeguards that ensure patients’ access to timely care (“States Target Health Insurers’ ‘Prior Authorization’ Red Tape,” Feb. 12).

Much of the legislation to address this growing problem centers around the use of “Gold Cards” that exempt providers whose previous requests for prior authorization have been approved for a certain period. In general, these laws are important for patients who can’t afford to wait for care — especially in the field of gastroenterology where severe abdominal pain or blood in the stool could indicate a serious condition like cancer.

However, some insurance companies are co-opting the “Gold Card” term to justify new prior authorization requirements instead of streamlining existing ones. Consider the case of UnitedHealthcare, which announced it would roll out a “Gold Card” prior authorization program this year for most colonoscopies and endoscopies. No other insurer has levied such a policy, nor does the research suggest there is an overutilization of these vital services. Despite nearly a year of good faith efforts to seek transparency and guidance from UHC, the company has failed to release any data or justification that these services are improperly utilized.

If anything, diagnostic and surveillance colonoscopies and endoscopies may be underutilized. New research from the American Cancer Society shows an alarming spike in the number of younger Americans being diagnosed with and dying from colorectal cancer. Since symptoms of colorectal cancer don’t often appear until the disease is at a more advanced stage, early detection is key. Any disruption to surveillance colonoscopies (which follow removal of a precancerous polyp and are part of the screening continuum) caused by UHC’s forthcoming prior authorization policy would be dangerous for the company’s 27 million commercial beneficiaries.

The American Gastroenterological Association strongly urges UHC to rescind its “Gold Card” prior authorization policy. Policymakers must monitor how insurers are co-opting concepts meant to protect patients, in particular UHC’s faux “Gold Card,” which threatens patient access to a procedure proven to save lives.

— Barbara Jung, president of the American Gastroenterological Association, Seattle

In an X post, a senior fellow at the Manhattan Institute pointed out the value in requiring prior authorization.

Case-by-case prior authorization is never fun, but surely preferable to most other methods of eliminating needless spending (ex post denials of reimbursement, higher cost-sharing, capped global budgets, etc…) https://t.co/nYijeiAUtP

— Chris Pope (@CPopeHC) February 12, 2024

— Chris Pope, a senior fellow at the Manhattan Institute, New York City

Hospice in Prison: A Transformative View

I was so impressed with Markian Hawryluk’s exceptionally well-written article “Death and Redemption in an American Prison” (Feb. 21). I was privileged to serve as an inaugural member of the American Hospital Association’s Circle of Life Award committee, from 1999 to 2004. The awards were established to recognize the most outstanding hospice and palliative care programs in the U.S. The very first year, we received an application from the country’s largest maximum-security prison in Angola, Louisiana, the subject of Mr. Hawryluk’s wonderful article. The prison was one of the five finalists chosen for a site visit in 2000. I volunteered to be on team to visit and evaluate the prison’s hospice services.

Twenty-four years later, I still remember my conversation with one of the inmate volunteers who had just returned from bathing and feeding a dying prisoner. He told me the inmate said, “I love you.” Then the inmate volunteer stated, “I never heard those words before — not from my father, who I never met, nor from my mother.” In 2000, if one were sentenced to life at the Louisiana State Penitentiary, there was no chance for parole. When we met with the warden, he mentioned there was a waiting list of prisoners who wanted to be hospice volunteers.

Please convey my deep appreciation to Mr. Hawryluk for his outstanding article.

— Paul Hofmann, president of the Hofmann Healthcare Group, Moraga, California

A digital storyteller shared the article on X.

Your one, long read for today – it's beautifully and thoughtfully written and reported"Sometimes when you're in a dark place, you find out who you really are and what you wish you could be," Steven Garner said. "Even in darkness, I could be a light."https://t.co/57asjh11ZV

— Ameera B. ا ميرة بت 🪬 (@meerabee) February 19, 2024

— Ameera Butt, Los Angeles

Feeling Insecure Because of Social Security Tactics

When will you continue your series on the overpayments to the Social Security Administration (“Overpayment Outrage”)? People are still suffering without benefits because the agency says people were overpaid and wants the money back. Why is nobody else asking more questions?

People in this country worked hard and paid taxes. And when it is time to retire, the Social Security Administration refuses to pay if, all of a sudden, it discovers you have been overpaid. They have told me I owe them $30,000 from over 20 years ago, and I do not know what they are talking about, but they want to take my retirement money until it’s paid off. Or they want you to say it is OK to take a percentage out. Doing that would say you’re guilty and you owe the money — to me, that’s blackmail.

New immigrants get free phones, medical care, debit cards, food assistance, schooling … that comes to more than my little amount of retirement money. It seems the government can afford to take care of them, but not their own. Everyone who has had their Social Security taken away should be entitled to the free services they get, as we are in the same position — now we have nothing either.

— Thomas Troy, New York City

Lifelong Minnesotan and epidemiologist Eric Weinhandl chimed in on X.

Relatively severe incompetency. Social Security Chief Apologizes to Congress for Misleading Testimony on Overpaymentshttps://t.co/HYPcTU5tVW

— Eric Weinhandl (@eric_weinhandl) December 27, 2023

— Eric Weinhandl, Victoria, Minnesota

A Balanced View of the Law Curbing Surprise Bills

KFF Health News’ Elisabeth Rosenthal has long advocated for quality, patient-centric medical care. However, her recent article, “The No Surprises Act Comes with Some Surprises” (Feb. 14), falls short in its analysis of surprise medical billing and the federal No Surprises Act (NSA). While she places blame on physicians, the reality is more complicated.

Patients with health insurance should not be burdened with paying more than their normal in-network cost-sharing amount for unexpected out-of-network care. This is not controversial. The legislative debate was never about whether to act on surprise billing, but rather how to act. While insurers favored policies that would allow them to calculate the payment rate medical providers receive, with the NSA, Congress instead chose an approach intended to protect sustainable payment rates that would preserve patients’ access to care. The NSA removes patients from payment disputes between insurers and providers and is intended to encourage negotiations between insurers and providers, with an option for neutral arbitration.

Rosenthal’s article implies a “greedy doctor” narrative, omitting discussion of insurers as contributing to the problems with the NSA’s implementation. While the article notes that many requests for arbitration came from private equity-associated provider organizations, it neglected to note that a single insurance company (UnitedHealthcare) was involved in almost 40% of arbitration disputes. That is more than the rest of the top five insurance organizations combined. The article also quotes and references papers by Zack Cooper, whose undisclosed connections with UnitedHealthcare came to light through litigation. As reported, UnitedHealthcare not only provided data to Cooper, but helped frame the narrative of the work.

NSA rulemaking has financially incentivized insurers to leverage the NSA to unilaterally reduce existing contracted rates and push physicians out-of-network. As for the projected number of requests for arbitration in 2022 (which underestimated “providers’ ire by an order of magnitude”), that projection ignored existing data. In just the first six months of 2021, Texas alone had more than twice as many arbitration submissions for its state law as the federal government projected for the nation for a full year. More importantly, the article ignores the issue of why doctors request arbitration. Since arbitration is baseball-style and “loser pays,” there is a strong disincentive to request it without a solid reason. In the second quarter of 2023, providers won nearly 80% of disputes, reflecting the fact that doctors are going to arbitration when insurers’ actions are unreasonable.

Further, while it is true that before the NSA too many patients were receiving bills for unexpected out-of-network care, a report from the Department of Health and Human Services noted that out-of-network billing was actually declining prior to the NSA. Physician survey data suggests that post-NSA out-of-network care is now increasing due to some insurers’ actions.

The bipartisan NSA is a balanced solution to a complicated problem. Difficulties with the law’s implementation, including the volume of dispute submissions and backlog of cases, are due to unintended consequences from rulemaking. Addressing these challenges requires an honest conversation about their cause. Going forward, rulemaking is needed to promote fair network contracting, limit the need for arbitration, and, most importantly, protect patients’ access to care.

— Rich Heller, a pediatric radiologist and the associate chief medical officer for health policy, Radiology Partners, Chicago

Anesthetist-emergency physician-family doctor David Moniz, in an X post, warned of the “unseen consequences” of the No Surprises Act.

Check out the surprising outcomes of the No Surprises Act, designed to protect patients from unexpected medical bills. While it's successfully shielded many patients, there are unseen consequences. Read the full article here: https://t.co/YFa0xweRe7#health, #healthpolicy, #he…

— David Moniz (@DavidMoniz15) February 14, 2024

— David Moniz, Chilliwack, British Columbia

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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If he lived in any of the 50 states, Medicare would have provided coverage for his medical needs. But because he lived in Puerto Rico, Medicare is far less useful to him.

Read the rest…

Last year alone, David Mitchell paid $16,525 for 12 little bottles of Pomalyst, one of the pricey medications that treat his multiple myeloma, a blood cancer he was diagnosed with in 2010.

The drugs have kept his cancer at bay. But their rapidly increasing costs so infuriated Mitchell that he was inspired to create an advocacy movement.

Patients for Affordable Drugs, which he founded in 2016, was instrumental in getting drug price reforms into the 2022 Inflation Reduction Act. Those changes are kicking in now, and Mitchell, 73, is an early beneficiary.

In January, he plunked down $3,308 for a Pomalyst refill “and that’s it,” he said. Under the law, he has no further responsibility for his drug costs this year — a savings of more than $13,000.

The law caps out-of-pocket spending on brand-name drugs for Medicare beneficiaries at about $3,500 in 2024. The patient cap for all drugs drops to $2,000 next year.

“From a selfish perspective, I feel great about it,” he said. But the payment cap will be “truly life-changing” for hundreds of thousands of other Medicare patients, Mitchell said.

President Joe Biden’s battle against high drug prices is mostly embodied in the IRA, as the law is known — a grab bag of measures intended to give Medicare patients immediate relief and, in the long term, to impose government controls on what pharmaceutical companies charge for their products. The law represents the most significant overhaul for the U.S. drug marketplace in decades.

With Election Day on the horizon, the president is trying to make sure voters know who was responsible. This month, the White House began a campaign to get the word out to seniors.

“The days where Americans pay two to three times what they pay for prescription drugs in other countries are ending,” Biden said in a Feb. 1 statement.

KFF polling indicates Biden has work to do. Just a quarter of adults were aware that the IRA includes provisions on drug prices in July, nearly a year after the president signed it. He isn’t helped by the name of the law, the “Inflation Reduction Act,” which says nothing about health care or drug costs.

Biden’s own estimate of drug price inflation is quite conservative: U.S. patients sometimes pay more than 10 times as much for their drugs compared with people in other countries. The popular weight loss drug Wegovy lists for $936 a month in the U.S., for example — and $83 in France.

Additional sections of the law provide free vaccines and $35-a-month insulin and federal subsidies to patients earning up to 150% of the federal poverty level, and require drugmakers to pay the government rebates for medicines whose prices rise faster than inflation. But the most controversial provision enables Medicare to negotiate prices for certain expensive drugs that have been on the market for at least nine years. It’s key to Biden’s attempt to weaken the drug industry’s grip.

Responding to Pressure

The impact of Medicare’s bargaining over drug prices for privately insured Americans remains unclear. States have taken additional steps, such as cutting copays for insulin for the privately insured.

However, insurers are increasing premiums in response to their higher costs under the IRA. Monthly premiums on traditional Medicare drug plans jumped to $48 from $40 this year, on average.

On Feb. 1, the Centers for Medicare & Medicaid Services sent pharmaceutical makers opening bids for the first 10 expensive drugs it selected for negotiation. The companies are responding to the bids — while filing nine lawsuits that aim to kill the negotiations altogether, arguing that limiting their profits will strangle the pipeline of lifesaving drugs. A federal court in Texas dismissed one of the suits on Feb. 12, without taking up the substantive legal issue over constitutionality.

The nonpartisan Congressional Budget Office predicted the IRA’s drug pricing elements would save the federal government $237 billion over 10 years while reducing the number of drugs coming to market in that period by about two.

If the government prevails in the courts, new prices for those 10 drugs will be announced by September and take effect in 2026. The government will negotiate an additional 15 drugs for 2027, another 15 for 2028, and 20 more each year thereafter. CMS has been mum about the size of its offers, but AstraZeneca CEO Pascal Soriot on Feb. 8 called the opening bid for his company’s drug Farxiga (which earned $2.8 billion in U.S. sales in fiscal year 2023) “relatively encouraging.”

Related Biden administration efforts, as well as legislation with bipartisan support, could complement the Inflation Reduction Act’s swing at drug prices.

The House and Senate have passed bills that require greater transparency and less self-serving behavior by pharmacy benefit managers, the secretive intermediaries that decide which drugs go on patients’ formularies, the lists detailing which prescriptions are available to health plan enrollees. The Federal Trade Commission is investigating anti-competitive action by leading PBMs, as well as drug company patenting tricks that slow the entry of cheaper drugs to the market.

‘Sending a Message’

Months after drug companies began suing to stop price negotiations, the Biden administration released a framework describing when it could “march in” and essentially seize drugs created through research funded by the National Institutes of Health if they are unreasonably priced.

The timing of the march-in announcement “suggests that it’s about sending a message” to the drug industry, said Robin Feldman, who leads the Center for Innovation at the University of California Law-San Francisco. And so, in a way, does the Inflation Reduction Act itself, she said.

“I have always thought that the IRA would reverberate well beyond the unlucky 10 and others that get pulled into the net later,” Feldman said. “Companies are likely to try to moderate their behavior to stay out of negotiations. I think of all the things going on as attempts to corral the market into more reasonable pathways.”

The IRA issues did not appear to be top of mind to most executives and investors as they gathered to make deals at the annual J.P. Morgan Healthcare Conference in San Francisco last month.

“I think the industry is navigating its way beyond this,” said Matthew Price, chief operating officer of Promontory Therapeutics, a cancer drug startup, in an interview there. The drugs up for negotiation “look to be assets that were already nearing the end of their patent life. So maybe the impact on revenues is less than feared. There’s alarm around this, but it was probably inevitable that a negotiation mechanism of some kind would have to come in.”

Investors generally appear sanguine about the impact of the law. A recent S&P Global report suggests “healthy revenue growth through 2027” for the pharmaceutical industry.

Back in Washington, many of the changes await action by the courts and Congress and could be shelved depending on the results of the fall election.

The restructuring of Medicare Part D, which covers most retail prescription drugs, is already lowering costs for many Medicare patients who spent more than $3,500 a year on their Part D drugs. In 2020 that was about 1.3 million patients, 200,000 of whom spent $5,000 or more out-of-pocket, according to KFF research.

“That’s real savings,” said Tricia Neuman, executive director of KFF’s Medicare policy program, “and it’s targeted to people who are really sick.”

Although the drug industry is spending millions to fight the IRA, the Part D portion of the bill could end up boosting their sales. While it forces the industry to further discount the highest-grossing drugs, the bill makes it easier for Medicare patients to pick up their medicines because they’ll be able to afford them, said Stacie Dusetzina, a Vanderbilt University School of Medicine researcher. She was the lead author of a 2022 study showing that cancer patients who didn’t get income subsidies were about half as likely to fill prescriptions.

States and foundations that help patients pay for their drugs will save money, enabling them to procure more drugs for more patients, said Gina Upchurch, the executive director of Senior PharmAssist, a Durham, North Carolina-based drug assistance program, and a member of the Medicare Payment Advisory Commission. “This is good news for the drug companies,” she said.

Relief for Patients

Lynn Scarfuto, 73, a retired nurse who lives on a fixed income in upstate New York, spent $1,157 for drugs last year, while most of her share of the $205,000 annual cost for the leukemia drug Imbruvica was paid by a charity, the Patient Access Network Foundation. This year, through the IRA, she’ll pay nothing because the foundation’s first monthly Imbruvica payment covered her entire responsibility. Imbruvica, marketed jointly by AbbVie and Janssen, a subsidiary of Johnson & Johnson, is one of the 10 drugs subject to Medicare negotiations.

“For Medicare patients, the Inflation Reduction Act is a great, wonderful thing,” Scarfuto said. “I hope the negotiation continues as they have promised, adding more drugs every year.”

Mitchell, a PR specialist who had worked with such clients as the Campaign for Tobacco-Free Kids and pharmaceutical giant J&J, went to an emergency room with severe back pain in November 2010 and discovered he had a cancer that had broken a vertebra and five ribs and left holes in his pelvis, skull, and forearm bones. He responded well to surgery and treatment but was shocked at the price of his drugs.

His Patients for Affordable Drugs group has become a powerful voice in Washington, engaging tens of thousands of patients, including Scarfuto, to tell their stories and lobby legislatures. The work is supported in part by millions in grants from Arnold Ventures, a philanthropy that has supported health care policies like lower drug prices, access to contraception, and solutions to the opioid epidemic.

“What got the IRA over the finish line in part was angry people who said we want something done with this,” Mitchell said. “Our patients gave voice to that.”

Arnold Ventures has provided funding for KFF Health News.

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

USE OUR CONTENT

This story can be republished for free (details).

By some measures, private equity investment lagged in 2023, a year marked by growing distress and high-profile downfalls among private equity-backed health care companies.

Even so, three sectors still managed to see strong deal flow and prices: med spa, cardiology, and clinical trial sites, according to a new PitchBook report analyzing private equity investments in health care services in 2023. Each of the three niches continue to generate buzz among investors, even as other areas fizzle.

It’s not that those three industries are perfect fits for private equity, it’s that the more obvious areas like autism therapists and physician practices are struggling with high interest rates and regulatory scrutiny, said Rebecca Springer, PitchBook’s lead health care analyst.

Continue to STAT+ to read the full story…

In September 2022, Elyse Greenblatt of Queens returned home from a trip to Rwanda with a rather unwelcome-back gift: persistent congestion.

She felt a pain in her sinuses and sought a quick resolution.

Covid-19 couldn’t be ruled out, so rather than risk passing on an unknown infection to others in a waiting room, the New Yorker booked a telehealth visit through her usual health system, Mount Sinai — a perennial on best-hospitals lists.

That proved an expensive decision. She remembers the visit as taking barely any time. The doctor decided it was likely a sinus infection, not covid, and prescribed her fluticasone, a nasal spray that relieves congestion, and an antibiotic, Keflex. (The Centers for Disease Control and Prevention says antibiotics “are not needed for many sinus infections, but your doctor can decide if you need” one.)

Then the bill came.

The Patient: Elyse Greenblatt, now 38, had insurance coverage through Empire BlueCross BlueShield, a New York-based insurer.

Medical Services: A telehealth urgent care visit through Mount Sinai’s personal record app. Greenblatt was connected with an urgent care doctor through the luck of the draw. She was diagnosed with sinusitis, prescribed an antibiotic and Flonase, and told to come back if there was no improvement.

All this meant a big bill. The insurer said the telehealth visit was deemed an out-of-network service — a charge Greenblatt said the digital service didn’t do a great job of warning her about. It came as a surprise. “In my mind, if all my doctors are ‘in-insurance,’ why would they pair me with someone who was ‘out-of-insurance’?” she asked. And the hospital system tried its best to make contesting the charge difficult, she said.

Service Provider: The doctor was affiliated with Mount Sinai’s health system, though where the bill came from was unclear: Was it from one of the system’s hospitals or another unit?

Total Bill: $660 for what was billed as a 45- to 59-minute visit. The insurer paid nothing, ruling it out of network.

What Gives: The bill was puzzling on multiple levels. Most notably: How could this be an out-of-network service? Generally, urgent care visits delivered via video are a competitive part of the health care economy, and they’re not typically terribly expensive.

Mount Sinai’s telehealth booking process is at pains to assure bookers they’re getting a low price. After receiving the bill, Greenblatt went back to the app to recreate her steps — and she took a screenshot of one particular part of the app: the details. She got an estimated wait time of 10 minutes, for a cost of $60. “Cost may be less based on insurance,” the app said; this information, Mount Sinai spokesperson Lucia Lee said, is “for the patient’s benefit,” and the “cost may differ depending on the patient’s insurance.”

A $60 fee would be in line with, if not a bit cheaper than, many other telehealth services. Doctor on Demand, for example, offers visits from a clinician for $79 for a 15-minute visit, assuming the customer’s insurance doesn’t cover it. Amazon’s new clinic service, offering telehealth care for a wide range of conditions, advertises that charges start at $30 for a sinus infection.

The Health Care Cost Institute, an organization that analyzes health care claims data, told KFF Health News its data shows an urgent care telehealth visit runs, on average, $120 in total costs — but only $14 in out-of-pocket charges.

So how did this visit end up costing astronomically so much more than the average? After all, one of the selling points of telemedicine is not only convenience but cost savings.

First, there was the length of the visit. The doctor’s bill described it as moderately lengthy. But Greenblatt recalled the visit as simple and straightforward; she described her symptoms and got an antibiotic prescription — not a moderately complex visit requiring the better part of an hour to resolve.

The choice of description is a somewhat wonky part of health care billing that plays a big part in how expensive care can get. The more complex the case, and the longer it takes to diagnose and treat, the more providers can charge patients and insurers.

Greenblatt’s doctor billed her at a moderate level of care — curious, given her memory of the visit as quick, almost perfunctory. “I think it was five minutes,” she recalled. “I said it was a sinus infection; she told me I was right. ‘Take some meds, you’ll be fine.’”

Ishani Ganguli, a doctor at Brigham and Women’s Hospital in Boston who studies telehealth, said she didn’t know the exact circumstances of care but was “a bit surprised that it was not billed at a lower level” if it was indeed a quick visit.

That leaves the out-of-network aspect of the bill, allowing the insurer to pay nothing for the care. (Stephanie DuBois, a spokesperson for Empire BlueCross BlueShield, Greenblatt’s insurer, said the payer covers virtual visits through two services, or through in-network doctors. The Mount Sinai doctor fit neither criteria.) Still, why did Mount Sinai, Greenblatt’s usual health care system, assign her an out-of-network doctor?

“If one gets their care from the Mount Sinai system and the care is within network, I don’t think it is reasonable for the patients to expect or understand that one of the Mount Sinai clinicians is suddenly going to be out of network,” said Ateev Mehrotra, a hospitalist and telehealth researcher at Beth Israel Deaconess Medical Center.

It struck the doctors specializing in telehealth research whom KFF Health News consulted as an unusual situation, especially since the doctor who provided the care was employed by the prestigious health system.

The doctor in question may have been in network for no insurers whatsoever: A review of the doctor’s Mount Sinai profile page — archived in November 2022 — does not list any accepted insurance. (That’s in contrast to other doctors in the system.)

Lee, Mount Sinai’s spokesperson, said the doctor did take at least some insurance. When asked about the doctor’s webpage not showing any accepted plans, she responded the site “instructs patients to contact her office for the most up-to-date information.”

Attempting to solve this billing puzzle turned into a major league headache for Greenblatt. Deepening the mystery: After calling Mount Sinai’s billing department, she was told the case had been routed to disputes and marked as “urgent.”

But the doctor’s office would seemingly not respond. “In most other professions, you can’t just ignore a message for a year,” she observed.

The bill would disappear on her patient portal, then come back again. Another call revealed a new twist: She was told by a staffer that she’d signed a form consenting to the out-of-network charge. But “when I asked to get a copy of the form I signed, she asked if she could fax it,” Greenblatt said. Greenblatt said no. The billing department then asked whether they could put the form in her patient portal, for which Greenblatt gave permission. No form materialized.

When KFF Health News asked Mount Sinai about the case in mid-October of this year, Lee, the system’s spokesperson, forwarded a copy of the three-page form — which Greenblatt didn’t remember signing. Lee said the forms are presented as part of the flow of the check-in process and “intended to be obvious to the patient as required by law.” Lee said on average, a patient signs two to four forms before checking into the visit.

But, according to the time stamp on the forms, Greenblatt’s visit concluded before she signed. Lee said it is “not standard” to sign forms after the visit has concluded, and said that once informed, patients “may contact the office and reschedule with an ‘in-network provider.’”

“If it was provided after the service was rendered, that is an exception and situational,” she concluded.

The business with the forms — their timing and their obviousness — is potentially a vital distinction. In December 2020, Congress enacted the No Surprises Act, designed to crack down on so-called surprise medical bills that arise when patients think their care is covered by insurance but actually isn’t. Allie Shalom, a lawyer with Foley & Lardner, said the law requires notice to be given to patients, and consent obtained in advance.

More from Bill of the Month

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• When That Supposedly Free Annual Physical Generates a Bill

  Oct 30, 2023

• She Received Chemo in Two States. Why Did It Cost So Much More in Alaska?

  Sep 29, 2023

More from the Series

But the legislation provides an exception. It applies only to hospitals, hospital outpatient facilities, critical access hospitals, and ambulatory surgery centers. Greenblatt’s medical bill variously presents her visit as “Office/Outpatient” or “Episodic Telehealth,” making it hard to “tell the exact entity that provided the services,” Shalom said.

That, in turn, makes its status under the No Surprises Act unclear. The rules apply when an out-of-network provider charges a patient for care received at an in-network facility. But Shalom couldn’t be sure what entity charged Greenblatt, and, therefore, whether that entity was in network.

As for Mount Sinai, Lee said asking for consent post-visit does not comply with the No Surprises Act, though she said the system needed more time to research whether Greenblatt was billed by the hospital or another entity.

The Resolution: Greenblatt’s bill is unpaid and unresolved.

The Takeaway: Unfortunately, patients need to be on guard to protect their wallets.

If you want to be a smart shopper, consider timing the length of your visit. The “Bill of the Month” team regularly receives submissions from patients who were billed for a visit significantly longer than what took place. You shouldn’t, for example, be charged for time sitting in a virtual waiting room.

Most important, even when you seek care at an in-network hospital, whose doctors are typically in network, always ask if a particular physician you’ve not seen before is in your network. Many practices and hospitals offer providers in both categories (even if that logically feels unfair to patients). Providers are supposed to inform you that the care being rendered is out of network. But that “informed consent” is often buried in a pile of consent forms that you auto-sign, in rapid fire. And the language is often a blanket statement, such as “I understand that some of my care may be provided by caregivers not in my insurance network” or “I agree to pay for services not covered by my insurance.”

To a patient trying to quickly book care, that may not feel like “informed consent” at all.

“It’s problematic to expect patients to read the fine print, especially when they feel unwell,” Ganguli said.

Emily Siner reported the audio story.

Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about 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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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.

Former president and current 2024 Republican front-runner Donald Trump is aiming to put a repeal of the Affordable Care Act back on the political agenda, much to the delight of Democrats, who point to the health law’s growing popularity.

Meanwhile, in Texas, the all-Republican state Supreme Court this week took up a lawsuit filed by more than two dozen women who said their lives were endangered when they experienced pregnancy complications due to the vague wording of the state’s near-total abortion ban.

This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of Johns Hopkins University and Politico Magazine, Victoria Knight of Axios, and Sarah Karlin-Smith of the Pink Sheet.

Panelists

Joanne Kenen
Johns Hopkins Bloomberg School of Public Health and Politico

@JoanneKenen

Read Joanne's stories

Victoria Knight
Axios

@victoriaregisk

Read Victoria's stories

Sarah Karlin-Smith
Pink Sheet

@SarahKarlin

Read Sarah's stories

Among the takeaways from this week’s episode:

• The FDA recently approved another promising weight loss drug, offering another option to meet the huge demand for such drugs that promise notable health benefits. But Medicare and private insurers remain wary of paying the tab for these very expensive drugs.
• Speaking of expensive drugs, the courts are weighing in on the use of so-called copay accumulators offered by drug companies and others to reduce the cost of pricey pharmaceuticals for patients. The latest ruling called the federal government’s rules on the subject inconsistent and tied the use of copay accumulators to the availability of cheaper, generic alternatives.
• Congress will revisit government spending in January, but that isn’t soon enough to address the end-of-the-year policy changes for some health programs, such as pending cuts to Medicare payments for doctors.
• “This Week in Medical Misinformation” highlights a guide by the staff of Stat to help lay people decipher whether clinical study results truly represent a “breakthrough” or not.

Also this week, Rovner interviews KFF Health News’ Rachana Pradhan, who reported and wrote the latest “Bill of the Month” feature, about a woman who visited a hospital lab for basic prenatal tests and ended up owing almost $2,400. If you have an outrageous or baffling medical bill you’d like to share with us, you can do that here.

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

Julie Rovner: KFF Health News’ “Medicaid ‘Unwinding’ Makes Other Public Assistance Harder to Get,” by Katheryn Houghton, Rachana Pradhan, and Samantha Liss.

Joanne Kenen: KFF Health News’ “She Once Advised the President on Aging Issues. Now, She’s Battling Serious Disability and Depression,” by Judith Graham.  

Victoria Knight: Business Insider’s “Washington’s Secret Weapon Is a Beloved Gen Z Energy Drink With More Caffeine Than God,” by Lauren Vespoli.

Sarah Karlin-Smith: ProPublica’s “Insurance Executives Refused to Pay for the Cancer Treatment That Could Have Saved Him. This Is How They Did It,” by Maya Miller and Robin Fields.

Also mentioned in this week’s episode:

• KFF Health News’ “Progressive and Anti-Abortion? New Group Plays Fast and Loose to Make Points,” by Darius Tahir.
• ProPublica’s “Some Republicans Were Willing to Compromise on Abortion Ban Exceptions. Activists Made Sure They Didn’t,” by Kavitha Surana.

click to open the transcript

Transcript: Trump Puts Obamacare Repeal Back on Agenda

KFF Health News’ ‘What the Health?’Episode Title: Trump Puts Obamacare Repeal Back on AgendaEpisode Number: 324Published: Nov. 30, 2023

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Nov. 30, at 10 a.m. As always, news happens fast, and things might’ve changed by the time you hear this. So, here we go.

We are joined today via video conference by Sarah Karlin-Smith of the Pink Sheet.

Sarah Karlin-Smith: Hi, Julie.

Rovner: Victoria Knight of Axios News.

Victoria Knight: Hello, everyone.

Rovner: And Joanne Kenen of the Johns Hopkins University and Politico Magazine.

Joanne Kenen: Hi, everybody.

Rovner: Later in this episode we’ll have my interview with my colleague Rachana Pradhan about the latest KFF Health News-NPR “Bill of the Month.” This month’s patient fell into an all-too-common trap of using a lab suggested by her doctor’s office for routine bloodwork without realizing she might be left on the hook for thousands of dollars. But first, this week’s news — and last week’s, too, because we were off.

Because nothing is ever gone for good, the effort to repeal and replace Obamacare is back in the news, and it’s coming primarily from the likely Republican presidential nominee, Donald Trump. Just to remind you, in case you’ve forgotten, Trump, during his presidency, even in the two years that Republicans controlled the House and the Senate, was unable to engineer a repeal of the Affordable Care Act, nor did his administration even manage to unveil an alternative. So what possible reason could he have for thinking that this is going to help him politically now?

Knight: My takeaway is that I think it’s a personal grudge that former President Trump still has, that he failed at this. And I think, when you talk to people, he’s still mad that Sen. John McCain did his famous thumbs-down when the rest of the Republican Party was on board. So I’m not sure that there is much political strategy besides wanting to just make it happen finally, because upset it didn’t happen.

Rovner: Is this part of his revenge tour?

Knight: I mean, I think somewhat. Because if you ask House Freedom Caucus people, they will say, “Yeah, we should repeal it.” But if you ask some more moderate Republican members, they’re like, “We’ve already been through that. We don’t want to do it again.” So I don’t think the Republican Party on the Hill has an appetite to do that, even if Congress goes to Republicans in both chambers.

Kenen: Trump never came up with a health plan and repeal died in the Senate, but remember, it was a struggle to even get anything through the House, and what the House Republicans finally voted for, they didn’t even like. So I don’t know if you call this a revenge tour, but it’s checking a box. But I think it’s important to remember that if you look closely at what Republican policies are, they don’t call it repeal, they don’t say, “We are going to repeal it.” That didn’t go so well for them, and it probably cost them an election.

But they still do have a lot of policy ideas that would water down or de facto repeal many key provisions of Obamacare. So they haven’t tried to go that route, and I’m not sure they would ever try a full-out repeal, but there are lots of other things they could do, some of which would have technical names: community rating and things like that, that voters might not quite understand what they were doing, that could really undermine the protections of Obamacare.

Rovner: Yeah, I mean, I was going to say the Republican Party, in general, this has been the running joke since they started “repeal and replace” in 2010, is that they haven’t had the “replace” part of “repeal and replace” at all. Trump kept saying he was going to have a great plan, it’s coming in two weeks, and, of course, now he’s saying he’s going to have a great plan. We’ve never seen this great plan because the Republicans have never been able to agree on what should come next. Aside from, as Joanne says, tinkering around with the Affordable Care Act.

Kenen: Some of that tinkering would be significant.

Rovner: It could be.

Kenen: I mean there are things that they could tinker that wouldn’t be called repeal, but would actually really make the ACA not work very well.

Rovner: But most of the things that the Republicans wanted to do to the ACA have already been done, like repealing the individual mandate, getting rid of a lot of the industry-specific taxes that they didn’t like.

Kenen: Right. So they ended up getting rid of the spinach and they end up with the stuff that even Republicans, they might not say they like the ACA, but they’re being protected by it. And the individual mandate was the single-most unpopular, contentious part of the law and even a lot of Democrats didn’t like it. And so that target of the animus is gone. So by killing part of it, they also made it harder to do things in the future. They could do damage, though.

Rovner: Yeah. Or they could take on entitlements which, of course, is where the real money is. But we’ll get to that in a minute. Sarah, we have not seen you in a while, so we need to catch up on a bunch of things that are FDA-related. First, a couple of payment items since you were last here. The FDA has, as expected, approved a weight loss version of the diabetes drug Mounjaro that appears to be even more effective than the weight loss version of Ozempic. But insurers are still very reluctant to pay for these drugs, which are not only very expensive, they appear to need to be consumed very long-term, if not forever. Medicare has so far resisted calls to cover the drugs, despite some pressure from members of Congress, but that might be about to change.

Karlin-Smith: I think Medicare is getting a lot of pressure. They’re going to have to probably re-look at it at some point. What I found interesting is recently CMS [the Centers for Medicare and Medicaid Services] regulates other types of health plans as well, and in the ACA space they seem to be pushing for coverage of these obesity drugs. And I think they’re thinking around that. They note that the non-coverage allowance for these ACA plans was based on … they were following what Medicare was doing and there’s some acknowledgment that maybe the non-Medicare population is different from the Medicare population. But I think it’s also worth thinking about some of their other reasoning for coverage there, including that these drugs are different than some of the older weight loss drugs that provided more minimal weight loss, had worse side effects, and it came at a time when weight loss was seen as more of a cosmetic issue. So if that ACA provision rule goes through, I think that does help the case for people pushing for coverage in Medicare Part D of these drugs.

Rovner: Yeah, I mean this seems to be one of these “between a rock and a hard place” … that the demand for these drugs is huge. The evidence suggests that they work very well and that they work not just to help people lose weight, but perhaps when they lose weight to be less likely to have heart attacks and strokes and all that other stuff that you don’t want people to have. On the other hand, at the moment, they are super expensive and would bankrupt insurance companies and Medicare.

Karlin-Smith: Right. I mean, we’ve seen this before where people worry there’s a new class of expensive drugs that a lot of people seem like they will need and it’s going to bankrupt the country, and oftentimes that doesn’t happen even whether it is, in theory, more coverage to some extent. We saw that with hep C. There was a new class of cholesterol drugs that came out a few years ago that just haven’t taken off in the way people worried they would. Some of these obesity drugs, they do work really well, not everybody really tolerates them as well as you would think. So there’s questions about whether that demand is really there. Sen. [Bill] Cassidy [R-La.] has made some interesting points about “Is there a way to use these drugs initially for people and then come up with something more for weight maintenance that wouldn’t be as expensive?”

Rovner: We should point out that Sen. Cassidy is a medical doctor.

Karlin-Smith: But I think the pressure is coming on the government. Recently, I got to hear the head of OPM [Office of Personnel Management], who deals with the insurance coverage for federal government employees, and they have a really permissible coverage of obesity drugs. Basically, they require all their health insurance plans to cover one of these GLP-1 drugs, and they have some really interesting language I’ve seen used by pharmaceutical companies to say, “Look, this part of the federal government has said obesity is a disease. It needs to be treated,” and so forth. So I don’t think the federal government is going to be able to use this argument of, “This is not a medical condition, and these are expensive, we’re not going to cover it.” But there’s definitely going to be tensions there in terms of costs.

Rovner: Well, definitely more to come here. Meanwhile, CMS is also looking at changing the rules, again, for some pharmacy copay assistance programs, which claim to assist patients but more often seem to enrich drug companies and payers. What is this one about? And can you explain it in English? Because I’m not sure I understand it.

Karlin-Smith: So most people, when you get a prescription for a drug, have some amount of copay, so your insurance company pays the bulk of the cost and you pay maybe $10, $20, $30 when you pick up your prescription. For really high-cost drugs, pharmaceutical companies and sometimes third-party charities often offer copay support, where they will actually pay your copay for you.

The criticism of these charities and pharma support is that it lets the companies keep the prices higher. Because once you take away the patient feeling the burden of the price, they can still keep that higher percentage that goes to your health plan and into your premiums that you don’t think about. And so health insurance companies have said, “OK, well we’re not going to actually count this coupon money towards your copay, your out-of-pocket max for the year, because you’re not actually paying it.”

So that doesn’t end up doing the patient much good in the end because, while you might get the drug for free the first part of the year, eventually you end up having to pay the money. The courts have weighed in, and the latest ruling was that the effect of it was essentially telling CMS, “You need to re-look at your rules. We don’t think your logic is consistent,” and they seem to potentially suggest that CMS should only allow copay accumulators if there’s a cheaper drug a patient could take.

So, basically, they’re saying it’s unfair to put this burden on patients and not let them benefit from the coupons if this is the only drug they can take. But if there’s a generic drug they should be taking, that’s the equivalent then, OK, insurance company, you can penalize them there. But interestingly, CMS has basically pushed back on the court ruling. They’re asking them for basically more information about what they’re exactly directing them to do and signaling that they want to keep their broader interpretation of the law.

It’s a tricky situation, I think, policy-wise, because there’s this tension of, yes, the drug prices are really high. The insurance companies have a point of how these coupons create these perverse incentives in the system, and, on the other hand, the person that gets stuck in the middle, the patient is not really the fair pawn in this game. And when talking about a similar topic with somebody recently, they brought up what happened with surprise billing and they made this parallel of we need to think about it as, OK, you big corporate entities need to figure out how to duke out this problem, but stop putting the patient in the middle because they’re the one that gets hurt. And that’s what happened in surprise billing. I’m not sure if there’s quite that solution of how you could do that in this pharmaceutical space though.

Rovner: I was just going to say that this sounds exactly like surprise billing, but for prescription drugs. Well, while we are talking about Capitol Hill, let’s turn to Capitol Hill, where the big news of the week is that House Republican conservatives, the so-called Freedom Caucus, have apparently agreed to abide by the deal they agreed to abide by earlier this year. At least that’s when it comes to the overall total for the annual spending bills. Then-Speaker [Kevin] McCarthy’s attempt to adhere to that deal is one of the things that led to his ouster. The conservatives had wanted to cut spending much more deeply than the deal that was cut, I think it was in May. Although I feel compelled to add: Cutting the appropriations bills, which is what we’re talking about here, doesn’t really do very much to help the federal budget deficit. Most of the money that the federal government spends doesn’t go through the appropriations process. It’s automatic, like Social Security and Medicare.

But I digress. Victoria, what prompted the Freedom Caucus to change their minds and what does that portend for actually getting some of these spending bills done before the next cutoff deadline, which is mid-January?

Knight: I mean, I think it’s the Freedom Caucus just facing reality and that it’s really hard to do budget cuts, and a lot of these bills, the cuts are very deep. For the Labor-HHS bill, which is the bill that funds the Department of Health and Human Services, the cut is 18%. To the CDC [Centers for Disease Control and Prevention], 12% to the department itself. Those are really big cuts. And all the bills, you look at them, they all have really deep cuts.

The agriculture bill has deep cuts to the Department of Agriculture that some moderate Republicans don’t like. So all of the bills have these issues, and so I think they’re realizing it is just not possible to get what they want. Some of them didn’t vote for the Fiscal Responsibility Act, which was the deal that former Speaker McCarthy did with the debt limit that set funding levels. So they’re not necessarily going back on something that they voted for.

Rovner: They’re going back on something that the House voted for.

Knight: Yeah. So yeah, I think they’re just realizing the appropriations process, it’s difficult to make these deep spending cuts. I’ve also heard rumors that there might still be a big omnibus spending bill in January. Despite all this talk of doing the individual appropriations bills, I’ve heard that it may end up, despite all the efforts of the Republican Caucus, it may end where they have to just do a big bill because this is the easiest thing to do and then move on to the rest of the business of Congress for the next year. So we’ll see if that happens. But I have heard some rumors already swirling around that.

Rovner: I mean the idea they have now “agreed” to a spending limit that should have been done in the budget in April, which would’ve given them several months to work on the appropriations bills coming in under that level. And, of course, now we’re almost three months into the new fiscal year, so I mean they’re going to be late starting next year unless they resolve this pretty soon. But in the meantime, one thing that won’t happen is that we won’t get a big omnibus bill before Christmas because the deadline is now not until January, and that’s important for a bunch of health issues because we have a lot of policies that are going to end at the end of the year. Things like putting off cuts in Medicare payments to doctors, which a lot of people care about, including, obviously, all the doctors. Is there a chance that some of these “extender provisions” will find their way onto something else, maybe the defense authorization bill that I think they do want to finish before Christmas?

Knight: Yeah, I think that’s definitely possible. I’ve also heard they can retroactively do that, so even if they miss the deadline, it will probably be fixed. So it doesn’t seem like too big a worry,

Rovner: Although those doctor cuts, I mean, what happens is that CMS pens the claims, they don’t pay the claims until it’s been fixed retroactively. They have done it before, it’s a mess.

Kenen: And it’s bad for the doctors because they don’t get paid. It takes even longer to get paid because they’re put in a hold pile, which gets rather large.

Rovner: It does. Not that the defense bill doesn’t have its own issues around defense, but while we’re on the subject of defense, it looks like Alabama Republican Sen. Tommy Tuberville might be ready to throw in the towel now on the more than 400 military promotions he’s been blocking to protest the Biden administration’s policy allowing members of active-duty military and their dependents to travel to other states for an abortion if it’s banned where they are stationed. This has been going on since February. My impression is that it’s his fellow Republicans who are getting worried about this.

Kenen: Yeah. They’re as fed up as the Democrats are now. Not 100% of them are, but there’s a number who’ve come out in public and basically told him to cut it out. And then there are others who aren’t saying it in public, but there are clearly signs that they’re not crazy about this either. But we keep hearing it’s about to break. We’ve been hearing for several weeks it’s about to be resolved, and until it’s resolved, it’s not resolved. So I think clearly there’s movement because the pressure has ramped up from his fellow Republicans.

Rovner: Well, to get really technical, I think that the Senate Rules Committee passed a resolution that could get around this whole thing-

Kenen: But they don’t really want to, I mean the Republicans would rather not confront him through a vote. They’d rather just stare him down and get him to pretend that he won and move on. And that’s what we’re waiting to see. Is it a formal action by the Senate or is there some negotiated way to move forward with at least a large number of these held-up nominations.

Rovner: It’s the George Santos-Bob Menendez health issue. In other words, they would like him to step down himself rather than have to vote to take it down, but they would definitely like him to back off.

Kenen: I mean, not confusing anybody but they’re not talking about expelling her from the Senate. They’re [inaudible] talking about “Cut this out and let these people get their promotions,” because some of them are very serious. These are major positions that are unfilled.

Rovner: Yes, I mean it’s backing up the entire military system because people can’t move on to where they’re supposed to go and the people who are going to take their place can’t move on to where they’re supposed to go, and it’s not great for the Department of Defense. All right, well, while we are on the subject of abortion, at least tangentially, the Texas Supreme Court this week heard that case filed by women who had serious pregnancy complications for which they were unable to get medical care because their doctors were afraid that Texas’ abortion ban would be used to take their medical licenses and/or put them in jail.

Kenen: For 99 years!

Rovner: Yeah, the Texas officials defending against the lawsuit say the women shouldn’t be suing the state. They should be suing their doctors. So what do we expect to happen here? This hearing isn’t even really on the merits. It’s just on whether the exceptions the lower court came up with will be allowed to take effect, which at the moment they’re not.

Kenen: The exception-by-exception policy, where things get written in, is problematic because it’s hard to write a law allowing every possible medical situation that could arise and then that would open it to all other litigation because people would disagree about is this close to death or not? So the plaintiffs want a broader, clearer exception where it’s up to the doctors to do what they think is correct for their patients’ health, all sorts of things can go wrong with people’s bodies.

It’s hard to legislate, which is OK and which isn’t. So the idea of suing your doctor, I mean, that’s just not going to go anywhere. I mean, the court is either going to clarify it or not clarify it. Either way, it’ll get appealed. These issues are not going away. There’s many, many, many documented cases of people not being able to get standard of care. Pregnancy complications are rare, but they’re serious and the state legislatures have been really resistant so far to broadening these exemptions.

Rovner: It’s not just Texas. ProPublica published an investigation this week that found that none of the dozen states with the strictest abortion bans broadened exceptions even after women and their doctors complained that they were being put at grave risk, as Joanne just pointed out. When we look at elections and polls, it feels like the abortion rights side very much has the upper hand, but the reverse seems to be the case in actual state legislatures. I mean, it looks like the anti-abortion forces who want as few exceptions as possible are still getting their way. At least that’s what ProPublica found.

Kenen: Right. One of the other points that the ProPublica piece made was many of these laws were trigger laws. They were written before Roe was toppled. They were written as just in case, if the Supreme Court lets us do this, we’ll do it. So they were symbolic and they were not necessarily written with a lot of medical input. And they were written by activists, not physicians or obstetricians.

And the resistance to changing them is coming from the same interest groups that want no abortions, who say it’s just not ever medically necessary or so rarely medically necessary, and it is medically necessary at times. I mean, there are people who, and this line saying, “Well, if you’re in trouble, you can’t have an abortion. But if you’re close to death you can,” that can happen in split seconds. You can be in trouble and then really be in real trouble. You can’t predict the course of an individual, and it’s tying the hands for physicians to do what needs to be done until it might be too late.

Knight: I think a lot of them don’t realize, until it starts happening, how many times it is sometimes medically necessary. It’s not even that a woman necessarily wants to get an abortion, it’s just something happens, and it’s safer for her to do that in order to save her life.

Karlin-Smith: And you’ve seen in some of these states, sometimes Republican women prominently coming out and pushing for this and trying to explain why it’s necessary. In some cases, they also have made the argument, too, that sometimes to preserve a woman’s fertility, these procedures are necessary given the current situations they face.

Kenen: There was a quote in that ProPublica story, and it’s not necessarily everybody on the anti-abortion rights side, but this individual was quoted as saying that the baby’s life is more important than the mother’s life. So that’s a judgment that a politician or activist is making. Plus, if the mother dies, the fetus can die too. So it doesn’t even make sense. It’s not even choosing one. I mean, in many cases if the pregnant person dies, the fetus will die.

Rovner: Well, finally this week, I want to give a shout-out to a story by my KFF Health News colleague Darius Tahir, who, by the way, became a father this week. Congratulations, Darius. The story’s about a group called the Progressive Anti-Abortion Uprising that purports to be both anti-abortion and progressively leftist and feminist. One of its goals appears to be to get courts to overturn the federal law that restricts protests in front of abortion clinics. The Freedom of Access to Clinic Entrances Act, known as FACE, is I think the only explicitly abortion rights legislation that became law in the entire 1990s, which makes you wonder if this group is really as leftist and feminist as it says it is, or if it’s just a front to try and go after this particular law.

Kenen: It sets limits of where people can be and tries to police it somewhat. But in Darius’ story, his reporting showed that they did, at least some of them, had ties to right-wing groups. So that they’re calling themselves leftist and progressive … it’s not so clear how accurate that is for everybody involved.

Rovner: Yeah, it was an interesting story that we will link to in the show notes. All right, now it is time for “This Week in Health Misinformation,” and it’s good news for a change. I chose a story from Stat News called “How to Spot When Drug Companies Spin Clinical Trial Results.” It’s actually an update of a 2020 guide that STAT did to interpret clinical trial results, and it’s basically a glossary to help understand company jargon and red flags, particularly in press releases, to help determine if that new medical “breakthrough” really is or not. It is really super helpful if you’re a layperson trying to make sense of this.

OK that is this week’s news, and I now will play my “Bill of the Month” interview with Rachana Pradhan, and then we will come back with our extra credits.

I am pleased to welcome back to the podcast my colleague Rachana Pradhan, who reported and wrote the latest KFF Health News-NPR “Bill of the Month” installment. Always great to see you, Rachana.

Rachana Pradhan: Thanks for having me, Julie.

Rovner: So this month’s patient fell into what’s an all-too-common trap. She went to a lab for routine bloodwork suggested by her doctor without realizing she could be subjected to thousands of dollars in bills she’s expected to pay. Tell us who she is and how she managed to rack up such a big bill for things that should not have cost that much.

Pradhan: So our patient is Reesha Ahmed. She lives in Texas, just in a suburb of the Dallas-Fort Worth area, and what happened to Reesha is she found out she was pregnant and she went to a doctor’s office that she had never gone to before for a standard prenatal checkup, and she also had health insurance. I want to underscore that that is an important detail in this story. So the nurse recommended that Reesha get routine blood tests just down the hall in a lab that was in the adjoining hospital. And it was routine. There was nothing unusual about the blood tests that Reesha received. So what she was advised to do is after her checkup, she was told, “Well, here’s the bloodwork you need, and just go down the hallway here, into the hospital,” to get her blood drawn.

Rovner: How convenient, they have their own lab.

Pradhan: Exactly. And Reesha did what she was told. She got bloodwork done. And then, soon after that, she started getting bills. And they first were small amounts, like there was a bill for $17, and she thought, “OK, well that’s not so bad.” Then she got a bill for over $300 and thought, “That’s unusual. Why would I get billed this?” Then came the huge one. It was over $2,000. In total, Reesha’s overall lab work bills were close to $2,400 for, again, standard bloodwork that every pregnant woman gets when they find out that they’re pregnant. And so she, needless to say, was shocked and immediately actually started trying to investigate herself as to how it was possible for her to get billed such astronomical amounts.

Rovner: And so what did she manage to find out?

Pradhan: She tried taking it up with the hospital and her insurance company. And she just got passed around over and over again. She appealed to her insurance. They denied her appeal saying that, “Well, this bloodwork was diagnostic and not preventive, so it was coded correctly based on the claim that was submitted to us,” and the hospital even sent her to collections for this bloodwork. Unfortunately for Reesha, this pregnancy ended in a miscarriage, and so it was particularly difficult. She was dealing with all the emotional, physical ramifications of that, and then on top of that, having to deal with this billing nightmare is just a lot for any one person to handle. It’s too much, honestly.

Rovner: So we, the experts in this, what did we discover about why she got billed so much?

Pradhan: You can get bloodwork at multiple places in our health system. You could get it maybe within a lab just in your doctor’s office. You can go to an outside lab, like an independent commercial one, to get bloodwork done and you can sometimes get labs within a hospital building. They may not look any different when you’re actually in there, but there’s a huge difference as to how much they will charge you.

Research has shown that if a patient is getting blood tests done, things that are relatively routine and just as a standalone service, hospital outpatient department labs charge much, much more. There’s research that we cite in the story about Reesha that … she lives in Texas … bloodwork in Texas, if it’s done in a hospital outpatient department is at least six times as expensive compared to if you get those same tests in a doctor’s office or in an independent commercial lab.

Rovner: To be clear, I would say it’s not just bloodwork. It’s any routine tests that you get in a hospital outpatient department.

Pradhan: That research, in particular, was looking at blood tests actually, in particular, just any lab work that you might get done. So the conclusion of that is really that there’s no meaningful quality difference. There’s really no difference at all when you get them in a doctor’s office versus a hospital or a lab, and yet the prices you pay will vary dramatically.

Rovner: Yeah, there should be a big sign on the door that says: “This may be more convenient, but if you go somewhere else, you might pay a lot less and so will your insurance.” What eventually happened with Reesha’s bill?

Pradhan: Well, eventually, the charges were waived and zeroed out and she was told that she would not have to pay anything and all the accounts would be zeroed out to nothing.

Rovner: Eventually, after we started asking questions?

Pradhan: Yes. It was a day after I had sent a litany of questions about her billing that they gave her a call and said, “You now won’t have to pay anything.” So it’s a big relief for her.

Rovner: Obviously this was not her fault. She did what was recommended by the nurse in her doctor’s office, but there are efforts to make this more transparent.

Pradhan: Yeah. I think in health care policy world, the issue that she experienced is a reflection of something called site-neutral payment, which essentially means if payment is site-neutral for a health care provider, it means that you get a service and regardless of where you get that service, there is no difference in the amount that you are paying. There are efforts in Congress and even in state legislatures to institute site-neutral pay for certain services.

Bloodwork is one that is not necessarily being targeted, at least in Congress. But I will say, I think one of the big takeaways about what patients can do is if they do get paperwork from your doctor’s office saying, “OK, you need to get some blood tests done,” you can always take that bloodwork request and get it done at an independent lab where the charges will be far, far less than in a hospital-based lab, to avoid these charges.

Rovner: Think of it like a prescription.

Pradhan: Exactly. It might not be as convenient in that moment. You might have to drive somewhere, you can’t just walk down a hallway and get your blood tests and labs done, but I think you will potentially avoid exorbitant costs, especially for bloodwork that is very standard and is not costly.

Rovner: Yet another cautionary tale. Rachana Pradhan, thank you very much.

Pradhan: Thanks for having me, Julie.

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

Karlin-Smith: Sure. I took a look at a ProPublica piece by Maya Miller and Robin Fields, “Insurance Executives Refused to Pay for the Cancer Treatment That Could Have Saved Him. This Is How They Did It.” And it tells the story of a Michigan man who had cancer, and the last resort treatment for him was CAR-T, which is a cellular therapy where they basically take some of your cells, reengineer them, and put them back into your body, and it is quite expensive and it can come with a lot of expensive side effects as well.

FDA considers it a drug, and Michigan state law requires cancer drugs be covered. The insurance company of this man, basically on a technicality, denied it, describing it as a gene therapy, and he did die before he was able to fully push this battle with the insurance company and get access to the treatment and so forth. But I think the piece raises these broader issues about [how] few states are able to proactively monitor whether insurance plans are properly implementing the laws around what is supposed to be covered and not covered.

Few people really have the knowledge or skill set, particularly when you’re dealing with devastating diseases like cancer, which are just taking all of your energy just to go through the treatment, to figure out how to fight the system. And it really demonstrates the huge power imbalances people face in getting health care, even if there are laws that, in theory, seem like they’re supposed to be protected.

I also thought there’s some really interesting statistics in the story about, yes, even though the price tag for these products are really expensive, that the health insurance company actually crunched the numbers and found that if they shifted the cost to premiums in their policyholders, it would lead to, like, 17 cents a month per premium. So I thought that was interesting, as well, because it gives you a sense of, again, where their motivation is coming from when you boil it down to how the costs actually add up.

Rovner: And we will, I promise, talk about the growing backlash against insurance company behavior next week. Victoria.

Knight: So my extra-credit article is a Business Insider story in which I’m quoted, but the title is “Washington’s Secret Weapon Is a Beloved Gen Z Energy Drink With More Caffeine Than God.” And it basically talks about the phenomenon of Celsius popping up around the Hill. So it’s an energy drink that contains 200 milligrams of caffeine. It tastes like sparkling water, it’s fruity, but it’s not like Monster or Red Bull. It tastes way better than them, which I think is partly why it’s become so popular.

But anyways, I’ve only been on the Hill reporting for about a year and in the past couple months it has really popped up everywhere. It’s all around in the different little stores within the Capitol complex, there’s machines devoted to it. So it talks about how that happened. And I personally drink almost one Celsius a day. I’m trying to be better about it, but the Hill is a hard place to work, and you’re running around all the time, and it just gets you as much caffeine as you need in a quick hit. But the FDA does recommend about 400 milligrams a day. So if you drink two, then you’re not going over the recommendation.

Rovner: Well, you can’t drink anything else with caffeine if you drink two.

Knight: That’s true. And I do drink coffee in the morning, but it has some funny quotes to our members of Congress and chiefs of staff and reporters about how we all rely on this energy drink to get through working on the Hill.

Rovner: I just loved this story because, forever, people wonder how these things happen in the middle of the night. It’s not the members, it’s the staff who are going 16 and 20 hours a day, and they’ve always had to rely on something. So, at least now, it’s something that tastes better.

Knight: It does taste better.

Rovner: That’s why it amused me, because it’s been ever thus that you cannot work the way Capitol Hill works without some artificial help, shall we say. Joanne.

Kenen: We used to just count how many pizza boxes were being delivered to know how long a night it was going to be. I guess now you count how many empty cans of Celsius.

Knight: Exactly.

Rovner: I personally ran more on sugar than caffeine.

Kenen: OK. This is a piece by Judy Graham of KFF Health News, and the headline is “A Life-Changing Injury Transformed an Expert’s View on Disability Services.” And it’s about a woman many of us know, actually Julie and I both know: Nora Super. I’ve known her for a long time. She’s an expert on aging. She ran one of the White House aging conferences. She worked at Milken for a long time. She worked at AARP for a while.

She’s in her late 50s now, and in midlife, she started having really severe episodes of depression, and she became very open about it, she became an advocate. Last summer, she had another episode and she couldn’t get an appointment for the treatment she needed quickly enough. And while she was waiting, which is the story of American health care right now, and while she was waiting for it, she did try to take her own life. She survived, but she now has no sensation from the waist down.

And her husband is a health economist, and I should disclose, my former boss at one point, I worked for and with Len for two years, Len Nichols. So this is a story about how she has now become an advocate for disability. And this is a couple with a lot of resources. I mean both knowledge, connections, and they’re not gazillionaires, but they have resources, and how hard it has been for them even with their resources and connections. And so now Nora who, when she’s well, she’s this effervescent force of nature, and this is how she is turning — her prognosis, it could get better, they don’t know yet — but clearly an extraordinarily difficult time. And she has now taken this opportunity to become not just an advocate for the aging and not just an advocate for people with severe depression, but now an advocate for people with severe disability.

Rovner: Yeah, I mean, it’s everything that’s wrong with the American health care system, and I will say that a lot of what I’ve learned about health policy over very many years came from both Len Nichols and Nora, his wife. So they do know a lot. And I think what shocked me about the story is just how expensive some of the things are that they need. And, again, this is a couple who should be well enough off to support themselves, but these are costs that basically nobody could or should have to bear.

Kenen: Even … it was just a lift to get her into their car, just that alone was $6,500. And there are many, many, many things like that. And then another thing that they pointed out in the article is that most physicians don’t have a way of getting somebody from a wheelchair onto the examining table other than having her 70-year-old husband hoist her. So that was one of the many small revelations in this story. Obviously, it’s heartbreaking because I know and like her, but it’s also another indictment of why we just don’t do things right.

Rovner: Yes. Where we are. Well, my story is yet another indictment of not doing things right. It’s by my colleagues Katheryn Houghton, Rachana Pradhan, who you just heard, and Samantha Liss, and it’s called “Medicaid ‘Unwinding’ Makes Other Public Assistance Harder to Get.” And it’s just an infuriating story pointing out that everything we’ve talked about all year with state reviews of Medicaid eligibility, the endless waits on hold with call centers, lost applications, and other bureaucratic holdups, goes for more than just health insurance. The same overworked and under-resourced people who determine Medicaid eligibility are also the gatekeepers for other programs like food stamps and cash welfare assistance, and people who are eligible for those programs are also getting wrongly denied benefits.

Among the people quoted in the story was DeAnna Marchand of Missoula, Montana, who is trying to recertify herself and her grandson for both Medicaid and SNAP (food stamps), but wasn’t sure what she needed to present to prove that eligibility. So she waited to speak to someone and picking up from the story, “After half an hour, she followed prompts to schedule a callback, but an automated voice announced slots were full and instructed her to wait on hold again. An hour later, the call was dropped.” It’s not really the fault of these workers. They cannot possibly do what needs to be done, and, once again, it’s the patients who are paying the price.

All right, that is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks this week to Zach Dyer for filling in as our technical guru while Francis [Ying] takes some much-deserved time off. Also, as always, you can email us your questions or comments. We are at whatthehealth@kff.org. Or you can still find me at X, for now, @jrovner, or @julierovner at Bluesky and Threads. Joanne.

Kenen: I’m mostly at Threads, @joannekenen1. Occasionally I’m still on X, but not very often, that’s @JoanneKenen.

Rovner: Sarah.

Karlin-Smith: I am @SarahKarlin, or @sarahkarlin-smith, depending on the platform.

Rovner: Victoria.

Knight: I am @victoriaregisk [on X and Threads]. Still mostly on X, but also on Threads at the same name.

Rovner: We’re all trying to branch out. We will be back in your feed next week. Until then, be healthy.

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“Surprisingly fine,” said Conway-Anderson, a 36-year-old agroforestry professor at the University of Missouri. There was an 11-millimeter precancerous polyp that the doctors had discovered, but they’d snipped it out of her colon and recommended surveillance every three years. “Obviously, it’s big news to hear, but grateful this seems to be manageable. I’ll do it,” she said. “Then the bill came.”

She was being charged nearly $12,000 for the procedure after insurance. Conway-Anderson’s head spun. She couldn’t understand how it could cost so much, especially when she thought the colonoscopy was preventative for cancer and thus covered. “I was floored,” she said. “I was like I can’t pay this. I don’t know what you want me to do.”

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