The Host

Julie Rovner
KFF Health News

@jrovner

Read Julie's stories.

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

A final deal cut between President Joe Biden and House Republicans extends the U.S. debt ceiling deadline to 2025 and reins in some spending. The bill signed into law by the president will preserve many programs at their current funding levels, and Democrats were able to prevent any changes to the Medicare and Medicaid programs.

Still, millions of Americans are likely to lose their Medicaid coverage this year as states are once again allowed to redetermine who is eligible and who is not; Medicaid rolls were frozen for three years due to the pandemic. Data from states that have begun to disenroll people suggests that the vast majority of those losing insurance are not those who are no longer eligible, but instead people who failed to complete required paperwork — if they received it in the first place.

This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico, Lauren Weber of The Washington Post, and Jessie Hellmann of CQ Roll Call.

Panelists

Jessie Hellmann
CQ Roll Call

@jessiehellmann

Read Jessie's stories

Joanne Kenen
Johns Hopkins Bloomberg School of Public Health and Politico

@JoanneKenen

Read Joanne's stories

Lauren Weber
The Washington Post

@LaurenWeberHP

Read Lauren's stories

Among the takeaways from this week’s episode:

• Lawmakers and White House officials spared health programs from substantial spending cuts in a last-minute agreement to raise the nation’s debt ceiling. And Biden named Mandy Cohen, a former North Carolina health director who worked in the Obama administration, to be the next director of the Centers for Disease Control and Prevention. Though she lacks academic credentials in infectious diseases, Cohen enters the job with a reputation as someone who can listen and be listened to by both Democrats and Republicans.
• The removal of many Americans from the Medicaid program, post-public health emergency, is going as expected: With hundreds of thousands already stripped from the rolls, most have been deemed ineligible not because they don’t meet the criteria, but because they failed to file the proper paperwork in time. Nearly 95 million people were on Medicaid before the unwinding began.
• Eastern and now southern parts of the United States are experiencing hazardous air quality conditions as wildfire smoke drifts from Canada, raising the urgency surrounding conversations about the health effects of climate change.
• The drugmaker Merck & Co. sued the federal government this week, challenging its ability to press drugmakers into negotiations over what Medicare will pay for some of the most expensive drugs. Experts predict Merck’s coercion argument could fall flat because drugmakers voluntarily choose to participate in Medicare, though it is unlikely this will be the last lawsuit over the issue.
• In abortion news, some doctors are pushing back against the Indiana medical board’s decision to reprimand and fine an OB-GYN who spoke out about providing an abortion to a 10-year-old rape victim from Ohio. The doctors argue the decision could set a bad precedent and suppress doctors’ efforts to communicate with the public about health issues.

Also this week, Rovner interviews KFF Health News senior correspondent Sarah Jane Tribble, who reported the latest KFF Health News-NPR “Bill of the Month” feature, about a patient with Swiss health insurance who experienced the sticker shock of the U.S. health care system after an emergency appendectomy. If you have an outrageous or exorbitant medical bill you want to share with us, you can do that here.

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

Julie Rovner: The New York Times’ “This Nonprofit Health System Cuts Off Patients With Medical Debt,” by Sarah Kliff and Jessica Silver-Greenberg.

Jessie Hellmann: MLive’s “During the Darkest Days of COVID, Some Michigan Hospitals Made 100s of Millions,” by Matthew Miller and Danielle Salisbury.

Joanne Kenen: Politico Magazine’s “Can Hospitals Turn Into Climate Change Fighting Machines?” by Joanne Kenen.

Lauren Weber: The Washington Post’s “Smoke Brings a Warning: There’s No Escaping Climate’s Threat to Health,” by Dan Diamond, Joshua Partlow, Brady Dennis, and Emmanuel Felton.

Also mentioned in this week’s episode:

KFF Health News’ “As Medicaid Purge Begins, ‘Staggering Numbers’ of Americans Lose Coverage,” by Hannah Recht.

Click to open the transcript

Transcript: Debt Deal Leaves Health Programs (Mostly) Intact

KFF Health News’ ‘What the Health?’Episode Title: Debt Deal Leaves Health Programs (Mostly) IntactEpisode Number: 301Published: June 8, 2023

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

Julie Rovner: Hello and welcome back to “What the Health?”. I’m Julie Rovner, chief Washington correspondent at KFF Health News. And I’m joined by some of the best and smartest health reporters in Washington. We are taping this week from the smoky, hazy, “code purple” Washington, D.C., area on Thursday, June 8, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So here we go. We are joined today via video conference by Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico.

Joanne Kenen: Hi, everybody.

Rovner: Lauren Weber, of The Washington Post.

Lauren Weber: Hi.

Rovner: And Jessie Hellmann, of CQ Roll Call.

Hellmann: Hello.

Rovner: Later in this episode we’ll have my interview with KFF Health News’s Sarah Jane Tribble about the latest KFF Health News-NPR “Bill of the Month.” This month is about the sticker shock of the American health care system experienced by residents of other countries. Before we get to this week’s news, I hope you all enjoyed our special panel of big health policy thinkers for our 300th episode. If you didn’t listen, you might want to go back and do that at some point. Also, that means we have two weeks of news to catch up on, so let us get to it. We’re going to start this week, I hope, for the last time with the fight over the debt ceiling. Despite lots of doubts, President Biden managed to strike a budget deal with House Republicans, which fairly promptly passed the House and Senate and was signed into law a whole two days before the Treasury Department had warned that the U.S. might default. The final package extends the debt ceiling until January 1, 2025, so after the next election, which was a big win for the Democrats, who don’t want to do this exercise again anytime soon. In exchange, Republicans got some budget savings, but nothing like the dramatic bill that House Republicans passed earlier this spring. So, Jessie, what would it do to health programs?

Hellmann: The deal cuts spending by 1.5 trillion over 10 years. It has caps on nondefense discretionary funding. That would have a big impact on agencies and programs like the NIH [National Institutes of Health], which has been accustomed to getting pretty large increases over the years. So nondefense discretionary spending will be limited to about 704 billion next fiscal year, which is a cut of about 5%. And then there’s going to be a 1% increase in fiscal 2025, which, when you consider inflation, probably isn’t much of an increase at all. So the next steps are seeing what the appropriators do. They’re going to have to find a balance between what programs get increases, which ones get flat funding — it’s probably going to be a lot of flat funding, and we’re probably at the end of an era for now with these large increases for NIH and other programs, which have traditionally been very bipartisan, but it’s just a different climate right now.

Rovner: And just to be clear, I mean, this agreement doesn’t actually touch the big sources of federal health spending, which are Medicare and Medicaid, not even any work requirements that the Republicans really wanted for Medicaid. In some ways, the Democrats who wanted to protect health spending got off pretty easy, or easier than I imagine they expected they would, right?

Hellmann: Advocates would say it could have been much worse. All things considered, when you look at the current climate and what some of the more conservative members of the House were initially asking for, this is a win for Democrats and for people who wanted to protect health care spending, especially the entitlements, because they — Republicans did want Medicaid work requirements and those just did not end up in the bill; they were a nonstarter. So, kind of health-care-related, depending on how you look at it, there was an increase in work requirements for SNAP [Supplemental Nutrition Assistance Program], which is, like, a food assistance program. So that will be extended to age 55, though they did include more exemptions for people who are veterans —

Rovner: Yeah, overall, that may be a wash, right? There may be the same or fewer people who are subject to work requirements.

Hellmann: Yeah. And all those changes would end in 2030, so —

Weber: Yeah, I just wanted to say, I mean, if we think about this — we’re coming out of a pandemic and we’re not exactly investing in the health system — I think it’s necessary to have that kind of step-back context. And we’ve seen this before. You know, it’s the boom-bust cycle of pandemic preparedness funding, except accelerated to some extent. I mean, from what I understand, the debt deal also clawed back some of the public health spending that they were expecting in the billions of dollars. And I think the long-term ramifications of that remain to be seen. But we could all be writing about that in 10 years again when we’re looking at ways that funding fell short in preparedness.

Rovner: Yeah, Joanne and I will remember that. Yeah, going back to 2001. Yeah. Is that what you were about to say?

Kenen: I mean, this happens all the time.

Weber: All the time, right.

Kenen: And we learn lessons. I mean, the pandemic was the most vivid lesson, but we have learned lessons in the past. After anthrax, they spent more money, and then they cut it back again. I mean, I remember in 2008, 2009, there was a big fiscal battle — I don’t remember which battle it was — you know, Susan Collins being, you know, one of the key moderates to cut the deal. You know, what she wanted was to get rid of the pandemic flu funding. And then a year later, we had H1N1, which turned out not to be as bad as it could have been for a whole variety of reasons. But it’s a cliche: Public health, when it works, you don’t see it and therefore people think you don’t need it. Put that — put the politics of what’s happened to public health over the last three years on top of that, and, you know, public health is always going to have to struggle for funds. Public health and larger preparedness is always going to happen to have to struggle for funds. And it would have, whether it was the normal appropriations process this year, which is still to come, or the debt ceiling. It is a lesson we do not learn the hard way.

Weber: That’s exactly right. I’ll never forget that Tom Harkin said to me that after Obama cut, he sacrificed a bunch of prevention funding for the CDC [Centers for Disease Control and Prevention] in the ACA [Affordable Care Act] deal, and he never spoke to him again, he told me, because he was so upset because he felt like those billions of dollars could have made a difference. And who knows if 10 years from now we’ll all be talking about this pivotal moment once more.

Rovner: Yeah, Tom Harkin, the now-former senator from Iowa, who put a lot of prevention into the ACA; that was the one thing he really worked hard to do. And he got it in. And as you point out, and it was almost immediately taken back out.

Weber: Yeah.

Kenen: Not all of it.

Weber: Not all of it, but a lot of it.

Kenen: It wasn’t zero.

Rovner: It became a piggy bank for other things. I do want to talk about the NIH for a minute, though, because Jessie, as you mentioned, there isn’t going to be a lot of extra money, and NIH is used to — over the last 30 years — being a bipartisan darling for spending. Well, now it seems like Congress, particularly some of the Republicans, are not so happy with the NIH, particularly the way it handled covid. There’s a new NIH director who has been nominated, Dr. Monica Bertagnolli, who is currently the head of the National Cancer Institute. This could be a rocky summer for the NIH on Capitol Hill, couldn’t it?

Hellmann: Yeah, I think there’s been a strong desire for Republicans to do a lot of oversight. They’ve been looking at the CDC. I think they’re probably going to be looking at the NIH next. Francis Collins is no longer at NIH. Anthony Fauci is no longer there. But I think Republicans have indicated they want to bring them back in to talk about some of the things that happened during the pandemic, especially when it comes to some of the projects that were funded.

Kenen: There was a lull in raising NIH spending. It was flat for a number of years. I can’t remember the exact dates, but I remember it was — Arlen Specter was still alive, and it … [unintelligible] … because he is the one who traditionally has gotten a lot of bump ups in spending. And then there was a few years, quite a few years, where it was flat. And then Specter got the spigots opened again and they stayed open for a good 10 or 15 years. So we’re seeing, and partly a fiscal pause, and partly the — again, it’s the politicization of science and public health that we did not have to this extent before this pandemic.

Rovner: Yeah, I think it’s been a while since NIH has been under serious scrutiny on Capitol Hill. Well, speaking of the CDC, which has been under serious scrutiny since the beginning of the pandemic, apparently is getting a new director in Dr. Mandy Cohen, assuming that she is appointed as expected. She won’t have to be confirmed by the Senate because the CDC director won’t be subject to Senate approval until 2025. Now, Mandy Cohen has done a lot of things. She worked in the Obama administration on the implementation of the Affordable Care Act. She ran North Carolina’s Department of Health [and Human Services], but she’s not really a noted public health expert or even an infectious disease doctor. Why her for this very embattled agency at this very difficult time?

Kenen: I think there are a number of reasons. A lot of her career was on Obamacare kind of things and on CMS kind of quality-over-quantity kind of things, payment reform, all that. She is a physician, but she did a good job in North Carolina as the top state official during the pandemic. I reported a couple of magazine pieces. I spent a lot of time in North Carolina before the pandemic when she was the state health secretary, and she was an innovator. And not only was she an innovator on things like, you know, integrating social determinants into the Medicaid system; she got bipartisan support. She developed not perfect, but pretty good relations with the state Republicans, and they are not moderates. So I think I remember writing a line that said something, you know, in one of those articles, saying something like, “She would talk to the Republicans about the return on investment and then say, ‘And it’s also the right thing to do.’ And then she would go to the Democrats and say, ‘This is the right thing to do. And there’s also an ROI.’”. So, so I think in a sort of low-key way, she has developed a reputation for someone who can listen and be listened to. I still think it’s a really hard job and it’s going to batter anyone who takes it.

Rovner: I suspect right now at CDC that those are probably more important qualities than somebody who’s actually a public health expert but does not know how to, you know, basically rescue this agency from the current being beaten about the head and shoulders by just about everyone.

Kenen: Yeah, but she also was the face of pandemic response in her state. And she did vaccination and she did disparities and she did messaging and she did a lot of the things that — she does not have an infectious disease degree, but she basically did practice it for the last couple of years.

Rovner: She’s far from a total novice.

Kenen: Yeah.

Rovner: All right. Well, it’s been a while since we talked about the Medicaid “unwinding” that began in some states in early April. And the early results that we’re seeing are pretty much as expected. Many people are being purged from the Medicaid rolls, not because they’re earning too much or have found other insurance, but because of paperwork issues; either they have not returned their paperwork or, in some cases, have not gotten the needed paperwork. Lauren, what are we seeing about how this is starting to work out, particularly in the early states?

Weber: So as you said, I mean, much like we expected to see: So 600,000 Americans have been disenrolled so far, since April 1. And some great reporting that my former colleague Hannah Recht did this past week: She reached out to a bunch of states and got ahold of data from 19 of them, I believe. And in Florida, it was like 250,000 people were disenrolled and somewhere north of 80% of them, it was for paperwork reasons. And when we think about paperwork reasons, I just want us all to take a step back. I don’t know about anyone listening to this, but it’s not like I fill out my bills on the most prompt of terms all of the time. And in some of these cases, people had two weeks to return paperwork where they may not have lived at the same address. Some of these forms are really onerous to fill out. They require payroll tax forms, you know, that you may not have easily accessible — all things that have been predicted, but the hard numbers just show is the vast majority of people getting disenrolled right now are being [dis]enrolled for paperwork, not because of eligibility reasons. And too, it’s worth noting, the reason this great Medicaid unwinding is happening is because this was all frozen for three years, so people are not in the habit of having to fill out a renewal form. So it’s important to keep that in mind, that as we’re seeing the hard data show, that a lot of this is, is straight-up paperwork issues. The people that are missing that paperwork may not be receiving it or just may not know they’re supposed to be doing it.

Rovner: As a reminder, I think by the time the three-year freeze was over, there were 90 million people on Medicaid.

Kenen: Ninety-five.

Rovner: Yeah. So it’s a lot; it’s like a quarter of the population of the country. So, I mean, this is really impacting a lot of people. You know, I know particularly red states want to do this because they feel like they’re wasting money keeping ineligible people on the rolls. But if eligible people become uninsured, you can see how they’re going to eventually get sicker, seek care; those providers are going to check and see if they’re eligible for Medicaid, and if they are, they’re going to put them back on Medicaid. So they’re going to end up costing even more. Joanne, you wanted to say something?

Kenen: Yeah. Almost everybody is eligible for something. The exceptions are the people who fall into the Medicaid gap, which is now down to 10 states.

Rovner: You mean, almost everybody currently on Medicaid is eligible.

Kenen: Anyone getting this disenrollment notification or supposed to receive the disenrollment notification that never reaches them — almost everybody is eligible for, they’re still eligible for Medicaid, which is true for the bulk of them. If they’re not, they’re going to be eligible for the ACA. These are low-income people. They’re going to get a lot heavily subsidized. Whether they understand that or not, someone needs to explain it to them. They’re working now, and the job market is strong. You know, it’s not 2020 anymore. They may be able to get coverage at work. Some of them are getting coverage at work. One of the things that I wrote about recently was the role of providers. States are really uneven. Some states are doing a much better job. You know, we’ve seen the numbers out of Florida. They’re really huge disenrollment numbers. Some states are doing a better job. Georgetown Center on Health Insurance — what’s the right acronym? — Children’s and Family. They’re tracking, they have a state tracker, but providers can step up, and there’s a lot of variability. I interviewed a health system, a safety net in Indiana, which is a red state, and they have this really extensive outreach system set up through mail, phone, texts, through the electronic health records, and when you walk in. And they have everybody in the whole system, from the front desk to the insurance specialists, able to help people sort this through. So some of the providers are quite proactive in helping people connect, because there’s three things: There’s understanding you’re no longer eligible, there’s understanding what you are eligible for, and then actually signing up. They’re all hard. You know, if your government’s not going to do a good job, are your providers or your community health clinics or your safety net hospitals — what are they doing in your state? That’s an important question to ask.

Rovner: Providers have an incentive because they would like to be paid.

Kenen: Paid.

Weber: Well, the thing about Indiana too, Joanne, I mean — so that was one of the states that Hannah got the data from. They had I think it was 53,000 residents that have lost coverage in the first amount of unwinding. 89% of them were for paperwork. I mean, these are not small fractions. I mean, it is the vast majority that is being lost for this reason. So that’s really interesting to hear that the providers there are stepping up to face that.

Kenen: It’s not all of them, but you can capture these people. I mean, there’s a lot that can go wrong. There’s a lot that — in the best system, you’re dealing with [a] population that moves around, they don’t have stable lives, they’ve got lots of other things to deal with day to day, and dealing with a health insurance notice in a language you may not speak delivered to an address that you no longer live at — that’s a lot of strikes.

Rovner: It is not easy. All right. Well, because we’re in Washington, D.C., we have to talk about climate change this week. My mother, the journalist, used to say whenever she would go give a speech, that news is what happens to or in the presence of an editor. I have amended that to say now news is what happens in Washington, D.C., or New York City. And since Washington, D.C., and New York City are both having terrible air quality — legendary, historically high air quality — weeks, people are noticing climate change. And yes, I know you guys on the West Coast are saying, “Uh, hello. We’ve been dealing with this for a couple of years.” But Joanne and Lauren, both of your extra credits this week have to do with it. So I’m going to let you do them early. Lauren, why don’t you go first?

Weber: Yeah, I’ve highlighted a piece by my colleague Dan Diamond and a bunch of other of my colleagues, who wrote all about how this is just a sign of what’s to come. I mean, this is not something that is going away. The piece is titled “Smoke Brings a Warning: There’s No Escaping Climate’s Threat to Health.” I think, Julie, you hit the nail on the head. You know, we all live here in Washington, D.C. A lot of other journalist friends live in New York. There’s been a lot of grousing on Twitter that everyone is now covering this because they can see it. But the reality is, when people can see it, they pay attention. And so the point of the story is, you know, look, I mean, this is climate change in action. We’re watching it. You know, it’s interesting; this story includes a quote from Mitch McConnell saying [to] follow the public health authorities, which I found to be quite fascinating considering the current Republican stance on some public health authorities during the pandemic. And I’m just very curious to see, as we continue to see this climate change in reality, how that messaging changes from both parties.

[Editor’s note: The quote Weber referenced did not come from McConnell but from Senate Majority Leader Chuck Schumer, a Democrat, and would not have warranted as much fascination in this context.]

Kenen: But I think that you’ve seen, with the fires on the West Coast, nobody is denying that there’s smoke and pollutants in the air — of either party. You know, we can look out our windows and see it right now, right? But they’re not necessarily accepting that it’s because of climate change, and that — I’m not sure that this episode changes that. Because many of the conservatives say it’s not climate change; it’s poor management of forests. That’s the one you hear a lot. But there are other explain — or it’s just, you know, natural variation and it’ll settle down. So it remains to be seen whether this creates any kind of public acknowledgment. I mean, you have conservative lawmakers who live in parts of the country that are already very — on coasts, on hurricane areas, and, you know, forest fire areas there. You have people who are already experiencing it in their own communities, and it does not make them embrace the awareness of poor air quality because of a forest fire. Yes. Does it do what Julie was alluding to, which is change policy or acknowledging what, you know, the four of us know, and many millions of other people, you know, that this is related to climate change, not just — you know, I’m not an expert in forestry, but this is not just — how many fires in Canada, 230?

Rovner: Yeah. Nova Scotia and Quebec don’t tend to have serious forest fire issues.

Kenen: Right. This is across — this is across huge parts of the United States now. It’s going into the South now. I was on the sixth floor of a building in Baltimore yesterday, and you could see it rolling in.

Rovner: Yeah. You have a story about people trying to do something about it. So why don’t you tell us about that.

Kenen: Well it was a coincidence that that story posted this week, because I had been working on it for a couple of months, but I wrote a story. The headline was — it’s in Politico Magazine — it’s “Can Hospitals Turn Into Climate Change Fighting Machines?” Although one version of it had a headline that I personally liked more, which was “Turn Off the Laughing Gas.” And it’s about how hospitals are trying to reduce their own carbon footprint. And when I wrote this story, I was just stunned to learn how big that carbon footprint is. The health sector is 8.5% of greenhouse gas emissions in the United States, and that’s twice as high as the health sector in comparable industrial countries, and —

Rovner: We’re No. 1!

Kenen: Yes, once again, and most of it’s from hospitals. And there’s a lot that the early adopters, which is now, I would say about 15% of U.S. hospitals are really out there trying to do things, ranging from changing their laughing gas pipes to composting to all sorts of, you know, energy, food, waste, huge amount of waste. But one of the — you know, everything in hospitals is use once and throw it out or unwrap it and don’t even use it and still have to throw it out. But one of the themes of the people I spoke to is that hospitals and doctors and nurses and everybody else are making the connection between climate change and the health of their own communities. And that’s what we’re seeing today. That’s where the phenomenon Laura was talking about is connected. Because if you look out the window and you can see the harmful air, and some of these people are going to be showing up in the emergency rooms today and tomorrow, and in respiratory clinics, and people whose conditions are aggravated, people who are already vulnerable, that the medical establishment is making the connection between the health of their own community, the health of their own patients, and climate. And that’s where you see more buy-in into this, you know, greening of American hospitals.

Rovner: Speaking of issues that that seem insoluble but people are starting to work on, drug prices. In drug price news, drug giant Merck this week filed suit against the federal government, charging that the new requirements for Medicare price negotiation are unconstitutional for a variety of reasons. Now, a lot of health lawyers seem pretty dubious about most of those claims. What’s Merck trying to argue here, and why aren’t people buying what they’re selling?

Hellmann: So there’s two main arguments they’re trying to make. The primary one is they say this drug price negotiation program violates the Fifth Amendment, which prohibits the government from taking private property for public use without just compensation. So they argue that under this negotiation process they would basically be coerced or forced into selling these drugs for a price that they think is below its worth. And then the other argument they make is it violates their First Amendment rights because they would be forced to sign an agreement they didn’t agree with, because if they walk away from the negotiations, they have to pay a tax. And so it’s this coercive argument that they are making. But there’s been some skepticism. You know, Nick Bagley noted on Twitter that it’s voluntary to participate in Medicare. Merck doesn’t have a constitutional right to sell its drugs to the government at a price that they have set. And he also noted — I thought this was interesting — I didn’t know that there was kind of a similar case 50 years ago, when Medicare was created. Doctors had sued over a law Congress passed requiring that a panel review treatment decisions that doctors were making. The doctors sued also under the Fifth Amendment in the courts, and the Supreme Court sided with the government. So he seems to think there’s a precedent in favor of the government’s approach here. And there just seems to be a lot of skepticism around these arguments.

Rovner: And Nick Bagley, for those of you who don’t know, is a noted law professor at the University of Michigan who specializes in health law. So he knows whereof he speaks on this stuff. I mean, Joanne, you were, you were mentioning, I mean, this was pretty expected somebody was going to sue over this.

Kenen: It’s probably not the last suit either. It’s probably the first of, but, I mean, the government sets other prices in health care. And, you know, it sets Medicare Advantage rates. It sets rates for all sorts of Medicare procedures. The VA [U.S. Department of Veterans Affairs] sets prices for every drug that’s in its formulary or, you know, buys it at a negotiated —

Rovner: Private insurers set prices.

Kenen: Right. But that’s not government. That’s different.

Rovner: That’s true.

Kenen: They’re not suing private insurers. So, you know, I’m not Nick Bagley, but I usually respect what Nick Bagley has to say. On the other hand, we’ve also seen the courts do all sorts of things we have not expected them to do. There’s another Obamacare case right now. So, precedent, schmecedent, you know, like — although on this one we did expect the lawsuits. Somebody also pointed out, I can’t remember where I read it, so I’m sorry not to credit it, maybe it was even Nick — that even if they lose, if they buy a extra year or two, they get another year or two of profits, and that might be all they care about.

Rovner: It may well be. All right. Well, let us turn to abortion. It’s actually been relatively quiet on the abortion front these last couple of weeks as we approach the one-year anniversary of the Supreme Court striking down Roe v Wade. I did want to mention something that’s still going on in Indiana, however. You may remember the case last year of the 10-year-old who was raped in Ohio and had to go to Indiana to have the pregnancy terminated. That was the case that anti-abortion activists insisted was made up until the rapist was arraigned in court and basically admitted that he had done it. Well, the Indiana doctor who provided that care is still feeling the repercussions of that case. Caitlin Bernard, who’s a prominent OB-GYN at the Indiana University Health system, was first challenged by the state’s attorney general, who accused her of not reporting the child abuse to the proper state authorities. That was not the case; she actually had. But the attorney general, who’s actually a former congressman, Todd Rokita, then asked the state’s medical licensing board to discipline her for talking about the case, without naming the patient, to the media. Last month, the majority of the board voted to formally reprimand her and fine her $3,000. Now, however, lots of other doctors, including those who don’t have anything to do with reproductive health care, are arguing that the precedent of punishing doctors for speaking out about important and sometimes controversial issues is something that is dangerous. How serious a precedent could this turn out to be? She didn’t really violate anybody’s private — she didn’t name the patient. Lauren, you wanted to respond.

Weber: Yeah, I just think it’s really interesting. If you look at the context, the number of doctors that actually get dinged by the medical board, it’s only a couple thousand a year. So this is pretty rare. And usually what you get dinged for by the medical board are really severe things like sexual assault, drug abuse, alcohol abuse. So this would seem to indicate quite some politicization, and the fact that the AG was involved. And I do think that, especially in the backdrop of all these OB-GYN residents that are looking to apply to different states, I think this is one of the things that adds a chilling effect for some reproductive care in some of these red states, where you see a medical board take action like this. And I just think in general — it cannot be stated enough — this is a rare action, and a lot of medical board actions will be, even if there is an action, will be a letter in your file. I mean, to even have a fine is quite something and not it be like a continuing education credit. So it’s quite noteworthy.

Rovner: Well, meanwhile, back in Texas, the judge who declared the abortion pill to have been wrongly approved by the FDA, Trump appointee Matthew Kacsmaryk, is now considering a case that could effectively bankrupt Planned Parenthood for continuing to provide family planning and other health services to Medicaid patients while Texas and Louisiana were trying to kick them out of the program because the clinics also provided abortions in some cases. Now, during the time in question, a federal court had ordered the clinics to continue to operate as usual, banning funding for abortions, which always has been the case, but allowing other services to be provided and reimbursed by Medicaid. This is another of those cases that feels very far-fetched, except that it’s before a judge who has found in favor of just about every conservative plaintiff that has sought him out. This could also be a big deal nationally, right? I mean, Planned Parenthood has been a participant in the Medicaid program in most states for years — again, not paying for abortion, but for paying for lots of other services that they provide.

Kenen: The way this case was structured, there’s all these enormous number of penalties, like 11,000 per case or something, and it basically comes out to be $1.8 billion. It would bankrupt Planned Parenthood nationally, which is clearly the goal of this group, which has a long history that — we don’t have time to go into their long history. They’re an anti-abortion group that’s — you know, they were filming people, and there’s a lot of history there. It’s the same people. But, you know, this judge may in fact come out with a ruling that attempts to shut down Planned Parenthood completely. It doesn’t mean that this particular decision would be upheld by the 5th Circuit or anybody else.

Rovner: Or not. The same way the mifepristone ruling finally woke up other drugmakers who don’t have anything to do with the abortion fight because, oh my goodness, if a judge can overturn the approval of a drug, what does the FDA approval mean? This could be any government contractor — that you can end up being sued for having accepted money that was legal at the time you accepted it, which feels like not really a very good business partner issue. So another one that we will definitely keep an eye on.

Kenen: I mean, that’s the way it may get framed later, is that this isn’t really about Planned Parenthood; this is about a business or entity obeying the law, or court order. I mean, that’s how the pushback might come. I mean, I think people think Planned Parenthood, abortion, they equate those. And most Planned Parenthood clinics do not provide abortion, while those that do are not using federal funds, as a rule; there are exceptions. And Planned Parenthood is also a women’s health provider. They do prenatal care in some cases; they do STD [sexually transmitted disease] treatment and testing. They do contraception. They, you know, they do other things. Shutting down Planned Parenthood would mean cutting off many women’s access to a lot of basic health care.

Rovner: And men too, I am always reminded, because, particularly for sexually transmitted diseases, they’re an important provider.

Kenen: Yeah. HIV and other things.

Rovner: All right. Well, that is this week’s news. Now we will play my “Bill of the Month” interview with Sarah Jane Tribble, and then we will be back with our extra credits. We are pleased to welcome back to the podcast Sarah Jane Tribble, who reported and wrote the latest KFF Health News-NPR “Bill of the Month” story. Sarah, thanks for coming in.

Sarah Jane Tribble: Thanks for having me.

Rovner: So this month’s patient is a former American who now lives in Switzerland, a country with a very comprehensive health insurance system. But apparently it’s not comprehensive enough to cover the astronomical cost of U.S. health care. So tell us who the patient is and how he ended up with a big bill.

Tribble: Yeah. Jay Comfort is an American expatriate, and he has lived overseas for years. He’s a former educator. He’s 66 years old. And he decided to retire in Switzerland. He has that country’s basic health insurance plan. He pays his monthly fee and gets a deductible, like we do here in the U.S. He traveled last year for his daughter’s wedding and ended up with an emergency appendectomy in the ER [emergency room] at the University of Pittsburgh in Williamsport.

Rovner: And how big was the ultimate bill?

Tribble: Well, he was in the hospital just about 14 hours, and he ended up with a bill of just over $42,000.

Rovner: So not even overnight.

Tribble: No.

Rovner: That feels like a lot for what was presumably a simple appendectomy. Is it a lot?

Tribble: We talked to some experts, and it was above what they had predicted it would be. It did include the emergency appendectomy, some scans, some laboratory testing, three hours in the recovery room. There was also some additional diagnostic testing. They had sent off some cells for a diagnostics and did find cancer at the time. Still, it didn’t really explain all the extra cost. Healthcare Bluebook, which you can look up online, has this at about $14,000 for an appendectomy. One expert told me, if you look at Medicare prices and average out in that region, it would be between $6,500 and $18,000-ish. So, yeah, this was expensive compared to what the experts told us.

Rovner: So he goes home and he files a claim with his Swiss insurance. What did they say?

Tribble: Well, first let me just say, cost in the U.S. can be two to three times that in other countries. Switzerland isn’t known as a cheap country, actually. Its health care is —

Rovner: It’s the second most expensive after the U.S.

Tribble: Considered the most expensive in Europe, right. So this is pretty well known. So he was still surprised, though, when he got the response from his Swiss insurance. They said they were willing to pay double because it was an emergency abroad. Total, with the appendectomy and some extra additional scans and so forth: About $8,000 is what they were willing to pay.

Rovner: So, double what they would have paid if he’d had it done in Switzerland.

Tribble: Yeah.

Rovner: So 42 minus 8 leaves a large balance left. Yeah. I mean, he’s stuck with — what is that — $34,000. He’s on the hook for that. I mean, it’s better than having nothing, obviously, but it’s a lot of money and it’s really striking, the difference, because, you know, in Switzerland, they’re very much like, we would pay this amount, then we’ll double it to pay you back. And he still has this enormous bill he’s left paying. He’s on a fixed income. He’s retired. So it’s quite the shock to his system.

Rovner: So what happened? Has this been resolved?

Tribble: Let me first tell you what happened at the ER, because Jay was very diligent about providing documents and explaining everything. We had multiple Zoom calls. Jay’s wife was with him, and she provided the Swiss insurance card to UPMC. Now, UPMC had confirmed that there was some confusion, and it took months for Jay to get his bill. He had to call and reach out to UPMC to get his bill. He wants to pay his bill. He wants to pay his fair share, but he doesn’t consider $42,000 a fair share. So he wants to now negotiate the bill. We’ve left it at that, actually. UPMC says they are charging standard charges and that he has not requested financial assistance. And Jay says he would like to negotiate his bill.

Rovner: So that’s where we are. What is the takeaway here? Obviously, “don’t have an emergency in a country where you don’t have insurance” doesn’t feel very practical.

Tribble: Well, yeah, I mean, this was really interesting for me. I’ve been a health care reporter a long time. I’ve heard about travel insurance. The takeaway here for Jay is he would have been wise to get some travel insurance. Now, Jay did tell me previously he had tried to get Medicare. He is a U.S. citizen residing in Switzerland. He does qualify. He had worked in the U.S. long enough to qualify for it. He had gone through some phone calls and so forth and didn’t have it before coming here. He told me in the last couple of weeks that he now has gotten Medicare. However, that may not have helped him too much because it was an outpatient procedure. And it’s important to note that if you have Medicare and you’re 65 in the U.S., when you go overseas, it’s not likely to cover much. So the takeaway: Costs in the U.S. are more expensive than most places in the world, and you should be prepared if you’re traveling overseas and you find yourself in a situation, you might consider travel insurance anyway.

Rovner: So both ways.

Tribble: Yeah.

Rovner: Americans going somewhere else and people from somewhere else coming here.

Tribble: Well, if you’re a contract worker or a student on visa or somebody visiting the U.S., you’re definitely [going to] want to get some insurance because, wherever you’re coming from, most likely that insurance isn’t going to pay the full freight of what the costs are in the U.S.

Rovner: OK. Sarah Jane Tribble, thank you very much.

Tribble: Thanks so much.

Rovner: OK, we’re back, and it’s time for our extra credit segment. That’s where we each recommend a story we read this week that we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Lauren and Joanne, you’ve already given us yours, so Jessie, you’re next.

Hellmann: Yeah. My extra credit is from MLive.com, an outlet in Michigan. It’s titled “During the Darkest Days of COVID, Some Michigan Hospitals Made 100s of Millions.” They looked at tax records, audited financial statements in federal data, and found that some hospitals and health systems in Michigan actually did really well during the pandemic, with increases in operating profits and overall net assets. A big part of this was because of the covid relief funding that was coming in, but the article noted that, despite this, hospitals were still saying that they were stretched really thin, where they were having to lay off people. They didn’t have money for PPE [personal protective equipment], and they were having to institute, like, other cost-saving measures. So I thought this was a really interesting, like, a local look at how hospitals are kind of facing a backlash now. We’ve seen it in Congress a little bit, just more of an interest in looking at their finances and how they were impacted by the pandemic, because while some hospitals really did see losses, like small, rural, or independent hospitals, some of the bigger health systems came out on top. But you’re still hearing those arguments that they need more help, they need more funding.

Rovner: Well, my story is also about a hospital system. It’s yet another piece of reporting about nonprofit hospitals failing to live up to their requirement to provide, quote, “community benefits,” by our podcast panelist at The New York Times Sarah Kliff and Jessica Silver-Greenberg. It’s called “This Nonprofit Health System Cuts Off Patients With Medical Debt.” And it’s about a highly respected and highly profitable health system based in Minnesota called Allina and its policy of cutting off patients from all nonemergency services until they pay back their debts in full. Now, nonemergency services because federal law requires them to treat patients in emergencies. It’s not all patients. It’s just those who have run up debt of at least $1,500 on three separate occasions. But that is very easy to do in today’s health system. And the policy isn’t optional. Allina’s computerized appointment system will actually block the accounts of those who have debts that they need to pay off. It is quite a story, and yet another in this long list of stories about hospitals behaving badly. OK, that is our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us too. Special thanks, as always, to our ever-patient producer, Francis Ying. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can tweet me, at least for now. I’m still there. I’m @jrovner. Joanne?

Kenen: @JoanneKenen

Rovner: Jessie.

Hellmann: @jessiehellmann

Rovner: Lauren.

Weber: @LaurenWeberHP

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

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

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

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

Among the takeaways from this week’s episode:

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

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

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

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

Click to open the transcript

Transcript: Our 300th Episode!

KFF Health News’ ‘What the Health?’

Episode Title: Our 300th Episode!

Episode Number: 300

Published: June 1, 2023

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

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

Ezekiel Emanuel: Great. Wonderful to be here.

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

Jeff Goldsmith: It’s a pleasure.

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

Mostashari: Pleasure to be here, Julie.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: Farzad.

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

Rovner: Also price transparency, right?

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

Rovner: What are the SGLT-2s?

Mostashari: Zeke, you want to take this?

Emanuel: No, no, that’s you.

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

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

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

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

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

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

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

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

Goldsmith: Oh, absolutely.

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

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

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

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

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

Rovner: You mean 18% of GDP?

Emanuel: Yeah. Yeah.

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

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

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

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

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

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

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

Rovner: Farzad, Farzad’s making air quotes.

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

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

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

Emanuel: Yeah.

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

Emanuel: You are?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Emanuel: Yeah.

Goldsmith: You’re right.

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

Rovner: 70 billion.

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

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

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

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

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

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

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

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

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

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

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

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

Goldsmith: Not surprising.

Mostashari: Right.

Goldsmith: Not surprising at all.

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

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

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

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

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

Goldsmith: We’ll see how far they get.

Rovner: Yeah. Farzad.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Panelists

Joanne Kenen
Johns Hopkins Bloomberg School of Public Health and Politico

@JoanneKenen

Read Joanne's stories

Tami Luhby
CNN

@luhby

Read Tami's stories

Margot Sanger-Katz
The New York Times

@sangerkatz

Read Margot's stories

Among the takeaways from this week’s episode:

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

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

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

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

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

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

Also mentioned in this week’s episode:

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

Click to open the transcript

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

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

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

Tami Luhby: Hello.

Rovner: Margot Sanger Katz, The New York Times.

Sanger-Katz: Good morning.

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

Joanne Kenen: Hi, everybody.

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

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

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

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

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

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

Rovner: After May 11.

Luhby: It’s very confusing.

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

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

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

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

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

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

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

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

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

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

Rovner: Yes, well, I actually —

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

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

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

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

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

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

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

Kenen: We could call it that way every week.

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

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

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

Kenen: Really?

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

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

Rovner: Oh, it is.

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

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

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

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

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

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

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

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

Kenen: The cost.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Kenen: Or people who say they’re voters.

Rovner: Or people who say they’re voters. That is a different issue. All right. Well, something not that confusing: Now it’s time for our extra credit segment. That’s when we each recommend a story we read this week we think you should read too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Tami, why don’t you go first this week?

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

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

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

Rovner: I know. Joanne.

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

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

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

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

Kenen: Or, not “The Bachelor.”

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

Kenen: @JoanneKenen.

Rovner: Tami.

Luhby: @Luhby.

Rovner: Margot.

Sanger-Katz: @sangerkatz.

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

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

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

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

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

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Alice Miranda Ollstein
Politico

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Rachel Cohrs
Stat News

@rachelcohrs

Read Rachel's stories

Joanne Kenen
Johns Hopkins Bloomberg School of Public Health and Politico

@JoanneKenen

Read Joanne's stories

Among the takeaways from this week’s episode:

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

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

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

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

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

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

Also mentioned in this week’s episode:

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

Click to open the transcript

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

KFF Health News’ ‘What the Health?’

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

Episode Number: 296

Published: May 4, 2023

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

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

Joanne Kenen: Hey, everybody.

Rovner: Rachel Cohrs of Stat News.

Rachel Cohrs: Good morning.

Rovner: And Alice Miranda Ollstein of Politico.

Ollstein: Hello.

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

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

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

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

Rovner: Yeah, I do too.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Kenen: I think he had a stroke, right?

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

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

Rovner: —he was not all there —

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

Rovner: Yeah, that’s for sure.

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

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

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

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

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

Rovner: Right. He knows how to negotiate.

Kenen: It just didn’t work.

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

Kenen: Maybe they’ll come out holding hands.

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

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

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

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

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

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

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

Ollstein: —right—

Rovner: —sort of balancing act going on.

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

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

Ollstein: Right.

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

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

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

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

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

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

Rovner: Yeah, mine too.

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

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

Kenen: That’s a whole other —

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

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

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

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

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

Ollstein: —exactly—

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

Ollstein: Exactly. You can’t boostrap loneliness.

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

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

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

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

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

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

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

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

Rovner: Oh, I can’t wait. Alice.

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

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

Ollstein: Yeah.

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

Kenen: @JoanneKenen.

Rovner: Alice.

Ollstein: @AliceOllstein.

Rovner: Rachel.

Cohrs: @rachelcohrs.

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

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Supreme Court justices could act at any moment on access to the abortion pill mifepristone. Beyond reproductive health, their ruling could carry significant implications for states’ rights and FDA independence and integrity. For now, though, observers are unsure what the court will do — or what exactly prompted justices to again delay their decision this week.

At the Capitol, lawmakers grumbled, scoffed, and bickered this week as House Speaker Kevin McCarthy revealed the Republican proposal to cut government spending. The package would be dead-on-arrival in the Democratic-controlled Senate. But of note is the pushback from within McCarthy’s own caucus, with some hard-right conservatives pressing to go further by demanding the repeal of the Inflation Reduction Act in exchange for raising the debt ceiling.

And President Joe Biden pursued new efforts to grant legal status to young immigrants living in the country illegally who were brought here as children, sometimes called “Dreamers,” as his administration announced a plan to grant them access to government-funded health coverage.

This week’s panelists are Mary Agnes Carey of KFF Health News, Rachel Cohrs of Stat, Sandhya Raman of CQ Roll Call, and Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico.

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Rachel Cohrs
Stat News

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Joanne Kenen
Johns Hopkins Bloomberg School of Public Health and Politico

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Sandhya Raman
CQ Roll Call

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Read Sandhya's stories

Among the takeaways from this week’s episode:

• The Supreme Court extended its stay on the use of mifepristone through Friday, giving justices longer to act on a major, complicated case with nationwide implications for reproductive health. It is unclear what the court will do, though there are several actions it could take — including sending the case back to the lower courts or again extending the stay and buying justices even more time to come to agreement or pen dissents.
• GenBioPro, which produces the generic version of mifepristone, sued the FDA on Wednesday, attempting to preserve access to the drug. About two-thirds of the mifepristone currently used in the United States is generic.
• In congressional news, House Speaker McCarthy released what is effectively Republicans’ opening offer in the fight over raising the debt ceiling. The package includes GOP health priorities that would not garner needed support in the Senate, like work requirements for Medicaid and the clawback of unspent covid-19 pandemic funds.
• While health costs are high across government programs, Medicaid takes the big hit in the Republican proposal to cut federal spending. Republicans have embraced work requirements for government assistance since at least the 1980s, yet in Arkansas — a state that implemented work rules for Medicaid — it has proved challenging to verify that enrollees are meeting those requirements.
• The Senate Finance Committee, which has jurisdiction over much of federal health spending, revealed a package this week to tackle drug pricing. While the proposal is in the early stages, it seeks to incorporate bipartisan measures touching pharmacy benefit managers, insulin users, and more.
• And on the coverage front, the Biden administration announced that immigrant kids brought to the United States who remain here under the Deferred Action for Childhood Arrivals program will be able to apply for Medicaid and Affordable Care Act coverage. This eligibility expansion comes as states prepare to disenroll those who no longer qualify for Medicaid as the public health emergency’s coverage protections expire. Expect a fight from some states as they resist being forced to cover insurance for individuals living in the U.S. without legal permission.

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

Mary Agnes Carey: The New York Times’ “A Beauty Treatment Promised to Zap Fat. For Some, It Brought Disfigurement,” by Anna Kodé

Joanne Kenen: The New York Times’ “My Transplanted Heart and I Will Die Soon,” by Amy Silverstein

Sandhya Raman: ABC News’ “Puerto Rico’s Water Supply Is Being Depleted, Contaminated by Manufacturing Industry on the Island, Experts Say,” by Jessie DiMartino, Lilia Geho, and Julia Jacobo

Rachel Cohrs: The Wall Street Journal’s “‘I Hate You, Kathie Lee Gifford!’ Ozempic Users Report Bizarre Dreams,” by Peter Loftus

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Transcript: Will They or Won’t They (Block the Abortion Pill)?

KFF Health News’ ‘What the Health?’Episode Title: Will They or Won’t They (Block the Abortion Pill)?Episode Number: 294Published: April 20, 2023

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

Mary Agnes Carey: Hello and welcome back to “What the Health?” I’m Mary Agnes Carey, partnerships editor for KFF Health News. I’m filling in this week for Julie Rovner, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, April 20, at 10 a.m. Eastern. As always, news happens fast and things might have changed by the time you hear this. So here we go. Joining us today by video conference are Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico.

Joanne Kenen: Hi, everybody.

Carey: Rachel Cohrs of Stat.

Cohrs: Morning, everyone.

Carey: And Sandhya Raman of CQ Roll Call.

Raman: Good morning.

Carey: Let’s start with the current court action on mifepristone. The Supreme Court was scheduled to rule yesterday on a decision from the U.S. Court of Appeals for the 5th Circuit that rolled back FDA action since 2016, allowing patients to get mifepristone through the mail, authorizing prescriptions by medical professionals other than doctors, and approving the drug’s use up to 10 weeks into a pregnancy instead of seven. Supreme Court Justice Samuel Alito Jr, who’d previously set Wednesday as the deadline for the court to act, extended that stay until Friday, and the justices could certainly act before they choose to —hopefully not while we’re taping. But I wanted to get everyone’s thoughts on why do you think the court didn’t act yesterday? Joanne, can I start with you?

Kenen: I mean, presumably they’re still hashing it out. There’re probably two or three judges who are still thinking about it or discussing it with their colleagues, or colleagues who want to think they can persuade them to their side. I mean, there’s something internal. On the other hand, I mean, they didn’t originally give themselves a lot of time to consider a complicated and historic case. We know there’s an anti-abortion majority. We know they’re not crazy about medical abortions any more than they are about surgical abortions. But this has large implications about states’ rights and about the sort of integrity of the FDA. So they may just wanted to sleep on it. They’re human, but the two sides are battling for two or three in the middle.

Carey: So what does this signal about how they might rule? I mean, to your point about the split, the battle, what are the options? What do you — Sandhya, what do you think about what they might —

Kenen: Well, if it was slam dunk, we’d have had it.

Carey: That is true. That is true. It is not a slam dunk.

Raman: And everyone that I have talked to in the last few weeks on this is just that there are so many different options, different permutations, that it’s difficult even for people that are experts on FDA policy, like expert lawyers, experts on abortion policy, to just kind of like predict the nuances. You know, they could let the stay expire. They could send it back to the 5th Circuit. They could decide to hold arguments and let it expire or not expire. They could decide something different than the 5th Circuit. You know, there’s so many different ways that things could happen that I think it makes it difficult. And then yesterday, the other manufacturer of mifepristone, GenBioPro, also filed suit against the FDA. So now we have, since Dobbs, like five different lawsuits related to mifepristone and three of them, post-Dobbs, are related to the FDA in particular. And I think it just gets very, very complicated to make a decision, even if ideologically some people might align with one way versus the other, given all of these different permutations and that we still have that Washington case that is attacking another part of this. So it’s just complicated to get people to do something. And the fact that this case has been moving so, so quickly.

Carey: Could we be in the same place on Friday? Could we get another stay? Could the justices certainly ask for more time, and are there any thoughts about the probability of that actually happening? Rachel, what are your thoughts?

Cohrs: I think they can do what they want.

Carey: That’s true.

Cohrs: They gave themselves time once more, and I think obviously there’s a benefit to having some certainty and predictability for people, for providers, but certainly they could stay again.

Carey: So, Sandhya, you just mentioned the Washington state case. So while this Texas ruling is before the Supreme Court, a federal district judge in Washington state issued a ruling in a separate case that instructed the FDA to not alter the current availability of the drug in 17 states and the District of Columbia. And as you just mentioned, a manufacturer of the generic version of the drug — the company’s name is GenBioPro; they make the generic version of mifepristone — they’re arguing that if the FDA implements a court order suspending approval of the drug, the agency would deprive the company of its rights to market the drug without due process of law. And as I understand, this company is a major manufacturer of the generic version of the drug, right? So let’s talk a bit more about this confusion of these split rulings. I mean, what is the public to make of it? What’s the reaction with facilities that are providing this medication or doctors who want to prescribe it or just the general public? The person who might be interested in this situation is very confused. I mean, talk a little bit about how people sort through it and what this means for them.

Raman: So the suit that was filed yesterday about the generic, they make two-thirds of the mifepristone that is used in the U.S. So if they were unable to be manufacturing theirs based on a ruling that only allowed the name-brand version of the drug, that’s a huge percentage of the market that is gone, and more than half of abortions are done through medication abortion. So that’s one thorn in it. And I think that another is that we have all of these states that have been stockpiling the drugs — several that have been, you know, in case they don’t know what is happening with the ruling. Washington is one of them. And there’s still not clarity depending on what happens with these cases of, you know, will they be able to use what that they have stockpiled? And then we have other states like New York and I think California that have been stockpiling misoprostol as another way to — in case there’s a court ruling that doesn’t go in their favor — to just give patients in their states access to medication abortion. I think that there are so many different permutations that it’s very difficult for even folks that are confident that the rule may go a different way to know what to predict, just because we’re in such uncertain territory, from all of the different former FDA officials that have said, “You know, this is a very different situation. We don’t even know, after decades of experience at the FDA, like, how this would play out, what it would mean, whether we’d have to pull everything off the market.” How it would play out, it’s just a lot of unknown territory given all of the different things going on.

Kenen: Well, also, whatever they do now isn’t necessarily the end of the story, right? I mean, if the court issues a stay, it will still go through the courts and it presumably ends up at the Supreme Court again. If they issue a stay pending full hearing of the case, it’ll be going on for months more. But either they issue a stay saying the 5th Circuit ruling, which did not totally — the lower federal court banned the use of the pill; the appeals court limited it to seven weeks instead of the FDA has ruled it’s for 10 weeks. So if they uphold the 5th Circuit Court of Appeals, there would still be use, but it would be limited. If they put a stay saying, “Yes, it can stay legal in the states that allow it for now,” then it would still be legal in those states but we’d still be back discussing what is the Supreme Court going to do a couple of months from now.

Carey: And how — where is the drug industry on this? I mean, this would have sweeping ramifications.

Kenen: They’re horrified. One of you might know the number — was it like 250 companies signed the brief that you’re going to have a court decide what drug is safe and what drug is not safe, rather than the FDA? I mean, the pharmaceutical company fights with the FDA all the time, but they need the FDA and they know they need the FDA and they admit they need the FDA. You know, you have one voice in this country saying a drug is safe or a drug is not safe or a drug is safe under the following conditions.

Raman: There have been hundreds of the drug companies that have spoken out against it, and PhRMA [Pharmaceutical Research and Manufacturers of America] more recently also finally came out against it. It’s been pretty uniform in a way that I have not really seen in the past where there have been, you know, the drug companies, the various people that have been regulators, the folks that are in favor of abortion rights, then just advocates — and just very unified in this response.

Carey: Rachel, what is the impact of the drug industry’s weighing in in this manner? How could that shape the decision? Was there anything surprising in how they worked together on this? I know you’ve done some reporting on this area.

Cohrs: Yes. Yeah. So I think certainly them actually filing briefs with the court will kind of help drive home the ramifications of this, just on a much larger scale. I mean, we’re not just talking about abortion now. We’re talking about any medication that could be at all controversial. You know, we’re talking PrEP for HIV. You know, there are so many areas where companies genuinely are concerned about lawsuits and about judges who aren’t experts. So I think this uniform voice will drive home the larger impacts here beyond this one issue. And also, I think, the drug industry has significant resources to invest. And I think, it took a little while, but the trade groups PhRMA and BIO [Biotechnology Innovation Organization] have said that they are willing to invest, and they haven’t made any specific commitments, but certainly I think down the line there could be legal challenges. And now that they have put themselves out there, they certainly are a significant player in the space, with resources.

Raman: The drug industry is also a huge player in, you know, donating to various campaigns and lobbying on the Hill. And it’s definitely going to be — put increasingly different folks in a tight spot if they are receiving a lot of backing from the pharmaceutical industry and if they’ve spoken out in favor of restricting the drug. And it’ll be interesting to see kind of as it goes on what happens there with some of these folks.

Carey: Sure. Well that’s a perfect segue way because we have lawmakers on Capitol Hill are also weighing in on this. About 150 Republicans are urging the Supreme Court to uphold the 5th Circuit’s ruling, while more than 250 Democrats have urged the court to not prevent access to mifepristone. Are Republicans taking a political risk here speaking out? Because I know it’s been talked about on the podcast before, about the abortion rights opponents have some splits on how far to go on some of these restrictions on abortion. You know, Republicans didn’t really seem eager to engage when the decision came out, but now they are. What does that mean? What do you make of it?

Raman: We’ve had that delay first that, you know, a lot of Republicans did not even comment on the case, which was kind of interesting, given that, you know, after a lot of these decisions, we see a lot from both sides kind of weighing in. And I think when you look at some of these briefs, they say a lot of the similar talking points as before, which is something that you can kind of look to. But I mean, the conversation is still moving, even on the Hill. Yesterday, Robert Califf from the FDA was facing questions about mifepristone from different Republicans, from Cindy Hyde-Smith, who had agreed with the lower court decision, from Susan Collins, who was kind of against the decision as one of the Republicans who generally supports abortion rights. And I think it’ll be very interesting if this gets taken up by a committee that has jurisdiction over the FDA, which we have not really seen a commitment to. Energy and Commerce [Committee] Democrats have asked for something on this to come up. But, you know, under Republican leadership, I don’t know that that would necessarily happen. The only committee that is really committed to looking at this issue has been, like, Senate Judiciary, which with Democratic control is going to look a different way. And they don’t really have the jurisdiction over FDA in the same way as some of the other committees do. So I think that’ll be interesting to look at if that changes.

Kenen: There is a divide in the Republican Party about how far to go. I mean, some are for rape and incest exceptions, some are not. Some are for six weeks, some are for 15 weeks, some are for zero weeks. This is reflecting those divisions. It also depends on the individual lawmaker’s district. You know, if you come from an extremely conservative district and you are an anti-abortion absolutist, then you’re going to speak out on this. But we’ve noted they don’t really want to antagonize pharma either. So you’ve seen, I guess it’s 150ish — you haven’t seen all of them. It’s a complicated issue for some of them, given the competing interests, you know. Is abolishing all abortions in the United States of America your top goal? In which case you’re going to want to support the lower court. If you have a more nuanced view, where you’re worried about precedent for overriding the FDA, you have competing — I mean, there are very few abortion rights Republicans, but they don’t all want to draw the line in the same place.

Carey: So while we’re on the subject of Capitol Hill, let’s talk about the debt ceiling. We have a little bit of action there this week. Speaker of the House Kevin McCarthy unveiled his plan to raise the debt ceiling. McCarthy and many Republicans have said they don’t want to raise the debt ceiling without spending cuts. President Biden and many Democrats are pushing for a clean debt ceiling increase. So among its provisions, Speaker McCarthy’s plan would cut federal spending by roughly $130 billion, and that would take spending back to fiscal 2022 levels. Health-related provisions include new work requirements for Medicaid and food stamp recipients, and the package would also claw back unspent covid aid funds. And there’s a bit of a twist on the work requirement proposals of the past: States could opt to keep those that don’t comply with the work rules covered under Medicaid, keep them on the rolls. But if they do, the state would bear the full cost of that coverage and forgo the federal money for those enrollees, right? The proposal also requires states to make use of existing resources like payroll databases, state health and human service agencies, to verify compliance with a work rule when possible. There’s a lot to unpack here. It’s pretty clear that, I mean, House Democrats aren’t going to vote for this. Does the speaker even have enough votes in his own caucus to pass it? I think he can only lose like four.

Kenen: TBD. But I don’t think the conventional wisdom is that he has the votes. You know, it’s a starting offer, but they can change, you know, has to go Rules [Committee]. They’ll change — you know, they could change things.

Carey: It is a starting offer. But your vote is next week and it’s Thursday. OK. Rachel, what’s your take on this?

Cohrs: Yeah, I think it was a bit of a roller coaster this week, as some members of the Freedom Caucus were demanding wholesale repeal of the Inflation Reduction Act around midweek, and they certainly backed off from that, especially the health care portion. So I think that is worth noting, at least right now. Again, unclear if he has the votes, or if the speaker has the votes, and then obviously Senate Democrats aren’t going to go for it and President Biden isn’t going to go for this. So I think, like Joanne said, it is kind of an opening offer here. And again, there isn’t a lot on Medicare in here. So I think we just, you know, finally, after so much rhetoric and so much back-and-forth, have some sort of tangible starting point from Republicans here, which is significant.

Kenen: But, you know, as soon as they made that pledge that we’re not going to touch Medicare, meaning traditional Medicare actually, and we’re not going to touch Social Security, we all knew that, Oh, that means that it’s all going to go to Medicaid. So this is a big Medicaid hit. And work rules have been something the Republicans have embraced at least since the Reagan era, maybe even before, but certainly since the 1980s. A few states tried them or at least said they were going to impose them under the Obama administration. At that point, the administration didn’t approve them and the courts didn’t uphold them. But we have a different court now. So I think this court would uphold; that’s likely. But this is not acceptable for Democrats, nor is it meant to be.

Raman: And when we had the various states propose these and in some cases implement them during the Trump administration, every single one of them was struck down by the court once, sometimes twice. You know, we had Arkansas, we had New Hampshire, we had Kentucky, we had Michigan. Every single time the judge at hand was, you know, “This is going against the function of Medicaid,” which — historically we’ve had work requirements in some of the other programs, but the way the Medicaid statute is written, it has been difficult to find a way to keep those in place. So if they were able to get that past, I mean, even the House, which seems like is a, is a question mark, I mean — whatever could get through would absolutely face court battles from some of the same folks that challenged them during the Trump administration.

Kenen: But I think the only one that actually went into effect was Arkansas. And in addition to it being thrown out by a court, it also just didn’t work. The mechanism didn’t work. It became really hard for people. The verification that you’re working, which this proposal actually addresses, that Mary Agnes just alluded to that, the verification was extraordinarily cumbersome. I mean, you had like lots of poor people in Arkansas — and rural Arkansas don’t have access to Internet — and you only had a few hours a day where you could use the portal and you have to leave work to go to the local library to prove that you were working. I mean, it was just — forget the ideology of it — the mechanics didn’t work, and people were thrown off even though they were compliant. And but this [is] just like a deep philosophical divide between the two parties, and they have compromised, and back in the Clinton years they compromised on welfare, what’s now called TANF [Temporary Assistance for Needy Families]. There’s work requirements for SNAP, for what we used to call food stamps. But Medicaid has been a red line for Democrats, that this is an entitlement based on health; it’s not like you deserve — some people deserve it and some people don’t. It’s been a philosophical, ideological, you know, something that Democrats feel very strongly about.

Cohrs: Oh, I just want to jump in on the covid money as well — much smaller deal, fewer impacts on patients — but it has been kind of interesting and over the last couple of weeks that the Biden administration has rolled out some new programs that cost quite a bit of money, as there’s this horizon, this call for Congress to claw back unspent covid funds. I mean, they’re spending $5 billion now on developing vaccines and therapeutics, $1 billion on vaccine access, when they said they didn’t have any money. So it’s just kind of interesting that, you know, when these funds are committed to a program legally, then Congress can’t claw them back. So I’m curious to see what else we’ll see as these negotiations solidify.

Carey: All right. We’ll keep our eye on it. And I want to just check in briefly on the Senate side. I know we’ve discussed these issues on the podcast before. The Senate Health, Education, Labor and Pensions Committee has been working on legislation focused on drug prices and pharmacy benefit managers. This morning we have a framework introduced from the Senate Finance Committee. It’s with Sen. Wyden, the chair from Oregon, who’s a Democrat, and Sen. Mike Crapo, Republican from Idaho, that also seeks to address PBMs in the prescription drug supply chain. We also have the moving, or maybe not moving, but introduce legislation, anything new there on insulin prices with Sen. Warnock and Sen. Kennedy to cap the out-of-pocket price at $35. Any movements there in the Senate, any insight you could offer?

Cohrs: On the Senate Finance [Committee] side, that is a very significant development, that they’ve decided to get in on the fun this week of putting together a package, just because their committees do have jurisdiction over so much federal spending. And Sen. Wyden has been involved in this issue. He’s put out — I found a package of bills from 2019, and, you know, he’s been on this issue a long time. So I think his team has proven they can craft big-picture, very impactful policy with the Inflation Reduction Act. So I think that’s certainly something to watch with that much federal spending on the line. And on insulin, you know, Sen. Schumer this week has committed to have some sort of insulin pricing provision in whatever package might come together — it’s still pretty amorphous — but it’s unclear what that’s going to look like. There is another proposal from Sen. Collins and Sen. Shaheen, two much more senior members of the caucus, and that mechanism works differently. For patients, it would look pretty similar. But on the back end, for insurers, for drugmakers, both of those programs would work differently. So they haven’t sorted that out yet. HELP hasn’t even picked a date for their hearing and formally announced it yet. So we are in early stages, but there’s certainly a lot swirling around.

Carey: Absolutely. And we’ll keep our eye on all of that as well. So I’d like to also chat a little bit about some ACA developments that happened this week. President Biden recently announced that hundreds of thousands of immigrants brought to the United States illegally as children will be able to apply for Medicaid and the Affordable Care Act’s health insurance exchanges. This allows participants in the Obama-era Deferred Action for Childhood Arrivals program, also known as DACA, to access government-funded health insurance programs. You can expect pushback from conservative leaders of states that have been reluctant to expand Medicaid, possibly also pushback from Republican members of the Hill on this provision. And then, in other ACA news, the administration has finalized new rules that are aimed at making it easier for consumers to sign up for ACA plans, in particular those who are losing their coverage through Medicaid or the Children’s Health Insurance Program. The Centers for Medicare & Medicaid Services, also known as CMS, will also give state marketplaces the option to hold a special enrollment period for people who lose their Medicaid or CHIP coverage. What could this possibly mean for enrollment in the program, right, to making it easier for DACA participants to enroll in the ACA or people losing their coverage through CHIP or Medicaid? I think it’s about 16 million people now in the program. Does this build more support for it? Are Republicans going to engage against it? Do they think that’s simply a losing battle because they’ve never agreed on an alternative?

Raman: I mean, right now, we’ve had historic levels of people in Medicaid and CHIP just because states have been unable to unenroll them from coverage during the public health emergency for covid. And now that states are starting to recheck their rolls and see who’s still eligible, who’s not eligible, we’ve been expecting just, you know, a big drop in different people that would be either getting uninsured or maybe moving to a different type of plan with a private or the exchanges. And I think it’s been something that, you know, states and the federal government have been working on for the entire time of just, you know, different ways to make sure that that drop-off in the number of uninsured folks doesn’t skyrocket as states are going through this process. And so I think the timing is important in that, you know, you’re trying to counteract the drop. And HHS [the U.S. Department of Health and Human Services] has been touting, you know, the high levels of uptake in the ACA and just like the low uninsured rate and this has been something they’ve just kind of been pushing, you know, month after month. This has been something that has been like a big achievement for them. And so now really like push comes to shove to say that, you know, it doesn’t drop off dramatically if you want to continue touting some of these achievements and making sure that people don’t drop off just because the emergency is ending and that guaranteed coverage isn’t there.

Kenen: So there are multiple issues in the question that are exposed, the DACA, which —

Carey: Of course it can’t be just one question I have to ask four at once.

Kenen: The DACA, which is also known as the Dreamers, Biden is trying to cover them. Democrats have been trying to give them legal status and got nowhere. In fact, they’re probably further away from that than they were five or six years ago. But to get them health coverage is something the Democrats — it’s like the least they can do to this population. But I can’t imagine there’s not going to be a political and/or a legal fight from the states who are going to have to pay for their share of it, right? I mean, Medicaid is a state-federal joint expenditure, and the states that don’t want to cover these people will well resist or sue. Or, I mean, everything ends up in court; I would imagine this will, too, or baked into the debt ceiling — you know, one more thing to fight about with the debt ceiling. So that’s one issue. I mean, the other issue is this unwinding of this huge Medicaid population. Most of these people are going to be eligible for some kind of coverage. Some of them are still going to be eligible for Medicaid. Some of them are going to be eligible for very good deals for sort of low-income working people on the ACA. And some have jobs that they can get insured through — theirs or a partner or a family member. But really, the only ones who are ineligible for anything would be those in the remaining Medicaid gap states. But that’s like theoretically, if we did everything right, the only people that would be ineligible are the Medicaid gap population, which is now down to about 10 states, assuming North Carolina, you know, finalizes their approval or, you know, enacts their expansion. But like, that’s the perfect world, and we don’t live in a perfect world. I mean, some of these people are going to get lost in the shuffle. And in fact, maybe several million; their estimates are like maybe 6 million, you know, no one knows. But, you know, our health care system is complicated. You know, getting a letter in the mail saying, you know, “Sayonara, Medicaid,” is not all of them will know how to negotiate new coverage even when they’re eligible, and we’re going to have to do a really good job of helping them. And that has to be from the federal government, from the state governments, from the health system itself, from advocates, from Congress. You know, everyone’s going to have to pitch in to get these people what they’re eligible for. And I don’t see that as an overnight success story. I think that there are people who should be covered and can be covered who won’t be covered. Eventually we’ll probably catch up and most of them enrolled. But I think that some of them have periods of uninsurance.

Carey: It’s absolutely a major undertaking. I know we’ll all be watching closely. OK, that’s the news for this week. Now it’s time for our extra credit segment. That’s when we each recommend a story we read this week and think you should read it too. As always, don’t worry if you miss it. We’ll post the links on our podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device.

Kenen: I actually want to read the first sentence of this piece. This is a guest essay in The New York Times by Amy Silverstein. She’s a heart transplant recipient. She’s, I guess, about 60 now, and she’s about to die, not because her heart, her transplanted heart is failing — she writes about how she kept that in pristine condition — but because she’s got cancer. And it’s called “My Transplanted Heart and I Will Die Soon,” and it begins, “Today, I will explain to my healthy transplanted heart why, in what may be a matter of days or weeks at best, she — well, we — will die.” And in addition to being just a heart-tugger, I did not know a lot of what she explores about transplant medicine, that we think of transplants as medical miracles — and they are; you know, she had like an extra 35 years of life — but they’re also, transplant medicine itself hasn’t really, according to what she writes, transplant medicine itself — the drugs, the care they get, these heavy-duty drugs haven’t improved in 40 years. While she has a healthy heart, she has metastatic lung cancer because of these drugs. The medical care around transplant can be quite dangerous. And I knew nothing about that, and I’ve covered health for a long time. So it’s a tragic story and it’s also a scientific failure or a medical system or a medical research failure story that I hope a lot of people who have the power to change it read.

Carey: Sandhya, what’s your extra credit?

Raman: So my extra credit is from ABC News. It’s called “Puerto Rico’s Water Supply Is Being Depleted, Contaminated by Manufacturing Industry on the Island, Experts Say.” It’s a triple byline from Jessie DiMartino, Lilia Geho, and Julia Jacobo. And I thought their story was really interesting because it looks at the effects of the manufacturing industry on the water supply in Puerto Rico. The manufacturing there is, in Puerto Rico, is really high because there used to be a tax incentive that’s now lapsed to create a huge boom in manufacturing in the ’60s and ’70s. And kind of looking at the impacts of that, and over time and to the environment, and pharma manufacturing in particular, is 65% of what has been the industrial groundwater withdrawals. So in areas that rely heavily on groundwater on an island, this is felt especially hard. And so they go through a lot of the implications of some of that and how the manufacturing affects it, especially in an island with a finite water supply.

Carey: Rachel.

Cohrs: Mine is, the headline is, “‘I Hate You, Kathie Lee Gifford!’ Ozempic Users Report Bizarre Dreams,” in The Wall Street Journal and by Peter Loftus. Our newsroom has been covering the weight loss drug explosion this year, and I think this story was just so colorful and just a great example of reporting on the side effects that emerge when so many people are interested or want to take a drug. And I think there is certainly a public service to people understanding what they’re getting into and just hearing from all sorts of people, because certainly there are agencies who are supposed to be doing that. But I think there’s also just a lot of buzz that’s fascinating. The writing was just so rich and bizarre. And yeah, it was a great read and a great illustration on it, too.

Carey: Well, speaking of weight loss and getting fat out of our bodies, my story is from The New York Times, called “A Beauty Treatment Promised to Zap Fat. For Some, It Brought Disfigurement,” by Anna Kodé, and I hope I’m pronouncing your name correctly. You might have heard or seen all these ads about the treatment called CoolSculpting. It uses a device on a targeted part of the body to freeze fat cells. Patients typically undergo multiple treatments in the same area, and in successful cases, the cells die and the body absorbs them. “But for some people,” Anna writes, “the procedure results in severe disfigurement. The fat can grow, harden and lodge in the body, sometimes even taking on the shape of the device’s applicator.” The manufacturer says this is a rare side effect, but a Times investigation that drew on internal documents, lawsuits, medical studies, and interviews indicates the risk to patients may be considerably higher. So that’s our show. As always, if you enjoyed the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left a review; that helps other people find us too. Special thanks, as always, to our ever-patient producer, Francis Ying. And as always, you can email us with your comments or questions. We’re at whatthehealth@kff.org. Or you can tweet me @maryagnescarey. Rachel?

Cohrs: @rachelcohrs.

Carey: Joanne?

Kenen: @JoanneKenen.

Carey: Sandhya.

Raman: @SandhyaWrites.

Carey: We’ll be back in your feed next week. Until then, be healthy.

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In 2014, Lisa French had spinal surgery. Before the operation, she was told she would have to pay $1,337 in out-of-pocket costs and that her insurance would cover the rest. However, the hospital ended up sending French a bill for $229,000. When she didn’t pay, it sued her.

The case went all the way to the Colorado Supreme Court. In this episode of “An Arm and a Leg,” host Dan Weissmann finds out how the court ruled and how the decision is reshaping the fine print on hospital bills in ways that could cost patients a lot of money.

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Transcript: A $229,000 Medical Bill Goes to Court

Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Dan: Hey there–

Lisa French was a clerk for a trucking company in Denver. She’d been in a car crash, and her doctor told her that to keep her spine stable, she ought to get surgery.

She asked the folks at the hospital what it was gonna cost her, out of pocket. They ran her insurance and told her: Your end is going to be one thousand, three hundred thirty-six dollars, and ninety cents.

She said, thanks.

Then, she and her husband sat down at their kitchen table and talked it over: They had a rainy-day fund. A thousand dollars they’d socked away, they kept it at home, in cash. Were they ready to spend it all for this? 

They decided they were, and Lisa went to the hospital with a thousand dollars cash. 

She had the surgery, it went fine. The hospital had been expecting about 55 thousand dollars from Lisa’s insurance. They actually got more like 74 thousand.

But they decided that wasn’t enough. They decided they wanted their full sticker price: 303 thousand dollars. So they billed Lisa French for the rest: 229 thousand dollars.

And when they didn’t get it, they sued her.

Lisa French had her surgery in 2014. The court case finally got resolved last year, in 2022, by the Colorado Supreme Court.

If you’ve been listening to this show for a while, you probably remember: We have gotten VERY interested in understanding, when we get a wild medical bill, what legal rights do we have? How can we use those rights to fight back? Even on a small scale, like in small claims court? 

And even though Lisa French’s case is a LONG way from small claims court, it has a LOT to teach us about these questions.

This is An Arm and a Leg, a show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann. I’m a reporter, and I like a challenge. So our job on this show is to take one of the most enraging, terrifying, depressing parts of American life, and bring you something entertaining, empowering, and useful.

And I should say upfront: We won’t be hearing from Lisa French directly.

Her case made a lot of headlines– in 2018, when a jury heard it, in YEAR when an appeals court overturned the trial court, and last year when the state supreme court made its ruling.

Not in the kind of detail that we’re gonna go into, but come on: Who can resist the headline?

Male Anchor: Well, tonight we have a story of David versus Goliath. David being a woman who needed spinal surgery in 2014 Goliath, the hospital that charged her more than $200,000 to do it.

Dan: So over the years, a lot of reporters wanted a sound bite from Lisa French. Her attorney used to let her know when there was an inquiry, and she’d say yes or no.

Eventually, she told her lawyer: Don’t even tell me when they call anymore. I just want to live my life.

Fair enough.

So here’s who we’ve got.

Ted Lavender: I’m Ted Lavender. I’m an attorney in Atlanta, Georgia. I’ve been practicing law for 26 years,

Dan: And he spent several of those years representing Lisa French.

It’s probably worth answering one question up front: If Lisa French had to empty her family’s rainy-day fund to pay the hospital a thousand bucks, who’s paying the lawyer from Atlanta?

The insurance from her job. Which had played a role in starting the whole mess.

Ted Lavender: the company that she worked for had a health benefits plan that was slightly different than what you might call run of the mill health insurance.

Dan: It worked this way: They weren’t in-network with any hospitals. Instead, they’d just take whatever bill any hospital sent, make their own evaluation of what a fair price would be, and send the hospital a check.

It’s a somewhat unusual model– one survey says about 2 percent of employers use a plan like this– but Ted Lavender says it often works.

Ted Lavender: a very large percentage of the time , the hospital would accept the check and no one would hear anything more from the hospital, which in legal parlance would mean acceptance

Dan: And as a backstop, in case there was any trouble, the health plan would send a lawyer. That’s Ted.

And here’s what happened that led to all the trouble in Lisa French’s case: Whoever ran her insurance card at the hospital, they didn’t read it very carefully.

If they had, they would’ve seen a little logo under the insurance-company name that said, “provider only” — that is: This plan only has doctors and nurses and other PROVIDERS in network.

With hospitals, there’s no network, no “in-network rate.” We’ll just send a check for what we think is right.

The same health-benefits company has a different plan, one that does have a hospital network. You know how it is. Insurance companies, a million different plans, every one its own snowflake.

The hospital mistook Lisa French’s snowflake for another one, and that’s how they came up with that estimate.

Ted Lavender: based on their calculation, they expected to collect a total of

$56,000, the 1,336 from Ms. French and the remainder from her health plan.

Dan: And they presumably would’ve been happy with 56 thousand. But they got more. They got about 75 thousand dollars.

But once they got it, they wised up to the mistake they had made about Lisa French’s insurance. They had no agreement with the insurance plan to accept 56 thousand.

So, they decided: There’s no reason for us not to charge our full sticker price here.Three hundred and three thousand dollars.

So Lisa French had been expecting a bill for three hundred thirty-six dollars and ninety cents. That’s the difference between what she’d been quoted and the thousand dollars she’d paid in advance. But the bill she got wasn’t what she expected.

Ted Lavender: it turned out to be a whopper of a bill. We ended up with an itemized bill that showed every line item for every charge that totaled this

$303,000

And then at the bottom was, you know, subtracting the thousand she paid, subtracting the money the insurance paid, leaving a balance of 229,000 and change

Dan: Of course, Lisa French did not have 229 thousand dollars, or anything like it.

Ted Lavender: Eventually she got a visit from the sheriff who served her with a lawsuit and she was sued for that $229,000.

Dan: And that’s where Ted Lavender entered the scene.

The jury trial in 2018 took six days. As Ted Lavender says, it wasn’t exactly a splashy murder trial, in terms of drama.

Ted Lavender: this was a six day trial involving hospital billing. So, you know, there was no murder weapon. There was no aha, big, gotcha moment that was really exciting.

Dan: But Ted Lavender did his best. Like one time, when he got a hospital executive on the witness stand.

To stabilize Lisa French’s spine, surgeons had implanted 13 pieces of metal into her body. So Ted Lavender had the hospital executive walk the jury through the price for each of those bits of metal. Or actually, the prices..

Ted Lavender: And I first showed him the itemized bill and asked him to identify what they charged for these 13 pieces of hardware .

I had given him sort of an oversized calculator that was sitting there in front of him on the witness stand, admittedly, for some dramatic effect

And through adding these up on the itemized bill, he arrived at the number which was $197,000.

Dan: A hundred and ninety-seven thousand dollars. So that’s about two-thirds of the three hundred and three thousand dollars the hospital is trying to charge Lisa French.

And then the next thing I did was I handed in the 13 invoices that we had received from the hospital,

Dan: That is, Ted handed the guy the invoices the hospital had received — and paid — when it bought those bits of metal..

Ted Lavender: and I asked him to add up and tell this jury what did the hospital pay for these 13 pieces of hardware.

He’s adding, and he’s adding and he’s punching in numbers, and he’s turning pages and he’s adding, and he’s adding with each addition, with each plus the jury seemed to ease a little closer up to the front of their chair, and ultimately he arrived at the total, which was $31,000 and change.

Dan: So the hospital’s charging like six and a half times what they paid. And that’s two thirds of this 300 thousand dollar bill.

Ted Lavender: It just, you know, the jury seemingly did not like that.

Dan: So that was a good moment for Lisa French’s side. I mean getting the jury mad at the other side, that’s a win.

And the big calculator wasn’t Ted Lavender’s only visual: He also had a giant post-it note, where he wrote down, in magic marker, all the different prices the hospital accepted for the surgery, depending on who was paying.

Ted Lavender: and we got these numbers from the hospital, they would’ve accepted $146,000 from private insurance.

Dan: That’s less than half of what they were trying to charge Lisa French. And they accepted less than that — a LOT less — from government-funded insurance, like Medicare, Medicaid, or Tricare, which covers folks in the military.

Ted Lavender: The average of what they would’ve accepted for these. Procedures that Ms. French had were $63,199. Again, Ms. French and her insurance company combined paid almost $75,000.

Dan: You can hear that post-it rustling around. It was a good prop, he’s held onto it. So, he’d shown the jury that the hospital charged a HUGE markup, and that what they were suing Lisa French for was way, way more than they charged anybody else.

On the hospital’s side, they were like, Yeah, but this is our actual sticker price. And Lisa French signed a piece of paper that said she would pay “all charges of the hospital.”

So the hospital was like, yep, and these are our charges. That 303 thousand dollars, it comes from a list we keep. It’s called the chargemaster. That’s what Lisa French was signing up for.

And this became something the jury had to decide:

When Lisa French signed a piece of paper saying she’d pay “all charges of the hospital” — was she specifically agreeing to pay what was on the chargemaster?

And here’s one thing that might’ve made jurors a little skeptical on that score: The hospital never showed that chargemaster list to Lisa French. Not before her surgery, not after it. They said it was a trade secret.

Ted Lavender: they went all the way through trial. Never producing it though. We, we, we asked at the very beginning, once the lawsuit was filed, , basically you get to ask questions. Give me this information, give me information that supports your case or helps my case.

And we ask specifically for the charge master and they refuse to produce it on the basis that it was confidential and proprietary.

Dan: By withholding that list, the hospital may have helped Ted Lavender make his argument: How could Lisa French have known what she was signing up for, if she couldn’t see the prices?

Ted Lavender: if we can’t get it through our subpoena power, how in the world would Lisa Friendship been able to use it by, had she asked?

And admittedly she didn’t ask for it, but if she had, surely they wouldn’t have given it to her either.

Dan: In the end, the jury agreed: Lisa French had not specifically agreed to pay the hospital’s chargemaster prices.

And the only other alternative was: She agreed to pay something reasonable.

The jury decided she owed the hospital seven hundred seventy six dollars and 74 cents

Basically, that’s the three hundred and some left over from the original estimate, plus some extra — because she wound up staying in the hospital one night more than expected: She owed a fee for late check-out.

Of course the hospital did not take that lying down. They appealed the outcome– and won! Ted Lavender appealed that decision, which is how the case ended up in front of the Colorado Supreme Court.

We’ve actually got tape of those proceedings. They’re kinda juicy. Plus the outcome, and why it matters for the rest of us. That’s right after this.

This episode of An Arm and a Leg is produced in partnership with KFF Health News–formerly known as Kaiser Health News.

They’re a national newsroom producing in-depth journalism about health care in America. We’ll have more information about KFF Health News at the end of this episode.

OK, so Lisa French’s case was headed to the Colorado Supreme Court.

And here’s the big issue. Remember how the jury found that Lisa French hadn’t actually agreed to pay the hospital’s chargemaster price, the three hundred and three thousand dollars?

The hospital argued: The jury never should’ve been asked to consider that question.

The law — legal precedent — makes it open and shut: The appeals court had agreed. And it had cited other cases from courts around the country.

So when the hospital’s lawyer, Mike McConnell, got up to address the Supreme Court, he led with those citations.

Mike McConnell: All of the questions that you have raised have been addressed in more than a dozen cases around the country. carefully and thoroughly.

Justice Richard L. Gabriel: Well, let me push back on you. Good morning to you, Mr. McConnell.

Mike McConnell: Good morning.

Dan: This is Justice Richard L Gabriel, stepping right in. He notes that these dozen other decisions all rest on one original case, from 2008, where a court had said: We can’t intervene in health care pricing. Courts shouldn’t try. Health care is too complicated.

Justice Gabriel wasn’t convinced.

Justice Richard L. Gabriel: I guess the question I have is why, you know? I, you know, we may not be the smartest people in the world, but this is a contract and why should the hospital industry— different than any other industry on the planet —have different rules for contract principles?

Dan: The hospital lawyer argued that hospitals couldn’t predict everything that would happen in a patient’s care. In fact, the hospital can’t even control it: Only physicians can decide what treatment to order.

Mike McConnell: You can, uh, I guess imagine that hospitals ought to be able to predict in advance what a particular physician is going to order for a particular patient. Um, and, uh, perhaps, you know, obviously you feel that is the way it ought to be. It is not the way it is, but now

Justice Melissa Hart: Mr. Mr. McConnell, I’m sorry, to interrupt…

Dan: Here’s justice Melissa Hart breaking in

Justice Melissa Hart: …the hospital did provide an estimate in this case. They did calculate what they thought this was going to cost and tell her that. So it is, it seems false to me that they can’t do it. Of course, they can’t predict with absolute certainty. In this case, she had the extra night stay in the hospital and she paid for that. But they can predict in a case like this, and they do.

Dan: The justices didn’t seem super-persuaded by McConnell’s response to that. And that left one more big question in front of the justices.

When Lisa French signed a document promising to pay “all charges,” was she definitely agreeing to pay three hundred and three thousand dollars? Or 229 after insurance.

The appeals court found that the chargemaster rate — the 303 thousand — had been “incorporated by reference” to the document she’d signed, officially called the “hospital services agreement.”

The supreme court wasn’t convinced. Here’s Justice Richard Gabriel again.

Justice Richard L. Gabriel: There’s no reference to the charge master on the face of the hospital services agreement.

How could she have assented to something she never even knew existed?

Dan: And here’s how the hospital’s lawyer responded.

Mike McConnell: When she read the provision, all charges not otherwise paid by insurance. She understood that the hospital charges would, she was responsible for paying the hospital charges that her insurance company did it,

Justice Richard L. Gabriel: Whatever it was. They could have charged her a billion dollars and she’s your position to be she’s bound because she agreed. All charges means all charges.

Dan: Huh! There wasn’t a real comeback to that.

The Supreme Court ruled against the hospital, unanimously. Specifically, they ruled that the chargemaster– the 303 thousand dollars– had not been “incorporated by reference” to the piece of paper Lisa French had signed.

She didn’t know those chargemaster list prices even existed. How could she agree to pay them?

So that meant, the court ruled that, quote, “the hospital services agreements left the price term open.”

Which is language that may ring a bell, if you’ve been listening to this show. It’s a legal principle — a bedrock of contract law:

How the law treats an open-price contract — a contract that doesn’t specify a price term.

Here’s a refresher on that principle from Ted Lavender.

Ted Lavender: if you go to McDonald’s and order a, a quarter pounder with cheese and you know, value meal number three, they tell you the price and that is the price that you have to pay. And then they give you your meal.

You enter that contract with an actual price term

Dan: But you can also enter an open-price contract — a contract without a price term.

Ted Lavender: if you have a contract without a price term, without a specific price in it, then the law infer into that contract a reasonable price.

Dan: In other words, a contract with the price term OPEN is not a blank check. I don’t have to pay whatever number the other side makes up.

And that’s what the Colorado Supreme Court found here.

They ruled that, quote, “principles of contract law can certainly be applied to hospital-patient contracts.” They say, a court may have ruled otherwise in 2008, and other courts may have cited that opinion. We disagree.

The Colorado Supreme Court is saying, even in health care, when no price is specified– when the price term is open– you have the right to a reasonable price.

Yes!

And that’s why Lisa French’s case is so interesting to us, here on this show.

Because we’ve talked here about using this legal principle to fight back against outrageous bills.

We’ve heard from one guy, Jeffrey Fox, who actually took a hospital to small claims court to enforce his right to a reasonable price. And won.

We’ve heard from a listener who tried and failed, but said, more of us should try this.

And this Colorado decision seems like good news for anybody interested in doing something like that.

But honestly, it also raises a few concerns that I had not known about before. First:

Well, there ARE all those other cases out there, in other states, that follow the 2008 case, the one that says health care is too complicated for courts to get into.

And yeah, here’s Colorado saying, “No it isn’t.”

But courts in other states aren’t bound by Colorado’s decision. Hm. And second: there’s also something the Colorado court DIDN’T decide:

What if the paper Lisa French signed had specified, “I agree to pay the hospital’s CHARGEMASTER rates?” Could she be required to pay them then? Even if they were a billion dollars?

In their decision, The Colorado court wrote that the chargemaster rates are “increasingly arbitrary” and “inflated” and “have lost any direct connection to hospitals actual cost.”

So Ted Lavender thinks they might’ve said, No, we can’t be held to a billion dollars, just by adding the word “chargemaster.”

Ted Lavender: I think they would’ve answered that. No, but they did not come right out and actually answer that.

Dan: Because they didn’t HAVE to answer that question.

Ted Lavender: Courts routinely, in fact, it’s almost an objective of appeals courts. They answer as few a number of questions as possible to get to an answer. ,

Dan: So the Colorado court simpley ruled that in Lisa French’s case, the chargemaster rates weren’t “incorporated by reference” into papers she signed.

Those papers didn’t didn’t mention the chargemaster at all– and the hospital kept that chargemaster as a trade secret. Open, shut.

But… hospitals aren’t supposed to keep those rates secret anymore. For the last couple of years, thanks to an executive order from the Trump administration, federal rules have required them to post their chargemaster to the internet.

And so I had all that in mind when I heard from a listener in Atlanta.

Cindi Gatton: my name is Cindy Gatton and I’ve been an independent patient advocate for 11 years now.

Dan: Cindi’s job is helping people deal with medical bills, but she had actually written to me about her experience as a patient.

Before a medical appointment, she got the usual forms online, including one for “Patient Financial Agreement and Responsibilities”

Cindi Gatton: so I thought, you know what? I’m gonna print it and just see exactly what it says. And I’m reading through the thing it says, patient understands and agrees that he, she will be charge. The Piedmont Healthcare Standard charge master rates for all services not covered by a payer or that are self-pay.

I’ve never seen that before, and it shocked me that there was a reference to charge master rates in the financial disclosure.

Dan: And Cindi has been dealing with medical bills full-time for a decade. She’s seen a lot. So when she says it’s new, and that it’s shocking, that seems worth noting.

Cindi Gatton: it just feels wrong to me. It feels really wrong because it, it reminds me of, you know, you, you go to a website and they give you their terms and conditions. Nobody reads those. I don’t read them. You click yes so that you can move on with what it is you wanna do, which is to get care, to be seen by the doctor to, you know, have your procedure.

And I don’t know this, this feels, um, it feels manipulative to me

Dan: Yeah, and to me, it feels ominous. Like lawyers who work for hospitals have been paying attention to the Lisa French decision and thinking:

There’s a wedge here maybe we could exploit. Like, if we get you to sign a document that says “chargemaster” on it, we’re getting you to sign away your right to a reasonable price. After all, the court in Colorado didn’t come out and say that wouldn’t be kosher.

So, where I’m landing at the end of this story is: I’ve got a couple big homework assignments:

First, if I’m interested in seeing how we can use our legal rights to fight back against outrageous, unreasonable bills — and I am —

I need to learn more about which states recognize our rights to a reasonable price in health care, and which ones … maybe don’t. I’m on it, and if you’ve got any tips, please bring them.

That’s the first assignment, and for the second, I’d love your help: How many hospitals are using this “chargemaster” language these days in those financial responsbility documents they ask us to sign?

Do me a favor: See if you can get a copy of that document from any hospital system or doctor group where you get seen. And send me a copy of it?

Redact anything you need to. And also know: we’re not aiming to share this with anybody outside our reporting team.

Here’s what happened when I tried this.

A hospital where I get seen uses a portal called MyChart– a lot of hospitals use it. I just logged on to MyChart there, and I did a little digging around. I found a link to something called “My Documents.” And I found a form there called Universal Consent.”

It has stuff about financial responsibility.

It doesn’t mention chargemaster rates. But it’s a year old. It also says it’s expired.

And here’s an idea I got from Cindi, which I’m gonna try– and which seems worth passing around.

When Cindi found that chargemaster language in the document from her Hospital, here’s what she did. She printed it out and changed it:

Cindi Gatton: what I did is instead of the standard charge master rates, I drew a line through it and I wrote in two x Medicare rates.

Dan: In other words, instead of saying “I’ll pay the chargemaster rates,” it says, “I’ll pay two times the Medicare rate.”

We’ve heard about this strategy before, from former ProPublica reporter Marshall Allen, who wrote about it in his book, “Never Pay the First Bill.”

Here’s the rationale. Medicare pays less than most commercial insurance; hospitals say that at least sometimes they lose money on Medicare. Doubling it seems … generous enough. But it also sets a limit.

So that’s what Cindi wrote on her printout.

Cindi Gatton: I have been taking it with me when I go to be seen that if they ask me for the document that I can say, you know, here it is.

Dan: So far, she says, nobody’s asked for it.

And, I don’t think anybody will be confused, but just to make sure, I’ll say: This isn’t legal advice. I’m not a lawyer. Cindi’s not a lawyer.

She’s just a person going to the doctor, doing her best not to leave too many openings where she could get really screwed. And I’m gonna try following her example.

And I’ve got another request for you: If you try this trick of printing the thing out, exxing out the chargemaster language and writing 2 x medicare rates– LET ME KNOW WHAT HAPPENS, OK?

The place to do all this is on our website at arm and a leg show dot com, slash contact. That’s arm and a leg show dot com, slash, contact.

You are this show’s secret weapon. You’re our eyes and ears. Cindi Gatton’s a listener who got in touch.

How did I first learn about Lisa French’s case? Email from a listener. [Thank you, Terry N, for that note last year! Took us a minute, but we got to this.]

Thank you for listening. You absolutely rule. I’ll catch you soon.

Till then, take care of yourself.

This episode of An Arm and a Leg was produced by me, Dan Weissmann, with help from Emily Pisacreta, and edited by Afi Yellow-Duke.

Daisy Rosario is our consulting managing producer. Adam Raymonda is our audio wizard. Our music is by Dave Winer and Blue Dot Sessions.

Gabrielle Healy is our managing editor for audience. She edits the First Aid Kit Newsletter.

Bea Bosco is our consulting director of operations. Sarah Ballema is our operations manager.

An Arm and a Leg is produced in partnership with KFF Health News–formerly known as Kaiser Health News.

That’s a national newsroom producing in-depth journalism about health care in America, and a core program at KFF — an independent source of health policy research, polling, and journalism.

And yes, you did hear the name Kaiser in there, and no: KFF isn’t affiliated with the health care giant Kaiser Permanente. You can learn more about KFF Health News at arm and a leg show dot com, slash KFF.

Zach Dyer is senior audio producer at KFF Health News. He is editorial liaison to this show.

Thanks to Public Narrative — That’s a Chicago-based group that helps journalists and nonprofits tell better stories– for serving as our fiscal sponsor, allowing us to accept tax-exempt donations. You can learn more about Public Narrative at www dot public narrative dot org.

And thanks to everybody who supports this show financially.

If you haven’t yet, we’d love for you to join us. The place for that is arm and a leg show dot com, slash support.

Thank you!

“An Arm and a Leg” is a co-production of KFF Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

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Dieciocho meses después de que April Adcox se enterara de que tenía cáncer de piel, el pasado mes de mayo, regresó por fin a la Universidad Médica de Carolina del Sur en Charleston para recibir tratamiento.

Para entonces, la zona rojiza a lo largo de la línea del cabello había pasado de ser un círculo de 2 pulgadas a cubrirle casi toda la frente. Supuraba líquido y le dolía.

“La verdad es que esperaba morir de esto, porque pensaba que eso era lo que tenía que pasar”, afirmó la mujer de 41 años, madre de tres hijos y residente en Easley, Carolina del Sur.

Adcox se había reunido por primera vez con los especialistas del centro médico a finales de 2020, después de que una biopsia diagnosticara un carcinoma basocelular. La operación para extirpar el cáncer requeriría varios médicos, le dijeron, incluido un neurocirujano, debido a lo cerca que estaba de su cerebro.

Pero Adcox no tenía seguro. Había perdido su trabajo en una fábrica de automóviles en los primeros días de la pandemia y, en el momento del diagnóstico, sentía pánico ante la complejidad de la operación y la perspectiva de una factura elevada. En lugar de seguir el tratamiento, intentó camuflar la zona cancerosa en expansión durante más de un año con sombreros y flequillos largos.

Si hubiera padecido cáncer de mama o de cuello uterino, probablemente habría tenido derecho a cobertura por una ley federal que amplía el Medicaid a los pacientes de bajos ingresos diagnosticados con esos dos tipos de cáncer.

Para las mujeres con otros tipos de cáncer, así como para casi todos los hombres, las opciones son escasas, especialmente en Carolina del Sur y los otros 11 estados que aún no han implementado la expansión de Medicaid, según oncólogos y expertos en política sanitaria que estudian el acceso a la atención.

Los estudios demuestran que, a veces, los adultos sin seguro retrasan la atención, lo que puede perjudicar las probabilidades de supervivencia. Pero que los pacientes obtengan un seguro para cubrir el tratamiento se parece un poco al juego de la ruleta, es decir, depende de dónde vivan y del tipo de cáncer que padezcan.

“Es muy aleatorio; creo que eso es lo más desgarrador”, afirmó el doctor Evan Graboyes, cirujano de cabeza y cuello, y uno de los médicos de Adcox. “Vivir o morir de cáncer no debería depender del estado en el que vives”.

La Ley de Cuidado de Salud a Bajo Precio (ACA) dio a los estados la opción de ampliar Medicaid para cubrir a más personas. Poco después de la aprobación de la ley, sólo el 2,6% de los adultos de 18 a 64 años con un nuevo diagnóstico de cáncer carecían de seguro en los estados de Medicaid ampliado frente al 7,8% en los estados sin expansión, según un estudio publicado en JAMA Oncology en 2018.

Investigadores de la Sociedad Americana del Cáncer, que realizaron el análisis, estiman que unas 30,000 personas sin seguro son diagnosticadas con cáncer cada año.

Pero en todos los estados, los pacientes sin seguro, de bajos ingresos, con cáncer de mama o de cuello uterino pueden obtener cobertura, incluso si no califican para Medicaid.

Los adultos con cáncer detectado a través del Programa Nacional de Detección Temprana de Cáncer de Mama y de Cuello Uterino pueden inscribirse en Medicaid durante la duración de su tratamiento contra el cáncer, gracias al activismo y la legislación federal que comenzó hace más de tres décadas.

En 2019, se inscribieron 43,549 pacientes con estos tipos de cáncer, según un informe de la Oficina de Rendición de Cuentas del Gobierno (GAO) publicado en 2020.

“Si te diagnostican cáncer de mama o de cuello uterino, tienes suerte”, dijo la doctora Fumiko Chino, oncóloga radioterapeuta del Memorial Sloan Kettering Cancer Center de Nueva York, que estudia el acceso y los costos del tratamiento del cáncer. “De no ser así, puedes enfrentar obstáculos importantes”.

El importe total facturado a la aseguradora durante el año siguiente a un diagnóstico de cáncer puede ser abultado. Por ejemplo, los costos en 2016 ascendieron a un promedio de $168,730 por cáncer de pulmón y $137,663 por cáncer colorrectal, según un estudio de 2022 que calculó las reclamaciones a la aseguradora por varias neoplasias malignas comunes diagnosticadas en pacientes con seguro privado.

Dado que los adultos sin seguro pueden tener dificultades para pagar la atención preventiva, su cáncer puede no ser identificado hasta que esté avanzado, por lo que es más costoso para el paciente y el sistema de salud, explicó Robin Yabroff, autor del estudio en JAMA Oncology y vicepresidente científico de la Sociedad Americana del Cáncer.

Los pacientes que no pueden obtener ayuda financiera a través de un centro de la red a veces acumulan deudas médicas, utilizan tarjetas de crédito o lanzan campañas de recaudación de fondos en internet, dijo Yabroff. “Nos cuentan historias de personas que hipotecan sus casas para pagar el tratamiento del cáncer”.

Los pacientes de cáncer pueden adquirir un seguro a través del mercado de seguros de salud de ACA. Pero a menudo deben esperar hasta el período de inscripción regular al final del año, y esos planes de salud no entran en vigor hasta el comienzo del año siguiente.

Esto se debe a que la ley federal fue diseñada para animar a la gente a inscribirse cuando están sanos, lo que ayuda a controlar los costos, señaló MaryBeth Musumeci, profesora de política y gestión de la salud en la Universidad George Washington en Washington, DC. Si un nuevo diagnóstico te calificara para la nueva cobertura, dijo, “entonces se incentivaría a la gente a permanecer sin seguro mientras están sanos y piensan que no van a necesitar cobertura”.

Mientras tanto, el acceso a la cobertura de Medicaid para pacientes de bajos ingresos con cáncer de mama y de cuello uterino, es una historia de éxito que se remonta a una ley de 1990 que creó el programa nacional de cribado de mama y cuello de útero. Las mamografías empezaron a recomendarse de forma generalizada en la década de 1980, y los activistas presionaron para llegar a más personas desfavorecidas, explicó Katie McMahon, directora de políticas de la Red de Acción contra el Cáncer de la Sociedad Americana del Cáncer.

Sin embargo, una investigación demostró que algunos adultos sin seguro tenían dificultades para recibir atención por los cánceres detectados a través de los cribados, dijo McMahon. Una ley del año 2000 permitía a los estados extender Medicaid a estas personas, y en 2008 los 50 estados y el Distrito de Columbia ya lo habían hecho, según el informe de la GAO de 2020.

Para otros enfermos de cáncer, una de las vías de cobertura que les quedan, según Chino, es reunir los requisitos para la discapacidad a través de la Administración de la Seguridad Social, tras lo cual pueden solicitar Medicaid. La agencia federal tiene una larga lista de criterios para los pacientes con cáncer. También cuenta con el programa Compassionate Allowances, (Beneficios por Compasión), que ofrece revisiones más rápidas para pacientes con determinadas afecciones médicas graves, incluidos cánceres avanzados o agresivos.

Aunque las normas varían, muchos pacientes no califican hasta que la enfermedad se ha extendido o el cáncer requiere al menos un año de tratamiento intenso, explicó Chino. Esto supone un dilema para las personas que no tienen seguro pero padecen cánceres curables.

“Para tener derecho a Medicaid, tengo que esperar a que mi cáncer sea incurable”, dijo, “lo cual es muy deprimente”.

Por ejemplo, el programa de Beneficios por Compasión no incluye el carcinoma basocelular, y sólo cubre el cáncer de cabeza y cuello si se ha extendido a otras partes del cuerpo o no puede extirparse quirúrgicamente.

Adcox dijo que antes de su operación de 12 horas, el pasado mes de junio, su solicitud de ayuda económica a la Universidad Médica de Carolina del Sur estaba aún pendiente. Alguien del hospital calculó que su factura ascendería a $176,000 y le preguntó cuánto podía adelantar. Consiguió reunir $700 con la ayuda de sus seres queridos.

Pero pudo optar a una ayuda económica y no ha recibido ninguna factura, salvo de un proveedor externo de servicios de laboratorio. “Se acabó”, exclamó Adcox. Desde entonces ha recibido radioterapia y se someterá a más operaciones reconstructivas. Pero ya no tiene cáncer. “No me ha matado. No me mató”.

Aun así, no todo el mundo encuentra una red de seguridad.

Brian Becker, de El Paso, Texas, no tenía seguro ni trabajo cuando supo que padecía leucemia mielógena crónica en el verano de 2021, según contó Stephanie Gamboa, su ex mujer y madre de su hija pequeña. Su médico oncólogo le exigió un pago por adelantado, dijo, y tardó varios meses en pedir prestado el dinero suficiente.

Empezó la quimioterapia al año siguiente y, con el paso de los meses, perdió peso y se debilitó, volviendo a urgencias con infecciones y un empeoramiento de la función renal, explicó Gamboa. La última vez que su hija vio a su padre, “no podía levantarse de la cama. Era literalmente piel y huesos”, dijo Gamboa.

Becker inició los trámites para solicitar prestaciones por incapacidad. El mensaje de texto que envió a Gamboa, y que ella compartió con KHN, decía que la revisión de su solicitud comenzó en junio de 2022 y se esperaba que durara seis meses.

La carta de denegación, fechada el 4 de febrero de 2023, llegó más de un mes después de la muerte de Becker en diciembre, a los 32 años. Decía en parte: “Basado en una revisión de sus condiciones médicas, usted no califica para beneficios en esta reclamación”.

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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Prashar, now 14, did a finger stick, saw her blood sugar was 127, and went back to the mat. For most people with diabetes, the target range is about 80-130, and up to 180 two hours after meals.

Prashar doesn’t have to check her blood sugar often. She wears a continuous glucose monitor, or CGM, that gives her blood glucose readings on her phone every five minutes. When she’s feeling differently than her CGM is showing, as on that March day at the gym, she checks her level by doing a finger stick.

But most of the time, she simply glances at her phone to see whether her numbers are trending low or high, which beats repeatedly pricking her finger, she said.

“I would hate it so much,” Prashar said. “It’s such a pain and it’s harder to see trends.”

Montana lawmakers are considering a bill that would require insurance companies to cover CGMs for people with Type 1 and Type 2 diabetes. Multiple studies and experts back up the effectiveness of the devices, showing better blood test results, fewer long-term complications, and a reduction in health care costs.

Studies show CGMs can greatly benefit people with Type 1 diabetes. There are also promising results for people with Type 2 diabetes, the more prevalent of the two types, but the research is limited compared with that on Type 1.

House Bill 758 has broad support from lawmakers, but it faces opposition from insurance companies and some providers. That opposition focuses on the cost, whether a CGM is medically necessary at all stages of diabetes, and the possibility that CGM manufacturers will raise their prices if there is an insurance mandate.

CGMs can be worn on the legs, stomach, or arms, and they stay in place with an adhesive patch. A thin tube goes under the skin and measures blood glucose levels from tissue fluid. The data is transmitted via Bluetooth to a phone or similar device. Instead of a finger prick, which provides a reading for a single point in time, a CGM gives the wearer a continuous stream of data.

According to GoodRx Health, CGMs can cost between $1,000 and $3,000 each year out-of-pocket.

Blue Cross and Blue Shield of Montana, the state’s largest insurer, estimates the bill, if passed, would cost the organization nearly $5 million a year, spokesperson John Doran said.

CGMs aren’t medically necessary in all circumstances, Doran said, and medical necessity should be determined through a partnership between provider and payer. But Doran said that he understands there are instances in which a CGM may be necessary and that Blue Cross already covers CGMs in those cases.

“These things are a convenience,” Doran said. “They provide you real-time information and there is some benefit to a person’s lifestyle to these monitors.”

Lawmakers in several states are considering bills to regulate coverage of CGMs, and Illinois’ governor signed one such bill into law last year.

A study published in the Journal of Diabetes Science and Technology in 2022 says about 30 million Americans have diabetes, a condition in which a person’s body can’t make enough insulin (as in Type 1) or use it effectively (as in Type 2). By 2030, the study estimated, 55 million people in the U.S. will have diabetes, with total medical and societal costs of more than $622 billion — a 53% increase from 2015. According to the American Diabetes Association, nearly 78,000 Montanans have been diagnosed with diabetes.

Various studies, diabetes educators, and health care providers say that CGMs can help people with diabetes reduce their A1C levels, a common measure of blood sugar levels used in diabetes management. Proper management can reduce complications from diabetes — like retinopathy, heart attack, and nerve damage — that lead to higher costs in the health care system through emergency room visits and hospitalizations.

Dr. Brian Robinson, an endocrinologist at St. Peter’s Health in Helena, said supplies for people with Type 1 diabetes are generally covered by insurance. When he considers recommending a glucose monitor for a patient, he said, the decision is driven by insurance rules that are informed by the American Diabetes Association’s standards of care.

“My patients are better because of CGMs, there’s no doubt about that,” Robinson said. But he noted the science doesn’t yet support his opinion that CGMs should be given to everyone with diabetes, no matter what.

Not all physicians, especially in endocrinology, agree that a person with Type 2 diabetes needs a continuous glucose monitor, Robinson said. But if a person needs a shot each day to manage diabetes, he said, that patient should have access to a CGM.

Lisa Ranes, manager of the diabetes, endocrinology, and metabolism center at Billings Clinic, said the benefits of a CGM are the same for people with Type 1 and Type 2 diabetes.

Many studies have shown that CGMs are just as effective for patients on lower quantities of insulin, like some people with Type 2 diabetes, as for people with Type 1 diabetes, who rely on insulin throughout the day.

“It gives patients that complete picture to help them make the decisions on what they need to do to keep their blood sugar safe,” Ranes said, giving examples like upping the frequency or dose of insulin, having some food, or exercising.

For people with Type 2 diabetes, Ranes said, CGMs could be helpful in early diagnosis. Type 2 diabetes is progressive, Ranes said, so the sooner it is under control, the better.

When Cass Mitchell, 76, was diagnosed with Type 2 diabetes over 30 years ago, her doctor told her that people with Type 2 diabetes don’t live long because they have a hard time managing their care.

Mitchell, who lives in Helena, warmed to finger pricks. But test strips were expensive, about $1 each at the time, she said.

About 10 years ago, she got a CGM. Mitchell went from testing maybe twice a day to looking at her blood sugar on an app 20 to 25 times each day. She said she’s more in tune with her diabetes and uses her device’s time-in-range reports — showing how often blood glucose stays within a set range — to make lifestyle changes.

Mitchell has lowered her A1C from around 11% to 7%. According to the ADA, the target for most adults with diabetes is less than 7%.

Mitchell’s device is covered under Medicare and supplemental insurance and would remain so with the passage of HB 758. She said if she had to pay out-of-pocket she wouldn’t be able to afford her CGM and that she was excited about the potential of the bill to give more people access to CGMs.

Dr. Hayley Miller, medical director of Mountain States Diabetes in Missoula, initially thought HB 758 sounded good, but now she isn’t so sure. She thinks the biggest risk of the bill passing is that prices for CGMs go up.

“It seems like I’m against it, but it really is, when insurance gets involved everything gets tricky,” Miller said.

Emma Peterson, a former diabetes educator for St. Vincent Healthcare in Billings and Providence Endocrinology in Missoula, said most people working in diabetes care think everyone diagnosed should just have a continuous glucose monitor.

“At the end of the day, both forms of diabetes and all the other many forms of diabetes have the same complications and still face the same struggles of trying to keep blood sugars in range,” Peterson said.

Keely Larson is the KHN fellow for the UM Legislative News Service, a partnership of the University of Montana School of Journalism, the Montana Newspaper Association, and Kaiser Health News. Larson is a graduate student in environmental and natural resources journalism at the University of Montana.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Nuila’s new book, The People’s Hospital: Hope and Peril in American Medicine, uses the innovative model of the Ben Taub Hospital in Houston, where he practices, to argue for a publicly funded health system in the U.S. that’s available to everybody, with or without insurance. 

Dan Weissmann

@danweissmann

Host and producer of "An Arm and a Leg." Previously, Dan was a staff reporter for Marketplace and Chicago's WBEZ. His work also appears on All Things Considered, Marketplace, the BBC, 99 Percent Invisible, and Reveal, from the Center for Investigative Reporting.

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Transcript: A Doctor’s Love Letter to ‘The People’s Hospital’

Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Dan: Ben Taub Hospital is a publicly funded safety net hospital in Houston, Texas. The majority of patients don’t have insurance of any kind. 

Dr. Ricardo Nuila has been working at Ben Taub since he was an intern, a medical student. He took me on a tour.

Ricardo Nuila: I started here and, you know, literally I just did not want to leave here cuz I just, just really enjoyed my job here

Dan: He’s just published a book called “The People’s Hospital” that’s not just a love letter to the place, it’s a pitch: 

Not only is this place way, way cheaper than what we’re used to, in many ways it’s better. And it’s a model, a real alternative to what-we’re-used-to.

So, I ask him to pick ONE patient’s story from the book to tell, he picks a patient he calls Stephen. A restaurant manager, a Republican. A guy who did not expect to end up here.

But he had a giant lump on the side of his throat, and his insurance didn’t cover much. He paid cash, upfront, to get seen in a local ER. 

Ricardo Nuila: finally there was a doctor who had seen a CAT scan and said, you have tonsillar cancer, cancer, however, you don’t have, uh, insurance 

Dan: Tonsillar cancer. Cancer of the tonsils. That landed hard. So did the “however.” 

Ricardo Nuila: He felt shitty you know, that somebody could tell you cancer, but there’s nothing that we are gonna do about it because of, of how much and…

Dan: It’s like it’s too painful — or too obvious — to finish the sentence: Because of your insurance. Somebody tells Steven to try the public hospital, Ben Taub. He expects the worst. But that’s not what he finds.

Ricardo Nuila: He comes to love this place. He gives, this is like so Steven, but he, he gives gift cards to the people greeting at the door because they’re nice and they do their job well cuz they make his day,

Dan: And it’s not just that he likes the people at the door.

Ricardo Nuila: He feels like he got really good healthcare and that he also, um, thought that the price was extremely reason.

Dan: Stephen lost his insurance when he got too sick to work, and he doesn’t qualify for Medicaid. He owns a house, he’s got savings, Texas has really stringent Medicaid restrictions– so he’s paying out of pocket.

Ricardo Nuila: But his final bill is pennies of what he thought he would pay.

Dan: Stephen’s dad had gotten radiation treatment for cancer, and the sticker price was 700 thousand dollars. Stephen had gotten radiation AND chemo AND surgery — and had been hospitalized for a good while. 

His bill was 32 thousand, three hundred and seventy-eight bucks. Real money for sure, but he can pay it. And it’s less than five percent of his dad’s bill for much less extensive treatment. 

Ricardo Nuila: And the healthcare is really good. And so he’s almost proud that he’s had this experience

Dan: Steven’s become a convert. And as Ricardo Nuila walks me into a conference room, it’s clear: He hopes his book will create more converts. 

Ricardo Nuila: you start to see this model and it makes you think, can things be different in healthcare? I think that that’s an option. But we as a country haven’t thought about that. Seriously. You know?

Dan: And if it seems politically unimaginable that we could have anything like this around the country– an effective, efficient, CHEAP, publicly-funded health system– 

Well, the idea that Houston could have one, that was pretty unlikely too.

In fact, the story of how Ben Taub got here may be the most surprising story in Ricardo Nuila’s whole book. 

This is An Arm and a Leg, a show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann. I’m a reporter, and I like a challenge. So our job on this show is to take one of the most enraging, terrifying, depressing parts of American life and to bring you a show that’s entertaining, empowering and useful.

Ben Taub Hospital sits at the edge of the Texas Medical Center– that’s a giant neighborhood full of hospitals and medical schools, including some of the best in the country, like the M.D. Anderson cancer center. 

In his book, Ricardo Nuila writes about how some patients at Ben Taub can see from their rooms the gleaming buildings of Ben Taub’s neighbors. 

So when I visit, I make him show me the view. We look out from a stairwell at a glass tower, M.D. Anderson’s Sheikh Zayed building.

Ricardo Nuila: that’s glamorous. Right? you get a glimpse into the rest of the medical center here. Ben Taub sticks out, I feel like, because it’s, it’s brick versus glass. 

Dan: But as Ricardo Nuila makes clear in his book: This unglamorous brick building gets the job done. 

In addition to Steven, there’s Ebonie, whose complicated pregnancy — there’s a lot of vaginal bleeding– gets tracked more precisely than it would elsewhere: 

At other hospitals, nurses eyeball the pads that absorb that blood and note heavy, medium or light bleeding. At Ben Taub, they’ve adopted an innovative approach: weighing each pad to get an exact measurement. 

Another patient, Christian, has bounced around other systems without anybody accurately diagnosing the dire kidney problems that have kept him in pain for years. Because he didn’t have good insurance, it wasn’t worth anybody’s time. 

At Ben Taub, insurance isn’t an obstacle, 

Ricardo Nuila: We organize things, which is basically, okay, we need to focus on your kidneys right now and we need to get you to see a geneticist. And both of those things happened.

Dan: they not only diagnose him, they get him on a form of dialysis that he can manage himself at home.

It’s cheaper, and delivers better quality of life for him.

Everything at Ben Taub is cheaper. The system spends about a third as much per patient as the national average. In part, that may be because nobody earns million-dollar salaries here. 

But Ricardo Nuila makes the case over and over again that they take the time– because they have it– to make wise use of resources. 

They don’t have as many MRI machines as other hospitals. But guess what? A lot of patients don’t need MRIs. 

But Ben Taub can’t meet every need: One patient, Geronimo, needs a liver transplant, and that requires resources the hospital just doesn’t have. 

But Ricardo Nuila and his colleagues put a lot of time into wrenching him back onto Medicaid, so he can get the transplant somewhere else. They rope in a Congressman to get it done. 

Geronimo tells his mom:”I feel so important. Everyone treats me like I’m rich.” 

Ricardo Nuila: That’s what I think a lot of people really want is just the sense that the person who’s responsible for your care is thinking through the problem with you and aware that you are not having a great day and wants to deal with that situation with you. And I just felt like this environment allowed me to like, have those moments.

Dan: So who pays for this environment? It may be cheaper, but it isn’t free. 

Some patients are on Medicaid. Some are on Medicare. Some have private insurance. But the majority don’t have any insurance at all. 

Some, like Stephen, pay cash. And a lot of the rest — about a third of Ben Taub’s patients — are treated for free.

The bulk of Ben Taub’s funding comes from a special property tax in Harris County, where Houston is located. It funds a whole system called Harris Health– Ben Taub, a second hospital, and a bunch of clinics. 

And of course, none of this has always existed. 

In fact, it’s only here, like this, because of a really wild story, with two big characters. One of whom wasn’t even from Houston. He was a writer I’d never heard of, a Dutch guy named Jan de Hartog.

Ricardo Nuila: de Hartog was one of the most amazing people that you could read about. He was a Nazi resistance fighter, Dutch ship captain. 

Dan: And while he was hiding out in Denmark during the war– in between saving a few Jewish babies and running war missions in his tugboat–  

he wrote a romantic dramedy that — later became a broadway hit. And then got adapted into a Broadway musical called I Do, I Do– which, Broadway-musical nerds in the house– starred Mary Martin and Robert Preston– you know, The Music Man– and had a song that your mom might still remember. 

 (musical sounds) 

Dan: Yeah. So, interesting guy. And in the early 1960s he came to Houston to teach playwriting at a local University.  It was a big time for him. He’d just gotten married — for the third time, but this one was for keeps- and become a Quaker. 

Ricardo Nuila: And when he and his wife Marjorie come to Houston, they find that there’s all these whisperings about this charity hospital in town in Houston about how, how awful the conditions are. That the children in the maternity ward would cry all night for the, for a lack of milk, and so as part of his faith, he decides that he needs to volunteer there

Dan: When de Hartog writes about the hospital later, he describes the experience of walking in for the first time as literally mind-boggling. 

He’s like: I know what a hospital smells like. Disinfectant, maybe some fresh laundry. And I know what a slaughterhouse smells like: Blood, and shit. And the smell here is slaughterhouse. 

As he looks around, the sights are something else.

Ricardo Nuila: He sees a cockroach crawling into the tracheostomy of like a patient. He sees like people sitting in their own filth. 

Dan: He and Marjorie do not up and quit. They stick around. And then they recruit a dozen Quakers and a few society ladies to come volunteer with them, and get the Red Cross to train them.

And it’s nuts. This is a rich city. The ZOO is air conditioned. But not this hospital. 

And he starts to catch on: Why it’s so horrible.

Number one is racism. 

The hospital serves mostly Black and Brown patients. When Jan and Marjorie start volunteering, the other volunteers are all society ladies, and the whole program is set up so they don’t touch patients. DeHartog later says he asked why, and the volunteer coordinator says, Southern ladies can’t have physical contact with black people.

But she doesn’t say black people. She uses the n-word. 

 When he asks staff why public officials don’t do something about the rotten conditions, they say: What politician is going to stick up for black people? The n-word comes up again. 

And– de Hartog doesn’t make this connection, but it seems pretty on the nose: The hospital itself is named after Jefferson Davis, who led the Confederacy in the Civil War. 

But there’s also a political mechanism for institutionalizing this neglect, without ever having to acknowledge the role of racism: 

No one particular political entity — no one particular political leader– is responsible for the public hospital, financially. The city of Houston and Harris County are each supposed to kick in HALF. So it doesn’t belong to either of them. Here’s de Hartog describing the city-county dynamic in a lecture he gave many years later. 

Jan de Hartog: And they were continuously at each other’s throats. The one said, you don’t pay enough. The other said, but you don’t. And they went back and forth

Dan: The top official for Harris County actually has the title County Judge. At that time, this was a guy named Bill Elliott. 

And you’ll hear in this clip from a local newscast, he wasn’t exactly reaching for the bill. Here he is, explaining why the some problem with the hospital is actually the CITY’s fault. 

Judge Bill Elliott: it’s absolutely ridiculous, uh, to say that, uh, this is a responsibility and this is the fault of Harris County.

Dan: And the city? At least one.council member is calling for a budget cut. 

Which really pisses de Hartog off. 

And de Hartog actually loves the city. It’s an exciting place. It’s booming– growing super-fast. And it’s not just an oil town. 

Ricardo Nuila: Houston at that time was the home of NASA.

NASA narrator: Future manned space flight missions to the moon and perhaps the planets will be commanded from this control room of the Mission Control Center at NASA’s Manned Spacecraft Center,

Ricardo Nuila: It had built this Astrodome, it was the city of the future. 

Dan: The Astrodome– you know, a sports stadium WITH AIR CONDITIONING. . 

Astrodome Narrator: A fully enclosed building, large enough for any sport convention show or conclave with constant temperature and humidity independent of outside weather,

Dan: CBS News does a report about the booming city: NASA, the oil wealth, the Astrodome. And de Hartog is a main character– talking about how much he loves the town.

Jan de Hartog:  it is a city of, a city of unlimited opportunities. It’s an immensely exciting town, and you feel that anything is possible, 

Dan: It wraps up with Walter Cronkite talking about how everybody in town is absolutely nuts about football.

Walter Cronkite: Their brand of football is like their brand of city and brand of life. Play wide open. Take a chance, try anything. Above all, do it with zest and do it big. 

Dan: Oh, and there’s this OTHER thing Houston is really becoming known for. 

Cutting edge medicine. For twenty years, the city’s been building the Texas Medical Center — that giant campus where more than a dozen hospitals and med schools now operate right on top of each other. Baylor College of Medicine actually moved from Dallas to Houston to be part of it. 

Ricardo Nuila: Houston is a really deeply medical city. And at that time they’re all working on extraordinary things

Dan: Yeah, in 1964, while Jan de Hartog is witnessing the suffering at the charity hospital, Dr. Michael deBakey is performing the world’s first coronary artery bypass at a private hospital in town. 

But the medical establishment were not allies. Jefferson Davis hospital, on the outskirts of town, was about to be replaced by a new building in the Texas Medical Center. 

But the Medical Society– the local doctors’ association — hadn’t wanted the charity hospital as a neighbor. They’d actually put up a ballot initiative to keep the new building at the old site. 

Medical Society Voice-Over: you the taxpayer, will pay the extra cost That’s why your doctor recommends you vote for the new hospital to remain at its present site. 

Dan: It hadn’t worked, but along with the budget cuts, officials were now talking about DELAYING the charity hospital’s move to the new building, which had just been completed. De Hartog and his friends, smell a rat. 

They think the powers that be are actually going to sell the new building in the Medical Center to some other hospital that wants in. This has been a public conversation.

Jan de Hartog: There had been offers to buy it and they wanted to wait for the highest bidder

Ricardo Nuila: He writes a series of op-eds for the Houston Chronicle that start to get press, not just in Houston, but around the country and in fact around the world. 

Dan: He describes the awful things he’s seen. And he appeals to Houstonians’ sense of pride in their bustling, futuristic city. A city he loves, too. Here’s how his first op-ed ends…

Jan de Hartog: I cannot believe that it is the will of the citizens of Houston, that our growing medical center rightly becoming famous all over the. Shall be allowed to harbor the cancerous sore of man’s inhumanity to man. It would turn the entire center planned as Houston’s glory into Houston’s shame. 

Dan: Even just that first op ed made a lot of noise.

Jan de Hartog: the bomb exploded and the national magazines and newspapers and TV zeroed in on the hospital to find out what was going on, 

Dan: … and immediately, the hospital DOES move into its new home in the Medical Center. But the funding issue isn’t solved. 

So de Hartog keeps pushing. 

Ricardo Nuila: He writes a book called “The Hospital” 

Dan: He goes to churches around town, synagogues, everywhere he can, recruiting hundreds of volunteers. 

But there’s no political progress — and conditions at the hospital actually get worse. Key nurses get burned out and quit. Things go to hell.

In a harrowing diary entry, he writes about full bedpans left on tables next to trays of food. About a patient crying out for help, and hearing back “Shut up!” 

Jan de Hartog: Never before had I realized to this extent, the depth of our damnation, and at that deepest moment of desperation, when we knew nothing could be done, nothing would change for the simple reason that

Jan de Hartog: those who had the fate of the hospital in their hands were not there. Mayor Welsh didn’t work there. Uh, commissioner Bill Elliot Judge, the county judge did not work there. 

Dan: But THEN, there’s a turn. Somebody shows up. That’s right after this.

This episode of An Arm and a Leg is produced in partnership with Kaiser Health News. That’s a non-profit newsroom about health care in America. KHN is not affiliated with the giant health care player Kaiser Permanente. We’ll have more information about KHN at the end of this episode.

So, Jan de Hartog keeps slogging away. 

He gives a talk at a Baptist church– he reads that diary entry, the one with the bedpans, and the absence of Judge Elliott and other leaders.

And at first he thinks he didn’t go over so big. Nobody even raises their hand to volunteer. 

But then it happens. 

Jan de Hartog: When, uh, we were about to leave, a man turned up with a baby on his hip who said, uh, do you train people at night?

Dan: And the guy seems to be looking around, trying to make sure nobody’s listening. De Hartog tells the guy, yeah, we could do that…

Jan de Hartog: He said, I mean, a dead of night without anybody seeing. 

Dan: De Hartog’s like, “um, sure, I guess. Why, though?” 

Jan de Hartog: He said, well, I am Judge Elliot, 

Dan: Judge Elliott. The county judge. Probably the most powerful politician in town. That’s who wants to volunteer. In secret. Without anybody seeing. He says to de Hartog

Jan de Hartog: I cannot do it as a judge, but I must do it as a man. And that was the moment that the whole damn thing changed.. 

Dan: Because Judge Bill Elliott followed through.

Ricardo Nuila: He trains himself in a clandestine manner to be an orderly, at night, and he verifies everything that de Hartog has said. 

Dan: de Hartog actually oversees the judge’s final practical exam, where Bill Elliott tends to an African-American man named Willie Small. 

Jan de Hartog: the judge with his thermometer went and put his hand on Willie’s shoulder and said, Mr. Small, sir, I’d like to take your temperature to hear that, to hear a southern judge, , say “Mr. Small, sir” 

Dan: It was a symbolic moment. The judge had to touch, had to defer to, a Black man. So not only had the judge now seen everything, he took responsibility for what he had seen. 

There’s a proposal for a county-wide property tax, to fund what’s called a Hospital District. Now there’s a referendum, and Elliott backs it all the way.

Jan de Hartog: and we all waited with baited breaths for the outcome. And it was no

Dan: Yeah. The referendum fails. And as de Hartog tells it, once it does, a real backlash starts to build. It gets personal.

Jan de Hartog: those who had resented our presence from the very beginning became vocal. Margie and I, were called communists

Ricardo Nuila: De Hartog just would not flinch. I mean, he and his wife’s lives were threatened. 

Dan: Also, somebody threw a bag of excrement at their door. 

Eventually, de Hartog says the Red Cross, which was training and supervising volunteers at the hospital, came to him and Marjorie and said, “It might be better for us if you left town for a while.” 

They did — went on to all kinds of adventures. 

Meanwhile, Bill Elliott kept pushing, and keeps pulling in allies– including, eventually, the Medical Society. 

Ricardo Nuila: he rallies them to get behind it.

Dan: He gets the question on the ballot AGAIN later that same year. And it passes in November 1965. 

It’s a big moment. 

Ricardo Nuila:  What’s also interesting is that it’s forgotten. Something that I’ve gleaned from all this is that you know, people will forget and you have to remind them. 

Dan:  And while we’re remembering: In 1965, the whole country is making some big commitments to health care for a lot of people. President Lyndon Johnson signs Medicare and Medicaid into law in July of that year.

It’s probably also worth noting that Medicare and Medicaid help make Ben Taub possible: About a third of the hospital’s patients are on one or the other. It’s a minority of patients, but it’s many millions of dollars of funding. 

The 1960s were a notoriously divisive time. And so is this. 

Ricardo Nuila doesn’t ignore today’s political polarization — or how that polarization makes it hard to imagine a national conversation about creating a different health care system. 

Or the role that doctors have historically played in resisting that conversation.

It’s part of his story. His family story. And in a book about a place where a lot of sad things do happen, this may be the toughest one.

Ricardo Nuila: I was born into a family of doctors and my dad in many ways was a hero to me. I saw how much pride he took in his work of being a doctor 

Dan: But over time– as insurance companies got tougher to deal with– the business side of running a medical practice looked a lot less apealing. 

Ricardo Nuila: . He had to hire more and more staff. He hired his mother, my grandmother, who is, uh, the type of person not to back down from Chicago, you know, . And so, her job was to be on the insurance companies to make sure that they wouldn’t, screw him out of money.

Dan: His dad turned away patients who didn’t have insurance. His dad growled and grumbled– about insurance companies, and about patients who didn’t have money to pay. 

When Ricardo finished college and got into medical school, he put off starting for two years. What he sees as his dad’s life in the business of health care is not appealing.

Ricardo Nuila: the grind wears on him, you know? The fighting with the insurance companies

Dan: I mean in the book, your dad is a bit of a stand-in for . For doctors as a doctoring, as profession and the, and the way in which doctors get alienated from medicine. 

Ricardo Nuila: yeah, he is a stand in a bit for doctors. And it’s gonna be, I think the doctors have a lot to say about how healthcare goes in America,

Ricardo Nuila: And unfortunately, the history shows that they haven’t been a great piece of that, at least as far as universal healthcare is concerned. 

Dan: This becomes part of Ricardo’s story with his dad. Dad invites him to form a family practice. Ricardo chooses Ben Taub. And over the years, it becomes clear: They’re on opposite sides of a political divide. There are painful conversations, and then they go months without speaking. 

Ricardo Nuila: that’s how deep politics run, you know, it’s really, it’s really difficult when you overlay like politics onto like a family dynamic,

Ricardo Nuila: It just felt like he was like totally on board with this idea that, you know, healthcare is something that is earned and healthcare is something that people, if you can’t afford it, you don’t deserve it. Is what I heard from what he was saying. 

Dan: is your dad an ideal reader of the book? Is your dad kind of who the person you wanna make that case to? 

Ricardo Nuila: That’s really interesting.

Ricardo Nuila: I would say this, that, I did not write this to preach to the choir for sure.

Dan: But he’s not sure his dad would actually pick up a book like this.

Ricardo Nuila: It’s just because I know my dad, he, my dad’s the type of person who reads John Grisham on a beach, you know? So I’m not a hundred percent sure if he would pick up this book, you know?

Dan: Unless, say, his son wrote it. Ricardo does expect his dad to read The People’s Hospital. And even if he doesn’t agree with everything his son has written, Ricardo thinks his dad will be proud.

Ricardo Nuila: I can tell you now as a, as a father, , it’s not clear that your kids are gonna come out Okay. . You know what I mean? I’m just saying that like he has reason to be proud just because I’m a, a living and breathing person right now, you know?

Ricardo Nuila: And I’m, I’m working in as a doctor. So I, I feel, I feel good for him. 

Ricardo Nuila: And I think that he’s probably very happy that I wrote about medicine cuz he loves medicine.

Dan: The last chapter of “The People’s Hospital” is called “faith” And in it, Ricardo Nuila describes a daily ritual that he says keeps him grounded. It starts with passing a plaque on his way in. Of course I have him show it to me. 

Ricardo Nuila: I park like right over there, .

Ricardo Nuila: I come in here and I just look at, look at this every time. 

Dan: So, and describe what we’re seeing here.

Ricardo Nuila: Well, we’re seeing, a plaque that, talks about when this hospital was founded, and the people who constructed the building. And there’s also the, I forgot this is, this is bad of me, but I forgot the name.

Dan: the snake around the stick?  

Ricardo Nuila: I’m in big trouble now because I’m on the Caduceus Caduceus. I, it’s the Cadus. Yeah. 

Ricardo Nuila: And it’s just a reminder, you know, that we have this structure in place to help care for people who don’t have, uh, the means and that, and 

Dan: that people decided to put this building here. Yeah. 

Ricardo Nuila: Exactly. It’s a community effort.

Dan: Ricardo Nuila writes that he sees that community as he walks from that plaque to his desk– all the co-workers, in every kind of job, doing their best. 

And this is the faith that he says gets affirmed— reading from the book here: 

If someone is suffering and there is the capacity within the community to help, in a way that doesn’t harm anyone else, then we not only owe it to that person, we owe it to ourselves to help. 

Whatever your politics are, I think that’s pretty great. 

Dr. Ricardo Nuila practices at Ben Taub Hospital. He’s associate professor of Medicine, Medical Ethics and Health Policy at Baylor College of Medicine. His book is called “The People’s Hospital.”

Honestly there’s a lot in this book, — more patient stories, more family stories, a very deft summary of a hundred years of health care economics and politics.

I’ll tell you: reading this book, I was reminded of an idea I’ve had before.  That it might be cool someday to convene a kind of “Arm and a Leg” book club. Because I’d like to have someone to talk with about a book like this– like maybe you. 

Right now, that’s just an idea. The how would take a LOT of figuring out.  

But I’m curious how that idea sounds to you. You can let me know at Arm and a Leg show dot com, slash contact.

I mean, that’s always a good place to send ideas and stories and questions— so many of our best episodes come from you.

And I’m curious what you think about this virtual book club idea. If you’ve taken part in something like this, or helped to organize it, I’d love to hear how it went.

That’s arm and a leg show dot com, slash contact.

Next time on An Arm and a Leg: A woman named Lisa French asked her hospital what her surgery would cost her. They said, with your insurance, about thirteen hundred bucks.

They expected about 55 thousand more from insurance. 

They got 75 thousand. But then they wanted more. 229 thousand more. They wanted it from Lisa French, and they sued her for it.

After eight years, the case finally got resolved last June. Lisa French won!

The case has a LOT to teach us about our legal rights. 

That’s next time on An Arm and a Leg.

Till then, take care of yourself.

This episode of An Arm and a Leg was produced by me, Dan Weissmann, with help from Emily Pisacreta, and edited by Afi Yellow-Duke.

The recording of Jan de Hartog’s lecture is courtesy of the Baylor College of Medicine Archives. 

The audio of Bill Elliott is from a KHOU-TV newscast, thanks to the Texas Archive of the Moving Image.

Big thanks to the archivists who helped us find some of the tape for this episode! 

That includes Emily Vinson at the University of Houston library 

Matt Richardson and Sandra Yates at the Texas Medical Center Archives

And David Olmos at the Baylor College of Medicine archives. 

Daisy Rosario is our consulting managing producer. Adam Raymonda is our audio wizard.  Our music is by Dave Winer and Blue Dot Sessions. 

Gabrielle Healy is our managing editor for audience. She edits the First Aid Kit Newsletter. 

Bea Bosco is our consulting director of operations. Sarah Ballema is our operations manager. 

This season of an arm and a leg is a co production with Kaiser health news. That’s a nonprofit news service about healthcare in America, an editorially-independent program of the Kaiser family foundation. 

KHN is not affiliated with Kaiser Permanente, the big healthcare outfit. They share an ancestor: The 20th century industrialist Henry J Kaiser. When he died, he left half his money to the foundation that later created Kaiser health news.

You can learn more about him and Kaiser health news at arm and a leg show dot com slash Kaiser. 

Zach Dyer is senior audio producer at KHN. He is editorial liaison to this show. 

Thanks to Public Narrative — That’s a Chicago-based group that helps journalists and non-profits tell better stories– for serving as our fiscal sponsor, allowing us to accept tax-exempt donations. You can learn more about Public Narrative at www dot public narrative dot org. 

And thanks to everybody who supports this show financially. 

If you haven’t yet, we’d love for you to join us. The place for that is arm and a leg show dot com, slash support.

Thank you!

“An Arm and a Leg” is a co-production of KHN and Public Road Productions.

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KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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