KFF Health News' 'What the Health?': Federal Health Work in Flux
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.
Two months into the new administration, federal workers and contractors remain off-balance as the Trump administration ramps up its efforts to cancel jobs and programs — even as federal judges declare many of those efforts illegal and/or unconstitutional.
As it eliminates programs deemed duplicative or unnecessary, however, President Donald Trump’s Department of Government Efficiency is also cutting programs and workers aligned with Health and Human Services Secretary Robert F. Kennedy Jr.’s “Make America Healthy Again” agenda.
This week’s panelists are Julie Rovner of KFF Health News, Jessie Hellmann of CQ Roll Call, Sarah Karlin-Smith of the Pink Sheet, and Rachel Roubein of The Washington Post.
Panelists
Jessie Hellmann
CQ Roll Call
Sarah Karlin-Smith
Pink Sheet
Rachel Roubein
The Washington Post
Among the takeaways from this week’s episode:
- Kennedy’s comments this week about allowing bird flu to spread unchecked through farms provided another example of the new secretary of health and human services making claims that lack scientific support and could instead undermine public health.
- The Trump administration is experiencing more pushback from the federal courts over its efforts to reduce and dismantle federal agencies, and federal workers who have been rehired under court orders report returning to uncertainty and instability within government agencies.
- The second Trump administration is signaling it plans to dismantle HIV prevention programs in the United States, including efforts that the first Trump administration started. A Texas midwife is accused of performing illegal abortions. And a Trump appointee resigns after being targeted by a Republican senator.
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 “The Free-Living Bureaucrat,” by Michael Lewis.
Rachel Roubein: The Washington Post’s “Her Research Grant Mentioned ‘Hesitancy.’ Now Her Funding Is Gone.” by Carolyn Y. Johnson.
Sarah Karlin-Smith: KFF Health News’ “Scientists Say NIH Officials Told Them To Scrub mRNA References on Grants,” by Arthur Allen.
Jessie Hellmann: Stat’s “NIH Cancels Funding for a Landmark Diabetes Study at a Time of Focus on Chronic Disease,” by Elaine Chen.
Also mentioned in this week’s podcast:
- The Wall Street Journal’s “Trump Administration Weighing Major Cuts to Funding for Domestic HIV Prevention,” by Liz Essley White, Dominique Mosbergen, and Jonathan D. Rockoff.
- The Washington Post’s “Disabled Americans Fear Losing Protections if States’ Lawsuit Succeeds,” by Amanda Morris.
click to open the transcript
Transcript: Federal Health Work in Flux
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, March 20, 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 Rachel Roubein of The Washington Post.
Rachel Roubein: Hi.
Rovner: Sarah Karlin-Smith of the Pink Sheet.
Sarah Karlin-Smith: Hi, everybody.
Rovner: And Jessie Hellmann of CQ Roll Call.
Jessie Hellmann: Hello.
Rovner: No interview today, but, as usual, way more news than we can get to, so let us jump right in. In case you missed it, there’s a bonus podcast episode in your feed. After last week’s Senate Finance Committee confirmation hearing for Dr. Mehmet Oz to head the Centers for Medicare & Medicaid Services, my KFF Health News colleagues Stephanie Armour and Rachana Pradhan and I summarized the hearing and caught up on all the HHS [Department of Health and Human Services] nomination actions. It will be the episode in your feed right before this one.
So even without Senate-confirmed heads at — checks notes — all of the major agencies at HHS, the department does continue to make news. First, Robert F. Kennedy Jr., the new HHS secretary, speaks. Last week it was measles. This week it was bird flu, which he says should be allowed to spread unchecked in chicken flocks to see which birds are resistant or immune. This feels kind of like what some people recommended during covid. Sarah, is there any science to suggest this might be a good idea?
Karlin-Smith: No, it seems like the science actually suggests the opposite, because doctors and veterinary specialists are saying basically every time you let the infection continue to infect birds, you’re giving the virus more and more chances to mutate, which can lead to more problems down the road. The other thing is they were talking about the way we raise animals, and for food these days, there isn’t going to be a lot of genetic variation for the chickens, so it’s not like you’re going to be able to find a huge subset of them that are going to survive bird flu.
And then the other thing I thought is really interesting is just it doesn’t seem economically to make the most sense either as well, both for the individual farmers but then for U.S. industry as a whole, because it seems like other countries will be particularly unhappy with us and even maybe put prohibitions on trading with us or those products due to the spread of bird flu.
Rovner: Yeah, it was eyebrow-raising, let us say. Well, HHS this week also announced its first big policy effort, called Operation Stork Speed. It will press infant formula makers for more complete lists of ingredients, increase testing for heavy metals in formula, make it easier to import formula from other countries, and order more research into the health outcomes of feeding infant formula. This feels like maybe one of those things that’s not totally controversial, except for the part that the FDA [Food and Drug Administration] workers who have been monitoring the infant formula shortage were part of the big DOGE [Department of Government Efficiency] layoffs.
Roubein: I talked to some experts about this idea, and, like you said, they thought it kind of sounded good, but they basically needed more details. Like, what does it mean? Who’s going to review these ingredients? To your point, some people did say that the agency would need to staff up, and there was a neonatologist who is heading up infant formula that was hired after the 2022 shortage who was part of the probationary worker terminations. However, when the FDA rescinded the terminations of some workers, so, that doctor has been hired back. So I think that’s worth noting.
Rovner: Yes. This is also, I guess, where we get to note that Calley Means, one of RFK Jr.’s, I guess, brain trusts in the MAHA movement, has been hired as, I guess, in an Elon Musk-like position in the White House as an adviser. But this is certainly an area where he would expect to weigh in.
Hellmann: Yeah, I saw he’s really excited about this on Twitter, or X. There’s just been concerns in the MAHA movement, “Make America Healthy Again,” about the ingredients that are in baby formula. And the only thing is I saw that he also retweeted somebody who said that “breast is best,” and I’m just hoping that we’re not going back down that road again, because I feel like public health did a lot of work in pushing the message that formula and breast milk is good for the child, and so that’s just another angle that I’ve been thinking about on this.
Rovner: Yes, I think this is one of those things that everybody agrees we should look at and has the potential to get really controversial at some point. While we are on the subject of the federal workforce and layoffs, federal judges and DOGE continue to play cat-and-mouse, with lots of real people’s lives and careers at stake. Various judges have ordered the reinstatement, as you mentioned, Rachel, of probationary and other workers. Although in many cases workers have been reinstated to an administrative leave status, meaning they get put back on the payroll and they get their benefits back, but they still can’t do their jobs. At least one judge has said that does not satisfy his order, and this is all changing so fast it’s basically impossible to keep up. But is it fair to say that it’s not a very stable time to be a federal worker?
Karlin-Smith: That’s probably the nicest possible way to put it. When you talk to federal workers, everybody seems stressed and just unsure of their status. And if they do have a job, it’s often from their perspective tougher to do their job lately, and then they’re just not sure how stable it is. And many people are considering what options they have outside the federal government at this point.
Rovner: So for those lucky federal workers who do still have jobs, the Trump administration has also ordered everyone back to offices, even if those offices aren’t equipped to accommodate them. FDA headquarters here in Maryland’s kind of been the poster child for this this week.
Karlin-Smith: Yeah, FDA is an interesting one because well before covid normalized working from home and transitioned a lot of people to working from home, FDA’s headquarters couldn’t accommodate a lot of the new growth in the agency over the years, like the tobacco part of the FDA. So it was typical that people at least worked part of their workweek at home, and FDA really found once covid gave them additional work-from-home flexibilities, they were able to recruit staff they really, really needed with specialized degrees and training who don’t live near here, and it actually turned out to be quite a benefit from them.
And now they’re saying everybody needs to be in an office five days a week, and you have people basically cramped into conference rooms. There’s not enough parking. People are trying to review technical scientific data, and you kind of can’t hear yourself think. Or you’re a lawyer — I heard of a situation where people are basically being told, Well, if you need to do a private phone call because of the confidentiality around what you’re doing, go take the call in your car. So I think in addition to all of the concerns people have around the stability of their jobs, there’s now this element of, on a personal level, I think for many of them it’s just made their lives more challenging. And then they just feel like they’re not actually able to do, have the same level of efficiency at their work as they normally would.
Rovner: And for those who don’t know, the FDA campus is on a former military installation in the Maryland suburbs. It’s not really near any public transportation. So you pretty much have to drive to get there. And I think that the parking lots are not that big, because, as you pointed out, Sarah, the workforce is now bigger than the headquarters was created to accommodate it. And we’re seeing this across the government. This week it happened to be FDA. You have to ask the question: Is this really just an effort to make the government not work, to make federal workers, if they can’t fire them, to make them quit?
Hellmann: I definitely think that’s part of the underlying goal. If you see some of the stuff that Elon Musk says about the federal workforce, it’s very dismissive. He doesn’t seem to have a lot of respect for the civil servants. And they’ve been running into a lot of pushback from federal judges over many lawsuits targeting these terminations. And so I think just making conditions as frustrating as possible for some of these workers until they quit is definitely part of the strategy.
Roubein: And I think this is overlaid with the additional buyout offers, the additional early retirement offers. There’s also the reduction-in-force plans that federal workers have been unnerved about, bracing for future layoffs. So it’s very clear that they want to shrink the size of the federal workforce.
Rovner: Yeah, we’ve seen a lot of these people, I’ve seen interviews with them, who are being reinstated, but they’re still worried that now they’re going to be RIF-ed. They’re back on the payroll, they’re off the payroll. I mean there’s nothing — this does not feel like a very efficient way to run the federal government.
Karlin-Smith: Right. I think that’s what a lot of people are talking about is, again, going back to offices, for many of these people, is not leading to productivity. I talked to one person who said: I’m just leaving my laptop at the office now. I’m not going to take it home and do the extra hours of work that they might’ve normally gotten from me. And that includes losing time to commute. FDA is paying for parking-garage spaces in downtown Silver Spring [Maryland] near the Metro so that they can then shuttle people to the FDA headquarters. I’ve taken buses from that Metro to FDA headquarters. In traffic, that’s a 30-minute drive. They’re spending money on things that, again, I think are not going to in the long run create any government efficiency.
And in fact, I’ve been talking to people who are worried it’s going to do the opposite, that drug review, device review, medical product review times and things like that are going to slow. We talked about food safety. I think The New York Times had a really good story this week about concerns about losing the people. We need to make sure that baby formula is actually safe. So there’s a lot of contradictions in the messaging of what they’re trying to accomplish and how the actions actually are playing out.
Rovner: Well, and finally, I’m going to lay one more layer on this. There’s the question of whether you can even put the toothpaste back in the tube if you wanted to. After weeks of back-and-forth, the federal judge ruled on Tuesday that the dissolution of USAID [the U.S. Agency for International Development] was illegal and probably unconstitutional, and ordered email and computer access restored for the remaining workers while blocking further cuts. But with nearly everybody fired, called back from overseas, and contracts canceled, USAID couldn’t possibly come close to doing what it did before DOGE basically took it apart, right?.
Karlin-Smith: You hear stories of if someone already takes a new job, they’re lucky enough to find a new job, why are they going to come back? Again, even if you’re brought back, my expectation is a lot of people who have been brought back are probably looking for new jobs regardless because you don’t have that stability. And I think the USAID thing is interesting, too, because again, you have people that were working in all corners of the world and you have partnerships with other countries and contractors that have to be able to trust you moving forward. And the question is, do those countries and those organizations want to continue working with the U.S. if they can’t have that sort of trust? And as people said, the U.S. government was known as, they could pay contractors less because they always paid you. And when you take that away, that creates a lot of problems for negotiating deals to work with them moving forward.
Rovner: And I think that’s true for federal workers, too. There’s always been the idea that you probably could earn more in the private sector than you can working for the federal government, but it’s always been a pretty stable job. And I think right now it’s anything but, so comes the question of: Are we deterring people from wanting to work for the federal government? Eventually one would assume there’s still going to be a federal government to work for, and there may not be anybody who wants to do it.
Roubein: Yeah, you saw various hiring authorities given to try and recruit scientists and other researchers who make a lot, lot more in the public health sector, and some of those were a part of the probationary workforce because they had been hired recently under those authorities.
Rovner: Yeah, and now this is all sort of coming apart. Well, meanwhile, the cuts are continuing even faster than federal judges can rule against them. Last week, the administration said it would reduce the number of HHS regional offices from 10 to four. Considering these are where the department’s major fraud-fighting efforts take place, that doesn’t seem a very effective way of going after fraud and abuse in programs like Medicare and Medicaid. Those regional offices are also where lots of beneficiary protections come from, like inspections of nursing homes and Head Start facilities. How does this serve RFK Jr.’s Make America Healthy Again agenda?
Karlin-Smith: I think it’s not clear that it does, right? You’re talking about, again, the Department of Government Efficiency has focused on efficiency, cost savings, and Medicare and Medicaid does a pretty good job of fighting fraud and making HHS OIG [Office of Inspector General], all those organizations, they collect a lot of money back. So when you lose people—
Rovner: And of course the inspector general has also been laid off in all of this.
Karlin-Smith: Right. It’s not clear to me, I think one of the things with that whole reorganization of their chief counsel is people are suggesting, again, this is sort of a power move of HHS wanting to get a little bit more control of the legal operations at the lower agencies, whether it’s NIH [the National Institutes of Health] or FDA and so forth. But, right, it’s reducing head count without really thinking about what people’s roles actually were and what you lose when you let them go.
Rovner: Well, the Trump administration is also continuing to cut grants and contracts that seem like they’d be the kind of things that directly relate to Make America Healthy Again. Jessie, you’ve chosen one of those as your extra credit this week. Tell us about it.
Hellmann: Yeah. So my story is from Stat [“NIH Cancels Funding for a Landmark Diabetes Study at a Time of Focus on Chronic Disease”], and it’s about a nationwide study that tracks patients with prediabetes and diabetes. And it was housed at Columbia University, which as we know has been the subject of some criticism from the Trump administration. They had lost about $400 million in grants because the administration didn’t like Columbia’s response to some of the protests that were on campus last year. But that has an effect on some research that really doesn’t have much to do with that, including a study that looked at diabetes over a really long period of time.
So it was able to over decades result in 200 publications about prediabetes and diabetes, and led to some of the knowledge that we have now about the interventions for that. And the latest stage was going to focus on dementia and cognitive impairment, since some of the people that they’ve been following for years are now in their older ages. And now they have to put a stop to that. They don’t even have funding to analyze blood samples that they’ve done and the brain scans that they’ve collected. So it’s just another example of how what’s being done at the administration level is contradicting some of the goals that they say that they have.
Rovner: Yeah, and it’s important to remember that Columbia’s funding is being cut not because they deemed this particular project to be not helpful but because they are, as you said, angry at Columbia for not cracking down more on pro-Palestinian protesters after Oct. 7.
Well, meanwhile, people are bracing for still more cuts. The Wall Street Journal is reporting the administration plans to cut domestic AIDS-HIV programming on top of the cuts to the international PEPFAR [President’s Emergency Plan for AIDS Relief] program that was hammered as part of the USAID cancellation. Is fighting AIDS and HIV just way too George W. Bush for this administration?
Hellmann: It’s interesting because President [Donald] Trump unveiled the Ending the HIV Epidemic initiative in his first term, and the goal was to end the epidemic in the United States. And so if they were talking about reducing some of that funding, or I know there were reports that maybe they would move the funding from CDC [the Centers for Disease Control and Prevention] to HRSA [the Health Resources and Services Administration], it’s very unclear at this point. Then it raises questions about whether it would undermine that effort. And there’s already actions that the Trump administration has done to undermine the initiative, like the attacks on trans people. They’ve canceled grants to researchers studying HIV. They have done a whole host of things. They canceled funding to HIV services organizations because they have “trans” in their programming or on their websites. So it’s already caused a lot of anxiety in this community. And yeah, it’s just a total turnaround from the first administration.
Rovner: I know the Whitman-Walker clinic here in Washington, which has long been one of the premier AIDS-HIV clinics, had just huge layoffs. This is already happening, and as you point out, this was something that President Trump in his first term vowed to end AIDS-HIV in the U.S. So this is not one would think how one would go about that.
Well, it’s not just the administration that’s working to constrict rights and services. A group of 17 states, led by Texas, of course, are suing to have Biden-era regulations concerning discrimination against trans people struck down, except as part of that suit, the states are asking that the entirety of Section 504 of the Rehabilitation Act be declared unconstitutional. Now, you may never have heard of Section 504, but it is a very big deal. It was the forerunner of the Americans With Disabilities Act, and it prevents discrimination on the basis of disability in all federally funded activities. It is literally a lifeline for millions of disabled people that enables them to live in the community rather than in institutions. Are we looking at an actual attempt to roll back basically all civil rights as part of this war on “woke” and DEI [diversity, equity, and inclusion] and trans people?
Hellmann: The story is interesting, because it seems like some of the attorneys general are saying, That’s not our intent. But if you look at the court filings, it definitely seems like it is. And yeah, like you said, this is something that would just have a tremendous impact. And Medicaid coverage of home- and community-based services is one of those things that states are constantly struggling to pay for. You’re just continuing to see more and more people need these services. Some states have waiting lists, so—
Rovner: I think most states have waiting lists.
Hellmann: Yeah. It’s something, you have to really question what the intent is here. Even if people are saying, This isn’t our intent, it’s pretty black-and-white on paper in the court records, so—
Rovner: Yeah, just to be clear, this was a Biden administration regulation, updating the rules for Section 504, that included reference to trans people. But in the process of trying to get that struck down, the court filings do, as you say, call for the entirety of Section 504 to be declared unconstitutional. This is obviously one of those court cases that’s still before the district court, so it’s a long way to go. But the entire disability community, certainly it has their attention.
Well, we haven’t had any big abortion news the past couple of weeks, but that is changing. In Texas, a midwife and her associate have become the first people arrested under the state’s 2022 abortion ban. The details of the case are still pretty fuzzy, but if convicted, the midwife who reportedly worked as an OB-GYN doctor in her native Peru and served a mostly Spanish-speaking clientele, could be sentenced to up to 20 years in prison. So, obviously, be watching that one. Meanwhile, here in Washington, Hilary Perkins, a career lawyer chosen by FDA commissioner nominee Marty Makary to serve as the agency’s general counsel, resigned less than two days into her new position after complaints from Missouri Sen. Josh Hawley that she defended the Biden administration’s position on the abortion pill mifepristone.
Now, Hilary Perkins is no liberal trying to hide out in the bureaucracy. She’s a self-described pro-life Christian conservative hired in the first Trump administration, but she was apparently forced out for the high crime of doing her job as a career lawyer. Is this administration really going to try to evict anyone who ever supported a Biden position? Will that leave anybody left?
Roubein: I think what’s notable is Sen. Josh Hawley here, who expressed concerns and I had heard expressed concerns to the White House, and the post on X from the FDA came an hour before the hearing. There were concerns that he was not going to make it out of committee and—
Rovner: Before the Marty Makary hearing.
Roubein: Yes, sorry, before the vote in the HELP [Health, Education, Labor and Pensions] Committee on Marty Makary. And Hawley said because of that, he would vote to support him. What was interesting is two Democrats actually ended up supporting him, so he could have passed without Hawley’s vote. But I think in general it poses a test for Marty Makary when he’s an FDA commissioner, and how and whether he’s going to get his people in and how he’ll respond to different pressure points in Congress and with HHS and with the White House.
Rovner: And of course, Hawley’s not a disinterested bystander here, right?
Karlin-Smith: So his wife was one of the key attorneys in the recent big Supreme Court case that was pushed down to the lower courts for a lack of standing, but she was trying to essentially get tighter controls on the abortion pill mifepristone. But it seems like almost maybe Hawley jumped too soon before doing all of his research or fully understanding the role of people at Justice. Because even before this whole controversy erupted, I had talked to people the day before about this and asked them, “Should we read into this, her being involved in this?” And everybody I talked to, including, I think, a lot of people that have different views than Perkins does on the case, that they were saying she was in a role as a career attorney. You do what your boss, what the administration, wants.
If you really, really had a big moral problem with that, you can quit your job. But it’s perfectly normal for an attorney in that kind of position to defend a client’s interest and then have another client and maybe have to defend them wrongly. So it seems like if they had just maybe even picked up the phone and had a conversation with her, the whole crisis could have been averted. And she was on CNN yesterday trying to plead her case and, again, emphasize her positions because perhaps she’s worried about her future career prospects, I guess, over this debacle.
Rovner: Yeah, now she’s going to be blackballed by both sides for having done her job, basically. Anyway, all right, well, one big Biden initiative that looks like it will continue is the Medicare Drug Price Negotiation program. And we think we know this because CMS announced last week that the makers of all of the 15 drugs selected for the second round of negotiations have agreed to, well, negotiate. Sarah, this is news, right? Because we were wondering whether this was really going to go forward.
Karlin-Smith: Yeah, they’ve made some other signals since taking over that they were going to keep going with this, including last week at his confirmation hearing, Dr. Oz, for CMS, also indicated he seemed like he would uphold that law and they were looking for ways to lower drug costs. So I think what people are going to be watching for is whether they yield around the edges in terms of tweaks the industry wants to the law, or is there something about the prices they actually negotiate that signal they’re not really trying to get them as low as they can go? But this seems to be one populist issue for Trump that he wants to keep leaning into and keep the same consistency, I think, from his first administration, where he always took a pretty hard line on the drug industry and drug pricing.
Rovner: And I know Ozempic is on that list of 15 drugs, but the administration hasn’t said yet. I assume that’s Ozempic for its original purpose in treating diabetes. This administration hasn’t said yet whether they’ll continue the Biden declaration that these drugs could be available for people for weight loss, right?
Karlin-Smith: Correct. And I think that’s going to be more complicated because that’s so costly. So negotiating the price of drugs saves money. So yes, basically because Ozempic and Wegovy are the same drug, that price should be available regardless of the indication. But I’m more skeptical that they continue that policy, because of the cost and also just because, again, HHS Secretary Robert F. Kennedy seems to be particularly skeptical of the drugs, or at least using that as a first line of defense, widespread use, reliance on that. He tends to, in general, I think, support other ways of medical, I guess, treatment or health treatments before turning to pharmaceuticals.
Rovner: Eating better and exercising.
Karlin-Smith: Correct, right. So I think that’s going to be a hard sell for them because it’s just so costly.
Rovner: We will see. All right, that is as much news as we have time for this week. Now, it is time for our extra-credit segment, that’s where we each recognize the 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. Jessie, you’ve done yours already this week. Rachel, why don’t you go next?
Roubein: My extra credit, the headline is “Her Research Grant Mentioned ‘Hesitancy.’ Now Her Funding Is Gone.” In The Washington Post by my colleague Carolyn Y. Johnson. And I thought the story was particularly interesting because it really dove into the personal level. You hear about all these cuts from a high level, but you don’t always really know what it means and how it came about. So the backstory is the National Institutes of Health terminated dozens of research grants that focused on why some people are hesitant to accept vaccines.
And Carolyn profiled one researcher, Nisha Acharya, but there was a twist, and the twist was she doesn’t actually study how to combat vaccine hesitancy or ways to increase vaccine uptake. Instead, she studies how well the shingles vaccine works to prevent the infection, with a focus on whether the shot also prevents the virus from affecting people’s eyes. But in the summary of her project, she had used the word “hesitancy” once and used the word “uptake” once. And so this highlights the sweeping approach to halting some of these vaccine hesitancy research grants.
Rovner: Yeah that was like the DOD [Department of Defense] getting rid of the picture of the Enola Gay, the plane that dropped the atomic bomb, because it had the word “Gay” in it. This is the downside, I guess, of using AI for these sorts of things. Sarah.
Karlin-Smith: I took a look at a KFF story by Arthur Allen, “Scientists Say NIH Officials Told Them to Scrub mRNA References on Grants,” and it’s about NIH officials urging people to remove any reference to mRNA vaccine technology from their grants. And the story indicates it’s not yet clear if that is going to translate to defunding of such research, but the implications are quite vast. I think most people probably remember the mRNA vaccine technology is really what helped many of us survive the covid pandemic and is credited with saving millions of lives, but the technology promise seems vast even beyond infectious diseases, and there’s a lot of hope for it in cancer.
And so this has a lot of people worried. It’s not particularly surprising, I guess, because again, the anti-vaccine movement, which Kennedy has been a leader of, has been particularly skeptical of the mRNA technology. But it is problematic, I think, for research. And we spent a lot of time on this call talking about the decimation of the federal workforce that may happen here, and I think this story and some of the other things we talked about today also show how we may just decimate our entire scientific research infrastructure and workforce in the U.S. outside of just the federal government, because so much of it is funded by NIH, and the decisions they’re making are going to make it impossible for a lot of scientists to do their job.
Rovner: Yeah, we’re also seeing scientists going to other countries, but that’s for another time. Well, my extra credit this week, probably along the same lines, also from The Washington Post. It’s part of a series called “Who Is Government?” This particular piece [“The Free-Living Bureaucrat”] is by bestselling author Michael Lewis, and it’s a sprawling — and I mean sprawling — story of how a mid-level FDA employee who wanted to help find new treatments for rare diseases ended up not only figuring out a cure for a child who was dying of a rare brain amoeba but managed to obtain the drug for the family in time to save her. It’s a really good piece, and it’s a really excellent series that tells the stories of mostly faceless bureaucrats who actually are working to try to make the country a better place.
OK, that’s 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. 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? Sarah?
Karlin-Smith: A little bit everywhere. X, Bluesky, LinkedIn — @SarahKarlin or @sarahkarlin-smith.
Rovner: Jessie.
Hellmann: I’m @jessiehellmann on X and Bluesky, and I’m also on LinkedIn more these days.
Rovner: Great. Rachel.
Roubein: @rachelroubein at Bluesky, @rachel_roubein on X, and also on LinkedIn.
Rovner: We will be back in your feed next week. Until then, be healthy.
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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.
As abortion and other reproductive issues gain more prominence in the looming election, some Republicans are trying to moderate their anti-abortion positions, particularly in states where access to the procedure remains politically popular.
Meanwhile, open enrollment is underway for Medicare, even as some health plans are challenging in court the federal government’s decision to reduce their quality ratings — with millions of dollars at stake.
This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs Zhang of Stat, Sarah Karlin-Smith of the Pink Sheet, and Victoria Knight of Axios.
Panelists
Rachel Cohrs Zhang
Stat News
Sarah Karlin-Smith
Pink Sheet
Victoria Knight
Axios
Among the takeaways from this week’s episode:
- With polls showing more voters citing abortion as a top voting issue, some candidates with long track records opposing abortion rights are working to moderate their positions.
- Many older Americans will spend less on prescription drugs next year due to a new out-of-pocket pricing cap, among other changes in store as provisions of the 2022 Inflation Reduction Act take effect. But some are realizing the limits on those benefits, as deeper problems persist in drug pricing, insurance coverage, and access.
- The FDA is reconsidering a weight-loss drug decision that caused confusion for patients and compounding pharmacies. Compounded drugs are intended for individual issues, like needing a different dosage — and while the process can be used to augment mass manufacturing during times of drug shortages, it is not well suited to address access and pricing issues.
- In abortion news, a comprehensive study shows abortions have increased since the overturn of Roe v. Wade, even among women in states with strict restrictions — and those states are seeing higher infant mortality rates, according to separate research. And an effort is underway to revive in a Texas court the challenge to mifepristone’s FDA approval. The last challenge failed because the Supreme Court found the plaintiffs lacked standing.
Also this week, Rovner interviews Tricia Neuman, senior vice president of KFF and executive director of its Program on Medicare Policy, about Medicare open enrollment and the changes to the program for 2025.
Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: NBC News’ “Crisis Pregnancy Center’s Forms Give Rare Insight Into Anti-Abortion Practices,” by Abigail Brooks.
Sarah Karlin-Smith: Vanity Fair’s “Inside the Bungled Bird Flu Response, Where Profits Collide With Public Health,” by Katherine Eban.
Rachel Cohrs Zhang: The Atlantic’s “The Perverse Consequences of Tuition-Free Medical School,” by Rose Horowitch.
Victoria Knight: NPR’s “Why Catholic Bishops Are Donating Less To Oppose Abortion Rights Measures This Year,” by Rosemary Westwood and Jack Jenkins.
Also mentioned on this week’s podcast:
- The New York Times’ “Abortions Have Increased, Even for Women in States With Rigid Bans, Study Says,” by Claire Cain Miller and Margot Sanger-Katz.
- CNN’s “Infants Died at Higher Rates After Abortion Bans in the US, Research Shows,” by Deidre McPhillips.
click to open the transcript
Transcript: Less Than Two Weeks To Go
[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, Oct. 24, 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 video conference by Rachel Cohrs Zhang of Stat News.
Rachel Cohrs Zhang: Hi, everybody.
Rovner: Victoria Knight of Axios.
Victoria Knight: Hello, everyone.
Rovner: And Sarah Karlin-Smith of the Pink Sheet.
Sarah Karlin-Smith: Hi, everybody.
Rovner: Later in this episode we’ll have my interview with my friend and KFF colleague Tricia Neuman about Medicare open enrollment and what to expect in Medicare in the coming year.
But first, this week’s news. We will start on the campaign trail since Election Day is now less than two weeks away. Let that sink in. Abortion is, at least according to many polls, on the upswing as a voting issue and, probably not coincidentally, abortion-adjacent issues, like contraception, are also getting more attention. But while it’s clear that Democrats are still pretty much the party of abortion rights and Republicans are pretty much the party representing anti-abortion activists, we’re seeing some Republican candidates working pretty hard to muddy the waters. Yes?
Knight: Yeah, it’s been interesting this election cycle. We have seen some Republicans saying that they are pro-choice. And this is at a time when, finally, on the Democratic side in Congress, there really are not many anti-abortion Democrats left. We have in the House congressman Henry Cuellar [of Texas] is really the only one left. [Pennsylvania] Sen. Bob Casey, we’ve kind of seen him swing over time to be more in the camp of pro-choice, pro-abortion rights and so …
Rovner: … which was really, in Casey’s case, really interesting, because his father, who was the governor of Pennsylvania, was sort of the original anti-abortion Democrat back in the early 1990s.
Knight: Yeah. I’m interested to see if this works in — we’re seeing, particularly in some more moderate, swinging House seats, that Republicans are trying to message in this way that they’re more moderate on abortion, saying they’re more pro-choice. I’m interested to see if this actually works. And then we have perhaps this caucus within the House, if that works, that are more moderate. I mean, you already see in the current makeup of the House, there are some House Republicans, particularly the New York Republicans, that were really careful in this 118th Congress when they were having to vote on certain bills that would restrict, for example, access to mifepristone. That was kind of a rider in the FDA appropriations bill, and they didn’t want to vote for it, and they helped cause chaos on the House floor for that bill, particularly, because they didn’t want to pass it because they knew that would look bad on their record and they were having to run for the House again. So, will this messaging work for the kind of new people that are running this cycle? I’m not sure, but we’ll see.
Rovner: I was kind of surprised to see Liz Cheney this week (who was out campaigning with Vice President [Kamala] Harris), who’s strongly anti-abortion, has been her entire career, actually pipe up on her own — and she’s not running for anything; she’s basically a person without a party at the moment — but say that even though she’s anti-abortion, she is not in favor of some of the things that are happening with some of these abortion bans, like women having miscarriages not being able to get immediate medical [care]. I was fascinated to see somebody who, with as strong anti-abortion credentials as she has, speak out about these things that one would assume even people who are anti-abortion would not be against. We do see the anti-abortion group saying making abortion illegal doesn’t make it illegal to treat ectopic pregnancies and miscarriage care, even though it gets all muddled when you’re actually on the ground doing it and you’re a doctor facing potential jail time.
Knight: Well, and I think the thing is, people are seeing the realities of the abortion bans a couple of years in. I think that’s really the consequences. … When these first happened two years ago, people can say all these kind of things, but now that they’ve been in place for a couple years and women have died, we’re hearing these stories from news outlets of how that happens and it’s often women that want the babies. It’s like people are having to moderate their stances somewhat, I think.
Rovner: It’s — there’s nuance. … Politics is not great with nuance, but we’re seeing nuance.
Well, one abortion-adjacent story that jumped out at me this week is happening in Florida, where it seems that the office of Florida Gov. Ron DeSantis himself was behind legal threats to TV stations running ads in favor of the ballot measure that would enshrine abortion rights in the state’s constitution. According to the Tampa Bay Times, “Florida Department of Health general counsel John Wilson said he was given prewritten letters from one of DeSantis’ lawyers … Oct. 3 and told to send them under his own name, he wrote in a sworn affidavit.” Wilson subsequently resigned rather than send out more letters. In between, a judge warned the state to cease and desist with the threat, saying, and I quote, “It’s the First Amendment, stupid.” I have honestly never seen anything quite like this, although I would also point out I’ve never seen anything quite like Florida’s surgeon general recommending against people getting vaccines. What the heck is going on in Florida?
Cohrs Zhang: I think we’ve seen state officials in Florida try to enact their will and challenge public health recommendations. Certainly, we saw that happen during the covid-19 pandemic. They were trying to put out their own guidelines on vaccination, and so I don’t think it’s a particular surprise. I think it is just uglier than usual now that we get the full backstory on how these letters came to be. And court cases take a long time, and I think that’ll extend to beyond the next couple of weeks. But it’s an interesting publicity stunt for what it is, and yeah I …
Rovner: I wouldn’t want to be one of the TV stations threatening to have its license canceled, although the head of the FCC, I think, got involved too and said, “Um, this is not how this works.”
Cohrs Zhang: Yeah, I think so. I don’t expect that the court would find that political ads you don’t like are illegal, so, yeah.
Rovner: Yeah, I don’t think the governor can tell you to pull political ads that they don’t like. Pretty sure that’s not how these things work.
Well, meanwhile, given the very real possibility that Donald Trump will return to the White House, the D.C. rumor mill is already spinning out names of those who could fill Cabinet and other senior health posts. What are you guys hearing? And is RFK Jr. really going to end up in some big health policymaking job?
Knight: That’s funny that you say that because I was just having a talk with my editors about the names that we’re hearing. I have heard, and I am sure Rachel and Sarah have names on their mind as well, but someone said this to me, I think it’s funny: A very 2004 pick would be Bobby Jindal. He’s at the America First Policy Institute, which has a lot of former Trump administration people there, and it’s kind of seen this swing, I think recently, now that Project 2025 is kind of like no one wants to touch Project 2025 anymore. It seems like more people are, like, OK, AFPI is the place to pick people from if there’s a new Trump administration. And there’s been some stories this week about the chief of staff potentially coming from AFPI. So, people have been telling me Bobby Jindal, but I think he seems to have some solid grounding in that. You probably are more familiar with him, Julie, than I am, but …
Rovner: Oh, yes. I’ve known him since 2004. I’ve known him since before 2004. He was actually … he was brought to Washington by Democratic Sen. John Breaux to staff a Medicare commission back in, I think it was the very late 1990s. He served in Congress, he was the governor of Louisiana, and he served in HHS [the Department of Health and Human Services] in the George W. Bush administration. So he’s got lots of experience, and he’s coincidentally all over Twitter this week with a paid ad, trashing Kamala Harris’ support for “Medicare for All,” which, of course, she hasn’t supported since 2019. But yeah, suddenly Bobby Jindal, who we hadn’t seen in a while, is kind of everywhere. He was one of the bright young lights about, what, eight years ago?
Knight: Right, right.
Rovner: But I guess before Trump, he was one of the bright young Republican lights. So yeah, I keep hearing his name too.
Cohrs Zhang: I don’t know …
Rovner: Go ahead, Rachel.
Cohrs Zhang: I was just going to say that I don’t think there are a lot of people that we’ve been talking to who are worried about RFK himself getting appointed to one of these posts, but I think there has been a lot of buzz about some of his allies, like Calley and Casey Means. I know my colleague Isa Cueto did a great — just, profile of kind of who they are and kind of how their rise has just been so meteoric, and I think we’re also seeing some allies. So people who rose in the conservative movement over skepticism, over vaccine mandates, and just like the whole public health establishment have really gotten a new platform. And so I think people are a little nervous, as we’ve reported, both health care industry leaders who are worried about anti-pharmaceutical industry sentiment, anti-science sentiment, and even establishment Republican leaders and officials who served in prior Trump administrations that the picks could be more extreme than a Bobby Jindal establishment-Republican type and that this could be taking a turn.
Rovner: Sarah, what are you hearing with FDA?
Karlin-Smith: I mean, it’s a little less clear, I think, who might end up in FDA, but the sentiment has been probably a more typical Trump pick than maybe we got last time. FDA was sort of insulated in some ways, I think, from some of the drama, if you will, of the Trump administration last time. Scott Gottlieb was able to run FDA with pretty hands-off from other parts of the administration, and I think he ran FDA more like you would expect a traditional Republican to run FDA, not necessarily a Trump Republican. And I think people are recognizing that FDA will be a lot more vulnerable this time around that we’re probably not going to get another kind of Scott Gottlieb to save FDA if Trump is president. There’s certainly more concerns about how that impacts staff turnover as well, among civil service folks.
Rovner: Yeah, we will see.
All right, well, moving on. Open enrollment for Medicare began last week and continues until Dec. 7. That’s when people on Medicare can join or change their private prescription drug and/or Medicare Advantage plans. We explore this in more detail in my interview later in this episode with KFF’s Tricia Neuman. We know that most people with Medicare and most people with private insurance, where they can change plans during an open enrollment season, don’t actually bother to do anything. But this year there really are a lot of changes coming in Medicare, particularly on the prescription drug side. Why is it extra important this year that people take a look at their coverage?
Karlin-Smith: So, some of the big changes with the IRA [Inflation Reduction Act] that kick in this year for Medicare and the prescription side, like the $2,000 out-of-pocket cap. Your plan actually has to cover that. One thing, I was at a conference this week and they’re saying that drug has to be, actually be on your plan for you to reap those savings of hitting that cap, which seems obvious, but …
Rovner: Oh, I don’t know. I think people don’t quite realize that. It’s like they think that there’s a $2,000 cap no matter what, and it’s important. It’s, like, if your drug is not one of the drugs that’s covered by your plan, does not count.
Karlin-Smith: Right, and so it’s looking for all of those things to make sure all the pieces of your plan actually fit together with your medical needs. There’s been, I think, a reduction, in some degree, into the amount of particularly Part D stand-alone plans for people who elect to use traditional Medicare for their other health benefits. So you may just want to look a little bit more closely at what the options are, what the premiums are, because some of these changes to Part D have impacted premiums a bit, though the federal government has stepped in to try to alleviate that.
But I think this is seen as an adjustment year for the plans because one of the ideas behind the IRA is to put both health insurance companies as well as the pharmaceutical companies more on the hook, in some ways, for the cost of drugs. The old way Part D plans worked, the government ended up bearing a lot of the costs of the drugs to a point where it didn’t give a lot of incentives for both the drug companies to want to lower the prices, for the insurance companies to push for that. So I think it may take a little bit of time for them to figure out now how to adjust the benefits and the premiums and so forth, given this new dynamic. So people just may want to pay a little bit more close attention for premium aspects and others as well to the plans they’re picking.
Rovner: And if you’re helping someone on Medicare, which I know many people are, it’s good to do a little extra homework this year.
Well, another story that caught my eye is a survey of independent drugstores that suggests many of them won’t stock the very expensive drugs that Medicare negotiations are making less expensive, because they would actually lose money dispensing them. Sarah, is this an unexpected glitch, and can it be fixed, or is this just the price of bringing down drug prices?
Karlin-Smith: I would say not entirely unexpected. These independent pharmacies have warned CMS [the Centers for Medicare & Medicaid Services] and tried to push in guidance so that when they’re dispensing a drug, basically, they will be entitled to get quicker rebates from the drug companies so that they can make stocking these drugs more reasonable for them. And these pharmacies, I think in particular, have been raising alarm bells outside of Medicare drug price negotiations for a while now, that they’re being placed in these difficult positions where they have to buy drugs at whatever the wholesale acquisition cost is. And then there’s all of this insurance back-end stuff going on, and they sometimes get reimbursed by the plans and so forth for less than they’ve actually bought the drugs.
So it’s not just a Medicare drug price negotiation issue here. Some of it is, again, about the time that the pharmaceutical companies have to rebate the costs and they ask Medicare for a bit of leeway. And others, it’s just this broader way our system works, where they’re buying wholesale. You have a patient come to the counter that pays their small portion of it, their plan pays, whatever, and everybody has to sort of, right at the end … and these pharmacies are saying, “We can’t afford to do that.” I do think, politically, if this becomes a problem, if patients can’t get the negotiated prices/drugs at the pharmacies they’re used to, this could be politically problematic for the IRA moving forward. Even though, again, I’m not entirely sure. It’s illuminating a broader problem in the system that I think existed without it.
Rovner: Right, it’s all a big mess, and it’s underlining it.
Karlin-Smith: Right, but that doesn’t mean that politics won’t come into play and blame drug price negotiation. And certainly, anytime an opposing party hates something — we know Democrats are really into this, Republicans aren’t, and I’m sure they will try and blame it on the IRA as much as possible. And we’ll see if CMS maybe realizes that they had a little more leverage to try and make this a little bit easier and fixes it for the next round.
Rovner: Yeah. Before we leave Medicare, I want to talk briefly about Medicare Advantage. This Medicare Advantage market is so valuable to insurers and so competitive that we now have at least two lawsuits charging that Medicare wrongly lowered the number of quality stars some plans received. Now, this feels like a restaurant suing Yelp for lowering its rating from four stars to three, but in Medicare Advantage, this is a really big deal, right, when they lose a star?
Cohrs Zhang: Right, I think if the Yelp rating was worth $70 million, or whatever that figure is, then yeah, maybe they would sue. So I think we certainly — I think it’s a measure that is so important to insurers, to regulators, but that individual people might not understand. And there were some really interesting details from that lawsuit about the potential that there was one call-center call that tipped the balance into a quality measure and that there might’ve been some technical difficulties, and it does just cast these larger questions that I think I’ll be interested to see what documents come out during these lawsuits. And just questioning how useful these metrics really are, if that really was the case.
Rovner: Yeah, I found it, I also was taken aback. It’s like, really, one call to a customer service center didn’t happen properly, and so the whole plan loses a star? That seemed a little bit dramatic, but yes, like you, I’ll be interested to see. There’s a lot of pressure on Medicare Advantage from every conceivable angle, but we are now in litigation over it.
Well, while we are on the subject of private health companies suing the federal government, the compounding pharmacies who have been legally selling unapproved copies of the very popular and very expensive diabetes/obesity drugs Mounjaro and Zepbound have apparently successfully gotten the FDA to reverse its earlier finding, based on the pharmaceutical manufacturers’ say-so, that those drugs are no longer in shortage. That’s a decision that would’ve made it illegal for the compounders to continue to make and sell those drugs. At the same time, Novo Nordisk, maker of the very popular and very expensive diabetes/obesity drugs Ozempic and Wegovy, are trying to get the FDA to stop compounders from copying their drugs, which are still in shortage. Can somebody please explain what’s going on here?
Karlin-Smith: So, basically, compounding is where pharmacists can sometimes make drugs in a more customized fashion because a person maybe can’t swallow a pill or needs a slightly different dose or a different inactive ingredient, but there’s not …
Rovner: And they add flavoring for kids too, right?
Karlin-Smith: Right.
Rovner: Isn’t that a big compounding thing?
Karlin-Smith: But it’s not supposed to be something that takes the place of mass-manufactured drugs. But one of the times when it kind of can — and FDA, after some big safety incidents in 2013, developed a sort of scheme where there can be some degree mass compounding, but there’s a little bit more safety oversight from their end.
And one of the cases where you can do more compounding is when a drug is in shortage. But once FDA flipped the switch and said, “Oh, OK, actually, these drugs are no longer in shortage,” that makes it illegal. So these companies sued. My understanding from talking to legal experts is it’s not necessarily clear that FDA is entirely reversing course and agreeing that drugs aren’t in shortage. They’re agreeing to re-look at their decision, which may mean they are going to bolster their case so when they get back into court, they have a much clearer documentation of why the drugs are actually out of shortage. But in the meantime, we have probably at least another four weeks or so where everybody can compound these products.
At the same time, I think Novo Nordisk and, actually, Eli Lilly before them had also submitted a similar citizen petition to FDA trying to basically get these drugs from being on lists where you really could not compound them at all. And there’s clearly a lot of money at stake here. These are probably some of the most well-known drugs right now with huge markets in the U.S., but they’re also really expensive and they haven’t been picked up and covered by a lot of insurance plans, particularly when you’re talking about the weight loss element. I think for Type 2 diabetes, there’s pretty good coverage. And the thing here that’s really so significant is this is probably one of the first times in the U.S. where we’ve seen this mass-market compounding for a drug kind of at the beginning-ish of its exclusivity, at least when you’re talking about weight loss — again, not diabetes. And it’s not like a niche thing. So many people are using it, through compounding. And again, it’s really like …
Rovner: The advertising is everywhere on social media.
Karlin-Smith: Right, I mean, that just surprised me, I think, at first to begin with, how open these companies were about it being available via compounding pharmacies. And so I think FDA is in a really tricky position, particularly if they can clearly document it’s not a shortage situation anymore, because there still probably is going to be a lot of demand because of the cheaper prices coming from compounders, because of health insurance coverage issues. But, again, the compounding system is not meant to address those sorts of price and access issues. Right? It’s supposed to be for very particular situations where people really can’t use the exact manufactured drug, in most cases. And so maybe this tension will force us to address the other issues of price and insurance coverage, but it’s an awkward position for FDA to be in.
And again, because, I think, it’s just also important just to go backtrack and remember, you know, FDA facilitates an important role of inspecting the manufacturing facilities, ensuring every lot is being manufactured to a consistent quality, approving the drug to begin with. So there’s certainly this delicate dance of you want people to be able to get drugs they need and you also don’t want this kerfuffle to undermine the entire drug-approval system we have that ensures that when you get a drug, a prescription drug, you know it’s a certain quality.
Rovner: And it is what it says it is.
Karlin-Smith: Right.
Rovner: Yes. All right, well, turning back to abortion. A new study out this week suggests that not only has the number of abortions not gone down since the Supreme Court overturned Roe v. Wade, it actually might’ve gone up. Now there are lots of caveats with these numbers and, clearly, one big reason is the loosening of restrictions on obtaining abortion medication by mail. We also have a separate study this week that found infant mortality in states with abortion bans are rising, perhaps due to less available medical care in some of those states, as well as more fetuses with deadly anomalies being carried to term. But I have to wonder what these numbers will prompt from the anti-abortion side. Are they going to double down on efforts to impose some sort of nationwide restrictions or bans if Republicans regain control of the White House and Congress? And how are they going to address the rising infant mortality numbers? Victoria, are you hearing anything from the anti-abortion side? I’ve heard kind of not a lot. I’ve been surprised at how much I have not heard.
Knight: Yeah, I mean I think this has been an interesting election for them because I think Trump has said different things throughout this election cycle on his stance on abortion and being — taking credit for appointing the Supreme Court justices who overturned Roe, but then at the same time being, like, it’s a states issue. And I’ve seen some reporting on that a lot of these groups are frustrated with Trump, but they kind of are sticking with him for the moment because they’re, like, this is the guy we have.
So I think that perhaps they will put more pressure, depending on what the makeup of Congress is, and I think it’s important to remember it really depends on the majorities, this upcoming Congress, what will that look like? So if there is a Republican sweep, how many senators will be there? How many Republican senators? Also in the House, it may not be a huge majority either. And as we talked about earlier in this episode, there are some Republicans that are trying to walk the line more and be more moderate on abortion. And will they want to vote for a national abortion ban? That seems doubtful to me. And, for now, the filibuster is still in place in the Senate, so you still need 60 votes to pass anything. So, I think that they’re being quiet for now, but I think, depending on what Congress looks like, they could up their ante later.
Cohrs Zhang: Again, I think Congress just has no appetite really to talk about these things, and I don’t expect that to change, especially, like you said, with narrow majorities. And I just think that the cost-benefit, maybe we’re going to see new leadership in the Senate Republican party too, and I think a lot of that could shape how much appetite they have to pick a fight on this. So yeah, just a lot of unknowns at this point.
Rovner: And, as we’ve discussed before, if Trump is elected, he can do a lot from the executive branch that wouldn’t require Congress, and I completely agree with Rachel: I think Congress does not have a whole lot of appetite for this.
Knight: Right.
Rovner: Possibly on either side.
Knight: And I think one more thing also interesting to point out is that the current House speaker, Mike Johnson, is very anti-abortion. Throughout his congressional career and even his career as a state lawmaker, he’s always been very anti-abortion, but he’s been in power now over a year, at least a year, and he has done, really, nothing on this. And he has a slim majority, but also I think you see that, yeah, as Rachel said, there’s just not an appetite for it, so …
Rovner: He doesn’t have the votes.
Knight: Yeah, exactly. He doesn’t have the votes, but he’s staunchly anti-abortion, has done really nothing, so.
Rovner: Well, Sarah, you have a story on the revived lawsuit challenging the FDA over its rules for the abortion pill mifepristone. This is my chance to say I told you so, when the Supreme Court ruled that the original plaintiffs in this case did not have standing to sue. We said at the time: not over. Not over, right?
Karlin-Smith: Yeah, three states are trying to revive that case in the court in Texas, where it originated. And it’s not particularly a surprise, like you said, the Supreme Court didn’t totally throw out the case. They said, “You guys don’t have standing,” that the doctors’ group that filed suit there. One of the interesting things now, given the timing, is as this case moves forward and if Trump wins the election, it’s not really clear to me whether his FDA and his Justice Department and so forth would actually want to defend this case or whether they would just, again, use the powers they have and push FDA to go back to the older restrictions around mifepristone’s availability. And basically make it …
Rovner: We’re no longer talking about pulling it from the market right now? We’re just talking about the changes that were made in 2016 that makes it more easily available?
Karlin-Smith: Right, so they sort of …
Rovner: Is that a fair way to put it?
Karlin-Smith: That’s like one change, which by the time we got to the Supreme Court, we were largely arguing about this as well, but they had initially started to just — by trying to get it off the market entirely. But now we’re basically arguing about changes that have made it easier to take later in pregnancy, so up to 10 weeks, and just made it easier to access. So you can now get it via telehealth and via mail and so forth, which has been really important given some of the state-specific bans on abortion. And it’s why abortion pills have become a really much more popular method for abortion. So a lot of legal experts don’t actually think these three states have standing either, or have jurisdiction, certainly in this court. However, I think they also acknowledge there’s a good chance this case proceeds and proceeds very similarly to how it did before, if for no other reason than the judges involved in the past have been willing to let these states be heard in their courtroom.
Rovner: Yeah, it is in the 5th Circuit land of mostly Republican anti-abortion judges.
Karlin-Smith: Right. So there’s a good chance, again, barring this sort of scenario where Trump administration comes in and just says, “We’re not going to defend this. We’re going to revert to the old restrictions anyway.” But under a Democratic administration, they could end up back all the way at the Supreme Court having to defend mifepristone’s newer availability as well.
And the other thing that there’s been a number of mifepristone cases around the country, but there’s one that’s very similar in the 9th Circuit, where judges have basically ruled that the entire, what’s known as a REMS [risk evaluation and mitigation strategy], these restrictions related to mifepristone should actually be removed altogether. And they, actually, in some ways, want to make it more easily accessible. So whenever you have a circuits … but you also know that the Supreme Court is likely to take things up against. So yeah, I think the big thing is if people thought that last June’s Supreme Court ruling was kind of like Eh, it’s over, mifepristone is here to stay, that was just sort of the first round of many fights in access and availability of that in the courts.
Rovner: Could a Trump administration just say, “The FDA should never have approved this drug,” and pull it from the market? Or does somebody have to file a petition for that to happen?
Karlin-Smith: Ooh, that’s a good, tough question. I mean, there are very formal processes that go around withdrawing a drug. I think it would be challenging because at least the generic companies that manufacture the drug still want to be manufacturing it at this point. And I would imagine there would be quite a process FDA would have to go through, particularly to try and declare it no longer safe and effective to be marketed. And you, again, to raise strange history, I think if you looked at all the documents in science, because you have FDA scientists who over the years have declared it’s safe and effective and said, “Actually, as we’ve got more use with this, we realize you can actually give it to more women at different parts of pregnancy, and it’s safer than we thought. We don’t need to monitor a woman at a doctor’s office while she takes it.” So I think it would be challenging. I certainly wouldn’t put it past them trying this.
But it does get to, I think, what’s been worrying about this mifepristone case to begin with for just people outside of the abortion space, but who follow FDA and the drug industry, which is this lack of certainty you start to lose when politicians come in and start trying to undermine the scientific drug-approval process and using politics instead, and their whims, to shift what is available or not available, because, obviously, it undermines FDA’s authority.
And for the drug industry, I mean, a big thing they dislike is certainty, right? You’re investing millions, maybe even billions, of dollars to bring a drug to market. You want some confidence that if it’s successful and FDA says yes, it’s going to stay there unless some new, real, true safety event happens, which it does occasionally happen, but for the most part, you don’t want a new president to come into office or a new member of the Congress to flip and all of a sudden you have a drug that they’ve decided to challenge. So it’s an abortion case that’s always had these broader undertones of just confidence and trust and certainty around our scientific agencies in the U.S.
Rovner: Yet another space we will continue to watch. All right, that is this week’s news. Now we’ll play my interview with KFF’s Tricia Neuman, and then we’ll come back and do our extra credits.
I am so pleased to welcome to the podcast Tricia Newman, who’s KFF’s senior vice president and executive director of KFF’s Program on Medicare Policy, and senior adviser to the president, and the person I always turn to first when I have a question about Medicare and have done so for more than three decades. Tricia, welcome back to “What the Health?”
Tricia Neuman: Hi, Julie. Thanks for having me back.
Rovner: So, as anybody who watches over-the-air or cable TV knows, it’s Medicare open enrollment right now until Dec. 7. What should people in Medicare or people helping people in Medicare know about changes coming for 2025?
Neuman: This is the time for people to really compare coverage options. What we’ve seen in our own research is that most people don’t compare options during the open enrollment period, but plans change, people’s needs change, and this is a great moment. People have between now until Dec. 7, as you said. The important thing to do is figure out what is actually most important to either yourself or the person you’re helping.
Some people really need certain drugs covered by their plan, and so that might be the go-to question. Other people care very much about being able to see certain doctors or hospitals. So, for them, it’s a question of do they want to be in traditional Medicare, where they can see virtually any doctor and go to any hospital? Or if they want to be in a Medicare Advantage plan for a variety of reasons, the question is, are the doctors that they care most about covered by their plan?
Rovner: There are big changes coming next year both for prescription drugs and for Medicare Advantage, right?
Neuman: Absolutely. I mean, Medicare Advantage plans also cover prescription drugs, and what the big thing people need to know there is there’s a new out-of-pocket limit that’s coming. There’s not really much you have to do in order to get; it’s a Medicare benefit. So that’s really a huge change and it really is a change that helps people who take very expensive medications. I mean, I can tell you how helpful it would be to some family members of mine. I have a family member who is taking a drug, she had a Part D plan, and it was costing her $13,000 a year for this particular drug for her cancer treatment. With the new $2,000 out-of-pocket cap, her costs would drop from $13,000 to $2,000. Keep in mind that half of all people on Medicare live on an income of $36,000 or less, so this is a big deal. And not everybody is going to need this benefit in any given year, but over time, you never know. And so it’s a big change that will be helpful to people who take expensive medications.
Rovner: Over the spring and summer, it looked like, because of this $2,000 cap, Part D plans were going to raise their premiums dramatically. That mostly didn’t happen. Why not?
Neuman: The administration, the government put in place what they call a demonstration or a model, and essentially what it did is it limited premium increases. So no Part D plan will have a premium increase greater than $35 between 2024 and 2025.
Rovner: … of $35 a month.
Neuman: … of $35-a-month increase. Now that said, some will increase by $35, some will decrease. There are going to be changes, and that’s an important thing for people to keep an eye on as they consider their drug coverage for next year.
Rovner: There are Republicans in Congress who say that what the administration did was sort of unfairly politically tinkering with Medicare, but this isn’t the first time this kind of thing has been put into place, right?
Neuman: That’s absolutely true. I mean, I would agree that there was some concern that people in Medicare would see big increases in their drug premiums, and that was part of the concern that motivated the administration. But that was also a concern that motivated prior administrations. In fact, right after the drug benefit went into effect, and that was under the Bush administration, there were similar demonstrations that took effect. And at the time, nobody really complained because the main issue was protecting people from higher premiums.
Rovner: But now everything is more political.
Well, regular listeners to the podcast know that Medicare Advantage has become not just more popular among beneficiaries, but also much more controversial. Some companies are even using artificial intelligence to deny benefits and micromanaging doctors and other health care providers. Has the cost-benefit analysis for Medicare Advantage shifted over the past few years?
Neuman: I think the focus on Medicare Advantage has changed. The way people are thinking about it is changing. Medicare Advantage is quite popular among people because plans, for a variety of reasons related to their payments, are able to offer extra benefits, and they are appealing. I mean, dental, vision, hearing. Now, the latest thing is “flex cards,” which is just kind of offering money for people to sign up for a plan. So it’s really appealing, particularly for people with fixed incomes. But the medical community has sort of surfaced and started raising concerns about what these prior authorizations and other cost-management tools mean for them and for their patients.
So hospitals, for example, have expressed concerns about delayed payments. Doctors are now talking about prior authorization hassles. We recently did a study that documented 46 million prior-authorization requests, close to 2 million requests per enrollee. That’s a hassle for doctors. It also can delay or lead to no care for beneficiaries when it’s been prescribed by their doctor. It could, of course, limit inappropriate care, not necessary care, but I think the medical community now sees that Medicare Advantage is a big part of their patient profile and has some concerns.
We’ve also been reading stories about some medical groups that are saying that we’re not going to take any more Medicare Advantage patients. So I think there’s a little bit more of an eye toward, gee, this has gotten really big. We know it’s really popular, but it might require a closer look.
Rovner: Speaking of which, I mean, Medicare hasn’t really been a big campaign issue in 2024 when maybe it should have been. It doesn’t seem that safe to leave a program of its size and importance on autopilot, which is kind of what former President Trump is promising. What do we know about what Vice President Harris would do for Medicare if she were elected and what former President Trump would do if he was elected?
Neuman: We actually know very little about what former President Trump would do.
Rovner: He says he wouldn’t touch it.
Neuman: He said he wouldn’t touch it. He said he’s concerned about drug costs, but we’re not really sure what more he would do there. He was for a proposal called Most Favored Nation, but he’s now withdrawn support for that. So it’s hard to know whether he would implement anything new or scale back what has already become the law of the land. For example, it’s not clear what he would do about government negotiations and whether or not there would be sufficient pressure in his caucus to scale back that pretty popular proposal that was included in the Inflation Reduction Act.
Vice President Harris has talked about strengthening Medicare and improving the solvency, mostly through revenues on higher-income people. So that is one major proposal she has with regard to solvency. She has recently put out a proposal that would add a home care benefit to Medicare. This responds to a huge issue that you and I have talked about, that a lot of families across the country have talked about where people are really struggling to care for a family member. Family members are dropping out of the workforce in order to care for somebody because they cannot afford to get help at home. Medicare really does not currently provide a home care benefit except under limited circumstances. So this is recognizing a huge issue for families that are, it’s an economic issue if people, mostly women, have to step out of the workforce. It’s also an issue if you just cannot afford or you’re paying huge amounts for people to come into your home to help a parent, grandparent, spouse who’s unable to care for themselves. So that’s a big initiative on her part that would be funded primarily out of expanding Medicare’s ability to negotiate drugs.
Rovner: So neither candidate is talking about solvency issues with Medicare, though, and that’s a long-term issue that somebody’s going to need to address, right?
Neuman: Yes, that is absolutely true. It is an issue that is not going away. We have more and more people aging onto Medicare and the people who are on Medicare are getting older. And as people grow older, they tend to be more expensive. So this is not an imminent concern, but it is an issue that policymakers will have to deal with one way or the other in the years to come.
Rovner: Well, we will keep talking about it. Tricia Neuman, thank you so much.
Neuman: And thank you for having me, Julie.
Rovner: OK, we are back. 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. Victoria, why don’t you go first this week?
Knight: Sure. My extra credit is a story on NPR, it’s called “Why Catholic Bishops Are Donating Less To Oppose Abortion Rights Measures This Year.” It was on Weekend Edition, and it is by Rosemary Westwood and Jack Jenkins, basically detailing that in the past, the Catholic Church and bishops have been really big in the anti-abortion movement and that has also translated to donating a lot of money to anti-abortion campaigns. But this year, they’re kind of seeing almost a historic low in how little they’re donating to anti-abortion campaigns. And they didn’t really have a clear answer of what the reason for that was, except that maybe they’re just acknowledging the reality of the situation. When you look at particularly the ballot measures in states and how popular those have been — we’ve seen since 2022 that the ballot measures, even in more conservative-leaning states, that protect abortion access, and those vary depending on the state, what they look like, they’ve been really, really popular. And they really have been really overwhelmingly approved, even if there’s Republicans running on the same ballot with them and that people are voting for. People still really support abortion rights mostly.
So that seems to be the reason — they didn’t really have a clear reason, but it was an interesting marker in the trend of just kind of following where abortion rights are going, as well as where the Catholic Church is moving as well. It seems to be becoming somewhat more progressive over time.
Rovner: I was fascinated by this story, which I just heard on the radio as I was driving, because the Catholic Church is the originator of the right-to-life movement in the United States. And for a long time, it was almost exclusively the Catholic Church that was pushing this, and now it seems to have moved sort of into other places. So this is sort of the exclamation point on that, that it’s broadened and changed, but it’s no longer being driven as much by the Catholic Church as it used to be. Rachel, why don’t you go next?
Cohrs Zhang: Sure. So my piece is in The Atlantic, and the headline is “The Perverse Consequences of Tuition-Free Medical School,” by Rose Horowitch. And I just love this story because it’s a look back on this policy that seemed like a good idea at the time, where these really wealthy benefactors are donating to elite, often elite medical schools to make tuition free. And the whole idea was that more doctors will go into primary care if they don’t have debt, and it might open medical school to a more diverse cohort of students. And the opposite has almost happened, where they’re not seeing any more doctors going into primary care and their student body has actually gotten more wealthy than it was before. So I mean, it’s just a great check-in, because I feel like so often we’re just looking forward with the news that we don’t take a moment to question whether some of these policies or stories that we’ve covered, how they’ve worked out a couple of years later. So, I thought it was a great look back.
Rovner: Yes, in health care, so many things go in, we try things with so much promise, and sometimes they don’t work. So it’s good to notice when they don’t work. Sarah?
Karlin-Smith: I took a look at a Vanity Fair piece by Katherine Eban: “Inside the Bungled Bird Flu Response, Where Profits Collide With Public Health.” And it’s a fascinating deep dive to the challenges the U.S. has faced in containing what is, right now at least, mostly just an epidemic in animals, but certainly has public health folks worried about the potential for a human spillover pandemic, if not properly contained. And it’s just a really great story that shows you all of the tensions, and how it has a lot of these flashbacks to early days of covid, where you had different parts of the government with different responsibilities, not quite working together well, and not quite knowing how to play together well. Because you have the USDA in this case, which in many ways has the economics of farmers and the dairy industry in mind more than perhaps broader health concerns. You have FDA, which regulates milk; CDC, which comes in and does the human health; and then you have states, which don’t necessarily always have to answer to everything the federal government would like them to be doing here.
And the biggest, I think, crisis we face now is just we don’t have a lot of data. We don’t have enough information to truly know the scope of this outbreak. And without knowing that, I think you risk something bad happening before we are on top of it. And that’s really what people are really concerned about now, particularly with seasonal flu season coming up, is if you mix this virus and a human being with seasonal flu or even in an animal, you could develop an even more dangerous virus. So, it’s a warning to everybody in the public health space that this is something we need to be paying attention to because, obviously, the best thing to do is contain it and tamp it out and not have to deal with a much larger human pandemic.
Rovner: Yes, that would be nice. Something else to keep us awake at night.
My story this week is from NBC News, it’s called “Crisis Pregnancy Center’s Forms Give Rare Insight Into Anti-Abortion Practices,” by Abigail Brooks. She got a hold of the intake forms of a pregnancy center in Idaho, which included not just the typical medical questions, but also questions about religious and financial status. And one asking, “What decision would the father like you to make, regarding the outcome of your pregnancy?” The answers, which are not protected by HIPAA, because crisis pregnancy centers are not technically medical providers, allow the staff to score whether a patient is “abortion-vulnerable,” which would lead them to try to talk her out of ending the pregnancy.
It also includes a story of one patient who was strung along so long waiting for test results from this crisis pregnancy center that she ended up needing a second-trimester abortion. It’s quite the look at what goes on behind the scenes at some of these centers, and I strongly recommend it.
OK, that’s all the time we have today. 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. Sarah, where are you hanging these days?
Karlin-Smith: A little bit on X, a little bit on Bluesky, at @SarahKarlin or @sarahkarlin-smith.
Rovner: Rachel?
Cohrs Zhang: I’m on X @rachelcohrs and also spending some time on LinkedIn, so feel free to follow me there.
Rovner: Great. Victoria?
Knight: I am @victoriaregisk still on X. I am trying to post more on LinkedIn, too.
Rovner: OK, well, we will be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': Yet Another Promise for Long-Term Care Coverage
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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 part of a media blitz aimed at women voters, Vice President Kamala Harris this week rolled out a plan for Medicare to provide in-home long-term care services. It’s popular, particularly for families struggling to care for both young children and older relatives, but its enormous expense has prevented similar plans from being implemented for decades.
Meanwhile, President Joe Biden called out former President Donald Trump by name for having “led the onslaught of lies” about the federal efforts to help people affected by hurricanes Helene and Milton. Even some Republican officials say the misinformation about hurricane relief efforts is threatening public health.
This week’s panelists are Julie Rovner of KFF Health News, Shefali Luthra of The 19th, Jessie Hellmann of CQ Roll Call, and Joanne Kenen of the Johns Hopkins schools of public health and nursing and Politico.
Panelists
Jessie Hellmann
CQ Roll Call
Joanne Kenen
Johns Hopkins University and Politico
Shefali Luthra
The 19th
Among the takeaways from this week’s episode:
- Vice President Kamala Harris’ plan to expand Medicare to cover more long-term care is popular but not new, and in the past has proved prohibitively expensive.
- Former President Donald Trump has abandoned support for a drug price policy he pursued during his first term. The idea, which would lower drug prices in the U.S. to their levels in other industrialized countries, is vehemently opposed by the drug industry, raising the question of whether Trump is softening his hard line on the issue.
- Abortion continues to be the biggest health policy issue of 2024, as Republican candidates — in what seems to be a replay of 2022 — try to distance themselves from their support of abortion bans and other limits. Voters continue to favor reproductive rights, which creates a brand problem for the GOP. Trump’s going back and forth on his abortion positions is an exception to the tack other candidates have taken.
- The Supreme Court returned from its summer break and immediately declined to hear two abortion-related cases. One case pits Texas’ near-total abortion ban against a federal law that requires emergency abortions to be performed in certain cases. The other challenges a ruling earlier this year from the Alabama Supreme Court finding that embryos frozen for in vitro fertilization have the same legal rights as born humans.
- The 2024 KFF annual employer health benefits survey, released this week, showed a roughly 7% increase in premiums, with average family premiums now topping $25,000 per year. And that’s with most employers not covering two popular but expensive medical interventions: GLP-1 drugs for weight loss and IVF.
Also this week, excerpts from a KFF lunch with “Shark Tank” panelist and generic drug discounter Mark Cuban, who has been consulting with the Harris campaign about health care issues.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week they think you should read, too:
Julie Rovner: KFF Health News’ “A Boy’s Bicycling Death Haunts a Black Neighborhood. 35 Years Later, There’s Still No Sidewalk,” by Renuka Rayasam and Fred Clasen-Kelly.
Shefali Luthra: The 19th’s “Arizona’s Ballot Measure Could Shift the Narrative on Latinas and Abortion,” by Mel Leonor Barclay.
Jessie Hellmann: The Assembly’s “Helene Left Some NC Elder-Care Homes Without Power,” by Carli Brosseau.
Joanne Kenen: The New York Times’ “Her Face Was Unrecognizable After an Explosion. A Placenta Restored It,” by Kate Morgan.
Also mentioned on this week’s podcast:
- The New York Times’ “Biden Accuses Trump of ‘Outright Lies’ About Hurricane Response,” by Michael D. Shear.
- The Miami Herald’s “Florida Threatens To Prosecute TV Stations Over Abortion Ad. FCC Head Calls It ‘Dangerous,’” by Claire Healy and Ana Ceballos.
- KFF’s “2024 Employer Health Benefits Survey.”
Click to open the Transcript
Transcript: Yet Another Promise for Long-Term Care Coverage
[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, October 10th, 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 Shefali Luthra of The 19th.
Shefali Luthra: Hello.
Rovner: Jesse Hellmann of CQ Roll Call.
Jessie Hellmann: Hi there.
Rovner: And Joanne Kenen of the Johns Hopkins Schools of Public Health and Nursing and Politico magazine.
Joanne Kenen: Hi everybody.
Rovner: Later in this episode, we’ll have some excerpts from the Newsmaker lunch we had here at KFF this week with Mark Cuban — “Shark Tank” star, part-owner of the Dallas Mavericks NBA team, and, for the purposes of our discussion, co-founder of the industry-disrupting pharmaceutical company Cost Plus Drugs. But first, this week’s news.
We’re going to start this week with Vice President [Kamala] Harris, who’s been making the media rounds on women-focused podcasts and TV shows like “The View.” To go along with that, she’s released a proposal to expand Medicare to include home-based long-term care, to be paid for in part by expanding the number of drugs whose price Medicare can negotiate. Sounds simple and really popular. Why has no one else ever proposed something like that? she asks, knowing full well the answer. Joanne, tell us!
Kenen: As the one full-fledged member of the sandwich generation here, who has lived the experience of being a family caregiver while raising children and working full time, long-term care is the unfulfillable, extremely expensive, but incredibly important missing link in our health care system. We do not have a system for long-term care, and people do not realize that. Many people think Medicare will, in fact, cover it, where Medicare covers it in a very limited, short-term basis. So the estimates of what families spend both in terms of lost work hours and what they put out-of-pockets is in, I think it’s something like $400 billion. It’s extraordinarily high. But the reason it’s been hard to fix is it’s extraordinarily expensive. And although Harris put out a plan to pay for this, that plan is going to have to be vetted by economists and budget scorers and skeptical Republicans. And probably some skeptical Democrats. It’s really expensive. It’s really hard to do. Julie has covered this for years, too. It’s just—
Rovner: I would say this is where I get to say one of my favorite things, which is that I started covering health care in 1986, and in 1986 my first big feature was: Why don’t we have a long-term care policy in this country? Thirty-eight years later, and we still don’t, and not that people have not tried. There, in fact, was a long-term-care-in-the-home piece of the Affordable Care Act that passed Congress, and HHS [the Department of Health and Human Services] discovered that they could not implement it in the way it was written, because only the people who would’ve needed it would’ve signed up for it. It would’ve been too expensive. And there it went. So this is the continuing promise of something that everybody agrees that we need and nobody has ever been able to figure out how to do. Shefali, I see you nodding here.
Luthra: I mean, I’m just thinking again about the pay-fors in here, which are largely the savings from Medicare negotiating drug prices. And what Harris says in her plan is that they’re going to get more savings by expanding the list of drugs that get lower prices. But that also feels very politically suspect when we have already heard congressional Republicans say that they would like to weaken some of those drug negotiation price provisions. And we also know that Democrats, even if they win the presidency, are not likely to have Congress. It really takes me back to 2020, when we are just talking about ideas that Democrats would love to do if they had full power of Congress, while all of us in Washington kind of know that that is just not going to happen.
Rovner: Yes, I love that one of the pay-fors for this is cutting Medicare fraud. It’s like, where have we heard that before? Oh, yes. In every Medicare proposal for the last 45 years.
Kenen: And it also involves closing some kind of international tax loopholes, and that also sounds easy on paper, and nothing with taxes is ever easy. The Democrats probably are not going to have the Senate. Nobody really knows about the House. It looks like the Democrats may have a narrow edge in that, but we’re going to have more years of gridlock unless something really changes politically, like something extraordinary changes politically. The Republicans are not going to give a President Harris, if she is in fact President Harris, her wish list on a golden platter. On the other hand there’s need for this.
Rovner: But in fairness, this is what the campaign is for.
Kenen: Right. There is a need for something on long-term care.
Rovner: And everybody’s complaining: Well, what would she do? What would she do if she was elected? Well, here’s something she said she would do if she could, if she was elected. Well, meanwhile, former President [Donald] Trump has apparently abandoned a proposal that he made during his first term to require drugmakers to lower their prices for Medicare to no more than they charge in other developed countries where their prices are government-regulated. Is Trump going soft on the drug industry? Trump has been, what, the Republican, I think, who’s been most hostile towards the drug industry until now.
Hellmann: I would say maybe. I think the “most favored nation” proposal is something that the pharmaceutical industry has feared even more than the Democrats’ Medicare negotiation program. And it’s something that Trump really pursued in his first term but wasn’t able to get done. In such a tight race, I think he’s really worried about angering pharmaceutical companies, especially after they were just kind of dealt this loss with Medicare price negotiation. And if he does win reelection, he’s going to be kind of limited in his ability to weaken that program. It’s going to be hard to repeal it. It’s extremely popular, and he may be able to weaken it.
Rovner: “It” meaning price negotiation, not the “most favored nations” prices.
Hellmann: Yeah. It’s going to be really hard to repeal that, and he may be able to weaken it through the negotiation process with drug companies. It’s definitely an interesting turn.
Rovner: Joanne, you want to add something?
Kenen: Trump rhetorically was very harsh on the drug companies right around the time of his inauguration. I think it was the week before, if I remember correctly. Said a lot of very tough stuff on drugs. Put out a list of something like dozens of potential steps. The drug companies have lots of allies in both parties, and more in one than the other, but they have allies on the Hill, and nothing revolutionary happened on drug pricing under Trump.
Rovner: And his HHS secretary was a former drug company executive.
Kenen: Yes, Eli Lilly. So we also pointed out here that former President Trump is not consistent in policy proposals. He says one thing, and then he says another thing, and it’s very hard to know where he’s going to come down. So Trump and drug pricing is an open question.
Rovner: Yes, we will see. All right, well, moving on. Drug prices and Medicare aside, the biggest health issue of Campaign 2024 continues to be abortion and other reproductive health issues. And it’s not just Trump trying to back away from his anti-abortion record. We’ve had a spate of stories over the past week or so of Republicans running for the House, the Senate, and governorships who are trying to literally reinvent themselves as, if not actually supportive of abortion rights, at least anti abortion bans. And that includes Republicans who have not just voted for and advocated for bans but who have been outspokenly supportive of the anti-abortion effort, people like North Carolina Republican gubernatorial candidate Mark Robinson, New Hampshire Republican gubernatorial candidate and former U.S. Senator Kelly Ayotte, along with former Michigan Republican representative and now Senate candidate Mike Rogers. Donald Trump has gotten away repeatedly, as Joanne just said, with changing his positions, even on hot-button issues like abortion. Are these candidates going to be able to get away with doing the same thing, Shefali?
Luthra: I think it’s just so much tougher when your name is not Donald Trump. And that’s because we know from focus group after focus group, and survey after survey, that voters kind of give Trump more leeway on abortion. Especially independent voters will look at him and say, Well, I don’t think he actually opposes abortion, because I’m sure he’s paid for them. And they don’t have that same grace that they give to Republican lawmakers and Republican candidates, because the party has a bad brand on abortion at large, and Trump is seen as this kind of maverick figure. But voters know that Republicans have a history of opposing abortion, of supporting restrictions.
When you look at surveys, when you talk to voters, what they say is, Well, I don’t trust Republicans to represent my interests on this issue, because they largely support access. And one thing that I do think is really interesting is, once again, what we’re seeing is kind of a repeat of the 2022 elections when we saw some very brazen efforts by Republican candidates for the House and Senate try and scrub references to abortion and to fetal personhood from their websites. And it didn’t work, because people have eyes and people have memories, and, also, campaigns have access to the internet archive and are able to show people that, even a few weeks ago, Republican candidates were saying something very different from what they are saying now. I don’t think Mark Robinson can really escape from his relatively recent and very public comments about abortion.
Rovner: Well, on the other hand, there’s some things that don’t change. Republican vice presidential candidate JD Vance told RealClearPolitics last week that if Trump is elected again, their administration would cut off funding to Planned Parenthood because, he said, and I quote, “We don’t think that taxpayers should fund late-term abortions.” Notwithstanding, of course, that even before the overturn of Roe, less than half of all Planned Parenthoods even performed abortions and almost none of those who did perform them later in pregnancy. Is it fair to say that Vance’s anti-abortion slip is showing?
Luthra: I think it might be. And I will say, Julie, when I saw that he said that, I could hear you in my head just yelling about the Hyde Amendment, because we know that Planned Parenthood does not use taxpayer money to pay for abortions. But we also know that JD Vance has seen that he and his ticket are kind of in a tough corner talking about abortion. He has said many times, We need to rebrand — he’s very honest about that, at least — and trying to focus instead on this nonmedical term of “late term” abortions.
It’s a gamble. It’s hoping that voters will be more sympathetic to that because they’ll think, Oh, well, that sounds very extreme. And they’re trying to shift back who is seen as credible and who is not, by focusing on something that historically was less popular. But again, it’s again tricky because when we look at the polling, voters’ understanding of abortion has shifted and they are now more likely to understand that when you have an abortion later in pregnancy, it is often for very medically complex reasons. And someone very high-profile who recently said that is Melania Trump in her new memoir, talking about how she supports abortion at all stages of pregnancy because often these are very heart-wrenching cases and not sort of the murder that Republicans have tried to characterize them as.
Rovner: I think you’re right. I think this is the continuation of the 2022 campaign, except that we’ve had so many more women come forward. We’ve seen actual cases. It used to be anti-abortion forces would say, Oh, well, this never happened. I mean, these are wrenching, awful things that happened to a lot of these patients with pregnancy complications late in pregnancy. And it is, I know, because I’ve talked to them. It’s very hard to get them to talk publicly, because then they get trolled. Why should they step forward?
Well, now we’ve seen a lot of these women stepping forward. So we now see a public that knows that this happens, because they’re hearing from the people that it’s happened to and they’re hearing from their doctors. I do know also from the polling that there are people who are going to vote in these 10 states where abortion is on the ballot. Many of them are going to vote for abortion access and then turn around and vote for Republicans who support restrictions, because they’re Republicans. It may or may not be their most important issue, but I still think it’s a big question mark where that happens and how it shakes out. Joanne, did you want to add something?
Kenen: You’re seeing two competing things at the same time. You have a number of Republicans trying to moderate their stance or at least sound like they’re moderating their stance. At the same time, you also have the whole, where the Republican Party is on abortion has shifted to the right. They are talking about personhood at the moment of conception, the embryo — which is, scientifically put, a small ball of cells still at that point — that they actually have the same legal rights as any other post-birth person.
So that’s become a fairly common view in the Republican Party, as opposed to something that just five or six years ago was seen as the fringe. And Trump is going around saying that Democrats allow babies to be executed after birth, which is not true. And they’re particularly saying this is true in Minnesota because of [Gov.] Tim Walz, and some voters must believe it, right? Because they keep saying it. So you have this trend that Shefali just described and that you’ve described, Julie, about this sort of attempting to win back trust, as Vance said. And it sounded more moderate, and at the same time as you’re hearing this rhetoric about personhood and execution. So I don’t think the Republicans have yet solved their own whiplash post-Roe.
Rovner: Meanwhile, the abortion debate is getting mired in the free-speech debate. In Florida, Republican governor Ron DeSantis is threatening legal action against TV stations airing an ad in support of the ballot measure that would overturn the state’s six-week abortion ban. That has in turn triggered a rebuke from the head of the Federal Communications Commission warning that political speech is still protected here in the United States. Shefali, this is really kind of out there, isn’t it?
Luthra: It’s just so fascinating, and it’s really part of a bigger effort by Ron DeSantis to try and leverage anything that he can politically or, frankly, in his capacity as head of the state to try and weaken the campaign for the ballot measure. They have used the health department in other ways to try and send out material suggesting that the campaign’s talking points, which are largely focused on the futility of exceptions to the abortion ban, they’re trying to argue that that is misinformation, and that’s not true. And they’re using the state health department to make that argument, which is something we don’t really see very often, because usually health departments are supposed to be nonpartisan. And what I will say is, in this case, at least to your point, Julie, the FCC has weighed in and said: You can’t do this. You can’t stop a TV station from airing a political ad that was bought and paid for. And the ads haven’t stopped showing at this point. I just heard from family yesterday in Florida who are seeing the ads in question on their TV, and it’s still—
Rovner: And I will post a link to the ad just so you can see it. It’s about a woman who’s pregnant and had cancer and needed cancer treatment and needed to terminate the pregnancy in order to get the cancer treatment. It said that the exception would not allow her to, which the state says isn’t true and which is clearly one of these things that is debatable. That’s why we’re having a political debate.
Luthra: Exactly. And one thing that I think is worth adding in here is, I mean, this really intense effort from Governor DeSantis and his administration comes at a time when already this ballot measure faces probably the toughest fight of any abortion rights measure. And we have seen abortion rights win again and again at the ballot, but in Florida you need 60% to pass. And if you look across the country at every abortion rights measure that has been voted on since Roe v. Wade was overturned, only two have cleared 60, and they are in California and they are in Vermont. So these more conservative-leaning states, and Florida is one of them, it’s just, it’s really, really hard to see how you get to that number. And we even saw this week there’s polling that suggests that the campaign has a lot of work to do if they’re hoping to clear that threshold.
Rovner: And, of course, now they have two hurricanes to deal with, which we will deal with in a few minutes. But first, the Supreme Court is back in session here in Washington, and even though there’s no big abortion case on its official docket as of now this term, the court quickly declined to hear two cases on its first day back, one involving whether the abortion ban in Texas can override the federal emergency treatment law that’s supposed to guarantee abortion access in medical emergencies threatening the pregnant woman’s life or health. The court also declined to overrule the Alabama Supreme Court’s ruling that frozen embryos can be considered legally as unborn children. That’s what Joanne was just talking about. Where do these two decisions leave us? Neither one actually resolved either of these questions, right?
Luthra: I mean, the EMTALA [Emergency Medical Treatment and Labor Act] question is still ongoing, not because of the Texas case but because of the Idaho case that is asking very similar questions that we’ve talked about previously on this podcast. And the end of last term, the court kicked that back down to the lower courts to continue making its way through. We anticipate it will eventually come back to the Supreme Court. So this is a question that we will, in fact, be hearing on at some point.
Rovner: Although, the irony here is that in Idaho, the ban is on hold because there was a court stay. And in Texas, the ban is not on hold, even though we’re talking about exactly the same question: Does the federal law overrule the state’s ban?
Luthra: And what that kind of highlights — right? — is just how much access to abortion, even under states with similar laws or legislatures, really does depend on so many factors, including what circuit court you fall into or the makeup of your state Supreme Court and how judges are appointed or whether they are elected. There is just so much at play that makes access so variable. And I think the other thing that one could speculate that maybe the court didn’t want headlines around reproductive health so soon into an election, but it’s not as if this is an issue that they’re going to be avoiding in the medium- or long-term future. These are questions that are just too pressing, and they will be coming back to the Supreme Court in some form.
Rovner: Yes, I would say in the IVF [in vitro fertilization] case, they simply basically said, Go away for now. Right?
Luthra: Yeah. And, I mean, right now in Alabama, people are largely able to get IVF because of the state law that was passed, even if it didn’t touch the substance of that state court’s ruling. This is something, for now, people can sort of think is maybe uninterrupted, even as we all know that the ideological and political groundwork is being laid for a much longer and more intense fight over this.
Rovner: Well, remember back last week when we predicted that the judge’s decision overturning Georgia’s six-week ban was unlikely to be the last word? Well, sure enough, the Georgia Supreme Court this week overturned the immediate overturning of the ban, which officially went back into effect on Monday. Like these other cases, this one continues, right?
Luthra: Yes, this continues. The Georgia case continued for a while, and it just sort of underscores again what we’ve been talking about, just how much access really changes back and forth. And I was talking to an abortion clinic provider who has clinics in North Carolina and Georgia. She literally found out about the decision both times and changed her plans for the next day because I texted her asking her for comment. And providers and patients are being tasked with keeping up with so much. And it’s just very, very difficult, because Georgia also has a 24-hour waiting period for abortions, which means that every time the decision around access has changed — and we know it very well could change again as this case progresses — people will have to scramble very quickly. And in Georgia, they have also been trying to do that on top of navigating the fallout of a hurricane.
Rovner: Yeah. And as we pointed out a couple of weeks ago when the court overturned the North Dakota ban, there are no abortion providers left in North Dakota. Now that there’s no ban, it’s only in theory that abortion is now once again allowed in North Dakota. Well, before we leave abortion for this week, we have two new studies showing how abortion bans are impacting the health care workforce. In one survey, more than half of oncologists, cancer doctors, who were completing their fellowships, so people ready to go into practice, said they would consider the impact of abortion restrictions in their decisions about where to set up their practice. And a third said abortion restrictions hindered their ability to provide care.
Meanwhile, a survey of OBGYNs in Texas by the consulting group Manatt Health found “a significant majority of practicing OB/GYN physicians … believe that the Texas abortion laws have inhibited their ability to provide highest-quality and medically necessary care to their patients,” and that many have already made or are considering making changes to their practice that would “reduce the availability of OB/GYN care in the state.” What’s the anti-abortion reaction to this growing body of evidence that abortion bans are having deleterious effects on the availability of other kinds of health care, too? I mean, I was particularly taken by the oncologists, the idea that you might not be able to get cancer care because cancer doctors are worried about treating pregnant women with cancer.
Luthra: They’re blaming the doctors. And we saw this in Texas when the Zurawski case was argued and women patients and doctors in the state said that they had not been able to get essential, lifesaving medical care because of the state’s abortion ban and lack of clarity around what was actually permitted. And the state argued, and we have heard this talking point again and again, that actually the doctors are just not willing to do the hard work of practicing medicine and trying to interpret, Well, obviously this qualifies. That’s something we’ve seen in the Florida arguments. They say: Our exceptions are so clear, and if you aren’t able to navigate these exceptions, well, that’s your problem, because you are being risk-averse, and patients should really take this up with their doctors, who are just irresponsible.
Rovner: Yes, this is obviously an issue that’s going to continue. Well, moving on. The cost of health care continues to grow, which is not really news, but this week we have more hard evidence, courtesy of my KFF colleagues via the annual 2024 Employer Health Benefit Survey, which finds the average family premium rose 7% this year to $25,572, with workers contributing an average of $6,296 towards that cost. And that’s with a distinct minority of firms covering two very popular but very expensive medical interventions, GLP-1 [glucagon-like peptide-1] drugs for obesity and IVF, which we’ve just been talking about. Anything else in this survey jump out at anybody?
Hellmann: I mean, that’s just a massive amount of money. And the employer is really paying the majority of that, but that doesn’t mean it doesn’t have an impact on people. That means it’s going to limit how much your wages go up. And something I thought of when I read this study is these lawsuits that we’re beginning to see, accusing employers of not doing enough to make sure that they’re limiting health care costs. They’re not playing enough of a role in what their benefits look like. They’re kind of outsourcing this to consultants. And so when you look at this data and you see $25,000 they’re spending per year per family on health care premiums, you wonder, what are they doing?
Health care, yes, it’s obviously very expensive, but you just kind of question, what role are employers actually playing in trying to drive down health care costs? Are they just taking what they get from consultants? And another thing that kind of stood out to me from this is, I think it’s said in there, employers are having a hard time lately of passing these costs on to employees, which is really interesting. It’s because of the tight labor market. But obviously health care is still very expensive for employees — $6,000 a year in premiums for family coverage is not a small amount of money. So employers are just continuing to absorb that, and it does really impact everyone.
Rovner: It’s funny. Before the Affordable Care Act, it was employers who were sort of driving the, You must do something about the cost of health care, because inflation was so fast. And then, of course, we saw health care inflation, at least, slow down for several years. Now it’s picking up again. Are we going to see employers sort of getting back into this jumping up and down and saying, “We’ve got to do something about health care costs”?
Hellmann: I feel like we are seeing more of that. You’re beginning to hear more from employers about it. I don’t know. It’s just such a hard issue to solve, and I’ve seen more and more interest from Congress about this, but they really struggle to regulate the commercial market. So …
Rovner: Yes, as we talk about at length every week. But it’s still important, and they will still go for it. Well, finally, this week in health misinformation. Let us talk about hurricanes — the public health misinformation that’s being spread both about Hurricane Helene that hit the Southeast two weeks ago, and Hurricane Milton that’s exiting Florida even as we are taping this morning. President [Joe] Biden addressed the press yesterday from the White House, calling out former President Trump by name along with Georgia Republican congresswoman Marjorie Taylor Greene for spreading deliberate misinformation that’s not just undermining efforts at storm relief but actually putting people in more danger. Now, I remember Hurricane Katrina and all the criticism that was heaped, mostly deservedly, on George W. Bush and his administration, but I don’t remember deliberate misinformation like this. I mean, Joanne, have you ever seen anything like this? You lived in Florida for a while.
Kenen: I went through Andrew, and there’s always a certain — there’s confusion and chaos after a big storm. But there’s a difference between stuff being wrong that can be corrected and stuff being intentionally said that then in this sort of divided, suspicious, two-realities world we’re now living in, that’s being repeated and perpetuated and amplified. It damages public health. It damages people economically trying to recover from this disastrous storm or in some cases storms. I don’t know how many people actually believe that Marjorie Taylor asserted that the Democrats are controlling the weather and sending storms to suppress Republican voters. She still has a following, right? But other things …
Rovner: She still gets reelected.
Kenen: … being told that if you go to FEMA [the Federal Emergency Management Agency] for help, your property will be confiscated and taken away from you. I mean, that’s all over the place, and it’s not true. Even a number of Republican lawmakers in the affected states have been on social media and making statements on local TV and whatever, saying: This is not true. Please, FEMA is there to help you. Let’s get through this. Stop the lies. A number of Republicans have actually been quite blunt about the misinformation coming from their colleagues and urging their constituents to seek and take the help that’s available.
This is the public health crisis. We don’t know how many people have been killed. I don’t think we have an accurate total final count from Helene, and we sure don’t have from Milton. I mean, the people did seem to take this storm seriously and evacuated, but it also spawned something like three dozen tornadoes in places where people hadn’t been told, there’s normally no need to evacuate. There’s flooding. It’s a devastating storm. So when people are flooding, power outages, electricity, hard to get access to health care, you can’t refrigerate your insulin. All these—
Rovner: Toxic floodwaters, I mean, the one thing …
Kenen: Toxic, yeah.
Rovner: … we know about hurricanes is that they’re more dangerous in the aftermath than during the actual storm in terms of public health.
Kenen: Right. This is a life-threatening public health emergency to really millions of people. And misinformation, not just getting something wrong and then trying to correct it, but intentional disinformation, is something we haven’t seen before in a natural disaster. And we’re only going to have more natural disasters. And it was really — I mean, Julie, you already pointed this out — but it was really unusual how precise Biden was yesterday in calling out Trump by name, and I believe at two different times yesterday. So I heard one, but I think I read about what I think was the second one really saying, laying it at his feet that this is harming people.
Rovner: Yeah, like I said, I remember Katrina vividly, and that was obviously a really devastating storm. I do also remember Democrats and Republicans, even while they were criticizing the federal government reaction to it, not spreading things that were obviously untrue. All right. Well, that is the news for this week. Now we will play a segment from our Newsmaker interview with Mark Cuban, and then we will be back with our extra credits.
On Tuesday, October 8th, Mark Cuban met with a group of reporters for a Newsmaker lunch at KFF’s offices in Washington, D.C. Cuban, a billionaire best known as a panelist on the ABC TV show “Shark Tank,” has taken an interest in health policy in the past several years. He’s been consulting with the campaign of Vice President Harris, although he says he’s definitely not interested in a government post if she wins. Cuban started out talking about how, as he sees it, the biggest problem with drug prices in the U.S. is that no one knows what anyone else is paying.
Mark Cuban: I mean, when I talk to corporations and I’ve tried to explain to them how they’re getting ripped off, the biggest of the biggest said, Well, so-and-so PBM [pharmacy benefit manager] is passing through all of their rebates to us.
And I’m like: Does that include the subsidiary in Scotland or Japan? Is that where the other one is?
I don’t know.
And it doesn’t. By definition, you’re passing through all the rebates with the company you contracted with, but they’re not passing through all the rebates that they get or that they’re keeping in their subsidiary. And so, yeah, I truly, truly believe from there everybody can argue about the best way. Where do you use artificial intelligence? Where do you do this? What’s the EHR [electronic health record? What’s this? We can all argue about best practices there. But without a foundation of information that’s available to everybody, the market’s not efficient and there’s no place to go.
Rovner: He says his online generic drug marketplace, costplusdrugs.com, is already addressing that problem.
Cuban: The crazy thing about costplusdrugs.com, the greatest impact we had wasn’t the markup we chose or the way we approach it. It’s publishing our price list. That changed the game more than anything. So when you saw the FTC [Federal Trade Commission] go after the PBMs, they used a lot of our pricing for all the non-insulin stuff. When you saw these articles written by the Times and others, or even better yet, there was research from Vanderbilt, I think it was, that says nine oncology drugs, if they were purchased by Medicare through Cost Plus, would save $3.6 billion. These 15, whatever drugs would save six-point-whatever billion. All because we published our price list, people are starting to realize that things are really out of whack. And so that’s why I put the emphasis on transparency, because whether it’s inside of government or inside companies that self-insure, in particular, they’re going to be able to see. The number one rule of health care contracts, particularly PBM contracts, is you can’t talk about PBM contracts.
Rovner: Cuban also says that more transparency can address problems in the rest of the health care system, not just for drug prices. Here’s how he responded to a question I asked describing his next big plan for health care.
We’ve had, obviously, issues with the system being run by the government not very efficiently and being run by the private sector not very efficiently.
Cuban: Very efficiently, yeah.
Rovner: And right now we seem to have this sort of working at cross-purposes. If you could design a system from the ground up, which would you let do it? The government or—
Cuban: I don’t think that’s really the issue. I think the issue is a lack of transparency. And you see that in any organization. The more communication and the more the culture is open and transparent, the more people hold each other responsible. And I think you get fiefdoms in private industry and you get fiefdoms in government, as well, because they know that if no one can see the results of their work, it doesn’t matter. I can say my deal was the best and I did the best and our outcomes are the best, but there’s no way to question it. And so talking to the Harris campaign, it’s like if you introduce transparency, even to the point of requiring PBMs and insurers to publish their contracts publicly, then you start to introduce an efficient market. And once you have an efficient market, then people are better able to make decisions and then you can hold them more accountable.
And I think that’s going to spill over beyond pharm. We’re working on — it’s not a company — but we’re working on something called Cost Plus Wellness, where we’re eating our own dog food. And it’s not a company that’s going to be a for-profit or even a nonprofit, for that matter, just for the lives that I cover for my companies, that we self-insure. We’re doing direct contracting with providers, and we’re going to publish those contracts. And part and parcel to that is going through the — and I apologize if I’m stumbling here. I haven’t slept in two days, so bear with me. But going through the hierarchy of care and following the money, if you think about when we talk to CFOs and CEOs of providers, one of the things that was stunning to me that I never imagined is the relationship between deductibles for self-insured companies and payers, and the risk associated with collecting those deductibles to providers.
And I think people don’t really realize the connection there. So whoever does Ann’s care [KFF Chief Communications Officer Ann DeFabio, who was present] — well, Kaiser’s a little bit different, but let’s just say you’re employed at The Washington Post or whoever and you have a $2,500 deductible. And something happens. Your kid breaks their leg and goes to the hospital, and you’re out of market, and it’s out of network. Well, whatever hospital you go to there, you might give your insurance card, but you’re responsible for that first $2,500. And that provider, depending on where it’s located, might have collection — bad debt, rather — of 50% or more.
So what does that mean in terms of how they have to set their pricing? Obviously, that pricing goes up. So there’s literally a relationship between, particularly on pharmacy, if my company takes a bigger rebate, which in turn means I have a higher deductible because there’s less responsibility for the PBM-slash-insurance company. My higher deductible also means that my sickest employees are the ones paying that deductible, because they’re the ones that have to use it. And my older employees who have ongoing health issues and have chronic illnesses and need medication, they’re paying higher copays. But when they have to go to the hospital with that same deductible, because I took more of a rebate, the hospital is taking more of a credit risk for me. That’s insane. That makes absolutely no sense.
And so what I’ve said is as part of our wellness program and what we’re doing to — Project Alpo is what we call it, eating our own dog food. What I’ve said is, we’ve gone to the providers and said: Look, we know you’re taking this deductible risk. We’ll pay you cash to eliminate that. But wait, there’s more. We also know that when you go through a typical insurer, even if it’s a self-insured employer using that insurer and you’re just using the insurance company not for insurance services but as a TPA [third-party administrator], the TPA still plays games with the provider, and they underpay them all the time.
And so what happens as a result of the underpayment is that provider has to have offices and offices full of administrative assistants and lawyers, and they have to not only pay for those people, but they have the associated overhead and burden and the time. And then talking to them, to a big hospital system, they said that’s about 2% of their revenue. So because of that, that’s 2%. Then, wait, there’s more. You have the pre-ops, and you have the TPAs who fight you on the pre-ops. But the downstream economic impacts are enormous because, first, the doctor has to ask for the pre-op. That’s eating doctor’s time, and so they see fewer patients. And then not only does the doctor have to deal with them, they go to HR at the company who self-insures and says, Wait, my employee can’t come to work, because their child is sick, and you won’t approve this process or, whatever, this procedure, because it has to go through this pre-op.
Or if it’s on medications, it’s you want to go through the step-up process or you want to go through a different utilization because you get more rebates. All these pieces are intertwined, and we don’t look at it holistically. And so what we’re saying with Cost Plus Wellness is, we’re going to do this all in a cash basis. We’re going to trust doctors so that we’re not going to go through a pre-op. Now we’ll trust but verify. So as we go through our population and we look at all of our claims, because we’ll own all of our claims, we’re going to look to see if there are repetitive issues with somebody who’s just trying to —there’s lots of back surgeries or there’s lots of this or there’s lots of that — to see if somebody’s abusing us. And because there’s no deductible, we pay it, and we pay it right when the procedure happens or right when the medication is prescribed. Because of all that, we want Medicare pricing. Nobody’s saying no. And in some cases I’m getting lower than Medicare pricing for primary care stuff.
Rovner: OK, we are back. Now 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 the links to all these stories in our show notes on your phone or other device. Joanne, why don’t you go first this week.
Kenen: There was a fascinating story in The New York Times by Kate Morgan. The headline was “Her Face Was Unrecognizable After an Explosion. A Placenta Restored It.” So I knew nothing about this, and it was so interesting. Placentas have amazing healing properties for wound care, burns, infections, pain control, regenerating skin tissue, just many, many things. And it’s been well known for years, and it’s not widely used. This is a story specifically about a really severe burn victim in a gas explosion and how her face was totally restored. We don’t use this, partly because placenta — every childbirth, there’s a placenta. There are lots of them around. There’s I think three and a half million births a year, or that’s the estimate I read in the Times. One of the reasons they weren’t being used is, during the AIDS crisis, there was some development toward using them, and then the AIDS crisis, there was a fear of contamination and spreading the virus, and it stopped decades later.
We have a lot more ways of detecting, controlling, figuring out whether something’s contaminated by AIDS or whether a patient has been exposed. It is being used again on a limited basis after C-sections, but it seems to have pretty astonishing — think about all the wound care for just diabetes. I’m not a scientist, but I just looked at the story and said, it seems like a lot of people could be healed quicker and more safely and earlier if this was developed. They’re thrown away now. They’re sent to hospital waste incinerators and biohazard waste. They’re garbage, and they’re actually medicine.
Rovner: Definitely a scientist’s cool story. Shefali.
Luthra: My story is from my brilliant colleague Mel Leonor Barclay. The headline is “Arizona’s Ballot Measure Could Shift the Narrative on Latinas and Abortion,” and as part of this really tremendous series that she has running this week, looking at how Latinas as a much more influential and growingly influential voter group could shape gun violence, abortion rights, and housing. And in this story, which I really love, she went to Arizona and spent time talking to folks on all sides of the issue to better understand how Latinas are affected by abortion rights and also how they’ll be voting on this.
And she really challenges the narrative that has existed for so long, which is that Latinas are largely Catholic, largely more conservative on abortion. And she finds something much more complex, which is that actually polls really show that a large share of Latina voters in Arizona and similar states support abortion rights and will be voting in favor of measures like the Arizona constitutional amendment. But at the same time, there are real divides within the community, and people talk about their faith in a different way and how it connects their stance on abortion. They talk about their relationships with family in different ways, and I think it just underscores how rarely Latina voters are treated with real nuance and care and thoughtfulness when talking about something as complex as abortion and abortion politics. And I really love the way that she approaches this piece.
Rovner: It was a super-interesting story. Jesse.
Hellmann: My story is from The Assembly. It’s an outlet in North Carolina. It’s called “Helene Left Some North Carolina Elder-Care Homes Without Power.” Some assisted living facilities have been without power and water since the hurricane hit. Several facilities had to evacuate residents, and the story just kind of gets into how North Carolina has more lax rules around emergency preparedness. While they do require nursing homes be prepared to provide backup power, the same requirements don’t apply to assisted living facilities. And it’s because there’s been industry pushback against that because of the cost. But as we see some more of these extreme weather events, it seems like something has to be done. We cannot just allow vulnerable people living in these facilities to go hours and hours without power and water. And I saw that there was a facility where they evacuated dozens of people who had dementia, and that’s just something that’s really upsetting and traumatizing for people.
Rovner: Yeah, once again, now we are seeing these extreme weather events in places that, unlike Florida and Texas, are not set up and used to extreme weather events. And it is something I think that a lot of people are starting to think about. Well, my story this week is from our KFF Health News public health project called Health Beat, and it’s called “A Boy’s Bicycling Death Haunts a Black Neighborhood. 35 Years Later, There’s Still No Sidewalk,” by Renuka Rayasam and Fred Clasen-Kelly. And it’s one of those stories you never really think about until it’s pointed out that in areas, particularly those that had been redlined, in particular, the lack of safety infrastructure that most of us take for granted — crosswalks, sidewalks, traffic lights are not really there. And that’s a public health crisis of its own, and it’s one that rarely gets addressed, and it’s a really infuriating but a really good story.
All right, that is our show. Next week, for my birthday, we’re doing a live election preview show here at KFF in D.C., because I have a slightly warped idea of fun. And you’re all invited to join us. I will put a link to the RSVP in the show notes. I am promised there will be cake.
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. Thanks as always to our technical guru, Francis Ying, and our fill-in editor this week, Stephanie Stapleton. 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 for the moment at X. I’m @jrovner. Joanne, where are you?
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KFF Health News' 'What the Health?': The Health of the Campaign
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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.
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.
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Sandhya Raman
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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?': American Health Under Trump — Past, Present, and Future
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Emmarie Huetteman
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Emmarie Huetteman, senior editor, oversees a team of Washington reporters, as well as “Bill of the Month” and KFF Health News’ “What the Health?” She previously spent more than a decade reporting on the federal government, most recently covering surprise medical bills, drug pricing reform, and other health policy debates in Washington and on the campaign trail.
Recent comments from former President Donald Trump and Republican lawmakers preview potential health policy pursuits under a second Trump administration. Trump is yet again eyeing changes to the Affordable Care Act, while key lawmakers want to repeal Medicare drug price negotiations.
Also, this week brought news of the first publicly reported death attributed to delayed care under a state abortion ban. Vice President Kamala Harris said the death shows the consequences of Trump’s actions to block abortion access.
This week’s panelists are Emmarie Huetteman of KFF Health News, Joanne Kenen of Politico and the Johns Hopkins University’s schools of nursing and public health, Tami Luhby of CNN, and Shefali Luthra of The 19th.
Panelists
Joanne Kenen
Johns Hopkins University and Politico
Tami Luhby
CNN
Shefali Luthra
The 19th
Among the takeaways from this week’s episode:
- Sen. JD Vance (R-Ohio), Trump’s running mate, says Trump is interested in loosening ACA rules to make cheaper policies available. While the campaign has said little about what Trump would do or how it would work, the changes could include eliminating protections against higher premiums for those with preexisting conditions. Republicans would also likely let enhanced subsidies for ACA premiums expire.
- Key Republican lawmakers said this week that they’re interested in repealing the Inflation Reduction Act’s provisions enabling Medicare drug pricing negotiations. Should Trump win, that stance could create intraparty tensions with the former president, who has vowed to “take on Big Pharma.”
- A state review board in Georgia ruled that the death in 2022 of a 28-year-old mother, after her doctors delayed performing a dilatation and curettage procedure, was preventable. Harris tied the death to Trump’s efforts to overturn Roe v. Wade, which included appointing three Supreme Court justices who voted to eliminate the constitutional right to an abortion.
- And in health tech news, the FDA has separately green-lighted two new Apple product functions: an Apple Watch feature that assesses the wearer’s risk of sleep apnea, and an AirPods feature that turns the earbuds into hearing aids.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Emmarie Huetteman: The Washington Post’s “What Warning Labels Could Look Like on Your Favorite Foods,” by Lauren Weber and Rachel Roubein.
Shefali Luthra: KFF Health News’ “At Catholic Hospitals, a Mission of Charity Runs Up Against High Care Costs for Patients,” by Rachana Pradhan.
Tami Luhby: Politico Magazine’s “Doctors Are Leaving Conservative States To Learn To Perform Abortions. We Followed One,” by Alice Miranda Ollstein.
Joanne Kenen: The New York Times’ “This Chatbot Pulls People Away From Conspiracy Theories,” by Teddy Rosenbluth, and The Atlantic’s “When Fact-Checks Backfire,” by Jerusalem Demsas.
Also mentioned on this week’s podcast:
ProPublica’s “Abortion Bans Have Delayed Emergency Medical Care. In Georgia, Experts Say This Mother’s Death Was Preventable,” by Kavitha Surana.
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Transcript: American Health Under Trump — Past, Present, and Future
[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: Hello, and welcome back to “What The Health?” I’m Emmarie Huetteman, a senior editor for KFF Health News and the regular editor on this podcast. I’m filling in for Julie this week, joined by some of the best and smartest health reporters in Washington. We’re taping on Thursday, September 19th, at 10 a.m. As always, news happens fast and things might’ve changed by the time you hear this. So, here we go.
We’re joined today, by videoconference, by Tami Luhby of CNN.
Tami Luhby: Good morning.
Huetteman: Shefali Luthra of The 19th.
Shefali Luthra: Hello.
Huetteman: And Joanne Kenan of Politico and Johns Hopkins University Schools of Nursing and Public Health.
Joanne Kenan: Hi everybody.
Huetteman: No interview this week, so let’s get right to the news, shall we? It’s big, it’s popular, and if Donald Trump reclaims the presidency, it could be on the chopping block again. Yes, I’m talking, of course, about the Affordable Care Act. Over the weekend, Senator JD Vance claimed that Trump had “protected Americans” insured under the ACA from “losing their health coverage.” Trump himself made a similar claim during the recent debate, where he also said he has the “concepts of a plan” for health reform. Vance, who is Trump’s running mate, suggested the GOP could loosen regulations to make cheaper policies available. But otherwise, the Trump campaign has not said much about what his administration might change.
Meanwhile, Vice President Kamala Harris has backed off her own plan to change the ACA. You may remember that when she was running for president in 2019, Harris embraced a “Medicare for All” plan. Now, Harris says she plans to build on the existing health system rather than replace it. So let’s talk about what Trump might do as president. What sort of changes could Trump implement to make policies cheaper, as Vance has suggested?
Luhby: Well, one of the things that Vance has talked about, when he talks about deregulating the market, giving people more choice of plans, it’s actually separating people, the healthier people and the sicker enrollees, into separate, different risk pools, which is what existed before the ACA. And that may be, actually, better for the healthy people. That might lower their premiums. But it would cause a lot of problems for sicker enrollees, those with chronic health conditions or serious illnesses, because they would see their premium skyrocket. And this is one of the reasons why health care was so unaffordable for many people prior to the ACA. So Vance says that he wants to protect people with preexisting conditions. That’s what everyone says. It’s a very popular and well-known provision of the ACA. But by separating people into different risk pools, it would actually hurt people with preexisting conditions, because it may make their health insurance unaffordable.
Kenan: The difference between pre-ACA and post-ACA is it might actually even be as bad or possibly worse for people with preexisting conditions. Right now, everybody’s in one unified risk pool, right? Whether you’re sick or healthy, your costs, more or less, get averaged out, and that’s how premiums are calculated. Before ACA, people with preexisting conditions just couldn’t get covered necessarily, or if they got covered, it was sky-high, the premiums. By doing what Tami just described, the people, presumably, in the riskiest pool, the sickest people, the insurers would have to offer them coverage. They couldn’t say, “No, you’re sick, you can’t have it,” because there’s guaranteed coverage. But it would be sky-high. So it would be de facto no insurance for most of those people unless the government were to subsidize them to a really high extent, which I didn’t hear JD Vance mention the other day.
Luthra: Right.
Luhby: And one of the other things that they talked about, more choice. I mean, one of the issues that a lot of people complained about in the ACA, early on, was that they didn’t want substance abuse coverage. There’s 10 health-essential benefits which every insurer has to cover — pregnancy, maternal care, et cetera. And 60-year-old men or even 60-year-old women said: Why am I paying for this? This is making my plan more expensive. But again, as Joanne said, it’s evening out the costs among everyone so that it’s making health care more affordable for everyone. And if you allow people to start picking and choosing what benefits they want covered, it’s going to make the plans more expensive for those who need the higher-cost care.
Luthra: Tami alluded to something that is really important, which is that these conditions we’re talking about are very common. A lot of people get pregnant, for example. A lot of people have chronic health conditions. We are not the healthiest country in the world. And so when you think about who would be affected by this, it’s quite a large number of Americans who would no longer be able to get affordable health coverage and a small group of people who probably would. Because, I mean, one thing that’s worth noting —right? — is even if you are healthy for a time, that’s a transient state. And you can be healthy when you are young and get older and suddenly have knee problems, and then things look very different.
Huetteman: It seems like if they use the exact words, “preexisting-condition protections,” and said they were trying to roll them back in order to make policies cheaper, that might be just a bad political move all around. Preexisting-condition protections are pretty popular, right?
Luhby: Yes, they certainly are. But that’s why they’re saying they’re going to continue it. But what’s also popular is choice. And that’s been one of the knocks against the Affordable Care Act, is that, while there are a lot of plans out there, they do have to conform to certain requirements, and therefore that gives people less choice. I mean, and remember, one of the things that we started by talking about, what a second Trump administration might look like for health care. One of the things the first Trump administration did is loosen the rules on short-term plans, which don’t have to conform to the ACA. And prior, they were available for a short time as a bridge between policies, but the Trump administration lengthened them to up to three years. And the goal of the Trump administration was that people would have more choice. They could pick skinnier plans that they felt would cover them. But they didn’t always realize that if they got into a car accident, if they were diagnosed with cancer, if something bad happened, they did not have all of the protections that ACA plans have.
Huetteman: Joanne, you have something to add.
Kenan: So the first thing is that they spent years and a lot of political capital trying and failing to repeal the ACA or to make major changes in the ACA. The reason it failed is because even then, when the ACA was sort of quasi-popular and there was a lot of controversy still, the preexisting-condition part was extremely popular. Since then, the ACA has become even more popular. What [former President Barack] Obama said when he was speaking to the Democratic National Committee convention the other night — remember that aside where he said, Hey, they don’t call it Obamacare anymore now that it’s popular. It is popular. You’ve even had Republican senators going on record saying it’s here to stay.
So major overhaul of it is, politically, not going to be popular. Plus, the Republicans, even if they capture the Senate, which is what most of the prognosticators are saying right now, it would be a small majority. If the Republicans have 51, 52, none of us know exactly what’s going to happen, because we’re in a rather rapidly changing political environment. But say the Republicans capture the Senate and say Trump is in the White House. They’re not going to have 60 votes. They’re not going to have anywhere near 60 votes. I’m not even sure if there was a way to do this under reconciliation, which would require 51. I’m not sure they have 51 votes. So and then if they do it through some kind of regulatory approach — which I think is harder to do, something this massive, but people find a way — then it ends up in court.
So I think it’s politically unfeasible, and I think it’s practically unfeasible. I think there are smaller things they could do to weaken it. I mean, they did last time, and coverage dropped under Trump, last time. I mean, they could not promote it. They could not market it. They could not have navigators helping people. There’s lots of things they could do to shrink it and damage it, but there’s a difference between denting something and having a frontal collision. And we’ve all seen Vance have to roll back other things that he’s predicted Trump would do, so this is very TBD.
Huetteman: One of the bigger issues with the ACA going into next year is these enhanced subsidies that Joe Biden implemented under the pandemic, that helped a lot of people pay for their premiums, will expire at the end of 2025. And depending on which party has control after this election, that could decide the fate of the subsidies. Joanne, you had something to add on this.
Kenan: That’s the big vulnerability. And it’s not so much, are they going to repeal it or define their concept of a plan? I mean, the subsidies are vulnerable because they expire without action, and they’re part of a larger debate that’s going to happen no matter who wins the presidency and no matter who wins Congress. It’s that a lot of the tax cuts expire in 2025. The subsidies are part of that tax, but many aspects of the tax bill are going to be a huge issue no matter who’s in charge.
The subsidies are vulnerable, right? Republicans think that they went too high. Basically those subsidies let more middle-class people with a higher income get ACA subsidies, so insurance is more affordable. And quite a few million people — Tami might remember how many, because I don’t — are getting subsidized this way. It’s not free. They don’t get the biggest subsidies as somebody who’s lower-income, but they are getting enough subsidies that we saw ACA enrollment go up. That is where the big political battle over the ACA is inevitable. I mean, that is going to happen no matter what else happens around aspects of repealing or redesigning or anything else. This is inevitable. They expire unless there’s action. There will be a fight.
Luhby: Yeah, these—
Kenan: And I don’t know how it’ll turn out, right?
Luhby: These subsidies were created as part of the American Rescue Plan in 2021 and were extended for two years as part of the Inflation Reduction Act, which the Republicans don’t like. And they have, as Joanne said, they’ve allowed more middle-class people to come in, and also, they’re more generous subsidies than in the past. Plus they’ve made policies free for a lot of lower-income people. Folks can get these policies without premiums. So enrollment has skyrocketed, in large part because of these subsidies. Now there are more than 20 million people enrolled. It’s a record. So the Biden administration would like to keep that intact, especially if Harris wins the presidency. But it will be a big fight in Congress next year, as part of the overall Tax Cuts and Jobs Act negotiations, and we’ll see what the Democrats might have to give up in order to retain the subsidies. The—
Kenan: It’s going to be, yeah.
Luhby: Enhanced subsidies.
Kenan: There are deals to be had with tax cuts versus subsidies, because these are large, sprawling bills with many moving parts. But it’s way too early to know if Republicans are willing to deal on this and what a deal would look like. We’re nowhere near there. But yeah, if you talk about ACA battles in 2025, that’s number one.
Huetteman: Well, speaking of health policies that are on the GOP agenda, some high-ranking Republican lawmakers are saying they want to repeal the Inflation Reduction Act if the party wins big in November, particularly the part that enables Medicare drug negotiations. You may recall their objections from when Congress passed the law two years ago. Republicans argue the negotiations harm innovation and amount to government price controls. But on the other hand, drug prices are an issue where Trump kind of sort of agrees with Democrats. He has promised to “take on Big Pharma.” Does this mean we could see a Republican Congress fighting with Trump over drug price negotiations?
Luhby: Well, he did have a lot of executive orders and a lot of efforts that were very un-Republican-like. One was called Most Favored Nation. He didn’t say that we should do negotiations. We were just going to piggyback on the negotiations done in other countries and get their lower prices. He didn’t really get very far in a lot of those measures, so it didn’t come to a fight with the Republican Congress. But he may leave the negotiation process alone, the next set of drugs, that’ll be 15 drugs, that, we’ll find out next year, that will be negotiated. So he could leave that alone. If he tries to expand it, yeah, he may have some problems with the Republican Congress. But as we’ve also seen, a Republican Congress has acquiesced to his demands in the past.
Huetteman: And Congress certainly has no shortage of battles teed up for 2025, of course. Speaking of, here we are again. Yesterday, in the House of Representatives, Democrats and Republicans joined together to defeat a stopgap spending bill that would’ve kept the government open. To be sure they didn’t have the same objections, Democrats opposed a Republican amendment that would impose new voter registration requirements about proving citizenship. And hard-right Republicans objected to the size of the temporary spending bill, $1.6 trillion. Trump weighed in on social media, calling on Republicans to oppose any government spending bill at all, unless it comes with a citizenship measure.
Now, Senate Republican leaders, in particular, are not thrilled about this. Here are the words of [Senate minority Leader] Mitch McConnell, who said it better than I can: “It would be politically beyond stupid for us to do that right before the election, because certainly, we’d get the blame” for that government shutdown. What happens now?
Kenan: Last-minute agreement, like, I feel. I used to cover the Hill full time. I no longer do, but it was, like, late nights standing in the hallway for a last-minute reprieve. At some point, they’re going to probably keep the government open, but with Trump’s demands and the citizenship proof of a life for voters and all that, it’s going to be really messy. Mike Johnson became speaker after a whole bunch of other speakers failed to keep the government open.
Huetteman: That’s right.
Kenan: Probation spell, we went through chaos, he has a small majority. He survived because the Democrats intervened on his behalf once, because of Ukraine. We have no idea the dynamics of — do the Democrats want to see complete chaos so the Republicans get blamed? Who knows? I don’t think it’s going to be a handshake tomorrow and Let’s do a deal. What they usually do is continue current spending levels and what they call a continuing resolution. So you keep status quo for one month, two months, three months, sometimes 10 months. The odds are, the government will stay open at some kind of a last-minute patchwork deal that nobody particularly likes, but that’s likely. I wouldn’t say that certain. Republicans have backed off shutting the government down for a while now, a couple of years.
Huetteman: It’s worth noting, though, that even this bill that they just voted down would’ve only kicked the can down to March. So we are still talking about something that the new Congress would have to deal with pretty quickly, even if we can get something done short-term. But we’ve got a lot of news today. So moving on to reproductive health news.
This week, Senate Republicans, again, blocked a bill that would’ve guaranteed access to in vitro fertilization nationwide. That federal bill would, of course, have overridden state laws that restrict access to the procedure. You may recall that Republicans also blocked that bill earlier this summer, describing it as a political show vote. And indeed, Democrats are trying to get Republicans on the record, opposing IVF, in order to draw contrast with the GOP before voters go to the polls. What do we think? Did Democrats succeed here in showing voters their lawmakers really think about IVF?
Luthra: I mean, realistically, yes, I think this is a very effective strategy for Democrats. If they could talk about abortion and IVF every day, all day, they would. We can look at Taylor Swift’s endorsement of Kamala Harris and [Minnesota Gov.] Tim Walz. She specifically mentions reproductive rights, and she mentions IVF in particular, noting that she thinks that these are the candidates who will support access to that fertility regimen. IVF is very popular, and it is obviously going to be a major battle, because it is the next frontier for the anti-abortion movement, and the Republican Party is allied very closely to this movement. Even if there have been more fractures emerging lately, I just don’t see how Republicans can find a way to make this a political winner for them, unless they figure out a way to change their tune, at least temporarily, without alienating that ally they have.
Huetteman: Absolutely. And meanwhile, speaking of the consequences of these actions on abortion lately, this week we learned of the first publicly reported death from delayed care under a state abortion ban. ProPublica reported the heart-wrenching story of a 28-year-old mother in Georgia who died in 2022 after her doctors held off on performing a D&C [dilation and curettage procedure]. Performing a D&C in Georgia is a felony, with a few exceptions. Sorry, this is difficult to talk about, especially if you or someone you know has needed a D&C, and that may be a lot of us, whether we know it or not.
Her name was Amber Thurman. Amber needed the D&C because she was suffering from a rare complication after taking the abortion pill. She developed a serious infection, and she died on the operating table. Georgia’s Maternal Mortality Review Committee determined that Amber Thurman’s death was preventable. ProPublica says at least one other woman has died from being unable to access illegal abortions and timely medical care. And as the story said, “There are almost certainly others.” On Tuesday, Vice President Harris said Amber’s death shows the consequences of Trump’s actions to block abortion access. How does this affect the national conversation about abortion? Does it change anything?
Luthra: I mean, it should, and I don’t think it’s that simple. And it’s tough, because, I mean, these stories are incredible pieces of journalism, and what they show us are that two women are dead because of abortion bans — and that there are almost certainly many more, because these deaths were in 2022, very soon after the Dobbs decision. And what has been really striking, at the same time, is that the anti-abortion movement has very clear talking points on these deaths. And they’re doing what we have seen them do, in so many cases, where women have almost lost their lives, and now, in these cases where they have, which is they blame the doctors. And they have been going out of their way to argue that, actually, the exceptions that exist in these laws are very clear, even though doctor after doctor will tell you they are not, and that it is the doctor’s fault for not providing care when there is very obviously an exception.
They are also arguing that this is further proof that medication abortion, which is responsible for the vast majority of abortions in this country, is unsafe, even though, as you noted and as these stories noted, the complications these women experienced are very rare and could be addressed and treated for and do not have to be fatal if you have access to health care and doctors who are not handcuffed by your state’s abortion laws. And so what I think happens then is this is something that should matter and that should change our conversation. And there are people talking about this and making clear that this is because of the reproductive health world that we live in, but I don’t think it will necessarily change the course of where we are headed, despite the fact that what abortion opponents are saying is not true and despite the fact that these abortion bans remain very unpopular.
Kenan: I think you can, and she said it really well, but I think in terms of, does it change minds? Think about the two bumper stickers, right? One is “Abortion bans kill,” and the other one is “The abortion pill kills.” And both of these women had medication abortions. Those side effects are very, very, very unusual, that dangerous side effects, are extremely unusual. There’s years of data, there’s like no drug on Earth that is a hundred percent, a thousand percent, a hundred thousand percent safe. So these were tragedies in which the women did develop severe life-threatening side effects, didn’t get the proper treatment. But think about your bumper stickers. I don’t think this changes a lot of minds.
Huetteman: All right. Well, unfortunately we will keep watching for this and more news on this subject. But in state news, Nevada will become the 18th state to use its Medicaid funds to cover abortions after a recent court ruling. While federal funds are generally barred from paying for abortions, states do have more flexibility to use their own Medicaid funds to cover the procedure. And, North Dakota’s abortion ban has been overturned, after a judge ruled that the state’s constitution protects a woman’s right to an abortion until the fetus is viable. But there’s a bigger challenge: The state has no abortion clinics left. We’ve talked a lot on this podcast about how overturning Roe has effectively created new, largely geographical classes of haves and have-nots, people who can access abortion care and people who can’t. It seems like the lesson out of North Dakota right now is that evening that playing field isn’t as simple as changing the law, yes?
Luthra: Absolutely. And this is something that we have seen even before Roe was overturned. I mean, an example that I think about a lot is Texas, which had had this very big abortion law passed in 2013, and it was litigated in the courts, was in and out of effect before it went to the Supreme Court and was largely struck down. But clinics closed in the meantime. And what that tells us is that when clinics close, they largely don’t reopen. It is very, very hard to open an abortion clinic. It is expensive. It can be dangerous because of harassment. You need to find providers. You need to build up a medical infrastructure that doesn’t exist. And we are seeing several states with ballot measures to try to undo abortion bans in their states — Florida, Missouri, Nebraska with their 12-week ban. We are seeing efforts across the country to try and restore access to these states.
But the question is exactly what you pointed out, which is there is a right in name and there is a right in practice. And for all the difficulties of creating a right in name, creating a right in practice is even harder. And there is just so much more that we will need to be following as journalists, and also as people who consume health care, to fully see what it takes for people to be able to get reproductive health care, including abortion, after they have lost it.
Huetteman: All right. And with fewer than 50 days left until Election Day and way fewer before early voting begins, a court in Nebraska has ruled that competing abortion rights measures can appear on the ballot there this fall. Two measures, one that would expand access and one that would restrict it, qualified for the ballot. Nebraska will be the first state to ask residents to vote on two opposing abortion ballot measures. Currently, the state bans abortion in most cases, starting at 12 weeks. There are at least nine other states with ballot measures to protect abortion rights this fall, but this one’s pretty unusual. What do we think? Will this be confusing to Nebraska voters?
Luthra: I mean, I imagine if I were a voter, I would be confused. Most people don’t follow the ins and outs of what’s on their ballot until you get close to Election Day and you are bombarded with advertisements. And I think this is really striking, because it is just part of, I guess, maybe not long, because this only happened two years ago, but part of a repeated pattern of abortion opponents trying to find different ways to get around the fact that ballot measures restoring abortion rights or protecting abortion rights largely win. And so how do you find a way around that? You can try and create confusion. You can try and raise the threshold for approval like they tried and failed to do in Ohio. You can, maybe in Nebraska this is more effective, put multiple measures on the ballot. You can try, as they tried and failed to do in Missouri, try and stop something from appearing on the ballot.
And I think this is just something that we need to watch and see. Is this the thing that finally sticks? Does this finally undercut efforts to use direct voting to restore abortion rights? Which we should also note is a strategy with an expiration date of sorts, because not every state allows for this direct democracy approach. And we’re actually hitting the end of the list of states very soon where this is a viable strategy.
Huetteman: And as we know, every state where a ballot measure has addressed this issue since Roe was overturned has fallen on the side of abortion rights, ultimately. It’ll be curious to see what happens here, where voters have both choices right before them.
Well, let’s wrap up with tech news this week. Are you wearing an Apple Watch right now? Or maybe you’re listening to us on AirPods? Well, that watch could soon tell you if you might have sleep apnea. Or, if you have trouble hearing, those earbuds could soon help you hear better. The FDA has given separate green lights to two new Apple product functions. One is an Apple Watch change that assesses the wearer’s risk of sleep apnea. And the FDA also authorized Apple AirPods as the first over-the-counter hearing-aid software, to assist those with mild to moderate hearing loss. Hearing aids can be pretty expensive, and some resist wearing them due to stigma or stubbornness. What does this mean for people with these conditions, and also about the possibilities for health tech?
Kenan: I mean, none of us are covering the FDA’s tech division full time or even much at all. So basically there’s been a trend toward sort of overlap with consumer and health products. Many of us have something on our wrists or something in our phone that is monitoring something or other, and there’s been some controversy about how accurate some of them are. My understanding with the sleep apnea thing, that it doesn’t actually diagnose it. It tracks your sleep patterns, and if it sees some red flags, it says: You might have sleep apnea. You should go see a doctor. That’s what I think that does.
Huetteman: That’s right.
Kenan: You’re asleep when you’re having sleep apnea. You don’t necessarily know what’s happening. So it’s arguably a useful thing that you have kind of an alert system. The hearing aids, it’s not just these. The FDA, a few months ago, authorized more over-the-counter hearing aids of various types, which have made them much cheaper and much more accessible. This is an advance, another category, another type to have people wearing earbuds anyway. I know people who have the over-the-counter hearing aids, and they are small and cheap, so that industry has really been disrupted by tech. So we are seeing not necessarily some of the sky-in-the-pie promises of health and tech from a few years ago but some useful things for consumers to either make things more accessible or affordable, like the earbuds — although I would lose them — or just a useful tool or a potentially useful tool, I don’t know how great the data is, saying ask your doctor about this. Sleep apnea is dangerous.
So my mom is about to turn 90, and we have a fall monitor on her watch that we actually pay for, an extra service, that they alert emergency. I was with her once when she fell. They called her and said, Are you okay? And she said, Yes, my daughter’s here and et cetera. Except, at 90, she still plays pingpong, doubles pingpong, not a lot of movement for 90 year olds, and it does get the fall monitor very confused. I think it’s been trained. So yeah, I mean, it’s not that expensive, and it’s great peace of mind. People would much rather have it on their watch, because young cool people wear smartwatches, than those buttons around their neck. I would’ve never gotten my mother to wear a button around her neck. So it’s part of a larger trend of tech becoming a health tool, and it’s not a panacea, but the affordability for over-the-counter hearing aids is a big deal.
Huetteman: Right, right. This is expanded access. If you’ve got this consumer product already in your pocket, on your wrist, in your ears, why not have it help with your health? We’ve already kind of adjusted, in many ways, to health tech. We had Fitbits. We’ve had things that have tracked our heart rates and that sort of thing, or even our phones can do that at this point. But hearing aids, in many cases for people who have mild or moderate hearing loss, they don’t even go for a hearing aid, because they don’t want to be stigmatized as being maybe a little older and being unable to hear, even if they might just muddle through. But if you’ve already got those AirPods in, because you’re going to take a call later, I mean, that’s pretty below the radar. You don’t have to feel too self-conscious about that one, so …
Kenan: Yeah, my mom would look cool, but she actually doesn’t need them, so that’s OK.
Huetteman: If she’s playing pingpong at her age, she already looks cool.
Kenan: She plays pingpong very slowly. I hope I’m doing the equivalent when I’m 90. I hope I’m 90, you know?
Huetteman: Hear, hear.
Kenan: You know.
Huetteman: OK, that’s this week’s news. Now it’s time for our extra credit segment. That’s when we each recommend a story we read this week that we think you should read, too. As always, don’t worry if you miss it. We’ll post the links in the podcast page at kffhealthnews.org and in our show notes, on your phone or other mobile device. Shefali, why don’t you go first this week?
Luthra: All right. My story is from KFF Health News by the great Rachana Pradhan. The headline is, “At Catholic Hospitals, a Mission of Charity Runs Up Against High Care Costs for Patients.” The story is one of my favorite genres of stories, which is stories about how everyone loves their hospital and their hospital is a business. And Rachana does a great job looking at the history of Catholic hospitals and the extent to which they were founded as these beacons of charitable care meant to improve the community. But actually, when you look at where Catholic hospitals are now — and Catholic hospitals have really proliferated in the past several years — they look a lot like businesses and a lot less like charities. There’s some fascinating patient stories and also analyses in here, showing that Catholic hospitals are less likely than other nonprofit hospitals to treat Medicaid patients. They are great at going after patients for unpaid medical bills, including suing them, garnishing wages, reporting them to credit bureaus. It’s really great. It’s the exact kind of journalism that I think we need more of, and I love this story, and I hope others do, too.
Huetteman: Excellent. It is a great piece of journalism. We hope everyone will take some time to read it. Tami, why don’t you go?
Luhby: OK. My extra credit is an in-depth piece by one of our very own, Alice Miranda Ollstein of Politico, and it’s titled, “Doctors Are Leaving Conservative States to Perform Abortions. We Followed One.” So Alice followed a doctor who spent a month in Delaware learning how to perform abortions, because she couldn’t obtain that training in her home state, across the country. Alice notes that Politico granted the doctor anonymity due to her fear of professional repercussions and the threat of physical violence for seeking abortion training, which is concerning to hear. While many stories have written about states’ abortion bans, Alice’s piece provides a different perspective. She writes about the lengths the doctors must go to obtain training in the procedure and the negative effects that the overturning of Roe has had on medical education.
The doctor she profiled spent nearly two years searching for a position where she could obtain this training, before landing at Delaware’s Planned Parenthood. It cost nearly $8,000. The doctor had to pull together grants and scholarships in order to cover the costs. Alice walked readers through the doctor’s training in both surgical and medical abortions and through her ethical and medical thoughts after seeing — and this is one thing that stuck with me in the story — what’s called the “products of conception” on a little tray. So the story is very moving, and it’s well worth your time.
Huetteman: Absolutely. And the more detail we can get about what these sorts of procedures and this training looks like for doctors, the better we understand what we’re actually talking about when we’re talking about these abortion bans and other restrictions on reproductive health. Joanne, why don’t you talk to us about your extra credit this week?
Luthra: OK. There’s a piece in the New York Times by Teddy Rosenbluth called “This Chatbot Pulls People Away from Conspiracy Theories.” And there’s also a related podcast at the Atlantic called, by Jerusalem Demsas, “When Fact-Checks Backfire.” They’re both about the same piece of research that appeared in Science. Basically, debunking, or fact-checking, has not really worked very well in pulling people away from misinformation and conspiracy theories. There had been some research suggesting that if you try to debunk something, it was the backfire effect, that you actually made it stick more. That doesn’t always happen. There’s sort of some people that it does and some people it doesn’t — that’s beginning to be understood more.
And what this study, the Times reported on and the Atlantic podcast discussed, is using AI, because we all think that AI is going to be generating more disinformation, but AI is also going to be fighting disinformation. And this is an example of it, where the people in this study had a dialogue, a written, typed-in dialogue, where the chatbot that gave a bespoke response to conspiracy beliefs, including vaccines and other public health things. And that these individually tailored, back-and-forth dialogue, with an AI bot, actually made about 20% of the people, which is, in this field, a lot, drop their or modify their beliefs or drop their conspiracy beliefs. And that it stuck. It wasn’t just because some of these fact-checks work for like a week or two. These, they checked in with people two months later and the changes in their thinking had stuck. So it’s not a solution to disinformation and conspiracy belief, but it is a fairly significant arrow to new techniques and more research to how to debunk it better without a backfire effect.
Huetteman: That’s great. Thanks for sharing those. All right. My extra credit this week comes from two of our podcast pals at The Washington Post, Lauren Weber and Rachel Roubein. The headline is, “What Warning Labels Could Look Like on Your Favorite Foods.” They report that the FDA is considering labeling food to identify when they have a high saturated fat content, sodium, sugar, those sorts of things that we should all be paying attention to on nutrition labels. But their proposal falls short, critics say. It’s not quite as good, they say, at identifying the health risk factors of certain amounts of sodium and sugar in our food, especially compared to other countries.
They do an extensive study on Chile’s food labeling, in fact. And if you’re like me and you buy a lot of your groceries for your household and you try to look at the nutrition labels, you might be surprised by some of the items the article identifies as being particularly high in sodium, like Cheerios. Bad news for my family this morning.
All right, that’s our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left a review. That helps other people find us, too. Special thanks, as always, to our amazing engineer, Francis Ying. And as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you could try tweeting me. I’m lurking on X, @emmarieDC. Shefali.
Luthra: I’m @shefalil.
Huetteman: Joanne.
Kenan: @JoanneKenen on Twitter, @joanneKenen1 on Threads.
Huetteman: And Tami.
Luhby: Best place to find me is cnn.com.
Huetteman: We’ll 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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Lauren Weber
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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.
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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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7 months 2 weeks ago
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STAT+: Medicare announces drug prices for historic first round of negotiations
WASHINGTON — The day drugmakers dreaded has finally arrived.
Medicare officials on Thursday unveiled the results of the program’s first 10 drug price negotiations, despite the industry’s two-decade, multimillion-dollar lobbying campaign and barrage of lawsuits to stop them.
WASHINGTON — The day drugmakers dreaded has finally arrived.
Medicare officials on Thursday unveiled the results of the program’s first 10 drug price negotiations, despite the industry’s two-decade, multimillion-dollar lobbying campaign and barrage of lawsuits to stop them.
The drugs that received negotiated prices are Bristol Myers Squibb’s blood thinner Eliquis, Boehringer Ingelheim’s diabetes drug Jardiance, Johnson & Johnson’s blood thinner Xarelto, Merck’s diabetes drug Januvia, AstraZeneca’s diabetes drug Farxiga, Novartis’ heart failure treatment Entresto, Amgen’s rheumatoid arthritis drug Enbrel, J&J and AbbVie’s blood cancer treatment Imbruvica, J&J’s anti-inflammatory medicine Stelara, and Novo Nordisk insulins that go by names including Fiasp and NovoLog.
7 months 3 weeks ago
Health Care, Pharma, drug pricing, Medicare, Pharmaceuticals, policy, STAT+
KFF Health News' 'What the Health?': Abortion Heats Up Presidential Race
The Host
Julie Rovner
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
The change at the top of the likely Democratic presidential ticket is prompting both abortion rights and anti-abortion organizations to recalibrate their campaigns, even as they fight over finalizing fall ballot proposals in many states.
Meanwhile, former President Donald Trump’s campaign is trying to distance itself from “Project 2025,” the controversial plan reportedly designed for the next GOP administration and put together by the conservative Heritage Foundation and former Trump administration officials. Although the head of the project’s policy arm was pushed out this week, the part of the project creating a database of Trump loyalists to staff a potential new administration remains up and running.
This week’s panelists are Julie Rovner of KFF Health News, Alice Miranda Ollstein of Politico, Lauren Weber of The Washington Post, and Sarah Karlin-Smith of the Pink Sheet.
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Sarah Karlin-Smith
Pink Sheet
Alice Miranda Ollstein
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Lauren Weber
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Among the takeaways from this week’s episode:
- Vice President Kamala Harris is promising to “restore reproductive freedom” if elected president; her campaign says that means restoring the constitutional right to an abortion under Roe v. Wade. Despite that goal having slim prospects in Congress, some abortion rights supporters are hoping the federal government would expand abortion access even beyond Roe under her presidency.
- President Joe Biden this week recommended a sweeping overhaul of the Supreme Court, including term limits for justices. Famously an institutionalist, Biden stopped short of embracing the progressive call to add more justices to the high court. Nonetheless, his proposal has been considered politically dangerous, even as the conservative-tilted court has overturned its own precedents and shrugged at its ethics policies — and shifts in the national conversation about the court could have a long-term effect.
- The Trump campaign’s attempts to distance itself from the controversial ideas of Heritage’s Project 2025 are more savvy marketing than anything: Even without adopting the document, the conservative policy personnel behind it could well become the conservative policy personnel of a second Trump administration.
- GOP state officials and anti-abortion groups are launching their next attempts to block potential abortion rights victories at the ballot box. The next few weeks will reveal whether voters in certain influential states — like Arizona and Florida — weigh in on abortion this fall.
Also this week, Rovner interviews KFF Health News’ Elisabeth Rosenthal, who reported and wrote the latest KFF Health News-NPR “Bill of the Month” installment about a preauthorized surgery that generated a six-figure bill.
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 “Online Portals Deliver Scary Health News Before Doctors Can Weigh In,” by Fenit Nirappil.
Alice Miranda Ollstein: ProPublica’s “A Lab Test That Experts Liken to a Witch Trial Is Helping Send Women to Prison for Murder,” by Duaa Eldeib.
Lauren Weber: The Tributary’s “Testimony: Florida Wrongly Cut People From Medicaid Due to ‘Computer Error,’ Bad Data,” by Charlie McGee.
Sarah Karlin-Smith: KFF Health News’ “Why Many Nonprofit (Wink, Wink) Hospitals Are Rolling in Money,” by Elisabeth Rosenthal; and The Hollywood Reporter’s “New York’s Largest Hospital System Is Setting Its Sights on the Entertainment Business,” by Alex Weprin.
Also mentioned on this week’s podcast:
Politico’s “States Break Out New Tactics To Thwart Abortion Ballot Measures,” by Alice Miranda Ollstein.
click to open the transcript
Transcript: Abortion Heats Up Presidential Race
KFF Health News’ ‘What the Health?’ Episode Title: ‘Abortion Heats Up Presidential Race’Episode Number: 358Published: Aug. 1, 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 a 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, Aug. 1, at 10 a.m. As always, news happens fast and things might change by the time you hear this, so here we go.
We are joined today via video conference by Lauren Weber, of The Washington Post.
Lauren Weber: Hello, hello.
Rovner: Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Hello.
Rovner: And Sarah Karlin-Smith of the Pink Sheet.
Sarah Karlin-Smith: Hi, everybody.
Rovner: Later in this episode, we’ll have my interview with KFF Health News’ Elisabeth Rosenthal, who reported and wrote the latest KFF Health News-NPR “Bill of the Month.” It’s about a woman who had a cochlear implant surgery that was preapproved by her insurer, but still, and say it with me, got an enormous bill anyway. But first, this week’s news.
We’re going to start this week with presidential politics, because I think everyone, or at least me, is still kind of processing the idea that the race is no longer Biden versus Trump, but Harris versus Trump. One thing we have already seen from Vice President [Kamala] Harris is a new focus on reproductive rights. As we mentioned last week, Iowa’s six-week abortion ban took effect this past Monday, making it the 22nd state to impose what the vice president is now calling a “Trump abortion ban,” referring to total bans as well as restrictions that wouldn’t have been allowed under Roe [v. Wade]. Alice, how are abortion rights groups refocusing themselves now that Harris, rather than Biden, is at the top of the ticket?
Ollstein: Well, in one sense, a lot has changed, and in another sense, nothing has changed. I mean, these groups were already holding events with Harris around the country. They stressed that when they endorsed Biden, they also endorsed Harris. They endorsed the ticket, and so it wasn’t a surprise or much of an internal discussion to decide to come out strong and endorse. What’s been sort of interesting for me is the politics and the messaging versus the policy on this front. So these activist groups were really excited about Harris and were saying that they’re confident that she’s going to both campaign and govern more aggressively in favor of abortion rights. And we haven’t really seen concrete signs that that’s the case. We wrote about how she was giving these speeches in her first week as the candidate at the top of the ticket, saying, “I’m going to restore reproductive freedom.” And she kept saying that over and over. And I saw that that became a Rorschach test for a lot of people. And some people said, “Oh, that is code for she’s going to go beyond Roe v. Wade.”
I saw a lot of projection on that front. But when we got the campaign to confirm, they said, “No, she means Roe v. Wade.” So she’s endorsing the exact same policy that Biden was endorsing, which a lot of abortion rights groups say is not good enough. They point out that many people were denied abortions under Roe v. Wade. States could impose all these restrictions, they could have bans on abortions later in pregnancy, they could have restrictions throughout pregnancy, they put clinics out of business, etc. And so the hopes that she would really advocate for going beyond restoring Roe v. Wade have sort of fizzled. Although there’s also a divide between sort of the big mainstream groups and the smaller, scrappier, more sort-of-militant progressive groups.
Rovner: It’s kind of the mirror image of what’s going on on the anti-abortion side.
Ollstein: Absolutely, absolutely. You have hard-liners and then you have more politically pragmatic, “Let’s just get done what we can get done.” And a lot of this conversation is theoretical because the likelihood of a Congress willing to pass either restoring Roe v. Wade, or going further, is very slim. What the administration could do on the executive front is also curtailed by recent Supreme Court opinions on Chevron. So, some of this is theoretical. It’s not totally clear to me what Kamala Harris would do on abortion rights that Biden has not already done. And it seems that a lot of this race is pledging to stop Donald Trump from undoing those things and imposing restrictions.
Rovner: So it looks like another issue that Harris is appearing to be highlighting is medical debt, something she’s been working on as vice president. The federal government this week approved a novel program out of North Carolina that would raise Medicaid rates for hospitals that forgive patient medical debt, as well as automatically enroll eligible low-income patients in financial assistance programs.
Now, there was a study a couple of months back that showed that forgiving medical debt after it’s gone to collections doesn’t actually help people all that much. Their credit rating is still a mess, and they still can’t afford a lot of things. What does seem to help is preventing those debts in the first place. So is this project — which includes some of these things like enrolling people automatically in assistance programs — maybe the beginning of an effort to address this debt further upstream?
Weber: I think, theoretically, it’s the beginning of an effort, but if you read the fine print, none of the hospitals have signed on yet, from what I understand. So, when you’ve got the hospital association saying, “Oh, we’re working on it,” but no one signed on, I don’t know that you have a deal yet. I mean, that remains to be seen. Obviously, this is something that they’re really hoping to get done. But if you don’t have hospital buy-in — which is the major player here — and the hospitals in lobbyists-speak are saying things like, “We think the insurers and other parts of the health care system should be involved,” I’m just hesitant to comment on the longevity of this project before these people actually sign on the dotted line.
Rovner: And it’s important to remember that hospitals are supposed to be doing this anyway. Nonprofit hospitals, at least, are supposed to be doing this anyway. That’s one of the things that they keep their nonprofit status for. And yet we have seen, obviously, rather painfully, over particularly more in this last decade or so, that that’s just not happening. And people are ending up with these big bills, and they’re being sent to collections, and their credit ratings are being ruined, and makes it harder for them to find a place to live, or in some cases get a job. I mean, this spin-out from unpaid medical debt is not great, and affects many other parts of people’s lives.
OK, well meanwhile, President Biden, who is still president for another five and a half months, this week proposed a pretty sweeping overhaul of the Supreme Court, including term limits and enforceable ethics requirements. This obviously isn’t going to happen while he’s still in office, but it lays down a marker going forward for Democrats. I know President Biden was very resistant to calls for major Supreme Court change earlier in his term. I guess some of the scandals that we’ve been hearing about with some of these Supreme Court justices have perhaps made him soften a little bit towards doing something.
Ollstein: I mean, this has kind of bubbled up for a while, and you’ve slowly seen more members of Congress endorsing these kinds of reforms. Biden has, he’s famously an institutionalist. He was resistant to calling for the end of the Senate filibuster. He was resistant to some of these big reforms. He sort of convened committees to study the issue and sort of kick it down the road a bit. But I think in the context of some of this was starting to be announced when he was attempting to save his own presidential candidacy and was shoring up support from progressives on that front. But there is not a Congress, and there is not likely to be a Congress, willing to pass these reforms. And so I think the shift in conversation is still important. And I think some of these reforms that were once considered crazy, fringe ideas are now being taken more seriously by top-level folks. Still, obviously a long way to go. But like you said, all of the scandals around ethics at the Supreme Court have really highlighted and brought this to the fore.
Karlin-Smith: It does seem notable to me that even though he did sort of tease this a little bit as he was still trying to save his campaign, he really didn’t lean into it until he was in this lame-duck period. And that gives you that sense of, it felt politically dangerous a bit to go this far, and gives you a sense of where we are on it. And that he has not brought up what I think some people on the left would like Democrats to think about, which is adding more justices to the Supreme Court, which could be something that I think might have a bigger impact. And there is some justification for that given that the expansion of the circuit court system and so forth over the years. So I think those are two big markers for me that give a sense of, there’s progress in this area, but for people that really want to see major reform, we’re a long way off from that.
Rovner: Yeah. It bears noting that the way that the term-limit proposal is structured, every president would get two appointments, because it would be 18 years and they would be staggered. So you wouldn’t have sort of the odd situation we’re in now, where Democrats have been in the presidency, in the nominating form, for more years than Republicans, and yet there’s now a 6 to 3, basically Republican-appointed majority, on the court. But as Alice says, I don’t think anybody thinks this is going to happen. Somewhat like medical debt, this is going to be a political talking point for this fall.
So, in Republican political news, the head of the Heritage Foundation’s Project 2025 resigned this week, as top staff at the Trump campaign tried to distance their candidate from some of the really-out-there proposals in the 900-page blueprint for the next Republican administration. But while the policy part of Project 2025 may or may not be winding down, we’ve heard differing ideas about the personnel part of the project. The presidential personnel database, which is arguably even more important, remains up and running. Trump has said he wants to remove civil service protections from tens of thousands of federal workers and replace them with people loyal to him and his agenda. And Project 2025 is presumably going to have those people ready, and waiting, and vetted. Sarah, just as an example, what could this mean in an agency like the FDA [Food and Drug Administration]?
Karlin-Smith: The FDA has a pretty small amount of political appointees and so forth, but it could kind of impact tenure of people higher up in senior positions and their ability to stay in them. And even if it doesn’t impact, even if the Trump administration didn’t necessarily go after them directly, I have heard reports from people that suggest it might initiate a series of people leaving, and then trickle-down effect there. And it really makes career positions a lot less secure, in part because it could give a lot of ammunition to basically move people around to jobs they don’t want to be in, or don’t like.
Rovner: Yeah, I mean we saw this during the Trump administration, just with the Trump administration picked up the Bureau of Land Management, moved it to Colorado, and a lot of people quit their jobs. There was, I think a piece of the Ag[riculture] Department that they moved to Kansas City. And civil servants — we’re not talking about these top political appointees — civil servants have wives and spouses, and kids in school, and it’s hard for them to just sort of up and say, “I’m going to move to another part of the country,” without really very much warning.
Weber: If anybody’s wondering, they should probably pick up Michael Lewis’ The Fifth Risk. I would highly recommend it as a very interesting book that gets at what happens if you eliminate career federal employees that you have no idea how important their job is because they operate in the background. So, it’s really helpful background. I just wanted to also add, I think we have to read aloud what the Trump campaign said about Project 2025, which is reports of Project 2025’s demise would be greatly welcomed and serve as notice to anyone or any group trying to misrepresent their influence of President Trump in his campaign: it will not end well with you. Which I found to be just a particularly savvy bit of marketing. Because I mean, the president, former President Trump, has made it very clear that he’s not going to give positions on things that he thinks could cost him votes, which is what I think this statement is from. That doesn’t necessarily mean he’s not going to take Project 2025’s guidebook by letter and key. I find this messaging moment to be very interesting.
Rovner: The people who wrote Project 2025 are people who are currently loyal to President Trump. Many of them are former Trump appointees, or people who worked for Trump. Basically what this is is a much more sophisticated preparation for if he gets back into office than he had in 2016 when he famously said he didn’t think he was going to win. And it took them months, and in some cases years, to actually get people into the administration.
Ollstein: Yeah, it’s become this interesting double-edged sword. Because like you said, when he was elected in 2016, they were clearly unprepared. And when they attempted to do all of these rule changes at federal agencies, a lot of them got blocked in court. They weren’t really ready for prime time. And so this was an attempt to have all of the groundwork laid, so that they could have this sort of blitz to remake federal law as soon as they entered office and have the loyal personnel ready to execute it. But it’s now backfiring politically, and Trump has always sort of been sensitive to portrayal of any group or person being the ideas generator and not himself. I’m thinking of “No puppet” from … if people remember that.
So any sort of portrayal of him as the mouthpiece or the puppet of some other group has always really sort of triggered him. And so you see him lashing out now and saying, “I have nothing to do with this group.” Even though, like you said, this group has lots and lots and lots of ties to him. And the repeated disavowals show that this is a sensitive point for them. But like Lauren said, there’s no sign this is stopping or severing ties to them in the future.
Rovner: And of course, Trump rather famously wants to preserve his ability to say different things to different audiences at different times. Sometimes he contradicts himself in the same paragraph. In fact, frequently he contradicts himself in the same paragraph. He’s thinking aloud, that’s sort of his thing. So he can pretend to be all things to all people. And having things written down, like Project 2025, sort of hamper his ability to do that. I think we all agree that the fact that this guy stepped down does not mean that this is not going to be what’s very much the plan for the administration, assuming he gets back into office.
Well, speaking of former President Trump, on Wednesday he took the stage at the National Association of Black Journalists conference in Chicago. And let us say, it was not very pretty. On abortion, he repeated his false claim that Democrats support abortion in the ninth month and even after birth. That’s murder, people. And he tried to make it clear that the issue is now successfully back to the states to decide, which is what he said he wanted. But Alice, you have a story this week about how anti-abortion forces in several different states are working hard to keep voters from getting to express their views on abortion-related ballot questions. So, what’s sort of the rundown here?
Ollstein: We’ve seen the states that are working to put this on the ballot. They’ve already overcome several waves of lawsuits and attempts by state legislatures to pass new rules, making the ballot initiative process more difficult. And so now we’re nearing the deadline, and we’re seeing a new blitz of efforts, both from Republican state officials and outside anti-abortion groups, to keep these off the ballot, or sort of put a thumb on the scale in terms of inserting wording that is favorable to the anti-abortion side. Inserting cost estimates saying, “Oh, if this passes, it’ll cost the state so much in litigation.” That’s happening in Florida.
And so I think the next few weeks, the certification deadlines, a lot of them are in late August so the next few weeks will be really crucial to see if these will or will not get on the ballot. In certain states, they could also have ripple effects on other political races by spurring higher turnout potentially. You see Democrats hoping that’s the case. But we’re seeing things are not yet settled in a lot of really major states — Arizona, Missouri, Montana, South Dakota, Florida — so wanting to keep a close eye on these fights. Obviously, all of the ones that have happened so far over the past two years have been victories for the pro-abortion-rights side. And knowing that, and anticipating that will continue, you see anti-abortion forces really mobilizing to make sure these votes don’t happen in the first place.
Weber: And as you pointed out, I mean, this is obviously important because this is a turnout election, especially now with the new Harris-Trump dynamic. And so all of these battles that are down-ticket have so much more emphasis now with what we’re looking at, especially as new poll results show this election could be pretty tight. We’ll still see. Obviously, there’s still a lot of adjustment to be done. But I think these battles that Alice reported on are so critical, because they have so much more reverberation than even just the abortion reverberation, but in the possible turnout that could drive other factors.
Rovner: In some of these very swingy states, too. Well, one final interesting piece of news on the reproductive health front this week. A patient in Kansas is suing the University of Kansas Health System for denying her an emergency abortion in 2022 in violation of the federal EMTALA law, the Emergency Medical Treatment and Active Labor Act. This appears to be the first such lawsuit of its type, and the patient is seeking not just financial compensation — her water broke early and she ended up having to go to another state — but she wants the hospital to admit that it violated both federal and Kansas law so that this doesn’t happen to anybody else. Do we expect to see more of these kinds of actions? And somebody remind us what EMTALA does and doesn’t do, and how the fight over this is still live because Supreme Court decide the case out of Idaho anyway.
Ollstein: Yeah. So we have seen some other patients sue over being turned away from hospitals. But what I think is really interesting is that the Biden administration pledged really aggressive enforcement of EMTALA. But yet you’re not seeing this lawsuit come from the administration, you’re seeing it come from a patient, an outside advocacy group. So I think that’s really notable. Maybe the Biden administration is doing more behind the scenes that we don’t know about. I’ve tried to ask them and they have not said. Like you said, the Supreme Court punted on this issue of the intersection between federal patient protections under EMTALA and state abortion bans and where to draw the line. And which one takes precedence when they’re in conflict, or whether they’re in conflict, is also up for debate.
So we could see more of this, but we’ve also seen over the past two years that a lot of patients don’t want to put themselves out there like this and become a public figure in the face of a lawsuit for very understandable reasons in this really painful moment. And so I think that’s why you see groups wanting the administration to do more on the front end to prevent this from happening, rather than patients having to take this on after it happens to them in a devastating way.
Rovner: I have also talked to people in the administration who have suggested to me that they are in fact doing more on this. Although Alice, as you say, we haven’t really seen it publicly. But I mean, I had somebody approach me to make it known that this is something that they are extremely concerned about. There is some reporting out this week from my former colleague, Joan Biskupic, who covers the Supreme Court for CNN, about speculation about that Idaho case was exactly correct. They took the case and they didn’t decide it. They sent it back to the lower court, because they had split 3-3-3. That the liberals wanted to dismiss the case entirely. The three hard-line conservatives wanted to find that Idaho did not have to provide abortions in emergency cases unless the life, rather than both the life and the health, were threatened. And that Chief Justice [John] Roberts and Justice [Brett] Kavanaugh and [Justice] Amy Coney Barrett were concerned and were stuck in the middle.
And the deal that they struck was to put back the stay that had kept the Iowa law from taking effect, but send it back to the lower court, which, of course, is what they ended up doing. So, as we said at the time, this case continues to go on. There is still not sort of a judicial decision about the situations in which hospitals have to provide emergency abortions for people in these cases that are health-threatening, and/or life-threatening, but not imminently life-threatening, which is what we’ve been seeing. So this is obviously something that’s going to continue.
All right, moving on. Medicare and Medicaid turned 59 this week, making the program almost old enough to qualify for benefits. And as of today, we are exactly a month away from the first 10 negotiated drug prices being officially unveiled. Sarah, what are you hearing about how this is going? I think there was another court case this week that pharma lost. So I mean, this is definitely going forward, right?
Karlin-Smith: Right. Novo Nordisk joined the slew of losses for the industry here. There are appeals, but I don’t think anybody is expecting anything to change the dynamic leading up to the announcements around this first set of drugs. The thing to remember is, and a number of the pharma companies that have drugs impacted have been speaking about the dynamics on their financial earnings calls, which just sort of are happening around now for this quarter of the year, and have kind of made some suggestions that have gone headlines like, “Oh, it’s not so bad, it’s fine.” But there’s sort of these caveats that, like, “We still hate the law!” And it’s still problematic. And I think it’s important to kind of understand the dynamics here. So one thing is this first set of drugs that’s going for negotiations are older drugs, just based on the way the law was written. The things around the money, and how long they have to be on the market. When you start a program like this, the first drugs are going to be older. So they’ve been on the market longer than drugs that’ll come up as part of the program in the past. A lot of them have competition, brand competition, are actually in some ways competitors to each other. So there’s a sense that Medicare Part D private plans are already getting pretty significant discounts through that private process.
So I think there’s not a ton of optimism in some ways that the government can do much better. And it’s going to be very hard to figure out whether they did or didn’t. Again, because so much of this is not transparent, right? We don’t actually know. Every Part D plan is going to have different discounts. And even one of the things that’s said is could we look at what other countries are paying compared to what the government gets. Well, even when many of these country systems negotiate discounts, we have a sense they’re getting better discounts than the U.S., but we don’t actually know what they are. So lack of transparency makes it hard.
So, it’s going to be a little bit of, I think, like this thing where the headlines are going to be a bit confusing for people to parse. That doesn’t mean that there may not be savings for taxpayers. There may not be savings for some consumers when they get their copay. But I think we’re going to have to wait and see later on as this law progresses what happens when drugs actually get thrown into the mix earlier on in their life cycle, and when we get what are known as Medicare Part B drugs, which are the drugs that you get at a doctor’s office administered to you, like say, an expensive chemotherapy or something. With those drugs, there really is no negotiation system going on now in the private sector, the government just pays a set formula that people say inflates the cost of drugs.
So, it’s going to be interesting to watch. Democrats are certainly going to highlight this. There’s some thought process they’ll actually try and time the government announcements to the Democratic [National] Convention. But I think it’s going to be really hard for people initially to make clear claims as to whether this is a success or a failure. And certainly industry is going to keep going after the law, particularly on the idea that just even this threat of government negotiation down the line impacts the amount of money and investment that goes into new innovation and treatments for people down the road.
Rovner: Well, I mean, obviously this was sort of a big deal for the administration. So one would think that they would want to have a chance. And of course, I think the first is the Friday before Labor Day. So it’s not the biggest news week in general. So yeah, I wouldn’t be surprised if they tried to do something a little bit beforehand.
OK, that is the news for this week. Now we will play my Bill of the Month interview with Elisabeth Rosenthal, and then we will come back and do our extra credits.
I am so pleased to welcome back to the podcast my KFF Health News colleague, Elisabeth Rosenthal, who reported and wrote the latest KFF Health News-NPR Bill of the Month. Libby, of course, is the person who launched this entire project in the first place more than six years ago. Libby, welcome back to “What the Health?”
Elisabeth Rosenthal: Thanks for having me again.
Rovner: So, tell us about this month’s patient. Who she is, where she’s from, and what kind of medical care she got.
Rosenthal: Well, her name is Caitlyn Mai, and she’s this wonderful woman from Oklahoma who, basically she needed a cochlear implant, because she’s had single-sided deafness since an infection when she was 12. And people will go like, “Single-sided deafness, what’s the big deal? She has one hearing ear.” But she couldn’t locate where things were, she couldn’t have conversations because she didn’t know who was talking. So actually, over time it’s become a real impediment in school and in work life. She got approved to have a cochlear implant. She was so excited, because it really would change her life. And she gets the implant: It’s magic. She can suddenly find her phone if it’s lost when it rings. And she’s so excited, except then she gets a bill for $139,000.
Rovner: Yeah. So let’s go back a second. As you have advised us so many, many times, she did all of her homework before the surgery …
Rosenthal: Totally.
Rovner: … checking to make sure she had the paperwork for the prior authorization from her insurance company, and checking to make sure that the hospital and all of the doctors were in-network. And as you say, the bill came! So what happened here?
Rosenthal: Well, the problem is we say, “Oh, the patient’s not responsible, there’s prior authorization,” blah, blah, blah, but there’s no problem in trying. You generate a bill, you send it to a patient, it scares the pants off of them. She said she had to leave work she was so upset. And my first piece of advice, which I would never give people in any other part of their lives is, “Don’t pay the bill.” You get a bill, it says you owe $139,000. Of course, she couldn’t pay it. And I believe it also said, “Hey, if you don’t have $139,000, you can pay it off with $19,000-a-month payments.”
And this is a young woman, getting started in life, newly married. And I guess $19,000 a month wasn’t a viable alternative. So Caitlyn starts doing what many patients do, and we’ve seen this more and more in Bill of the Month: She calls the hospital, she calls the insurer. She’s like the referee. Like, the insurer says they didn’t do the billing codes right. She calls the hospital and says, “Oh, you didn’t give us an itemized bill. Can you generate one?” She calls the insurance, says they’re generating an itemized bill. They go back and forth, and back and forth. Then the itemized bill isn’t right, it contains the wrong codes. And in the meantime, for three months, or four months even, she’s getting these bills that say what you owe now: “prompt payment,” “discount,” and “overdue.” And many patients now are in the terrifying position of playing go-between between their provider and their insurance.
She actually said to the provider, “Send me an itemized bill. Send it to me and I will send it to the right person at the insurance company.” And she said to them, “Look, I’ve done all your work for you. Now just figure it out, you guys.” And, in the meantime, she wasn’t actually sent to collections, but threats were made and it was scary. And she spent endless amounts of time. She works for a nonprofit. She’s lucky, she has a job where she can play this kind of go-between role. But really it should be the provider and the insurer that work it out when you have preauth[orization]. There was no reason why any bills should be sent. And that’s one of my mantras. While you’re working this stuff out, don’t send patient bills, because they’re not responsible for this stuff.
Rovner: Well, that’s the whole point of Congress passing the No Surprises Act, that was supposed to take the patient out of the middle. Why is the patient still in the middle?
Rosenthal: Well, because the No Surprises Act did a lot of great things. It held the patient harmless. And this is actually not a surprise bill, it’s a slightly different issue. But even with the No Surprises Act and with surprise bills, it never said you can’t try. And that’s the problem. Americans are good bill-paying citizens. You send people a bill, and they think, “Wow, I guess I owe it.” So what should be added to the No Surprises Act — and I’m not supposed to use the word should — is you can’t send a bill until the insurer and the provider work it out. I know my mailbox is filled with medical bills that I know I don’t owe, right? But the mantra of the provider is, “Well, there’s no harm in trying. Let’s see if someone pays.”
Rovner: Eventually, she did get this worked out.
Rosenthal: She did get this worked out after hours of her time playing go-between, and many hours spent terrified that she would end up somehow having to foot this bill. Once again, the treatment is miraculous. The bills are not miraculous. I mean, they’re miraculous, but in a really different way. They’re horrifying.
Rovner: So what’s the takeaway here? I mean, we’ve given all the advice, “Don’t pay the first bill. Do your homework in advance.” Is there anything else that you can do to avoid getting six-figure bills for preauthorized surgery?
Rosenthal: Well, there is that “don’t pay your bill” advice, and “don’t be scared by the prompt payment discount,” which she had, too. But I think, unfortunately, you have to be the go-between often. And that’s a terrible position for Americans to be in, because it’s really an equity issue. You and I have jobs and knowledge where we can navigate between these two warring parties, essentially, being the peacemaker. And Caitlyn was lucky she had that kind of job. But many Americans don’t have 20 hours to spend on the phone to avoid a huge bill, and they end up in collections if it’s huge. Or if it’s a small bill — and I’ve done this, and I feel like I’m so angry when I do — if it’s a small bill, you’re like, “All right, fine. I’ll just pay it to get this over with.” Even though I know I don’t owe it.
So I do think there should be a policy that you can’t try to send bills to patients that they don’t owe. They know the patients don’t owe these bills. But like I said, there’s no harm in trying, and there’s no HHS [Department of Health and Human Services] police force out there saying, “You shouldn’t do this.” So, it should have been part of the act, but I think the health care system is endlessly agile in figuring out ways to get around laws that Congress has passed to rein in some of their more outrageous practices.
Rovner: As I like to say, full employment for health care reporters. Libby Rosenthal, thank you so much.
Rosenthal: Take care, Julie. Thanks.
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. Sarah, why don’t you go first this week?
Karlin-Smith: Sure. I looked at a piece from Elisabeth Rosenthal, “Why Many Nonprofit (Wink, Wink) Hospitals Are Rolling in Money.” And we sort of alluded to this in the conversation around medical debt. But nonprofit hospitals are supposed to, as part of their nonprofit status, be providing certain sorts of commitments to how they serve patients and our greater society. And over the years, they have morphed from looking not much like nonprofits in many ways. And her lead sort of talks about the various for-profit businesses that they have acquired and lumped under their umbrella, and how that affects what they’re doing. And some of them do not even necessarily seem completely connected to health care.
And just, again, it raises this issue of if you’re going to have this nonprofit status you should be fulfilling that other end of the commitment for not paying taxes. And if you don’t, perhaps we need to rethink that, if we are not getting the charity care and the other commitments to society, is health that we should get. And I wanted to flag, it was a Hollywood Reporter article [“New York’s Largest Hospital System Is Setting Its Sights on the Entertainment Business,”] that I had seen last week about Northwell [Health] Hospital getting into the movie and filmmaking business. And that just gives you a crazy example of what some of these nonprofit systems are doing. And I think it’s why it’s become so egregious and people have been making marks about it.
Rovner: Congress has been talking about the “nonprofit” health entities, particularly hospitals, since the 1990s. It goes along with drug prices, this sort of evergreen issue on Capitol Hill. Lauren, why don’t you go next?
Weber: Yeah. I have something from The Tributary called “Testimony: Florida Wrongly Cut People From Medicaid Due to ‘Computer Error,’ Bad Data.” It’s a story we’ve heard over and over again, but I will just note that highlighted in this story is the company Deloitte, who my former colleagues, who I love dearly at KFF News, Rachana Pradhan and Samantha Liss, had a great investigation on just, I think, a month ago? So, I think that you see these stories about people being removed from Medicaid rolls. And to be clear, this was in Florida, and I believe it was a bunch of moms who were removed the year after they gave birth. So, these are serious consequences for “computer errors.” And I mean, we have no idea the catastrophic impact these could have had. But I think it’s important to keep an eye on this, and I know Racha and Sam certainly have. And pretty wild stuff to see continued reporting on that.
Rovner: We’ve seen a continuing software programs that went in and thought that they would sort of efficiently look at household income, and to determine whether people were still eligible. And forgot that when they were programming it, that eligibility varies by income, depending on whether you’re a kid, or a pregnant woman, or a mom who’s just given birth. That those eligibility amounts are not the same, and that you can’t just go in and say, “You’re over a certain cutoff, you’re off.” So we’re continuing to see this in the continuing unwinding. Alice.
Ollstein: So, I have a really interesting piece from ProPublica about something I had never heard about. It’s called “A Lab Test That Experts Liken to a Witch Trial Is Helping Send Women to Prison for Murder.” So this is about a forensic practice that some states and counties use for determining whether a baby was stillborn, or that the mother ended the baby’s life after it was born alive. Sorry if this is graphic, folks, but it involves removing the lungs and seeing if they float or not. The reasoning being that that will help you determine if the baby was born alive and took a breath before it died, or if it was stillborn. But we’ve been learning about a lot of forensic “tests.” This is pseudoscience. It is really inaccurate. There are many ways that this could inaccurately convict someone of murder when, in fact, they suffered a stillbirth. So I think people think it’s scientific, it’s unbiased, but science is more complicated than that. So this was a really fascinating story.
Rovner: Yeah, this is something that’s been around for a good while. I became aware of it in, I think, the 2010s, when it was used to convict someone who, I believe her conviction was eventually overturned.
Well, my extra credit this week is from The Washington Post by Fenit Nirappil, and it’s called “Online Portals Deliver Scary Health News Before Doctors Can Weigh In.” It’s about a likely unintended impact of the transparency provisions of the 2016 [21st Century] Cures Act, requiring that patients be given access to test results as soon as they’re available, even before their doctors in many cases. Doctors are lobbying for a change in the regulations so they can at least have time to review the results first, so patients don’t open up a portal and find out that they have cancer. But the Biden administration, at least so far, says it’s the patient’s own information and that the patients have a right to it.
The story’s a really very nuanced look at how the solution to just about every problem in health policy inevitably creates problems of its own.
OK, that is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, @jrovner. Sarah?
Karlin-Smith: I’m @SarahKarlin.
Rovner: Lauren?
Weber: @LaurenWeberHP on X. “HP” is for health policy.
Rovner: Alice.
Weber: @AliceOllstein on X.
Rovner: We will be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': Harris in the Spotlight
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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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Stephanie Armour
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Rachel Cohrs Zhang
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Alice Miranda Ollstein
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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.
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Rovner: We will be back in your feed next week. Until then, be healthy.
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