KFF Health News' 'What the Health?': American Health Gets a Pink Slip
The Host
Julie Rovner
KFF Health News
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 Department of Health and Human Services underwent an unprecedented purge this week, as thousands of employees from the National Institutes of Health, the FDA, the Centers for Disease Control and Prevention, and other agencies across the department were fired, placed on administrative leave, or offered transfers to far-flung Indian Health Service facilities in such places as New Mexico, Montana, and Alaska. Altogether, the layoffs mean the federal government, in a single day, shed hundreds if not thousands of years of health and science expertise.
Meanwhile, the Supreme Court heard a case about whether states can bar Planned Parenthood from providing non-abortion-related services to Medicaid patients. But by the time the case is settled, it’s unclear how much of Medicaid or the Title X Family Planning Program will remain intact.
This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs Zhang of Bloomberg News, Sarah Karlin-Smith of the Pink Sheet, and Lauren Weber of The Washington Post.
Panelists
Rachel Cohrs Zhang
Bloomberg News
Sarah Karlin-Smith
Pink Sheet
Lauren Weber
The Washington Post
Among the takeaways from this week’s episode:
- As details trickle out about the major staffing purge underway at HHS, long-serving and high-ranking health officials are among those who have been shown the door: in particular, senior scientists at FDA, including the top vaccine regulator, and even the head veterinarian working on bird flu response.
- The Trump administration has also gutted entire offices, including the FDA’s tobacco division — even though the division’s elimination would not save taxpayer money because it’s not funded by taxpayers. Still, the tobacco industry stands to benefit from less regulatory oversight. Many health agencies have their own examples of federal jobs cut under the auspices of saving taxpayer money when the true effect will be undermining federal health work.
- Democratic Sen. Cory Booker of New Jersey set a record this week during a marathon, 25-hour-plus chamber floor speech railing against Trump administration actions, and he used much of his time discussing the risks posed to Americans’ health care. With Republicans considering deep cuts that could hit Medicaid hard, it’s possible that health changes could be the area that resonates most with Americans and garner key support for Democrats come midterm elections.
- And the tariffs unveiled by President Donald Trump this week reportedly touch at least some pharmaceuticals, leaving the drug industry scrambling to sort out the impact. It seems likely tariffs would raise the prices Americans pay for drugs, as tariffs are expected to do for other consumer products — leaving it unclear how Americans stand to benefit from the president’s decision to upend global trade.
Also this week, Rovner interviews KFF Health News’ Julie Appleby, whose latest “Bill of the Month” feature is about a short-term health plan and a very expensive colonoscopy. Do you have a baffling, confusing, or outrageous medical bill 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: Stat’s “Uber for Nursing Is Here — And It’s Not Good for Patients or Nurses,” by Katie J. Wells and Funda Ustek Spilda.
Sarah Karlin-Smith: MSNBC’s “Florida Considers Easing Child Labor Laws After Pushing Out Immigrants,” by Ja’han Jones.
Lauren Weber: The Atlantic’s “Miscarriage and Motherhood,” by Ashley Parker.
Rachel Cohrs Zhang: The Wall Street Journal’s “FDA Punts on Major Covid-19 Vaccine Decision After Ouster of Top Official,” by Liz Essley White.
Also mentioned in this week’s podcast:
- Stat’s “Laid-Off HHS Leaders Offered Transfers to Remote Indian Health Service Regions,” by Usha Lee McFarling.
- The Washington Post’s “Fired Health Workers Were Told To Contact an Employee. She’s Dead.” By Lauren Weber.
- Georgia Recorder’s “Bill That Criminalizes Abortion, Undermines IVF Access Gets Georgia House Panel Hearing,” by Jill Nolin.
Click to open the transcript
Transcript: American Health Gets a Pink Slip
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, April 3, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go.
Today we are joined via videoconference by Sarah Karlin-Smith of the Pink Sheet.
Sarah Karlin-Smith: Hi, Julie.
Rovner: Lauren Weber of The Washington Post.
Lauren Weber: Hello hello.
Rovner: And we welcome back to the podcast Rachel Cohrs Zhang, now at Bloomberg News.
Rachel Cohrs Zhang: Hi, everyone.
Rovner: Later in this episode we’ll have my interview with my colleague Julie Appleby, who reported and wrote the latest KFF Health News “Bill of the Month,” about yet another very expensive colonoscopy. But first, this week’s news.
We’re going to start this week, as usual, with the latest changes to the Department of Health and Human Services from the Trump administration. But before we dive in, I want to exercise my host prerogative to make a personal observation for those who think that what’s happening here is, quote, “politics as usual.” I am now a month into my 40th year of covering health policy in Washington and HHS in particular. When I began, Ronald Reagan was still president. So I’ve been through Democratic and Republican administrations, and Democratic- and Republican-controlled Congresses, and all the changeovers that have resulted therefrom.
And obviously the HHS I cover today is far different from the one I covered in 1986, but I can safely say I have never seen such a swift and sweeping dismantling of the structure that oversees the U.S. health system as we’ve witnessed these past 60 days. Agencies and programs that were the result of years of expert consultations and political compromises have been summarily eliminated, and health and science professionals with thousands of years of combined experience cut loose via middle-of-the-night form emails. To call the scope and speed of the changes breathtaking is an understatement, and while I won’t take any more personal time here, if you want to hear me expand further on just how different this all really is, I’m on this week’s episode of my friend Dan Gorenstein’s “Tradeoffs” podcast, which you should all be listening to anyway.
All right. That said, now let’s dive in. I suppose it was inevitable that we would see the results of last week’s announced reorganization of HHS on April Fools’ Day. Let’s start with who was let go. While the announcement last week suggested it would mostly be redundancies and things like IT and HR and procurement, there were a bunch of longtime leaders included in this purge, right?
Karlin-Smith: Yeah. At FDA [the Food and Drug Administration] there were some of the most senior scientists, like their Office of New Drugs directors, their chief medical officer, almost everybody who works on policy, legislative affairs, entire communications offices, external affairs. And even in the case where they are laying off people whose job titles might sound extraneous, or not as important to the health of people in the U.S., I think you can sort of debate that, but they did it in such a way that they laid off so many people in those departments that the people they said, We are protecting, because we do at least understand these jobs are important, cannot actually fully do their jobs. So scientists are not able to access the supplies they need. It’s not even clear how people at FDA are going to get paid and do their timesheets and track time given how many people they laid off.
And it also just seems like there’s been a ton of, again, to the extent they were trying to protect certain positions that they deemed more critical to U.S. health and well-being, like medical reviewers or inspectors, they didn’t quite understand who actually is critical to doing that work, because it’s not just somebody who has, like, “inspector” in the title. Vanity Fair had a great piece about this man who really has saved people in the U.S. from going blind by helping inspectors catch sterility issues in eye drops, and they walk through very clearly how people like him do not have a title of inspector but are absolutely needed to ensure we have drugs that are safe for people in the U.S. So, probably not surprising to people who’ve tracked the administration so far, but it’s been a lot of the move-fast -break-things, and then realize on the back end that they maybe broke things they didn’t necessarily mean to, or don’t actually care as much about whether it’s broken.
Rovner: Lauren.
Weber: They got rid of the head veterinarian on the bird flu response. That would seem to be a thing that is surprising. I spoke to a congressman yesterday who said that seems very dumb. It’s not just that. They also eliminated entire swaths of the CDC [Centers for Disease Control and Prevention], small agencies that maybe a lot of people have no idea alphabetically what they do but are pivotal in preventing injury deaths, and in really the preventative and chronic disease care that RFK [Robert F. Kennedy Jr.] has said is really vital to getting America back on track. When we talk about dollars and cents saved in health care, a lot of that is in chronic disease and in preventative care. And to see some of these places get hit so broadly is quite shocking considering the end goal is allegedly to save money.
Rovner: There are also a lot of things that seem sort of at odds with [President Donald] Trump’s own agenda. David Kessler, the former FDA commissioner, was on TV last night talking about how the people who answer the phones when a doctor wants to get an emergency use authorization for a drug that’s not yet approved. That’s something that’s been a very big deal for Donald Trump. The people who answer the phones got fired. So, when a doctor has a patient who, nothing else will work and they need an experimental drug, and they’re supposed to be able to call FDA. And I think there are rules about how fast FDA is supposed to respond. But now there’s nobody to actually answer the phone and take those requests.
Karlin-Smith: Yeah, I think the list of things that don’t seem to align is very long. One thing I was talking to somebody about yesterday who said, well, pretty much everybody who deals with tracking pesticides in foods, and food safety at the FDA in regards to pesticides was let go. And making our food system healthier and safer, and concerns about pesticides, has actually been a big focus of RFK. Similarly, Martin Makary talked a lot in his opening speech to FDA employees yesterday about obesity, and they are basically gutting offices that work on pediatrics, minority health. They’ve laid off lots of people in their tobacco division at FDA, and FDA’s tobacco division actually is not funded at all by taxpayer funding. So, I have a hard time understanding how anybody besides the tobacco industry really benefits from this loss. As Lauren said, it’s like every health agency, you can kind of find examples of that. They say America is not healthy, but they’re cutting these top researchers that have found incredible advances in Parkinson’s and some of the chronic diseases he’s most cared about.
Rovner: They also, I mean, there are some big names who were let go. We didn’t even — the Peter Marks firing at FDA happened last week after we taped, so we haven’t even talked about that. Somebody tell us who Peter Marks is and why everybody’s all freaked out about that.
Cohrs Zhang: Well, Peter Marks was head of the division of biologics and the top regulator of vaccines, and complicated injectable medicines like insulin products, too, fell under his purview. And I think we saw markets react in a panic on Monday. The shares of vaccine makers like Moderna were falling. And we saw companies selling gene therapies that Peter Marks has been really involved in regulating and championing through some of those processes, they were kind of freaked out because it just creates uncertainty as to kind of what the new philosophy toward these medicines will be. And the Trump administration, we’ve seen, especially on the Marks being pushed out, I think they’ve tried to highlight some of his more controversial actions in the past.
We saw a White House adviser, Calley Means, was personally attacking Marks for some conflicts he had with vaccine regulators during debate over the covid booster approvals, and just his decisions to overrule recommendations by FDA experts on some innovative medications that some people disagreed with. But the perspective from former officials has been that, like Peter Marks or not, the idea that scientific expertise is being purged in this way is concerning. And it wasn’t just Peter Marks. There’s another regulator at the Office of New Drugs, Peter Stein. who was pushed out. We have Anthony Fauci’s successor at NIH [the National Institutes of Health] was pushed out, Jeanne Marrazzo, as well as a couple other heads of scientific research institutes at NIH.
Rovner: Anthony Fauci’s wife was pushed out—
Cohrs Zhang: Yeah. Yeah.
Rovner: —as the head of the office of bioethics at NIH.
Cohrs Zhang: Truly, and I think we had heard that some of these more politically sensitive center leader positions would be at risk. We’ve heard this for a very long time, but it seems like they took advantage of the chaos to implement some of these high-level cuts to people that they may have disagreed with. But, like, people will be filling those positions. I don’t know that there’s a cost-saving argument there. But it certainly seems like they were trying to push out senior leaders with a lot of experience.
Rovner: It also feels like, the way that people were let go seems, to put it bluntly, purposely cruel, like sending out RIF [reduction in force] notices at 5 a.m. and then having people find out they’ve been let go when they stand in long lines only to find out that their IDs no longer work, or CMS [Centers for Medicare & Medicaid Services] employees being directed to contact a person who died last year. Is there a strategy here? Lauren, you wanted to add something.
Weber: I wrote a story on the CMS employees being told to contact someone who was dead. And I spoke to one of this woman Anita Pinder’s former colleagues who said she was just heartbroken. She said CMS employees who got that email had gone to this woman’s funeral, and what a gut punch. She said, Look — this person who was talking to me is a former CMS employee — said: Look, you know, there always is a way to reorganize. It’s not that there isn’t waste or ability to consolidate or streamline in the federal government. She’s like, That’s not my problem. My problem, this woman told me, was that it was done in such a way that you really can’t take that back. People getting a dead woman’s name as their point of contact to contest their firings is something that is difficult to take back.
Rovner: I guess my question is: Is this just sloppy, or are they actually trying to be cruel in this? Because it certainly feels like they’re trying to be cruel.
Karlin-Smith: I think it’s possible. It’s both, a combination, one or the other. Again, it seems like the people who are doing this are not expert, right? They didn’t actually take the time to assess HHS and all what the agency does to understand what people do for the government beyond just looking at their job titles. And so some of it may be intentional cruelty, and some of it just may be really just rushing and not understanding the process. I mean, there were other notices at FDA that were signed by somebody that no longer worked there. People’s performance scores were wrong. The sense is they didn’t follow the normal process of, like, when you do a RIF, you have to give — there’s certain people that get preferences and who stays and who goes and whether it’s veteran status, disability, all those things.
And I think some of that will probably result in legal challenges down the line, including they got rid of certain offices, or everybody in them, that were mandated by Congress. So some of it’s probably sloppy, but some of it is — right? — they don’t really care how they treat people, because there is like a very clear message that comes from their rhetoric of kind of lack of respect for government bureaucracy.
Rovner: And I know some of these senior leaders, they figured out that they can’t just summarily fire them. So a number of them were offered transfers to the Indian Health Service in places like Alaska and Montana, and they were given 36 hours to decide whether they would accept the transfer. And we are told that Secretary Kennedy is very concerned about Native populations and the Indian Health Service, which is short of workers in a lot of places. But this seemed to be insulting to both the people who were given these quote-unquote “transfers” and to the Indian Health Service, because it wasn’t sending the Indian Health Service what it actually needs, which are practitioners, doctors and nurses, and laboratory workers. It was sending research analysts and bench scientists and people whose qualifications do not match what the IHS needs.
Karlin-Smith: Right. They wanted to send, I think, the FDA’s tobacco head to the IHS to do, I think, medical care. So it enraged people in the IHS.
Rovner: Yeah, I don’t think the Native population was really thrilled about this, either. Lauren, you wanted to add something.
Weber: Yeah, I would just say that this is a playbook the Trump administration has executed in other government agencies. Members of the FBI, top leaders of the FBI were reassigned to child sex trafficking crimes or faraway distant lands in the hopes of getting them to resign. So, I think we are seeing that play out at HHS, but it certainly is a tactic they’ve used in other federal agencies to, quote-unquote, “drain the swamp.”
Rovner: Right. And in the first Trump administration, they did move some offices out of Washington to the middle of the country, if you will, and most people obviously didn’t go. And now there’s a lot of expertise that, again, that we lost. I think that really can’t be overstated, is how much expertise is being pushed out the door right now, in terms of things that, as I said, this administration says that it wants to do or get accomplished. Meanwhile, Secretary Kennedy has been invited — or should I say summoned — to come testify next week before the Senate health committee at the behest of Republican Chairman Bill Cassidy, Democratic ranking member Bernie Sanders. So far Congress has mostly just been kind of sitting back and watching all of this happen. Is there any indication that that’s about to change?
Karlin-Smith: I think Democrats are pushing a little bit harder, but I’m not sure they have enough power or have enough, again, momentum yet to actually do what they can with their power. I’m interested to see how Cassidy handles this hearing going forward because his statement the day of the big reduction in force seemed to suggest that the media was maybe unfairly reporting on it and that Kennedy may have another side to the story to share to justify it. And it didn’t sound like somebody that was necessarily going to go particularly hard at RFK. It seemed like somebody who wanted to give him a chance to justify his moves. But we’ll see what happens. I think Cassidy has been, despite RFK walking back a lot of his promises he made to Cassidy around vaccines and so forth, Cassidy has not been that willing to go hard on him so far.
Rovner: Yeah, the other thing we’ve seen is that most of the big health groups that you would expect to be out on the front lines, hair on fire, have actually been keeping their heads down through most of these huge changes. But that seems to be maybe changing a little bit, too. This is a pretty dramatic change to get not a huge response from. I’ve seen way lesser changes get way bigger responses.
Cohrs Zhang: Yeah, I think I spend a lot of time thinking about what is going to be the last straw for some of these organizations. And I think we saw some more effective organizing from the, like, medical device industry when actual medical device reviewers were laid off, and I think they went public pretty quickly, and those people were rehired. But I think it’s important to remember that some of these larger trade organizations in these companies are looking at a broader picture here. And there are all these different pieces of the puzzle. And certainly I think we’ve seen some trade groups that represent, like, pharmaceutical companies criticize some of the cutbacks at HHS, but also for now they were spared in a tariff announcement this week.
And so I think they are trying to walk this tightrope where they have to figure out how to get the wins that they think they need and take losses in other place, and hope it kind of all evens out for them. So, I think they’re in a tough situation, and I think there’s much more concern behind the scenes than we’re seeing spill out into the public. But I think at some point maybe the line will be crossed, and I just don’t think we’ve seen that quite yet.
Karlin-Smith: Yeah, I think the dam is definitely starting to break a bit, though. I was shocked — I guess, what day was it, Tuesday, when all this happened? — when finally late in the day, pharma sent a statement, and it was more scathing than you might even expect. And I think it was the first time they’ve actually responded to anything I’ve asked them to respond to that the administration does. And they said that it’s going to raise crucial questions about the FDA’s ability to fulfill its role. And so I think that is a big sign because, as Rachel mentioned, the medical device community was willing to stick their neck out there when they felt they were really harmed. Smaller trade associations have been starting to push back, but the silence has really been notable, and notable I think by people outside who were hoping that these powerful industries that have sort of more connections to the Republican Party would use that leverage, and they sort of felt abandoned by them. So, I think that is a significant crack to follow.
Rovner: I feel like everybody’s waiting for somebody else to stand up and see if they get their head chopped off. I agree. I mean, I’m hearing, quietly, I’m hearing the concern, too, but publicly not so much. Well, moving to Capitol Hill, Congress is in this week. Well, they were in. We’ll get to the House in a minute. But first in the Senate, New Jersey’s Cory Booker set a new record for holding the floor, which is saying something for a place where being long-winded is basically a prerequisite. Twenty-five hours and five minutes, besting by almost an hour the 1957 filibuster against the Civil Rights Act by Strom Thurmond of South Carolina. Much of what Booker talked about during his more than a day on the Senate floor was health care. Is this still the issue that Democrats are hoping to ride to their political return?
Weber: I was going to say, if the massive Medicaid cuts that are forecast come through, I do think that will be the midterm political return of Democrats. I think the writing is on the wall politically for Republicans if those do go through, which is why I think you’re seeing a lot of Republican leaders start to say: Oh, no. No, no, no. We don’t want some of these Medicaid cuts like this. But to be determined how that actually plays out.
Rovner: Rachel.
Cohrs Zhang: I was just going to say that Democrats are just trying to figure out something that will break through to people. They’re just trying to throw spaghetti at the wall and see if there’s some strategy they can find to get through to people. And I think this, just given the viewership of Sen. Booker’s speech, seemed to break through in a way and felt like even though Democrats do have really limited levers of power in Washington right now, that at least somebody was doing something, you know. And that’s kind of the takeaway that I had from that speech.
But I will say I think Congressman Jake Auchincloss appeared after White House adviser Calley Means criticized the scientific establishment and HHS and was defending these cuts, and Congressman Auchincloss, I think, did have a more forceful tone in pushing back and just arguing for the scientific advances that have happened and had some really camera-ready little tidbits about the new administration being run by like conspiracy theorists and podcast bros. And I think they’re trying to figure out how to push back and how to get through to people and what approaches are going to work. And I think that was just a new tactic that we saw break through.
Rovner: Well, if the Democrats did want to make a statement about Medicaid, they could make a stand against President Trump’s nominee to head the Medicaid program, as well as Medicare and the ACA [Affordable Care Act], Dr. Mehmet Oz. That vote is scheduled in the Senate for today after we finish taping. But we’re not really seeing that much pushback. Are we, Lauren?
Weber: Not so far. I guess we’ll see. We’re taping before this happens. But Mehmet Oz really waltzed through his confirmation hearing process. It’s rare that you see someone who will lead such a massive agency on health care mention the multiple Daytime Emmys he’s won, but I think that helped in his charming of legislators. His daytime bona fides were on high display. He was able to dodge multiple questions about what he would do about cuts to Medicaid, and even Democratic senators were inviting him to come to church. I would be surprised if we see some sort of big stand today.
Rovner: He was super well prepped, which we said — we did a special after the hearing — which is of all of the Trump nominees, I think he was the best prepped of anybody I’ve seen. He was ready with tidbits from every single member of the committee. But I will say that, going back years, and as I said, you know, 40 years, this is a position that one party or the other has frequently blocked, not for reasons that the nominee was not qualified but because they wanted to make a point about something that was going on at the agency. And it kind of surprises me that we haven’t seen that sort of thing. There were years where we did not have a Senate-approved head of Medicare and Medicaid. Sarah, as you pointed out, there were years when we didn’t have a Senate-approved head of the FDA for the same reason. Had nothing to do with the nominee. Had everything to do with the party that was out of power trying to use that as leverage to make a point. And we’re just not even seeing the Democrats try that.
Weber: I guess we’ll see this afternoon. You could be forecasting what’s going to happen, Julie. But I think on top of him being well prepped, Oz does have a history in health care, is a very accomplished surgeon. But what is fascinating to me is that he’s coming back to the Senate after a 2014 grilling by the Senate on his pushing of supplements and other things for, quote, “fat blasting” and, quote, “weight loss” products. And it’s just the turnaround of daytime TV star to failed Senate candidate to potential administrator for CMS, which runs hundreds of millions Americans’ health insurance, potentially at a very consequential period in which there are massive cuts to them, is really going to be something.
Rovner: Yes. Yet another eye-opening thing out of this administration. Well, over in the House, things are a little more confusing. On Tuesday, the usually unified Republicans rejected a rule, normally a party-line , because Speaker Mike Johnson was using it to avoid a vote on a bill that would allow new parents to vote by proxy, basically granting them parental leave. I did not have this fight on my bingo card for this year. It’s actually less a partisan fight than one between younger — read, childbearing age — members of Congress and older ones from both parties. I’m kind of surprised that this of all things is what stopped the House from doing business this week.
Cohrs Zhang: Yeah, I think that it is an interesting contrast here because House Republicans have had this very pro-family rhetoric in the campaign, but they also have been so against remote work in any fashion, and members of Congress travel really far. There’s a time in pregnancy when you can no longer fly on a plane. And so I think given Republicans’ really, really slim majority in the House, it puts them in kind of a pickle where they need these votes to keep the majority, but it kind of sits at the intersection of all these different forces at play. So, I think, yeah, just a really weird political pickle that House Republicans have found themselves in this week.
Rovner: Yeah, and of course this was a member of the House Freedom Caucus, a Republican member of the House Freedom Caucus, who was pushing this, who got a majority of the House to sign her discharge petition, which is supposed to bring this bill to the floor. So, we will see how that one plays out. Obviously, with everything else that’s going on, it’s not the biggest story, but it sure is interesting.
Well, the big non-health news of the week are the tariffs that President Trump announced in the Rose Garden Wednesday afternoon. There is a health care angle to this story. The tariffs reportedly include at least some drugs and drug ingredients that are manufactured overseas. This, again, feels like it’s going to do exactly the opposite of what the president says he wants to do in terms of reducing drug prices, right?
Weber: I mean, yes, yes. That would seem to be exactly how that is likely to go. Even look at drugs we get from Canada. They’re going to have tariffs on them. I think we have to wait and see exactly what happens. Trump has had a history of proposing these and then taking them back. Obviously these are much more sweeping than the ones we’ve seen so far. So, I think it, the jury is out on how exactly this will play out over the next couple weeks.
Rovner: Right. And I said there’s also the exception process, right?
Karlin-Smith: So, yeah, there’s been I think a lot of confusion and lack of clarity around exactly what happened yesterday here. It seems like the drug industry did get some key exemptions, but people are trying to kind of clarify some of those, including, like: Do you just apply to finished product? Do ingredients that they need lower down in the supply chain get impacted? So, I think it seems like pharma at least got some amount of a win here and got some of the typical exemptions for medicines, but people are not confident in all of that and how it’s going to play out. And I’ve seen sort of mixed reactions from analysts in the space. But yeah, it’s just like other parts of the economy that people have talked about with tariffs. It’s not entirely clear how the average American consumer would actually benefit from these tariffs versus having to just pay more money for goods.
Rovner: We are apparently going to tariff penguins from islands off the coast of Australia. That much we seem clear on this morning. Turning to abortion, this week, as we mentioned last week, the Supreme Court heard a case out of South Carolina testing whether a state can kick Planned Parenthood not just out of the federal Family Planning Program, Title X, but whether Planned Parenthood can be disallowed from providing Medicaid services as well. Now, Planned Parenthood gets way more money from Medicaid than it does from Title X, and neither program allows the use of federal funds to pay for abortion. I will say that again: Neither program allows the use of federal funds to pay for abortion. Interestingly, it seems the high court might actually be leaning towards Planned Parenthood in this case, not because the conservative justices have any sympathy towards Planned Parenthood but because the court has fairly recently made it clear that the provision of Medicaid law that says patients can choose any qualified provider actually means what it says: The patient can choose any qualified provider.
At the same time, though, the Trump administration this week declined to distribute a big swath of that Title X funding. And you have to wonder whether, even if Planned Parenthood wins this South Carolina case, what’s going to be left of either Title X or the Medicaid program. Possibly a Pyrrhic victory coming here? It seems that this administration is just whacking things, and even if the court ultimately says you can’t kick them out, there’s going to be nothing for them to stay in.
Karlin-Smith: Well, the any-willing-provider debate struck me as sort of most interesting here because that type of clause seems to be something you typically see conservatives want to put into a government health program. They don’t feel comfortable kind of restricting people and choices in that way around who they see. So that was one of the elements of this case. The other thing that I think is being watched is this argument that the state is making around, like, how you enforce disagreements, I guess, around how the Medicaid program is being operated. And that seems like it could have a lot of long-lasting impacts as well if people, depending on if the court weighs in on that and so forth, just what rights people have to contest problematic decisions made in state Medicaid programs.
Rovner: Yeah, for the first hour of the debate, the word “abortion” wasn’t mentioned. The word “Planned Parenthood” wasn’t mentioned. This was really about whether patients actually have a right to sue over not being able to get the kind of care that they want, which has been a long-standing fight in Medicaid, back to, I think, pretty much the beginning of Medicaid. So, we’ll see how this one comes out. Well, turning to the states and another case we have talked about, Texas wants to prosecute a New York doctor who was acting legally under New York law from prescribing abortion pills via telemedicine to a Texas patient. The latest is that the court clerk in Ulster County, New York, has refused to file a judgment for the $100,000 fine that Texas says the New York doctor owes.
At the other end of the spectrum, in Georgia, meanwhile, lawmakers held a hearing on a bill that would — and I’m quoting from a Georgia state news service here — “ban abortions in Georgia from the moment of fertilization and codify it as a felony homicide crime unless a pregnant woman was threatened with violence to have the procedure.” Now, under this bill, both the woman and the doctor could be charged with murder. This bill is unlikely to be enacted this year, but I feel like the Overton window on this continues to move towards maybe punishing women with poor pregnancy outcomes.
Karlin-Smith: Well, and punishing women who have trouble getting pregnant, as some of the opponents of this bill are arguing. It’s not clear whether it will really be possible to do IVF procedures if the bill was enacted how it was written. And even it seems like some of the reason why some pretty anti-abortion groups are concerned about this law, because they feel uncomfortable that it’s penalizing or going after the woman rather than other people involved in the abortion system.
Rovner: I feel like we’ve been creeping this direction for a while, though. Obviously, this bill’s probably not going to move this cycle, but it got a hearing. We’ve seen a lot of things like this introduced. We’ve rarely seen it progress to the hearing stage. Another thing that bears watching. So, last week in the segment that I’m now calling “MAHA [Make America Healthy Again] in the States,” we talked about West Virginia banning food dyes and additives. Well, hold my beer — um, make that water, says Utah. Utah has now become the first state to ban fluoride in public water systems, something takes effect next month. Lauren, I feel like states are rushing to match RFK Jr. Is that what we’re seeing?
Weber: There is some interest at the state level, but I also think it speaks to RFK’s limitations. I think everybody always thinks the game is always in D.C., but there’s a lot the states can do. And so I think it’ll be fascinating to kind of see how this continues to play out.
Rovner: Yeah, well, we will keep watching it. All right, that is this week’s health news. Now we will play my interview with KFF Health News’ Julie Appleby. Then we will come back and do our extra credits.
I am pleased to welcome back to the podcast KFF Health News’ other Julie, Julie Appleby, who reported and wrote the latest KFF Health News “Bill of the Month.” Julie, welcome back.
Julie Appleby: Thanks for having me.
Rovner: So, this month’s patient is yet another with a gigantic colonoscopy bill, but there’s a twist with this one. Tell us who he is and, important for this story, what kind of health insurance he has.
Appleby: Yes, absolutely. His name is Tim Winard, and he lives in Addison, Illinois. He bought his own health insurance after he left his management job to launch his own business. So he shopped around a little bit. This is the first time he’s bought insurance. And he chose a short-term policy, which is good for six months in his state. And the first six months went pretty well. And he was still working on starting his business, so he signed up for another short-term policy with a different insurer. And this one cost about $500 a month.
Rovner: So, remind us again. What is short-term health insurance? And how is it different from most employer and Affordable Care Act coverage?
Appleby: Right. These types of policies have been sold for years. They’re generally intended for people who are, like, between jobs or maybe just getting out of school. They’re a temporary bridge to more comprehensive insurance, and as such they are not considered Affordable Care Act-qualified plans. So they don’t have to meet the rules that are set under the Affordable Care Act. So, for example, they might look like comprehensive major medical policies, but they all have sort of significant caveats. And some of these might surprise people who are accustomed to work-based or ACA plans. So, for example, like in Tim Winard’s plan, some set specific dollar caps on certain types of medical care, and sometimes those are, like, per day or per visit or something like that, and they can be sometimes far below what it actually costs.
And all of them — this is a key difference with ACA plans — all of these types of short-term plans screen applicants for health conditions, and they can reject people because of health problems or exclude those conditions from coverage. Many also do not cover drugs or maternity care. So people really have to read their policies carefully to see what they cover and what they don’t cover.
Rovner: So this is sort of like pre-ACA. It’s cheap because it doesn’t cover that much.
Appleby: Exactly. That’s why they can offer them lower premiums. Now, again, some people with a subsidized ACA plan, these are not necessarily cheaper, but for others these are less expensive.
Rovner: So back to our patient this month. He does what we always advise and calls his insurance company before he goes for this, because it is obviously scheduled care, not an emergency. What did they tell him?
Appleby: Well, I think he only asked where he could go. He was concerned that he would go to a facility that was in-network, and they told him he could pretty much go anywhere. He did not ask about cost in that phone call.
Rovner: Yeah, so he gets his colonoscopy. Everything turns out OK medically. And then, as we say, the bill comes. How big was it?
Appleby: He was left owing $7,226 after his plan paid about $817 towards the bill. They got a little bit of a discount for being insured, but then he was still left owing more than $7,000.
Rovner: And what was the explanation for him owing that much? Just a reminder that this should have been fully covered if he’d had an ACA plan, right?
Appleby: That’s correct. Under the ACA, screening colonoscopies and other types of cancer screenings are covered without a copay for the patient. But he didn’t have an ACA plan here. So, what was the explanation? Well, this time he did email his insurance company, which is Companion Life Insurance of Columbia, South Carolina, and they wrote him back, and they told him his policy classified the procedure and all of its costs, including the anesthesia, under his policy’s outpatient surgery facility benefit. What is that? you might ask. Well, in his policy, that benefit caps insurance payments within that facility to a maximum of a thousand dollars per day. So, the most they were going to pay towards this was a thousand dollars, because they classified the whole thing as an outpatient procedure with that cap. And this surprised Winard because he thought the cancer screening was covered and he would only owe 20% of the bill, not almost the entire thing, basically.
Rovner: So how did this eventually work out?
Appleby: Well, we reached out and tried to reach Companion Life, and we also talked to Scott Wood, who works as a program manager and is a co-founder of a marketing company that markets Companion Life and other insurance plans. And he thought there was some room for interpretation in the billing and in the policy language. So he asked Companion Life to take another look. And shortly after that, Winard said he was contacted by his insurer, and a representative told him that upon reconsideration the bill had been adjusted. And he wasn’t really given a reason why that happened, but as it turns out his new bill showed he owed only $770.
Rovner: Which is, I assume, about what he expected when he went into this, right?
Appleby: That’s, yes, correct. He didn’t think he was going to have to pay as much as it was initially billed at.
Rovner: So, what’s the takeaway here other than to come to us if you have a bill that you can’t deal with?
Appleby: Right. Well, I think experts say to be very cautious and read the plans very carefully if you’re shopping for a short-term plan. And realize they have some of these limits and they may not cover everything. They may not cover preexisting conditions. And this could become more widespread in the coming years as — short-term plans have been somewhat of a political football. So, out of concern that people would choose them over more comprehensive coverage, President Barack Obama’s administration limited them to terms of three months. Those rules were lifted during the first Trump administration, and he allowed the plans to again be sold as 364-day policies, just one day short of a year, and then you could try to get another one. Or in some cases the insurer could opt to renew them.
And then Joe Biden came in, and President Biden called them “junk insurance,” and he restricted the policies to four months. So, it’s been bouncing back and forth, back and forth. Everybody really expects the Trump administration to do what it did the last time and make them available for longer periods. So I think if we’re going to hear more about short-term plans. They may become more common. And again, it’s just a matter of trying to understand what you’re buying, and why they might be less expensive in your mind than an ACA plan, but they might not turn out to be.
Rovner: And you can always ask for an estimate, right?
Appleby: And always ask for an estimate. That’s a given. Experts always say, before any kind of scheduled procedure, call your insurer, call the provider, ask for an estimate on how much this might cost you out-of-pocket.
Rovner: Good. And if all else fails, then you can write to us.
Appleby: There you go.
Rovner: Julie Appleby, thank you very much.
Appleby: Thanks for having me.
Rovner: OK, we’re back. Now it’s time for our extra-credit segment. That’s where we each recognize a story we read this week we think you should read, too. Don’t worry if you miss it. We will put the links in our show notes on your phone or other mobile device. Rachel, why don’t you go first this week?
Cohrs Zhang: All right. My extra credit is a piece in The Wall Street Journal, and the headline is “FDA Punts on Major COVID-19 Vaccine Decision After Ouster of Top Official,” by Liz Essley White. It’s a great story, and I think, as we talked about earlier, I’m thinking about: What are the breaking points for companies, for industries, as they look at how the HHS is changing? And I think one of those metrics is if the FDA starts missing deadlines to approve products. I think this one is a little bit of a special case because it is a covid-19 vaccine, which is, like, the most highly politicized medical product right now. But I think there could be other cases, and I think industry is watching this so closely to see if some of these changes at FDA really do bleed into approvals, whether the approval process will be politicized, whether they’re going to start missing deadlines. And given just the amount of financial support that industry provides to fund routine activities, I think this was kind of a really good marker in this process as we learn what the impacts are.
Rovner: Yeah, agree. Lauren.
Weber: I read “Miscarriage and Motherhood” by Ashley Parker, now at The Atlantic. And I’ve got to be honest — if you read it, be in a place where you can cry. It’s an incredibly moving piece about tragedies of miscarriage, and frankly about women’s health care, and how little support and understanding there is in general about what surrounds that entire field. And some of the fascinating parts in it is when Ashley details going in for a D&C [dilation and curettage] and being told that is an abortion. And it’s kind of an interesting interplay between how what words mean, what people understand what words mean, and what exactly parenthood entails in modern America today.
Rovner: And how extremely common miscarriage is. I think people just don’t realize, because it’s something that’s just not talked about very much. It’s a really beautiful story. Sarah.
Karlin-Smith: I looked at an MSNBC piece [“Florida Considers Easing Child Labor Laws After Pushing Out Immigrants”] by Ja’han Jones, about Florida considering easing their child labor laws after pushing out immigrants. And, yeah, the state is considering bills that would allow very young teenagers to work overnight, to maybe work at the kinds of jobs that would normally be seen as too unsafe for such young people. And, yeah, it just seems like an interesting sort of consequence of pushing out immigrant workers. But also it comes after some really moving reports over the past few years, too, about just how dangerous some of this work is, and how even under current law that is supposed to prevent this, particularly immigrants and the most vulnerable workers have ended up with young people in this job, and they’ve really — these types of jobs — and they’ve been harmed by it.
Rovner: Who could have possibly seen this coming? Sorry. My extra credit this week is from Stat, and it’s called “Uber for Nursing is Here — and It’s Not Good for Patients or Nurses,” by Katie J. Wells and Funda Ustek Spilda. And it’s yet another case of something that sounds really good, using an app to help nurses who want to find extra work and set their own schedules get it, and helping facilities that need extra help find workers. But like so many of these things, it’s not as rosy as it appears unless you’re the one that’s collecting the fees from the app. Workers are basically all temps. They may not be familiar with the facilities they’ve been assigned to, much less the patients, which doesn’t always result in optimal care. And they bid against each other for who will do the job for the lowest rate, creating a race to the bottom for wages. It’s another one of those quote-unquote “advances” that’s a lot less than meets the eye.
All right, that is this week’s 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 producer, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, @jrovner, and at Bluesky, @julierovner. Where are you guys these days? Rachel, you’re still on LinkedIn, right?
Cohrs Zhang: Still on LinkedIn. Still on X. I do have a Bluesky account, too. But any and all the places.
Rovner: Excellent. Sarah.
Karlin-Smith: Yeah, I’m at Bluesky, some X, some LinkedIn, @SarahKarlin or @sarahkarlin-smith.
Rovner: Lauren.
Weber: I’m still on X, and I am on Bluesky, @LaurenWeberHP. And as a member of — a congressional staffer asked me: Does the “HP” really stand for “health policy”? And yes, it does. So, still there.
Rovner: Absolutely. We will be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': LIVE From KFF: Health Care and the 2024 Election
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Julie Rovner
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
The 2024 campaign — particularly the one for president — has been notably vague on policy. But health issues, especially those surrounding abortion and other reproductive health care, have nonetheless played a key role. And while the Affordable Care Act has not been the focus of debate the way it was over the previous three presidential campaigns, who becomes the next president will have a major impact on the fate of the 2010 health law.
The panelists for this week’s special election preview, taped before a live audience at KFF’s offices in Washington, are Julie Rovner of KFF Health News, Tamara Keith of NPR, Alice Miranda Ollstein of Politico, and Cynthia Cox and Ashley Kirzinger of KFF.
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Ashley Kirzinger
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Cynthia Cox
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Alice Miranda Ollstein
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Tamara Keith
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Read and listen to Tamara's stories.
Among the takeaways from this week’s episode:
- As Election Day nears, who will emerge victorious from the presidential race is anyone’s guess. Enthusiasm among Democratic women has grown with the elevation of Vice President Kamala Harris to the top of the ticket, with more saying they are likely to turn out to vote. But broadly, polling reveals a margin-of-error race — too close to call.
- Several states have abortion measures on the ballot. Proponents of abortion rights are striving to frame the issue as nonpartisan, acknowledging that recent measures have passed thanks in part to Republican support. For some voters, resisting government control of women’s health is a conservative value. Many are willing to split their votes, supporting both an abortion rights measure and also candidates who oppose abortion rights.
- While policy debates have been noticeably lacking from this presidential election, the future of Medicaid and the Affordable Care Act hinges on its outcome. Republicans want to undermine the federal funding behind Medicaid expansion, and former President Donald Trump has a record of opposition to the ACA. Potentially on the chopping block are the federal subsidies expiring next year that have transformed the ACA by boosting enrollment and lowering premium costs.
- And as misinformation and disinformation proliferate, one area of concern is the “malleable middle”: people who are uncertain of whom or what to trust and therefore especially susceptible to misleading or downright false information. Could a second Trump administration embed misinformation in federal policy? The push to soften or even eliminate school vaccination mandates shows the public health consequences of falsehood creep.
Also mentioned on this week’s podcast:
- The New York Times’ “Resistance to Public Health, No Longer Fringe, Gains Foothold in G.O.P. Politics,” by Sheryl Gay Stolberg.
- KFF Health News’ “‘What the Health?’: SCOTUS Ruling Strips Power From Federal Health Agencies.”
- KFF’s Health Misinformation and Trust Initiative, a program aimed at tracking health misinformation in the U.S., analyzing its impact on the American people, and mobilizing media to address the problem.
click to open the transcript
Transcript: LIVE From KFF: Health Care and the 2024 Election
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Emmarie Huetteman: Please put your hands together and join me in welcoming our panel and our host, Julie Rovner.
Julie Rovner: Hello, good morning, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the very best and smartest health reporters in Washington, along with some very special guests today. We’re taping this special election episode on Thursday, October 17th, at 11:30 a.m., in front of a live audience at the Barbara Jordan Conference Center here at KFF in downtown D.C. Say hi, audience.
As always, news happens fast and things might have changed by the time you hear this. So, here we go.
So I am super lucky to work at and have worked at some pretty great places and with some pretty great, smart people. And when I started to think about who I wanted to help us break down what this year’s elections might mean for health policy, it was pretty easy to assemble an all-star cast. So first, my former colleague from NPR, senior White House correspondent Tamara Keith. Tam, thanks for joining us.
Tamara Keith: Thank you for having me.
Rovner: Next, our regular “What the Health?” podcast panelist and my right hand all year on reproductive health issues, Alice Ollstein of Politico.
Alice Miranda Ollstein: Hi Julie.
Rovner: Finally, two of my incredible KFF colleagues. Cynthia Cox is a KFF vice president and director of the program on the ACA [Affordable Care Act] and one of the nation’s very top experts on what we know as Obamacare. Thank you, Cynthia.
Cynthia Cox: Great to be here.
Rovner: And finally, Ashley Kirzinger is director of survey methodology and associate director of our KFF Public Opinion and Survey Research Program, and my favorite explainer of all things polling.
Ashley Kirzinger: Thanks for having me.
Rovner: So, welcome to all of you. Thanks again for being here. We’re going to chat amongst ourselves for a half hour or so, and then we will open the floor to questions. So be ready here in the room. Tam, I want to start with the big picture. What’s the state of the race as of October 17th, both for president and for Congress?
Keith: Well, let’s start with the race for President. That’s what I cover most closely. This is what you would call a margin-of-error race, and it has been a margin-of-error race pretty much the entire time, despite some really dramatic events, like a whole new candidate and two assassination attempts and things that we don’t expect to see in our lifetimes and yet they’ve happened. And yet it is an incredibly close race. What I would say is that at this exact moment, there seems to have been a slight shift in the average of polls in the direction of former President [Donald] Trump. He is in a slightly better position than he was before and is in a somewhat more comfortable position than Vice President [Kamala] Harris.
She has been running as an underdog the whole time, though there was a time where she didn’t feel like an underdog, and right now she is also running like an underdog and the vibes have shifted, if you will. There’s been a more dramatic shift in the vibes than there has been in the polls. And the thing that we don’t know and we won’t know until Election Day is in 2016 and 2020, the polls underestimated Trump’s support. So at this moment, Harris looks to be in a weaker position against Trump than either [Hillary] Clinton or [Joe] Biden looked to be. It turns out that the polls were underestimating Trump both of those years. But in 2022 after the Dobbs decision, the polls overestimated Republican support and underestimated Democratic support.
So what’s happening now? We don’t know. So there you go. That is my overview, I think, of the presidential race. The campaigning has really intensified in the last week or so, like really intensified, and it’s only going to get more intense. I think Harris has gotten a bit darker in her language and descriptions. The joyful warrior has been replaced somewhat by the person warning of dire consequences for democracy. And in terms of the House and the Senate, which will matter a lot, a lot a lot, whether Trump wins or Harris wins, if Harris wins and Democrats lose the Senate, Harris may not even be able to get Cabinet members confirmed.
So it matters a lot, and the conventional wisdom — which is as useful as it is and sometimes is not all that useful — the conventional wisdom is that something kind of unusual could happen, which is that the House could flip to Democrats and the Senate could flip to Republicans, and usually these things don’t move in opposite directions in the same year.
Rovner: And usually the presidential candidate has coattails, but we’re not really seeing that either, are we?
Keith: Right. In fact, it’s the reverse. Several of the Senate candidates in key swing states, the Democratic candidates are polling much better than the Republican candidates in those races and polling with greater strength than Harris has in those states. Is this a polling error, or is this the return of split-ticket voting? I don’t know.
Rovner: Well, leads us to our polling expert. Ashley, what are the latest polls telling us, and what should we keep in mind about the limitations of polling? I feel like every year people depend a lot on the polls and every year we say, Don’t depend too much on the polls.
Kirzinger: Well, can I just steal Tamara’s line and say I don’t know? So in really close elections, when turnout is going to matter a lot, what the polls are really good at is telling us what is motivating voters to turn out and why. And so what the polls have been telling us for a while is that the economy is top of mind for voters. Now, health care costs — we’re at KFF. So health care plays a big role in how people think about the economy, in really two big ways. The first is unexpected costs. So unexpected medical bills, health care costs, are topping the list of the public’s financial worries, things that they’re worried about, what might happen to them or their family members. And putting off care. What we’re seeing is about a quarter of the public these days are putting off care because they say they can’t afford the cost of getting that needed care.
So that really shows the way that the financial burdens are playing heavily on the electorate. What we have seen in recent polling is Harris is doing better on the household expenses than Biden did and is better than the Democratic Party largely. And that’s really important, especially among Black women and Latina voters. We are seeing some movement among those two groups of the electorate saying that Harris is doing a better job and they trust her more on those issues. But historically, if the election is about the economy, Republican candidates do better. The party does better on economic issues among the electorate.
What we haven’t mentioned yet is abortion, and this is the first presidential election since post-Dobbs, in the post-Dobbs era, and we don’t know how abortion policy will play in a presidential election. It hasn’t happened before, so that’s something that we’re also keeping an eye on. We know that Harris is campaigning around reproductive rights, is working among a key group of the electorate, especially younger women voters. She is seen as a genuine candidate who can talk about these issues and an advocate for reproductive rights. We’re seeing abortion rise in importance as a voting issue among young women voters, and she’s seen as more authentic on this issue than Biden was.
Rovner: Talk about last week’s poll about young women voters.
Kirzinger: Yeah, one of the great things that we can do in polling is, when we see big changes in the campaign, is we can go back to our polls and respondents and ask how things have changed to them. So we worked on a poll of women voters back in June. Lots have changed since June, so we went back to them in September to see how things were changing for this one group, right? So we went back to the same people and we saw increased motivation to turn out, especially among Democratic women. Republican women were about the same level of motivation. They’re more enthusiastic and satisfied about their candidate, and they’re more likely to say abortion is a major reason why they’re going to be turning out. But we still don’t know how that will play across the electorate in all the states.
Because for most voters, a candidate’s stance on abortion policy is just one of many factors that they’re weighing when it comes to turnout. And so those are one of the things that we’re looking at as well. I will say that I’m not a forecaster, thank goodness. I’m a pollster, and polls are not good at forecasts, right? So polls are very good at giving a snapshot of the electorate at a moment in time. So two weeks out, that’s what I know from the polls. What will happen in the next two weeks, I’m not sure.
Rovner: Well, Alice, just to pick up on that, abortion, reproductive health writ large are by far the biggest health issues in this campaign. What impact is it having on the presidential race and the congressional races and the ballot issues? It’s all kind of a clutter, isn’t it?
Ollstein: Yeah, well, I just really want to stress what Ashley said about this being uncharted territory. So we can gather some clues from the past few years where we’ve seen these abortion rights ballot measures win decisively in very red states, in very blue states, in very purple states. But presidential election years just have a different electorate. And so, yes, it did motivate more people to turn out in those midterm and off-year elections, but that’s just not the same group of folks and it’s not the same groups the candidates need this time, necessarily. And also we know that every time abortion has been on the ballot, it has won, but the impact and how that spills over into partisan races has been a real mixed bag.
So we saw in Michigan in 2022, it really helped Democrats. It helped Governor Gretchen Whitmer. It helped Michigan Democrats take back control of the Statehouse for the first time in decades. But that didn’t work for Democrats in all states. My colleagues and I did an analysis of a bunch of different states that had these ballot measures, and these ballot measures largely succeeded because of Republican voters who voted for the ballot initiative and voted for Republican candidates. And that might seem contradictory. You’re voting for an abortion rights measure, and you’re voting for very anti-abortion candidates. We saw that in Kentucky, for example, where a lot of people voted for (Sen.) Rand Paul, who is very anti-abortion, and for the abortion rights side of the ballot measure.
I’ve been on the road the last few months, and I think you’re going to see a lot of that again. I just got back from Arizona, and a lot of people are planning to vote for the abortion rights measure there and for candidates who have a record of opposing abortion rights. Part of that is Donald Trump’s somewhat recent line of: I won’t do any kind of national ban. I’ll leave it to the states. A lot of people are believing that, even though Democrats are like: Don’t believe him. It’s not true. But also, like Ashley said, folks are just prioritizing other issues. And so, yes, when you look at certain slices of the electorate, like young women, abortion is a top motivating issue. But when you look at the entire electorate, it’s, like, a distant fourth after the economy and immigration and several other things.
I found the KFF polling really illuminating in that, yes, most people said that abortion is either just one of many factors in deciding their vote on the candidates or not a factor at all. And most people said that they would be willing to vote for a candidate who does not share their views on abortion. So I think that’s really key here. And these abortion rights ballot measures, the campaigns behind them are being really deliberate about remaining completely nonpartisan. They need to appeal to Republicans, Democrats, independents in order to pass, but that also … So their motivation is to appeal to everyone. Democrats’ motivation is to say: You have to vote for us, too. Abortion rights won’t be protected if you just pass the ballot measure. You also have to vote for Democrats up and down the ballot. Because, they argue, Trump could pursue a national ban that would override the state protections.
Rovner: We’ve seen in the past — and this is for both of you — ballot measures as part of partisan strategies. In the early 2000s, there were anti-gay-marriage ballot measures that were intended to pull out Republicans, that were intended to drive turnout. That’s not exactly what’s happening this time, is it?
Keith: So I was a reporter in the great state of Ohio in 2004, and there was an anti-gay-rights ballot measure on the ballot there, and it was a key part of George W. Bush’s reelection plan. And it worked. He won the state somewhat narrowly. We didn’t get the results until 5 a.m. the next day, but that’s better than we’ll likely have this time. And that was a critical part of driving Republican turnout. It’s remarkable how much has changed since then in terms of public views. It wouldn’t work in the same way this time.
The interesting thing in Arizona, for instance, is that there’s also an anti-immigration ballot measure that’s also polling really well that was added by the legislature in sort of a rush to try to offset the expected Democratic-based turnout because of the abortion measure. But as you say, it is entirely possible that there could be a lot of Trump abortion, immigration and [House Democrat and Senate candidate] Ruben Gallego voters.
Ollstein: Absolutely. And I met some of those voters, and one woman told me, look, she gets offended when people assume that she’s liberal because she identified as pro-choice. We don’t use that terminology in our reporting, but she identified as pro-choice, and she was saying: Look, to me, this is a very conservative value. I don’t want the government in my personal business. I believe in privacy. And so for her, that doesn’t translate over into, And therefore I am a Democrat.
Rovner: I covered two abortion-related ballot measures in South Dakota that were two years, I think it was 2006 and 2008.
Ollstein: They have another one this year.
Rovner: Right. There is another one this year. But what was interesting, what I discovered in 2006 and 2008 is exactly what you were saying, that there’s a libertarian streak, particularly in the West, of people who vote Republican but who don’t believe that the government has any sort of business in your personal life, not just on abortion but on any number of other things, including guns. So this is one of those issues where there’s sort of a lot of distinction. Cynthia, this is the first time in however many elections the Affordable Care Act has not been a huge issue, but there’s an awful lot at stake for this law, depending on who gets elected, right?
Cox: Yeah, that’s right. I mean, it’s the first time in recent memory that health care in general, aside from abortion, hasn’t really been the main topic of conversation in the race. And part of that is that the Affordable Care Act has really transformed the American health care system over the last decade or so. The uninsured rate is at a record low, and the ACA marketplaces, which had been really struggling 10 years ago, have started to not just survive but thrive. Maybe also less to dislike about the ACA, but it’s also not as much a policy election as previous elections had been. But yes, the future of the ACA still hinges on this election.
So starting with President Trump, I think as anyone who follows health policy knows, or even politics or just turned on the TV in 2016 knows that Trump has a very, very clear history of opposing the Affordable Care Act, or Obamacare. He supported a number of efforts in Congress to try to repeal and replace the Affordable Care Act. And when those weren’t successful, he took a number of regulatory steps, joined legal challenges, and proposed in his budgets to slash funding for the Affordable Care Act and for Medicaid. But now in 2024, it’s a little bit less clear exactly where he’s going.
I would say earlier in the 2024 presidential cycle, he made some very clear comments about saying Obamacare sucks, for example, or that Republicans should never give up on trying to repeal and replace the ACA, that the failure to do so when he was president was a low point for the party. But then he also has seemed to kind of walk that back a little bit. Now he’s saying that he would replace the ACA with something better or that he would make the ACA itself much, much better or make it cost less, but he’s not providing specifics. Of course, in the debate, he famously said that he had “concepts” of a plan, but there’s no … Nothing really specific has materialized.
Rovner: We haven’t seen any of those concepts.
Cox: Yes, the concept is … But we can look at his record. And so we do know that he has a very, very clear record of opposing the ACA and really taking any steps he could when he was president to try to, if not repeal and replace it, then significantly weaken it or roll it back. Harris, by contrast, is in favor of the Affordable Care Act. When she was a primary candidate in 2020, she had expressed support for more-progressive reforms like “Medicare for All” or “Medicare for More.” But since becoming vice president, especially now as the presidential candidate, she’s taken a more incremental approach.
She’s talking about building upon the Affordable Care Act. In particular, a key aspect of her record and Biden’s is these enhanced subsidies that exist in the Affordable Care Act marketplaces. They were first, I think … They really closely mirror what Biden had run on as president in 2019, 2020, but they were passed as part of covid relief. So they were temporary, then they were extended as part of the Inflation Reduction Act but, again, temporarily. And so they’re set to expire next year, which is setting up a political showdown of sorts for Republicans and Democrats on the Hill about whether or not to extend them. And Harris would like to make these subsidies permanent because they have been responsible for really transforming the ACA marketplaces.
The number of people signing up for coverage has doubled since Biden took office. Premium payments were cut almost in half. And so this is, I think, a key part of, now, her record, but also what she wants to see go forward. But it’s going to be an uphill battle, I think, to extend them.
Rovner: Cynthia, to sort of build on that a little bit, as we mentioned earlier, a Democratic president won’t be able to get a lot accomplished with a Republican House and/or Senate and a Republican president won’t be able to get that much done with a Democratic House and/or Senate. What are some of the things we might expect to see if either side wins a trifecta control of the executive branch and both houses of Congress?
Cox: So I think, there … So I guess I’ll start with Republicans. So if there is a trifecta, the key thing there to keep in mind is while there may not be a lot of appetite in Congress to try to repeal and replace the ACA, since that wasn’t really a winning issue in 2017, and since then public support for the ACA has grown. And I think also it’s worth noting that the individual mandate penalty being reduced to $0. So essentially there’s no individual mandate anymore. There’s less to hate about the law.
Rovner: All the pay-fors are gone, too.
Cox: Yeah the pay-fors are gone, too.
Rovner: So the lobbyists have less to hate.
Cox: Yes, that too. And so I don’t think there’s a ton of appetite for this, even though Trump has been saying, still, some negative comments about the ACA. That being said, if Republicans want to pass tax cuts, then they need to find savings somewhere. And so that could be any number of places, but I think it’s likely that certain health programs and other programs are off-limits. So Medicare probably wouldn’t be touched, maybe Social Security, defense, but that leaves Medicaid and the ACA subsidies.
And so if they need savings in order to pass tax cuts, then I do think in particular Medicaid is at risk, not just rolling back the ACA’s Medicaid expansion but also likely block-granting the program or implementing per capita caps or some other form of really restricting the amount of federal dollars that are going towards Medicaid.
Rovner: And this is kind of where we get into the Project 2025 that we’ve talked about a lot on the podcast over the course of this year, that, of course, Donald Trump has disavowed. But apparently [Senate Republican and vice presidential candidate] JD Vance has not, because he keeps mentioning pieces of it.
Ollstein: And they’re only … They’re just one of several groups that have pitched deep cuts to health safety net programs, including Medicaid. You also have the Paragon group, where a lot of former Trump officials are putting forward health policy pitches and several others. And so I also think given the uncertainty about a trifecta, it’s also worth keeping in mind what they could do through waivers and executive actions in terms of work requirements.
Rovner: That was my next question. I’ve had trouble explaining this. I’ve done a bunch of interviews in the last couple of weeks to explain how much more power Donald Trump would have, if he was reelected, to do things via the executive branch than a President Harris would have. So I have not come up with a good way to explain that. Please, one of you give it a shot.
Keith: Someone else.
Rovner: Why is it that President Trump could probably do a lot more with his executive power than a President Harris could do with hers?
Cox: I think we can look back at the last few years and just see. What did Trump do with his executive power? What did Biden do with his executive power? And as far as the Affordable Care Act is concerned or Medicaid. But Trump, after the failure to repeal and replace the ACA, took a number of regulatory steps. For example, trying to expand short-term plans, which are not ACA-compliant, and therefore can discriminate against people with preexisting conditions, or cutting funding for certain things in the ACA, including outreach and enrollment assistance.
And so I think there were a number — and also we’ve talked about Medicaid work requirements in the form of state waivers. And a lot of what Biden did, regulatory actions, were just rolling that back, changing that, but it’s hard to expand coverage or to provide a new program without Congress acting to authorize that spending.
Kirzinger: I think it’s also really important to think about the public’s view of the ACA at this point in time. I mean, what the polls aren’t mixed about is that the ACA has higher favorability than Harris, Biden, Trump, any politician, right? So we have about two-thirds of the public.
Rovner: So Nancy Pelosi was right.
Kirzinger: I won’t go that far, but about two-thirds of the public’s now view the law favorably, and the provisions are even more popular. So while, yes, a Republican trifecta will have a lot of power, the public — they’re going to have a hard time rolling back protections for people with preexisting conditions, which have bipartisan support. They’re going to have a hard time making it no longer available for adult children under the age of 26 to be on their parents’ health insurance. All of those components of the ACA are really popular, and once people are given protections, it’s really hard to take them away.
Cox: Although I would say that there are at least 10 ways the ACA protects people with preexisting conditions. I think on the surface it’s easy to say that you would protect people with preexisting conditions if you say that a health insurer has to offer coverage to someone with a preexisting condition. But there’s all those other ways that they say also protects preexisting conditions, and it makes coverage more comprehensive, which makes coverage more expensive.
And so that’s why the subsidies there are key to make comprehensive coverage that protects people with preexisting conditions affordable to individuals. But if you take those subsidies away, then that coverage is out of reach for most people.
Rovner: That’s also what JD Vance was talking about with changing risk pools. I mean, which most people, it makes your eyes glaze over, but that would be super important to the affordability of insurance, right?
Cox: And his comment about risk pools is — I think a lot of people were trying to read something into that because it was pretty vague. But what a lot of people did think about when he made that comment was that before the Affordable Care Act, it used to be that if you were declined health insurance coverage, especially by multiple insurance companies, if you were basically uninsurable, then you could apply to what existed in many states was a high-risk pool.
But the problem was that these high-risk pools were consistently underfunded. And in most of those high-risk pools, there were even waiting periods or exclusions on coverage for preexisting conditions or very high premiums or deductibles. So even though these were theoretically an option for coverage for people with preexisting conditions before the ACA, the lack of funding or support made it such that that coverage didn’t work very well for people who were sick.
Ollstein: And something conservatives really want to do if they gain power is go after the Medicaid expansion. They’ve sort of set up this dichotomy of sort of the deserving and undeserving. They don’t say it in those words, but they argue that childless adults who are able-bodied don’t need this safety net the way, quote-unquote, “traditional” Medicaid enrollees do. And so they want to go after that part of the program by reducing the federal match. That’s something I would watch out for. I don’t know if they’ll be able to do that. That would require Congress, but also several states have in their laws that if the federal matches decreased, they would automatically unexpand, and that would mean coverage losses for a lot of people. That would be very politically unpopular.
It’s worth keeping in mind that a lot of states, mainly red states, have expanded Medicaid since Republicans last tried to go after the Affordable Care Act in 2017. And so there’s just a lot more buy-in now. So it would be politically more challenging to do that. And it was already very politically challenging. They weren’t able to do it back then.
Rovner: So I feel like one of the reasons that Trump might be able to get more done than Harris just using executive authority is the makeup of the judiciary, which has been very conservative, particularly at the Supreme Court, and we actually have some breaking news on this yesterday. Three of the states who intervened in what was originally a Texas lawsuit trying to revoke the FDA’s [Federal Drug Administration’s] approval of the abortion pill mifepristone, officially revived that lawsuit, which the Supreme Court had dismissed because the doctors who filed it initially didn’t have standing, according to the Supreme Court.
The states want the courts to invoke the Comstock Act, an 1873 anti-vice law banning the mailing and receiving of, among other things, anything used in an abortion, to effectively ban the drug. This is one of those ways that Trump wouldn’t even have to lift a finger to bring about an abortion ban, right? I mean, he’d just have to let it happen.
Ollstein: Right. I think so much of this election cycle has been dominated by, Would you sign a ban? And that’s just the wrong question. I mean, we’ve seen Congress unable to pass either abortion restrictions or abortion protections even when one party controls both chambers. It’s just really hard.
Rovner: And going back 60 years.
Ollstein: And so I think it’s way more important to look at what could happen administratively or through the courts. And so yes, lawsuits like that, that the Supreme Court punted on but didn’t totally resolve this term, could absolutely come back. A Trump administration could also direct the FDA to just unauthorize abortion pills, which are the majority of abortions that take place within the U.S.
And so — or there’s this Comstock Act route. There’s — the Biden administration put out a memo saying, We do not think the Comstock Act applies to the mailing of abortion pills to patients. A Trump administration could put out their own memo and say, We believe the opposite. So there’s a lot that could happen. And so I really have been frustrated. All of the obsessive focus on: Would you sign a ban? Would you veto a ban? Because that is the least likely route that this would happen.
Kirzinger: Well, and all of these court cases create an air of confusion among the public, right? And so, that also can have an effect in a way that signing a ban — I mean, if people don’t know what’s available to them in their state based on state policy or national policy.
Ollstein: Or they’re afraid of getting arrested.
Kirzinger: Yeah, even if it’s completely legal in their state, we’re finding that people aren’t aware of whether — what’s available to them in their state, what they can access legally or not. And so having those court cases pending creates this air of confusion among the public.
Keith: Well, just to amplify the air of confusion, talking to Democrats who watch focus groups, they saw a lot of voters blaming President Biden for the Dobbs decision and saying: Well, why couldn’t he fix that? He’s president. At a much higher level, there is confusion about how our laws work. There’s a lot of confusion about civics, and as a result, you see blame landing in sort of unexpected places.
Rovner: This is the vaguest presidential election I have ever covered. I’ve been doing this since 1988. We basically have both candidates refusing to answer specific questions — as a strategy, I mean, it’s not that I don’t think — I think they both would have a pretty good idea of what it is they would do, and both of them find it to their political advantage not to say.
Keith: I think that’s absolutely right. I think that the Harris campaign, which I spend more time covering, has the view that if Trump is not going to answer questions directly and he is going to talk about “concepts” of a plan, and he’s just going to sort of, like, Well, if I was president, this wouldn’t be a problem, so I’m not going to answer your question — which is his answer to almost every question — then there’s not a lot of upside for them to get into great specifics about policy and to have think tank nerds telling them it won’t work, because there’s no upside to it.
Cox: We’re right here.
Panel: [Laughing]
Rovner: So regular listeners to the podcast will know that one of my biggest personal frustrations with this campaign is the ever-increasing amount of mis- and outright disinformation in the health care realm, as we discussed at some length on last week’s podcast. You can go back and listen. This has become firmly established in public health, obviously pushed along by the divide over the covid pandemic. The New York Times last week had a pretty scary story by Sheryl Gay Stolberg — who’s working on a book about public health — about how some of these more fringe beliefs are getting embedded in the mainstream of the Republican Party.
It used to be that we saw most of these kind of fringe, anti-science, anti-health beliefs were on the far right and on the far left, and that’s less the case. What could we be looking forward to on the public health front if Trump is returned to power, particularly with the help of anti-vaccine activist and now Trump endorser R.F.K. [Robert F. Kennedy] Jr.?
Kirzinger: Oh, goodness to me. Well, so I’m going to talk about a group that I think is really important for us to focus on when we think about misinformation, and I call them the “malleable middle.” So it’s that group that once they hear misinformation or disinformation, they are unsure of whether that is true or false, right? So they’re stuck in this uncertainty of what to believe and who do they trust to get the right information. It used to be pre-pandemic that they would trust their government officials.
We have seen declining trust in CDC [Centers for Disease Control and Prevention], all levels of public health officials. Who they still trust is their primary care providers. Unfortunately, the groups that are most susceptible to misinformation are also the groups that are less likely to have a primary care provider. So we’re not in a great scenario, where we have a group that is unsure of who to trust on information and doesn’t have someone to go to for good sources of information. I don’t have a solution.
Cox: I also don’t have a solution.
Rovner: No, I wasn’t — the question isn’t about a solution. The question is about, what can we expect? I mean, we’ve seen the sort of mis- and disinformation. Are we going to actually see it embedded in policy? I mean, we’ve mostly not, other than covid, which obviously now we see the big difference in some states where mask bans are banned and vaccine mandates are banned. Are we going to see childhood vaccines made voluntary for school?
Ollstein: Well, there’s already a movement to massively broaden who can apply for an exception to those, and that’s already had some scary public health consequences. I mean, I think there are people who would absolutely push for that.
Kirzinger: I think regardless of who wins the presidency, I think that the misinformation and disinformation is going to have an increasing role. Whether it makes it into policy will depend on who is in office and Congress and all of that. But I think that it is not something that’s going away, and I think we’re just going to continue to have to battle it. And that’s where I’m the most nervous.
Keith: And when you talk about the trust for the media, those of us who are sitting here trying to get the truth out there, or to fact-check and debunk, trust for us is, like, in the basement, and it just keeps getting worse year after year after year. And the latest Gallup numbers have us worse than we were before, which is just, like, another institution that people are not turning to. We are in an era where some rando on YouTube who said they did their research is more trusted than what we publish.
Rovner: And some of those randos on YouTube have millions of viewers, listeners.
Keith: Yes, absolutely.
Rovner: Subscribers, whatever you want to call them.
Ollstein: One area where I’ve really seen this come forward, and it could definitely become part of policy in the future, is there’s just a lot of mis- and disinformation around transgender health care. There’s polling that show a lot of people believe what Trump and others have been saying, that, Oh, kids can come home from school and have a sex change operation. Which is obviously ridiculous. Everyone who has kids in school knows that they can’t even give them a Tylenol without parental permission. And it obviously doesn’t happen in a day, but people are like, Oh, well, I know it’s not happening at my school, but it’s sure happening somewhere. And that’s really resonating, and we’re already seeing a lot of legal restrictions on that front spilling.
Rovner: All right, well, I’m going to open it up to the audience. Please wait to ask your question until you have a microphone, so the people who will be listening to the podcast will be able to hear your question. And please tell us who you are, and please make your question or question.
Madeline: Hi, I’m Madeline. I am a grad student at the Milken Institute of Public Health at George Washington. My question is regarding polling. And I was just wondering, how has polling methodologies or tendencies to over-sample conservatives had on polls in the race? Are you seeing that as an issue or …?
Kirzinger: OK. You know who’s less trusted than the media? It’s pollsters, but you can trust me. So I think what you’re seeing is there are now more polls than there have ever been, and I want to talk about legitimate scientific polls that are probability-based. They’re not letting people opt into taking the survey, and they’re making sure their samples are representative of the entire population that they’re surveying, whether it be the electorate or the American public, depending on that.
I think what we have seen is that there have been some tendencies when people don’t like the poll results, they look at the makeup of that sample and say, oh, this poll’s too Democratic, or too conservative, has too many Trump voters. Or whatever it may be. That benefits no pollster to make their sample not look like the population that they’re aiming to represent. And so, yes, there are lots of really, really bad polls out there, but the ones that are legitimate and scientific are still striving to aim to make sure that it’s representative. The problem with election polls is we don’t know who the electorate’s going to be. We don’t know if Democrats are going to turn out more than Republicans. We don’t know if we’re going to see higher shares of rural voters than we saw in 2022.
We don’t know. And so that’s where you really see the shifts in error happen.
Keith: And if former President Trump’s — a big part of his strategy is turning out unlikely voters.
Kirzinger: Yeah. We have no idea who they are.
Rovner: Well, yeah, we saw in Georgia, their first day of in-person early voting, we had this huge upswell of voters, but we have no idea who any of those are, right? I mean, we don’t know what is necessarily turning them out.
Kirzinger: Exactly. And historically, Democrats have been more likely to vote early and vote by mail, but that has really shifted since the pandemic. And so you see these day voting totals now, but that really doesn’t tell you anything at this point in the race.
Rovner: Lots we still don’t know. Another question.
Rae Woods: Hi there. Rae Woods. I’m with Advisory Board, which means that I work with health leaders who need to implement based on the policies and the politics and the results of the election that’s coming up. My question is, outside some of the big things that we’ve talked about so far today, are there some more specific, smaller policies or state-level dynamics that you think today’s health leaders will need to respond to in the next six months, the next eight months? What do health leaders need to be focused on right now based on what could change most quickly?
Ollstein: Something I’ve been trying to shine a light on are state Supreme Courts, which the makeup of them could change dramatically this November. States have all kinds of different ways to … Some elect them on a partisan basis. Some elect them on a nonpartisan basis. Some have appointments by the governor, but then they have to run in these retention elections. But they are going to just have so much power over … I mean, I am most focused on how it can impact abortion rights, but they just have so much power on so many things.
And given the high likelihood of divided federal government, I think just a ton of health policy is going to happen at the state level. And so I would say the electorate often overlooks those races. There’s a huge drop-off. A lot of people just vote the top of the ticket and then just leave those races blank. But yes, I think we should all be paying more attention to state Supreme Court races.
Rovner: I think the other thing that we didn’t, that nobody mentioned we were talking about, what the next president could do, is the impact of the change to the regulatory environment and what the Supreme Court’s decision overturning Chevron is going to have on the next president. And we did a whole episode on this, so I can link back to that for those who don’t know. But basically, the Supreme Court has made it more difficult for whoever becomes president next time to change rules via their executive authority, and put more onus back on Congress. And we will see how that all plays out, but I think that’s going to be really important next year.
Natalie Bercutt: Hi. My name is Natalie Bercutt. I’m also a master’s student at George Washington. I study health policy. I wanted to know a little bit more about, obviously, abortion rights, a huge issue on the ballot in this election, but a little bit more about IVF [in vitro fertilization], which I feel like has kind of come to the forefront a little bit more, both in state races but also candidates making comments on a national level, especially folks who have been out in the field and interacting with voters. Is that something that more people are coming out to the ballot for, or people who are maybe voting split ticket but in support of IVF, but for Republican candidate?
Ollstein: That’s been fascinating. And so most folks know that this really exploded into the public consciousness earlier this year when the Alabama Supreme Court ruled that frozen embryos are people legally under the state’s abortion ban. And that disrupted IVF services temporarily until the state legislature swooped in. So Democrats’ argument is that because of these anti-abortion laws in lots of different states that were made possible by the Dobbs decision, lots of states could become the next Alabama. Republicans are saying: Oh, that’s ridiculous. Alabama was solved, and no other state’s going to do it. But they could.
Rovner: Alabama could become the next Alabama.
Ollstein: Alabama could certainly become the next Alabama. Buy tons of states have very similar language in their laws that would make that possible. Even as you see a lot of Republicans right now saying: Oh, Republicans are … We’re pro-IVF. We’re pro-family. We’re pro-babies. There are a lot of divisions on the right around IVF, including some who do want to prohibit it and others who want to restrict the way it’s most commonly practiced in the U.S., where excess embryos are created and only the most viable ones are implanted and the others are discarded.
And so I think this will continue to be a huge fight. A lot of activists in the anti-abortion movement are really upset about how Republican candidates and officials have rushed to defend IVF and promised not to do anything to restrict it. And so I think that’s going to continue to be a huge fight no matter what happens.
Rovner: Tam, are you seeing discussion about the threats to contraception? I know this is something that Democratic candidates are pushing, and Republican candidates are saying, Oh, no, that’s silly.
Keith: Yeah, I think Democratic candidates are certainly talking about it. I think that because of that IVF situation in Alabama, because of concerns that it could move to contraception, I think Democrats have been able to talk about reproductive health care in a more expansive way and in a way that is perhaps more comfortable than just talking about abortion, in a way that’s more comfortable to voters that they’re talking to back when Joe Biden was running for president. Immediately when Dobbs happened, he was like, And this could affect contraception and it could affect gay rights. And Biden seemed much more comfortable in that realm. And so—
Rovner: Yeah, Biden, who waited, I think it was a year and a half, before he said the word “abortion.”
Keith: To say the word “abortion.” Yes.
Rovner: There was a website: Has Biden Said Abortion Yet?
Keith: Essentially what I’m saying is that there is this more expansive conversation about reproductive health care and reproductive freedom than there had been when Roe was in place and it was really just a debate about abortion.
Rovner: Ashley, do people, particularly women voters, perceive that there’s a real threat to contraception?
Kirzinger: I think what Tamara was saying about when Biden was the candidate, I do think that that was part of the larger conversation, that larger threat. And so they were more worried about IVF and contraception access during that. When you ask voters whether they’re worried about this, they’re not as worried, but they do give the Democratic Party and Harris a much stronger advantage on these issues. And so if you were to be motivated by that, you would be motivated to vote for Harris, but it really isn’t resonating with women voters and the way now that abortion, abortion access is resonating for them.
Rovner: Basically, it won’t be resonating until they take it away.
Kirzinger: Exactly. If, I think, the Alabama Supreme Court ruling happened yesterday, I think it would be a much bigger issue in the campaign, but all of this is timing.
Ollstein: Well, and people really talked about a believability gap around the Dobbs decision, even though the activists who were following it closely were screaming that Roe is toast, from the moment the Supreme Court agreed to hear the case, and especially after they heard the case and people heard the tone of the arguments. And then of course the decision leaked, and even then there was a believability gap. And until it was actually gone, a lot of people just didn’t think that was possible. And I think you’re seeing that again around the idea of a national ban, and you’re seeing it around the idea of restrictions on contraception and IVF. There’s still this believability gap despite the evidence we’ve seen.
Rovner: All right. I think we have time for one more question.
Meg: Hi, my name’s Meg. I’m a freelance writer, and I wanted to ask you about something I’m not hearing about this election cycle, and that’s guns. Where do shootings and school shootings and gun violence fit into this conversation?
Keith: I think that we have heard a fair bit about guns. It’s part of a laundry list, I guess you could say. In the Kamala Harris stump speech, she talks about freedom. She talks about reproductive freedom. She talks about freedom from being shot, going to the grocery store or at school. That’s where it fits into her stump speech. And certainly in terms of Trump, he is very pro–Second Amendment and has at times commented on the school shootings in ways that come across as insensitive. But for his base — and he is only running for his base — for his base, being very strongly pro–Second Amendment is critical. And I think there was even a question maybe in the Univision town hall yesterday to him about guns.
It is not the issue in this campaign, but it is certainly an issue if we talk about how much politics have changed in a relatively short period of time. To have a Democratic nominee leaning in on restrictions on guns is a pretty big shift. When Hillary Clinton did it, it was like: Oh, gosh. She’s going there. She lost. I don’t think that’s why she lost, but certainly the NRA [National Rifle Association] spent a lot of money to help her lose. Biden, obviously an author of the assault weapons ban, was very much in that realm, and Harris has continued moving in that direction along with him, though also hilariously saying she has a Glock and she’d be willing to use it
Ollstein: And emphasizing [Minnesota governor and Democratic vice presidential candidate Tim] Walz’s hunting.
Keith: Oh, look, Tim Walz, he’s pheasant hunting this weekend.
Rovner: And unlike John Kerry, he looked like he’d done it before. John Kerry rather famously went out hunting and clearly had not.
Keith: I was at a rally in 2004 where John Kerry was wearing the jacket, the barn jacket, and the senator, the Democratic senator from Ohio hands him a shotgun, and he’s like … Ehh.
Kirzinger: I was taken aback when Harris said that she had a Glock. I thought that was a very interesting response for a Democratic presidential candidate. I do think it is maybe part of her appeal to independent voters that, As a gun owner, I support Second Amendment rights, but with limitations. And I do think that that part of appeal, it could work for a more moderate voting block on gun rights.
Rovner: We haven’t seen this sort of responsible gun owner faction in a long time. I mean, that was the origin of the NRA.
Keith: But then more recently, Giffords has really taken on that mantle as, We own guns, but we want controls.
Rovner: All right, well, I could go on for a while, but this is all the time we have. I want to thank you all for coming and helping me celebrate my birthday being a health nerd, because that’s what I do. We do have cake for those of you in the room. For those of you out in podcast land, as always, if you enjoy the podcast, you could subscribe wherever you get your podcast.
We’d appreciate it if you left us a review. That helps other people find us, too. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman, and our live-show coordinator extraordinaire, Stephanie Stapleton, and our entire live-show team. Thanks a lot. This takes a lot more work than you realize. As always, you can email us your comments or questions. We’re at whatthehealth, all one word, @KFF.org, or you can still find me. I’m at X at @jrovner. Tam, where are you on social media?
Keith: I’m @tamarakeithNPR.
Rovner: Alice.
Ollstein: @AliceOllstein.
Rovner: Cynthia.
Cox: @cynthiaccox.
Rovner: Ashley.
Kirzinger: @AshleyKirzinger.
Rovner: We will be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': The Health of the Campaign
The Host
Julie Rovner
KFF Health News
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.
When it comes to health care, this year’s presidential campaign is increasingly a matter of which candidate voters choose to believe. Democrats, led by Vice President Kamala Harris, say Republicans want to further restrict reproductive rights and repeal the Affordable Care Act, pointing to their previous actions and claims. Meanwhile, Republicans, led by former President Donald Trump, insist they have no such plans.
Meanwhile, with open enrollment approaching for Medicare, the Biden administration dodges a political bullet, avoiding a sharp spike next year in Medicare prescription drug plan premiums.
This week’s panelists are Julie Rovner of KFF Health News, Alice Miranda Ollstein of Politico, Sandhya Raman of CQ Roll Call, and Anna Edney of Bloomberg News.
Panelists
Anna Edney
Bloomberg
Alice Miranda Ollstein
Politico
Sandhya Raman
CQ Roll Call
Among the takeaways from this week’s episode:
- This week, Sen. JD Vance of Ohio muddled his ticket’s stances on health policy during the vice presidential debate, including by downplaying the possibility of a national abortion ban. And Melania Trump, the former president’s wife, spoke out in support of abortion rights. Their comments seem designed to soothe voter concerns that former President Donald Trump could take actions to further block abortion access.
- Vance raised eyebrows with his debate-night claim that Trump “salvaged” the Affordable Care Act — when, in fact, the former president vowed to repeal the law and championed the GOP’s efforts to deliver on that promise. Meanwhile, Trump deflected questions from AARP about his plans for Medicare, replying, “What we have to do is make our country successful again.”
- On the Democratic side, Vice President Kamala Harris is campaigning on health, in particular by pushing out new ads highlighting the benefits of the ACA and Trump’s efforts to restrict abortion. Polls show health is a winning issue for Democrats and that the ACA is popular, especially its protections for those with preexisting conditions.
- Also in the news, the Centers for Medicare & Medicaid Services reported a slight dip in average Medicare drug plan premiums for next year. Coming in an annual report — out shortly before Election Day — it looks as though government subsidies cushioned changes to the system, sparing seniors from potentially paying in premiums what they may save under the new $2,000 annual out-of-pocket drug cost cap, for instance.
- And in abortion news, a judge struck down Georgia’s six-week abortion ban — but many providers have already left the state. And a new California law protects coverage for in vitro fertilization, including for LGBTQ+ couples.
Also this week, Rovner interviews KFF Health News’ Lauren Sausser, who reported and wrote the latest KFF Health News-Washington Post “Bill of the Month,” about a teen athlete whose needed surgery lacked a billing code. Do you have a confusing or outrageous medical bill you want to share? Tell us about it.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: KFF Health News’ “Doctors Urging Conference Boycotts Over Abortion Bans Face Uphill Battle,” by Ronnie Cohen.
Anna Edney: Bloomberg News’ “A Free Drug Experiment Bypasses the US Health System’s Secret Fees,” by John Tozzi.
Alice Miranda Ollstein: The Wall Street Journal’s “Hospitals Hit With IV Fluid Shortage After Hurricane Helene,” by Joseph Walker and Peter Loftus.
Sandhya Raman: The Asheville Citizen Times’ “Without Water After Helene, Residents at Asheville Public Housing Complex Fear for Their Health,” by Jacob Biba.
Also mentioned on this week’s podcast:
- SisterSong v. State of Georgia: Superior Court of Fulton County decision.
Click to open the transcript
Transcript: The Health of the Campaign
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Friday, October 4th, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go.
Rovner: Today we are joined via teleconference by Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Hello.
Rovner: Sandhya Raman of CQ Roll Call.
Raman: Hello, everyone.
Rovner: And Anna Edney of Bloomberg News.
Anna Edney: Hi there.
Rovner: Later in this episode, we’ll have my “Bill of the Month” interview with my KFF Health News colleague Lauren Sausser. This month’s patient is a high school athlete whose problem got fixed, but his bill did not. But first, the news.
We’re going to start this week with the campaign. It is October. I don’t know how that happened. On Tuesday, vice-presidential candidates Senator JD Vance of Ohio and Governor Tim Walz of Minnesota held their first and only debate. It felt very Midwestern nice, with Walz playing his usual Aw shucks self and Vance trying very hard to seem, for want of a better word, likable. Did we learn anything new from either candidate?
Edney: I don’t think I heard anything new, no — not that I can remember.
Rovner: I know, obviously, they exchanged some views on abortion. Vance tried very hard to distance himself from his own hard-line views on the subject, including denying that he’d ever supported a national abortion ban, which he did, by the way. Meanwhile, during the debate, former President [Donald] Trump announced on social media that he would veto a national abortion ban, something he’d not said in those exact words before. Alice, you’ve got a pretty provocative story out this week suggesting that this all might actually be working on a skeptical public. Is it?
Ollstein: Yes. This has been a theme I’ve been tracking for a little bit. It was part of the reporting I was doing in Michigan a couple weeks ago. One, what I thought was interesting about that night was Trump and Vance have been talking past each other on abortion and contradicting each other, and now …
Rovner: Oh, yeah.
Ollstein: … it finally seems that they are on the same page, in terms of trying to convince the public: Nothing to see here. We won’t do a national ban. Don’t worry about it. Democrats and abortion rights groups are running around screaming: They’re lying. Look at their record. Look at what their allies have proposed in things like Project 2025. But the Republican message on this front does seem to be working. Polls show that even people who care about abortion rights and support abortion rights in some of these key battleground states still plan to vote for Trump. It’s a continuation of a pattern we’ve seen over the past few years where a decent chunk of people vote for these state ballot initiatives to protect abortion but then also vote for anti-abortion politicians.
Voters contain multitudes. We don’t know exactly if it’s because they are not worried that Trump and Vance will pursue national restrictions. We don’t know if it’s because just other issues are more important to them. But I think it’s really worth keeping an eye on in terms of a pattern. And KFF has done some really interesting polling showing that people in states where the ballot initiatives have already passed sort of view it as, Oh, we took care of that, it’s settled, and they don’t see the urgency and the threat of a national ban in the way that Democrats and abortion rights groups want them to.
Rovner: Which we’ll talk about separately in a minute. In late breaking news, Melania Trump this week came out and said that she supports abortion rights. Is this part of the continuing muddle where everybody can see what it is that they want to see, or is this going to have any impact at all?
Ollstein: Can I say one more thing about the debate first?
Rovner: Sure.
Ollstein: OK. So what really struck me about what Vance said about abortion at the debate is he really portrayed two arguments that I’ve seen sort of trickle up from the grass roots of the anti-abortion movement. So one, there were some semantics quibbles around what is a ban. There’s really been an effort in the anti-abortion movement to say that only a total ban throughout pregnancy with no exceptions, only that they call a ban. Everything else, they don’t consider it a ban.
Rovner: It’s a national standard.
Ollstein: Yeah, minimum standard, federal standard. There’s a lot of different words they use — “limit,” “restriction.” But what they’re describing is what others call a ban. It’s not a different policy, and so we saw that on full display on the debate stage. We also saw this argument sort of that these government programs and funding and support are the answer to abortion, so, basically, promoting the idea that with enough child care supports and health care supports, fewer people would have abortions — which the data is mixed on that, I will say, from the U.S. and from other countries. But financial hardship is just one of many reasons people have abortions, so that would impact some people and not others. It also goes against a lot of the sort of traditional small-government, cut-government-spending Republican ethos, and so it is this really interesting sort of pro-natalist direction that some of the party wants to go in and some of the activist movement wants to go in. But there’s definitely some tension around that. And, of course, we’ve seen Republicans vote against those programs and funding at the state and federal level.
Rovner: Things like paid family leave have been a Democratic priority much, much longer than it’s been a Republican priority, if it ever was and if it is now.
Ollstein: But it’s interesting that he was promoting that to sort of show a kinder, gentler face to the anti-abortion movement, which has been a trend we’ve been seeing.
Rovner: Yes. Yes, not just from JD Vance but from lots of Republicans on the anti-abortion side. And Melania—
Ollstein: Sorry, back to Melania.
Rovner: Is there any impact from this?
Edney: Oh, it’s certainly worked for the Trump campaign to muddy the waters on any subject. If you think about immigration, certainly that worked before, and I think you can see where they’re realizing that. And they are coming together, like Alice mentioned, with JD Vance and Trump talking on the same page now a bit better but using sort of a, I don’t want to say “underling,” but like a second …
Rovner: A surrogate.
Edney: Yeah, a surrogate, a secondary character to say, I support abortion rights. And she has Trump’s ear, and that could really be a solid salve to a lot of people.
Rovner: I was fascinated because she’s been pretty much invisible all year. I think this is the first time we have actually heard her voice, the first time I have heard her voice in 2024.
Raman: I would add that it’s not unprecedented for a first lady on the Republican side to come out in favor of abortion rights. I think what makes it so interesting is, A, how close we are to the election and that we are actively in a campaign. When we look at the remarks that Laura Bush made several years ago, it was after [former President George W.] Bush had left office for a few years. And so this, I think, is just what really makes it, if the book is going to come out about a month or so before the election that …
Rovner: Melania’s book.
Raman: Yeah, Melania’s book, yes.
Rovner: So yes, we will see. All right. Well, abortion was not the only health issue that came up during the debate. So did the Affordable Care Act. JD Vance went as far to claim that Donald Trump is actually the one that saved the Affordable Care Act. That’s not exactly how I remember things happening. You’re shaking your head.
Raman: I think this was one of the most striking parts of the debate for me, just because he made several comments about how this was a bipartisan process and Trump was trying to salvage the ACA. And for those of us that were reporting in 2017, he was kind of ringleading the effort to repeal and replace the Affordable Care Act. And I guess there were just numerous claims within the few statements he made that were just all incorrect. He was talking about how Trump had divided risk pools, and that was not something that happened. I think that we assume that he was referring to the reinsurance waivers, but those were also created under the Obama administration, so it wasn’t like a Trump invention. We just had some approved under Trump. And he’d mentioned that enrollment was reaching record heights. Health enrollment grew more under the Biden administration than it did under Trump.
Rovner: Yeah, I went back and actually looked up those numbers because I was so, like, “What are you talking about?” Actually, it was the moderator question: Didn’t enrollment go up during the Trump administration? No, it went down every year.
Ollstein: The number of uninsured went up, in fact, during the Trump administration.
Rovner: That’s right.
Ollstein: But, I mean, this is, again, part of a long pattern. Trump has routinely taken credit for things that were the decisions of other administrations, both before and after him.
Rovner: And things that he tried to do and failed to do.
Ollstein: Right.
Rovner: Like lowering drug prices.
Ollstein: Right. Right, right, right. Exactly. Exactly. Like Anna said, there was very little new that was revealed in this exchange.
Rovner: Well, elsewhere on the campaign trail, the Harris campaign is working hard to elevate health care as an issue, including rolling out not just a 60-second ad warning of what repealing the Affordable Care Act could mean, but also issuing a 43-page white paper theorizing what Trump and Vance are likely to have in mind with their, quote, “concepts” of a health care plan based on what they’ve said and done in the past. They must be seeing something in the polls suggesting this could have some legs, don’t you think? I’m a little surprised, because everybody keeps saying: Not a health care election. This is not a health care election. But I don’t know. The Harris campaign sure keeps behaving like it might be.
Raman: Hammering in on the preexisting conditions and protecting those, just because that is such a popular part of the ACA across the board, is probably a good strategy for them, just because that is something that is not the most wonky with that and that people can understand in a campaign ad and kind of distill down.
Edney: Yeah, that was what I was thinking as well, is it’s a popular issue for, certainly, to be talking about, but also just the idea that he’s talking about it in a way that people think, Oh, we don’t have to worry. And Alice has made this point on abortion before. There’s a lot that he can do through executive order and things like that, and did do like taking away money for the navigators and things to help people enroll. So even if they don’t think it’s maybe going to be about health care fully, it makes sense to try to counter some of that. And you can’t do that on a debate stage most of the time, not in an effective way, but certainly putting out this paper, I mean, it did get some press and things like that, and if you really wanted to go read it, you could.
Rovner: Even I didn’t want to read all 43 pages.
Edney: Yeah.
Rovner: Well, as Anna previewed, the AARP released what’s normally a pretty routine interview with both candidates about issues important to Americans over age 50, things like Medicare, Social Security, and caregiving. But I think it’s fair to say that, at least, former President Trump’s answers were anything but routine. Asked how he would protect Medicare from cuts and improve the program, he said, and I quote: “What we have to do is make our country successful again. This has to do with Medicare and Social Security and other things. We have to let our country become successful, make our country successful again, and we’ll be able to do that.” How do you even respond to things like that? Or is this campaign now so completely divorced from the issues that literally nothing matters?
Edney: Well, I kind of noticed a trend in between that answer and one JD Vance gave when he was talking about abortion, and he said: We just need to make women trust us. They need to trust us again. We need to make them trust us. I was like, I don’t understand how that even connects. But also, how are you going to do that? And I think that this is the same thing. You’re just saying these words over and over again in relation. So in somebody’s mind, Medicare and success is Trump’s word, and trust and abortion as JD Vance’s thing, and you’re connecting these in their minds. And I was seeing this as a trend. It just felt familiar to me after listening to the vice-presidential debate. They’re not going to talk about any policy or anything, but repeating these words over and over again like you were listening to morning affirmations or something was going to really get that through in a voter’s mind is maybe what they’re going for.
Rovner: And I have to say, I mean, when candidates start to talk about actual policy ideas, it gets really wonky really fast. Sort of going back to the debate, JD Vance was talking about visas and immigration, and I think it’s an app that he was talking about. I know this stuff pretty well. I had no idea what he was talking about. I mean, maybe it does work better when Trump says, I’m not going to cut Medicare or Social Security, and leave it at that.
Ollstein: Well, right, because when you talk specific policies, that opens it up to critique. And when you just talk total platitudes, then it’s harder to pick apart and criticize, even though it’s clearly not an answer to the questions they’re asking. And it was even a little bit funny to me for the AARP interview, because I believe they sent in written responses, and so they had the ability—
Rovner: I think they also talked on the phone.
Ollstein: Oh, OK.
Rovner: So I think it was a little bit of both.
Ollstein: Right. Right, right, right. It wasn’t the sort of live televised interview. They could have looked up — it was an open-book test.
Rovner: It was.
Ollstein: And yet all of the responses from Trump were just like, We’re going to do something and it’s going to be great and awesome and it’ll fix everything, and it was completely devoid of policy specifics, which again may be smarter politically than actually saying what you plan to do, which as we’ve seen in Project 2025, generates a lot of backlash. But it is also a little bit dangerous to go into the election not knowing the specifics of what someone wants to do on health care.
Rovner: Yeah, I know. I find when I listen to some of these focus groups with undecided voters, we want to know what exactly they’re going to do, except they don’t really want to know what exactly they’re going to do. They think they do, but it appears that that is not necessarily the case. One thing that we know does matter, at least to people on Medicare, is the premiums they pay for their coverage. And unfortunately, for every administration, that announcement comes just weeks before Election Day every year. So this year, the Biden administration was worried about big jumps in premiums for Medicare Part D drug coverage, mostly thanks to the new caps on spending that will save consumers money but will cost insurers more. That didn’t happen, though. And in fact, average premiums will actually fall slightly next year.
Now, I’m not sure I understand exactly what the administration did to avoid this, but they used existing demonstration authority to boost payments to insurers. And, not surprisingly, Republicans are pretty furious. On the other hand, Republicans used pretty much this same authority to avoid Medicare premium spikes in the past. Anna, is this just political manipulation or good governing, or a little bit of both?
Edney: Yeah, it is certainly very timely and probably necessary also because the IRA, the Inflation Reduction Act, kept the seniors’ out-of-pocket pay at $2,000 a year. And so that was going to skyrocket premiums, and they did not want to face that, particularly in an election year. And as you mentioned, this all happens around that time. And so they did this demonstration, and I have read a few things trying to figure out exactly what it does, and I can’t.
Rovner: So it’s not just me. It’s complicated.
Edney: It’s not just you. It’s really complicated, and it has to do with payments that usually come at the end that insurers are now going to get upfront. And that’s the best I can tell you. But they’ll be getting some subsidies upfront, and it’s to try to spread these premium increases to help mitigate those so that seniors don’t have to then pay on that end instead of for their drugs out-of-pocket. So I think that they need to do something. I mean, already, the premiums were able to go up. I think it’s $35 a month, and some plans did elect to do that and others have them staying even. And you even have some with them going down a little bit. So I guess the moral of the story is for consumers to shop around this year, certainly.
Rovner: That’s right, and we will talk more about Medicare open enrollment, which opens in a couple of weeks, because it’s October, and all of these things happen at once. Moving back to abortion, a judge in Georgia struck down, at least for now, the state’s six-week abortion ban, quoting from “The Handmaid’s Tale” about how the law requires women to serve as human incubators. And I’ll put a link to the decision, because that’s quite the decision. But Alice, this is far from the last word on this, right?
Ollstein: Yes. It’s just so fascinating what a slow burn these lawsuits are. I mean, this, the one in North Dakota recently that restored access, these just sort of simmer under the radar for months or even years, and then a decision can have a major impact. And so access has been restored in some of these states. Some interesting things that came to mind were, one, it could be reversed again and pingpong back and forth, and all of that is very challenging for doctors and patients to manage.
But also — and I’m thinking more of North Dakota, because Georgia is sort of a medical powerhouse with a lot of providers and hospitals and facilities and stuff — but in North Dakota, the state’s only abortion clinic moved out of state, and they do not plan to move back as a result of this decision. This isn’t a switch you can flip back and forth. And so when access is restored on paper in the law, that doesn’t mean it’s going to be restored in practice. You need doctors willing to work in these states and provide the procedure. And even with the court rulings, they may not feel comfortable doing so, or the logistics are just too daunting to move back. So I would urge people to keep that in mind.
Rovner: Yeah, and the state’s already said that it’s going to appeal to the next-higher court. So we will see this continue, but I think it was definitely worth mentioning. We’ve talked a lot this year about women experiencing pregnancy complications not being able to get care in states with abortion bans and restrictions. Well, it’s happening in states where abortion is supposed to be widely available, too.
In California, the state’s attorney general filed suit this week against a Catholic hospital in the rural northern part of the state that refused to terminate the doomed pregnancy of a woman carrying twins after her water broke at 15 weeks, because they said one of the twins still had a heartbeat. She eventually was driven to the only other hospital within a hundred miles of the labor and delivery unit, where she did get the care that she needed, although she was hemorrhaging, but not until after a nurse at the Catholic hospital gave her a bucket of towels, quote, “in case something happens in the car.” Meanwhile, the labor and delivery unit at the hospital she was taken to is itself scheduled to close. Are women starting to get the idea that this is about more than just selective abortions and that no matter where they live, that being pregnant could be more dangerous than it has been in the past?
Raman: I was going to say this is something that abortion rights advocates have been saying for years now, that it’s not just abortion, that they point to things like the whole ordeal that we’ve been having with IVF [in vitro fertilization] and birth control and so many other things. Even in the last couple years, people trying to get other medications that have nothing to do with pregnancy and not being able to get those because they might have an effect or cause miscarriage or things like that. So I think in one way, yes. But at the same time, when you look at something like what we saw happen with the two deaths in Georgia, right? The messaging from the anti-abortion crowd has been that this was not because of the abortion ban but because of the regulations that allowed these people to get a medication abortion and that’s what’s driving the death.
So we think that, in some ways, there’s certain camps that are just going to be focused on a different side of how the emergency might not be related to abortion at all, or the branding is that this is not an abortion in certain cases versus an abortion, it’s just semantics. So I don’t know how many minds it’s changing at this point.
Ollstein: Like Sandhya said, the awareness that this is not just for so-called elective abortions. Obviously, that term is disputed and there’s gray area of what that means. I think the overwhelming focus in messaging — from Democrats, anyway — has been about these wanted pregnancies that suffer medical complications and people can’t get care, and so the spillover effect on miscarriage care. But I think the piece that’s new that this could emphasize is that it’s not a strict red-state-blue-state divide, that Catholic hospitals and other facilities in states with protections, like California — it could happen there, too. So I think that’s what this case may be contributing in a new way to people’s understanding.
Rovner: And, of course, this was happening long before Dobbs — I mean, with Catholic hospitals, particularly Catholic hospitals in areas where there are not a lot of hospitals, denying care according to Catholic teachings and women having basically no place, at least nearby, to go. So I think people are seeing it in a new light now that it seems to be happening in many, many places at the same time. Well, while we are visiting California, Governor Gavin Newsom this week signed legislation requiring large group health insurance plans to cover IVF and other fertility treatments starting next year. California is far from the first state to do this. I think it’s now up to over a dozen. But it’s by far the most populous state to do this. Do we expect to see more of this, particularly given, as you were saying, Sandhya, the attention that IVF is suddenly getting?
Raman: I think we could. We’ve had a lot of states do different variations of those so far, and they haven’t necessarily been blue versus red. I think one thing that was interesting about the California law in particular was that it included LGBTQ people within the infertility definition, which we’ve been having IVF laws for over 20 years at this point and I don’t know that that has been necessarily there in other ones. So I would be watching for more things like that and seeing how widespread that would be in some of the bills coming up in the next legislative cycle.
Rovner: Yes, and another issue that I suspect will continue to simmer beyond this election. Well, finally this week, two big business-of-health-related stories: Over the summer, we talked about how the CEO of Steward Health Care, which is a chain of hospitals bought out by private equity and basically run into bankruptcy, refused to show up to testify before the Senate Health, Education, Labor and Pensions Committee. Well, in the last two weeks, the committee, followed by the full Senate, voted to hold CEO Ralph de la Torre in criminal contempt. And as of last week, he is now ex-CEO Ralph de la Torre, and now he is suing the Senate over that contempt vote. If nothing else, I guess this raises the stakes in Congress to continue to look at the impact of private equity in health care?
Edney: Yeah, I think it’s interesting, because when you look at [Sen.] Bernie Sanders calling in pharmaceutical CEOs, they typically show up and they take their hits and they go home. And in this case, it probably kind of heightens that idea that private equity is the evil person. And I’m not saying everyone thinks pharma is not, but they do understand Washington. And there’s a chance that a lot of New York–focused, Wall Street–focused private equity folks may not get that quite in the same way or just may not view it as important. But now, that may be changing.
Rovner: I was surprised by how bipartisan this was.
Edney: Yeah.
Rovner: I mean, beating up on pharma tends to be a Democratic thing, but this was bipartisan in the committee and bipartisan in the Senate. I mean, it’s also important to remember that Steward Health Care is a chain of hospitals in a whole bunch of states, so there are a lot of senators who are seeing hospitals in, now, dire straits through this whole private equity thing, who I imagine are not very happy about it. And their constituents are not very happy about it. But I think the bipartisanship of it is what sort of stuck out to me.
Raman: I was just going to say hospitals are such a big employer for so many districts that I think that, but I would say this was the first time in 50 years they’ve sent a contemptor to the DOJ [Department of Justice]. And especially doing that in a unanimous fashion is just very striking to me, and I’m curious if DOJ kind of goes forth and does, takes penalty and action with it.
Rovner: Yeah, this is a real under-the-radar story that I think could explode in a big way at some point. Well, the other big, evolving business story this week involves Medicare Advantage, the private sector alternative that gives enrollees extra benefits and makes insurance shareholders rich, mostly at taxpayer expense. Well, the party is, if not ending, then at least slowly closing down. Humana’s stock price dropped dramatically this week after the company reported the new way Medicare officials are calculating quality scores from Medicare Advantage. They get stars. The more stars, the better. The new way that Humana appears to be getting its stars could effectively deprive it of its entire operating profit.
In separate news, UnitedHealthcare is suing Medicare over its Medicare Advantage payments in one of those single-judge conservative districts in Texas, of course. Democrats have been working to at least somewhat rein in these excess payments to Medicare Advantage for the past, I don’t know, two decades or so, but I assume this will all likely be reversed if Trump wins. And Medicare Advantage has been a troublesome issue because it’s really popular with beneficiaries, but it’s really expensive, because it’s really popular, because they get extra money, and some of that extra money goes to give extra benefits. Talk about things that are hard to explain to people. It’s great that you get all these extra benefits, but it’s costing the government more than it should.
Edney: Yeah.
Raman: I guess I do wonder if people, how much attention they’re paying. Are they going to switch plans if it’s dropping that many stars? If you’re on a Humana plan and a huge number of them got demoted to a lower rating, the next time you’re looking for a plan, are you going to switch to something else? And how often people are doing that and just if that would move the needle, because it’s just a longer process than overnight.
Rovner: Although, I think it isn’t just that people have to switch. If people stay in those plans with fewer stars, the company gets less money.
Raman: Yeah.
Rovner: Because they get bonuses when people are in the, quote-unquote, “higher quality” plan. So even if their four-star plan is now a three-star plan and they stay in it, the company’s going to lose money, which I think is why the stock price took such a quick and dramatic bath.
Edney: Yeah, I was surprised. It’s such a seemingly wonky issue, but it did really hit Humana very hard in the stock price. Technically, I think — correct me if I’m wrong — the stars aren’t even out yet. This is people doing searches to see if they can find some of them that have been changed at all, and so they’re coming out soon, but Humana particularly is very Medicare-focused out of all of the insurers. They rely on that for a large part of their revenue, so it is a big deal for them. I don’t know how much, but certainly Wall Street was. And as you mentioned with Trump, the Republicans typically really have supported Medicare Advantage because it is private insurers offering this instead of being just government-run Medicare. So that could have an effect.
It’s hard to tell why their stars went down currently. With UnitedHealth, you at least get a little insight. They’re suing because, last year, their star rating went down for some plans, they said, because of one bad customer service phone call. So someone from Medicare calls and does a test thing, and UnitedHealth says they didn’t ask the right question, so the person never got a chance to answer it correctly, and then their star ratings went down. So, it does feel like it could happen at any point for any reason, so I don’t know how conducive that is, how much that actually plays into people who might have a Humana plan that think, “Oh, I haven’t had any issues, so why would I change?”
Rovner: Yeah. All these under-the-hood things, as you point out, we have all looked at and don’t quite understand is worth billions and billions and billions of dollars. It’s one of the reasons why health care is so expensive and such a big part of the economy. All right. Well, we will continue to watch that space, too. That is the news for the week. Now we will play my “Bill of the Month” interview with Lauren Sausser, and then we will come back with our extra credits.
I am pleased to welcome to the podcast my KFF Health News colleague Lauren Sausser, who reported and wrote the latest KFF Health News “Bill of the Month.” Lauren, thanks for joining us.
Lauren Sausser: Thanks for having me.
Rovner: So tell us about this month’s patient, who he is, and what kind of medical care he needed.
Sausser: This month’s patient is a young man named Preston Nafz. He’s 17. He’s a senior in high school. He lives in Hoover, Alabama, which is right outside of Birmingham. And he played youth sports his whole life and recently is focused on lacrosse, but like many kids in this country, he has sort of cycled through a bunch of different sports, and ended up injured last year.
Rovner: And what happened?
Sausser: He had really debilitating pain in his hip, and the pain was progressive. And, obviously, they tried some treatments on one end of the spectrum, but it kept growing worse and worse. And at one point last year, he ended up limping off of the lacrosse field. He couldn’t do really simple things like turning over in bed or getting in and out of a car. These things were really painful for him. So he ended up as a patient at a sports medicine clinic, and providers at that clinic recommended surgery.
Rovner: And to cut to the chase, the story, at least medically, has a happy ending, right? The surgery worked? He’s better?
Sausser: Yes, the surgery worked. He ended up getting something late last year, a procedure called a sports hernia repair, which is a little bit of a misnomer because he didn’t actually have a hernia. But it’s kind of a catchall phrase that orthopedic surgeons use to talk about a procedure to relieve this type of pain that he was having in his pelvis, groin area. And the recovery was longer than he was anticipating, but yes, it medically does have a happy ending. He was able to play lacrosse again, although the last time I spoke to him, he had another sports-related injury. But the sports hernia repair did do what it was supposed to do, so that’s the good news.
Rovner: So it sounded like it should have been routine. Kid growing up, gets hurt playing sports, family has health insurance, goes to sports medicine, doctor fixes problem. Except for the bill, right?
Sausser: Yeah. So the interesting thing about this story, and this is really why we pursued it, is because there is no CPT [Current Procedural Terminology] code for a sports hernia repair. CPT codes, your listeners are probably familiar with, but they’re the medical codes that providers and insurers use to figure out how things get paid for. And it can become more complicated when there’s no code for a procedure, which was the case here. So Preston’s dad was told before the surgery that he was going to have to pay upfront because his insurance company, which was Blue Cross Blue Shield of Alabama, likely wasn’t going to pay for it.
Rovner: And how much was it upfront?
Sausser: It was just over $7,000. So the surgery itself was $6,000. There was, I think, almost $500 for anesthesia, a little over $600 for the facility fee. And Preston’s dad paid for it on a few different credit cards.
Rovner: So kid has the surgery, is in rehab, and Dad is now trying to recoup this money that he has paid for upfront. And what happened then?
Sausser: Yeah. Before the surgery even happened, Preston’s dad tried to call his insurance company and say: Can I get this covered? My son’s doctor says this is medically necessary. And initially, he got good news. His insurer said: It sounds like this is something that should be covered. If this is something that’s medically necessary, your insurance plan generally covers those things. As the date of the surgery grew closer and closer, he found that the people he was talking to at the insurance company weren’t being as definitive with their answers. And so before the surgery, he got a no. He said he got a no from his insurer saying that they were not going to cover this. Now, on the back end of the surgery, after he’d paid the bill with those credit cards, he tried to appeal that decision by filing a lot of paperwork. And he did end up getting a few hundred dollars reimbursed, but when the insurer sent him that check, it was unclear exactly what they were covering. And, obviously, that didn’t come close to the $7,000-plus that they had paid for it.
Rovner: So that’s what eventually happened with the bill, right? He ended up getting stuck with almost all of it?
Sausser: Yeah.
Rovner: Is there anything he could have done differently that might’ve helped this get reimbursed?
Sausser: That’s the tricky thing about this story, because they did do almost everything right. But it’s almost a cautionary tale for people who are faced with this prospect in the future. So if your provider is recommending something that doesn’t have a CPT code, it is going to be harder to get reimbursed from your insurer. You should assume that. That’s not to say it’s impossible, but it’s going to take more work on your end. It’s going to take more paperwork, it may take more work on your doctor’s end, and you should be prepared to get some pushback, if that makes sense.
Rovner: And has he just sort of written this off?
Sausser: I mean, he paid off the surgery using the credit cards. And the last I spoke to this family, they were still getting some confusing communication from their insurer. I don’t know that they’ve gotten the final, final no yet. I think that he still is invested in getting reimbursed if he can. But at this point, we’re approaching almost the one-year anniversary of the surgery, so it’s looking less likely.
Rovner: Well, we will keep following it. Lauren Sausser, thank you so much.
Sausser: Thanks for having me.
Rovner: OK, we’re back. 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. Don’t worry if you miss the details. We’ll include links to all these stories in our show notes on your phone or other mobile device. We have two hurricane-related extra credits this week. Sandhya, why don’t you go first?
Raman: My extra credit this week is called “Without Water After Helene: Residents at Asheville Public Housing Complex Fear for Their Health,” and it is from the Asheville [North Carolina] Citizen Times, by Jacob Biba. And the story just looks at the residents of a specific complex in Asheville that have been hit really hard by the hurricane. And, when this was written, they’d been without water for two days and it might not come back for weeks, and just some of the public health impacts they were facing. One person couldn’t clean their nebulizer or their tracheostomy tube. Others were worrying about sanitation from not being able to flush toilets. I think it’s a good one to check out.
Rovner: Yeah. We think about so many things with hurricanes. We think about being without power. We don’t tend to think about being without water. Alice, you have a related story.
Ollstein: Yeah, and this is more of a supply chain story but really shows that these hurricanes and natural disasters can have really widespread impacts outside the region that they’re in. And so this is from The Wall Street Journal. It’s called “Hospitals Hit With IV Fluid Shortage After Hurricane Helene.” It’s by Joseph Walker and Peter Loftus, and it’s about a facility in North Carolina that produces, like I said, IV bag fluids that hospitals around the country depend on. And yeah, we’ve talked before about just how vulnerable our medical supply chains are and we don’t spread the risk around maybe as much as we need to in this age of climate instability. And so, yeah, hospitals, they’re not rationing the fluids, but they are taking steps to conserve. And so they’re thinking, OK, certain patients can take fluids orally instead of intravenously in order to conserve. And so that’s happening now. Hopefully, it doesn’t become rationing down the road. But, yeah, with the long recovery the region is expecting, it’s a bit scary.
Rovner: Anna.
Edney: I did one from a colleague of mine at Bloomberg, John Tozzi. It’s “A Free Drug Experiment Bypasses the US Health System’s Secret Fees.” So he looked at this Blue Shield of California plan that is deciding to just bypass the pharmacy benefit managers and go directly to a drugmaker to get a biosimilar of Humira, the rheumatoid arthritis and many other ailments drug. And they’re going to be getting it for $525 a month for this drug that a lot of the PBMs are offering for more than a thousand dollars. And so the PBMs mentioned to him, We give rebates, and it’s less than a thousand dollars. But they didn’t say if it was as low as $525. And Blue Shield of California seems to think that this is a really good deal and that they’re basically going to give it for free just to show that it can reach Americans affordably. And so I thought it was a good look at this plan and at maybe a trend, I don’t know, that plans might start going outside of the PBM network.
Rovner: We shall see. Well, I chose a story from KFF Health News this week from Ronnie Cohen, and it’s called “Doctors Urging Conference Boycotts Over Abortion Bans Face Uphill Battle,” and it’s a really thoughtful piece about how to best protest things you disagree with. In this case, some doctors want medical groups to move professional conferences out of states with abortion bans, in order to exert financial pressure and to make a point. But there are those who worry that that amounts to punishing the victims and that it won’t do much anyway, frankly, unless you’re the Super Bowl or the baseball All-Star Game. It’s not like your conference is going to make or break some city’s annual budget. But it’s a microcosm of a bigger debate that’s going on in medicine that I’ve been covering. How do doctors balance their duty to serve patients with their duty to themselves and their own families? There are obviously pregnant medical professionals who do not wish to travel to states with abortion bans lest something bad happens. It’s a struggle that is obviously going to continue. It’s a really interesting story.
OK. That is our show. Before we go this week, it is October and we want your scariest Halloween haikus. The winner will get their haiku illustrated by our award-winning in-house artists, and I will read it on the podcast that we tape on Halloween. We will have a link to the entry page in our show notes.
As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us too. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. Also, as always, you can email us your comments or questions. We’re at whatthehealth, all one word, @kff.org, or you can still find me at X. I’m @jrovner. Sandhya?
Raman: @SandhyaWrites.
Rovner: Anna?
Edney: @annaedney.
Rovner: Alice.
Ollstein: @AliceOllstein.
Rovner: We will be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': Trump-Harris Debate Showcases Health Policy Differences
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Julie Rovner
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
As expected, the presidential debate between former President Donald Trump and Vice President Kamala Harris offered few new details of their positions on abortion, the Affordable Care Act, and other critical health issues. But it did underscore for voters dramatic differences between the two candidates.
Meanwhile, the Biden administration issued rules attempting to better enforce mental health parity — the federal government’s requirement that services for mental health care and substance use disorders be covered by insurance to the same extent as other medical services.
This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs Zhang of Stat, Riley Griffin of Bloomberg News, and Lauren Weber of The Washington Post.
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Rachel Cohrs Zhang
Stat News
Riley Griffin
Bloomberg
Lauren Weber
The Washington Post
Among the takeaways from this week’s episode:
- Trump declined to say during the debate whether he’d veto legislation implementing a nationwide abortion ban. But he could effectively ban the procedure without Congress passing anything because of the 150-year-old Comstock Act. And Project 2025, a policy blueprint by the conservative Heritage Foundation, calls for doing just that.
- There is a good chance that enhanced federal subsidies for ACA coverage that were introduced during the pandemic could expire next year, depending on which party controls Congress. The subsidies have helped more people secure zero-premium health coverage through the ACA exchanges, though Republicans say the subsidies cost too much to keep. Residents in states that haven’t expanded Medicaid coverage — including Florida and Texas — would be most affected.
- The Census Bureau reports that the uninsured rate didn’t change much last year after hitting a record low in the first quarter. But the report’s methodology prevented it from capturing the experiences of many people disenrolled and left uninsured after what’s known as the Medicaid “unwinding” began. Meanwhile, a Treasury Department report sheds light on just how many Americans have benefited from the ACA, as polls show the health law has also grown more popular.
- And Congress has yet to pass key government spending bills, meaning the nation (again) faces a possible federal government shutdown starting Oct. 1. It remains to be seen what could pass during a lame-duck session after the November elections. In 2020, the end-of-the-year spending package featured many health care priorities — and that could happen again.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: The Wall Street Journal’s “A Nurse Practitioner’s $25,000 in Student-Debt Relief Turned Into a $217,500 Bill From the Government,” by Rebecca Ballhaus.
Lauren Weber: Stat’s “Youth Vaping Continues Its Tumble From a Juul-Fueled High,” by Lizzy Lawrence.
Riley Griffin: Bloomberg News’ “Lilly Bulks Up Irish Operations in Obesity Drug Production Push,” by Madison Muller.
Rachel Cohrs Zhang: ProPublica’s “‘I Don’t Want To Die’: Needing Mental Health Care, He Got Trapped in His Insurer’s Ghost Network,” by Max Blau.
Also mentioned on this week’s podcast:
- KFF Health News’ “US Uninsured Rate Was Stable in 2023, Even as States’ Medicaid Purge Began,” by Phil Galewitz.
- Louisiana Illuminator’s “Doctors Grapple With How To Save Women’s Lives Amid ‘Confusion and Angst’ Over New Louisiana Law,” by Lorena O’Neil.
- ProPublica’s “Why I Left the Network,” by Annie Waldman, Maya Miller, Duaa Eldeib, and Max Blau.
- The New York Times’ “How a Leading Chain of Psychiatric Hospitals Traps Patients,” by Jessica Silver-Greenberg and Katie Thomas.
- Stat’s “Troubled For-Profit Chains Are Stealthily Operating Dozens of Psychiatric Hospitals Under Nonprofits’ Names,” by Tara Bannow.
click to open the transcript
Transcript: Trump-Harris Debate Showcases Health Policy Differences
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Sept. 12, at 10 a.m. As always, news happens fast and things might’ve changed by the time you hear this, so here we go.
Today we are joined via teleconference by Rachel Cohrs Zhang of Stat News.
Rachel Cohrs Zhang: Hi, everybody.
Rovner: Riley Griffin of Bloomberg News.
Riley Griffin: Hey, hey.
Rovner: And Lauren Weber of The Washington Post.
Lauren Weber: Hello, hello.
Rovner: I hope you enjoyed last week’s special episode on health equity from the Texas Tribune Festival. Now we have a lot of news to catch up on, so we will get right to it. We’re going to start with politics and with the much-anticipated presidential debate Tuesday night, obviously the big health issue was abortion. And as I said afterwards on the radio, the most consistent thing about former President Trump’s abortion position is how inconsistent it has been. Did we learn anything new from everything he tried to say about abortion?
Cohrs Zhang: I think he didn’t provide a lot of clarity on the issue of whether he would veto a nationwide abortion ban, and I think that has been the question that is kind of hard to nail down. And his response is that, Well, that’s not going to pass Congress, so I won’t have to worry about it.
Rovner: Which is kind of true. I mean, it’s not going to pass Congress. That was Nikki Haley’s point.
Cohrs Zhang: Yeah, so I think we have seen, though, some talk floating around about ending the filibuster for abortion from [Sen.] Chuck Schumer’s side of things, at least. So I think it’s not completely out of the question to think that things could be different in the future. We don’t entirely know. But that’s his argument that I don’t really have to answer that question, because it’s not actually going to happen. So I think that’s not really an answer to the question.
Rovner: Riley?
Griffin: It does beg the question what he has to gain from answering that question. If he says he supports vetoing a national abortion ban, it’s certain to anger some of his base, and the opposite is true, too. He’s been threading a really tenuous needle here in trying to appease very different crowds within the Republican Party. And I think that is perhaps, at this point, more interesting to think about his positioning around abortion than the Democratic Party’s.
Rovner: So this is where I get to jump up and down and say for the millionth time: He doesn’t have to sign a nationwide ban to ban abortion nationwide. This is where the Comstock Act comes in that we have talked about so many times and that Project 2025 talks about starting to enforce it, which it has not been in decades and decades, but it is still on the books. And a lot of people say, oh, they could ban the abortion pill by enforcing the Comstock Act, which bans the mailing of things that can be used for abortion. But as others point out, it could be not just the abortion pill. Anything that is used to perform any sort of abortion travels in the mail or FedEx or UPS, all of which are covered by the Comstock Act. So in fact, he could support a nationwide abortion ban and still say that he would veto legislation calling for a nationwide abortion ban.
Cohrs Zhang: Right. And it seems like when he’s been questioned about this in the past, he hasn’t quite understood or seems like he understands the nuances of that. And I think our frequent panelist Alice Ollstein had some good reporting indicating that the pro-life groups wanted more commitments from him on the Comstock Act and aren’t getting them. So I think there are certainly some questions out there. But as a reporter in D.C., we have the privilege of covering health care almost exclusively, and sometimes you can tell when a lawmaker or a public official doesn’t understand the question, and I think that’s a little bit of what’s happening here. But obviously it’s his campaign’s job to prep him and make clear what his position is so voters can make an informed decision.
Rovner: And, of course, with Trump, you’re never sure whether he really doesn’t understand it or whether he’s purposely pretending that he doesn’t understand it.
Cohrs Zhang: Right, right.
Rovner: Lauren, you wanted to add something?
Weber: On a lot of issues, Trump doesn’t necessarily always give a straight answer and often walks them back. So it’s somewhat representative of also playing, as Riley pointed out, to political points as we get so very close to the election and to pick up some of the folks that are undecided. So as you said, we didn’t learn much.
Rovner: So what about Vice President [Kamala] Harris? Those of us sitting here and those of us who listen to the podcast know that she’s been on the trail talking about reproductive health since before the fall of Roe. It’s an issue that she is super comfortable with. I was, I think, surprised at how surprised people watching were when she was able to articulate a really thorough answer. Did that surprise any of you?
Weber: That did not surprise me at all. But I think what was so shocking about it was everyone remembers where they were when Joe Biden got the abortion question at the debate, not so long ago, and truly butchered that answer. That was one of the worst moments of the debate for him. He really could not get through it. The man has notoriously not felt comfortable talking about abortion — older man, Catholic, et cetera. But the contrast, I think, is what was so surprising, because Democrats consider this very much an essential issue for winning the election. Abortion issues are polling incredibly well, obviously with women. You have abortion rights on the ballot in several states, including swing states. This is kind of a make-or-break issue to win the presidential for Democrats. And for Kamala Harris to be able to give not just a coherent answer but one that actually had some resonance, I think, was just so markedly different that people ended up as surprised as you pointed out.
Griffin: Just want to add here that this is a space that she is so incredibly comfortable talking about on the campaign trail. Even before she assumed the top of the ticket, this had been her marquee subject. And I’ve been moonlighting as a Kamala Harris campaign reporter for the last few months. Every rally you go to, this is where she gets the biggest applause. This is the note that strikes, that resonates with the crowd. She had been doing what she called a “Reproductive Freedom” tour through swing states four months prior to assuming the top of the ticket. So it’s no surprise that she is quick not just to talk about the stakes of the overturning of Roe v. Wade but also fact-check the former president. There was a really fitting moment during the debate where she said: “Nowhere in America is a woman carrying a pregnancy to term and asking for an abortion. That is not happening.” So that she could not only come and deliver the lines but also listen to Donald Trump respond to some of the factual errors in real time was again a marked difference from President Joe Biden.
Rovner: Yes, it was a very different debate, I will say. There was actually, a bit surprising to me also, some discussion of the Affordable Care Act. Apparently Donald Trump is now saying that he’s the one who saved it, which is not exactly how I remember things going down. Is that an acknowledgment that the ACA is now here to stay? Or should we still assume that if Republicans take control of the White House and Congress they will, at the very least, let those expanded ACA subsidies expire?
Cohrs Zhang: I think there’s a very good chance that those subsidies do expire. It just obviously depends on control of Congress and how much leverage Democrats have and what they’re willing to give up to get them. And again, it’s kind of difficult because a lot of the states that benefit the most from these subsidies are Republican states that have not expanded Medicaid. So I think there are some difficult political considerations for the Republican Caucus on that issue. But I think Trump was implying that maybe he could have done more to sabotage the ACA without actually revealing it.
Rovner: That’s kind of true.
Cohrs Zhang: Yeah, so I think that was an interesting point. And of course he returned to the refrain that he’s going to have a plan. We haven’t seen a plan for nine years.
Rovner: He has the …
Rovner and Weber (together): … “concepts” of a plan.
Cohrs Zhang: We’ll see it soon.
Weber: I think it’s important to also fact-check Trump on saying he improved the ACA. I want to read a list of things from a great Stat article: “While in office, Trump’s administration shortened open enrollment periods, cut funding for navigators who help people enroll … expanded short-term insurance plans, lowered standards for health benefits provided by small employers that banded [together] into larger groups and enabled employers with religious or moral objections to contraceptive coverage to opt out of requirements to provide no-cost coverage.” So I think some of his as assertations about improving the ACA are up for debate, depending on how you feel about that list of things I just read.
Griffin: And you can also see the impact in enrollment. We had some really interesting data released just before the debate, conveniently, by the Treasury Department showing that the Biden administration had ushered in this all-time-high enrollment in the ACA insurance marketplaces. But what was also tucked into that data was that under the Trump administration, there was also pretty significant lows compared to the other parts of the last 10 years. So that’s notable, too.
Rovner: Yes. And actually you’re anticipating my very next question, which is, while we are on the subject of the ACA, the Census Bureau was also out this week with its annual estimate of people without insurance, and, surprise, even with the Medicaid unwinding and people being dumped off of the Medicaid rolls, the 2023 uninsured rate of about 8% remained near the all-time low that it achieved under the Biden administration. Now, this is not the complete picture of the uninsured. Those who lost coverage at any point during 2023, which is when everybody on the unwinding lost coverage, wouldn’t be counted as uninsured for the purposes of this particular survey, which counts people who were uninsured for the entire year. But the Biden administration, the day before, released an analysis finding that over the 10 years that the Affordable Care Act marketplaces have been operational, 1 in 7 Americans has been enrolled in one of the plans. Is this a first election where the ACA could turn out to be a boon for its backers rather than an albatross around their necks?
Weber: I think KFF polling, recent numbers say some 60% of Americans support the ACA. So that would be a majority of Americans that would be very unhappy if it was repealed. So I mean to your point, Julie, I think the popular opinion has shifted on the ACA and we’re in new ground here.
Cohrs Zhang: Even in 2020, I think after all of that happened, I think there was this realization that maybe this isn’t a viable option, so we should stop promising it to people. And I think Democrats had gotten so much momentum on all of the claims that Republicans did want to take apart the ACA, and we saw that conversation in the Supreme Court as well. And I think that reality has just become so much more real with Dobbs and seeing that when the makeup of a court changes, court decisions can change, and that elections matter in that calculus. So I think we started to see the movement in 2020, but obviously there was so much pandemic going on that I think some of these other health care lines got lost in that election, that we’re seeing come out a little more clearly this time around.
Rovner: And, of course, despite Donald Trump now becoming a latter-day champion of the ACA — sort of — if Republicans win back control of Congress and the White House, we’ve got both these expanded subsidies — that, as we pointed out, have enabled this big enrollment — expiring, and the Trump tax cuts expiring. It’s hard to imagine both of those getting extended. One would think that the Republicans’ priority would be the tax cuts and not the subsidies, right?
Cohrs Zhang: Yeah. Again, depends on whether Democrats are able to hold a chamber of Congress and what kind of leverage they have.
Rovner: Yeah, that’s obviously a 2025 issue. Well, turning to elected officials who are already in office, today is Sept. 12, and that means Congress has basically eight more working days to avoid a government shutdown by either passing all of the 12 regular spending bills or some sort of continuing resolution to keep agencies funded after the Oct. 1 start of fiscal 2025. This is where I get to say for the millionth time that when Congress settled the funding for fiscal 2024 last — checks notes — March, House Republicans vowed again to have this year’s funding bills finished on time. Rachel, that did not happen. So where are we?
Cohrs Zhang: It does not happen. Yeah, I think it’s business as usual around here. I think, honestly, the posturing has started earlier than I expected with the House speaker, Mike Johnson, putting out this proposal for a CR [continuing resolution] that he couldn’t even get through the House. He kind of pulled that before it came to a vote on the floor. So I guess that’s, at least, an opening salvo earlier than we see, usually, early in September.
Rovner: Well, this was the big fight about: Do we want a CR that goes to after Thanksgiving, which would be the typical CR, and then we’ll come back after the election and fight about next year’s funding? Or, in this case, they wanted a CR that went until next March, I guess betting that maybe the Republicans will be in charge then and they’ll have more of a say over this year’s spending than they do now?
Cohrs Zhang: Right. I think that’s certainly an open question, and I think it seems like Senate appropriators are not necessarily on board with that March timeline at this point. They really would like to wrap things up in December. And again, I think, looking back in 2020, we did see a really significant appropriations package with a lot of health care policy pass at the end, kind of in the December time frame of 2020, in lame-duck. So I think it’s a really big question.
And then the other question is: Do all these expiring health care programs that are currently slated to end in December get extended with that appropriations package? I think there’s just a lot of moving parts here, and we don’t exactly know what the deadlines are going to be yet. But at least they’re arguing about it in the public sphere, so that’s a start.
Rovner: They’re legislating. That’s what they do. Lauren?
Weber: I just wanted to say, Julie, I think you should have a segment that’s a tally of how many times you ask on this podcast if the funding bill has passed. Because I know myself, I’ve been on many, and I really think it’d be kind of funny. So I’m just saying it’s quite fascinating over the years, the many, many times these bills do not seem to make it.
Rovner: Well, this is just me as the lifelong Capitol Hill reporter who — we’re always talking about what’s going to happen next year and the year after. It’s like: You have a job to do this year. Let’s see how you’re doing in the job that you have to do this year. Does anybody think there’s actually going to be a shutdown? I mean, that’s still a possibility if they don’t get a deal, although that would be — I’m trying to remember if we’ve ever seen a government shutdown in a presidential election year. That seems risky politically? Riley, I see you sort of raising your eyebrows.
Griffin: Yeah, it’s definitely risky and clearly something right now you can see that the Biden administration wants to avoid. I was sitting in the White House press briefing room on Monday and Karine [Jean-Pierre], the press secretary, was like: This is Congress’ one job. This is their main job. It’s to keep the government open. So there’s a level of frustration that, I think, this is coming into the discourse yet again, but to be expected.
Rovner: Yeah. And I should point out, it’s not just Republicans that are unable to get funding bills done on time. The Democrats are unable to get their funding bills done on time, either. I believe that the last time all of the funding bills were actually passed before Oct. 1 was the year 2000.
Weber: This is why this should be a Julie segment. I’m telling you, you should run a tally.
Rovner: Yes. Well, it is kind of a Julie segment.
Weber: Yes.
Rovner: And I will keep at it, because this is my job, too. All right, turning back to abortion, in the debate Tuesday night, Vice President Harris talked at some length about some of the unintended consequences of abortion bans, as we discussed — women unable to get miscarriage care, girls being forced to carry pregnancies resulting from incest all the way to term. Now we have another new potential health risk in Louisiana. The new law that makes the abortion medications mifepristone and misoprostol controlled substances is resulting in a major disruption to hemorrhage care. It seems that misoprostol, which is used for a variety of purposes other than abortion — it was originally an ulcer drug — is a key emergency drug used in a wide variety of reproductive health emergencies. And it’s not clear what will take its place on emergency carts, since you can’t have controlled substances just hanging around in the hallways. Is this yet another example of lawmakers basically practicing medicine without a license?
Weber: I think that’s right, Julie. I spoke to a Louisiana ER doctor last week who put it pretty bluntly. He’s like, Look, I have a woman who’s bleeding out in front of me, and I need to call down to the pharmacy and put in an order? That could take not just seconds, not just minutes, but many minutes, even longer in possibly rural pharmacieswhere the access may not be as readily available. He’s like, This is truly a life-or-death issue. Women, when you are bleeding out from post-birth complications, which by the way is not as uncommon as people would like to think it is, this is really quite something. And so folks in Louisiana are obviously very up in arms.
And I think it speaks, as you pointed out, to the larger environment that Kamala Harris has pointed to — and many reporters that have been on your show and that we have discussed many times on the show — is that there are many unintended consequences for laws that limit abortion and for women seeking access to care where hospitals afraid that they’re not going to interpret the law correctly are leaving women to seek care elsewhere. And what are the health ramifications of that? But this is a pretty frightening unintended consequence.
Rovner: Yeah, this was something that I was not aware of, that I had not seen. Of course, Louisiana is the first state to basically declare these controlled substances. So it seems that every time we get a new restriction, there’s a new twist to it that I think most people did not expect.
There’s also been lots of court actions, obviously, on abortion in the past few weeks. In Missouri, last week a judge tried to strike the state’s abortion rights referendum from the ballot, although this week a higher court ordered it back on the ballot. I believe that’s the final word on Missouri. They will vote on it in November. In Alaska, a judge struck down a state law that limited who could perform abortions to just doctors rather than doctors and other medical professionals. And in Texas, Attorney General Ken Paxton filed suit against a new federal rule that shields the medical records of women who cross state lines to obtain an abortion in a state where it’s legal, which it’s not in Texas. It would seem the implication here is that Texas wants to prosecute women who leave the state for a legal medical procedure. Or am I misinterpreting that somehow?
Griffin: That’s my understanding as well. And it’s a development that, I believe the rule was announced in April when Biden had said that no one should have their medical records used against them, and lo and behold we’re a few months later, but this Texas lawsuit does suggest that this could be a part of criminal prosecution.
Rovner: I know. I mean this seems to be sort of this underlying issue of what happens to women who live in banned states who go to other states to obtain abortions. And there’s been a lot of back-and-forth and a lot of people, even on the anti-abortion side, trying to say that this is not our intent. But this certainly seems to be the intent of some people. Seeing nods all around. We will continue to follow this string.
Finally this week, I want to talk about mental health. Over the objections of some insurers and large employer groups, the Biden administration finalized the latest set of rules attempting to guarantee parity between coverage for mental health and substance abuse and every other type of medical care. This is literally a 30-year fight that’s been going on to regularize, if you will, coverage of mental health. This action comes just as ProPublica is unveiling a pretty remarkable series on the inability of patients, even patients with insurance — in fact, mostly patients with insurance — to obtain needed health care, often with catastrophic consequences. Rachel, one of those stories is your extra credit this week. Why don’t you tell us about it?
Cohrs Zhang: It is, yes. So my extra credit is “‘I Don’t Want To Die’: Needing Mental Health Care, He Got Trapped in His Insurer’s Ghost Network,” by Max Blau and ProPublica. And I think this story kind of really makes clear the consequences for certain patients, especially mental health patients in crisis, of when the list that you get from your insurer of in-network providers is inaccurate.
And I think ghost networks, it’s kind of a weird, jargon-y term, I think. There have been some hearings on the issue on the Hill. But when we think about somebody who desperately needs some crisis counseling and they’re doing everything they can, they’re exhausted, they’re already dealing with so much to already have to call provider after provider who doesn’t take their insurance anymore, doesn’t know what they’re talking about, it’s just such a frustrating process that I think many of us have experienced. I personally have experienced it getting an MRI in Los Angeles, and the list is out of date. And I think there’s definitely room for regulation here. And I think that mental health care, through this series, was just highlighted as such an important part of that conversation.
Rovner: Yeah, we’ve all had this, and we’ve all written the stories about people who have lists of in-network providers and can’t find one or can’t find one who’s taking new patients, or the provider there does not do what the directory suggests that they do. They may say they may only treat children, or they may not treat children. But I think in mental health, these are people in mental health crises trying to get care that they are guaranteed by law and guaranteed under their insurance and being unable to do it — and as I say, often, sometimes, not un-often with catastrophic consequences. Needing mental health care is not just somebody who says, “Oh, I don’t feel well today.” These often are people who are in actual crisis situations.
So speaking of people who are in actual mental health crisis situations, The New York Times has a piece this week on a chain of mental hospitals that’s basically holding patients in their facilities against their will to get as much as they can collect from insurance. In some cases, patients’ relatives have had to get court orders to get their patients released. How did we let our mental health system get so far off the tracks? Either you can’t get care or you get care that you can’t get out of.
Weber: Well, this piece by Jessica Silver-Greenberg and Katie Thomas, which is truly phenomenal — everyone who’s listening to this should read it — makes a very astute point, which is that the government and nonprofits have really gotten out of the psychiatric hospital business, and for-profit companies have swept in. And they interview several former employees who make it very clear that these were run with profit incentives in mind, of holding patients to maximize the insurance money they could get, to catastrophic effects. The details in this are wild. They talk about people having to go to court to get folks out, very clear violations. And again, they speak to not just one, not just two, but multiple former employees who allege that this company was acting in such a way that was not for its patients’ best interest.
Cohrs Zhang: And I do have to do a plug for my colleague Tara Bannow, who also reported on Acadia and how they’re kind of operating mental health institutions under the brand names of Catholic hospitals. So people might even think that they’re going to a well-respected community hospital under the name, but these for-profit institutions have even made their way into not-for-profit spaces, and these services are just being contracted out, because they’re simply unprofitable.
Rovner: And we talked about Tara’s story when it came out.
Cohrs Zhang: We did, yeah.
Rovner: A month or two ago.
Cohrs Zhang: Yeah, this next story is a great — kind of building on, building just a fuller story around the implications of for-profit.
Rovner: It does sort of, both this and, I think, the ProPublica series highlight in the ’60s and ’70s, the problem was people who were in state-run facilities. And they were warehoused, and they were underfunded, and people just didn’t get the care that they needed. And that was one of the things that led to deinstitutionalization, which of course is one of the things that ended up leading us to the homeless, because when they deinstitutionalized these patients, they were promised outpatient care which never materialized. So now we’ve kind of profitized this, if you will, and we have a different set of problems. It’s every bit as bad. It’s kind of a microcosm of the entire health care system. It’s like, well, we don’t really trust the nonprofit sector to run it right, because they don’t have enough money. And now we don’t trust the for-profit sector to run it right, because they have too much of a profit motive. Is there any middle ground here?
Griffin: I think we could spend weeks, you could have a whole podcast just dedicated to this question, and it’s a harrowing one. And there’s a parallel discussion to be had also about the centers that navigate patients who are seeking treatment for substance use, right? Often those are one and the same, but I think the same dynamics are playing out here. And to the mental health parity regulation that was finalized, that included substance use benefits, too. It wasn’t just mental health. So yeah, I don’t know. I say with a heavy heart that we could talk about this a long time, but I don’t have any answers for where the best care is going to be.
Rovner: Yeah, none of us, I think, does. And that’s why we were all going to have jobs from now until eternity as we at least keep working on this.
All right, well, that is the news for this week. Now it is time for our extra credits. That’s when we each recommend a story we read this week, we think you should read, too. Don’t worry if you miss the details. We will include links to all these stories in our show notes, on your phone or other mobile device. Rachel, you’ve already done yours. Lauren, why don’t you go next?
Weber: So I picked a story from Stat titled “Youth Vaping Continues Its Tumble From a Juul-Fueled High,” written by Lizzy Lawrence. And I was really struck, I’m sure public health officials are really struck, by how far vaping rates have gone. I mean, they’re down to 6% of middle and high school students using vapes in 2024. That’s down from 8% last year and 20% in 2019. I mean, that is a marked change. And I expected to read this article and see, Oh, but don’t worry, they’re all using Zyn, which is another nicotine product. But, actually, that had only gone up to about 1.8%. It was not nearly the same bit. And I think if you’re a public health official, you’ve got to be pretty pleased with yourself, because this would seem to show that the public health action that they very aggressively took at both the federal, national, and in some places locality level to limit flavored vapes and have other actions for kids has resulted in a pretty steep decline, much faster than you saw cigarette use decline. So I was really impressed to see these numbers. It’s quite a change.
Rovner: Yeah. Yay public health. Riley?
Griffin: Yeah, I want to tout a story from my colleague Madison Muller. It’s titled “Lilly Bulks Up Irish Operations in Obesity Drug Production Push.” And she’s actually in Ireland right now. She was reporting out this story. Ultimately, we all know there’s been this immense demand for obesity drugs — Eli Lilly and Co. has two, Mounjaro and Zepbound — and they just can’t seem to build out production quickly enough. My colleague did some data analysis here and actually found that since 2020, believe it or not, Lilly has poured 17.3 billion [dollars] into weight-loss drug manufacturing. I mean, what an insane number. And the latest push is in Ireland, which is notable because here in Washington there’s been a lot of work to scrutinize and even prevent U.S. drugmakers from collaborating with Chinese manufacturers of biologics. So sometimes they talk about “near-shoring” or “friend-shoring” in D.C., which is really a kitschy term to refer to seeing more friendly countries to the United States bolstering up manufacturing, and here you see Lilly doing just that. So it’s a fun story, and kudos to Madison, who went out to Ireland to tell it.
Rovner: I’d love to be sent to Ireland.
Weber: Yeah, I need to get more stories in Ireland. I mean, what? That’s amazing.
Rovner: Just saying. It is a good story. All right. Well, my story this week is from The Wall Street Journal, by Rebecca Ballhaus, and it’s called “A Nurse Practitioner’s $25,000 in Student-Debt Relief Turned Into a $217,500 Bill From the Government.” And it’s a really infuriating story about a really excellent government program called the National Health Service Corps that helps medical professionals pay off their loans if they agree to practice in underserved areas. The problem is that there are penalties if you fail to complete your term of service, which obviously there should be.
But in this case, one of the nurse practitioners’ supervising physicians died, and the other one retired, and there were no other eligible placements within two hours of her Alabama home, where she cared for her three young children as well as her elderly parents. Obviously there should be consequences for breaching a contract, but this is far from the only case where people who are obviously deserving of exceptions are being denied them. The National Student Legal Defense Network has filed suit on the nurse practitioner’s behalf, and I’ll be watching to see how this all turns out.
OK. That is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X. I’m @jrovner. Riley, where are you hanging these days?
Griffin: I’m on X, though infrequently, @rileyraygriffin.
Rovner: Lauren?
Weber: Still only on X, @LaurenWeberHP.
Rovner: Rachel?
Cohrs Zhang: Still on X, @rachelcohrs.
Rovner: We will be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': Let the General Election Commence
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Julie Rovner
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
The conventions are over, and the general-election campaign is officially on. While reproductive health is sure to play a key role in the race between Vice President Kamala Harris and former President Donald Trump, it’s less clear what role other health issues will play.
Meanwhile, Medicare recently announced negotiated prices of the first 10 drugs selected under the 2022 Inflation Reduction Act. The announcement is boosting attention to what was already a major pocketbook issue for both Republicans and Democrats.
This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of Politico and Johns Hopkins University’s schools of nursing and public health, Shefali Luthra of The 19th, and Alice Miranda Ollstein of Politico.
Panelists
Joanne Kenen
Johns Hopkins University and Politico
Shefali Luthra
The 19th
Alice Miranda Ollstein
Politico
Among the takeaways from this week’s episode:
- The Democratic National Convention highlighted reproductive rights issues as never before, with a parade of public officials and private citizens recounting some of their most personal, painful memories of needing abortion care. But abortion rights activists remain concerned that Harris has not promised to push beyond codifying the rights established under Roe v. Wade, which they believe allows too many barriers to care.
- As reproductive rights have taken center stage in her campaign, Harris has been less forthcoming about her other health policy plans so far. In her career, she has embraced fights against anticompetitive behavior by insurers and hospitals and in drug pricing.
- Would former President Donald Trump make Robert Kennedy Jr. his next health secretary? Even many Republicans would consider his elevation a bridge too far. Polls show Trump stands to gain from Kennedy’s departure from the presidential race, but likely only slightly more than Harris.
- In other national health news, abortion access will be on the ballot this fall in Arizona and Montana, and the federal government recently announced the first drug prices secured under Medicare’s new drug-negotiation program.
Also this week, Rovner interviews KFF Health News’ Tony Leys, who reported and wrote the latest KFF Health News-NPR “Bill of the Month” installment about a woman who fought back after being charged for two surgeries despite undergoing only one. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!
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’ “Hot Summer Threatens Efficacy of Mail-Order Medications,” by Emily Baumgaertner.
Joanne Kenen: The Milwaukee Journal Sentinel’s “Who Is Gus Walz and What Is a Non-Verbal Learning Disorder?” by Natalie Eilbert.
Alice Miranda Ollstein: The Wall Street Journal’s “The Fight Against DEI Programs Shifts to Medical Care,” by Theo Francis and Melanie Evans.
Shefali Luthra: The Washington Post’s “Weight-Loss Drugs Are a Hot Commodity. But Not in Low-Income Neighborhoods,” by Ariana Eunjung Cha.
click to open the transcript
Transcript: Let the General Election Commence
KFF Health News’ ‘What the Health?’Episode Title: ‘Let the General Election Commence’Episode Number: 361Published: Aug. 23, 2024
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Friday, Aug. 23, at 10 a.m. As always, news happens fast and things might’ve changed by the time you hear this. So here we go. Today we are joined via teleconference by Joanne Kenen of the Johns Hopkins schools of public health and nursing and Politico Magazine.
Joanne Kenen: Hi, everybody.
Rovner: Shefali Luthra of The 19th.
Shefali Luthra: Good morning.
Rovner: And Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Hello.
Rovner: Later in this episode, we’ll have my interview with KFF Health News’ Tony Leys, who reported and wrote the latest KFF Health News-NPR “Bill of the Month,” about a woman who got two bills for the same surgery and refused to back down. But first, this week’s news. So, now both conventions are over. Labor Day is just over a week away. And I think it’s safe to declare the general election campaign officially on. What did we learn from the just-completed Democratic [National] Convention, other than that Beyoncé didn’t show up?
Luthra: I think the obvious thing we learned is there is a lot of abortion for Democrats to talk about and very little abortion Republicans would like to. I did the fun brain exercise of going back through old Democratic conventions to see how much abortion came up. It might be interesting to note that in 2012, for instance, [the former president of Planned Parenthood] Cecile Richards spoke, never mentioned abortion.
A Planned Parenthood patient came and didn’t talk about abortion, talked about endometriosis care. And I think that really underscores what a shift we have seen in the party from treating abortion as an issue for the base, but not one that got center stage very often. And that shifted a bit in 2016, but is really very different now.
We had abortion every night, and that is just such a marked contrast from the RNC, where Republicans went to great lengths to avoid the topic because Democrats are largely on the winning side of this issue and Republicans are not.
Rovner: I’ve watched every Democratic convention since 1984. I have to say, I’m still trying to wrap my brain around the idea of all of these, and not just women, but men and [Sen.] Tammy Duckworth talking about IVF and women who had various difficulties with pregnancy. Usually, it would be tucked into a section of one night, but every single night we had people getting up and telling their individual stories. I was kind of surprised. Alice, you wanted to add something?
Ollstein: Yeah. We also wrote about how the breadth of the kinds of abortion stories being told has also changed. There’s been frustration on the left for a while that only these medical emergency cases have been lifted up.
Rovner: The good abortions.
Ollstein: Exactly. So there’s a fear that that further stigmatizes people who just had an abortion because they simply didn’t want to be pregnant, which is the majority of cases. These really awful medical emergencies are the minority, even though they are happening, and people do want those stories told. But I think it was notable that the head of Planned Parenthood talked about a case that was simply someone who didn’t want to be pregnant and the lengths she had to go through to get an abortion.
I think we’re still mostly seeing the more politically palatable, sympathetic stories of sexual assault and medical emergencies, but I think you’re starting to see the discourse broaden a little bit more. It’s still not what a lot of activists want, but it’s widening. It’s opening the door a little bit more to those different stories.
Rovner: And certainly having [Kamala] Harris at the top of the ticket rather than Biden, I mean, she’s been the point person of this administration on reproductive health even before Roe v. Wade got overturned.
Ollstein: Right. And I think it’s been interesting to see the policy versus politics side of this, where politically she’s seen as such a stronger ally on abortion rights, and her messaging is much more aggressive than [President Joe] Biden’s, a lot more specific. But when it comes to the policy, she’s exactly where Biden was. She says, “I want to restore Roe v. Wade,” where a lot of activists say that’s not enough. Roe v. Wade left a lot of people out in the cold who couldn’t get an abortion that they wanted later in pregnancy, or they ran into all these restrictions earlier in pregnancy that were allowed under Roe. And so I think we’re going to see that tension going forward of the messaging is more along the lines of what the progressive activists want, but the policy isn’t.
Luthra: And to build on Alice’s point, I mean, a lot of the speakers we had this week are speakers who would’ve been there for a Biden campaign as well. Amanda Zurawski was a very effective Biden surrogate. She is now a Harris surrogate.
And I think what’s really important for us to remember as we look not just to November, but to potentially January and beyond, is that what Harris is campaigning on, what Biden tried to campaign on, although he struggled to say the words, is something that probably isn’t going to happen because they’re talking about signing a law to codify Roe’s protections and they in all likelihood won’t have the votes to do so.
Rovner: Yes. And they either have to get rid of the filibuster in the Senate or they have to have 60 votes, neither of which seems probable. And as I have pointed out many times, the Democrats have never had enough votes to codify Roe v. Wade. There’s never actually been a basically pro-choice Congress. The House has never been pro-choice until Trump was president, when obviously there was nothing they could do.
It’s not that Congress didn’t want to, or the Democrats in Congress didn’t want to or didn’t try, they never had the votes. For years and years and years, I would say, there were a significant number of Republicans who were pro-abortion rights and a significant, even larger number of Democrats who were anti-abortion. It’s only in the last decade that it’s become absolutely partisan, that basically each party has kicked out the ones on the other side. Joanne, you wanted to add something?
Kenen: Remember that the very last snag that almost pulled down the Affordable Care Act at zero hour, or zero minus, after zero hour, was anti-abortion Democrats. And that was massaged out and they cut a deal and they put in language and they got it through. But no, the phenomenon Julie’s talking about was that the dynamics have changed because of the polarization.
I mean, it wasn’t just abortion; there were centrists in both parties, and they’re pretty much gone. The other thing that struck me last night is there was rape victims and victims of traffic and abuse speaking both within the context of abortion. I mean, that was a mesmerizing presentation by a really courageous young woman.
And then there were other episodes about sexual violence against women, a nod to Biden a couple of times, who actually wrote the original Violence Against Women Act in ’94, part of the crime bill, but also in terms of liberal Democrats or progressives who … “prosecutor” isn’t their favorite title. But because they tied these themes together or at least link them or they were there in a basket together of her as a protector of victims of trafficking, rape, and abuse, starting when she was in high school with her friend.
So I thought that that was another thing that we would not have spoken about. You did not have young women talking about being raped by their stepfather and impregnated at age 12.
Rovner: So aside from reproductive rights, which was obviously a headline of this convention, it’s almost impossible to discern what a second Trump administration might mean for health because Trump has been literally all over the place on most health issues. And he may or may not hire back the former staffers who compiled Project 2025.
But we don’t really know what a Harris administration would mean either. There is still no policy section on the official Harris for President website. One thing we do seem to know is that she seems to have backed away from her support for “Medicare for All,” which she kind of ran on in 2019.
Luthra: Sort of.
Rovner: Yeah, kind of, sort of. What else do we know about what she would do on health care other than on reproductive health, where she’s been quite clear?
Ollstein: So the focus on the policies that have been rolled out so far have been cost of living and going after price-gouging. She also has a history, as California attorney general, of using antitrust and those kinds of legal tools to go after monopolistic practices in health care. In California, she did that on the insurance front and the hospital front and the drug pricing front. So there is an expectation that that would be a focus. But again, they have not disclosed to us what the plans are.
Kenen: I mean, one of the immediate things, and I watched a fair amount of the convention and none of us absorbed every word, but I don’t think I heard a single mention of it was the extension of the ACA subsidies, which expire next year. I mean, if they mentioned it, it was in passing by somebody. So you didn’t really hear too much ACA, right? You hear that wonderful line from President [Barack] Obama when he said the Affordable Care Act, and then he said that aside: “Now that it’s popular, they don’t call it Obamacare anymore.”
But you didn’t hear a lot of ACA discussion. You heard a lot of drug price and you heard a lot of some vague Medicare, mostly in the context of drug prices. But there wasn’t a segment of one night devoted to the health policy. So I mean, I think we can assume she’s pretty much going to be Biden-like. I would be surprised if she didn’t fight to preserve the subsidies.
The Medicare drug stuff is in law now and going ahead. I think Julie wants to come back to that, but I don’t think we know what’s different. And I don’t know what, in that to-do list, I don’t think she articulated the priorities, although I would imagine she’ll start talking about the subsidies because the Republicans are probably going to oppose that. But no, it wasn’t a big focus. It was like sprinkles on an ice cream cone instead of serving a sundae.
Rovner: It’s hard to remember that just four years ago in 2020, there was this huge fight about the future of health care. Do we want to go to Medicare for All? What do we want to do about the ACA? Biden was actually the most conservative, I think, of the Democratic candidates when it came to health care.
Kenen: And then he expanded things way more than people expected him to.
Rovner: Yes, that’s true. I was going to say, but the other thing that jumped out at me is how many liberals, [Rep.] Alexandria Ocasio-Cortez, talking like a moderate basically, I mean, giving this big speech. It feels like the left wing of the Democratic Party, at least on health care, has figured out that it’s better to be pragmatic and get something done, which apparently the right wing of the Republican Party has not figured out.
Luthra: Well, part of what happened, right, is, I mean, the left lost in 2020. Joe Biden won. He became president. And there’s this real interesting effort that we saw this week to try and recapture the energy of 2008, 2012, the Obama era, and that wasn’t a Medicare-for-All-type time. That was much more vibes and pragmatism, which is what we are seeing now.
Kenen: The other thing is that the progressives, more centrist, more moderate, whatever you call the mainstream bring, they kissed and made up. I mean, [Sen.] Bernie Sanders became an incredible backer of Biden. I mean, they fought on the original Bring [Build] Back Better. That became the watered-down Inflation Reduction [Act]. They had some policy differences and some of which were stark.
But basically, Bernie Sanders became this bulwark for it, helped create party unity, helped move it ahead, supported Biden when he was thinking about staying in the race. So I think that Bernie’s support of Biden, who did do an awful lot of things on the progressive agenda; he did expand health care, although not through single-payer, but through expanded ACA. He did do a lot on climate. He did do a lot of things they cared about, and the party is less divided. We don’t know how long that’ll last. We had, not just unusual, but unprecedented last two months. So these things like Medicare for All versus strengthening the ACA, they’ll bubble up again, but they’re not going to divide the party in the next seven weeks, eight weeks, whatever we’re out: 77 days. Do the math, 10 weeks.
Rovner: Seventy-some days. In other political news, third-party candidate and anti-vax crusader Robert F. Kennedy Jr. is going to drop out of the race later today and perhaps endorse Donald Trump. The rumor is he’s hoping to win a position in a second Trump administration, if there is one, possibly even secretary of Health and Human Services. What would that look like? A lot of odd faces from our panelists here.
Ollstein: I’m always skeptical. There’s also talk about Elon Musk getting a Cabinet job. I’m always skeptical of these incredibly wealthy individuals — who, currently, as private citizens, can basically do whatever they want — I have a hard time imagining them wanting to submit to the constrictures and the oversight of being in the Cabinet. I would be surprised. I think that it sounds good to have that power, but to actually have to do that job, I think, would not be appealing to such people. But I could be surprised.
Rovner: We did have Steve Mnuchin as secretary of the Treasury, and he seemed to have a pretty good time doing it.
Ollstein: I guess so, but I think his background was maybe a little more suited to that. I don’t know.
Kenen: Mnuchin, you’ve also had Democrats who appoint Wall Street types. Rubin being one of several, at least.
Rovner: We tend to have billionaires at the Treasury Department.
Kenen: The idea of Bobby Kennedy running HHS, I think even many Republicans who support Trump would find a bridge too far. And remember they want … if you look at the part of the Republican Party that really equate … their priority is anti-abortion, that’s it for them. There’s some on the right who talked about — I’m pretty sure this is in 2025, but at least it’s out there — change it to the Department of Life.
There’s a faction within the Republican Party who sees HHS as the way of driving an anti-abortion agenda. What’s left of abortion, right? It has oversight over the NIH [National Institutes of Health] and FDA [Food and Drug Administration] and CDC [Centers for Disease Control and Prevention], et cetera. You can’t say that Trump won’t do something because he is a very unpredictable person. So, who knows what Donald Trump would do? I don’t think it’s all that likely that Bobby Kennedy gets HHS.
But I do think that in order to get the endorsement that Trump wants, he’d have to promise him something in the health realm — whether it’s a special adviser for vaccine safety, who knows what it would be? But something that makes him feel like he got something in exchange for the support.
Rovner: I do wonder what the support would mean politically to have prominent anti-vaxxer. If Trump is out trying to capture swing voters, this doesn’t seem necessarily a way to appeal to suburban moms.
Kenen: Remember the vaccine commission to study vaccine safety? And it was Bobby Kennedy who came out of a meeting with Trump and said it was going to happen, that he was going to be the chair of it. The commission didn’t happen, and Bobby Kennedy didn’t chair it. So we already know that this goes back, what, eight years now. So there’s going to be a tit-for-tat. That’s politics. Whether the tat is HHS secretary, I’m skeptical. But again, I’d never say anything isn’t possible in Washington.
Rovner: If nothing else, this year has shown us that …
Kenen: I think it’s extremely unlikely.
Luthra: To your point about who Bobby Kennedy appeals to, the polls tell us that everyone who supports him, by and large, would vote for Trump if he dropped out. So I mean, that’s obviously why this would happen. It’s because it is a net gain for Trump and his calculus is probably that it would outweigh the losses he might get from having someone with a strong anti-vax bent on his side. I think that’s a pretty obvious, to me at least, gain for him rather than loss, especially given how close the race is.
Rovner: While we are on the subject of national politics and abortion, former President Trump this week said in an interview with CBS that he would not enforce the Comstock Act to basically impose a national abortion ban, reiterating that he wants to leave it to the states to decide what they want to do. Alice, it’s fair to say this did not go over very well with the anti-abortion base, right?
Ollstein: That’s right. It’s interesting. I reached out to lots of different folks in the anti-abortion movement to get their take, and I expected at least some of them to say, “Oh, Trump’s just saying that. He doesn’t really mean it. He’ll still do it anyways.” None of them said that. They all completely took him seriously and said that they were extremely upset about this. I mean, it’s also not happening in a vacuum.
They were already upset about the RNC [Republican National Convention] platform having some anti-abortion language being taken out of it. There is still some anti-abortion language in there. Folks should remember him declining to endorse a national abortion ban. Him refusing to say how he plans to vote in Florida’s referendum on abortion coming up. So this is one more thing that they’re upset about. And they told me that they think it could really cost him some votes and enthusiasm from the base.
He’s having trouble winning over these moderate swing voters. If that’s true, then he needs every vote on the more religious right/conservative wing of things. And they’re saying, look, most people are probably going to vote for him anyways because they don’t want Kamala Harris to be president. But will they volunteer? Will they tell a friend? Will they go knock on doors? Begrudgingly voting for someone versus being enthusiastic difference.
Rovner: I think it’s fair to say that it was the anti-abortion right that basically got him over the finish line in 2016 when he put out that list of potential Supreme Court nominees and signed a now-infamous letter that Marjorie Dannenfelser of the SBA [Susan B. Anthony Pro-Life America] list put together. Then the anti-abortion movement put a lot of money into door-knocking and getting out the vote. And obviously, as we all remember, it was just a few thousand votes in a couple of states that made him president.
So I was a little bit surprised that he was that definitive — although as we said 14 times already this morning — he often says one thing and does another, or says one thing and says another thing later, right.
Kenen: In the same day!
Rovner: Or in the same conversation sometimes. I was interested to see Kamala Harris in her speech refer to the Comstock Act without doing it by name. I thought that was artfully done.
Ollstein: Yeah, and several other speakers did talk about it by name, which is interesting because I think earlier this year there was this attitude among Democrats and some abortion rights leaders that there should not be a lot of talk about the Comstock Act because they didn’t want to give the right ideas. But I think now it’s pretty clear that the right doesn’t need to be given ideas. They already had these ideas. And so there’s a lot more open talk about it.
And just this piece of Project 2025, along with all of the focus on Project 2025 in general, just really seemed to resonate with voters in a really unusual way. And no matter how much Trump tries to disavow it or distance himself from it, it doesn’t seem like people are convinced, because these are very close allies of Trump who worked for him, who are likely to work for him in the future, who are the authors of this.
Rovner: And who put together this whole list of people who could work in a second administration. It’s basically the second Trump term all ready to go. It’s hard to imagine where he would then find a list of people to populate his agencies if not turning to the list that was put together by Project 2025.
So Trump says, as we’ve mentioned, that he wants voters in each state to decide how to regulate abortion. And that’s pretty much what he’s getting. Since we last talked, several states have finalized abortion rights ballot questions. But some have come with a couple of twists. Alice, where are we on the state ballot measure checklist?
Ollstein: It’s been a crazy couple of weeks. So we have Arizona and Montana certified for the ballot. Those are two huge states that also have major Senate races. Arizona is a presidential swing state. Montana, arguably not. But these are states that are going to get a blitz of ads and campaign attention. I think there is an expectation that the abortion measures on the ballot will benefit the Democratic candidates.
I would caution people to be skeptical about this. We’ve done analyses of the abortion ballot measures that have been on the ballot in the past couple of years in other states, and they did not always benefit the Democratic candidates who shared the ballot. Of course, this is a presidential year. It could be totally different.
At the same time, the big news this week was that a Arkansas Supreme Court ruling means that their abortion rights ballot measure will almost certainly not be on the ballot in November. And there’s a lot of consternation about that. The dissenting justices accused the majority of making up rules out of whole cloth and treating different ballot measures differently based on the content.
So basically there was a medical marijuana ballot measure and the sponsors of it wrote a brief saying, “Hey, we made the same alleged paperwork error that the abortion rights folks are accused of making, yet ours was certified for the ballot and theirs wasn’t. What gives?” So there are accusations of the conservative officials of Arkansas making these rulings to prevent a vote on abortion rights in that state. So they could try again in 2026. They are weighing their options right now.
Rovner: So abortion issues are not just bubbling among voters and in the elections. We now have a series of lawsuits with patients accusing hospitals that deny them emergency care of violating the Emergency Medical Treatment and Active Labor Act. Some may remember this was also the subject of a Supreme Court case this term. For those who have forgotten, Shefali, what happened with that Supreme Court case? Where are we with EMTALA?
Luthra: Great question, Julie. We are waiting, as ever, and we will be waiting for a long time because the Supreme Court after taking up that case said, “Actually, never mind. We were wrong to take this case up now. It should go back to the lower courts and continue to progress.” And what that means is uncertainty. It does mean that EMTALA’s protections exist for now in Idaho. They do not exist in Texas, where there is a related corresponding case going through the courts as well.
But regardless, EMTALA’s protections are quite meaningful for providers compared to not having them. But they are still pretty vague and pretty limited in terms of how abortion can come up in pregnancy. And that’s why we are still seeing patients filing these complaints saying, “My rights were violated. I did not get this emergency care I needed until it was very late.” But the problem there is that: A, EMTALA is retroactive.
So these complaints only come up when people know to file them; when they have perhaps already suffered medical consequences such as losing a fallopian tube, as two women in Texas both reported experiencing. You know, serious implications for their future fertility. And the other thing that’s important to note is that complaints are one step, but enforcement is another one.
And we haven’t seen a ton of hospitals being penalized by the federal government for not giving people care in these medical emergencies. And so if you’re a hospital, the dilemma is complicated, but in some ways not. Because if you provide care for someone and you find yourself in violation of state law, that’s a felony, potentially. But if you are going against EMTALA, well, maybe it’ll be reported, maybe it won’t be. Maybe you’ll be fined or penalized by the federal government, but maybe you won’t be. And that creates a real challenge for patients in particular because they are once again caught in a situation where they need emergency medical care, and the incentives are against hospitals providing it.
Ollstein: The Biden administration has not been transparent on how many complaints have been filed, how many hospitals they’ve investigated, what measures they’ve taken to make hospitals correct their behavior, whether they’ve come into compliance or not, whether they are getting these penalties, including losing Medicare status, which is one of the most severe penalties possible.
We just don’t know. And so they say they’re making this big focus on EMTALA enforcement, but we are not really seeing the evidence of that. And the only way we even know anything is happening is when the patients themselves are choosing to disclose it, either to advocacy groups or the media.
Rovner: Or the Democratic National Convention, where we saw several of these stories. It is a continuing theme as we go forward. Well, moving on. While we were celebrating the 50th anniversary of ERISA [Employee Retirement Income Security Act] here on “What the Health?” last week — and if you did not hear that special episode, I highly recommend it — the Biden administration unveiled negotiated prices for the first 10 drugs chosen under the new authority granted by the Inflation Reduction Act.
It’s hard to tell how much better the prices that they got are because so much of the information remains proprietary. But Joanne, what’s the reaction been, both in the drug industry and larger in the political realm?
Kenen: The drug industry obviously doesn’t like it. This is only 10 drugs this year, but it’ll be more in the future. Look, I’m not so sure how well that message has gotten through yet. The Medicare drugs came under what ended up being called the Inflation Reduction Act. There’s several measures in it. There’s protection for everybody in Medicare, how much you spend on drugs in a year, it’s $2,000. That’s it. Which is a big difference from what some of the out-of-pocket vulnerabilities people had in the past.
When you look at the polls or you look at interviews with undecided voters, you wonder who’s paying attention other than us? The Democrats have wanted this for more than 20 years. Twenty years is a conservative estimate. I mean, it was part of the fight over what became the Medicare Modernization Act in 2003.
They fought for it every year. They lost every year. They finally got it through. So the idea of having Medicare negotiating drug prices is a huge victory for the Democrats. Ten drugs, not a big deal for the industry, but they know something changed. They will fight every opportunity for a lawsuit or a lobbying campaign or blocking a new regulation or the next round of negotiations.
This is going to be probably just like these annual fights we have about physician pay. This’ll be an annual fight about how much can PhRMA punch back. That would assume that a Democrat wins and that these policies don’t get rescinded. It’s a big deal. It’s not a big deal for individual pocketbooks yet, but it’s a big, big deal on the balance of power between PhRMA, which is so powerful, and the federal government, which pays for these drugs.
Rovner: I’m reminded of a sentence I wrote about the Medicare Catastrophic Coverage Act, which was passed and repealed much at the behest of the drug industry because it had what would’ve been the first Medicare outpatient drug benefit ever. And I wrote, the drug industry fought this tooth and nail because they were concerned that if Medicare started covering drugs, they would want to have some say in how much they cost. That was, I think, 1989.
Kenen: Right.
Rovner: And here we are, however many years later it is.
Kenen: It’s really hard to take away a benefit, as the Republicans learned when they spent all that energy trying and failing to repeal the ACA. Once people have a benefit, it’s hard to say, “Whoops! No more.” However, that doesn’t mean there’s not fights about technical matters or how the regulations are worded or how deep discounts are or what other things they could get in exchange that make up for the losses on this.
I mean, PhRMA is really a huge lobby, hugely influential, and sympathetic in some ways because they do create a pro … — unlike something like tobacco — they do create products that saves our lives, right? And their argument, innovation, and those arguments resonate with people. But I don’t really see this turning back. I don’t think any of us can predict how PhRMA will regain some of the influence that it did lose in this battle.
It’s certainly not permanent defeat of PhRMA. I mean, PhRMA is powerful. PhRMA has allies in both parties. But this was a huge victory for the Democrats. They got something after 20-plus years.
Rovner: Well, finally this week, earlier this spring we talked at some length about the Biden administration’s Federal Trade Commission proposal to ban noncompete clauses, which in health care often applied to even the lowest-level jobs. It was supposed to take effect Sept. 4, but a federal district court judge in Texas has ruled in favor of the U.S. Chamber of Commerce that the agency lacks the authority to implement such a sweeping rule.
And the appeals court there in the 5th Circuit is notoriously conservative and unlikely to overturn that lower-court decision even if Vice President Harris wins and becomes president. Are we just going to continue to see every agency effort blocked by some Trump-appointed judge in Texas? That seems to be what’s happening now.
Ollstein: I mean, I think especially with the recent Supreme Court rulings on Chevron, I think we’re just … I mean, that plus the makeup of the judiciary means that executive power is just a lot more curtailed than it used to be. Theoretically, that should apply to both parties to whoever is president, but we have seen courts be very politicized and treat different things differently. So I think that it will be a special challenge for a Democratic or progressive administration to push those policies going forward.
Rovner: And of course in Texas, as we have pointed out on many occasions, there are all these single-judge districts, where if you file in certain places you know which judge you’re going to get. I mean, it’s the ultimate in judge shopping.
Luthra: I was just thinking about [U.S. District Judge] Reed O’Connor and [U.S. District Judge] Matthew Kacsmaryk, two names that listeners know well.
Rovner: Yes, that’s right. And this was a third judge, by the way. This was neither Reed O’Connor nor Matthew Kacsmaryk in this case.
Ollstein: But a secret third thing.
Rovner: A secret, a secret third thing.
Kenen: I mean, what Alice just referred to as the Supreme Court reducing the power of the regulators, and they said Congress has to pass the laws. You’re not going to get something this sweeping through Congress. But could you end up getting bits of it written into legislation about hospital personnel or doctors or things like that? I can see nibbles added in certain fields. And also you’re going to see some of it at the state level. I’m pretty sure Maryland has passed some kind of a noncompete.
Rovner: Yeah, there are states that have their own noncompete laws.
Kenen: I think they’ll go at it piecemeal. They may not be able to do anything that huge, all noncompetes, but by profession, or sector by sector, I think they may try to keep nibbling away at it. But the effort that we saw is gone.
Rovner: I mean, just to broaden it out, obviously this was something that the Biden administration has relied on the power of the FTC, the Federal Trade Commission, something that the Biden administration has highlighted. It’s something that I think Vice President Harris is relying on going forward. So this is probably not a good sign for wanting to make policy in this way.
See, nods all around. All right, that is this week’s news. Now we will play my “Bill of the Month” interview with Tony Leys, and then we will come back and do our extra credits.
I am so pleased to welcome to the podcast my KFF Health News colleague Tony Leys, who reported and wrote the latest KFF Health News-NPR “Bill of the Month.” Tony, welcome back to “What the Health?”
Tony Leys: Hi, Julie.
Rovner: So tell us about this month’s patient: who she is, where she’s from, and what kind of medical care she got.
Leys: The patient is Jamie Holmes, who lives in Washington state. In 2019, she went to a surgical center to have her fallopian tubes tied. While she was on her anesthesia, the surgeon noticed early signs of endometriosis, a common condition in which fibrous tissue grows in and around the uterus. The surgeon took care of that secondary issue. Holmes said he later told her the whole operation was done within the allotted time for the original surgery, which was about an hour.
Rovner: As one who’s had and knows a lot of people who’ve had endometriosis, it is extremely painful and very difficult to treat. So medically, at least this story seems to have a happy ending, a doctor who was on his toes spotted an impending problem and took care of it on the spot. But then, as we say, the bill came.
Leys: The bill came. The surgery center billed her for two separate operations, $4,810 each.
Rovner: So even though she only went under anesthesia once and simply had two different things done to her at the time.
Leys: Right. And the surgery center is the place that does the support work for the operation. And there was just one operation.
Rovner: So obviously she figured this must be a mistake and complained. What happened?
Leys: She thought once she explained what really happened, they would go, “Oh,” and they would fix it. But that didn’t work. And after adjustments and the insurance payment for the one operation, they said that she still owed the surgery center $2,605, and she said, “Nope.”
Rovner: This was in 2019. So obviously things have happened since then.
Leys: Right. The bill was turned over to a collections agency, which wound up suing Holmes last year for about $3,800, including interest and fees.
Rovner: Now, to be clear, Jamie says she doesn’t object to paying extra for the extra service that she got. What she does object to is being charged as if it was two separate surgical procedures. So what happened next?
Leys: I mean, she joked that it was as if she went to a fast-food restaurant and ordered a value meal, ended up with one extra order of fries and then got charged for two full meals. The collections agency went to court. They asked for a summary judgment, which could have allowed the collection agency to garnish Holmes’ wages.
But she went to a couple of court hearings and explained her side, and the judge ruled last February that he wasn’t going to grant summary judgment to the collection agency. And if it really wanted to pursue the matter, it would have to go to trial. And she has not heard from them since then.
Rovner: Because presumably it would cost them more to go to trial than it would to collect her … however many couple of thousand dollars they say she still owes, right?
Leys: That could certainly be the explanation. We don’t know.
Rovner: So what’s a takeaway here?
Leys: The takeaway is if you get a bill that’s totally bogus, don’t necessarily pay it. Don’t be afraid to fight it. And if someone sues you, don’t be afraid to go to court and tell your side of it.
Rovner: Yeah, because I mean, that’s mostly what happens is that these collection agencies go to court, nobody shows up on the other side, and they get to start garnishing wages, right?
Leys: Exactly. That’s probably what would’ve happened here.
Rovner: She didn’t even have to hire a lawyer. She just showed up and told her side of the story.
Leys: And her take on it is she could have arranged to pay it. It’s not a huge, huge amount of money. But she just wasn’t going to do it. So she stood her ground.
Rovner: And as we pointed out, she was willing to pay for the extra order of fries. She just wasn’t willing to pay for an entire second meal that she didn’t get.
Leys: Right. I mean, she told me, “I didn’t get the extra burger and drink and a toy.”
Rovner: There we go. So basically fight back if you have a problem, and don’t be afraid to fight back.
Leys: Exactly.
Rovner: Tony Leys, thank you so much.
Leys: Thanks, Julie.
Rovner: OK, we are back. It’s time for our extra credits. That’s when we each recommend a story we read this week we think you should read, too. Don’t worry if you miss the details. We will include links to all of these stories in our show notes on your phone or other device. Alice, you chose first this week. Why don’t you go first?
Ollstein: Sure. So I had an interesting piece from The Wall Street Journal by Theo Francis and Melanie Evans called “The Fight Against DEI Programs Shifts to Medical Care.” So we’ve seen this growing effort from conservative activists to go after so-called DEI [diversity, equity, and inclusion] programs, to go after affirmative action, to go after a lot of various programs in government and in the private sector that take race into account when allocating resources.
And so now this is coming to health care where you have a lot of major players. This story is about a complaint filed against the Cleveland Clinic. But throughout health care, you have efforts to say, OK, certain racial groups and other demographics have higher risk and are less likely to get treatment for various diseases. This one is about strokes, but it applies in many areas of health care. And so they have created these targeted programs to try to help those populations because they are at higher risk and have been historically marginalized and denied care. And now those efforts are coming under attack. And so it’s unclear. So this is a federal complaint, and so the federal government would have to agree with it and take action. I don’t think that’s super likely from the Biden administration to crack down on a minority health care program. But this could be yet another thing people should keep in mind regarding the stakes of the election because a conservative administration could very well take a different approach.
Rovner: Shefali.
Luthra: My story is from The Washington Post. It is by Ariana Eunjung Cha, and the headline is “Weight-Loss Drugs Are a Hot Commodity. But Not in Low-Income Neighborhoods.” I think this is a really smart framing and it gets at something that folks have been worried about for a long time, which is that we have these revolutionary drugs like Ozempic and Wegovy. They show massive improvements for people with diabetes, for people with obesity. And they are so expensive and often not covered by Medicaid. Or if you are uninsured, you cannot get them. And what this story gets at really …
Rovner: If you’re insured, you can’t get them in a lot of cases.
Luthra: It’s true. What I love about this story is it sets us in place. It takes us to Atlanta and helps us see in the different parts of the city, based on income, on access to all sorts of other, to use the jargon, race, social determinants of health, obesity and diabetes are already very unequal diseases. They hit people differently because of access to safe places to exercise, walkable streets, affordable groceries, time to cook, all of that. And then you add on it another layer, which is this drug that can be very helpful is just out of reach for people who are already at higher risk because of systemic inequalities. The story also gets into some of the more social challenges that you might see from a drug like Ozempic. People saying, “Well, I know that rich people get that drug, but how do I know they would be giving the same thing to me? How do I know that the side effects will not be really damaging down the line because these drugs are so new?” And what it speaks to, in a way that I think we’re seeing a lot more journalism do very intelligently, is that there are going to be very real challenges — economic and cultural and social and political — to helping these drugs have the impact that they were touted as potentially able to have.
Rovner: Indeed. Joanne.
Kenen: Well, after that amazing moment with Gus Walz and his dad on the convention floor, I looked up the quick 24-hour coverage of what was going to best explain what a nonverbal learning disorder is and a little bit about who Gus Walz is. And Natalie Eilbert of The Milwaukee Journal Sentinel did a nice piece [“Who Is Gus Walz and What Is a Non-Verbal Learning Disorder?”]
Nothing I read yesterday answered every question I had about this particular processing disorder, but this was a good one and it explained what kind of things kids with these kinds of issues have trouble comprehending, and also what kind of things they’re really good at. This is not a learning disability. You can be really, really smart and still have a learning disability.
There’s actually an acronym, as there always is, which is GTLD: gifted and talented and learning disabled. Much of the country responded really warmly, as we all saw, and some of the country did not. But in terms of just what is this disorder and how does it affect your ability to communicate, which is part of what it is, understanding language cues, Natalie Eilbert did a good job.
Rovner: And no matter what you can be proud of your dad, particularly when he’s just been nominated to run for vice president. All right, my extra credit this week is from The New York Times. It’s called “Hot Summer Threatens Efficacy of Mail-Order Medications.” And it’s something I’ve been thinking about for a while because packages get subjected to major extremes of temperature in both the summer and the winter.
Indeed, now we have studies that show particularly that heat can degrade the efficacy and safety of some medications. One new study that embedded data-logging thermometers in packages found that those packages spent more than two-thirds of their transit time outside the recommended temperature range.
While the FDA has very strict temperature guidelines for shipping and storing medications between manufacturers and wholesalers and pharmacies, once it leaves the pharmacy it’s apparently up to each state to regulate. Just one more unexpected consequence of climate change.
OK, that is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, I’m @jrovner. Shefali, where are you these days?
Luthra: I am on the former Twitter platform @shefalil.
Rovner: Alice?
Ollstein: On X @aliceollstein.
Rovner: Joanne?
Kenen: On X @JoanneKenen and on Threads @JoanneKenen1.
Rovner: Before we go, a quick note about our schedule. We are taking next week off. I’m going to the beach. The week after that, we’ll have a very special show from The Texas Tribune TribFest in Austin. We’ll be back with our regular panel and all the news we might’ve missed on Sept. 12. Until then, be healthy.
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KFF Health News' 'What the Health?': Harris in the Spotlight
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Julie Rovner
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
As Vice President Kamala Harris appears poised to become the Democratic Party’s presidential nominee, health policy in general and reproductive health issues in particular are likely to have a higher profile. Harris has long been the Biden administration’s point person on abortion rights and reproductive health and was active on other health issues while serving as California’s attorney general.
Meanwhile, Congress is back for a brief session between presidential conventions, but efforts in the GOP-led House to pass the annual spending bills, due by Oct. 1, have run into the usual roadblocks over abortion-related issues.
This week’s panelists are Julie Rovner of KFF Health News, Stephanie Armour of KFF Health News, Rachel Cohrs Zhang of Stat, and Alice Miranda Ollstein of Politico.
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Among the takeaways from this week’s episode:
- President Joe Biden’s decision to drop out of the presidential race has turned attention to his likely successor on the Democratic ticket, Vice President Kamala Harris. At this late hour in the campaign, she is expected to adopt Biden’s health policies, though many anticipate she’ll take a firmer stance on restoring Roe v. Wade. And while abortion rights supporters are enthusiastic about Harris’ candidacy, opponents are eager to frame her views as extreme.
- As he transitions from incumbent candidate to outgoing president, Biden is working to frame his legacy, including on health policy. The president has expressed pride that his signature domestic achievement, the Inflation Reduction Act, took on the pharmaceutical industry, including by forcing the makers of the most expensive drugs into negotiations with Medicare. Yet, as with the Affordable Care Act’s delayed implementation and results, most Americans have yet to see the IRA’s potential effect on drug prices.
- Lawmakers continue to be hung up on federal government spending, leaving appropriations work undone as they prepare to leave for summer recess. Fights over abortion are, once again, gumming up the works.
- In abortion news, Iowa’s six-week limit is scheduled to take effect next week, causing rippling problems of abortion access throughout the region. In Louisiana, which added the two drugs used in medication abortions to its list of controlled substances, doctors are having difficulty using the pills for other indications. And doctors who oppose abortion are pushing higher-risk procedures, like cesarean sections, in lieu of pregnancy termination when the mother’s life is in danger — as states with strict bans, like Texas and Louisiana, are reporting a rise in the use of surgeries, including hysterectomies, to end pregnancies.
- The Government Accountability Office reports that many states incorrectly removed hundreds of thousands of eligible people from the Medicaid rolls during the “unwinding” of the covid-19 public health emergency’s coverage protections. The Biden administration has been reluctant to call out those states publicly in an attempt to keep the process as apolitical as possible.
Also this week, Rovner interviews Anthony Wright, the new executive director of the consumer health advocacy group Families USA. Wright spent the past two decades in California, working with, among others, now-Vice President Kamala Harris on various health issues.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: NPR’s “A Study Finds That Dogs Can Smell Your Stress — And Make Decisions Accordingly,” by Rachel Treisman.
Alice Miranda Ollstein: Stat’s “A Pricey Gilead HIV Drug Could Be Made for Dramatically Less Than the Company Charges,” by Ed Silverman, and Politico’s “Federal HIV Program Set To Wind Down,” by Alice Miranda Ollstein and David Lim.
Stephanie Armour: Vox’s “Free Medical School Won’t Solve the Doctor Shortage,” by Dylan Scott.
Rachel Cohrs Zhang: Stat’s “How UnitedHealth Harnesses Its Physician Empire To Squeeze Profits out of Patients,” by Bob Herman, Tara Bannow, Casey Ross, and Lizzy Lawrence.
Also mentioned on this week’s podcast:
- States Newsroom’s “Anti-Abortion Researchers Back Riskier Procedures When Pregnancy Termination Is Needed, Experts Say,” by Sofia Resnick.
- KFF Health News’ “Louisiana Reclassifies Drugs Used in Abortions as Controlled Dangerous Substances,” by Rosemary Westwood, WWNO.
- The New York Times’ “Biden and Georgia Are Waging a Fight Over Medicaid and the Future of Obamacare,” by Noah Weiland.
click to open the transcript
Transcript: Harris in the Spotlight
KFF Health News’ ‘What the Health?’Episode Title: ‘Harris in the Spotlight’Episode Number: 357Published: July 25, 2024
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, July 25, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this, so here we go. We are joined today via video conference by Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Hello.
Rovner: Rachel Cohrs Zhang of Stat News.
Rachel Cohrs Zhang: Hi, everybody.
Rovner: And we welcome back to the podcast one of our original panelists, Stephanie Armour, who I am pleased to say has now officially joined us here at KFF Health News. Stephanie, so great to have you back.
Stephanie Armour: Great to be back.
Rovner: Later in this episode, we will have my interview with Anthony Wright, the new executive director of the consumer health advocacy group Families USA. Anthony previously spent two decades working on health issues in California so he’s pretty familiar with the health work of the current vice president and soon-to-be Democratic presidential nominee, Kamala Harris, and he’ll share some of that knowledge with us. But first, this week’s news.
So it’s safe to say a lot has changed since the last time we met. In fact, it may be fair to say that just about everything has changed. President Joe Biden announced he would not seek reelection after all, he endorsed his vice president, Kamala Harris, and she proceeded to all but lock up the nomination in less than 48 hours. Obviously, this will be a huge deal for the fight over abortion and reproductive health care, which we will get to in a moment. But how is this going to impact health care, in general, as a campaign issue?
Ollstein: Yeah, it’s interesting because Kamala Harris has been a public figure for a while and has held a bunch of different offices, and so we can glean some clues as to where she is on various health care issues. But she’s been a bit hard to pin down. And when my colleagues and I were talking to a lot of folks throughout the health care industry over the past week, there were a lot of question marks on their end, so we know a few things. We know that she used the powers of the AG [attorney general] office to go after monopolies and consolidation and anticompetitive practices in California.
She did that in the insurance space, in the provider space, in the drug space, and so people are expecting that she would be maybe more aggressive on that front. We know that she did co-sponsor [Sen. Bernie Sanders’] “Medicare for All” bill, but then she also introduced her own, arguably more moderate, one that preserved private health insurance. And then, of course, abortion rights. She’s been very vocal on that front, but since becoming the presumptive nominee, she hasn’t really laid out what, if anything, she would do differently than Joe Biden. So like I said, a lot of question marks.
Rovner: Stephanie, you led our coverage of Harris’ health record. What did you learn?
Armour: Well, I think a number of the people that I’ve talked with really expect that she’ll be a standard-bearer to what Biden has already done, and I think that’s probably true. I don’t think she’s going to go back stumping for Medicare for All right now, for example. What I did find really interesting is, yes, she’s very much made abortion and reproductive rights a cornerstone of her vice presidency and, I assume, will be of her campaign. But based on where abortion is polling right now, a number of the strategists I spoke to said she really needs to do something pretty major on it in order to get a real uptick in terms of galvanizing voters, just because economy and immigration are so high. They’re saying that she really needs to do something like say that she’ll bring back legislation to restore Roe v. Wade, for example, to really make a difference. So I think it’ll be interesting to see how much that can really motivate voters when there’s so much competing for interest right now.
Cohrs Zhang: Oh, there is one other issue that I wanted to bring up. And I think especially from her time in the Senate, she didn’t sit on health care committees, but she did go out of her way to take ownership over concerns about maternal mortality. She was lead Senate sponsor of the Momnibus Act, which included a whole slew of different policies and programs that could help support mothers, especially Black mothers. And I think she has continued that interest in the White House and really championed health equity, which does, again, just draw a very stark contrast. So we haven’t seen a lot of passion or interest in the traditional health policy sense from her outside of abortion, but that is one issue she really has owned.
Rovner: Yeah, I mean, it has not been part of her quote-unquote “portfolio” as vice president, anything except, as I mentioned, reproductive rights, which will obviously be the biggest change from Biden to Harris. The president, as we all know, does not even like to say the word “abortion.” She, on the other hand, has been all over the issue since well before Roe got overturned and obviously particularly since then. Alice, how are advocates on both sides of this issue reacting to this switch at the top of the ticket?
Ollstein: Yeah, honestly, it’s been this interesting convergence because the pro-abortion-rights side is really jazzed. They’ve basically all rushed to endorse her and talk about how they’ve been working with her for years and really know her and trust her, and they believe she’ll be more aggressive than Biden was. But you also have the anti-abortion side being excited to have her as the villain, basically. They’ve had a hard time portraying Biden as extreme on this issue and they think they’ll have an easier time portraying Kamala Harris as extreme on abortion rights. One other thing from her record and background is her fight with the conservatives who recorded sting videos at Planned Parenthood that the anti-abortion movement still brings that up a lot. So yeah, it’ll be really interesting to see for which side this really lights a fire more because we’re hearing claims from both that it will fuel them.
Rovner: And, actually, I think it will actually fuel both sides of this. I would think that the abortion-rights groups were very — I mean everybody was pretty quick to endorse her — but the abortion-rights groups were right there right away, as were the anti-abortion groups saying she is extreme on abortion, which in some ways will fuel the abortion-right side. It’s like, “Oh good. The more the antis don’t like her, the stronger that means she is for us.” I mean, I literally could see this fueling both sides of this issue and …
Armour: Whereas you see Republicans backing away increasingly from abortion like the RNC [Republican National Committee] platform. And so it’s turning out to be still very much a hot-button issue and difficult issue for Republicans.
Rovner: So they say that the vice presidency is not very good for much, and I definitely agree with that. I mean, everybody always says, “The vice president hasn’t done anything.” Because the vice president doesn’t really have a job to do anything. Often the only time the vice president is on TV is when he or she sits behind the president at the State of the Union. But I feel like, in Harris’ case, it’s made her a much more confident and natural and comfortable campaigner. I watched her a lot when she was running for president in 2019 and 2020, and she was, to be kind, a little bit awkward; I mean she was just not one of those natural, had-that-rapport with a crowd, and I feel like that has changed a lot having watched her crisscross the country, particularly on reproductive health. Am I the only one that feels that way? I feel like people are going to see a very different vice president than they think they saw, while she was doing her due diligence as vice president.
Ollstein: Definitely, and I’ve found it interesting that it’s only been a few days since all of this went down, but I have noticed that while she has brought up abortion rights in pretty much every speech and appearance she’s given, she has not given specifics. She has not indicated if she is in the Biden camp of let’s restore Roe v. Wade, or with a lot of the rest of the movement that says Roe was never good enough, we need to aim for something much more expansive. So we didn’t know where she is on that. I mean, largely she’s been just saying, “Oh, I will stop Donald Trump from banning abortion nationally.” And using him as the foil and pledging to stop him. And so we haven’t really seen her make an affirmative case of what she would do on this front.
Rovner: Well, I think that would probably be as difficult for her as it is for the Republicans to try and figure out how far they want to go banning. Because yeah, as you mentioned, I mean, there’s a lot of the abortion-rights movement that think that restoring Roe, even if they could, is not enough because obviously under Roe, many, many types of restrictions were allowed and were in place. That is obviously not where the abortion-rights side wants to end up. And on the other side, as we’ve talked about ad nauseum, do anti-abortion forces, are they OK with state-by-state bans? Do they want a national ban? If so, what would it look like? So that will obviously continue.
Now that we have, relatively, mostly settled who’s going to be at the top of the ticket, we are once again, back to the “Who will be the VP pick?” sweepstakes. Now that we’ve finished the Republican side, we’re back to the Democratic side of the short list. We’ve all been hearing Kentucky Gov. Andy Beshear, North Carolina Gov. Roy Cooper, Arizona Sen. Mark Kelly, and Pennsylvania Gov. Josh Shapiro. They all have significant health records, but mostly on different issues. Who do you think of the people who are being mentioned would make the biggest splash on the health care scene?
Ollstein: I’ve been hearing a lot of people talk about Gov. Beshear’s record on Medicaid expansion and pushing back against work requirements, and also opposing legislation to restrict trans care. And so there’s definitely a lot there. Really, a lot of them have something there, but I’ve been hearing the most about him.
Rovner: And Mark Kelly, of course, is married to Gabrielle Giffords, who was shot at a campaign event and is now a leading voice in the gun control movement. So they all seem to have slightly different major health issues. Roy Cooper in North Carolina got North Carolina to expand Medicaid, which was a very, very, very big deal with a very, very, very Republican legislature. I’m not going to ask anybody to guess who it’s going to be because I can’t imagine that any of us have any major insight into this. Whoever it turns out to be, and I imagine we’ll know in the next week or two, we will go in and examine their health care record. One of the advantages that Vice President Harris will have on the campaign trail is she gets to campaign on the Biden administration’s record, which is fairly accomplished on the health care front without the drag of being in her 80s. Somebody remind us of all the health policies the Biden administration has gotten done. Start with the Inflation Reduction Act.
Cohrs Zhang: The name of the legislation is very general, but I think President Biden, in his goodbye speech last night, did mention the drug pricing portion of that bill. He’s described it as beating Big Pharma. And I think that’s definitely something that he talked about in his State of the Union, that he wanted to expand some of those pricing mechanisms to more people, not just people in Medicare, but people in commercial health plans, too. So I think that’s been something that he has really felt passionate about and Vice President Harris now could certainly use on the campaign trail. It’s a really popular issue and, again, not a huge policy departure, but, certainly, there’s more work to be done there on Democrats’ side.
Armour: And also I think the ACA [Affordable Care Act] extensions in terms of how many more people have been eligible for coverage is something that will definitely be part of Biden’s legacy as well. And the record-low uninsurance that we saw is something I bet that will be remembered, too.
Rovner: Yeah, I mean I’ve been personally surprised at some of the things that he’s gotten done in a Congress with virtually minuscule majority. I mean, one vote in the Senate and, when the Democrats were controlling the House, it was, what, four votes in the House. That takes, I think, a certain kind of legislator to get things passed. I know people walk around and say, “Oh, the Biden administration hasn’t done anything.” And you want to pull your hair out because that’s all we’ve spent the last six years talking about, things that have actually gotten done and not gotten done.
Cohrs Zhang: Right. Well, I mean doing things and communicating well about doing things are different issues, and I think that’s going to be Vice President Harris’ challenge over the next few months.
Rovner: Yeah, and so we’ve seen, and I think the Biden administration has prevented a lot of things from happening, which is always very hard to campaign on. It’s like, “Well, if we hadn’t done this, then this might’ve happened.” I mean, I think that’s true about the pandemic. Things could have gone much, much worse and didn’t and that’s tricky to say, “Hey, we prevented things from getting even more terrible than they were.”
Ollstein: And on the drug pricing front, I mean it just always reminds me of the Affordable Care Act where the payoff is years down the road, and so selling it to voters in the moment when they’re not feeling the effects yet is really hard. So it makes sense that people aren’t aware that they got this major legal change that’s been decades in the making over the finish line because the drugs aren’t cheaper yet for a lot of people.
Rovner: That’s true. And the caps on spending haven’t really kicked in yet. It is a lot like the Affordable Care Act, which took four years from the time of passage to the time it was fully implemented.
Well, in other news, and there is some other news, Congress is back after a break for the Republican [National] Convention, although they’re about to leave again. At the top of the House’s list was passing the spending bills that they didn’t manage to pass last year. So how’s that all going, Rachel?
Cohrs Zhang: I think they’ve just thrown in the towel this week, given up a bit. I think there’s been an attitude of just apathy on the Hill and especially on health care issues that the sense has been, “We’ll return to this in December when we all have a little bit more information about the dynamics going to the lame-duck session.” And I think that clearly has bled over into any will that remains to pass appropriations bills before August recess. I think they’re ready to get out there, ready to be on the campaign trail and put this on the back burner.
Rovner: Yeah, and in an election year, you basically have the six months leading up to the first convention and then almost nothing until they come back after the election. They were going gangbusters on some of these spending bills. They were getting them out of committee even though they were obviously not in the kind of shape that they were going to become law. We talked at some length about all of the riders and all of the funding cuts that the Republicans have put in some of these bills, but they couldn’t even get them through the floor. I mean, Alice we’re hung up on abortion, again!
Ollstein: Oh, as always. And it’s the exact same policy fights as last time. The fight’s going to happen in the ag[riculture] bill, around FDA [Food and Drug Administration] regulation of abortion pills. There’s going to be fights about the provisions helping veterans and active-duty service members access abortion, knowing that these appropriations bills are the only real legislation that has any chance of going anywhere. People are putting all of their policy priorities in as riders. And last round of this, there were anti-abortion provisions tacked onto basically every single spending bill, and almost all of them got stripped out in the end and did not become law. Obviously, they kept long-standing things like the Hyde Amendment, but they didn’t add the new restrictions Republicans wanted to add. That is likely to happen again. We’ll see. This could drag past the election potentially. So the dynamics, depending on the outcome of the election, could be really different than they are today.
Rovner: Yeah, I mean, I guess the House is going out and they won’t be back until September. It used to be there would be an August recess in an election year, and they would come back in September, and they would actually work until the beginning or even the middle of October. And even that seems to have gone away. Now, once they’re gone for the quote-unquote “August recess,” it’s like, bye-bye getting much of anything done.
Well, there’s also some more news on the abortion front: The on-again off-again, on-again, off-again, six-week abortion ban in Iowa appears to be on again, possibly to start as soon as next week. Alice, I think we’ve mentioned this before, but this is going to affect a lot more than just people in Iowa.
Ollstein: Yeah, definitely. I mean, we’re seeing a big erosion of access across the Midwest Great Plains, like that whole area, that whole swath, the Dakotas, et cetera. And there’s already a lot of pressure on Illinois as the destination and clinics there are already overwhelmed with folks coming in from all over. And so this will add to that. As we’ve seen when this has happened in other states, wait times can go up, shortages of providers needed to care for everyone. Telemedicine does relieve some of that, and there are these groups that mail abortion pills into any state regardless of restrictions. But not everyone is comfortable doing that or knows how to do that or wants to do that or can afford to do that. And so this is said to have a big impact, and we’ll have to see what happens.
Rovner: There were two other pieces about abortion that caught my eye this week, and they’re both about things that we’ve talked about before. One is the push by anti-abortion doctors to change medical practice. In Louisiana, the abortion drugs mifepristone and misoprostol, both of which are used for many more things than just abortion, are now on the state’s list of controlled substances. And then from States Newsroom, there’s a piece about how anti-abortion OB-GYNs are trying to get medically necessary abortions that happen later in pregnancy, switched instead to C-sections or having the pregnant person go through and induce labor and delivery. I’ve been covering this issue, as I like to say, for nearly 40 years. This is the most intense effort I’ve ever seen from inside the medical profession to actually change how medicine is practiced in terms of what’s considered the standard of care, both for things like — not even so much mifepristone the abortion pill, but misoprostol, which is used for a lot of things other than abortion.
Armour: Was it initially an ulcer medication?
Rovner: Yes, yes, misoprostol.
Armour: That’s what I thought. Yeah.
Rovner: Cytotec. It was for a long time one of the go-to ulcer medicine. And in fact, the only reason it stopped becoming the go-to ulcer medicine because, if you were pregnant and wanted to be, it could help end your pregnancy. It is known to have that as a side effect, but yes, it’s an ulcer medication.
Armour: Yeah, this is the first I had seen anywhere, and I could be wrong, but of a real push to try and change the management of late-term medical miscarriages to how it would actually be carried out, which was just very interesting and to see what they were recommending instead.
Rovner: ACOG, the American College of Obstetricians and Gynecologists, has put out guidelines — forever, that’s what they do — about how to handle pregnancy problems later in pregnancy. Generally using the least invasive procedure is considered the safest and, therefore, best for the patient. And that’s not necessarily having a C-section, which is major surgery, or going through labor and delivery. People forget that it’s really dangerous to be pregnant. I mean, it’s amazing that we have all of these kids and happy parents because if you go back and look in history, a lot of women used to die in childbirth. They still do. It’s obviously not as bad as it used to be, but it is not everything-goes-fine-99%-of-the-time thing that I think a lot of people think it is.
Armour: That’s right. Yeah.
Rovner: All right, well, meanwhile, before we bid Congress goodbye for the rest of the summer, the House Oversight Committee, which is usually as partisan a place as there is in this Congress, held a hearing this week on PBMs [pharmacy benefit managers] and there seems to be pretty bipartisan support that something needs to be done. Rachel, I keep asking this question: It seems that just about everybody on Capitol Hill wants to do something to rein in PBM drug price abuse, and yet no one ever does. So are we getting closer yet?
Cohrs Zhang: We are getting closer, I think, as we approach December. My understanding was that lawmakers were pretty close on a deal on PBMs back in March. But I think it was just a symptom of “Appropriations Bill Has to Move.” They want it to be clean. If they add one committee’s extra stuff, they have to let other committees add extra stuff, too, and it gets too complicated on deadline. But it’s wild to me that we’re still seeing new PBM reform bills at this point. But there’s just a huge, huge pile of bills at this point, everyone wants their name on it. And so I really do believe that we’re going to see something in December. I think the big question is how far some of these reforms will reach: whether they’ll be limited to the Medicare program or whether some of these will start to touch private insurance as well. I think that’s what the larger industry is waiting to see. But I think there’s a lot of appetite. I mean with congresswoman Cathy McMorris Rodgers retiring, she’s led a package on this issue …
Rovner: She’s chairman of the House Energy and Commerce Committee, which obviously has the main jurisdiction over this in the House.
Cohrs Zhang: Right. So if we’re thinking about legacy, getting some of these things across the finish line, it does depend how dynamics change in the lame duck. But I think there is a very good chance that we’re going to see some sort of action here.
Rovner: Congressman Jamie Raskin, at that hearing, had maybe my favorite line ever about PBMs, which is, he said, “The more I hear about this, the less I understand it.” It’s like you could put that on a T-shirt.
Ollstein: That’s great. Yeah.
Cohrs Zhang: Yes.
Rovner: The PBM debate in one sentence. All right. Finally, this week we have some Medicaid news, a new report from the GAO [Government Accountability Office] finds pretty much what we already knew: that states have been wrongly kicking eligible people off of their Medicaid coverage as they were, quote, “unwinding from the public health emergency.” According to the report, more than 400,000 people lost coverage because the state looked at the household’s eligibility instead of individual eligibility. Even though Medicaid income thresholds are much higher for many people, like children and pregnant women. So if the household wasn’t eligible, possibly, even probably, the children still were. It’s a pretty scathing report. Is anybody going to do anything about it? I mean, the GAO’s recommendation was that the administration act a little more strongly and the administration says, “We already are.”
Cohrs Zhang: Yeah, I actually had the chance to talk with a White House official about this dynamic, and just, I think there’s only so far that they’re willing to go, and I think might talk about, in a while. I think there’s been clashes between the Biden administration and conservative states, especially on Medicaid programs, and there’s really only so much influence they can exert. And I think without provoking an all-out war, I’m personally expecting them to get much more aggressive in the last six months of their administration, if they weren’t going to do it before, when they really could have potentially made a difference and really made it a calling card in some of these states. So I’m not expecting much change from the White House on this issue.
Rovner: Yeah, I remember the administration was so sensitive about this that when we were first learning about how states were cutting people off who they shouldn’t have been, the administration said, “We’re working with the states.” And we all said, “Which states?” And they said, “We’re not going to tell you.” I mean, that’s literally how sensitive it was. They would not give us the list of the states who they said were incorrectly knocking people off the roll. So yeah, clearly this has been politically sensitive for the administration, but I’m …
Armour: And the Medicaid directors, too. They really pushed back, especially initially, about not wanting it to be too adversarial. I think the administration really took that to heart. Whether that was the right call or not remains to be seen, but there was a lot of tension around that from the get-go.
Rovner: Yeah. Well, also this week, The New York Times has a deep dive into the one remaining Medicaid work requirement in the country, Georgia’s Pathways to Coverage. In case you don’t remember, this was the program that Georgia said would enroll up to 100,000 people, except, so far it’s only managed to sign up about 4,500. It feels relevant again though, because the Heritage Foundation’s Project 2025, which is now all over the campaign trail, would go even further than previous Republican efforts to rein in Medicaid by possibly imposing lifetime caps on coverage. Cutting Medicaid didn’t go very well in 2017 when the Republicans tried to repeal and replace the Affordable Care Act. What makes them think an even bigger cutback would be more popular now?
Armour: Well, the study’s authors say to me that if they’re not cutting Medicaid, which goes back to the original debate back when they were talking about …
Rovner: The Project 2025 authors.
Armour: Yes, authors. Right. And that goes back to the original debate of how do you define it? A little bit of sleight of hand. And the other thing is that would definitely bring back the Medicaid work requirements and some premiums for some, which also turned out not to be super-popular as well. So it does dive right into an issue. But it’s also an issue that conservatives have been, boy, working on for years and years now to try and get this accomplished.
Rovner: Oh yeah, block-granting Medicaid goes back decades.
Armour: Exactly. Yeah.
Rovner: And there’ve been various ways to do it. And then work requirements, obviously Alice, you were the queen of our work requirement coverage in Arkansas because they put in a work requirement and it didn’t go well. Remind us.
Ollstein: Yeah. So this is what a lot of experts and advocates predicted, which is that we know from years of data that pretty much everybody on Medicaid who can work is already working and those who aren’t working are not working because they are a student or they have to care for a relative or they have a disability or there are all these reasons. And so when these work requirements actually went into effect, just a lot of people who should have been eligible fell through the cracks. It was hard to navigate the bureaucracy of it all. And so even people who were working struggled to prove it and to get their benefits. And so people really point to that as a cautionary tale for other states. But this is something conservatives really believe in ideologically, and so I don’t expect it to be going away anytime soon.
Rovner: To swing back to where we started. I imagine we will see more talk about health care on the presidential campaign trail as we go forward.
All right, well that’s as much news for this week as we can fit in. Now we will play my interview with Families USA’s Anthony Wright, and then we’ll come back and do our extra credits.
I am so pleased to welcome to the podcast Anthony Wright, the brand-new executive director of Families USA, one of the nation’s leading consumer health advocacy groups. And a big part of why we even have the ACA. Anthony is no stranger to health care battles. He spent more than 20 years heading up the group Health Access California, where he worked on a variety of health issues, large and small, and encountered someone who is suddenly very much in the news: Vice President Kamala Harris. Anthony Wright, welcome to “What the Health?”
Anthony Wright: Thank you so much for having me. I’m a longtime listener, but first-time caller.
Rovner: Awesome. So, for those who are not familiar with Families USA, tell us about the group and tell us what your immediate priorities are.
Wright: So, Families USA has been a longtime voice for health care consumers in Congress, at the administration, working nationally for the goal of quality, affordable, equitable health care for all Americans. I’m pleased to take on that legacy and to try to uplift those goals. I’m also particularly interested in continuing to uplift and amplify the voices of patients in the public in health policy debates. It’s opaque to try to figure out how normal people engage in the federal health policy discussions so that health reforms actually matter to them. I would like families to do more to provide pathways so that they have an effective voice in those policy discussion tables. There’s so many policy debates where it’s the fight between various parts of the industry, when, in fact, the point of the health care system is patients, is the public, and they should be at the center of these discussions.
Rovner: Yes, and I’m embarrassed to admit that we spend an enormous amount of time talking about the players in the health care debate that are not patients. They are basically the people who stand to make money from it. What’s your biggest priority for this year and next?
Wright: Yeah, I want to take some of the lessons that I’ve learned over the 22 years of working in California, where we had the biggest drop of the uninsured rate of all 50 states, mostly working to implement and improve the Affordable Care Act. And I recognize that some of those lessons will have to be adopted and changed for the different context of [Washington,] D.C., or the 49 other states. But there is work that we can do, and we should do, moving forward. There are things on the plate right now. For example, in the next year, the additional affordability assistance that people have in the exchanges is set to expire. And so we can either have a system where everybody has a guarantee that their premiums are capped at 8.5% of their income or less on a sliding scale, or we can let those enhanced tax credits expire and to have premiums go up by hundreds, or for many people, thousands of dollars literally in the next year or so.
So that’s a very important thing that will be on the ballot this fall, along with a number of other issues and we want to highlight that. But frankly, I’m also interested in the work around expanding coverage, including in those 10 states that haven’t expanded Medicaid yet. In California, we’ve done a lot of work on health equity dealing with racial and ethnic disparities and just meeting the specific needs of specific communities. That was an imperative in California with the diversity and the size and scale of that state. But there’s more we can do both in California, but nationally, with regard to that. And then I think there’s more to work on costs with regard to just how darn expensive health care is and how do we fix the market failures that lead to, not just high, but irrational and inflated health prices.
Rovner: So obviously a big part of what you will or won’t be able to do next year depends on who occupies the White House and who controls Congress. You’re from California and so is Vice President Harris. Tell us about her record on health care.
Wright: Yeah, she actually has a significant record, mostly from her time as attorney general of California. She didn’t have much of a portfolio as district attorney, but when she did become the attorney general — attorney generals have choices about where they focus their time and she made a point to focus more on health care and start an evolution of the attorney general being more involved in health care issues — on issues like reviewing mergers of hospitals and putting conditions to make sure that emergency rooms stayed open, that hospitals continued their commitments to charity care. She worked on broader issues of consolidation, for example, joining the [U.S.] Justice Department in opposing the merger of Anthem and Cigna.
And she took on, whether it’s the insurers or the drug companies or the hospital chains, on issues of pricing and anticompetitive practices, whether it was Bayer and Cipro and other drug companies with regard to pay-for-delay practices, basically schemes to keep the price of drugs inflated. Or on the issue of high hospital prices. She began the investigations that led to a landmark Sutter settlement where that hospital chain paid $575 million in fines, but also agreed to a series of conditions with regard to no longer engaging in anticompetitive contracting practices. And that kind of work is something that we worked on with her, and I think is really relevant to the moment we’re in now where we really do see that consolidation is one of the major drivers of why health care prices are so high. And that kind of experience that she could talk about as she talks about health care costs broadly, medical debt, and some of the issues that are on the campaign trail today.
Rovner: So, obviously, with the exception of reproductive health, health in general has not been a big part of the campaign this year. Do you think it’s going to get bigger now that Harris is at the head of the ticket?
Wright: One of the things that I’m happy with is that, after several weeks where the conversation has much been about the campaign processes, we can maybe focus back on policy and the very real issues that are at stake. Our health care is on the ballot, whether it is reproductive health and abortion care, but also there’s a very easy leap to also talk about the threats, not just to reproductive health, but also to the Affordable Care Act, to Medicaid, to Medicare. There’s very different visions and records of the last two administrations with regard to the Affordable Care Act, whether to repeal it or build upon it, on Medicaid and whether to bolster it or to block-grant it. And even on the question of something like prescription drug negotiation, whether we took some important steps under the Inflation Reduction Act. Do we now expand that authority to cover more drugs for more discounts for more people? Or do we give up that authority to negotiate for the best possible price?
Those are very key issues that are at stake in this election. We are a nonpartisan, non-endorsing organization, but we do want to make sure that health care issues are on people’s minds, and also, frankly, policymakers to make some commitments, including on something like what I was talking about earlier with those enhanced tax credits. Again, at a time when people are screaming about affordability, but we know that they’ve been actually screaming about health care affordability for not just years but decades. And that’s a very specific, concrete thing that literally means hundreds or thousands of dollars in people’s pockets.
Rovner: So then-presidential candidate Kamala Harris was a supporter of Medicare for All in 2020 when she ran. Do you expect that that may have changed, as she’s learned how hard it is even to make incremental change? I haven’t seen anybody ask her yet what her feeling is on systemic health reform.
Wright: I mean, she had a modified proposal that I think was trying to both take seriously the question of how do we get to universal coverage while also recognizing the politics and procedural barriers that exist. And so I think there’s a practical streak of how do we get the most help to the most people and help change, frankly, the financial incentives in our system, which are right now just to get bigger, not to get better. And so I think that there’s some very practical questions on the table right now, like these tax credits, this cap on how much a percentage of your income should go for premium. That’s something that’s front of mind because it literally expires next year. So it’s something that maybe gets dealt with in a lame duck, but hopefully early in the next year, since rates need to be decided early. And so those are the immediate things.
But I do think she’s also, in her record — I’m not going to talk about what may be — but in her record, she’s been supportive of the Affordable Care Act. I mean our biggest actual engagement with then-U.S. Sen. Harris was at a time when we all thought that the Affordable Care Act was a goner. It would be repealed and replaced. She was willing to be loud and proud at our rallies, in front of a thousand people, in front of a Los Angeles public hospital, talking about the need to defend the Affordable Care Act and protections for people with preexisting conditions. And she came again in July and just at a time where we needed that forceful defense of the Affordable Care Act. She was there and we very much appreciated that. I think she would continue to do that as well as want to work to build upon that financing and framework to make additional gains forward.
Rovner: This being Washington, everybody’s favorite parlor game this week is handicapping the vice presidential sweepstakes. And who about-to-be-candidate Harris is going to choose to be her running mate. Are any of the big names in contention more or less important in terms of their health care backgrounds?
Wright: I have my credentials to talk about the Californian on the ticket. I probably have less there. I do know that some of those governors and others have their own records of trying to take the framework of the ACA and adapt it to their state. And I think that would be a useful thing to continue to move forward on the trail. I’m not in a position, again, as a non-endorsing organization, we’re focused on the issues.
Rovner: You’re agnostic about the vice presidential candidate.
Wright: You’re right, I think the point is how can we make sure that people recognize what is at stake for the health care that they depend on and, frankly, the financial piece of it. Affordability has been something that has been talked about a lot and there is no greater source of economic anxiety and insecurity than the health care bill. A hospital bill is the biggest bill that anybody will get in their entire life. So how do you deal with it? And whether it’s a conversation about medical debt and how you deal with it, or what kind of tax credits we can provide to provide some security that you don’t pay more than the percentage of your income. Or how do you deal with the root causes of the market failures in our health care system, whether it’s consolidations and mergers or anticompetitive practices. Those are the things that I think we should have a bigger conversation in this campaign cycle about.
Rovner: Hopefully we’ll be able to do this again as it happens. Anthony Wright, thank you so much.
Wright: Thank you.
Rovner: OK, we are back. It’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Rachel, why don’t you go first this week?
Cohrs Zhang: Sure. There’s a lot of good health journalism out there, but I have to highlight a new project from my colleagues. Bob Herman, Tara Bannow, Casey Ross, and Lizzy Lawrence are looking into UnitedHealth’s business practices, and there’s been a lot of buzz about UnitedHealthcare on the Hill, and the first part of their investigation is headlined “How UnitedHealth Harnesses Its Physician Empire To Squeeze Profits out of Patients.” It focuses on the trend that UnitedHealth has been acquiring so many physician practices and looks at the incentives of what actually happens when an insurer owns a physician practice.
What pressures are they putting on? What’s the patient experience? What’s the physician experience? Their physicians on the record were telling them about their experiences: having to turn through patients; feeling pressure to make patients look sicker on paper so UnitedHealth could get more money from the federal government to pay for them. And just, I mean, the documentation here is just really superb reporting. It’s part one of a series. And I think reporting like this really helps inform Washington about how these things are actually playing out and what’s next in terms of whether action should be taken to rein these practices in.
Rovner: I feel like the behemoth that is UnitedHealthcare is going to keep a lot of health reporters busy for a very long time to come. Alice.
Ollstein: Yeah. So there’s been a lot of news on the PrEP front recently. That’s the drug that prevents transmission of HIV. And so basically two steps forward, one step back. I chose this piece from Stat News [“A Pricey Gilead HIV Drug Could Be Made for Dramatically Less Than the Company Charges”], about a new form of PrEP that is an injection that you get just twice a year that has proven wildly effective in clinical trials. And so folks are really excited about that, and I think it could really make a difference because, as with birth control and as with lots of other medication, the effectiveness rate is only if you use it perfectly, which, you know, we’re humans. And humans don’t always adhere perfectly. And so something like just a couple injections a year that you could get from your doctor would go a long way towards compliance and making sure people are safe with their medications.
But my colleague and I also scooped this week that HHS [the Department of Health and Human Services] is ending one of its big PrEP distribution programs [“Federal HIV Program Set To Wind Down”]. It’s called Ready, Set, PrEP. It debuted under the Trump administration in 2019. And the reason given by HHS for it ending — which, by the way, they were very quiet about and didn’t even tell a lot of providers that it was ending — they said it was because there are all these other ways people can get PrEP now, that didn’t exist back then, like generic versions. And while that’s true, we also heard from a lot of advocates who said the program was just really flawed from the start and didn’t reach even a fraction of the people it should have reached. And so we’ll continue to dig on that front.
Rovner: Good stories. Stephanie.
Armour: Yes. I picked the story by Dylan Scott on Vox about “Free Medical School Won’t Solve the Doctor Shortage.” And it looks at Michael Bloomberg, who is donating a billion dollars to Johns Hopkins to try to pay for medical school for students there. The idea being that, “Look, there’s this doctor shortage and what can we do to help?” And what’s really interesting about the story is it goes beyond just the donation to look at the fact that it’s not really that there’s a doctor shortage, it’s that we don’t have the right kind of doctors and it’s the distribution. Where you don’t have nearly what we need when it comes to psychiatrists, for example. And there’s a real dearth of physicians in areas that are rural or in the Midwest. So I think what it raises is what resources do we want to spend and where? What other steps can we do that would really help drive doctors to where they’re most needed? So it’s a good story. It’s worth a read.
Rovner: Yeah, it is a good story. It is a continuing problem that I continue to harp on. But we now have quote-unquote “free medical school,” mostly in really urban, really expensive places.
Armour: Yes.
Rovner: New York, Los Angeles, Baltimore. That’s nice for the doctors who will now graduate without $200,000 in medical debt. But yeah, as Dylan points out, it’s not exactly solving the problem that we have. Well, I went cute this week. My extra credit this week is from NPR. It’s called “A Study Finds That Dogs Can Smell Your Stress — And Make Decisions Accordingly,” by Rachel Treisman. Now, we’ve known for a fairly long time that dogs’ sensitive noses can detect physical changes in their humans. That’s how alert dogs for epilepsy and diabetes and other ailments actually work.
But what we didn’t know until now is that if a dog smells a person’s stress, it can change the dog’s emotional reaction. It was a complicated experiment that you can read about if you want, but as somebody who competes with my dogs, and who knows how differently they act when I am nervous, this study explains a lot.
All right, that is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us too. Special thanks, as always, to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, @jrovner. Alice, where are you?
Ollstein: @AliceOllstein on X.
Rovner: Rachel.
Cohrs Zhang: @rachelcohrs on X.
Rovner: Stephanie.
Armour: @StephArmour1.
Rovner: We will be back in your feed next week. Until then, be healthy.
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8 months 2 weeks ago
california, Elections, Health Care Costs, Medicaid, Medicare, Multimedia, Pharmaceuticals, States, Abortion, Biden Administration, Iowa, KFF Health News' 'What The Health?', Louisiana, Podcasts, reproductive health, texas, Women's Health
California Health Care Pioneer Goes National, Girds for Partisan Skirmishes
SACRAMENTO — When then-Gov. Arnold Schwarzenegger called for nearly all Californians to buy health insurance or face a penalty, Anthony Wright slammed the 2007 proposal as “unwarranted, unworkable, and unwise” — one that would punish those who could least afford coverage.
The head of Health Access California, one of the state’s most influential consumer groups, changed course only after he and his allies extracted a deal to increase subsidies for people in need.
The plan was ultimately blocked by Democrats who wanted the state to adopt a single-payer health care system instead. Yet the moment encapsulates classic Anthony Wright: independent-minded and willing to compromise if it could help Californians live healthier lives without going broke.
This summer, Wright will assume the helm of the health consumer group Families USA, taking his campaign for more affordable and accessible health care to the national level and a deeply divided Congress. In his 23 years in Sacramento, Wright has successfully lobbied to outlaw surprise medical billing, require companies to report drug price increases, and cap hospital bills for uninsured patients — policies that have spread nationwide.
“He pushed the envelope and gave people aspirational leadership,” said Jennifer Kent, who served as Schwarzenegger’s head of the Department of Health Care Services, which administers the state Medicaid program. The two were often on opposing sides on health policy issues. “There was always, like, one more thing, one more goal, one more thing to achieve.”
Recently, Wright co-led a coalition of labor and immigrant rights activists to provide comprehensive Medicaid benefits to all eligible California residents regardless of immigration status. The state funds this coverage because the federal government doesn’t allow it.
His wins have come mostly under Democratic governors and legislatures and when Republican support hasn’t been needed. That will not be the case in Washington, D.C., where Republicans currently control the House and the Senate Democratic Caucus has a razor-thin majority, which has made it extremely difficult to pass substantive legislation. November’s elections are not expected to ease the partisan impasse.
Though both Health Access and Families USA are technically nonpartisan, they tend to align with Democrats and lobby for Democratic policies, including abortion rights. But “Anthony doesn’t just talk to his own people,” said David Panush, a veteran Sacramento health policy consultant. “He has an ability to connect with people who don’t agree with you on everything.”
Wright, who interned for Vice President Al Gore and worked as a consumer advocate at the Federal Communications Commission in his 20s, acknowledges his job will be tougher in the nation’s capital, and said he is “wide-eyed about the dysfunction” there. He said he also plans to work directly with state lawmakers, including encouraging those in the 10, mostly Republican states that have not yet expanded Medicaid under the Affordable Care Act to do so.
In an interview with California Healthline senior correspondent Samantha Young, Wright, 53, discussed his accomplishments in Sacramento and the challenges he will face leading a national consumer advocacy group. His remarks have been edited for length and clarity.
Q: Is there something California has done that you’d like to see other states or the federal government adopt?
Just saying “We did this in California” is not going to get me very far in 49 other states. But stuff that has already gone national, like the additional assistance to buy health care coverage with state subsidies, that became something that was a model for what the federal government did in the American Rescue Plan [Act] and the Inflation Reduction Act. Those additional tax credits have had a huge impact. About 5 million Americans have coverage because of them. Yet, those additional tax credits expire in 2025. If those tax credits expire, the average premium will spike $400 a month.
Q: You said you will find yourself playing defense if former President Donald Trump is elected in November. What do you mean?
Our health is on the ballot. I worry about the Affordable Care Act and the protections for preexisting conditions, the help for people to afford coverage, and all the other consumer patient protections. I think reproductive health is obviously front and center, but that’s not the only thing that could be taken away. It could also be something like Medicare’s authority to negotiate prices on prescription drugs.
Q: But Trump has said he doesn’t want to repeal the ACA this time, rather “make it better.”
We just need to look at the record of what was proposed during his first term, which would have left millions more people uninsured, which would have spiked premiums, which would have gotten rid of key patient protections.
Q: What’s on your agenda if President Joe Biden wins reelection?
It partially depends on the makeup of Congress and other elected officials. Do you extend this guarantee that nobody has to spend more than 8.5% of their income on coverage? Are there benefits that we can actually improve in Medicare and Medicaid with regard to vision and dental? What are the cost drivers in our health system?
There is a lot we can do at both the state and the federal level to get people both access to health care and also financial security, so that their health emergency doesn’t become a financial emergency as well.
Q: Will it be harder to get things done in a polarized Washington?
The dysfunction of D.C. is a real thing. I don’t have delusions that I have any special powers, but we will try to do our best to make progress. There are still very stark differences, whether it’s about the Affordable Care Act or, more broadly, about the social safety net. But there’s always opportunities for advancing an agenda.
There could be a lot of common ground on areas like health care costs and having greater oversight and accountability for quality in cost and quality in value, for fixing market failures in our health system.
Q: What would happen in California if the ACA were repealed?
When there was the big threat to the ACA, a lot of people thought, “Can’t California just do its own thing?” Without the tens of billions of dollars that the Affordable Care Act provides, it would have been very hard to sustain. If you get rid of those subsidies, and 5 million Californians lose their coverage, it becomes a smaller and sicker risk pool. Then premiums spike up for everybody, and, basically, the market becomes a death spiral that will cover nobody, healthy or sick.
Q: California expanded Medicaid to qualified immigrants living in the state without authorization. Do you think that could happen at the federal level?
Not at the moment. I would probably be more focused on the states that are not providing Medicaid to American citizens [who] just happen to be low-income. They are turning away precious dollars that are available for them.
Q: What do you take away from your time at Health Access that will help you in Washington?
It’s very rare that anything of consequence is done in a year. In many cases, we’ve had to run a bill or pursue a policy for multiple years or sessions. So, the power of persistence is that if you never give up, you’re never defeated, only delayed. Prescription drug price transparency took three years, surprise medical bills took three years, the hospital fair-pricing act took five years.
Having a coalition of consumer voices is important. Patients and the public are not just another stakeholder. Patients and the public are the point of the health care system.
This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.
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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8 months 4 weeks ago
california, Health Care Costs, Health Industry, Insurance, Medicaid, Medicare, Spotlight, States, Obamacare Plans, U.S. Congress
KFF Health News' 'What the Health?': SCOTUS Ruling Strips Power From Federal Health Agencies
The Host
Julie Rovner
KFF Health News
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.
In what will certainly be remembered as a landmark decision, the Supreme Court’s conservative majority this week overruled a 40-year-old legal precedent that required judges in most cases to yield to the expertise of federal agencies. It is unclear how the elimination of what’s known as the “Chevron deference” will affect the day-to-day business of the federal government, but the decision is already sending shockwaves through the policymaking community. Administrative experts say it will dramatically change the way key health agencies, such as the FDA and the Centers for Medicare & Medicaid Services, do business.
The Supreme Court also this week decided not to decide a case out of Idaho that centered on whether a federal health law that requires hospitals to provide emergency care overrides the state’s near-total ban on abortion.
This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of the Johns Hopkins schools of public health and nursing and Politico Magazine, Victoria Knight of Axios, and Alice Miranda Ollstein of Politico.
Panelists
Joanne Kenen
Johns Hopkins University and Politico
Victoria Knight
Axios
Alice Miranda Ollstein
Politico
Among the takeaways from this week’s episode:
- In 1984, the Supreme Court ruled broadly that courts should defer to the decision-making of federal agencies when an ambiguous law is challenged. On Friday, the Supreme Court ruled that the courts, not federal agencies, should have the final say. The ruling will make it more difficult to implement federal laws — and draws attention to the fact that Congress, frequently and pointedly, leaves federal agencies much of the job of turning written laws into reality.
- That was hardly the only Supreme Court decision with major health implications this week: On Thursday, the court temporarily restored access to emergency abortions in Idaho. But as with its abortion-pill decision, it ruled on a technicality, with other, similar cases in the wings — like one challenging Texas’ abortion ban.
- In separate rulings, the court struck down a major opioid settlement agreement, and it effectively allowed the federal government to petition social media companies to remove falsehoods. Plus, the court agreed to hear a case next term on transgender health care for minors.
- The first general-election debate of the 2024 presidential cycle left abortion activists frustrated with their standard-bearers — on both sides of the aisle. Opponents didn’t like that former President Donald Trump doubled down on his stance that abortion should be left to the states. And abortion rights supporters felt President Joe Biden failed to forcefully rebut Trump’s outlandish falsehoods about abortion — and also failed to take a strong enough position on abortion rights himself.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: The Washington Post’s “Masks Are Going From Mandated to Criminalized in Some States,” by Fenit Nirappil.
Victoria Knight: The New York Times’ “The Opaque Industry Secretly Inflating Prices for Prescription Drugs,” by Rebecca Robbins and Reed Abelson.
Joanne Kenen: The Washington Post’s “Social Security To Drop Obsolete Jobs Used To Deny Disability Benefits,” by Lisa Rein.
Alice Miranda Ollstein: Politico’s “Opioid Deaths Rose 50 Percent During the Pandemic. in These Places, They Fell,” by Ruth Reader.
Also mentioned in this week’s podcast:
- Politico’s “Inside the $100 Million Plan To Restore Abortion Rights in America,” by Alice Miranda Ollstein.
- JAMA Network Open’s “Use of Oral and Emergency Contraceptives After the US Supreme Court’s Dobbs Decision,” by Dima M. Qato, Rebecca Myerson, Andrew Shooshtari, et al.
- JAMA Health Forum’s “Changes in Permanent Contraception Procedures Among Young Adults Following the Dobbs Decision,” by Jacqueline E. Ellison, Brittany L. Brown-Podgorski, and Jake R. Morgan.
- JAMA Pediatrics’ “Infant Deaths After Texas’ 2021 Ban on Abortion in Early Pregnancy,” by Alison Gemmill, Claire E. Margerison, Elizabeth A. Stuart, et al.
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SCOTUS Ruling Strips Power From Federal Health Agencies
KFF Health News’ ‘What the Health?’Episode Title: ‘SCOTUS Ruling Strips Power From Federal Health Agencies’Episode Number: 353Published: June 28, 2024
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Mila Atmos: The future of America is in your hands. This is not a movie trailer, and it’s not a political ad, but it is a call to action. I’m Mila Atmos and I’m passionate about unlocking the power of everyday citizens. On our podcast, “Future Hindsight,” we take big ideas about civic life and democracy and turn them into action items for you and me. Every Thursday, we talk to bold activists and civic innovators to help you understand your power and your power to change the status quo. Find us at futurehindsight.com or wherever you listen to podcasts.
Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Friday, June 28, at 10:30 a.m. As always, news happens fast and things might’ve changed by the time you hear this, so here we go.
We are joined today via video conference by Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Hello.
Rovner: Victoria Knight of Axios News.
Victoria Knight: Hello, everyone.
Rovner: And Joanne Kenen of the Johns Hopkins Schools of Nursing and Public Health and Politico Magazine.
Joanne Kenen: Hi, everybody.
Rovner: I hope you enjoyed last week’s episode from Aspen Ideas: Health. This week we’re back in Washington with tons of breaking news, so let’s get right to it. We’re going to start at the Supreme Court, which is nearing, but not actually at, the end of its term, which we now know will stretch into next week. We have breaking news, literally breaking as in just the last few minutes: The court has indeed overruled the Chevron Doctrine. That’s a 1984 ruling that basically allowed experts at federal agencies to, you know, expert. Now it says that the court will get to decide what Congress meant when it wrote a law. We’re obviously going to hear a lot more about this ruling in the hours and days to come, but does somebody have a really quick impression of what this could mean?
Ollstein: So this could prevent or make it harder for health agencies, and all the federal agencies that touch on health care, to both create new policies based on laws that Congress pass and update old ones. Things need to be updated; new drugs are invented. There’s been all these updates to what Obamacare does and doesn’t have to cover. That could be a lot harder going forward based on this decision. It really takes away a lot of the leeway federal agencies had to interpret the laws that Congress passed and implement them.
I think kicking things back to courts and Congress could really slow things down a lot, and a lot of conservatives see that as a good thing. They think that federal agencies have been too untouchable and not have the same accountability mechanisms because they’re career civil servants who are not elected. But this has health policy experts … Honestly, we interviewed members of previous Republican administrations and Democratic administrations and they’re both worried about this.
Rovner: Yeah, going forward, if Donald Trump gets back into the presidency, this could also hinder the ability of his Department of Health and Human Services to make changes administratively.
Knight: These agencies are stacked with experts. This is what they work on. This is what they really are primed to do. And Congress does not have that same type of staffing. Congress is very different. It’s very young. There’s a lot of turnover. There are experienced staffers, but usually when they’re writing these laws, they leave so much up to interpretation of the agency because they are experts.
So I think pushing things back on Congress would really have to change how Congress works right now. When I talked to experts, we would need staffers who are way more experienced. We would need them to write laws that are way more specific. And Congress is already so slow doing anything. This would slow things down even more. So that’s a really important congressional aspect I think to note.
Rovner: I think when we look back at this term, this is probably going to be the biggest decision. Joanne, you want to add something before we move on?
Kenen: We’re recording. We don’t know if immunity just dropped, which is all still going to be, not a health care decision but an important decision of the country. I’ve got SCOTUSblog on my other screen. Here’s a quote from [Justice Elena] Kagan’s dissent. She says, because it’s very unfocused for what we do on this podcast, “Chevron has become part of the warp and woof of modern government, supporting regulatory efforts of all kinds, to name a few, keeping air and water clean, food and drugs safe and financial markets honest.” So two of the three of us. Financial markets affect the health industry as well.
Rovner: Oh, yeah.
Kenen: But I think that what the public doesn’t always understand is how much regulatory stuff there is in Washington. Congress can write a 1,000-page law like the ACA [Affordable Care Act]. I’ve never counted how many pages of regulation because I don’t think I can count that high. It’s probably tens of thousands.
Rovner: At least hundreds of thousands.
Kenen: Right. And that every one of those, there’s a lobbying fight and often a legal fight. It’s like the coloring book when we were kids. Congress drew the outline and then we all tried to scribble within the lines. And when you go out of the lines, you have a legal case. So the amount of stuff, regulatory activity is something that the public doesn’t really see. None of us have read every reg pertaining to health care. You can’t possibly do it in a lifetime. Methuselah couldn’t have done it. And Congress cannot hire all the expert staff and all the federal agencies and put them in; they won’t fit in the Capitol. That’s not going to happen. So how do they come to grips with how specific are they going to have to be? What kind of legal language can they delegate some of this to agency experts. We’re in really uncharted territory.
Rovner: I think you can tell from the tones of all of our voices that this is a very big deal, with a whole lot of blanks to be filled in. But for the moment …
Kenen: Maybe they’ll just let AI do it.
Rovner: Yeah, for the moment, let’s move on because, until just now, the biggest story of the week for us was on Thursday. We finally got a decision in that case about whether Idaho’s near-total ban on abortion can override a federal law called EMTALA, the Emergency Medical Treatment and Active Labor Act, which requires doctors in emergency rooms to protect a pregnant woman’s health, not just her life. And much like the decision earlier this month to send the abortion pill case back to the lower courts because the plaintiffs lacked legal standing, the court once again didn’t reach the merits here. So Alice, what did they do?
Ollstein: So like you said, both on abortion pills and on EMTALA, the court punted on procedural issues. So it was standing on the one and it was ripeness on the other one. This one was a lot more surprising. I think based on the oral arguments in the mifepristone case, we could see the standing-based decision coming. That was a big focus of the arguments. This was more of a surprise. This was a majority of justices saying, “Whoops, we shouldn’t have taken this case in the first place. We shouldn’t have swooped in before the 9th Circuit even had a chance to hear it. And not only take the case, but allow Idaho to fully enforce its law even in ways that people feel violate EMTALA in the meantime.” And so what this does temporarily is restore emergency abortion access in Idaho. It restores a lower-court order that made that the case, but it’s not over.
Rovner: Right. It had stayed Idaho’s ban to the extent that it conflicted with EMTALA.
Ollstein: So this goes back to lower courts and it’s almost certain to come back to the Supreme Court as early as next year, if not at another time. Because this isn’t even the only major federal EMTALA case that’s in the works right now. There’s also a case on Texas’ abortion ban and its enforcement in emergency situations like this. And so I think the main reaction from the abortion rights movement was temporary relief, but a lot of fear for the future.
Rovner: And I saw a lot of people reminding everybody that this Texas ruling in Idaho, now the federal law is taking precedence, but there’s a stay of the federal law in the 5th Circuit. So in Texas, the Texas ban does overrule the federal law that requires abortions in emergency circumstances to protect a woman’s health. That’s what the dispute is basically about. And of course, you see a lot of legal experts saying, “This is a constitutional law 101 case that federal law overrides state law,” and yet we could tell by some of the add-on discussion in this case, as they’re sending it back to the lower court, that some of the conservatives are ready to say, “We don’t think so. Maybe the federal law will have to yield to some of these state bans.” So you can kind of see the writing on the wall here?
Ollstein: It’s really hard to say. I think that you have some justices who are clearly ready to say that states can fully enforce their abortion bans regardless of what the federal government’s federal protections are for patients. I think they put that out there. I think the case is almost certain to come back to them, and there was clearly not a majority ready to fully side with the Biden administration on this one.
Rovner: And clearly not a majority ready to fully side with Idaho on this one. I think everything that I saw suggested that they were split 3-3-3. And with no majority, the path of least resistance was to say, “Our bad. You take this back lower court. We’ll see when it comes back.”
Ollstein: It was a very unusual move, but some of the justification made sense to me in that they cited that Idaho state officials’ position on what their abortion ban did and didn’t do has wavered over time and changed. And what they initially said when they petitioned to the court is not necessarily exactly what they said in oral arguments, and it’s not exactly what they have said since. And so at the heart here is you have some people saying there’s a clear conflict between the patient protections under EMTALA — which says you have to stabilize anyone that comes to you at a hospital that takes Medicare — and these abortion bans, which only allow an abortion when there’s imminent life-threatening situation. And so you have people, including the attorney general of Idaho, saying, “There is no conflict. Our law does allow these emergency abortions and the doctors are just wrong and it’s just propaganda trying to smear us. And they just want to turn hospitals into free-for-all abortion facilities.” This is what they’re arguing. And then you have people say …
Rovner: [inaudible 00:11:12] … in the meanwhile, we know that women are being airlifted out of Idaho when they need emergency abortions because doctors are worried about actually performing abortions …
Ollstein: Correct.
Rovner: And possibly being charged with criminal charges for violating Idaho’s abortion ban.
Ollstein: Sure, but I’m saying even amongst conservatives, there are those who are saying, “There’s no conflict between these two policies. The doctors are just wrong either intentionally or unintentionally.” And then there’s those who say there is a conflict between EMTALA and state bans, and it should be fine for the state to violate EMTALA.
Rovner: No. Obviously this one will continue as the abortion pill case is likely to continue. Well, also in this end-of-term Supreme Court decision dump, an oddly split court with liberals and conservatives on both sides, struck down the bankruptcy deal reached with Purdue Pharma that would’ve paid states and families of opioid overdose victims around $6 billion, but would also have shielded the company’s owners, the Sackler family, from further legal liability. What are we to make of this? This was clearly a difficult issue. There were a lot of people even who were involved in this settlement who said the idea of letting the Sackler family, which has hidden billions of dollars from the bankruptcy settlement anyway, and clearly acted very badly, basically giving them immunity in exchange for actually getting money. This could not have been an easy… obviously was not an easy decision even for the Supreme Court.
Kenen: No, it wasn’t theoretical. The ones who opposed blowing up the agreement were very much, “This is going to add delay any kind of justice for the families and the plaintiffs.” It was not at all abstract. It was like there are a lot of people who aren’t going to get help. At least the help will be delayed if this money doesn’t start flowing. So I was struck by how practical, relating to the families who have lost people because of the actions of Purdue. But the other side was, also that was much more a clear-cut legal issue, that people didn’t give up their right to sue. It was cutting off the right to sue was imposed on potential plaintiffs by the settlement. So that was a much more legalistic argument versus, it was a little bit more real world, but they need the help now. And including some of the conservatives. This is an interesting thing to read. This was painstaking. This is a huge settlement. It took so long. It had many, many moving parts. And I don’t know how you go back and put it together again.
Rovner: But that’s where we are.
Kenen: Yes.
Rovner: They have to basically start from scratch?
Kenen: I don’t know if they have to start entirely from scratch. You’d have to be nuts to get the Sacklers to say, “OK, we’ll be sued,” which they’re obviously you’re not going to. Is somebody going to come up with a “Split the difference, let’s get this moving and we won’t sue anymore?” I don’t know. But I don’t know that you have to start 100% from scratch, but you’re surely not anywhere near a finish line anymore.
Rovner: That’s big Supreme Court case No. 3 for this week. Now let’s get to big Supreme Court case No. 4. Earlier this week, the court turned back a challenge that the government had wrongly interfered with free speech by urging social media organizations to take down covid misinformation. But again, as with the abortion pill case, the court did not get to the merits. But instead, they ruled that the states and individuals who sued did not have standing. So we still don’t know what the court thinks of the role of government in trying to ensure that health information is correct. Right?
Knight: Right. And I thought it was interesting. Basically the White House was like, “Well, we talked to the tech companies, but it was their decision to do this. So we weren’t really mandating them do this.” I think they’re just being like, “OK, we’ve left it up to the tech companies. We haven’t really interfered. We’re just trying to say these things are harmful.” So I guess we’ll have to see. Like you said, they didn’t take it up on standing, but overall, conservatives that were saying, “This was infringing on free speech.” It was particularly some scientists, I think, that promoted the herd immunity theory, things like that.
So I think they’re obviously going to be upset in some way because their posts were depromoted on social media. But I think it just leaves things the way they are, the same way. But it would be interesting, I guess, if Trump does go to the White House, how that might play out differently?
Rovner: This court has been a lot of the court deciding not to decide cases, or not to decide issues. Sorry, Alice, go ahead.
Ollstein: Yeah, so I think it is pretty similar to the abortion pill case in one key way, which is that it’s the court saying, “Look, the connection between the harm you think you suffered and the entity you are accusing of causing that suffering, that connection is way too tenuous. You can’t prove that the Biden administration voicing concerns to these social media companies directly led to you getting shadow-banned or actual banned,” or whatever it is. And the same in the abortion pill case, the connection between the FDA [Food and Drug Administration] approving the drug and regulating the drug and these individual doctors’ experiences is way too tenuous. And so that’s something to keep in mind for future cases that, we’re seeing a pattern here.
Rovner: Yes, and I’m not suggesting that the court is directly trying to duck these issues. These are legitimate standing cases and important legal precedents for who can sue in what circumstance. That is the requirement of constitutional review that first you have to make sure that there’s both standing in a live controversy and there’s all kinds of things that the court has to go through before they get to the merits. So more often than not, they don’t get there.
Well, meanwhile, we have our first hot-button, Supreme Court case slotted in for next term. On Monday, the court granted “certiorari” [writ by which a higher court reviews a decision of a lower court] to a case out of Tennessee where the Biden administration is challenging the state’s ban on transgender care for minors. It was inevitable that one of these cases was going to get to the high court sooner or later, right?
Kenen: Yeah, I think it’s not a surprise, the politics of it and the techniques or tools used by the forces that are against the treatment for minors. It’s very similar to the politics and patterns of the abortion case, of turning something into an argument that it’s to protect somebody. A lot of the abortion requirements and fights were about to protect the woman. Ostensibly, that was the political argument. And now we’re seeing we have to protect the children so that it’s the courts, as opposed to families and doctors, who are, “protecting the children.”
There’s a lot of misunderstanding about what these treatments do and who gets them and at what age; that they’re often described as mutilation and irreversible. For the younger kids, for preteen, middle school age-ish, early teens, nothing is irreversible. It’s drugs that if you stop them, the impact goes away. But it has become this enormous lightning rod for the intersection of health and politics. And I think we all have a pretty good guess as to where the Supreme Court’s going to end up on this. But you’re sometimes surprised. And also, there could be some …
Rovner: Maybe they don’t have standing.
Kenen: There could be some kind of moderation, too. It could be a certain … they don’t have to say all … it depends on how clinical they want to get. Maybe they’ll rule on certain treatments that are more less-reversible than a puberty blocker, which is very reversible, and some kind of safeguards. We don’t know the details. We’re not surprised that it ended up … and we know going in, you could have a gut feeling of where it’s likely to turn out without knowing the full parameters and caveats and details. They haven’t even argued it yet.
Rovner: This is a decision that we’ll be waiting for next June.
Kenen: Right. Well, could not. Maybe it’s so clear-cut, it’ll be May. Who knows, right?
Rovner: Yeah, exactly. All right, well, moving on. There was a presidential debate last night. I think it was fair to say that it didn’t go very well for either candidate, nor for anybody interested in what President Biden or former President Trump thinks about health issues. What did we learn, if anything?
Ollstein: Well, I was mainly listening for a discussion of abortion and, boy was it all over the place. What I thought was interesting was that both candidates pissed off their activist supporters with what they said. I was texting with a lot of folks on both sides and conservatives were upset that Trump doubled down on his position that this should be entirely left to states, and they disagree. They want him to push for federal restrictions if elected.
And on the left, there was a lot of consternation about Biden’s weird, meandering answer about Roe v. Wade. He was asked about abortions later in pregnancy. One, neither he nor the moderators pushed back on what Trump’s very inflammatory claims about babies being murdered and stuff. There was no fact-checking of that whatsoever. But then Biden gave a confusing answer, basically saying he supports going to the Roe standard but not further, which is what I took out of it. And that upset a lot of progressives who say Roe was never good enough. For a lot of people, when Roe v. Wade was still in place, abortion was a right in name only. It was not actually accessible. States could impose lots of restrictions that kept it out of reach for a lot of people. And in this moment, why should we go back to a standard that was never good enough? We should go further. So just a lot of anxiety on both sides of this.
Rovner: Yeah. Meanwhile, Trump seemed to say that he would leave the abortion pill alone, which jumped out at me.
Kenen: But that was a completely … CNN made a decision not to push back. They were going to have online fact-checking. Everybody else had online fact. … And they didn’t challenge. And I guess they assumed that the candidates would challenge each other, and Biden had a different kind of challenging night. Trump actually said that the previous Supreme Court had upheld the use of the abortion drug and that it’s over, it’s done. That was not a true statement. The Supreme Court rejected that case, as Alice just explained, on standing. It’s going to be back. It may be back in multiple forms, multiple times. It is not decided. It is not over, which is what Trump said, “Oh, don’t worry about the abortion drug. The Supreme Court OK’d it.” That’s not what the Supreme Court did, and Biden didn’t counter that in any way.
And then Biden, in addition to the political aspect that Alice just talked about, he also didn’t describe Roe, the framework of Roe, particularly accurately. And, as Alice just pointed out, the things that Trump said were over-the-top even for Trump, and that they went unchallenged by either the moderators or President Biden.
Rovner: I was a little bit surprised that there wasn’t anything else on health care or there wasn’t much else.
Knight: Biden tried to hit his health care talking points and did a very terrible job. Alice had a really good tweet getting the right. … He initially said wrong numbers for the insulin cap, for the cap on out-of-pocket for Medicare beneficiaries, how much they can spend on prescription drugs. He got both of those wrong. I think he got insulin right later in the night. And then the very notably, “We will beat Medicare.” That was just unclear what he even meant by that. Maybe it was about drug price negotiations, I’m sure. So he was trying, but just could not get the facts right and I don’t think it came across effective in any way. And health care does do really well for Democrats. Abortion does really well for Democrats. So he was not effective in putting those messages.
I also noticed the moderators asked a question about opioids, addressing the opioid epidemic. Trump did not answer at all, pivoted to I think border or something like that. I don’t think Biden really answered either, honestly. So that was an opportunity for them to also talk about addressing that, which I think is something they could both probably talk about in a winning way for both. But I thought it was mentioned more than I expected a little bit. I thought they may want to talk about it at all. So it was still not much substantive policy discussion on health care.
Kenen: Biden tried to get across some of the Democratic policies on drug prices and polls have shown that the public doesn’t really understand that is actually the law in going forward. So if any attempt to message that in front of a very large audience was completely muddled. Nobody listening to that debate would’ve come out — unless they knew going in — they would’ve not have come out knowing what was in the law about Medicare price negotiations. They would’ve gotten four different answers of what happened with insulin, although they probably figured something good, helpful happened. And a big opportunity to push a Democratic achievement that has some bipartisan popularity was completely evaporated.
Rovner: I think Biden did the classic over-prepare and stuff too many talking points into his head and then couldn’t sort them all out in the moment. That seemed pretty clear. He was trying to retrieve the talking point and they got a little bit jumbled in his attempt to bring them out. Well, back to abortion: Alice, you got a cool scoop this week about abortion rights groups banding together with a $100 million campaign to overturn the overturn of Roe. Tell us about that?
Ollstein: Yeah, so it’s notable because there’s been so much focus on the state level battles and fighting this out state by state, and the ballot initiatives that have passed at the state level and restored or protected access have been this glimmer of hope for the abortion rights movement. But I think there was a real crystallization of the understanding that that strategy alone would leave tens of millions of people out in the cold because a lot of states don’t have the ability to do a ballot initiative. And also, if there were to be some sort of federal restrictions imposed under a Trump presidency or whatever, those state level protections wouldn’t necessarily hold. So I think this effort of groups coming together to really spend big and say that they want to restore federal protections is really notable.
I also think it’s notable that they are not committing to a specific bill or plan or law they want to see. They are keeping on the, “This is our vision, this is our broad goal.” But they’re not saying, “We want to restore Roe specifically, we want to go further,” et cetera. And that’s creating some consternation within the movement. I’ve also, since publishing the story, heard a lot of anxiety about the level of spending going to this when people feel that that should be going to direct support for people who are suffering on the ground and struggling to access abortion. Right now you have abortion funds screaming that they’re being stretched to the breaking point and cannot help everyone who needs to travel out of state right now. So, of course, infighting on the left is a perennial, but I think it’s particularly interesting in this case.
Rovner: Well, meanwhile, we have a trio this week of examples of what I think it’s safe to call unintended consequences of the Supreme Court’s overturn of Roe. First, a study in the medical journal JAMA Pediatrics this week, found that in the first year abortion was dramatically restricted in Texas — remember, that was before the overturn of Roe — infant deaths rose fairly dramatically. In particular, deaths from congenital problems rose, suggesting that women carrying doomed fetuses gave birth instead of having abortions. What’s the takeaway from seeing this big spike in infant mortality?
Ollstein: So I’ve seen a lot of anti-abortion groups trying to spin this and push back really hard on it. Specifically picking up on what you just said, which is that a lot of these are fatal fetal anomalies. And so they were saying, “Were abortion still legal, those pregnancies could have been terminated before birth.” And so they’re saying, “There’s no difference really, because we consider that an infant death already. So now it’s an infant death after birth. Nothing to see here.”
Rovner: When everybody has suffered more, basically.
Ollstein: Yeah, that is the response I’m seeing on the right. On the left, I am seeing arguments that anyone who labels themselves pro-life should think twice about the impact of these policies that are playing out. And like you said, we’re only just beginning to get glimmers of this data. In part because Texas was out in front of everybody else, and so I think there’s a lot more to come.
The other pushback I’ve seen from anti-abortion groups is that infant mortality also rose in states where abortion remains legal. So I think that’s worth exploring, too. Obviously, correlation is not always causation, but I think it’s hard when you’re getting the data in little dribs and drabs instead of a full complete picture that we can really analyze.
Rovner: Well, in another JAMA study, this one in JAMA Network Open, they found that the use of Plan B, the morning-after birth control pill, fell by 60% in states that implemented abortion bans after the Dobbs [v. Jackson Women’s Health Organization] decision. Now, for the millionth time, Plan B is not the same as the abortion pill. It’s a high-dose contraceptive. But apparently, a combination of the closure of family planning clinics in states that impose bans, which are an important source of pills for people with low incomes who can’t afford over-the-counter versions, and misinformation about the continuing legality of the morning-after pill, which continues to be legal, contributed to the decline. At least that’s what the authors theorize. This is one of many ironies in the wake of Dobbs; that states with abortion bans may well be ending up with more unintended pregnancies rather than fewer.
Ollstein: Well, one trends that could be feeding this is that some of the clinics where people used to go to to access contraception, also provided abortion and have not been able to keep their doors open in a post-Roe environment. We’ve seen clinics shutting down across the South. I went to Alabama last year to cover this, and there are clinics there that used to get most of their revenue from abortion, and they’re trying to hang on and provide nonabortion gynecological services, including contraception, and the math just ain’t mathing, and they’re really struggling to survive.
And so this goes back to the finger-pointing within the movement about where money should be going right now. And I know that red state clinics that are trying to survive feel very left behind and feel that this erosion of access is a result of that.
Kenen: Julie, and also to put in, even before Dobbs, it was not easy in many parts of the country for low-income women to get free contraception. There are states in which clinics were few and far between. Federal spending on Title X has not risen in many years.
Rovner: Title X is a federal [indecipherable].
Kenen: Right. Alice knows this, and maybe I’ve said on the podcast, I once just pretty randomly with me and my cursor plunked my cursor down on a map of Texas and said, “OK, if I live here, how far is the nearest clinic?” And I looked at the map of the clinics and it was far, it was something like 95 miles, the nearest one. So we had abortion deserts. We’ve also had family planning deserts, and that has only gotten worse, but it wasn’t good in the first place.
Rovner: Well, finally, and for those who really want to make sure they don’t have unintended pregnancies, according to a study in a third AMA journal, JAMA Health Forum, the number of young women aged 18 to 30 who were getting sterilized doubled in the 15 months after Roe was overturned. Men are part of this trend, too. Vasectomies tripled over that same period. Are we looking at a generation that’s so scared, they’re going to end up just not having kids at all?
Kenen: Well, there are a lot of kids in this generation who are saying they don’t want to have kids for a variety of reasons: economic, climate, all sorts of things. I think that I was a little surprised to see that study because there are safe long-acting contraceptives. You can get an IUD that lasts seven to nine years, I think it is. I was a little surprised that people were choosing something irreversible because.. I do know young people who… You’re young, you go through lots of changes in life, and there is an alternative that’s multiyear. So I was a little surprised by that. But that’s apparently what’s happening. And it’s for… This generation is not as… What are they, Gen[eration] Z? They’re not as baby-oriented as their older brothers and sisters even.
Knight: Well, that age range is millennial and Gen Z. But I don’t know. I’m a millennial. I think a lot of my friends were not baby-oriented. So I think that’s probably a fair statement to say. But it is interesting that they wouldn’t choose an IUD or something like that instead. But I do think people are scared. We’ve seen the stories of people moving out of states that have really strict abortion bans because they are so concerned on what kind of medical care they could have, even if they think they want to get pregnant. And sometimes you don’t have a healthy pregnancy and then need to get an abortion. So I’m sure it has something to do with that but…
Rovner: Yeah, it’s one of those trends to keep an eye out for. Well, moving on, U.S. Surgeon General Vivek Murthy has been busy these past couple of weeks. First, he published an op-ed in The New York Times calling for a warning label for social media that’s similar to the one that’s already on tobacco products, warning that social media has not been proven safe for children and teenagers. Of course, he doesn’t have his own authority to do that. Congress would have to pass a law. Any chance of that? I know Congress is definitely into the “What are we going to do about social media” realm.
Kenen: But talking about it and doing something or thinking, it’s a long way. Is this as, compared to his other topic of the week, which was gun safety? He’s got a lot more bipartisan …
Rovner: We’re getting to that.
Kenen: … He’s got a lot more bipartisan support for the concern about health of young people and what social media is. What is social media? Social media is mixed. There are good things and bad things, and what is that balance? There is a bipartisan concern. I don’t know that that means you get to the labeling point. But the labeling point is one thing. That the larger concept of concern about it, and recognition about it, and what do we do about it, is bipartisan up to a point. How do you even label? What do you label? Your phone? Your computer? I’m not sure where the label goes. Your eyelids? [inaudible 00:33:07]
Knight: Right. Well, tech bills in Congress in general are like… Even though TikTok was surprisingly able to get done in the House. But TikTok lobby was big. But there would be a big social media lobby, I’m sure, against that. I guess there is bipartisan support. I don’t know. It’s not something I’ve asked members about, but I think that would be pretty far off from a reality actually happening.
Rovner: Well, also this week, as Joanne mentioned, the surgeon general issued a Surgeon General’s Advisory, declaring gun violence a public health crisis, calling for more research funding on gun injuries and deaths, universal background checks for gun buyers, and bans on assault weapons and high-capacity ammunition magazines. I feel like the NRA [National Rifle Association] has lost some of its legendary clout on Capitol Hill over the past few years, thanks to a series of scandals, but maybe not enough for some of these things. I feel like I’ve heard these suggestions before, like over the last 25 or 30 years.
Kenen: I think one of the interesting things about Vivek Murthy is he came to public prominence on gun safety and guns in public health before people were really talking about guns in public health. I forgot what year it was — 2016, 2017, whenever Obama first nominated him. Because remember, this is his second run as surgeon general. It was an issue that he had spoken about and had made a signature issue, and as he became a more public figure before the nomination. And then he went silent on it. He had trouble getting confirmed. He didn’t do anything about it. We never really heard … as far as I can recollect, we never even heard him talk about it once. Maybe there was a phrase or two here or there. He certainly didn’t push it or make it a signature issue.
Right now, he’s at the end of the last year with the Biden administration. Some kind of arc is being completed. He’s a young man, there’ll be other arcs. But this arc is winding down and the president cares about gun violence. Congress actually did, not the full agenda, but they did something on it, which was unusual. And I think that this is his chance to use his bully pulpit while he still has it in this particular perch to remind people that we do have tools. We don’t have all the solutions to gun violence. We do not understand everything about it. We do not understand why some people go and shoot a movie theater or a school or a supermarket or whatever, and there are multiple reasons. There are different kinds of mass killers. But we do know that there are some public health tools that do work. That red flag laws do seem to help. That safe gun storage … There are things that are less controversial than a spectrum of things one can do.
Some of them have broader support, and I think he is using this time — not that he expects any of these things to become law in the final year of the Biden administration — but I think he’s using it. This is bully pulpit. This is saying, “Moving forward, let’s think about what we can come to agreement on and do what we can on certain evidence-based things.” Because there’s been a lot of work in the last decade or so on the public health, not just the criminal… Obviously, it’s a legal and criminal justice issue. It’s also a public health issue, and what are the public health tools? What can we do? How do we treat this as basically an epidemic? And how can we stop it?
Rovner: Finally this week, since we didn’t really do news last week, there have been a couple of notable stories we really ought to mention. One is a court case, Braidwood v. Becerra. This is the case where a group of Christian businesses are claiming that the Affordable Care Act’s preventive services provisions that require them to provide no cost-sharing access to products, including HIV preventive medication, violates their freedom of religion because it makes them complicit in homosexual behavior. Judge Reed O’Connor, district court judge — if that name is familiar, it’s because he’s the Texas judge who tried to strike down the entire ACA back in 2018. Judge O’Connor not only found for the plaintiffs, he tried to slap a nationwide injunction on all of the ACA’s preventive services, which even the very conservative 5th Circuit appeals court struck down. But meanwhile, the appeals court has come up with its ruling. Where does that leave us on the ACA preventive services?
Ollstein: It leaves us right where we were when the 5th Circuit took the case because they said that, “We’re going to allow the lower court ruling to be enforced just for the plaintiffs in the meantime, but we’re not going to allow the entire country’s preventive care coverage to be disrupted while this case moves forward.” And so that basically continues to be the case. Some of the arguments are getting sent back down to the lower court for further consideration. And we still don’t know whether either side will appeal the 5th Circuit’s ruling to the Supreme Court.
Rovner: But notably, the appeals court said that U.S. Preventive Services Task Force, which is appointed by the Department of Health and Human Services, is basically illegally constituted because it should be nominated by the president, approved by the Senate, which it is not. That could in the long run be kind of a big deal. This is a group of experts that supposedly shielded from politics.
Kenen: Yeah, I don’t think this story is over either. It is for now. Right now we’re at the status quo, except for this handful of people who brought recommendations on all sorts of health measures, including vaccination and cancer screenings and everything else. They stand. They’re not being contested at this moment. How that will evolve under the next administration and this court remains to be seen.
Rovner: Finally, finally, finally, to end on a bit of a frustrating note, the National Academies of Sciences, Engineering, and Medicine, has found that two decades after it first called out some of the most egregious inequities in U.S. health care, not that much has changed. Joanne, this has been a very high-profile issue. What went wrong?
Kenen: Well, I think this report got very little attention probably because it’s like, oh, reports aren’t necessarily news stories. And it was like nothing changed, so why do we report it? But I think when I read the report — and I did not get through all 375 pages yet, but I did read a significant amount of it and I listened to a webinar on it — I think what really struck me is how we’re not any better than we really were 20 years ago. And what really was jarring is the report said, “And we actually know how to fix this and we’re not doing it. And we have the scientific and public health and sociological knowledge. We know if we wanted to fix it, we could, and we haven’t. Some of that is needing money and some of it is needing will.” So I thought the bottom line of it was really quite grim. If we didn’t know how bad it was, if the general public didn’t know how bad it was, the pandemic really should have taught them that because of the enormous disparities, and we’re back on this glide path toward nothing.
Rovner: I do think at very least, it is more talked about. It’s a little higher profile than it was, but obviously you’re right.
Kenen: They didn’t say no gains in any… I mean, the ACA helped. There are people who have coverage, including minorities, who didn’t have it before. That was one of the bright spots. But there’s still 10 states where it hasn’t been fully implemented. It was a pretty discouraging report.
Rovner: All right, well, that is this week’s news. Now it is time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Victoria, why don’t you go first this week?
Knight: Sure. So I was reading a story in The New York Times about PBMs [pharmacy benefit managers]. It was called “The Opaque Industry Secretly Inflating Prices for Prescription Drugs.” It’s by Rebecca Robbins and Reed Abelson. And so it kind of is basically an investigation into PBM practices. It was interesting for me because I cover health care in Congress, and so it’s always the different industries are fighting each other. And right now, one of the biggest fights is about PBMs. And for those that don’t know, PBMs negotiate with drug companies, they’re supposed to pay pharmacies, they help patients get their medications. And so they’re this middleman in between everyone. And so people don’t really know they exist, but they’re a big monopoly. There’s only three of them, really big ones in the U.S. that make up 80% of the market. And so they have a lot of control over things.
Pharma blames them for high drug prices and the PBMs blame pharma. So that’s always a fun thing to watch. There actually is quite a bit of traction in Congress right now for cracking down on PBM practices. Basically, The Times reporters interviewed a bunch of people and they came away with saying that PBMs …
Rovner: They interviewed like 300 people, right?
Knight: Yes, it said 300.
Rovner: A large bunch.
Knight: Yeah, and they came away with a conclusion that PBMs are causing higher drug prices and they’re pushing patients towards higher drugs. They’re charging employers of government more money than they should be. But it was interesting for me to watch this play out on Twitter because the PBM lobby was, of course, very upset by the story. They were slamming it and they put out a whole press release saying that it’s anecdotal and they don’t have actual data. So it was interesting, but I think it’s another piece in the policy puzzle of how do we reduce drug prices? And Congress thinks at least cracking on PBMs is one way to do it, and it has bipartisan support.
Rovner: And apparently this story is the first in a series, so there’s more to come.
Knight: Yes, I saw that. Yeah, more to come, so it’ll be fun. I also just noticed as I was just pulling it up on my phone and they had closed the comment section. It was causing some robust debate.
Rovner: Yes, indeed. Joanne?
Kenen: I should just say that after I read that story in The Times that same day, I think I got a phone call from a relative, a copay that had been something like $60 for 30 days is now $1,000. And this relative walked away without getting the drug because that’s not OK. So anyway, my extra credit [“Social Security To Drop Obsolete Jobs Used To Deny Disability Benefits,”] is from The Washington Post. Lisa Rein posted an investigation a couple of years ago, and this was the coda of the Social Security Administration finally followed through on what that investigation revealed. And Lisa wrote about the move, how it’s being addressed. That to get disability benefits, you have to be unemployable basically. And the Social Security Administration had a list of … it’s called the Dictionary of Occupational Titles. It had not been updated in 47 years. So disabled people were being denied Social Security disability benefits because they were being told, well, they could do jobs like being a nut sorter or a pneumatic tube operator or a microfilm something or other. And these jobs stopped existing decades ago.
So the Social Security Administration got rid of these obsolete jobs. You’re no longer being told, literally, to go store nuts. If you are, in fact, legitimately disabled, you’ll now be able to get the Social Security disability benefits that you are, in fact, qualified for. So thousands of people will be affected.
Rovner: No one can see this, but I’m wearing my America Needs Journalists T-shirt today. Alice?
Ollstein: I chose a piece [“Opioid Deaths Rose 50 Percent During the Pandemic. in These Places, They Fell”] by my colleague Ruth Reader, about a county in Ohio that, with some federal funds, implemented all of these policies to reduce opioid overdoses and deaths, and they had a lot of success. Overdoses went down 20% there, even as they went up by a lot in most of the country. But bureaucracy and expiring funding means that those programs may not continue, even though they’re really successful. The federal funding has run out. It is not getting renewed, and the state may not pick up the slack.
So it’s just a really good example. We see this so often in public health where we invest in something, it works, it makes a difference, it helps people, and then we say, “Well, all right, we did it. We’re done.” And then the problems come roaring back. So hopefully that does not happen here.
Rovner: Alas. Well, my extra credit this week is from The Washington Post. It’s called “Masks Are Going From Mandated to Criminalized in Some States.” It’s by Fenit Nirappil. I hope I’m pronouncing that right. In some ways, it’s a response to criminals who have obviously long used masks, and also to protesters, particularly those protesting the war in Gaza. But it’s also a mark of just how intolerant we’ve become as a society that people who are immunocompromised or just worried about their own health can’t go out masked in public without getting harassed. The irony, of course, is that this is all coming just as covid is having what appears to be now its annual summer surge, and the big fight of the moment is in North Carolina where the Democratic governor has vetoed a mask ban bill, that’s likely to be overridden by the Republican legislature. Even after covid is no longer front and center in our everyday lives, apparently a lot of the nastiness remains.
All right, that is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcast. We’d appreciate it if you left us a review. That helps other people find us, too. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comment or questions. We’re at whatthehealth@kff.org, or you can still find me at Twitter, which the Supreme Court has now decided it’s going to call Twitter. I’m @jrovner. Alice?
Ollstein: I’m @AliceOllstein on X.
Rovner: Victoria?
Knight: I’m @victoriaregisk.
Rovner: Joanne?
Kenen: I’m at Twitter, @JoanneKenen. And I’m on Threads @joannekenen1, and I occasionally decided I just have better things to do.
Rovner: It’s all good. We will be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': Live From Aspen: Health and the 2024 Elections
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Julie Rovner
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
The presidential election is less than five months away, and while abortion is the only health policy issue expected to play a leading role, others are likely to be raised in the presidential and down-ballot races. This election could be critical in determining the future of key health care programs, such as Medicaid and the Affordable Care Act.
In this special episode of KFF Health News’ “What the Health?” taped at the Aspen Ideas: Health festival in Aspen, Colorado, Margot Sanger-Katz of The New York Times and Sandhya Raman of CQ Roll Call join Julie Rovner, KFF Health News’ chief Washington correspondent, to discuss what the election season portends for top health issues.
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Margot Sanger-Katz
The New York Times
Sandhya Raman
CQ Roll Call
Among the takeaways from this week’s episode:
- Policies surrounding abortion — and reproductive health issues, in general — likely will dominate in many races, as Democrats try to exploit an issue that is motivating their voters and dividing Republican voters. The topics of contraception and in vitro fertilization are playing a more prominent role in 2024 than they have in past elections.
- High prescription drug prices — which, for frustrated Americans, are a longtime symbol, and symptom, of the nation’s dysfunctional health care system — have been a priority for the Biden administration and, previously, the Trump administration. But the issue is so confusing and progress so incremental that it is hard to say whether either party has an advantage.
- The fate of many major health programs will be determined by who wins the presidency and who controls Congress after this fall’s elections. For example, the temporary subsidies that have made Affordable Care Act health plans more affordable will expire at the end of 2025. If the subsidies are not renewed, millions of Americans will likely be priced out of coverage again.
- Previously hot-button issues like gun violence, opioid addiction, and mental health are not playing a high-profile role in the 2024 races. But that could change case by case.
- Finally, huge health issues that could use public airing and debate — like what to do about the nation’s crumbling long-term care system and the growing shortage of vital health professionals — are not likely to become campaign issues.
click to open the transcript
Transcript: Live From Aspen: Health and the 2024 Elections
KFF Health News’ ‘What the Health?’ Episode Title: ‘Live From Aspen: Health and the 2024 Elections’Episode Number: 352Published: June 21, 2024
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Mila Atmos: The future of America is in your hands. This is not a movie trailer and it’s not a political ad, but it is a call to action. I’m Mila Atmos and I’m passionate about unlocking the power of everyday citizens. On our podcast “Future Hindsight,” we take big ideas about civic life and democracy and turn them into action items for you and me. Every Thursday we talk to bold activists and civic innovators to help you understand your power and your power to change the status quo. Find us at futurehindsight.com or wherever you listen to podcasts.
Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent at KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. I am joined tonight by a couple of our regular panelists: Margot Sanger-Katz, The New York Times.
Sanger-Katz: Hey, everybody.
Rovner: And Sandhya Raman of CQ Roll Call.
Raman: Good evening everyone.
Rovner: For those of you who aren’t regular listeners, we have a rotating panel of more than a dozen health policy reporters, all of whom just happen to be women, and every week we recap and analyze the week’s top health news. But tonight we’ve been given a slightly different assignment to talk about how health policy is likely to shape the 2024 elections and, vice versa, how the elections are likely to shape health policy.
So, this is actually my 10th presidential election season as a health reporter, which is terrifying, and I can say with some experience that health is one of those issues that’s always part of the political debate but is relatively rarely mentioned when pollsters ask voters what their top issue is. Of those of you who went to the pollsters session this afternoon might’ve seen that or said we’re not going to… it’s not going to be a health election this year.
This year, though, I think will be slightly different. As you’ll hear, I’ve divided these issues into three different buckets: Those that are likely to be pivotal or very important to how people vote; those that are likely to come up over the next few months in the presidential and/or congressional and Senate races; and finally, a couple of issues that aren’t as likely to come up but probably should. It would be good to have a debate about them.
So we will start with the political elephant in the room: reproductive health. Since the Supreme Court overturned Roe v. Wade two years ago next week, abortion has been front and center in just about every political contest, usually, though not always, with the abortion-right side prevailing. How do you two see abortion playing out both at the presidential and congressional level these next couple of months?
Raman: I see it playing out in kind of two different ways. We see already at the presidential level that President Joe Biden has been really going in, all in, that this is his No. 1 issue, and I think this will continue to play out, especially next week with the anniversary of the Dobbs [v. Jackson Women’s Health Organization] decision.
And a lot of the Democrats in the Senate have kind of been taking lead from that and also really amping up the issue. They’ve been doing kind of messaging votes on things within the reproductive health spectrum and it seems like they’re going to continue that in July. So we’re going to see it really focused on there. On the Republican side, they’ve been not focused on this issue as much.
Rovner: They’ve been ducking this issue.
Raman: Yes, they’ve been ducking this issue, so I think it’ll just be continued to be downplayed. They’ve really been going in on immigration more than any other of the issues that they’ve got this year.
Sanger-Katz: If you look at the public polling, abortion is one of really the only issues where the Democrats and Joe Biden seem to have a real advantage over the Republicans and Donald Trump. And so I think that that tells you that they’re going to have to be hitting it a lot. This is an issue where the voters are with the Democrats. They trust Biden more. They agree more with the policies the Democrats are promoting around reproductive health care. So it’s just impossible for me to imagine a scenario in which we don’t see Democrats kind of up and down the ticket really taking advantage of this issue, running ads on it, talking about it, and trying to really foreground it.
I think for Biden, in particular, it’s a hard issue. I think he has always had some personal ambivalence about abortion. He’s a Catholic. He, early in his career, had opposed certain abortion rights measures that other Democrats had endorsed, and you can kind of see him slowly getting comfortable with this issue. I think he said the word abortion for the first time just in the last six months. I think I would anticipate a real ramping up of discussion of this issue among Democrats. The other dynamic that I think is pretty important is that there are a number of states that have ballot initiatives to try to kind of permanently enshrine abortion rights into state constitutions.
And some of those are in states that are not pivotal to the election, and they will be important in those states, and for those state senate races and governor races and other things, because they may pull in more of these voters who care a lot about reproductive rights. But there are some of these ballot measures that are in pivotal states for the presidential race, the kind of battleground states that we’re all watching. And so there’s a big emphasis on those as well. And I think there’s some interesting tensions with those measures because abortion rights actually are valued by people across the political spectrum.
So I think we tend to think of this as a Democrat-Republican issue where Republicans want to restrict abortion rights, and Democrats want to promote them. But we’re seeing in the public polling now that’s not really true. There are a lot of Republicans that are uncomfortable with the kind of abortion bans that we’re seeing in certain parts of the country now. So it’s this question: Are they going to come out and vote and split their ticket where they’ll vote for constitutional measure to protect abortion rights and still vote for President Trump? Or will the abortion issue mobilize them so much that they will vote across the board as Democrats?
And I think that’s a big question, and I think it’s a big challenge. In fact, for many of the people that are running these campaigns to get these ballot measures passed, how much they want to kind of lean into the Democratic messaging and try to help prop up Democratic candidates in their state. And how much they want to just take a step back and try to get Republicans to support their particular measure, even if it doesn’t help Democratic candidates on the ticket.
Rovner: Well, of course, it’s not just abortion that’s on the ballot, literally and figuratively. There’s a not-insignificant portion of the anti-abortion movement that not only wants to ban abortion nationwide but wants to establish in law something called personhood. The concept that a person with full legal rights is created at fertilization.
That would result in outlawing many forms of contraception, as well as if we have seen rather vividly this spring, IVF. Unlike abortion, contraception and IVF are very widely supported, not nearly as divisive as abortion itself is. Are we potentially looking at a divorce between the Republican Party and its longtime absolutist, anti-abortion backers?
Raman: I think that Republicans have been toeing the line on this issue so far. We’ve seen them not support some of the Democrats’ bills on the state level, the federal level, that are related to IVF, but at the same time, kind of introducing their counterparts or issuing broad statements in support of IVF, in support of contraception. Even just like a couple of weeks ago, we had Sen. Rick Scott of Florida release an IVF-themed full ad.
And so we have a lot of messaging on this, but I think at the same time a lot of these are tiptoeing the line in that they might not add any new protections. They might not codify protections for any of these procedures. They might just issue support or not address some of the other issues there that people have been going back and forth with the personhood issue.
Sanger-Katz: I think this is a big challenge for the Republican Party, not just over the course of this particular election cycle, but I think thinking further into the future. The pro-life movement has been such a pivotal group of activists that have helped elect Republicans and have been so strongly allied with various other Republican interest groups across the last few decades. And you can see that those activists helped overturn Roe after nearly 50 years of having a constitutional right to abortion.
Many of them don’t want to give up there. They really want to abolish abortion. They think it’s a morally abhorrent and something that shouldn’t happen in this country. And they’re concerned that certain types of contraception are similar to abortion in certain ways and that IVF is also morally abhorrent. And we saw recently with the [Southern] Baptist Convention that there was a vote basically to say that they did not support in vitro fertilization and assisted reproductive technologies.
Yet, at the same time, you can see in public polling and in the way that the public responds to these kinds of messages that the activists are way out further than the typical voter and certainly way out further than the typical Republican voter. And there’s this interesting case study that happened a few months ago where the Alabama Supreme Court issued a ruling — the implications of which suggested that IVF might be imperiled in that state — and it was kind of uncertain what the result that would be.
And what happened, in fact, is that Republicans and the Alabama State Legislature and the Republican governor of Alabama, many of whom had sort of longtime pro-life connections and promises, immediately passed a bill to protect in vitro fertilization because they saw that it was something that their voters really cared about and that’s something that could really hurt them politically if they were being seen as being allied with a movement that wanted to ban it.
But the activists in this movement are really important part of the Republican coalition, and they’re very close to leadership. And I think this is going to be a real tension going forward about how does the party accommodate itself to this? Do they win hearts and minds? They figure out a way to get the public on their side? Or do they kind of throw over these people who have helped them for so long, and these ideological commitments that I do think that many Republican politicians really deeply do hold?
Rovner: How much wild card is Donald Trump can be in this? He’s been literally everywhere on this issue, on reproductive rights in general. He is not shy about saying he thinks that abortion is a loser of an issue for Republicans. He wants to just continue to say, “Let the states do whatever they want.”
But then, of course, when the states do things like perhaps ban IVF — that I would think would even make Donald Trump uncomfortable — he seems to get away with being anywhere he wants with these very strong evangelical and pro-life groups who have supported him because, after all, he appointed the two Supreme Court justices that overturned Roe. But I’m wondering if, down-ballot, how all these other candidates are going to cope with the forever sort of changing position of the head of their ticket.
Sanger-Katz: I think it’s pretty interesting. I was talking with a colleague about this recently. It seems like Trump’s strategy is to just have every position. If you look at his statements, he said just about every possible thing that you could possibly say about abortion and where he stands on it. And I think it’s actually quite confusing to voters in a way that may help him because I think if you’re only looking for the thing that you want to hear, you can find it.
If you’re someone who’s really a pro-life activist who cares a lot about restricting abortion, he brags about having been responsible for overturning Roe. And if you’re someone who really cares about protecting IVF, he’s said that he wants that. If you’re someone who want… lives in a state that has… continues to have legal abortion, he said, “We’re going to leave that up to the states.”
If you’re in a state that has banned abortion, that has very extreme bans, he said something that pleases you. And so, I don’t know. I did a story a few weeks ago where I interviewed voters who had been part of a New York Times/Siena poll, and these were voters who, they were asked a question: Who do you find responsible for the Dobbs decision for the overturning of Roe v. Wade? And these were voters who supported abortion rights but thought that Joe Biden was responsible. And there’re like… it’s not a lot of people, but it’s …
Rovner: But it’s like 20%, isn’t it?
Sanger-Katz: Yeah, it’s like 10[%], 15% of voters in battleground states, people whose votes are really going to matter and who support abortion rights. They don’t know who was responsible. They don’t really understand the dynamics of where the candidates are on this issue. And I think for those of us who are very politically engaged and who are following it closely, it’s kind of hard to imagine. But they’re just a lot of people who are not paying close attention.
And so I think that makes Trump being everywhere on the issue, it makes it easier for those people to not really engage with abortion. And I think that’s again why I think we’re going to see the Biden campaign and other Democrats kind of hitting it over and over and over again. “This is Trump’s fault. We are going to protect abortion rights.” Because I think that there are a lot of voters who don’t really know what to make of the candidates and don’t know what to make of Trump on this particular issue.
Rovner: Well, Sandhya, they keep trying to bring it up in Congress, but I don’t think that’s really breaking through as a big news story.
Raman: No, and I think that for Congress, we’ve seen the same thing this year, but we’ve also seen it in previous years where they coalesce around a certain week or a certain time and bring up different bills depending on who’s in control of that chamber to message on an issue. But it hasn’t really moved the needle either way that we get similar tallies, whether it was this year or three years ago or 10 years ago.
One thing that I think activists are really looking at on the pro-life side is just really Trump’s record on these issues. Regardless of what he’s saying this week or last week or in some of these different interviews that’s a little all over the place. They’ve pointed to a lot of things that he’s done, like different things that he’s expanded more than previous Republican presidents. And for them, that might be enough.
That’s if it’s just the dichotomy of Biden versus Trump, that to get to their end goal of more pro-life policies, then Trump is the easy choice. And in the past years, the amount of money that they have poured into these elections to just really support issues… candidates that are really active on these issues, has grown astronomically. So I don’t know that necessarily if he does make some of these statements it’s going to make a huge difference in their support.
Sanger-Katz: And I think it also comes back to Julie’s opening point, which is I think abortion is an issue on which the Democrats have a huge edge, and I do think it is an issue that is very mobilizing for certain types of voters. But I also think that this is an election in which a lot of voters, whatever their commitments are on abortion, may be deciding who to vote for based on another set of issues. Those people that I talked to who were kind of confused about abortion, they really cared a lot about the economy.
They were really concerned about the cost of groceries. And so I think for those people, they may have a preference on abortion. If they could sort of pick each individual issue, they might pick something different. But I think the fact that they supported abortion rights did not necessarily mean that even if they really understood where the candidates were that they were necessarily going to vote for Joe Biden. I think a lot of them were going to vote for Donald Trump anyway because they thought he was better on the issues that were affecting their daily lives more.
Rovner: Well, Margot, to your point about voters not knowing who’s responsible for what, I think another big issue in this campaign is going to be prescription drug prices. As we know, drug prices are kind of the stand-in for everything that’s currently wrong with the nation’s health care system. The system is byzantine. It can threaten people’s health and even their lives if they can’t afford it.
And just about every other country does it better than we do. Interestingly, both President Biden and former President Trump made drug prices a top health priority, and both have receipts to show what they have done, but it’s so confusing that it’s not clear who’s going to get credit for these things that have gotten done.
Trump said that Biden was lying when Biden said that he had done the insulin cap for Medicare, which in fact was done by the Democrats, although Trump had done sort of a precursor to it. So, who wins this point, or do you think it’s going to end up being a draw? Because people are not going to be able to figure out who was responsible for which parts of this. And by the way, we haven’t really fixed it anyway.
Raman: I would say it was a draw for two reasons. I think, one, when we deal with something like drug prices, it takes a while for you to see the effects. When we have the IRA [Inflation Reduction Act] that made it so that we can negotiate the price of some drugs under Medicare, the effects of that are over a long tailwind. And so it’s not as easy to kind of bring that up in political ads and that kind of thing when people aren’t seeing that when they go to the pharmacy counter.
And I think another thing is that for at least on the congressional level, there’s been a little bit of a gap in them being able to pass anything that kind of moves the point along. They made some efforts over the past year but weren’t able to get it over the finish line. I think it’s a lot more difficult to say, “Hey, we tried but didn’t get this done” without a … as a clear campaign message and to get votes on that.
Sanger-Katz: I also think it’s this issue that’s really quite hard because — setting aside $35 insulin, which we should talk about — most people have insurance, and so the price of the drug doesn’t always affect them in a direct way. A lot of times, when people are complaining about the high cost of drugs, they’re really complaining about the way that their insurance covers the drug. And so the price of the drug might, in fact, be astronomical, but it’s the $100 copayment that people are responding to.
And so it could be that the government is taking all these actions, or the companies by themselves, and the price has gone down, but if you’re still paying that $100 copayment, you’re not really experiencing the benefits of that change. So I do think that the Democrats and Joe Biden have done two things that are helpful in that regard. So, one, is this $35 cap on copayments for insulin. So that’s just for people in Medicare, so it’s not everyone. But I do think that is… it’s a great talking point. You can put that on an ad. It’s a real thing.
People are going to go to the pharmacy counter, and they’re not going to pay more than that. It’s easy to understand. The other thing that they did, and I think this is actually harder to understand, is they redesigned the drug benefit for people who have Medicare. So it used to be in Medicare that if you had a really expensive set of drugs that you took, like, say, you had cancer and you were taking one of these newer cancer drugs that cost tens of thousands dollars a year, you could be on the hook for tens of thousands of dollars a year out of your own pocket, on top of what your insurance covered.
If you took less-expensive drugs, your insurance kind of worked the way it works for people in the commercial market where you have some copayments, not that you don’t pay anything, but it wasn’t sort of unlimited. But for really high-cost drugs in Medicare, people in Medicare were on the hook for quite a lot of money, and the Inflation Reduction Act changed that. They changed the Medicare drug benefit, and now these people who have these really expensive health conditions have a limit. They only have to pay a couple of thousand dollars a year.
Rovner: But it doesn’t start until next year.
Sanger-Katz: But it doesn’t start until next year. So I just think a lot of this stuff around drug prices is, people feel this sense of outrage that the drugs are so expensive. And so I think that’s why there’s this huge appetite for, for example, having Medicare negotiate the price of drugs. Which is another thing that the Inflation Reduction Act enabled, but it’s not going to happen in time for the election.
But I don’t think that really hits people at the pharmacy counter. That is more the benefits of that policy are going to affect taxpayers and the government. They’re not going to affect individual people so much. And I think that’s part of why it’s such a hard issue. And I think that President Trump bumped up against this as well.
His administration was trying all of these little techniques deep in the works of the drug pricing and distribution system to try to find ways to lever down the prices of drugs. And some of them worked, and some of them didn’t. And some of them got finalized, and some of them didn’t. But I think very few of them had this obvious consumer impact. And so it was hard for them to go to the voters and say, “We did this thing. It affected your life.”
Rovner: I see some of these ads, “We’ve got to do something about the PBMs [Pharmacy Benefit Managers].” And I’m like, “Who’s this ad even aimed at? I cover this for a living, and I don’t really understand what you’re talking about.” I wonder, though, if some… if candidates really on both sides, I mean, this is a unique election in that we’ve got two candidates, both of whom have records behind them.
I mean, normally, you would have at least one who’s saying, “This is what I will do.” And, of course, when it comes to drug prices, the whipping boy has always been the drug companies. And I’m wondering if we’re not going to see candidates from both parties at all levels just going up against the drug companies because that’s worked in the past.
Raman: I think it’s kind of a difficult thing to do when I think so many candidates, congressional level especially, have good relationships with pharmaceutical companies as some of the top donors for their campaigns. And so there’s always that hesitation to go too hard on them when that is helping keep them in office.
So it’s a little bit more difficult there to see teeth-out going into an ad for something like that. I think when we go back to something like PBMs where it seems like everyone in Congress just has made that kind of the bully of this past couple years, then that might be something that’d be easier to throw into ads saying, “I will go after PBMs.”
Sanger-Katz: I think we’re likely to see, especially in congressional races, a lot of candidates just promising to lower your drug prices without a whole lot of detail under that.
I don’t know that it’s necessarily going to be like the evil pharmaceutical companies, and I don’t think it’s going to be detailed policy proposals for all the reasons I just said: because it’s complicated; doesn’t always affect people directly; it’s hard to understand. But I think it will be a staple promise that we’ll particularly see from Democrats and that I expect we will hear from President Trump as well because it’s something that has been part of his kind of staple of talking points.
Rovner: So let’s move on to some of the issues that are sort of the second-tier issues that I expect will come up, just won’t be as big as immigration and abortion. And I want to start with the Affordable Care Act. I think this is the first time in a presidential election year that it seems that the continuing existence of the ACA is no longer in question. If you disagree, do let me know, but that’s not to suggest …
Sanger-Katz: Maybe last time.
Rovner: Little bit. That’s not to suggest, though, that the fate of the Affordable Care Act is not also on the line in this election. The additional subsidies that the Democrats added in the Inflation Reduction Act, which will sunset at the end of next year unless they are renewed, are responsible in large part for the largest percentage of Americans with health insurance ever measured.
And conversely, the Congressional Budget Office estimates that enrollment would fall by an immediate 20% if the subsidies are allowed to expire. It’s hard to see how this becomes a campaign issue, but it’s obviously going to be really important to what… I mean who is elected is going to be really important to what happens on this issue, and it’s a lot of people.
Raman: Using the subsidies as a campaign point is a difficult thing to do. It’s a complicated issue to put in a digestible kind of ad thing. It’s the same thing with a lot of the prescription drug pricing policies where, to get it down to the average voter, is hard to do.
And I think had we not gotten those subsidies extended, we would’ve seen people more going into that in ads. But when it’s keeping the status quo, people aren’t noticing that anything has changed. So it’s an even more difficult thing to kind of get across.
Sanger-Katz: I think this is one of, in health care, one of the highest-stakes things. That I feel like there’s just a very obvious difference in policy depending on who is elected president. Whereas a lot of the things that we’ve talked about so far, drug prices, abortion, a little harder to predict. But just to get out of the weeds for a second, Congress increased the amount of money that poor and middle-class people can get when they buy their own health insurance on the Obamacare exchanges. And they also made it possible for way more people to get health insurance for free.
So there are a lot of Americans who were uninsured before who now have insurance that they don’t pay a single dollar for. And there are also a lot of Americans that are higher, the kind of people that were disadvantaged in the early years of Obamacare, sort of self-employed people, small business owners who bought their own insurance and used to just have sort of uncapped crazy premiums. People who earn more than $100,000 a year now have financial assistance for the first time ever. And that policy has been in place for several years, and we’ve seen record enrollment.
There’s lots more people with insurance now, and their insurance is more affordable than it’s ever been. And those things are, of course, related. I think it’s almost definitely going to go away if Trump is elected to the presidency and if Republicans take at least one house of Congress because basically it’s on a glide path to expiration. So if nothing is done, that money will go away. What needs to happen is for Congress to pass a new law that spends new money to extend those subsidies and for a president to sign it.
And I just think that the basic ACA, the stuff that passed in 2010, I think is relatively safe, as Julie says. But lots of people are going to face much more expensive insurance and maybe unaffordable insurance. And again, the CBO [Congressional Budget Office] projects that a lot of people will end up giving up their insurance as a result of those changes if these policies are allowed to expire. And so I don’t know. I think we don’t see candidates talking about it very much. But I don’t actually think it’s that hard to message on. You could just say, “If you vote for this guy, your insurance premiums are going to go up by 50% or whatever.”
That doesn’t seem like a terrible message. So I do wonder if we’ll see more of that, particularly as we get closer to the election. Because it does feel like a real pocketbook issue for people. The cost of health care, the cost of health insurance, like the cost of drugs, I think, is something that really weighs on people. And we’ve seen in these last few years that making insurance cheaper has just made it much more appealing, much more accessible for people. There’s lots more Americans who have health insurance now, and that’s at risk of going away.
Rovner: Well, also on the list of things that are likely to come up, probably not in the presidential race, but certainly lower down on the ballot, is gender-affirming care. Republicans are right now are all about parental control over what books their children read and what they’re taught in school, but not apparently about medical care for their children.
They want that to be determined by lawmakers. This is very much a wedge issue, but I’m wondering for which side. I mean, traditionally, it would’ve been the conservatives and the evangelicals sort of pushing on this. But as abortion has sort of flip-flopped in importance among voters, I’m wondering where this kind of falls into that.
Raman: I think that the messaging that I’ve seen so far has still prominently been from Republicans on this issue. Whether or not it’s bills that they’ve been introducing and kind of messaging on in Congress or just even in the ads, there’s still been a lot of parental safeguards and the language related to that with relation to gender-affirming care. I have not actually seen as many Democratic ads going super into this. I think they have been way more focused on abortion.
I’m thinking back to, I saw a statistic that 1 in 4 Democratic ads go into abortion, which is really high compared to previous years. And so I don’t know that it will be as big of an issue. I even see some people kind of playing it down because the more attention it gets, sometimes it rallies people up, and they don’t… It’s kind of the flip of Republicans not wanting to bring attention to the abortion issue. And I think a lot of Democrats are trying to shy away so that some of these things aren’t elevated, that we aren’t talking about some of the talking points and the messaging that Republicans are bringing up on the same thing.
Sanger-Katz: Yeah, it feels to me almost like a mirror image of the abortion issue in the sense that the Democrats have this challenge where their activists are out in front of their voters. There clearly are parts of the Democratic coalition that are really concerned about transgender rights and wanting to protect them and are very opposed to some of the action that we’re seeing at the state and local level, both in terms of what’s happening in schools, but also regulation of medical care. But I think voters I think are less comfortable with transgender rights.
Even Democratic voters, you see sort of there’s more of a generational split on this issue than on some of these other issues where I think older voters are just a little bit less comfortable. And so I do think that it is an issue where — particularly certain parts of it like transgender athletes — that seems to be an area where you see the Republican message really getting more traction among certain subsets of Democratic voters. And I think it’s a hard issue for Democrats except in the places where there’s really broad acceptance.
Rovner: So I want to move on to the things that are less likely to come up, but probably should. We’re going to start with Medicaid. During the pandemic, it grew to cover over 90 million Americans. That’s like a third more than Medicare, which most people still think of as the largest government health program.
But as states pare back their roles after the expiration of the public health emergency, it seems that lots of people — particularly children, who are still eligible — are getting dropped nonetheless. During the fight over repealing the Affordable Care Act in 2017, it was the fate of Medicaid in large part that saved the program.
Suddenly, people realized that their grandmother was getting Medicaid and that one out of every three births, maybe one of every two births, is paid for by Medicaid. But now it seems not so much. Has Medicaid gotten invisible again in national politics?
Raman: I think, in a way, it has. I mean, it doesn’t mean that it’s any less important, but I haven’t seen as big of a push on it, as many people talking about it. And I think it is more of a tricky thing to message on at this point, given that if you look at where the states that have been disenrolling a lot of people, a lot of the ones that are near the top, are blue states.
California is a bigger population, but it’s also the one where they’ve disenrolled the most people. And so messaging on this is going to be difficult. It’s a harder thing to kind of attack your opponent on if this is something that is also being … been difficult in your state. It’s something that states have been grappling with even before we even got to this point.
Sanger-Katz: I think this is another issue where, I think, the stakes of the election are actually quite high. I do think it’s relatively invisible as an issue. I think part of the reason is that we don’t really see the Republicans talking about it, and I think the Democrats don’t really know how to message on it. I think they were really good at, “We’re going to protect you. We’re going to prevent the Republicans from taking this away from you.” But I think they don’t have a good affirmative message about, “How we love this program and we want to support and extend it.”
I don’t think voters are really responding to that. But if you look at what President Trump did in his first administration, he had budgets every single year that proposed savage cuts to Medicaid, big changes to the structure and funding of the program. Those did not get enacted into law. But even after Obamacare repeal was abandoned, you did not see the Trump budgets and the Trump administration, economic officials and health officials, abandoning those plans to make significant cuts to Medicaid.
And I think there are quite a lot of people in the Republican health policy world who think that Medicaid is sort of a bloated and wasteful program that needs to be rethought in a kind of fundamental way, needs to be handed back to the states to give them more fiscal responsibility and also more autonomy to run the program in their own way. I think we will see that again. I also think it’s very hard to know, of course, I feel like anytime… whoever’s in power is always less concerned about the deficit than they are when they are running for election.
But something we haven’t talked about because it’s not a health care issue, is that the expiration of the Trump tax reform bill is going to come up next year, and all of our budget projections that we rely on now assume that those tax cuts are going to expire. I think we all know that most of them probably are not going to expire regardless of who is elected. But I think if Trump and the Republicans take power again, they’re going to want to do certainly a full renewal and maybe additional tax cuts.
And so I think that does put pressure, fiscal pressure on programs like Medicaid because that’s one of the places where there’s a lot of dollars that you could cut if you want to counterbalance some of the revenues that you’re not taking in when you cut taxes. I think Medicaid looks like a pretty ripe target, especially because Trump has been so clear that he does not want to make major cuts to Medicare or to Social Security, which are kind of the other big programs where there’s a lot of money that you could find to offset major tax cuts if you wanted to.
Rovner: Yet, the only big program left that he hasn’t promised not to cut, basically. I guess this is where we have to mention Project 2025, which is this 900-page blueprint for what could happen in a second Trump term that the Trump campaign likes to say, whenever something that’s gets publicized that seems unpopular, saying, “It doesn’t speak for us. That’s not necessarily our position.”
But there’s every suggestion that it would indeed be the position of the Trump administration because one of the pieces of this is that they’re also vetting people who would be put into the government to carry out a lot of these policies. This is another one that’s really hard to communicate to voters but could have an enormous impact, up and down, what happens to health.
Sanger-Katz: And I think this is true across the issue spectrum that I think presidential candidates, certainly congressional candidates and voters, tend to focus on what’s going to happen in Congress. What’s the legislation that you’re going to pass? Are you going to pass a national abortion ban, or are you going to pass a national protect-abortion law? But actually, most of the action in government happens in regulatory agencies. There’s just a ton of power that the executive branch has to tweak this program this way or that.
And so on abortion, I think there’s a whole host of things that are identified in that Project 2025 report that if Trump is elected and if the people who wrote that report get their way, you could see lots of effects on abortion access nationwide that just happened because the federal agencies change the rules about who can get certain drugs or how things are transported across state lines. What happens to members of the military? What kind of funding goes to organizations that provide contraception coverage and other related services?
So, in all of these programs, there’s lots of things that could happen even without legislation. And I think that always tends to get sort of undercovered or underappreciated in elections because sort of hard to explain, and it also feels kind of technical. I think, speaking as a journalist, one thing that’s very hard is that this Project 2025 effort is kind of unprecedented in the sense that we don’t usually have this detailed of a blueprint for what a president would do in all of these very detailed ways. They have, I mean, it’s 100…
Rovner: Nine-hundred …
Sanger-Katz: … 900-page document. It’s like every little thing that they could do they’ve sort of thought about in advance and written down. But it’s very hard to know whether this document actually speaks for Trump and for the people that will be in leadership positions if he’s reelected and to what degree this is sort of the wish casting of the people who wrote this report.
Rovner: We will definitely find out. Well, kind of like Medicaid, the opioid crisis is something that is by no means over, but the public debate appears to have just moved on. Do we have short attention spans, or are people just tired of an issue that they feel like they don’t know how to fix? Or the fact that Congress threw a lot of money at it? Do they feel like it’s been addressed to the extent that it can be?
Raman: I think this is a really difficult one to get at because it’s — at the same time where the problem has been so universal across the country — it has also become a little fragmented in terms of certain places, with different drugs becoming more popular. I think that, in the past, it was just so much that it was the prescription opioids, and then we had heroin and just different things. And now we have issues in certain places with meth and other drugs. And I think that some of that attention span has kind of deviated for folks. Even though we are still seeing over 100,000 drug-related deaths per year; it hasn’t dipped.
And the pandemic, it started going up again after we’d made some progress. And I’m not sure what exactly has shifted the attention, if it’s that people have moved on to one of these other issues or what. But even in Congress, where there have been a lot of people that were very active on changing some of the preventative measures and the treatment and all of that, I think some of those folks have also left. And then when there’s less of the people focused on that issue, it also just slowly trickles as like a less-hyped-up issue in Congress.
Sanger-Katz: I think it continues to be an issue in state and local politics. In certain parts of the country I think this is a very front-of-mind issue, and there’s a lot of state policy happening. There’s a lot also happening at the urban level where you’re seeing prosecutors, mayors, and others really being held accountable for this really terrible problem. And also with the ancillary problems of crime and homelessness associated with people who are addicted to drugs. So, at the federal level, I agree, it’s gotten a little bit sleepy, but I think in certain parts of the country, this is still a very hot issue.
And I do think this is a huge, huge, huge public health crisis that we have so many people who are dying of drug overdoses and some parts of the country where it is just continuing to get worse. I will say that the latest data, which is provisional, it’s not final from the CDC [Centers for Disease Control and Prevention], but it does look like it’s getting a little bit better this year. So it’s getting better from the worst ever by far. But it’s the first time in a long time that overdoses seem to be going down even a little. So I do think there’s a glimmer of hope there.
Raman: Yeah. But then the last time that we had that, it immediately changed again. I feel like everyone is just so hesitant to celebrate too much just because it has deviated so much.
Sanger-Katz: It’s definitely, it’s a difficult issue. And even the small improvements that we’ve seen, it’s a small improvement from a very, very large problem, so.
Rovner: Well, speaking of public health, we should speak of public health. We’re still debating whether or not covid came from a wet market or from a lab leak, and whether Dr. [Anthony] Fauci is a hero or a villain. But there seems to be a growing distrust in public health in general. We’ve seen from President Trump sort of threatened to take federal funds away from schools with vaccine mandates.
The context of what he’s been saying suggests he’s talking about covid vaccines, but we don’t know that. This feels like one of these issues that, if it comes up at all, is going to be from the point of view of do you trust or do you not trust expertise? I mean, it is bigger than public health, right?
Raman: Yeah. I think that… I mean, the things that I’ve seen so far have been largely on the distrust of whether vaccines are just government mandates and just ads that very much are aligning with Trump that I’ve seen so far that have gone into that. But it does, broader than expertise.
I mean, even when you go back to some of the gender-affirming care issues, when we have all of the leading medical organizations that are experts on this issue speaking one way. And then we having to all of the talking points that are very on the opposite spectrum of that. It’s another issue where even if there is expertise saying that this is a helpful thing for a lot of folks that it’s hard to message on that.
Sanger-Katz: And we also have a third-party candidate for the presidency who is, I think, polling around 10% of the electorate — and polling both from Democratic and Republican constituencies — whose kind of main message is an anti-vaccine message, an antipublic health message.
And so I think that reflects deep antipublic health sentiments in this country that I think, in some ways, were made much more prominent and widespread by the covid pandemic. But it’s a tough issue for that reason.
I think there is a lot of distrust of the public health infrastructure, and you just don’t see politicians really rushing into defend public health officials in this moment where there’s not a crisis and there’s not a lot of political upside.
Rovner: Finally, I have a category that I call big-picture stuff. I feel like it would be really refreshing to see broad debates over things like long-term care. How we’re going to take care of the 10,000 people who are becoming seniors every day. The future solvency of Medicare. President Trump has said he won’t cut Medicare, but that’s not going to help fix the financial issues that still ail at end, frankly, the structure of our dysfunctional health care system.
Everything that we’ve talked about in terms of drug prices and some of these other things is just… are all just symptoms of a system that is simply not working very well. Is there a way to raise these issues, or are they just sort of too big? I mean, they’re exactly the kinds of things that candidates should be debating.
Raman: That is something that I have been wondering that when we do see the debate next week, if we already have such a rich background on both of these candidates in terms of they’ve both been president before, they have been matched up before, that if we could explore some of the other issues that we haven’t had yet. I mean, we know the answers to so many questions. But there are certain things like these where it would be more refreshing to hear some of that, but it’s unclear if we would get any new questions there.
Rovner: All right. Well, I have one more topic for the panel, and then I’m going to turn it over to the audience. There are folks with microphones, so if you have questions, be thinking of them and wait until a microphone gets to you.
One thing that we haven’t really talked about very much, but I think it’s becoming increasingly important, is data privacy in health care. We’ve seen all of these big hacks of enormous storages of people’s very personal information. I get the distinct impression that lawmakers don’t even know what to do. I mean, it’s not really an election issue, but boy, it almost should be.
Sanger-Katz: I did some reporting on this issue because there was this very large hack that affected this company called Change Healthcare. And so many things were not working because this one company got hacked. And the impression I got was just that this is just an absolute mess. That, first of all, there are a ton of vulnerabilities both at the level of hospitals and at the level of these big vendors that kind of cut across health care where many of them just don’t have good cybersecurity practices.
And at the level of regulation where I think there just aren’t good standards, there isn’t good oversight. There are a lot of conflicting and non-aligned jurisdictions where this agency takes care of this part, and this agency takes care of that part. And I think that is why it has been hard for the government to respond, that there’s not sort of one person where the buck stops there. And I think the legislative solutions actually will be quite technical and difficult. I do think that both lawmakers and some key administration officials are aware of the magnitude of this problem and are thinking about how to solve it.
It doesn’t mean that they will reach an answer quickly or that something will necessarily pass Congress. But I think this is a big problem, and the sense I got from talking to experts is this is going to be a growing problem. And it’s one that sounds technical but actually has pretty big potential health impacts because when the hospital computer system doesn’t work, hospitals can’t actually do the thing that they do. Everything is computerized now. And so when there’s a ransomware attack on a main computer electronic health record system, that is just a really big problem. That there’s documentation has led to deaths in certain cases because people couldn’t get the care that they need.
Rovner: They couldn’t … I mean, couldn’t get test results, couldn’t do surgeries. I mean, there was just an enormous implications of all this. Although I did see that there was a hack of the national health system in Britain, too. So, at least, that’s one of the things that we’re not alone in.
Sanger-Katz: And it’s not just health care. I mean, it’s like everything is hackable. All it takes is one foolish employee who gives away their password, and you think, often, the hackers can get in.
Raman: Well, that’s one of the tricky parts is that we don’t have nationally, a federal data privacy law like they do in the E.U. and stuff. And so it’s difficult to go and hone in on just health care when we don’t have a baseline for just, broadly … We have different things happening in different states. And that’s kind of made it more difficult to get done when you have different baselines that not everyone wants to come and follow the model that we have in California or some of the other states.
Rovner: But apparently Change Healthcare didn’t even have two-factor authentication, which I have on my social media accounts, that I’m still sort of processing that. All right, so let’s turn it over to you guys. Who has a question for my esteemed panel?
[Audience member]: Private equity and their impact on health care.
Rovner: Funny, one of those things that I had written down but didn’t ask.
Sanger-Katz: I think this is a really interesting issue because we have seen a big growth in the investment of private equity into health care, where we’re seeing private equity investors purchasing more hospitals, in particular, purchasing more doctors’ practices, nursing homes. You kind of see this investment across the health care sector, and we’re just starting to get evidence about what it means. There’s not a lot of transparency currently. It’s actually pretty hard to figure out what private equity has bought and who owns what.
And then we really don’t know. I would say there’s just starting to be a little bit of evidence about quality declines in hospitals that are owned by private equity. But it’s complicated, is what I would say. And I think in the case of medical practices, again, we just don’t have strong evidence about it. So I think policymakers, there are some who are just kind of ideologically opposed to the idea of these big investors getting involved in health care. But I think there are many who are… feel a little hands-off, where they don’t really want to just go after this particular industry until we have stronger evidence that they are in fact bad.
Rovner: Oh, there’ve been some pretty horrendous cases of private equity buying up hospital groups, selling off the underlying real estate. So now that the… now the hospital is paying rent, and then the hospitals are going under. I mean, we’ve now seen this.
Sanger-Katz: Yeah, there’s… No, there’s… There have clearly been some examples of private equity investments in hospitals and in nursing homes that have led to really catastrophic results for those institutions and for patients at those places. But I think the broader question of whether private equity as a structure that owns health care entities is necessarily bad or good, I think that’s what we don’t know about.
Rovner: Yeah, I mean, there’s an argument that you can have the efficiencies of scale, and that there may be, and that they can bring some business acumen to this. There are certainly reasons that it made sense when it started. The question is what the private equity is in it for.
Is it there to try to support the organization? Or is it there to do what a lot of private equity has done, which is just sort of take the parts, pull as much value as you can out of them, and discard the rest, which doesn’t work very well in the health care system.
Sanger-Katz: I also think one thing that’s very hard in this issue — and I think in others that relate to changes in the business structure of health care — is that it’s, like, by the time we really know, it’s almost too late. There’s all of this incredible scholarship looking at the effects of hospital consolidation, that it’s pretty bad that when you have too much hospital concentration; particularly in individual markets, that prices go up, that quality goes down. It’s really clear. But by the time that research was done so many markets were already highly consolidated that there wasn’t a way to go back.
And so I think there’s a risk for private equity investment of something similar happening that when and if we find out that it’s bad, they will have already rolled up so much of medical practice and changed the way that those practices are run that there’s not going to be a rewind button. On the other hand, maybe it will turn out to be OK, or maybe it will turn out to be OK in certain parts of the health care system and not in others. And so there is, I think, a risk of over-regulating in the absence of evidence that it’s a problem.
Raman: Yeah. And I would just echo one thing that you said earlier is that about the exploratory stages. Everything that I can rack my brain and think of that Congress has done on this has been very much like, “Let’s have a discussion. Let’s bring in experts,” rather than like really proposing a lot of new things to change it. I mean, we’ve had some discussion in the past of just changing laws about physician-owned practices and things like that, but it hasn’t really gone anywhere. And some of the proponents of that are also leaving Congress after this election.
Rovner: And, of course, a lot of this is regulated at the state level anyway, which is part of the difficulty.
Sanger-Katz: And there is more action at the state level. There are a bunch of states that have passed laws that are requiring more transparency and oversight of private equity acquisitions in health care. That seems to be happening faster at the state level than at the federal level.
Raman: And so many times, it trickles from the state level to the federal level anyway, too.
Rovner: Maybe the states can figure out what to do.
Sanger-Katz: Yes.
Rovner: More questions.
[Audience member]: Oh, yeah. I have a question about access to health care. It seems that for the past few years, maybe since covid, almost everybody you talked to says, “I can’t get an appointment with a doctor.” They call, and it’s like six months or three months. And I’m curious as to what you think is going on because … in this regard.
Raman: I would say part of it is definitely a workforce issue. We definitely have more and more people that have been leaving due to age or burnout from the pandemic or from other issues. We’ve had more antagonism against different types of providers that there’ve been a slew of reasons that people have been leaving while there’s been a greater need for different types of providers. And so I think that is just part of it.
Rovner: I feel like some of this is the frog in the pot of water. This has been coming for a long time. There have been markets where people have… people unable to get in to see specialists. You break your leg, and they say, “We can see you in November.” And I’m not kidding. I mean, that’s literally what happens. And now we’re seeing it more with primary care.
I mean that the shortages that used to be in what we called underserved areas, that more and more of the country is becoming underserved. And I think because we don’t have a system. Because we’re all sort of looking at these distinct pieces, I think the health care workforce issue is going kind of under the radar when it very much shouldn’t be.
Sanger-Katz: There’s also, I think, quite a lot of regional variation in this problem. So I think there are some places where there’s really no problem at all and certain specialties where there’s no problem at all. And then there are other places where there really are not enough providers to go around. And rural areas have long had a problem attracting and retaining a strong health care workforce across the specialties.
And I think in certain urban areas, in certain neighborhoods, you see these problems, too. But I would say it’s probably not universal. You may be talking to a lot of people in one area or in a couple of areas who are having this problem. But, as Julie said, I think it is a problem. It’s a problem that we need to pay attention to. But I think it’s not a problem absolutely everywhere in the country right now.
Rovner: It is something that Congress… Part of this problem is because Congress, in 1997, when they did the Balanced Budget Act, wanted to do something about Medicare and graduate medical education. Meaning why is Medicare paying for all of the graduate medical education in the United States, which it basically was at that point? And so they put in a placeholder. They capped the number of residences, and they said, “We’re going to come back, and we’re going to put together an all-payer system next year.”
That’s literally what they said in 1997. It’s now 27 years later, and they never did it, and they never raised the cap on residencies. So now we’ve got all these new medical schools, which we definitely need, and we have all of these bright, young graduating M.D.s, and they don’t have residencies to go to because there are more graduating medical school seniors than there are residency slots. So that’s something we’re… that just has not come up really in the past 10 years or so. But that’s something that can only be fixed by Congress.
Raman: And I think even with addressing anything in that bubble we’ve had more difficulty of late when we were… as they were looking at the pediatric residency slots, that whole discussion got derailed over a back-and-forth between members of Congress over gender-affirming care.
And so we’re back again to some of these issues that things that have been easier to do in the past are suddenly much more difficult. And then some of these things are felt down the line, even if we are able to get so many more slots this year. I mean, it’s going to… it takes a while to broaden that pipeline, especially with these various specialized careers.
Rovner: Yeah, we’re on a trajectory for this to get worse before it gets better. There’s a question over here.
[Audience member]: Hi. Thanks so much. I feel like everybody’s talking about mental health in some way or another. And I’m curious, it doesn’t seem to be coming at the forefront in any of the election spaces. I’m curious for your thoughts.
Raman: I think it has come up some, but not as much as maybe in the past. It has been something that Biden has messaged on a lot. Whenever he does his State of the Union, mental health and substance use are always part of his bipartisan plan that he wants to get done with both sides. I think that there has been less of it more recently that I’ve seen that them campaigning on. I mean, we’ve done a little bit when it’s combined with something like gun violence or things like that where it’s tangentially mentioned.
But front and center, it hasn’t come up as much as it has in the past, at least from the top. I think it’s still definitely a huge issue from people from the administration. I mean, we hear from the surgeon general like time and time again, really focusing on youth mental health and social media and some of the things that he’s worried about there. But on the top-line level, I don’t know that it has come up as much there. It is definitely talked about a lot in Congress. But again, it’s one of those things where they bring things up, and it doesn’t always get all the way done, or it’s done piecemeal, and so …
Rovner: Or it gets hung up on a wedge issue.
Raman: Yep.
Sanger-Katz: Although I do think this is an issue where actually there is a fair amount of bipartisan agreement. And for that reason, there actually has been a fair amount of legislation that has passed in the last few cycles. I think it just doesn’t get the same amount of attention because there isn’t this hot fight over it. So you don’t see candidates running on it, or you don’t see people that…
There’s this political science theory called the Invisible Congress, which is that sometimes, actually, you want to have issues that people are not paying attention to because if they’re not as controversial, if they’re not as prominent in the political discourse, you can actually get more done. And infrastructure, I think, is a kind of classic example of that, of something like it’s not that controversial. Everybody wants something in their district. And so we see bipartisan cooperation; we got an infrastructure bill.
And mental health is kind of like that. We got some mental health investments that were part of the pandemic relief packages. There was some mental health investment that was part of the IRA, I believe, and there was a pretty big chunk of mental health legislation and funding that passed as part of the gun bill.
So I do think there’s, of course, more to do it as a huge problem. And I think there are probably more creative solutions even than the things that Congress has done. But I think just because you’re not seeing it in the election space doesn’t mean that there’s not policymaking that’s happening. I think there has been a fair amount.
Rovner: Yeah, it’s funny. This Congress has been sort of remarkably productive considering how dysfunctional it has been in public. But underneath, there actually has been a lot of lawmaking that’s gone on, bipartisan lawmaking. I mean, by definition, because the House is controlled by Republicans and the Senate by Democrats. And I think mental health is one of those issues that there is a lot of bipartisan cooperation on.
But I think there’s also a limit to what the federal government can do. I mean, there’s things that Congress could fix, like residency slots, but mental health is one of those things where they have to just sort of feed money into programs that happen. I think at the state and local level, there’s no federal… Well, there is a federal mental health program, but they’re overseeing grants and whatnot. I think we have time for maybe one more question.
[Audience member]: Hi. To your point of a lot of change happens at the regulatory level. In Medicaid one of the big avenues for that is 1115 waivers. And let’s take aside block granting or anything else for a minute. There’s been big bipartisan progress on, including social care and whole-person care models. This is not just a blue state issue. What might we expect from a Trump administration in terms of the direction of 1115s, which will have a huge effect on the kind of opportunity space in states for Medicaid? And maybe that we don’t know yet, but I’m curious. Maybe that 900-page document says something.
Sanger-Katz: Yeah, I think that’s an example of we don’t know yet because I think the personnel will really matter. From everything that I know about President Trump, I do not think that the details of Medicaid 1115 waiver policy are something that he gets up in the morning and thinks about or really cares that much about. And so I think …
Rovner: I’m not sure it’s even in Project 2025, is it?
Sanger-Katz: I think work requirements are, so that was something that they tried to do the last time. I think it’s possible that we would see those come back. But I think a lot really depends on who is in charge of CMS [Centers for Medicare & Medicaid Services] and Medicaid in the next Trump administration and what are their interests and commitments and what they’re going to say yes and no to from the states. And I don’t know who’s on the shortlist for those jobs, frankly. So I would just put that in a giant question-mark bin — with the possible exception of work requirements, which I think maybe we could see a second go at those.
Raman: I would also just point to his last few months in office when there were a lot of things that could have been changed had he been reelected; where they wanted to change Medicaid drug pricing. And then we had some things with block grants and various things that had we had a second Trump presidency we could have seen some of those waivers come to a fruition. So I could definitely see a push for more flexibility in asking states to come up with something new that could fall for under one of those umbrellas.
Rovner: Well, I know you guys have more questions, but we are out of time. If you enjoyed the podcast tonight, I hope you will subscribe. Listen to “What the Health?” every week. You can get it wherever you get your podcast. So good night and enjoy the rest of the festival. Thanks.
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KFF Health News' 'What the Health?': SCOTUS Rejects Abortion Pill Challenge — For Now
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
A unanimous Supreme Court turned back a challenge to the FDA’s approval and rules for the abortion pill mifepristone, finding that the anti-abortion doctor group that sued lacked standing to do so. But abortion foes have other ways they intend to curtail availability of the pill, which is commonly used in medication abortions, which now make up nearly two-thirds of abortions in the U.S.
Meanwhile, the Biden administration is proposing regulations that would bar credit agencies from including medical debt on individual credit reports. And former President Donald Trump, signaling that drug prices remain a potent campaign issue, attempts to take credit for the $35-a-month cap on insulin for Medicare beneficiaries — which was backed and signed into law by Biden.
This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Rachana Pradhan of KFF Health News, and Emmarie Huetteman of KFF Health News.
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Rachana Pradhan
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Among the takeaways from this week’s episode:
- All nine Supreme Court justices on June 13 rejected a challenge to the abortion pill mifepristone, ruling the plaintiffs did not have standing to sue. But that may not be the last word: The decision leaves open the possibility that different plaintiffs — including three states already part of the case — could raise a similar challenge in the future, and that the court could then vote to block access to the pill.
- As the presidential race heats up, President Joe Biden and former President Donald Trump are angling for health care voters. The Biden administration this week proposed eliminating all medical debt from Americans’ credit scores, which would expand on the previous, voluntary move by the major credit agencies to erase from credit reports medical bills under $500. Meanwhile, Trump continues to court vaccine skeptics and wrongly claimed credit for Medicare’s $35 monthly cap on insulin — enacted under a law backed and signed by Biden.
- Problems are compounding at the pharmacy counter. Pharmacists and drugmakers are reporting the highest numbers of drug shortages in more than 20 years. And independent pharmacists in particular say they are struggling to keep drugs on the shelves, pointing to a recent Biden administration policy change that reduces costs for seniors — but also cash flow for pharmacies.
- And the Southern Baptist Convention, the nation’s largest branch of Protestantism, voted this week to restrict the use of in vitro fertilization. As evidenced by recent flip-flopping stances on abortion, Republican candidates are feeling pressed to satisfy a wide range of perspectives within even their own party.
Also this week, Rovner interviews KFF president and CEO Drew Altman about KFF’s new “Health Policy 101” primer. You can learn more about it here.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: HuffPost’s “How America’s Mental Health Crisis Became This Family’s Worst Nightmare,” by Jonathan Cohn.
Anna Edney: Stat News’ “Four Tops Singer’s Lawsuit Says He Visited ER for Chest Pain, Ended Up in Straitjacket,” by Tara Bannow.
Rachana Pradhan: The New York Times’ “Abortion Groups Say Tech Companies Suppress Posts and Accounts,” by Emily Schmall and Sapna Maheshwari.
Emmarie Huetteman: CBS News’ “As FDA Urges Crackdown on Bird Flu in Raw Milk, Some States Say Their Hands Are Tied,” by Alexander Tin.
Also mentioned on this week’s podcast:
- Bloomberg News’ “Dozens of CVS Generic Drug Recalls Expose Link to Tainted Factories,” by Anna Edney and Peter Robison.
- KFF Health News’ “Biden Plan To Save Medicare Patients Money on Drugs Risks Empty Shelves, Pharmacists Say,” by Susan Jaffe.
- KFF Health News’ “More States Legalize Sales of Unpasteurized Milk, Despite Public Health Warnings,” by Tony Leys.
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Transcript: SCOTUS Rejects Abortion Pill Challenge — For Now
KFF Health News’ ‘What the Health?’ Episode Title: ‘SCOTUS Rejects Abortion Pill Challenge — For Now’Episode Number: 351Published: June 13, 2024
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Mila Atmos: The future of America is in your hands. This is not a movie trailer and it’s not a political ad, but it is a call to action. I’m Mila Atmos and I’m passionate about unlocking the power of everyday citizens. On our podcast “Future Hindsight,” we take big ideas about civic life and democracy and turn them into action items for you and me. Every Thursday we talk to bold activists and civic innovators to help you understand your power and your power to change the status quo. Find us at futurehindsight.com or wherever you listen to podcasts.
Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, June 13, 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 Anna Edney of Bloomberg News.
Anna Edney: Hi there.
Rovner: Rachana Pradhan of KFF Health News.
Rachana Pradhan: Hello.
Rovner: And Emmarie Huetteman, also of KFF Health News.
Emmarie Huetteman: Good morning.
Rovner: Later in this episode we’ll have my interview with KFF President and CEO Drew Altman, who I honestly can’t believe hasn’t been on the podcast before. He is here to talk about “Health Policy 101,” which is KFF’s all-new, all-in-one introductory guide to health policy. But first, this week’s news.
So, as we tape, we have breaking news from the Supreme Court about that case challenging the abortion pill mifepristone. And you know how we always say you can’t predict what the court is going to do by listening to the oral arguments? Well, occasionally you can, and this was one of those times the court watchers were correct. The justices ruled unanimously that the anti-abortion doctors who brought the suit against the pill lack standing to sue. So the suit has been dismissed, wrote Justice [Brett] Kavanaugh, who wrote the unanimous opinion for the court: “A plaintiff’s desire to make a drug less available for others does not establish standing to sue.” So, might anybody have standing? Have we not maybe heard the end of this case?
Edney: Yeah, I think certainly there could be someone else who could decide to do that. I mean, just quickly looking around when this came out, it seems like maybe state AGs [attorneys general] could take this up, so it doesn’t seem like it’s the last of it. I also quickly saw a statement from Sen. [Bill] Cassidy, a Republican, who mentioned this wasn’t a ruling on the merits exactly of the case, but just that these doctors don’t have standing. So it does seem like there would be efforts to bring it back.
Rovner: This is not going to be the last challenge to the abortion pill.
Edney: Yeah.
Pradhan: Just looking in my inbox this morning after the decision, I mean it’s clear the anti-abortion groups are really not done yet. So I think there’s going to be a lot of pressure, of course, from them. It is an election year, so they’re trying to get, notch wins as far as races go, but also to get various AGs to keep going on this.
Rovner: And if you listen to last week’s podcast, there are three AGs who are already part of this case, so they may take it back with the district court judge in Texas. We shall see. Anyway, more Supreme Court decisions to come.
But moving on to campaign 2024 because, and this seems impossible, the first presidential debate is just two weeks away.President [Joe] Biden is still struggling to convince the public that he’s doing things that they support. Along those lines, this week the administration proposed rules that would ban medical debt from being included in calculating people’s credit scores. I thought that had happened already. What would this do that hasn’t already been done?
Huetteman: Well, last year the big credit agencies volunteered to cut medical debt that’s below $500 from people’s credit reports. Of course, there’s a lot of evidence that shows that that’s not really the way that people get hurt with their credit scores, they get hurt when they have big medical bills. So this addresses a major concern that a lot of Americans have with paying for health care in the United States.
I oversee our “Bill of the Month” project with NPR and I can say that a lot of Americans will pay their medical bills without question, even for fear of harm to their credit score, even if they think that their bill might be wrong. Also, it’s worth noting also that researchers have found that medical debt does not accurately predict whether an individual is credit-worthy, actually, which is unlike other kinds of debt that you’d find on credit scores.
Rovner: So yeah, not paying your car payment suggests what you might or might not be able to do with a mortgage or a credit card. But not paying your surprise medical bill, maybe not so much?
Huetteman: Yes, exactly. Really, we can all end up in the emergency room with a big bill. You don’t get a big bill just because you have trouble meeting your credit card bills or you have trouble meeting your car payments, for example.
Rovner: We’ll see if this one resonates with the public because a lot of the things that the administration has done have not. Meanwhile, President [Donald] Trump, who presided over one of the most rapid and successful vaccine development projects ever, for the covid vaccine, now seems to be moving more firmly into the anti-vax camp, and it’s not just apparently anti-covid vaccine. Trump said at a rally last month that he would strip federal funding from schools with vaccine mandates — any vaccines apparently, like measles and mumps and polio — and he says he would do it by executive order. No legislation required. This feels like it could have some pretty major consequences if he followed through on this. Anna, I see you nodding. You have a toddler.
Edney: Right, right. I was just thinking about that going into kindergarten, what that could mean, and there’s just so many … I mean, even kids don’t have to get chickenpox nowadays. That seems like a really great thing. I don’t know. I mean, I had chickenpox. I think that it could take us backwards, obviously, into a time that we’re seeing pockets of as measles crops up in certain places and things like that. I’d be curious. What I don’t know is how much federal funding supports a lot of these schools. I know there’s state funding, county funding, how much that’s actually taking away if it would change the minds of certain ones. But I guess if you’re in maybe a state that doesn’t like vaccines in the first place, it’s a free-for-all to go ahead and do that.
Pradhan: One of the questions I have, too, is through the CDC [Centers for Disease Control and Prevention] we have the Vaccines for Children Program, which provides free immunizations to children for a lot of these infectious diseases, for children who are either uninsured or underinsured or low-income. And so that’s been a really long-standing program and I’m very curious as to whether they would try to maybe reduce or eliminate a bunch of the vaccines that are provided through that, which obviously could affect a significant number of children nationwide.
Rovner: Yeah, it’s funny, the anti-vax movement has been around for, I don’t know, 20, 25 years; whenever that Lancet piece that later got rescinded came out that connected vaccines to autism. It seems it’s getting a boost and, yes, that’s an intended pun right now. I guess covid, and the doubts about covid, is pushing onto these other vaccines, too.
Edney: I think that we’ve certainly seen that. Before covid, at least my understanding of a lot of the concerns around the behavioral issues and autism linked to vaccines or things like that was more of the left-wing, maybe crunchier people who were seeing it as not wanting to put, in their words, poison in their bodies. But now we’re seeing this also right-wing opposition to it, and I think that’s certainly linked to covid. Any mandate at this point from the government is pushed back against more so than before.
Rovner: Well, we have lots of news this week on drugs and drug prices. Anna, you have quite the story about how trying to save money by buying generic might not always be the best move? As I describe it: the scary story of the week. Tell us about it.
Edney: Yes. Yeah, thank you. Yeah, I did this data dive looking into store-brand medication. So when you go into CVS or Walgreens, for example, you can see the Tylenol brand name there, but next to it you’ve got one that looks a lot like it, but it’s got CVS Health or Walgreens on the name and it costs usually a few dollars less. What I found is that of those store brands, CVS has a lot more recalls than the rest, even though they’re selling these same store-brand drugs. So they have two to three times more recalls than Walgreens and Walmart. And what’s happening is they are more often going to shady contract manufacturers to make their generic products that they’re selling over the counter. I found one that was making kids’ medication with contaminated water. And then the really disturbing one that was nasal sprays for babies on the same machines that this company was using to make pesticides. And just wrote about a whole litany of these kinds of companies that CVS is hiring at a higher rate than the other two — Walgreens and Walmart — that I was able to do the data dive on.
And interestingly, these store brands have a loophole, so they’re not responsible for the quality of those medications, even though their name’s on it. They can just walk away and say, “Well, we put it on the shelves. We agree with that, but it’s up to these companies that are making it to verify the quality.” And so, that’s usually not how this works. Even if there’s contract manufacturers, which a lot of drugmakers use, they usually have to also verify the quality. But store brands are considered just distributors, and so there’s this separation of who even owns the responsibility for this drug.
Pradhan: Yeah, I think a collective reaction reading this. I know, how many people did I text your story to Anna, saying, “Yikes! … FYI.”
Rovner: So on the one hand, you get what you pay for. On the other hand, price is not the only problem that we find with drugs. A new study from the University of Utah Drug Information Service just found that pharmacists are reporting the largest number of drugs in shortage since the turn of the century. And my colleague Susan Jaffe has a story on how some shortages are being exacerbated at the pharmacy level by a new Medicare rule that was intended to lower prices for patients at the counter.
Anna, how close are we to the point where the drug distribution system is just going to collapse in on itself? It does not seem to be working very well.
Edney: Yeah, it does feel that way because I always think of that example of the long balloon and when you squeeze it at one end the other end gets bigger. Because when you’re trying to help patients at the counter, somebody’s taking that hit, that money isn’t just appearing out of thin air in their pockets. So the pharmacists are saying — and particularly smaller pharmacies, but also some of the bigger ones — are saying the way that these drugs are now being reimbursed, how that’s working under this new effort, is they don’t have as much cash on hand, so they’re having trouble getting these big brand-name drugs. It was a really interesting story that Susan wrote. Just shows that you can’t fix one end of it, you need to fix the whole thing somehow. I don’t know how you do that.
And shortages are another issue just of other kinds, whether it’s quality issues or whether it’s the demand is growing for a lot of these drugs, and depending even on the time of year. So I think we’re all seeing it just appear to be disintegrating and hoping that there’s just no tragedy or big disaster where we really need to rely on it.
Rovner: Yeah, like, you know, another pandemic.
Edney: Exactly.
Rovner: There’s also some good news on the drug front. An FDA [Food and Drug Administration] advisory committee this week recommended approval for yet another potential Alzheimer’s drug, donanemab, I think I’m pronouncing that right. I guess we’ll learn more as we go on. The drug appears to have better evidence that it actually slows the progression of the disease without the risks of Aduhelm, the controversial drug approved by the FDA that’s been discontinued by its manufacturer. This would be the second promising drug to be approved following Leqembi last year. When we first started talking about Aduhelm — what was that, two years ago — we talked about how it could break Medicare financially because so many people would be eligible for such an expensive drug. So now we’re looking at maybe having two drugs like this and I don’t hear people talking about the potential costs anymore.
Is there a reason why or are we just worried about other things?
Edney: Well, I think there’s a benefit that they seem to have proven more than Aduhelm. But there’s also still a risk of brain swelling and bleeding, and that I’m sure would factor into someone’s decision of whether they want to try this. So maybe people aren’t exactly flocking in the same way to want to get these drugs. As they’re used more, maybe that changes and we see more of “Can you spot the swelling? Can you stop it?” And things like that. But I think that there just seems to be a lot of questions around them. Also, Aduhelm was the biggest one, which obviously Medicare didn’t cover, and then they’re not even trying to sell anymore. But I think that there’s just always questions about how they’re tested, how much benefit really there is. Is a few months worth that risk that you could have a major brain issue?
Rovner: While we are on the subject of drugs and drug prices, we have “This Week in Misinformation” from former President Trump, who as we all know, likes to take credit for things that are not his and deflect blame from things that are. Now in a post on his Truth Social platform, he says that he is the one who lowered insulin copayments to $35 a month, and that President Biden “had nothing to do with it.” Yes, the Trump administration did offer a voluntary $35 copayment program for Medicare Part D plans, but it was limited. It was time-limited and not all the plans adopted it. President Biden actually didn’t do the $35 copay either, but he did propose and sign the law that Congress passed that did it. It was part of the Inflation Reduction Act. Ironically, President Biden didn’t get all he wanted either. The intent was to limit insulin copayments for all patients, but so far, it’s only for those on Medicare. I would guess that Trump is saying this to try to neutralize one of the few issues that maybe is getting through to the public about something that President Biden did.
Pradhan: Well, I mean, I think even during President Trump’s first term, I mean lowering drug prices, he made it very clear that that was something that was important to him. He certainly wasn’t following the traditional or older Republican Party’s friendliness to the pharmaceutical industry. I mean, he was openly antagonizing them a lot, and so it’s certainly something that I think he understands resonates with people. And it’s a pocketbook issue similar to what’s going on on medical debt that we talked about earlier, right? These new regulations that are being proposed — they may not be finalized, we’ll have to see about that because of the timing — but these are things that are, I think at the end of the day, of course, are very relatable to people. Unlike, perhaps, abortion is a big campaign issue, but it’s not necessarily going to resonate with people in the same way and certainly not potentially men and women in the same way. But I think that there’s much more broad-based understanding of having to pay a lot for medications and potentially not being able to afford it. Obviously, insulin is probably the best poster child for a lot of reasons for that. So no surprise he wants to take credit for it, and also perhaps that it’s not really what happened, so …
Rovner: If nothing else, I think it signals that drug prices are still going to be a big issue in this campaign.
Pradhan: For sure. And I mean Joe Biden has made it very clear. I mean the Inflation Reduction Act of course included other measures to lower people’s out-of-pocket costs for drugs, which he’s very eagerly touting on the trail right now to shore up support.
Rovner: Let’s move on from drugs to abortion via the FDA spending bill on Capitol Hill this week. The annual appropriations bills are starting to move in House committees, which is notable itself because this is when they are supposed to start moving if they’re going to get done by Oct. 1, the start of the next fiscal year. We haven’t seen that in a long time. So last year Republicans got hung up because they wanted their leaders to attach all manner of policy riders to the spending bills, most of them aimed at abortion, which can’t get through the Senate. Well in a big shift, Republicans appear to be backing off of that, and the current version of the bill that funds the Department of Agriculture, as well as the FDA, does not include language trying to ban or further restrict the abortion pill mifepristone. Of course, that could still change, but my impression is that the new [House] Appropriations chairman, [Rep.] Tom Cole, who’s very much a pragmatist, wants to get his bills signed into law.
Pradhan: I do wonder, though, if because of the Supreme Court decision that just came out today, whether that will change the calculation, or at the very least, the pressure that he is under to include something in the FDA bill. But as you know, there’s plenty of time for abortion riders to make it in or out. I feel like this is, it’s like Groundhog Day. Usually something related to abortion policy will upend various pieces of legislation. So I’ll be curious to be on the lookout for that, whether it changes anything.
Rovner: Anna, were you surprised that they left it out, at least at the start?
Edney: Yeah, I think you’re just what we’ve seen with all of the rancor around abortion and abortion-related issues, I guess a little surprised. But also maybe it makes sense in just the sense that there are Republicans who are struggling with that issue and don’t want to have to keep talking about it or voting on it in the same way.
Rovner: Well, that leads right to my next subject, which is that the Senate is voting this afternoon, after we tape, on a bill that would guarantee access to IVF. Republicans are expected to block it as they did last week on the bill to guarantee access to contraception. But as of Wednesday, it’s going to be harder for Republicans to say they’re voting against the bill because no one is threatening to block IVF. That’s because the influential Southern Baptist Convention, one of the nation’s largest evangelical groups, voted, if not to ban IVF, at least to restrict the number of embryos that can be created and ban their destruction, which doctors say would make the treatments more expensive and less successful. It sounds like the rift among conservatives over contraception and IVF is a long way from getting settled here.
Huetteman: That certainly seems to be true. It’s also worth noting that there are a lot of influential members of Congress who are Baptist, of course, including House Speaker Mike Johnson. And I was refreshing my memory of the religious background of the current Congress with a Pew report: They say 67 members of this Congress are Baptist. Of course, Southern Baptist is the largest piece of that. And 148 are Catholic, which of course is another denomination that opposes IVF as well. So that’s a pretty big constituency that has their churches telling them that they oppose IVF and should, too.
Rovner: Yeah, everybody says they’re not coming for contraception, they’re not coming for IVF. I think we’re going to see a very spirited and continued debate over both of those things.
Well, speaking of the rift over reproductive health, former President Trump is struggling to please both sides and not really succeeding at it. He made a video address last week to the evangelical group, The Danbury Institute, which is a conservative subset of the aforementioned Southern Baptist Convention, in which former President Trump didn’t use the word abortion and skirted the issue. That prompted some grumbling from some of the attendees, reported Politico. Even as Democrats called him an anti-abortion radical for even speaking to the group, which has labeled abortion “child sacrifice.”
So far, Trump has gotten away with telling audiences what they want to hear, even if he contradicts himself regularly. But I feel like abortion is maybe the one issue where that’s not going to work.
Pradhan: Well, I think the struggle really is even if people are more forgiving of him saying different things, it puts a lot of down-ballot candidates in a really difficult position. And I know, Julie, you’d wanted to talk about this, but Republican candidates for U.S. Senate, I mean just how they have to thread the needle, and I don’t know that voters will be as forgiving about changes in their position. So I think they say it’s like, it’s not just about you. It’s like when two people get married, they’re like, “It’s not just about the two of you. It’s like your whole family.” This is like the family is your party and everyone down-ballot who has to now figure out what the best message is, and as we’ve seen, they’ve really struggled with “We’ve shifted now from being many candidates and Republican officeholders supporting basically near-total abortion bans, if not very early gestational limits, to the 15-week ban being a consensus position.” And now saying, well, Trump’s saying he’s not going to sign a national abortion ban, so let’s leave it to the states. I mean, it keeps changing, and I think obviously underscores the difficulty that they’re all having with this. So I don’t think it helps for him to be saying inconsistent things all the time because then these other candidates for office really struggle, I think, with explaining their positions also.
Rovner: So as I say every week, I’ve been covering abortion for a very long time, and before Roe [v. Wade] was overturned the general political rule is you could change positions on abortion once. If you were anti-abortion you could become pro-choice, and we’ve seen that among a lot of Democrats, Sen. [Bob] Casey in Pennsylvania, sort of a notable example. And if you supported abortion rights, you could become anti-abortion, which Trump kind of did when he was running the first time. Others have also as, there are … and again we’re seeing this more among Republicans, but not exclusively.
But people who try to change back usually get hammered. And as I say, Trump has violated every political rule about everything. So not counting him, I’m wondering about, as you say, Rachana, some of these Senate candidates, some of these down-ballot candidates who are struggling to really rationalize their current positions with maybe what they’d said before is something I think that bears watching over the next couple of months.
Huetteman: Absolutely. And we’re seeing candidates who will change their tone within weeks of saying something or practically days at this point. They’re really banking on our attention being pretty low as a public.
Rovner: Yeah. Although they may be right about that part.
Pradhan: Yeah, that’s true. And there’s a lot of time between now and November, but I think even the … just all the things, even this week of course, between now and November is an eternity. But we just talked about the Southern Baptist Convention stance on IVF. Of course, usually when these things happen, it prompts a lot of questions to lawmakers about whether they support that decision or not, whether they agree with it. And I think these court decisions … the Supreme Court, of course, will be out by the end of June, and so right now it might be fresh on people’s minds. But it’s hard to know whether September or October is the dominant or very prominent campaign issue in the same way.
Rovner: At the same time, we have a long way to go and a short way to go, so we will actually all be watching.
All right, well that is the news for this week. Now we will play my interview with Drew Altman and then we will come back and do our extra credits.
I am pleased to welcome to the podcast Drew Altman, president and CEO of KFF, and of course my boss. But lest you think that this is going to be a suck-up interview, you will see in a moment it’s also a shameless self-promotion interview. Drew, thank you so much for joining us.
Drew Altman: It’s great to be on “What the Health?” Thank you.
Rovner: I asked you here to talk about KFF’s new “Health Policy 101” project which launched last month, as a resource to help teach the basics of health policy. I know this is something you’ve been thinking about for a while. Tell us what the idea was and who’s the target audience here.
Altman: Well, since the Bronze Era, when I started KFF, faculty and students found their way to our stuff and they found it useful. It might’ve been a fact sheet about Medicaid or a policy brief about Medicare or a bunch of charts that we produced. But they’ve had to hunt and peck to find what they wanted and someone would find something on Medicaid or Medicare or the ACA [Affordable Care Act] or health care costs or women’s health policy or international comparisons or whatever it was. And for a very long time, I have wanted to organize our material about health policy for their world so that it was easy to find. It was one stop, and you could find all the basic materials that you wanted on the core stuff about health policy as a service to faculty and students interested in health policy because we don’t just analyze it and poll about it and report on it. We have a deep commitment. We really care about health policy and health policy education.
Rovner: You said those are the main topics covered. I assume that other topics could be added in the future? I mean, I could see a chapter on AI and health care.
Altman: Yes, and we’re starting with an introduction for me. There’s a chapter by Larry Levitt about challenges ahead. There’s a chapter by somebody named Julie Rovner on Congress and the agencies, who also wrote a book about all of that stuff, which is still available, folks.
Rovner: It desperately needs updating. So I’m pleased to be contributing to this.
Altman: But this is just the first year. And there were 13 chapters on the issues that I ticked off a moment ago and many more issues. And we’re starting the process of adding chapters. So the next chapter will probably be on LGBTQ issues, and then, though it’s not exactly the same thing as health policy, by popular demand, we will have a chapter on the basics of public health and what is the public health system, and spending on public health.
And I will admit, some of this also has origins in my own personal experience because before I was in government or in the nonprofit world or started and ran KFF, I was an academic at MIT [Massachusetts Institute of Technology] and I was fine when it came to big thoughts. And there I was and I’d written a book about health cost regulation. But what I didn’t know much about was how stuff really worked and the basics. And if I really needed to understand what was happening with regulation of private health insurance or the Medicaid program or the Medicare program, I didn’t really have any place to go to get basic information about the history of the program, or the details of the program, or a few charts that would give me the facts that I needed, or what are the current challenges. And when it really sunk in was when I left MIT and I went to work in what is now CMS [Centers for Medicare & Medicaid Services] and then was called the HCFA [Health Care Financing Administration], and boy on the first day did I realize what I did not know. It was only when I entered the real world of health policy that I understood how much I had to learn. So I wanted to bridge the two worlds a little bit by making available this basic “Health Policy 101.”
Rovner: I confess, I’m a little bit jealous that this hadn’t existed when I started to learn health policy because, like you, I had to ferret it all out, although thankfully KFF was there through most of it and I was able to find most of it along the way.
Altman: Exactly, and I think there’ll be other audiences for this because if you’re working on the Hill — but you don’t work full time on health — if you’re working in an association, if you’re working anywhere in the health care system, there’s lots of times when you really just need to understand. I just read about an 1115 waiver. What is that? Or what really is the difference between traditional Medicare and the Medicare Advantage plan? How is it that you get your drugs covered in the Medicare program? It seems to be lots of different ways. And just I’m confused. How does this actually work?
I’ll admit to you, also, I personally have an ulterior motive in all of this. And my ulterior motive is that it is my feeling now, and this has been a slowly creeping problem, that there isn’t enough what I would call health policy in health policy education. So that over time it has become more about what is fashionable now, which is delivery and quality and value.
And I won’t name names, but I spent a couple of days advising a health policy center at a renowned medical school about their curriculum in what they called health policy. And the draft of it had nothing in it that I recognized as health policy. Some of this is understandable. It’s because if you’re faculty with a disciplinary base — economics, political science, sociology, whatever — there’s no reason you would know a lot about what we recognize as the core of health policy. There has been a serious decline in faith in government, in young people taking jobs in certainly the federal government, but a little bit in state government as well. So the jobs now are all in the health care industry, they’re in tech, they’re in consulting firms. And so I think there’s just less of an incentive to learn a lot about Medicare, Medicaid, the ACA, the federal agencies, because you’re not going to go work in the federal agencies, at least as frequently as students did in my time. And so just to be blunt about it, I am, in my mind, trying to get more health policy back into health policy education.
Rovner: Well, as you know, I endorse that fully because that’s what we’re trying to do, too. One more question since I have you. I’ve been thinking about this a lot. When I started covering health policy shortly after you left HCFA, the big issue was people without insurance. And then throughout the early 2000s the big issue was spiraling costs. I feel like now the big issue is people who simply cannot navigate the system. The system has become so byzantine and complicated that, well, now there’s a “South Park” about it. I mean, it’s really to get even minor things dealt with is a major undertaking. I mean, what do you see as the biggest issue in policy for the next five or 10 years?
Altman: Well, I think the big issue for health care people used to be access to care. Now only about 8% of the population is uninsured. The big issue now is affordability, in my mind, and the struggles Americans are having paying their health care bills. It is an especially acute problem, virtually a crisis, for people with severe illnesses or people who are chronically ill. Fifty[%], 60% of those people really struggle to pay their medical bills. The crisis or the problem that isn’t discussed enough — because it isn’t a single problem it rears its head in so many ways — is the one you’re talking about: that is the complexity of the health care system. Just the sheer complexity of it; how difficult it is to navigate and to use for people who have insurance or don’t have insurance. Larry Levitt and I wrote a piece in JAMA about this, and we, all of us at KFF, are trying to focus more attention on that problem. Need to do more work on that problem and the many parts of it. It’s partly why we set up an entire program a couple of years ago on consumer and patient protection, where we intend to focus more on just this issue of the complexity of the system makes it hard to make it work for people. But especially for patients who are people who encounter the system because they need it.
Rovner: Well, we will both continue to try to keep explaining it as it keeps getting more byzantine. Drew Altman, thank you so much for joining us.
Altman: Thank you, Julie, very much.
Rovner: OK, we are back. It’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Emmarie, why don’t you go first this week?
Huetteman: Sure. My story comes from CBS [News]. The headline is “As FDA Urges Crackdown on Bird Flu in Raw Milk, Some States Say Their Hands Are Tied.” So the story says that there are three more states that have had their first reported cases of bird flu in the last month. And two of them don’t really have a way to conduct increased oversight of dairy cows and the industry that seems to be particularly having problems here. Wyoming and Iowa are those two states. Basically, these are states where raw milk is unregulated, so there’s no way for them to implement surveillance and restrictions on raw milk that might protect people from the fact that pasteurization appears to kill bird flu. But you don’t have pasteurization with raw milk, of course, that’s the definition.
Actually, this leads me to an extra, extra credit. KFF Health News’ Tony Leys wrote about the raw milk change in Iowa last year, and he was reporting on how Iowa only just changed their law, allowing legal sales of raw milk. And his story, among other things, pointed out that pasteurization helped rein in many serious illnesses in the past, including tuberculosis, typhoid, and scarlet fever. So unfortunately, this is a public health issue that’s been going on for a century or more, and we’ve got a method to deal with this, but not if you’re drinking raw milk. So that’s my story this week.
Rovner: Now people are going to drink raw milk and not get childhood vaccines. We’ll see how that goes. Sorry. Anna, you go next.
Edney: Yeah, mine is from Stat and it’s “Four Tops Singer’s Lawsuit Says He Visited ER for Chest Pain, Ended Up in Straitjacket.” It’s really scary, and maybe not totally surprising, unfortunately, that this is how an older Black man was treated when he went to the hospital. But this is Alexander Morris, a member of the Motown group The Four Tops. These are in the Rock & Roll Hall of Fame, The Four Tops, and he had chest pain and problems breathing and went to the hospital in Detroit and was immediately just assumed he was mentally ill, and he ended up quickly in a straitjacket. So he is suing this hospital. And I think he brought up in this article he’d seen people talk about driving while Black or walking while Black, and he essentially had become sick while Black. And he was able to prove he was a famous person and they took him out of the straitjacket. But how many other people haven’t had that ability, and just been assumed, because of the color of their skin, to not be having a serious health issue? So I think it’s worth a read.
Rovner: Yeah, it was quite a story. Rachana.
Pradhan: This week, I will take a story from The New York Times that is headlined “Abortion Groups Say Tech Companies Suppress Posts and Accounts.” It is basically an examination of how TikTok, Instagram, and others, how they moderate/remove content about abortion. What’s interesting about this is, so this is being told from the perspective of individuals who support access to abortion services. And it recounts some examples of Instagram suspending one group, it was called Mayday Health, which provides information about abortion pill access. There’s a telemedicine abortion service called Hey Jane, where TikTok briefly suspended them. What I thought was really interesting about this is anti-abortion groups have said for longer, actually, that technology companies have suppressed or censored information about crisis pregnancy centers, for example, that designed to dissuade women from having abortions. But I think it’s concerns about, broadly speaking, just what the policies are of some of these social media companies and how they decide what information is acceptable or not. And it details these examples of, again, women who support abortion access or posting TikToks that maybe spell abortion phonetically. Like “tion” is, instead of T-I-O-N, it’s S-H-U-N. Or they’ll put a zero instead of an O, and so it doesn’t get flagged in the same way. So yeah, definitely an interesting read.
Rovner: The fraughtness of social media moderation on this issue and many others. Well, my extra credit this week is from my fellow Michigan fan and sometime podcast guest Jonathan Cohn of HuffPost, and it’s called “How America’s Mental Health Crisis Became This Family’s Worst Nightmare.” And it’s basically the story of the entire mental health system in the United States over the last century, as told through the eyes of one middle-class American family, about one patient whose trip through the system came to a tragic end. Even if you think you know about this country’s failure to adequately treat people with mental illness, even if you do know about this country’s failures on mental health, you really do need to read this story. It is that good.
All right, that is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks as always to our technical guru, Francis Ying, and our doing-double-duty editor this week, Emmarie Huetteman. As always, you can email us your comments or questions. We’re whatthehealth, all one word, @kff.org. Or you can still find me at X, I’m @jrovner. Anna?
Edney: @annaedney.
Rovner: Rachana?
Pradhan: I’m @rachanadpradhan on X.
Rovner: Emmarie?
Huetteman: I’m lurking on X @EmmarieDC.
Rovner: We will be back in your feed next week. Actually, we’ll be coming to you from Aspen next week. But until then, be healthy.
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